ANEMIA

What is anemia?

Anemia is a medical condition in which the red blood cell count or hemoglobin is less than
normal. The normal level of hemoglobin is generally different in males and females. For men,
anemia is typically defined as hemoglobin level of less than 13.5 gram/100ml and in women as
hemoglobin of less than 12.0 gram/100ml. These definitions may vary slightly depending on the
source and the laboratory reference used.

What causes anemia?

Any process that can disrupt the normal life span of a red blood cell may cause anemia. Normal
life span of a red blood cell is typically around 120 days. Red blood cells are made in the bone
marrow.

Anemia is caused essentially through two basic pathways. Anemia is either caused:

by a decrease in production of red blood cell or hemoglobin, or

by a loss or destruction of blood.

As more common classifications of anemia (low hemoglobin) is based on the MCV, or the
volume of individual red blood cells.

If the MCV is low (less than 80), the anemia is categorized as microcytic anemia (low cell
volume).

If the MCV is in the normal range (80-100), it is called a normocytic anemia (normal cell
volume).

If the MCV is high, then it is called a macrocytic anemia (large cell volume).

Can not enough iron cause anemia?

Absolutely! This is because iron is major component of hemoglobin and essential for its proper
function. Chronic blood loss due to any reason is the main cause of low iron level in the body as
it depletes the body's iron stores to compensate for the ongoing loss of iron. Anemia that is due
to low iron levels is called iron deficiency anemia. Iron deficiency it is a very common cause of
anemia.
Women are more likely than men to have iron deficiency anemia because of the loss of blood
each month through normal menstruation. This is generally without any major symptoms as the
blood loss is relatively small and temporary.

Iron deficiency anemia can also be due to small repeated l bleeding, for instance from colon
cancer or from stomach ulcers. Stomach ulcer bleeding that may or may no be induced by
medications even very common over-the-counter drugs as aspirin and ibuprofen (Advil, Motrin).
In infants and young children, iron deficiency anemia is most often due to a diet lacking iron.

Interpretation of CBC may lead to clues to suggest this type of anemia. For instance, iron
deficiency anemia usually presents with low mean corpuscular volume (microcytic anemia) in
addition to low hemoglobin.

What about acute (sudden) blood loss as a cause of anemia?

Acute blood loss from internal bleeding (as from a bleeding ulcer) or external bleeding (as from
trauma) can produce anemia in an amazingly short span of time. This type of anemia could
result in severe symptoms and consequences if not addressed promptly.

What are other causes of anemia?

Some of the most common causes include:

Vitamin B12 deficiency may cause pernicious anemia. This type of anemia could happen in
people who are unable to absorb vitamin B12 from their intestines due to a number of reasons:

strict vegetarians who may not be taking adequate vitamin supplements, or

long-term alcoholics.

This typically causes macrocytic (large cell volume) anemia. Vitamin B12, along with folate, is a
involved in making the heme molecule that is an integral part of hemoglobin. Folate deficiency
can be the culprit of anemia. This may also be caused by inadequate absorption, under-
consumption of green, leafy vegetables, and also long-term heavy alcohol use.

There can be rupture of red blood cells (hemolytic anemia) due to antibodies clinging to the
surface of the red cells (for example, hemolytic disease of the newborn and in many other
conditions).

A wide assortment of bone marrow diseases can cause anemia.

For example, cancers that spread (metastasize) to the bone marrow, or cancers of the bone
marrow (such as leukemia or multiple myeloma) can cause the bone marrow to inadequately
produce red blood cells, resulting in anemia.

Certain chemotherapy for cancers can also cause damage to the bone marrow and decrease red
blood cell production, resulting in anemia.

Certain infections may involve the bone marrow and result in bone marrow impairment and
anemia.

Finally, patients with kidney failure may lack the hormone necessary to stimulate normal red
blood cell production by the bone marrow.

Another common cause of anemia is called anemia of chronic disease. This could typically occur
in individuals with long-standing chronic diseases.

Some medications can cause anemia in a variety of ways.

Human immunodeficiency virus (HIV) and acquired immune deficiency syndrome (AIDS) can
cause anemia.

Can anemia be hereditary?

Yes, anemia may be genetic. Hereditary disorders can shorten the life-span of the red blood cell
and lead to anemia (for example, sickle cell anemia). Hereditary disorders can also cause
anemia by impairing the production of hemoglobin (for example, alpha thalassemia and beta
thalassemia).

Depending on the degree of the genetic abnormality, hereditary anemias may cause mild,
moderate, or severe anemia. In fact, some may be too severe to be compatible with life and
may result in death of the fetus (unborn infant). On the other hand, some of these anemias are
so mild that they are not noticeable and are incidentally revealed during a routine blood work.

What are the symptoms of anemia?

Some patients with anemia have no symptoms. Others with anemia may feel:

tired,

fatigue easily,

appear pale,
develop palpitations (feeling of heart racing), and

become short of breath.

Additional symptoms may include:

hair loss,

malaise (general sense of feeling unwell), and

worsening of heart problems.

It is worth noting that if anemia is longstanding (chronic anemia), the body may adjust to low
oxygen levels and the individual may not feel different unless the anemia becomes severe. On
the other hand, if the anemia occurs rapidly (acute anemia), the patient may experience
significant symptoms relatively quickly.

How is anemia diagnosed?

Anemia is usually detected or at least confirmed by a complete blood cell (CBC) count. CBC test
may be ordered by a physician as a part of routine general check-up and screening or based on
clinical signs and symptoms that may suggest anemia or other blood abnormalities.

What is a complete blood cell (CBC) count?

A CBC is a test for counting and examining the different types of cells in the blood. Traditionally,
CBC analysis was performed by a physician or a laboratory technician by viewing a glass slide
prepared from a blood sample under a microscope. Today, much of this work is often
automated and done by machines. Six component measurements make up a CBC test:

Red blood cell (RBC) count

Hematocrit

Hemoglobin

White blood cell (WBC) count

Differential blood count (the "diff")

Platelet count

Only the first three of these tests: the red blood cell (RBC) count, the hematocrit, and the
hemoglobin, are relevant to the diagnosis of anemia.
Additionally, mean corpuscular volume (MCV) is also often reported in a CBC, which basically
measures the average volume of red blood cells in a blood sample. This is important in
distinguishing the causes of anemia. Units of MCV are reported in femtoliters, a fraction of one
millionth of a liter.

Other useful clues to causes of anemia that are reported in a CBC are the size, shape, and color
of red blood cells.

How is blood collected for a CBC?

Blood is collected by venipuncture (using a needle to draw blood from a vein) in a lab, hospital,
or physician's office. Typically, blood is collected in a special sterile tube from an arm vein. The
tube has some preservatives to prevent clotting of the blood. Results may be available in an
hour or longer depending on the setting.

In some instances, a quick in office test called hemoglobin rapid test may be performed using a
few drops of blood from a finger prick. The advantage of this quick test is that results may be
obtained in a few minutes and only a few drops of blood may be required.

What is the red blood cell (RBC) count?

The red blood cells (RBCs or erythrocytes) are the most common type of cells in the blood. We
each have millions and millions of these little disc-shaped cells. The RBC count is done to
determine if the number of red blood cells is low (anemia) or high (polycythemia).

In an RBC count, the number and size of the RBCs are determined. This is usually reported as
number of RBCs per a specified volume, typically in millions of RBC's in micro-liters (one one-
thousandth of an ml) of whole blood. The shape of the red blood cells is also evaluated under a
microscope. All of this information, the number, size and shape of the RBCs, is useful in the
diagnosis of anemia. Further, the specific type of anemia may be determined by this
information.

What is hemoglobin?

Hemoglobin is a red pigment that imparts the familiar red color to red blood cells and to blood.
Functionally, hemoglobin is the key chemical compound that combines with oxygen from the
lungs and carries the oxygen from the lungs to cells throughout the body. Oxygen is essential for
all cells in the body to produce energy.

The blood also transports carbon dioxide, which is the waste product of this energy production
process, back to the lungs from which it is exhaled into the air. The transport of the carbon
dioxide back to the lung is also achieved by hemoglobin. The carbon dioxide bound to
hemoglobin is unloaded in the lungs in exchange for oxygen to be transported to the tissues of
the body.

What does a low hemoglobin level mean?

Low hemoglobin is called anemia. When there is a low hemoglobin level, there is often a low red
blood cell count and a low hematocrit, too. Reference ranges are slightly different from one
source to another, but typically hemoglobin of less than 13.5 is abnormal in men less than 12.0
in women.

What is the hematocrit?

The hematocrit is specifically a measure of how much of the blood is made of red cells. The
hematocrit is a very convenient way to determine whether the red blood cell count is too high,
too low, or normal. The hematocrit is a measure of the proportion of blood that is composed of
the red blood cells.

How is hematocrit determined?

The RBCs in the sample of blood are packed down by spinning the tube in a centrifuge under
prescribed conditions. The proportion of the tube that consists of RBCs is then measured. Let's
say that it is 45%. The hematocrit is 45.

How is anemia treated?

The treatment of the anemia varies greatly. First, the underlying cause of the anemia should be
identified and corrected. For example, anemia as a result of blood loss from a stomach ulcer
should begin with medications to heal the ulcer. Likewise, surgery is often necessary to remove
a colon cancer that is causing chronic blood loss and anemia.

Sometimes iron supplements will also be needed to correct iron deficiency. In severe anemia,
blood transfusions may be necessary. Vitamin B12 injections will be necessary for patients
suffering from pernicious anemia or other causes of B12 deficiency.

In certain patients with bone marrow disease (or bone marrow damage from chemotherapy) or
patients with kidney failure, epoetin alfa (Procrit, Epogen) may be used to stimulate bone
marrow red blood cell production.

If a medication is thought to be the culprit, then it should be discontinued under the direction of
the prescribing doctor.
What are the complications of anemia?

As mentioned earlier, hemoglobin has the important role of delivering oxygen to all parts of the
body for consumption and carries back carbon dioxide back to the lung to exhale it out of the
body. If hemoglobin level is too low, this process may be impaired, resulting in body having low
oxygen level (hypoxia).

What is the outlook (prognosis) for anemia?

Anemia generally has a very good prognosis and it may be curable in many instances. The
overall prognosis depends on the underlying cause of anemia, its severity, and the overall health
of the patient.