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Nutrition Science Hub · Iron

Iron deficiency without anaemia:
tired with a ‘normal’ blood test.

Your haemoglobin is normal, your report shows no red flags, and yet you are tired all the time. Iron deficiency without anaemia is one of the most common reasons. Here is what it is, the one test that finds it, why it makes you tired, what drains iron, what gets mistaken for it, and how to refill your stores safely.

This guide is for education. Iron levels are checked and treated with a doctor, and iron doses are set by a doctor. Tiredness has many causes, so test before you treat.

By Evo Hominus™Updated 11 min read
Which tests to ask forTry the Nutrient Gap Finder
84%of young women with low iron stores in a large US survey were not anaemic
Over 1 in 4adult women in an eight-state Indian blood survey had iron deficiency (27.7%)
1 in 3adolescent girls in India had iron deficiency in the national nutrition survey
48% vs 29%drop in tiredness with iron vs a dummy pill in non-anaemic women with low ferritin

What is iron deficiency without anaemia?

The Short Answer

What is iron deficiency without anaemia?

Iron deficiency without anaemia means your body’s iron stores are low, but your haemoglobin is still normal. It is the early stage of iron deficiency, before anaemia appears. It shows up as low ferritin on a blood test, and it can cause tiredness, poor focus and hair shedding even when your blood count looks fine.

Doctors also call it latent iron deficiency or non-anaemic iron deficiency; online you will often see it written as iron deficiency without anemia. Your body uses iron in two places: the iron working in your blood today, and the iron saved for later, held mostly as ferritin in the liver.1 When you lose or miss iron for months, the savings go first. Haemoglobin falls only when the savings run out.

Iron matters well before that point. Iron contributes to the normal formation of red blood cells and haemoglobin, normal oxygen transport, normal energy-yielding metabolism, normal cognitive function, normal immune function and the reduction of tiredness and fatigue.2

The three stages of iron deficiency
StageWhat is happeningWhat blood tests show
1. Low storesIron savings run downFerritin low; haemoglobin normal3,1
2. Iron-short red cellsToo little iron reaches the bone marrowFerritin low; transferrin saturation falls; haemoglobin still normal1
3. Iron deficiency anaemiaRed cells become fewer and smallerHaemoglobin low (under 12 g/dL in women who are not pregnant); small red cells4,1

Stages 1 and 2 are iron deficiency without anaemia. They are common: in a large US survey, 84% of girls and young women aged 12 to 21 with low iron stores were not anaemic.5 In India, an eight-state venous blood survey found iron deficiency in 27.7% of adult women and 31.5% of adolescent girls,6 and the national nutrition survey found it in 30.4% of adolescent girls.7

Can you have iron deficiency with a normal blood test?

The Short Answer

Can you have iron deficiency with a normal blood test?

Yes. A routine blood count (CBC) checks haemoglobin and red cells, not your iron stores. Your stores can be almost empty while haemoglobin is still normal. The test that finds iron deficiency without anaemia is serum ferritin, ideally with a CRP test to rule out inflammation.

This is the “normal blood test” trap. Most people who feel tired get a complete blood count, which is a good first test, but it is built to find anaemia, not low stores.8 Ask your doctor whether these were checked:

Which blood tests show iron stores?
TestWhat it tells youCatches early iron deficiency?
Haemoglobin (in a CBC)Whether you are anaemic todayNo — falls last4
MCV and MCH (in a CBC)Size and iron content of red cellsUsually not until later1
Serum ferritinHow much iron you have savedYes — the key test; 30 ng/mL or lower signals deficiency in adults3,9
Transferrin saturation (TSAT)How much iron is moving in bloodHelpful, especially with inflammation; under 20% points to low iron3,10
CRPWhether inflammation is presentTells you if ferritin is falsely high9

Ferritin needs care in two ways. First, many labs flag ferritin only when it is below about 15 ng/mL, so a result of 20 may not be marked low,4 although the American Society of Hematology’s 2026 guideline classes 30 ng/mL or lower as iron deficiency, and 50 or lower with heavy periods, symptoms or pregnancy plans.3 Second, infection and inflammation push ferritin up, so a “normal” ferritin during illness can hide low stores.9 Our ferritin test guide explains every number.

Why is my iron low but I’m not anaemic?

The Short Answer

Why is my iron low but I’m not anemic?

Because anaemia is the last stage of iron loss, not the first. Your body protects haemoglobin by spending its stored iron first, so ferritin falls months before haemoglobin does. Low iron with normal haemoglobin usually means you are losing or missing more iron than you take in, most often through periods.

Think of iron like money. Haemoglobin is the cash you spend each day, and ferritin is your savings account. Each day you absorb only about 1 to 2 mg of iron from food, roughly what you lose, and the body has no way to get rid of extra.1 So a small, steady drain, such as monthly periods, empties the savings slowly. Haemoglobin keeps looking normal until the savings are gone. Researchers using US survey data found that the body starts making fewer red cells and calling for more iron at a ferritin of about 25 ng/mL in women, well above the old 15 cut-off.11

Can iron deficiency without anaemia make you tired?

The Short Answer

Can iron deficiency without anemia make you tired?

Yes. In a Swiss trial of 198 tired women with normal haemoglobin and ferritin under 50, iron cut tiredness by 48%, compared with 29% on a dummy pill. A review of 18 trials in adults with low iron but no anaemia also found that iron reduced tiredness.

This is where “tired but blood test normal” often ends. The evidence:

  • Tiredness fell with iron. 198 menstruating women with unexplained tiredness, normal haemoglobin and ferritin under 50 µg/L took iron or a placebo for 12 weeks. Tiredness fell by 47.7% with iron and 28.8% with placebo.12
  • The wider evidence agrees. A review of 18 trials in 1,170 adults with low iron but no anaemia found iron reduced self-reported tiredness, with moderate certainty.13
  • Exercise felt easier. In a review of 22 trials in women of reproductive age, iron improved maximum oxygen uptake and lowered heart rate during exercise.14
  • Thinking was sharper. In young women, those with low iron were slower and less accurate on thinking tests, and as ferritin rose with iron, performance improved.15

Not every tired person with low iron feels a change. In Swiss blood donors with ferritin of 50 or lower, a single iron drip raised ferritin and haemoglobin but did not change tiredness after 6 to 8 weeks.16 That is why testing matters: iron helps when low iron is the reason, and the other causes of tiredness need checking too.

What are 5 unexpected signs of low iron?

The Short Answer

What are 5 unexpected signs of low iron?

Craving ice or chewing ice, restless legs at night, hair shedding, always feeling cold, and spoon-shaped or brittle nails. They can appear with low iron stores even before anaemia. Each has other possible causes, so a ferritin test is the way to check.

  1. Craving iceOf 262 adults with low iron or iron depletion, 45% had unusual cravings (pica), and most of those craved ice. The cravings stopped within three weeks of iron treatment.17
  2. Restless legsAn urge to move the legs at night is linked to low iron; iron eased symptoms in trials, and sleep doctors consider iron at a ferritin of 75 or lower.18,10
  3. Hair sheddingWomen with non-scarring hair loss have lower ferritin on average, especially before menopause.19
  4. Always feeling coldLow iron reduces the body’s ability to make and hold heat.20
  5. Spoon-shaped nailsThin nails that curve upwards like a spoon should prompt an iron check.21

For the full list, see our guide to iron deficiency symptoms in women.

What drains iron from your body?

The Short Answer

What drains iron from your body?

Blood loss drains iron fastest, mostly through heavy periods, and also through pregnancy, childbirth, blood donation and hidden bleeding in the gut. Low absorption drains it slowly: vegetarian meals, tea with food, coeliac disease and stomach infections such as H. pylori. Fast growth in teenagers also raises the need.

  • Heavy periods. About 6 in 10 women with heavy periods have iron deficiency, and many never see a doctor about the bleeding.22
  • Pregnancy and childbirth. A pregnancy uses about 1,200 mg of iron in total, and losing half a litre of blood at delivery costs about 250 mg more.1
  • Blood donation. Regular donors often run low, which is why donor studies are a key source of evidence.16
  • Vegetarian, cereal-based meals. Iron from plants is absorbed less well than iron from meat, and tea with a meal cut plant-iron absorption by 79 to 94% in one study; vitamin C undoes much of that block.23,24
  • Gut causes. Coeliac disease and H. pylori infection reduce absorption, and slow bleeding from ulcers or tumours drains iron without you noticing.25,4

What cancers cause low iron?

Low iron is not a sign of cancer on its own. But slow bleeding from bowel or stomach cancer can drain iron, which is why men and women after menopause with iron deficiency are usually offered a gut examination, while younger women are usually tested for coeliac disease first.4,25 In younger women, low iron most often comes from periods.

What gets mistaken for iron deficiency?

The Short Answer

What gets mistaken for iron deficiency?

Thalassaemia trait, which also makes small red cells; anaemia from long-term inflammation; vitamin B12 or folate deficiency; an underactive thyroid; and poor sleep or low mood, which also cause tiredness. Ferritin, CRP and a few other tests tell them apart.

  • Thalassaemia trait. Common in many Indian communities (about 3 to 17% carry it in different groups), it makes red cells small, just like iron deficiency. Iron does not fix it, and taking iron you don’t need can build up.26
  • Anaemia of inflammation. Long-term illness traps iron inside the body. Ferritin can look normal or high while iron is short for making blood.1,9
  • B12 or folate deficiency. These can sit alongside low iron, especially in people who eat little or no meat, eggs or milk.1
  • Other causes of tiredness. Doctors usually check thyroid, blood sugar (HbA1c), kidney and liver tests, inflammation and coeliac disease in someone who is tired all the time.8

What is worse, anaemia or low iron?

Iron deficiency anaemia is the more advanced stage, so it is worse: it can cause breathlessness, a fast heartbeat and, in pregnancy, risks for the baby. But low iron without anaemia is not harmless. It can already cause tiredness, hair shedding and restless legs, and left alone it often becomes anaemia. Treat it early, when it is easier to fix.13,3

Can you fully recover from iron deficiency?

The Short Answer

Can you fully recover from iron deficiency?

Yes. Most people refill their iron stores once the cause is found and iron intake improves. Ferritin rises over weeks to months, and doctors usually continue iron for about three months after haemoglobin is normal to refill the stores, then recheck ferritin.

  1. Test firstAsk for ferritin with a CRP, plus your blood count. Don’t start long-term iron without a test.3,9
  2. Find the causeHeavy periods, diet, blood donation or a gut cause; men and women after menopause need a doctor’s check for bleeding.4,25
  3. Eat iron with vitamin CGarden cress seeds, til, masoor, chana and bajra, with lemon, amla or guava at the same meal.27,24
  4. Move your chaiKeep tea and coffee at least an hour away from iron-rich meals and iron tablets.24
  5. Take iron only as your doctor advisesDoctors set the dose and how often. Taking iron twice a day doesn’t add absorption, and doctors usually give it once a day or on alternate days.28,4
  6. Recheck and keep goingYour doctor will recheck your blood tests and usually continues iron for about three months after haemoglobin is normal, to refill the stores.4
See a doctor promptly if

You have chest pain, fainting, a racing heart or breathlessness at rest; black or bloody stools or vomiting blood; very heavy periods; or low iron as a man or a woman after menopause. Do not take iron if your ferritin is high or you have haemochromatosis or thalassaemia, unless your doctor advises it. Keep iron tablets out of children’s reach: an iron overdose is dangerous for children.

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About the studies
  • The tiredness trial gave 80 mg of iron a day for 12 weeks, a treatment dose well above daily needs; tiredness also fell in the placebo group.12 The review of 18 trials found no clear gain in measured exercise capacity in non-anaemic adults.13
  • The blood-donor trial used one 800 mg iron drip and measured tiredness at 6 to 8 weeks, in donors who were not necessarily tired to begin with.16
  • The exercise review included only three trials at low risk of bias.14 The thinking study compared young women with different iron levels over 16 weeks.15
  • The 84% figure is from US girls and women aged 12 to 21 using ferritin under 25 µg/L. The Indian figures used inflammation-adjusted ferritin, and the eight-state survey did not cover the whole country.5,6,7
  • The 25 ng/mL figure comes from US survey data and needs confirming in other populations.11 The 2026 cut-offs are conditional, low-certainty recommendations for diagnosis, not an automatic reason to take iron.3
  • In the ice-craving study, cravings stopped after iron given through a drip.17 Several restless-legs trials also used iron through a drip, and the ferritin line of 75 is a consensus figure.18,10 The hair-loss review compared ferritin levels; it did not test iron supplements.19
  • The thalassaemia figures come from studies of specific Indian communities, not a national survey.26
Questions

Low iron, normal blood test, answered simply.

Can you have iron deficiency with a normal blood test?

Yes. A routine blood count checks haemoglobin, not iron stores, so it can be normal while your stores are low. Ask for a serum ferritin test, ideally with CRP, to see your stored iron.

Why is my iron low but I’m not anemic?

Because your body spends its stored iron first to keep haemoglobin normal. Ferritin falls months before haemoglobin does, so low iron without anaemia is the early stage. Periods, pregnancy, blood donation and low-iron diets are the usual reasons.

Can iron deficiency without anemia make you tired?

Yes. In a trial of 198 tired women with normal haemoglobin and ferritin under 50, iron cut tiredness by 48% versus 29% on a dummy pill. A review of 18 trials also found less tiredness with iron.

What are 5 unexpected signs of low iron?

Craving ice, restless legs at night, hair shedding, always feeling cold, and spoon-shaped or brittle nails. They can appear before anaemia. Each has other causes too, so check with a ferritin test.

What gets mistaken for iron deficiency?

Thalassaemia trait, anaemia from long-term inflammation, vitamin B12 or folate deficiency, and an underactive thyroid. Poor sleep and low mood also cause tiredness. Ferritin, CRP and a few other blood tests tell them apart.

What drains iron from your body?

Blood loss drains it fastest: heavy periods, pregnancy and childbirth, blood donation and hidden bleeding in the gut. Low absorption drains it slowly: cereal-based vegetarian meals, tea with food, coeliac disease and stomach infections.

What is worse, anemia or low iron?

Anaemia is the more advanced stage, so it is worse. But low iron without anaemia can already cause tiredness, hair shedding and restless legs, and left alone it often becomes anaemia. It is easier to fix early.

Can you fully recover from iron deficiency?

Yes, most people do once the cause is found and iron intake improves. Stores refill over weeks to months, and doctors usually continue iron for about three months after haemoglobin is normal, then recheck.

What cancers cause low iron?

Bowel and stomach cancers can cause slow, hidden bleeding that drains iron. Low iron alone is not a sign of cancer, but men and women after menopause with iron deficiency are usually offered a gut check. In younger women, periods are the usual cause.

Can low ferritin cause fatigue?

Yes, it can. Ferritin shows your iron stores, and trials in people with low ferritin but normal haemoglobin found iron reduced tiredness. Tiredness has many causes, so your doctor will check others too.

What is latent iron deficiency?

It is another name for iron deficiency without anaemia: your iron stores are low but haemoglobin is still normal. It is found with a ferritin test, not a routine blood count.

Should I take iron if ferritin is low?

Ask your doctor. If your ferritin is low, your doctor will look for the cause and advise the iron dose and how long to take it. Don’t take iron long-term without a test.

Which tests show iron stores?

Serum ferritin is the main test for iron stores. Transferrin saturation helps, especially if inflammation is present, and CRP shows whether inflammation may be pushing ferritin falsely high.

What ferritin level is too low?

The American Society of Hematology’s 2026 guideline classes a ferritin of 30 ng/mL or lower as iron deficiency in adults, and 50 or lower with heavy periods, symptoms or pregnancy plans. Many labs flag only results below about 15.

Is a ferritin of 20 normal?

Many labs will call it normal, but newer guidance classes 30 ng/mL or lower as iron deficiency in adults. If you are tired with a ferritin of 20, talk to your doctor about it.

Why am I tired if my blood test is normal?

Your routine test may not have checked iron stores, vitamin B12, vitamin D or thyroid. Sleep, stress, mood and other illnesses also cause tiredness. Ask your doctor which tests were done.

Can you have low ferritin and normal haemoglobin?

Yes. This is iron deficiency without anaemia, the early stage of iron loss. Haemoglobin stays normal until your iron stores are almost empty.

How long does it take to feel better after low iron?

In the main trial, tiredness was measured after 12 weeks of iron. Many people need weeks to a few months; your doctor will recheck your blood to see how your stores are refilling.

Can low iron cause hair loss without anaemia?

It may. Women with non-scarring hair loss have lower ferritin on average, especially before menopause. Hair loss has many causes, so check ferritin and see a doctor if it continues.

Can low iron cause anxiety or poor focus?

Iron contributes to normal cognitive function. In young women, low iron was linked to slower and less accurate thinking, which improved as ferritin rose. Anxiety has many causes; talk to a doctor if it persists.

Is iron deficiency without anaemia common in India?

Yes. An eight-state blood survey found iron deficiency in about 28% of adult women and 32% of adolescent girls, and the national nutrition survey found it in 30% of adolescent girls.

Can heavy periods cause low iron without anaemia?

Yes. Heavy periods are the most common cause of low iron in women, and about 6 in 10 women with heavy periods are iron deficient. Get heavy periods checked by a doctor.

Does tea stop iron absorption?

Tea taken with a meal cut plant-iron absorption by 79 to 94% in one study. Drink tea or coffee at least an hour away from iron-rich meals, and add vitamin C foods like lemon or amla to meals.

Can men have iron deficiency without anaemia?

Yes, but it is less common. Men and women after menopause with low iron should see a doctor, who will look for hidden blood loss, often with a gut examination.

Can I have thalassaemia trait and low iron together?

Yes, both can occur. Thalassaemia trait also makes small red cells, so a ferritin test is needed to know whether iron is actually low. Iron does not help thalassaemia trait itself.

Which vegetarian foods are rich in iron in India?

Garden cress seeds, sesame seeds, horse gram, soya, masoor and whole moong, chana, bajra and ragi. Pair them with lemon, amla or guava to help absorption.

Is it safe to take iron without a blood test?

It is better not to take iron for long without a test. Too much iron can build up, and tiredness may have another cause. Keep iron tablets away from children: an overdose is dangerous for them.

Does a normal haemoglobin mean my iron is fine?

No. Haemoglobin shows whether you are anaemic, not how much iron you have saved. Ferritin shows your stores, and they can be low with a normal haemoglobin.
Sources

Studies behind this guide

  1. Cappellini MD, Santini V, Braxs C, Shander A. Iron metabolism and iron deficiency anemia in women. Fertil Steril. 2022;118(4):607–614. DOI 10.1016/j.fertnstert.2022.08.014
  2. European Commission. Regulation (EU) No 432/2012 establishing a list of permitted health claims made on foods (iron).
  3. Powers JM, Lim MY, Achebe MQ, et al. American Society of Hematology 2026 guidelines for diagnosis of iron deficiency. Blood Advances. 2026. DOI 10.1182/bloodadvances.2025015950
  4. Snook J, Bhala N, Beales ILP, et al. British Society of Gastroenterology guidelines for the management of iron deficiency anaemia in adults. Gut. 2021;70(11):2030–2051.
  5. Weyand AC, Chaitoff A, Freed GL, Sholzberg M, Choi SW, McGann PT. Prevalence of iron deficiency and iron-deficiency anemia in US females aged 12–21 years, 2003–2020. JAMA. 2023;329(24):2191–2193. DOI 10.1001/jama.2023.8020
  6. Ghosh S, Laxmaiah A, Chandak GR, et al. Anaemia and iron deficiency in India: a venous blood-based survey of adolescents, adults, and the elderly in eight states. Eur J Clin Nutr. 2025. DOI 10.1038/s41430-024-01559-w
  7. Kulkarni B, Peter R, Ghosh S, et al. Prevalence of iron deficiency and its sociodemographic patterning in Indian children and adolescents: findings from the Comprehensive National Nutrition Survey 2016–18. J Nutr. 2021. PMID 34049401
  8. National Institute for Health and Care Excellence. Clinical Knowledge Summaries: Tiredness/fatigue in adults — first-line investigations.
  9. World Health Organization. WHO guideline on use of ferritin concentrations to assess iron status in individuals and populations. Geneva: WHO; 2020 — ferritin below 15 µg/L in healthy people and below 70 in adults with infection or inflammation; measure CRP alongside.
  10. Winkelman JW, Berkowski JA, DelRosso LM, et al. Treatment of restless legs syndrome and periodic limb movement disorder: an American Academy of Sleep Medicine clinical practice guideline. J Clin Sleep Med. 2025 — consider iron at ferritin 75 ng/mL or lower or transferrin saturation under 20%.
  11. Mei Z, Addo OY, Jefferds ME, Sharma AJ, Flores-Ayala RC, Brittenham GM. Physiologically based serum ferritin thresholds for iron deficiency in children and non-pregnant women: a US NHANES serial cross-sectional study. Lancet Haematol. 2021;8(8):e572–e582. PMID 34329578
  12. Vaucher P, Druais PL, Waldvogel S, Favrat B. Effect of iron supplementation on fatigue in nonanemic menstruating women with low ferritin: a randomized controlled trial. CMAJ. 2012;184(11):1247–54. DOI 10.1503/cmaj.110950
  13. Houston BL, Hurrie D, Graham J, et al. Efficacy of iron supplementation on fatigue and physical capacity in non-anaemic iron-deficient adults: a systematic review of randomised controlled trials. BMJ Open. 2018;8(4):e019240. PMID 29626044
  14. Pasricha SR, Low M, Thompson J, Farrell A, De-Regil LM. Iron supplementation benefits physical performance in women of reproductive age: a systematic review and meta-analysis. J Nutr. 2014;144(6):906–914.
  15. Murray-Kolb LE, Beard JL. Iron treatment normalizes cognitive functioning in young women. Am J Clin Nutr. 2007;85(3):778–787. DOI 10.1093/ajcn/85.3.778
  16. Keller P, et al. Sci Rep. 2020;10(1):14219. DOI 10.1038/s41598-020-71048-0 — randomised, placebo-controlled trial of a single 800 mg intravenous ferric carboxymaltose dose in 405 non-anaemic blood donors with ferritin 50 µg/L or lower.
  17. Barton JC, Barton JC, Bertoli LF. Pica associated with iron deficiency or depletion: clinical and laboratory correlates in 262 non-pregnant adult outpatients. BMC Hematol. 2010;10:9. DOI 10.1186/1471-2326-10-9
  18. Trotti LM, Becker LA. Iron for the treatment of restless legs syndrome. Cochrane Database Syst Rev. 2019;1:CD007834. DOI 10.1002/14651858.CD007834.pub3
  19. Treister-Goltzman Y, Yarza S, Peleg R. Iron deficiency and nonscarring alopecia in women: systematic review and meta-analysis. Skin Appendage Disord. 2022;8(2):83–92. PMID 35415182
  20. Iron and thermoregulation: a review. Crit Rev Food Sci Nutr. 1996;36(8):747–63. PMID 8989508
  21. Moiz B. Spoon nails: still seen in today’s world. Clin Case Rep. 2018;6(3):547–548. PMID 29531740
  22. Vannuccini S, Jain V, Critchley H, Petraglia F. From menarche to menopause, heavy menstrual bleeding is the underrated compass in reproductive health. Fertil Steril. 2022;118(4):625–636. DOI 10.1016/j.fertnstert.2022.07.021
  23. ICMR-NIN. Nutrient Requirements for Indians, 2020 — iron chapter (8% absorption from cereal-based meals; daily needs 29 mg for women and 19 mg for men).
  24. Hurrell RF, Reddy M, Cook JD. Inhibition of non-haem iron absorption in man by polyphenolic-containing beverages. Br J Nutr. 1999;81(4):289–95; Siegenberg D, Baynes RD, Bothwell TH, et al. Ascorbic acid prevents the dose-dependent inhibitory effects of polyphenols and phytates on nonheme-iron absorption. Am J Clin Nutr. 1991;53(2):537–41. PMID 1989423
  25. Ko CW, Siddique SM, Patel A, et al. AGA clinical practice guidelines on the gastrointestinal evaluation of iron deficiency anemia. Gastroenterology. 2020;159(3):1085–1094. DOI 10.1053/j.gastro.2020.06.046
  26. Kumari K, et al. Online J Health Allied Scs. 2019;18(2):2 — beta-thalassaemia trait in Gujarat, with carrier frequencies of about 3–17% reported across Indian communities.
  27. Longvah T, Ananthan R, Bhaskarachary K, Venkaiah K. Indian Food Composition Tables 2017. Hyderabad: National Institute of Nutrition (ICMR); 2017.
  28. Moretti D, Goede JS, Zeder C, et al. Oral iron supplements increase hepcidin and decrease iron absorption from daily or twice-daily doses in iron-depleted young women. Blood. 2015;126(17):1981–1989. DOI 10.1182/blood-2015-05-642223 PMID 26289639
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