Anemia

What is Anemia?

Anemia refers to the condition where the number of red blood cells in your body decreases. It’s a symptom of a deeper health issue rather than a disease in itself. The way it affects a patient can vary depending upon the cause of the anemia, how quickly it develops, and whether they have any other health problems, especially heart diseases. Mostly, when the hemoglobin level, a protein in red blood cells that carries oxygen, falls below 7.0 g/dL, people start showing signs linked to anemia.

A kidney-made substance known as erythropoietin (EPO) majorly influences the creation of red blood cells. EPO production increases when there’s insufficient oxygen in the body’s tissues, often tied to low hemoglobin concentrations. So, a person with anemia, marked by low hemoglobin levels, will generally have higher EPO levels. But in people with kidney problems, EPO levels can be unexpectedly low. Also, in a type of anemia related to chronic diseases, while EPO levels are higher, they’re not as high as they should be, indicating a relative EPO deficiency.

Typical hemoglobin ranges, which might vary a bit depending on the laboratory, are generally:

* Men: 13.5 – 18.0 g/dL
* Women: 12.0 – 15.0 g/dL
* Children: 11.0 – 16.0 g/dL
* Pregnant women: Varies with trimesters but generally greater than 10.0 g/dL

What Causes Anemia?

Anemia, or a lower than normal number of red blood cells, can have different causes, and it depends on if the body is not making enough new red blood cells, known as “hypoproliferative,” or if the body is making a lot of new red blood cells, known as “hyperproliferative.”

In cases where the body isn’t making enough red blood cells, we further classify the anemia based on the average size of the red blood cells.

1) Small-sized red blood cells (Microcytic Anemia)

* Shortage of iron (Iron deficiency anemia)
* Chronic illnesses
* Sideroblastic anemia, where body can’t process iron properly
* Thalassemia, a genetic disorder which affects how the body creates hemoglobin
* Lead poisoning

2) Normal-sized red blood cells (Normocytic Anemia)

* Chronic illnesses
* Kidney failure
* Bone marrow not producing enough new blood cells (Aplastic anemia)
* Deficiency in creation of red blood cells (Pure red cell aplasia)
* Bone marrow replaced by fibrous tissue (Myelofibrosis) or fibrosis due to cancer cells (Myelophthisic processes)
* Cancer of plasma cells in the bone marrow (Multiple myeloma)

Anemia with large-sized red blood cells (Macrocytic Anemia) can happen if new red blood cells aren’t being produced quickly enough, or if existing red blood cells are being destroyed, known as “hemolysis,” or both. To determine this, doctors will examine the percentage of immature red blood cells, called “reticulocytes” in the blood.

3) Large-sized red blood cells with slower production (Hypoproliferative Macrocytic Anemia)

* Alcohol use
* Liver disease
* Slow metabolism (Hypothyroidism)
* Deficiencies in Folate and Vitamin B12
* Conditions that interfere with the production of blood cells in the bone marrow (Myelodysplastic syndromes or MDS)
* Several drugs can cause this, like diuretics, chemotherapy, blood sugar controllers, HIV medication, anti-infective drugs, and seizure medication.

On the other hand, if you have Anemia due to destruction of red blood cells (Hemolytic Anemia), this can be due to causes outside of or within the blood vessels.

4) Hemolytic Anemia

* Destruction by liver and spleen (Extravascular hemolysis): this is the most common type
* Defects in hemoglobin (sickle cell, thalassemias)
* Enzyme deficiencies (G6PD deficiency, pyruvate kinase deficiency)
* Abnormalities of the red blood cell membrane
* Certain drugs can cause this
* Destruction within the blood vessels (Intravascular hemolysis): this is less common
* Certain diseases and disorders like PNH and AIHA
* Bad reaction to blood transfusion
* Microangiopathic hemolytic anemia (MAHA)
* Disseminated intravascular coagulation (DIC)
* Infections
* Snake bites/venom.

Risk Factors and Frequency for Anemia

Anemia, a disease affecting the red blood cells, impacts approximately a third of people worldwide. Many people experience a mild form of anemia that doesn’t cause any symptoms and doesn’t need treatment. However, anemia becomes more common as people get older. It’s particularly common in women who are able to have children, pregnant women, and older adults. In fact, more than 20% of people over 85 have anemia. Half to 60% of people who live in nursing homes are afflicted with anemia.

• For one-third of older adults, their anemia comes from not getting enough nutrients like iron, folate, and vitamin B12.
• Another one-third of older adults with anemia have it because of kidney failure or chronic inflammation.

Mild anemia caused by lack of iron is commonly seen in women who can have children. Poor diet and the regular menstrual cycle often cause this. Anemia is also prevalent in the elderly, usually because of poor nutrition, particularly a lack of iron and folic acid. Other groups at risk for anemia include people who drink alcohol excessively, homeless people, and those who are facing neglect or abuse.

If someone over 55 suddenly develops anemia, it’s important to investigate the cause. This could be a sign of cancer until proven otherwise. This is particularly critical in men of any age who show symptoms of anemia.

Besides age and gender, race is another important factor in anemia. The disease is more common among African Americans.

Signs and Symptoms of Anemia

When evaluating for signs and conditions such as anemia, doctors will typically take a detailed medical history and do a physical examination. Some of the crucial aspects they might ask about during the medical history include signs of obvious bleeding, dietary habits, consumption of non-food substances, and any abnormal stools like those which are bulky or fatty and have a foul smell. They will carefully review any abdominal or gastric surgeries you had, your family’s history of certain diseases, and the daily medications you’re taking.

Anemia has certain symptoms and signs that can help doctors diagnose it. For instance, symptoms related to the rate of blood loss might include:

• Weakness or tiredness
• Feeling lethargic
• Restless legs
• Shortness of breath or chest pain, especially when active
• A desire to eat unusual and non-dietary substances

However, mild anemia might not have any symptoms. On the physical examination side, doctors might look for signs like:

• Cool skin to touch
• Rapid breathing
• Pale color on the white part of your eyes or inside your mouth
• Yellowish skin and eye whites which might suggest elevated bilirubin levels
• Swollen or inflamed areas, such as lymph nodes, tongue or the corners of the mouth
• Enlarged liver or spleen
• Scarring from surgery, which might affect vitamin B12 absorption
• Fast heart rate or flow murmur
• Pale areas on the mucous membranes, nail bed or inner creases of the hand
• Red pinpoint skin spots called petechiae
• Nails changing shape or becoming spoon-like

Lastly, a rectal and pelvic exam might be required if there’s significant rectal bleeding to check for hemorrhoids or lumps that might suggest cancer.

Testing for Anemia

When investigating anemia, the process begins with identifying the type of anemia through several steps:

1. A complete blood count (CBC) is performed, which includes differential.

2. The corrected reticulocyte count, which is a measure of new red blood cells, is calculated using the formula: percent reticulocytes x (patient’s HCT/normal HCT). The normal HCT is typically 45% in men and 40% in women. A result greater than 2 suggests the presence of hemolysis (breakdown of red blood cells) or acute blood loss. On the other hand, a result lower than 2 indicates a slow production of new blood cells.

3. Then, the MCV (Mean Corpuscular Volume, a measure of the average size of red blood cells) is checked. Depending on the MCV value, different conditions may be suggested:

* If MCV is less than 80, conditions that can be considered include iron deficiency, lead poisoning, thalassemia, or sideroblastic anemia.

* If the MCV is between 90 and 100, possible conditions include aplastic anemia, renal failure, and others.

* If the MCV is more than 100, conditions like B12/folate deficiency, hypothyroidism, liver disease, alcohol-related problems could be evaluated.

In case of suspected hemolytic anemia, specific steps are carried out:

1. First, the presence of hemolysis is confirmed through tests including elevated LDH, corrected reticulocyte count >2%, elevated indirect bilirubin, and low haptoglobin levels.

2. Then, it’s determined whether hemolysis is happening inside (intravascular) or outside (extravascular) the blood vessels through different tests and observations.

3. An examination of the peripheral blood smear is carried out to look for specific signs of different types of anemia.

4. If spherocytes (abnormally shaped red blood cells) are present, a DAT test is performed to differentiate between immune hemolytic anemia and hereditary spherocytosis.

Depending on the exact symptoms, other tests may be carried out such as a scope down the throat (esophagogastroduodenoscopy) to check for an upper gastrointestinal bleeding, or a colonoscopy for lower gastrointestinal bleeding. Also, imaging studies could be done in case of suspected malignancy or internal bleeding. In menstruating women with heavy bleeding, a pelvic ultrasound might be necessary to check for fibroids.

Treatment Options for Anemia

The treatment for anemia varies depending on the exact cause. Here are some possible treatment approaches:

1) If anemia is caused by sudden loss of blood, it can be treated with intravenous (IV) fluids, oxygen, and blood transfusions. The aim is to maintain a level of hemoglobin (a protein in blood cells that carries oxygen) of more than 7 grams per deciliter for most patients. However, people with heart disease may need a level higher than that, at 8 grams per deciliter.

2) Anemia due to a lack of certain nutrients can be treated with oral or IV supplements of iron, vitamin B12, and folate.

Iron can be taken orally and is the most common means of making up for an iron deficiency. The dose will depend on the person’s individual needs and how well they can tolerate any side effects. These can include a metallic taste in the mouth and stomach-related symptoms, such as constipation and dark-colored stools. If side effects are a problem, iron can be taken every other day to help with stomach absorption. With this kind of treatment, the amount of hemoglobin should get back to normal within 6 to 8 weeks and there should be an increase in new red blood cells within 7 to 10 days.

If levels need to be increased quickly, IV iron can be used. This is an option for people who can’t tolerate the side effects of oral iron or are losing blood rapidly.

3) For cases of anemia caused by problems with bone marrow or stem cells, a bone marrow transplant might be needed.

4) In some cases, anemia is linked to chronic illness. For instance, kidney failure can lead to anemia, which responds well to a hormone called erythropoietin. Anemia caused by autoimmune and rheumatological diseases requires treatment of the underlying condition.

5) When anemia is a result of red blood cells being destroyed too quickly, treatments might include:

• Replacing faulty mechanical heart valves that are causing the issue.
• If a medication is causing anemia, it should be discontinued.
• If hemolytic anemia (where red blood cells are destroyed faster than the body can replace them) continues, removing the spleen may be necessary.
• For blood conditions like sickle cell anemia, treatments could involve blood transfusions, exchange transfusions, and a drug known as hydroxyurea which can help reduce the sickling of cells.
• If anemia is due to Disseminated Intravascular Coagulation (DIC), a condition characterized by excessive clotting and bleeding, the underlying cause needs to be treated. If the bleeding is causing a life-threatening situation, medicines that prevent the breakdown of blood clots (antifibrinolytic agents) might be needed.

What else can Anemia be?

Certain conditions can lead to a misleadingly low count of red blood cells. For example, if a blood sample is broken down or diluted significantly during testing, this can lead to an inaccurate measurement.

Sometimes, after a significant loss of blood due to an injury, the initial blood test might not show signs of anemia (low red blood cells). This can happen because it takes time for the body to balance out the remaining blood cells in circulation.

Here are few conditions you might want to keep in mind:

• Anemia linked to chronic illnesses: If you’re experiencing kidney failure, have cancer, or autoimmune diseases, you could develop this type of anemia.
• Bone marrow problems: If you’ve lost weight or are feeling fatigue, it could be due to issues with your bone marrow.
• Anemia due to B12/folate deficiency: If you have numbness or tingling sensations, follow a vegan/vegetarian diet, or had recent weight loss surgery, you might be lacking in B12 or folate causing anemia.
• Hemolytic anemia: This type of anemia occurs when your body destroys red blood cells faster than it can produce. You might notice symptoms like jaundice (yellowing of the skin) or dark urine. Certain medications can also induce this condition.
• Acute bleeding in the digestive tract: Certain conditions might cause bleeding in the digestive tract’s upper or lower part, such as injury, cancer, ulcers, or long-term use of certain over-the-counter anti-inflammatory medicines.

These instances are a reminder of how crucial it is to understand a patient’s background and consider all possibilities when interpreting lab results.

What to expect with Anemia

The outlook for people with anemia really depends on what’s causing it.

As soon as anemia is diagnosed, it’s important to start dietary supplements of iron, B12, and folate. If the anemia is due to a lack of iron, taking supplements should continue for at least three months after iron levels return to normal to ensure iron stores in the body are replenished. Generally, if nutritional deficiencies are addressed early and properly, the outlook is good.

Similarly, if anemia is caused by sudden blood loss and this is treated and stopped early, the outlook is also typically good.

Possible Complications When Diagnosed with Anemia

Anemia, if not spotted or untreated for a long time, can result in failure of multiple vital organs or even lead to death. This condition presents additional risks for pregnant women, potentially triggering early labor and resulting in babies born with a low weight. The presence of anemia during pregnancy can also increase the chance of the baby developing anemia and elevate blood loss in the mother.

Older individuals with anemia tend to experience more complications due to having multiple existing health conditions. The cardiovascular system, which includes the heart and blood vessels, is usually the most affected in those with chronic anemia. There’s a high risk of experiencing heart attacks, chest pain due to the heart not getting enough oxygen (angina) and heart failure where the heart can’t pump enough blood to meet the body’s needs (high output heart failure). Arrhythmias – irregular heartbeats, and cardiac hypertrophy – the thickening of the heart muscle, are other potential heart complications.

Extreme lack of iron, a condition related to anemia, has been linked to restless leg syndrome, a disorder that causes a strong urge to move the legs, and esophageal webs, thin tissue growths that can partially block your esophagus.

Severe anemia from a young age may lead to problems with brain development, including potential cognitive, mental, and developmental delays. Unfortunately, these types of complications are unlikely to improve with medical treatment.

Preventing Anemia

People who have nutritional anemia due to a lack of iron should be advised to eat more iron-rich foods. This includes foods like green vegetables, tofu, red meats, raisins, and dates. In addition, vitamin C can also help improve the body’s ability to absorb iron from food, so it’s good to include in the diet. However, it’s also crucial to limit intake of tea or coffee, as these beverages can actually decrease the body’s ability to absorb iron.

When taking iron supplements, patients should know that they might experience constipation or black tarry stools – this is normal. However, if the iron supplements are causing severe discomfort or side effects, patients should contact their doctor. They might be able to get their iron levels up via an intravenous (or IV) route instead.

For those following a vegan or vegetarian diet who might be lacking in vitamin B12, they should be encouraged to eat foods that are fortified with this vitamin. This could include certain plant and soy products. Lastly, patients who have had specific stomach surgeries, such as gastric sleeve operations and sleeve gastrectomies, may have a higher risk of being deficient in vitamin B12 and folate. This happens because these surgeries reduce the area in the intestines that can absorb these nutrients. They may need additional supplements to ensure proper nutrition.