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/100 ml and in women as hemoglobin of less than 12.0 gram/100 ml. 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 caused by either: 1. 2. a decrease in production of red blood cells or hemoglobin, or an increase in loss or destruction of red blood cells.

A more common classification of anemia (low hemoglobin) is based on the Mean Corposcular Volume (MCV) which signifies the average volume of individual red blood cells. 1. If the MCV is low (less than 80), the anemia is categorized as microcytic anemia (low cell volume). 2. If the MCV is in the normal range (80-100), it is called a normocytic anemia (normal cell volume). 3. If the MCV is high, then it is called a macrocytic anemia (large cell volume).

Looking at each of the components of a complete blood count (CBC), especially the MCV, a physician can gather clues as to what could be the most common reason for anemia in each patient.

Can inadequate iron cause anemia?

Absolutely! As a matter of fact, iron deficiency is a very common cause of anemia. 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 bodys iron stores to compensate for the ongoing loss of iron. Anemia that is due to low iron levels is called iron deficiency anemia. Young women are likely to have low grade 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.

Another common reason for iron deficiency anemia can be due to recurring or small ongoing bleeding, for instance from colon cancer or from stomach ulcers. Stomach ulcer bleeding may be induced by medications, even very common over-the-counter drugs such as aspirin and ibuprofen (Advil, Motrin). Slow and chronic oozing from these ulcers can lead to loss of iron. Gradually, this could result in anemia. 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. Dizziness, lightheadedness, fatigue, confusion, shortness of breath, and even loss of consciousness can occur with severe, sudden blood loss anemia. 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. o Strict vegetarians are at risk if they do not take adequate vitamin supplements. o Long-term alcoholics. o People who have abnormal structure or function of the stomach or intestines leading to impaired B12 absorption despite adequate intake.

This typically causes macrocytic (large blood cell volume) anemia. Vitamin B12, along with folate, is involved in making the heme molecule that is an integral part of hemoglobin. Folate deficiency can be the culprit of anemia as well. 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 or destruction of red blood cells (hemolytic anemia) due to antibodies clinging to the surface of the red cells. Examples of hemolytic anemia include hemolytic disease of the newborn, medication induced hemolytic anemia, transfusion related hemolysis, and autoimmune hemolytic anemia. A wide assortment of bone marrow diseases can cause anemia. o 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. o Certain chemotherapy for cancers can also cause damage to the bone marrow and decrease red blood cell production, resulting in anemia. o 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. o Chronic alcohol consumption may lead to anemia via different pathways and thus, anemia is commonly seen in alcoholics. Another common cause of anemia is called anemia of chronic disease. This could typically occur in individuals with longstanding 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 types and causes of anemia?

Anemia happens when: 1. The body loses too much blood (such as with heavy periods, certain diseases, and trauma); or 2. 3. or 4. The body has problems making red blood cells; or Red blood cells break down or die faster than the body can replace them with new ones;

More than one of these problems happen at the same time.

There are many types of anemia, all with different causes:

Iron deficiency anemia (IDA). IDA is the most common type of anemia. IDA happens when you dont have enough iron in your body. You need iron to make hemoglobin. People with this type of anemia are sometimes said to have iron-poor blood or tired blood.

A person can have a low iron level because of blood loss. In women, iron and red blood cells are lost when bleeding occurs from very heavy and long periods, as well as from childbirth. Women also can lose iron and red blood cells from uterine fibroids, which can bleed slowly. Other ways iron and red blood cells can be lost include:
o o

Ulcers, colon polyps, or colon cancer Regular use of aspirin and other drugs for pain

o o o

Infections Severe injury Surgery

Eating foods low in iron also can cause IDA. Meat, poultry, fish, eggs, dairy products, or ironfortified foods are the best sources of iron found in food. Pregnancy can cause IDA if a woman doesnt consume enough iron for both her and her unborn baby. Some people have enough iron in their diet, but have problems absorbing it because of diseases, such as Crohns disease and Celiac disease, or drugs they are taking.

Vitamin deficiency anemia (or megaloblastic [MEG-uh-loh-BLASS-tik] anemia). Low levels of vitamin B12 or folate are the most common causes of this type of anemia.

Vitamin B12 deficiency anemia (or pernicious [pur-NISH-us] anemia). This type of anemia happens due to a lack of vitamin B12 in the body. Your body needs vitamin B12 to make red blood cells and to keep your nervous system working normally. This type of anemia occurs most often in people whose bodies are not able to absorb vitamin B12 from food because of an autoimmune disorder. It also can happen because of intestinal problems. You also can get this type of anemia if the foods you eat dont have enough vitamin B12. Vitamin B12 is found in foods that come from animals. Fortified breakfast cereals also have vitamin B12. Folic acid supplements (pills) can treat this type of anemia. But, folic acid cannot treat nerve damage caused by a lack of vitamin B12. With this type of anemia, your doctor may not realize that youre not getting enough vitamin B12. Not getting enough vitamin B12 can cause numbness in your legs and feet, problems walking, memory loss, and problems seeing. The treatment depends on the cause. But you may need to get vitamin B12 shots or take special vitamin B12 pills. Folate deficiency anemia. Folate, also called folic acid, is also needed to make red blood cells. This type of anemia can occur if you dont consume enough folate or if you have problems absorbing vitamins. It also may occur during the third trimester of pregnancy, when your body needs extra folate. Folate is a B vitamin found in foods such as leafy green vegetables, fruits, and dried beans and peas. Folic acid is found in fortified breads, pastas, and cereals.

Anemias caused by underlying diseases. Some diseases can hurt the bodys ability to make red blood cells. For example, anemia is common in people with kidney disease. Their kidneys cant make enough of the hormones that signal the body to make red blood cells. Plus, iron is lost in dialysis (what some people with kidney disease must have to take out waste from the blood). Anemias caused by inherited blood disease. If you have a blood disease in your family, you are at greater risk to also have this disease. Here are some types:

Sickle cell anemia. The red blood cells of people with sickle cell disease are hard and have a curved edge. These cells can get stuck in the small blood vessels, blocking the flow of blood to the organs and limbs. The body destroys sickle red cells quickly. But, it cant make new red blood cells fast enough. These factors cause anemia.

Thalassemia (thal-uh-SEE-mee-uh). People with thalassemia make less hemoglobin and fewer red blood cells than normal. This leads to mild or severe anemia. One severe form of this condition is Cooleys anemia. Aplastic (ay-PLAS-tik) anemia. This is a rare blood disorder in which the body stops making enough new blood cells. All blood cells red cells, white cells, and platelets are affected. Low levels of red blood cells leads to anemia. With low levels of white blood cells, the body is less able to fight infections. With too few platelets, the blood cant clot normally. This can be caused by many things:
o o o o o o

Cancer treatments (radiation or chemotherapy) Exposure to toxic chemicals (like those used in some insecticides, paint, and household cleaners) Some drugs (like those that treat rheumatoid arthritis) Autoimmune diseases (like lupus) Viral infections Family diseases passed on by genes, such as Fanconi anemia

What are the signs of anemia?

Anemia takes some time to develop. In the beginning, you may not have any signs or they may be mild. But as it gets worse, you may have these symptoms:

Fatigue (very common) Weakness (very common) Dizziness Headache Numbness or coldness in your hands and feet Low body temperature Pale skin Rapid or irregular heartbeat Shortness of breath Chest pain Irritability Not doing well at work or in school

All of these signs and symptoms can occur because your heart has to work harder to pump more oxygen-rich blood through the body. Additional symptoms may include:

Hair loss Malaise (general sense of feeling unwell) 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. A CBC test may be ordered by a physician as a part of routine general checkup 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? 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: 1. 2. 3. 4. 5. 6. 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 physicians 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 RBCs in microliters (one one-thousandth of an ml) of whole blood. The shape of the RBCs 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 gram/100 ml is abnormal in men and less than 12.0 gram/100 ml 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 red blood cells 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 red blood cells is then measured. Lets 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 will happen if my anemia goes untreated?

Some types of anemia may be life threatening if not diagnosed and treated. Too little oxygen in the body can damage organs. With anemia, the heart must work harder to make up for the lack of red blood cells or hemoglobin. This extra work can harm the heart and even lead to heart failure.

How do I prevent anemia?

There are steps you can take to help prevent some types of anemia.

Eat foods high in iron: o Cereal/breads with iron in it (100% iron-fortified is best. Check food label.) o Liver o Lentils and beans o Oysters o Tofu o Green, leafy vegetables such as spinach o Red meat (lean only) o Fish o Dried fruits such as apricots, prunes, and raisins Eat and drink foods that help your body absorb iron, like orange juice, strawberries, broccoli, or other fruits and vegetables with vitamin C. Dont drink coffee or tea with meals. These drinks make it harder for your body to absorb iron. Calcium can hurt your absorption of iron. If you have a hard time getting enough iron, talk to your doctor about the best way to also get enough calcium. Make sure you consume enough folic acid and vitamin B12. Make balanced food choices. Most people who make healthy, balanced food choices get the iron and vitamins their bodies need from the foods they eat. Food fads and dieting can lead to anemia. Talk to your doctor about taking iron pills (supplements). Do not take these pills without talking to your doctor first. These pills come in two forms: ferrous and ferric. The ferrous form is better absorbed by your body. But taking iron pills can cause side

effects, like nausea, vomiting, constipation, and diarrhea. Reduce these side effects by taking these steps: o Start with half of the recommended dose. Gradually increase to the full dose. o Take the pill in divided doses. For example, if you are prescribed two pills daily, take one in morning with breakfast and the other after dinner. o Take the pill with food. o If one type of iron pill is causing problems, ask your doctor for another brand. It is important to keep iron pills tightly capped and away from childrens reach. In children, death has occurred from ingesting 200 mg of iron.

If you are a non-pregnant woman of childbearing age, get tested for anemia every five to 10 years. This can be done during a regular health exam. Testing should start in adolescence. If you are a non-pregnant woman of childbearing age with these risk factors for iron deficiency, get tested every year: o Heavy periods o Low iron intake o Have been diagnosed with anemia in the past Follow your doctors orders for treating the underlying cause of your anemia. This will prevent the anemia from coming back or becoming serious.

How much iron do I need every day?

Most people get enough iron by making healthy, balanced food choices and eating iron-rich foods. But some groups of people are at greater risk for low iron levels:

Teenage girls/women of childbearing age (who have heavy bleeding during their period, who have had more than one child, or use an intrauterine device [IUD]) Older infants and toddlers (mainly those who drink a lot of milk or are having a growth spurt) Pregnant women (about half of pregnant women have iron-deficiency anemia) Female athletes who engage in regular, intense exercise

These groups of people should be screened at times for iron deficiency. If the tests show that the body isnt getting enough iron, iron pills (supplements) may be prescribed. In extreme cases of iron deficiency, your doctor might prescribe iron shots. Many doctors prescribe iron pills during pregnancy because many pregnant women dont get enough iron. Iron pills can help when diet alone cant restore the iron level back to normal. Talk with your doctor to find out if you are getting enough iron through the foods you eat or if you or your child needs to be taking iron pills. Please see the chart below to see how many milligrams (mg) of iron you should consume every day.

How much iron do I need if I am pregnant?

Pregnant women need to consume twice as much iron as women who are not pregnant. But about half of all pregnant women do not get enough iron. During pregnancy, your body needs more iron because of the growing fetus, the higher volume of blood, and blood loss during delivery. If a pregnant woman does not get enough iron for herself or her growing baby, she

has an increased chance of having preterm birth and a low-birth-weight baby. If youre pregnant, follow these tips:

Make sure you get 27mg of iron every day. Take an iron supplement (pill). It may be part of your prenatal vitamin. Start taking it at your first prenatal visit. Get tested for anemia at your first prenatal visit. Ask if you need to be tested for anemia 4 to 6 weeks after delivery.

I am taking menopausal hormone therapy (MHT). Does that affect how much iron I should take?
It might. If you are still getting your period while taking MHT, you may need more iron than women who are postmenopausal and not taking MHT. Talk to your doctor.

Does birth control affect my risk for anemia?

It could. Some women who take birth control pills have less bleeding during their periods. This would lower their risk for anemia. But women who use an intrauterine device (IUD) may have more bleeding and increase their chances of getting anemia. Talk to your doctor.

What happens if my body gets more iron than it needs?

Iron overload happens when too much iron builds up in the body over time. This condition is called hemochromatosis (HEE-moh-kroh-muh-TOH-suhss). The extra iron can damage the organs, mainly the liver, heart, and pancreas. Many problems can cause iron overload. Most people with hemochromatosis inherit it from their parents. It is one of the most common genetic (runs in families) diseases in the United States. Some other diseases also can lead to iron overload. It also can happen from years of taking too much iron or from repeated blood transfusions or dialysis for kidney disease. Signs of early hemochromatosis may include:

Fatigue Weakness Weight loss Abdominal pain Joint pain Fluttering in chest

As iron builds up in the body, common symptoms include:

Arthritis Missed periods Early menopause Loss of sex drive Impotence (repeated inability to get or keep an erection firm enough for sexual intercourse) Heart problems like shortness of breath, chest pain, and changes in rate or rhythm

Signs of advanced hemochromatosis include:

Arthritis Liver disease, including an enlarged liver, cirrhosis, cancer, and liver failure Damage to the pancreas, possibly causing diabetes Chronic (ongoing) abdominal pain Severe fatigue Weakening of the heart muscle Heart failure Changes in skin color, making it look gray, yellow or bronze (not caused by sun)

Treatment depends on how severe the iron overload is. The first step is to get rid of the extra iron in the body. Most people undergo a process called phlebotomy (fluh-BOT-uh-mee), which means removing blood. It is simple and safe. A pint of blood will be taken once or twice a week for several months to a year, and sometimes longer. Once iron levels go back to normal, you will give a pint of blood every 2 to 4 months for life. People who cannot give blood can take medicine to remove extra iron. This is called iron chelation (kuh-LAY-shuhn) therapy. Although treatment cannot cure the problems caused by hemochromatosis, it will help most of them. Arthritis is the only problem that does not improve after excess iron is removed.

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 the hemoglobin level is too low, this process may be impaired, resulting in low levels of oxygen in the body (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.

anemia