Causes of Anemia in Polish Older Population—Results from the PolSenior Study

Vitamin B12, folate, iron deficiency (IDA), chronic kidney disease (CKD), and anemia of inflammation (AI) are among the main causes of anemia in the elderly. WHO criteria of nutritional deficiencies neglect aging-related changes in absorption, metabolism, and utilization of nutrients. Age-specific criteria for the diagnosis of functional nutritional deficiency related to anemia are necessary. We examined the nationally representative sample of Polish seniors. Complete blood count, serum iron, ferritin, vitamin B12, folate, and renal parameters were assessed in 3452 (1632 women, 1820 men) participants aged above 64. Cut-off points for nutritional deficiencies were determined based on the WHO criteria (method-A), lower 2.5 percentile of the studied population (method-B), and receiver operating characteristic (ROC) analysis (method-C). Method-A leads to an overestimation of the prevalence of vitamin B12 and folate deficiency, while method-B to their underestimation with over 50% of unexplained anemia. Based on method-C, anemia was classified as nutritional in 55.9%. In 22.3% of cases, reasons for anemia remained unexplained, the other 21.8% were related to CKD or AI. Mild cases were less common in IDA, and more common in non-deficiency anemia. Serum folate had an insignificant impact on anemia. It is necessary to adopt the age-specific criteria for nutrient deficiency in an old population.

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POS0567 HEPCIDIN IS POTENTIAL BIOMARKER TO DISTINGUISH BETWEEN IRON DEFICIENCY ANEMIA AND ANEMIA OF INFLAMMATION IN RHEUMATOID ARTHRITIS

Annals of the Rheumatic Diseases ◽

10.1136/annrheumdis-2021-eular.3303 ◽

2021 ◽

Vol 80 (Suppl 1) ◽

pp. 518.2-518

Author(s):

E. Galushko ◽

A. Semashko ◽

A. Gordeev ◽

A. Lila

Keyword(s):

Rheumatoid Arthritis ◽

Iron Deficiency ◽

Iron Deficiency Anemia ◽

Complete Blood Count ◽

Deficiency Anemia ◽

Reactive Protein ◽

Potential Biomarker ◽

Serum Hepcidin ◽

Proper Diagnosis ◽

Anemia Of Inflammation

Background:Anemia of inflammation (AI) and iron deficiency anemia (IDA) are the two most prevalent forms of anemia in patients with rheumatoid arthritis (RA). Diagnosis becomes challenging if AI is associated with true ID (AI/ID), as there is still a lack of a gold standard for differentiation between AI and AI/ID. However, as therapies to overcome anemia differ, proper diagnosis and understanding of underlying pathophysiological regulations are necessary.Objectives:The aim of the study was to evaluate the clinical efficiency of hepcidin, a key regulator of iron metabolism, in the diagnosis of IDA, as well as the differential diagnosis of AI/ID and AI in patients with RA.Methods:The study was undertaken 96 patients with RA, 67 of them were diagnosed anemia according to WHO criteria (104,3±21,4 g/l). Anemic patients and anemia-free patients with RA (n=29) were comparable (p>0.05) in age (44.4±14.8 and 49.8±9.3 years), disease duration (73.5±65.4 and 59.8±48.3 months) and DAS28 (6.3±1.6 and 5.9±1.9). All cases were subjected to following tests: complete blood count with peripheral smear, serum C-reactive protein, serum interleukin-6, iron studies, serum soluble transferrin receptor (sTfR), and serum hepcidin. Patients with RA and anemia were divided two groups: 25 patients with IDA and 42 - with AI. The AI cases were subdivided into pure AI and AI with coexistent ID (n=15).Results:The mean serum hepcidin concentration was significantly increased in pure AI patients (123.85±25.8 ng/mL) as compared to those in IDA patients (63.9±22.8 ng/mL, P < 0.05) and anemia-free patients with RA (88.1±39.09 ng/mL). Also, compared to pure AI patients [normal sTfR levels (<3 µg/mL)], the serum hepcidin concentration was reduced significantly in AI patients with ID [high sTfR levels (≥3 µg/mL)] with a mean of 79.0±23.97 ng/mL.Conclusion:Hepcidin measurement can provide a useful tool for differentiating AI from IDA and also help to identify an iron deficiency in AI patients. This might aid in the appropriate selection of therapy for these patients.Disclosure of Interests:None declared

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The prevalence of anemia among the tribal children from the western districts of West Bengal, India

International Journal of Community Medicine and Public Health ◽

10.18203/2394-6040.ijcmph20210239 ◽

2021 ◽

Vol 8 (2) ◽

pp. 791

Author(s):

Tuphan Kanti Dolai ◽

Somnath Mondal ◽

Manisha Jain ◽

Prakas Kumar Mandal

Keyword(s):

Vitamin B12 ◽

West Bengal ◽

Complete Blood Count ◽

Significant Proportion ◽

Serum Vitamin ◽

Serum Folate ◽

P Value ◽

Cross Sectional ◽

High Prevalence ◽

Prevalence Of Anemia

Background: Tribal population in West Bengal constitutes a significant proportion (5.1%) and the vulnerable group because of lower socio-economic status, poor literacy rate and malnutrition. The present study was conducted to evaluate hemoglobin level and prevalence of anemia among the tribal children from the western districts of West Bengal, India.Methods: A cross-sectional study was conducted on school going (class I to class VIII) tribal children (≥5 to <13years) during March 2019 to February 2020. A complete blood count was done by automated blood cell counter and anemia was classified as per WHO criteria. They were also tested for markers of common nutritional anemias (serum ferritin, serum vitamin B12 and serum folate). Data entry and analysis was done on SPSS version 15. A p-value of <0.05 was considered statistically significant.Results: Total 1, 010 tribal children were included with male:female=1:1.35. Among these, 46.34% (n=468) children had anemia. Among all anemic children 47.65% (n=223), 51.93% (n=243/468) and 0.42% (n=2) respectively had mild, moderate and severe anemia. There was a high prevalence (81.68%) of microcytic red blood cells in the total cohort; among anemic children, 53.94% have microcytosis while no macrocytosis was revealed. Among all grade anemias, iron, folate and vitamin B12 deficiency were found in 44.65% (n=209/468), 13.24% (n=62/468) and 25% (n=117/468) respectively.Conclusions: The prevalence of anemia among tribal children of West Bengal is a matter of concern. The high prevalence of microcytic indices in non-anemic population highlights the dire need for screening for the causes of anemia in this population.

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Anemia profile in Diabetic patients with preserved renal function

Asian Journal of Medical Sciences ◽

10.3126/ajms.v12i2.31437 ◽

2021 ◽

Vol 12 (2) ◽

pp. 54-58

Author(s):

Vinay Krishnamurthy ◽

Akhila Rao Kerekoppa

Keyword(s):

Renal Function ◽

General Population ◽

Vitamin B12 ◽

Vitamin B12 Deficiency ◽

Deficiency Anemia ◽

Diabetic Patients ◽

Severe Anemia ◽

B12 Deficiency ◽

Anemia Of Inflammation ◽

Prevalence Of Anemia

Background: Diabetes is one of the largest global health emergencies of the 21st century. Prevalence of anemia in diabetic patients is two to three times higher than for patients with comparable renal impairment and iron stores in the general population. Aims and Objective: This study was done to analyse the prevalence of anemia and its profile in patients with preserved renal function. Materials and Methods: One-hundred diabetic patients with anemia with normal renal functions were selected. Complete blood count, peripheral blood smear, iron studies, vitamin B12 levels were assessed. Diabetic control was monitored by HbA1c. Patients were identified to have specific type of anemia, based on iron profile and vitamin B12 levels. Severity of anemia was also assessed. Appropriate statistical tests were applied to analyse the results. Results: Mean age of subjects in the study group was 53.4±13.6 years. The mean haemoglobin level was 9.41±2.18 g/dl. Out of the 100 cases, 43 patients had iron deficiency anemia, 40 patients had anemia of inflammation, and 8 patients had vitamin B12 deficiency, 8 patients had combined iron and vitamin B12 deficiency, and 1 patient had pancytopenia. Mean HbA1c was higher in iron deficient individuals with a significant p value and mean HbA1c was lower in Vitamin B12 deficient individuals. Among the cases, 16% had mild anemia, 61% had moderate anemia, and 23% had severe anemia. Severe anemia had a significantly lower HbA1c, which was statistically significant. Conclusion: According to our study, iron deficiency anemia was the commonest, followed by anemia of inflammation in diabetic patients with preserved renal function. Diabetes being a pro-inflammatory state had a higher incidence of anemia of inflammation compared to general population. We have to identify and acknowledge the higher prevalence of Anemia of Inflammation in diabetic patients in the absence of renal dysfunction.

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Severe folate deficiency anemia associated with the use of a PARP inhibitor (olaparib) in a patient with fallopian tube cancer

Case Reports in Internal Medicine ◽

10.5430/crim.v6n1p1 ◽

2018 ◽

Vol 6 (1) ◽

pp. 1

Author(s):

Binoy Yohannan ◽

Kristi McIntyre ◽

Mark Feldman

Keyword(s):

Folic Acid ◽

Fallopian Tube ◽

Complete Blood Count ◽

Parp Inhibitor ◽

Folate Deficiency ◽

Serum Folate ◽

Deficiency Anemia ◽

Folic Acid Deficiency ◽

Fallopian Tube Cancer ◽

Increased Risk

Treatment of cancer patients with olaparib (PARP inhibitor) is associated with an increased risk of anemia, which is seen in a majority of treated patients. However, symptomatic anemia requiring transfusion is rare. Olaparib-induced anemia can be secondary to bone marrow suppression, hemolysis or folate deficiency. We report a case of new onset severe folic acid deficiency anemia in a patient with breast and relapsed fallopian tube cancer being treated with olaparib. Complete blood count on admission showed a hemoglobin of 4.2 g/dl and serum folate was undetectable (< 1.6 ng/ml; reference range 7-31.4 ng/ml). This is the second report of olaparib-induced folate deficiency anemia. She received three units packed red cell transfusion and parenteral folic acid supplementation and improved symptomatically. This case highlights the importance of recognizing folate deficiency as a reversible cause of anemia with PARP inhibitor therapy.

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Anaemia in the Hospitalized Elderly in Tanzania: Prevalence, Severity, and Micronutrient Deficiency Status

Anemia ◽

10.1155/2021/9523836 ◽

2021 ◽

Vol 2021 ◽

pp. 1-6

Author(s):

Clara Chamba ◽

Ahlam Nasser ◽

William F. Mawalla ◽

Upendo Masamu ◽

Neema Budodi Lubuva ◽

...

Keyword(s):

Vitamin B12 ◽

Elderly Population ◽

Vitamin B12 Deficiency ◽

The Elderly ◽

Micronutrient Deficiency ◽

Sub Saharan Africa ◽

Serum Folate ◽

Deficiency Anaemia ◽

Hospitalized Elderly ◽

B12 Deficiency

Introduction. Anaemia is a common problem in sub-Saharan Africa. While most literature has focused on children, women of childbearing age, and pregnant women, data for the elderly population are relatively scarce. Anaemia exhorts negative consequences to functional ability of elderly patients, both physically and cognitively. The purpose of this study was to determine the prevalence of anaemia, severity, and micronutrient deficiency status in the elderly hospitalized patients in Tanzania. Methods. A total of 156 hospitalized adults aged 60 years and above were enrolled in this study. A structured questionnaire was used to capture sociodemographic and clinical characteristics. Blood samples were collected, and a complete blood count, serum cobalamin, serum ferritin, and serum folate levels were measured to assess anaemia and micronutrient deficiency status in all participants who had anaemia. Results. The prevalence of anaemia was 79.5% (124/156) with severe anaemia in 33.9% (42/124) of participants, moderate anaemia in 42.7% (53/124) of participants, and 23.4% (29/124) of all participants had mild anaemia. Micronutrient deficiency was found in 14.5% (18/124) of all participants with anaemia. Combined deficiency (either iron and vitamin B12 deficiency or iron and folate deficiency) was the most common micronutrient deficiency anaemia with a frequency of 33.3% (6/18), followed by isolated iron and folate deficiencies at equal frequency of 27.8% (5/18) and vitamin B12 deficiency at 11.1% (2/18). Conclusion. The prevalence of anaemia in the hospitalized elderly population is high warranting public health attention and mostly present in moderate and severe forms. Micro-nutrient deficiency anaemia is common in this age group and is mostly due to combined micronutrient deficiency.

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Racial Differences in Nutritional Anemias: Analysis of Folate, Vitamin B12, and Iron Deficiencies

Blood ◽

10.1182/blood-2019-123791 ◽

2019 ◽

Vol 134 (Supplement_1) ◽

pp. 3387-3387

Author(s):

Miguel Gonzalez Velez ◽

Carolyn Mead-Harvey ◽

Heidi E. Kosiorek ◽

Yael Kusne ◽

Leslie Padrnos

Keyword(s):

Vitamin B12 ◽

Racial Differences ◽

The United States ◽

Racial Group ◽

Serum Folate ◽

Nutritional Deficiencies ◽

Racial Groups ◽

The Us ◽

Level Analysis ◽

Prevalence Of Anemia

Background: Serum folate (SF), vitamin B12 (B12), and iron deficiencies (def) are common causes of nutritional anemias. These deficiencies are usually multifactorial, with nutritional and non-nutritional factors playing a role. SF, B12, and iron levels are usually ordered in the setting of anemia, and malnutrition with or without neurologic symptoms. Since folic acid fortification, the prevalence of SF def in the United States (US) is <1% in the general population. B12 def and iron def range between 6-12%, and 1-11% respectively depending on the population studied. The prevalence of nutritional anemias secondary to SF, B12, and/or iron def by racial groups in the US is poorly studied, and most data available focuses on non-Hispanic whites (NHW). We aimed to determine the prevalence of anemia secondary to nutritional deficiencies by racial groups in the US. Methods: We performed a retrospective analysis of patients with SF, B12 and iron levels at Mayo Clinic Arizona between 01/2010 and 10/2018. Race was classified according to the NIH criteria. Normal laboratory values were determined according to our lab reference and the US National Health and Nutrition Examination Survey (NHANES) III. SF levels (mcg/Lt) were defined as deficient <4, normal ≥4.0, and excess ≥20. B12 levels (ng/L) as deficient <150, borderline 150-400, normal >400-900, and excess ≥900. Iron def was determined by ferritin levels (mcg/L) as low <24, normal 24-336, elevated ≥336 for men, low <11, normal 11-307, elevated ≥307 for women. Demographics and clinical variables were compared between groups by chi-square test for frequency data or Kruskal Wallis rank-sum test for continuous variables. Multivariable logistic regression was used for a sample-level analysis adjusting for age and gender and using NHW as a reference group. Results: A total of 79,926 SF, 107,731 B12, and 39,827 ferritin samples from 67,683 patients were analyzed. Demographics and sample analysis are presented in Table 1. In the sample-level analysis, 23,008 (25%) had anemia with higher prevalence in the American Indian/Alaskan Native (AI/AN) 49% and African Americans (AA) 43% (p<0.001). The prevalence of SF def was 446/79,926 (0.6%), B12 def 1,548/107,731 (1.4%), and iron def 5,212/39,827 (13.1%). 23 had concomitant SF and B12 deficiency, 25 SF and iron def, and 144 B12 and iron def. The SF def prevalence by racial groups was: AI/AN 11 (1.9%), AA 19 (1.1%), NHW 378 (0.6%), Hispanic 28 (0.5%), Asian 4 (0.2%). The B12 def prevalence by racial groups was: Asian 89 (3.4%), NHW 1,274 (1.4%), Hispanic 87 (1.3%), AA 30 (1.3%), AI/AN 10 (1.3%). Iron def prevalence by racial groups: AI/AN 71 (20.5%), Asian 198 (17.6%), AA 180 (16.9%), Hispanic 432 (15.6%), NHW 4,161 (12.4%). In the multivariate sample-level analysis, the presence of anemia was higher in the AI/AN (OR: 4.51, 95%CI: 3.70-5.49, p<0.0001), AA (OR 3.34, 95%CI: 2.99-3.74, p<0.0001), Asian (OR 1.52, 95%CI: 1.35-1.73, p<0.0001) and Hispanic racial group (OR 1.41, 95%CI: 1.30-1.52, p<0.0001). SF def was more common in the AI/AN (OR: 2.94, 95%CI: 1.60-5.39, p<0.001) and AA (OR 1.71, 95%CI: 1.08-1.53, p=0.02). B12 def was more common in the Asian racial group (OR: 2.535, 95%CI: 20.03-3.16, p<0.0001). Iron def was more common in the AI/AN (OR: 1.62, 95%CI: 1.21-2.17, p<0.001), Asian (OR 1.31, 95%CI: 1.0-1.57, p=0.003), and AA racial group (OR 1.26, 95%CI: 1.05-1.52, p=0.001). Conclusions: In our cohort, we show that despite the low prevalence of nutritional anemias in the US, racial disparities exist. Major differences were observed in the prevalence of anemia, SF def and iron def especially among AI/AN and AA. These differences may be linked to medical causes, nutritional practices and other social determinants of health. More research regarding the causes of these disparities and its clinical implications on a population level are needed. Targeted strategies to improve folate, B12 and iron intake in at higher risk populations could decrease adverse outcomes and decrease healthcare disparities caused by nutritional anemias. T able 1. Sample-level comparison by race Disclosures No relevant conflicts of interest to declare.

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Evaluation of Anemia in Adults: Going after the Common Causes.

Blood ◽

10.1182/blood.v106.11.3769.3769 ◽

2005 ◽

Vol 106 (11) ◽

pp. 3769-3769

Author(s):

Peter McPhedran ◽

Robert B. Hall

Keyword(s):

Vitamin B12 ◽

Blood Smear ◽

Binding Capacity ◽

Post Partum ◽

Serum Vitamin ◽

Chronic Inflammatory Disease ◽

Nutritional Deficiencies ◽

Deficiency Anemia ◽

Study Population ◽

Work Up

Abstract Unexplained anemia is a common problem in adult medicine. Traditional approaches to etiologic diagnosis have included testing for “nutritional” deficiencies such as serum vitamin B12, folic acid, iron and iron binding capacity (IBC)(often a house staff approach); performing upper and lower endoscopy (often the Gastroenterologist or the Surgeon); or review of peripheral blood and bone marrow smears and biopsy (the Hematologist). Decision trees starting from MCVs and reticulocyte counts are commonly suggested in Hematology teaching manuals. However none of these approaches are based on knowledge of the most likely causes of anemia in the population to be tested. We hoped to improve on these largely unfounded and unevaluated empiric strategies by determining the actual frequencies of different causes of anemia among non-pregnant adults (20 and older) with initially unexplained anemias (Hb <12 in men, <11 in women) in our hospital, and have done such studies on three occasions in the last 15 years at Yale New Haven Hospital. Patients selected were 1) 202 consecutive adults with anemia new to the hospital laboratory database; 2) 800 consecutive adults treated, or retreated, with iron in the hospital, focussing the analysis on the 200 who were anemic and not just given iron because they were post-operative or post-partum; and 3) 100 consecutive adults having what we would consider “anemia tests” drawn for work up (such as reticulocyte counts, or vitamin B12 assays, etc). Using standard criteria for diagnosis of different causes of anemia, and, mostly, available data, we were able to classify 80–90% of the anemic patients in each study population. From each of these patient groups we were able to draw pie charts showing relative frequencies of different causes of anemia. We recognized a total of 14 causes and groups of causes of anemia (we grouped hemoglobinopathies as one category, for example) in our hospital population. But the four commonest causes were the same in all three studies: anemia of chronic (inflammatory) disease (ACD) (24, 30, and 37%), acute, missed G I bleed (17, 16, and 13%), iron deficiency anemia (IDA)(13, 23, and 16%) and anemia of chronic renal insufficiency (13, 28, and 14%). Popular targets of work up such as B12 and folate deficiency, and hemolytic anemias, together constituted less than 4% of each study population. We therefore propose as initial work up/evaluation of unexplained anemia in adults the following tests: review of the patient’s history for ACD causes; erythocyte sedimentation rate; iron and IBC (and hepcidin when available); stool exam for blood, especially non-occult blood and melena, before considering colonoscopy; ferritin; attention to the probably already available MCV, RDW, and creatinine; and serum erythropoietin (relating its result to Hb and Hct). According to our hospital epidemiologic studies this approach should reveal the causes of anemia in 67–97% of adults. Clues to other specific anemias learned from the patient, such as a history of sickle cell disease, or the technologist’s discovery of many spherocytes on the blood smear should of course be attended to, as priorities. And, although helpful in only two of the four commonest anemias (ACD, IDA), review of a good blood smear is an important cross-check that occasionally yields surprises (Please see BJ Bain, NEJM, 8/4/05).

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High Prevalence of Elderly Anemia Is Seen in a Large Inner City Outpatient Population and Is Predictive of Decreased Overall Survival across All Ethnic Groups

Blood ◽

10.1182/blood.v112.11.3447.3447 ◽

2008 ◽

Vol 112 (11) ◽

pp. 3447-3447

Author(s):

Anthony P Lam ◽

Jordan Golubcow-Teglasi ◽

Krishna Gundabolu ◽

Howard Ratech ◽

K. H. Ramesh ◽

...

Keyword(s):

Bone Marrow ◽

Overall Survival ◽

Inner City ◽

Cox Regression ◽

Complete Blood Count ◽

Bone Marrow Failure ◽

The Elderly ◽

Deficiency Anemia ◽

Laboratory Findings ◽

Abnormal Results

Abstract Recent work has hinted at the prognostic importance of anemia in the elderly and has tried to identify causes. In an effort to further explore this important clinical problem, we decided to determine the prevalence, etiology and prognostic implications of anemia in a large inner city cohort of elderly outpatients. A total of 40,417 individuals ≥65 years of age seen at Montefiore medical system outpatient clinics from January 1st 1997 to May 1st 2008 who underwent a complete blood count within 3 months of the visit were included in the cohort. Using gender specific WHO criteria, we determined 35.3% of men (out of 15,629) and 28.8% of women (out of 24,788) were anemic at the time of their first clinic visit. A follow up of their blood counts showed that ultimately 70.7% of men and 65.4% of women subsequently developed anemia, thus demonstrating a very high incidence in this population. Among anemic patients, 14.2% had microcytosis and 11.2% had macrocytosis. Of all microcytic anemic patients, 57.3% had both ferritin and iron saturation performed and 19.1% of those tested met criteria for iron deficiency anemia. Of all macrocytic anemic patients, 51.7% had folate and 53.2% had B12 levels checked. However, of those tested only 0.6% and 6.8% had folate and B12 deficiency respectively. This percentage of abnormal findings was similar to non-anemics (0.3% and 5.5% respectively). Evaluation for further etiologies of anemia revealed that 10.0% had thrombocytopenia, 13.5% had leukopenia, and 2.0% had neutropenia, raising the possibility of bone marrow failure and myelodysplastic syndrome (MDS) in these patients. Of the 3,471 anemic patients with other cytopenias, only 6.1% had a bone marrow examination (n=213). Subsequent diagnosis of MDS was made in a minority of these patients. A search for other chronic diseases among the anemic group revealed an elevated creatinine in 11.2%, a subsequently elevated TSH in 17.5%, transaminitis in 28.0% and hypoalbuminemia in 21.9%. Of anemic patients who had an ESR and an ANA assay performed, 69.7% and 23.1% had abnormal results respectively. Overall, a possible etiology based on the above laboratory findings was only identified in 61.9% of anemic patients. Of the small number of anemic patients who had every one of the above tests performed (n=662), 12.1% did not have any abnormal results. To determine the functional importance of these findings, Kaplan-Meier curves and multivariate Cox regression analyses were performed to compare survival and mortality in this cohort. Anemic patients had reduced overall survival regardless of ethnicity (Figure 1). Interestingly, among the elderly, minorities appeared to have better survival than Caucasian whites regardless of anemia status. This is likely secondary to selection bias in this age group as minorities have higher mortality rates below age 65. Adjusting for age and gender, the overall hazard ratio (HR) comparing anemic patients with nonanemic patients was 2.15 (p<0.001). Repeating for each ethnicity subgroup resulted in adjusted HRs of 1.93 (p<0.001) in whites, 2.00 (p<0.001) in blacks, and 2.44 (p<0.001) in Hispanics. Multivariate analyses of various lab parameters demonstrated that an elevated RDW (>16.6%) was the strongest predictor of decreased survival in anemic patients with an age/gender/Hb-adjusted HR of 1.73 (p<0.001). (Figure 2) Thrombocytopenia (HR= 1.37, p<0.001), leukocytosis (HR=1.37, p<0.001), neutropenia (HR=1.23, p=0.032) and macrocytosis (HR=1.24, p<0.001) were additional poor prognostic factors, raising the possibility of MDS as an adverse diagnostic subcategory of anemia in the elderly. In conclusion, we determined that anemia is very common among the elderly in the outpatient setting, and the majority of non-anemic patients ≥65 years of age ultimately develop this condition. Folate/B12 screening has minimal diagnostic utility in anemic patients. Anemia is associated with decreased survival in all racial groups, with larger effects in African Americans and Hispanics. An elevated RDW and the presence of other cytopenias are highly predictive of mortality in anemic patients even after controlling for age, gender and hemoglobin. Figure 1 Figure 1. Figure 2 p<0.001 Figure 2. p<0.001

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Unexplained Anemia Is Common in Elderly Patients with Anemia and Is Characterized by a Low Erythropoietin Level

Blood ◽

10.1182/blood.v112.11.3446.3446 ◽

2008 ◽

Vol 112 (11) ◽

pp. 3446-3446

Author(s):

Elizabeth A Price ◽

Renee Mehra ◽

Stanley L. Schrier

Keyword(s):

Elderly Patients ◽

Radiation Treatment ◽

Complete Blood Count ◽

Comprehensive Evaluation ◽

Hematologic Malignancy ◽

Health Care Systems ◽

Hypoxia Inducible Factor ◽

The Elderly ◽

World Health ◽

Deficiency Anemia

Abstract BACKGROUND: Anemia is common in the elderly and associated with substantial morbidity and even mortality. Previous reports suggest that approximately one third of patients ≥65 have an anemia that remains unexplained after hematologic evaluation. The purpose of this study was to evaluate a cohort of elderly patients for underlying causes of anemia with a thorough hematologic evaluation in an attempt to better isolate the “unexplained anemia” group for further study. METHODS: Men and women 65 years and older with anemia as defined by World Health Organization criteria and seen either at Stanford Hospital and Clinics (SHC) or VA Palo Alto Health Care Systems (VAPAHCS) underwent a comprehensive hematologic evaluation to determine the etiology of the anemia. Evaluation included a complete blood count, red cell indices, review of the peripheral smear, and assessments of iron and cobalamin status and renal function, with additional assessment driven by initial clinical findings. RESULTS: 113 patients were enrolled, 77 (68%) at VAPAHCS and 36 (32%) at SHC. Of the 113 patients, 98 (87%) were men, 79 (70%) caucasian, 15 (13%) asian, and 14 (12 %) black. The mean age was 78 years (range 65 to 93), median hemoglobin (Hb) was 11.5 g/dL (range 6.4 to 12.9), mean MCV was 92 femtoliters (fL) (range 73–118), mean absolute reticulocyte count (ARC) in 112 patients was 52 K/uL (range 14.7–157.3), mean reticulocyte production index in 112 patients was 0.68 (range 0.15–1.99) and the median erythropoietin (epo) level in 109 patients was 18.6 mU/mL (range 3.8–700). Ninety-eight of 113 (87%) patients have completed their evaluation for anemia. In these 98, 43 were diagnosed with UA; 15 were judged to have anemia related, at least in part, to hormonal and/or radiation treatment for prostate cancer; 13 patients were diagnosed or strongly suspected to have a hematologic malignancy (including myelodysplastic syndrome); 11 were diagnosed with iron deficiency anemia; 2 each had renal insufficiency alone (defined as an estimated glomerular filtration rate (eGFR) < 30 ml/min/1.73 m2), alpha thalassemia or an associated underlying non-hematologic malignancy; one patient had anemia of chronic inflammation; and the remainder had combined or other disorders. The median Hb in the UA group was 11.9 g/dL (range 10.4–12.8). The median epo level in the UA group was 16.0 mU/mL (range 3.8–43.0), significantly lower than in the non-UA group (23.0 mU/mL, range 5.4–700.0; p = 0.0010). The median eGFR in the UA group was 74.5 compared to 66.5 in the non-UA group (NS). In those with UA with an eGFR between 30 and 60, the median Hb was 11.5 g/dL (range 10.4–12.6) and the median epo level was 16.3 mU/mL (range 3.8–40.7). This was similar to those in the UA group with an eGFR ≥ 60, who had a median Hb of 11.9 g/dL (range 10.7–12.8, NS) and a median epo level of 16.0 mU/mL (5.7–43.0; NS). DISCUSSION: Despite a comprehensive evaluation for anemia, 44% of anemic elderly patients were found to have unexplained anemia. Those with unexplained anemia had a normocytic, hypoproliferative anemia with normal to low epo levels, regardless of whether the eGFR was below or above 60. We hypothesize that these patients with UA who have distinctly lower epo levels may have age-dependent impairment in the hypoxia-inducible-factor oxygen sensing mechanisms.

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Senior Labor Study: A New Definition Of Normal Hemoglobin Values In Older Healthy Individuals

Blood ◽

10.1182/blood.v122.21.956.956 ◽

2013 ◽

Vol 122 (21) ◽

pp. 956-956

Author(s):

Lorenz Risch ◽

Corina Risch ◽

Pedro Medina ◽

Urs Nydegger ◽

Martin Risch ◽

...

Keyword(s):

Folic Acid ◽

Vitamin B12 ◽

Clinical Laboratory ◽

Complete Blood Count ◽

Age Groups ◽

The Elderly ◽

Exclusion Criteria ◽

B12 Deficiency ◽

Older Subjects ◽

Definition Of

Abstract With increasing mean age of the world population it becomes clear that biological and chronological ages might diverge on individual levels. In contrast to working age adults, older people have a higher incidence of anemia mostly in association with medical comorbidities (Artz, Fergusson et al. 2004, Merchant and Roy 2012). Incidence of anemia in the elderly has so far been investigated in large studies mostly performed on hospitalized patients, nursing homes subjects or mobile examination centers subjects seeking medical care with a variety of complaints (Kikuchi, Inagaki et al. 2001, Guralnik, Eisenstaedt et al. 2004). In the USA, the 3rd NHANES study focused on racial groups of elderly revealing a prevalence of anemia in men and women >65 yrs of ∼10% (Izaks, Westendorp et al. 1999, Guralnik, Ershler et al. 2005). In patients over 85 yrs, this number exceeded 20%. Current reference intervals for clinical laboratory assays are based on younger adult's samples. Physiologic concentrations of hemoglobin (Hb) in human blood range from 120 g/l (female) and 130 g/l (male) to 168 g/l (both genders) under which anemia and above which polycythemia get diagnosed. We are currently in need for reference ranges suited for normal older subject and unbiased by already debilitated individuals. The defining cut-offs provided by the WHO are 120 g/l for women and 130 g/l for men (WHO Technical Report Series 1968); although older age is generally associated with lower Hb levels, these cut-offs do not account for age. We have performed a large recruitment as part of our Senior Labor study (Risch, Medina et al. 2012). In contrast to previous studies, we have prospectively recruited healthy Caucasian subjects over 60, implementing strong exclusion criteria for participating subjects. For those healthy individuals, a complete blood count (CBC) as well as frequently performed clinical laboratory tests were prospectively performed. A total of 1255 subjects consented to enroll for the study after having passed the primary clinical exclusion criteria which comprised one or more of the following questions affirmatively answered (primary exclusion criteria): drugs: do you take drugs containing steroids, are you under ill-adjusted antihypertensive therapy, do you suffer from thyroid diseases/are you substituted with thyroid hormones, do you have diabetes mellitus, have you suffered from cancer during the last 5 years, were you hospitalized during the month prior to enrolment and do you abuse alcohol. Complete blood count assays were done using an XE-5000 hematology analyzer and clinical chemistry assays followed routine workflow on modular platforms. We evaluated 696 women and 559 with ages ranging from 60 to 99 years old. Mean Hb and 95% confidence intervals were calculated using logarithmic transformation in order to correct of skewness of the data. Overall, women had a mean Hb of 136 (95%CI 120-155) and men had a mean Hb of 148 (95%CI 128-172). Detailed results by age groups are presented in figure 1. Hb level was steady over age groups until 74 yo for men and 79 for women. Interestingly, only a few subjects fell outside the WHO limits with 20 women having a Hb less than 120 (2.9%) and 20 men a Hb less than 130 (3.6%). We looked for frequent causes for anemia such as low ferritin and vitamin deficiencies (folic acid and B12). In the cohort, 37 subjects had a ferritin lower than 20 µg/l (2.9%). Among these, 9/37 (24.3%) had a low Hb (WHO definition) and only one in 37 (2.7%) had a MCHC below 310. The micronutrients folic acid and vitamin B12 were also assessed; 98 subjects (7.8%) had folic acid < 10 nmol/l. Among these individuals, 6/98 (6.1%) were anemic. The definition of vitamin B12 deficiency varies but is usually accepted as lower than 200 pmol/l in older persons: in the whole population, 398/1255 (31.7%) subjects had vitamin B12 levels < 200 pmol/L, and 105/1255 (8.4%) had vitamin B12 concentrations less than 150 pmol/L. Using these two limits, these subjects were anemic in 11/398 (2.8%) and 4/105 (3.8%) respectively. This indicates a limited impact of folic acid and B12 deficiency on anemia of the elderly. In this study, we were able to define new Hb reference range in older subjects reporting healthy by strict clinical criteria in a large cohort of subjects. Our results show a very limited proportion of subject with WHO defined anemia, thus indicating that even in older subjects, the discovery of a low Hb is likely to be associated to an underlying pathology. Disclosures: No relevant conflicts of interest to declare.

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