Abnormal erythropoiesis and the pathophysiology of chronic anemia

Erythropoiesis, the bone marrow production of erythrocytes by the proliferation and differentiation of hematopoietic cells, replaces the daily loss of 1% of circulating erythrocytes that are senescent. This daily output increases dramatically with hemolysis or hemorrhage. When erythrocyte production rate of erythrocytes is less than the rate of loss, chronic anemia develops. Normal erythropoiesis and specific abnormalities of erythropoiesis that cause chronic anemia are considered during three periods of differentiation: a) multilineage and pre-erythropoietin-dependent hematopoietic progenitors, b) erythropoietin-dependent progenitor cells, and c) terminally differentiating erythroblasts. These erythropoietic abnormalities are discussed in terms of their pathophysiological effects on the bone marrow cells and the resultant changes that can be detected in the peripheral blood using a clinical laboratory test, the complete blood count.     

Congenital dyserythropoietic anemia type I

Summary A new case of congenital dyserythropoietic anemia type I is reported in a 12-year-old Spanish boy. In regard to the morphological study at an optical and ultrastructural level, the most outstanding feature was the internuclear bridging connecting two erythroblastic nuclei within a single cytoplasm or stretched between two erythroblasts perfectly individualized.     

A guide to diagnosis of iron deficiency and iron deficiency anemia in digestive diseases

Iron deficiency （ID）, with or without anemia, is often caused by digestive diseases and should always be investigated, except in very specific situations, as its causes could be serious diseases, such as cancer. Diagnosis of ID is not always easy. Low serum levels of ferritin or transferrin saturation, imply a situation of absolute or functional ID. It is sometimes difficult to differentiate ID anemia from anemia of chronic diseases, which can coexist. In this case, other parameters, such as soluble transferrin receptor activity can be very useful. After an initial evaluation by clinical history, urine analysis, and serological tests for celiac disease, gastroscopy and colonoscopy are the key diagnostic tools for investigating the origin of ID, and will detect the most important and prevalent diseases. If both tests are normal and anemia is not severe, treatment with oral iron can be indicated, along with stopping any treatment with non-steroidal anti-inflammatory drugs. In the absence of response to oral iron, or if the anemia is severe or clinical suspicion of important disease persists, we must insist on diagnostic evaluation. Repeat endoscopic studies should be considered in many cases and if both still show normal results, investigating the small bowel must be considered. The main techniques in this case are capsule endoscopy, followed by     

四种常见贫血患者红细胞寿命的研究

目的:研究自身免疫性溶血性贫血(AIHA)患者的红细胞寿命,并与常见贫血患者的红细胞寿命比较。方法:回顾性分析AIHA、骨髓增生异常综合征(MDS)、重型再生障碍性贫血(SAA)和缺铁性贫血(IDA) 4组共55例患者的临床资料,以同期12例健康志愿者为正常对照组。采用一氧化碳(CO)呼气法测定红细胞寿命,比较4种贫血患者和健康志愿者红细胞寿命并作分析。结果:AIHA患者红细胞寿命为(30.41±31.12)d,比MDS(53.44±32.61)d、SAA(54.53±22.56)d和IDA(58.75±31.29)d患者的红细胞寿命均缩短(P0.05),4组患者红细胞寿命均较12例健康志愿者红细胞寿命(118.16±25.88)d显著缩短(P0.01)。结论:红细胞寿命缩短参与了AIHA、MDS、SAA和IDA患者贫血的发生,但在不同贫血疾病中所起作用程度不尽相同。     

Pancytopenia,including macrocytic anemia,associated with leflunomide in a rheumatoid arthritis patient

A female rheumatoid arthritis patient was admitted for productive cough and general fatigue that had gradually developed after leflunomide therapy. Side effects including severe hypoxia, thrombocytopenia, lymphocytopenia, and macrocytic anemia with schistocytes (probably drug-induced megaloblastic anemia) were noted. Leflunomide-eliminating cholestyramine therapy successfully treated all conditions excluding severe hypoxia, which occurred owing to deteriorating interstitial pneumonia and complicated bacterial pneumonia following antibiotic treatment. This is a rare case of leflunomide-associated multiple hematopoietic impairments.     

Pancytopenia,including macrocytic anemia,associated with leflunomide in a rheumatoid arthritis patient

Abstract

A female rheumatoid arthritis patient was admitted for productive cough and general fatigue that had gradually developed after leflunomide therapy. Side effects including severe hypoxia, thrombocytopenia, lymphocytopenia, and macrocytic anemia with schistocytes (probably drug-induced megaloblastic anemia) were noted. Leflunomide-eliminating cholestyramine therapy successfully treated all conditions excluding severe hypoxia, which occurred owing to deteriorating interstitial pneumonia and complicated bacterial pneumonia following antibiotic treatment. This is a rare case of leflunomide-associated multiple hematopoietic impairments.     

铁代谢指标测定对慢性病贫血并发缺铁的诊断意义

目的 :了解血清铁蛋白 (SF)、转铁蛋白饱和度 (TS)、血清转铁蛋白受体 (sTFR)及sTFR/log(SF)等外周血铁代谢指标对缺铁性贫血 (IDA)、慢性病贫血 (ACD)和慢性病贫血并发缺铁 (ACD/ID)的鉴别诊断意义。方法 :病例为IDA患者 18例 ,ACD患者 2 0例 ,其中 10例为ACD/ID患者。SF测定采用微粒酶免疫法 ,TS测定采用化学发光法 ,sTFR测定采用双夹心抗体酶联免疫吸附法。结果 :IDA患者的SF值、TS值显著低于ACD患者 ,其sTFR、sTFR/log(SF)值显著高于ACD患者。ACD患者中 ,ACD/ID患者与无缺铁的ACD(ACD/IR)患者间SF值无显著差别 ;但ACD/ID患者的TS值明显低于ACD/IR患者 ,而sTFR和sTFR/log(SF)值则显著高于ACD/IR患者。TS<4 0 %对ACD/ID检出的敏感性为 10 0 % ,特异性为 6 7% ;sTFR >30nmol/L对ACD/ID检出的敏感性为 90 % ,特异性为 82 % ;sTFR/log(SF) >2 0对ACD/ID检出的敏感性和特异性均为 90 %。结论 :新的铁代谢指标sTFR ,尤其是sTFR/log(SF)是传统铁代谢指标的必要补充 ,联合应用上述铁代谢指标可对ACD、IDA和ACD/ID患者进行准确的鉴别诊断。     

Causes of iron deficiency anemia in an adult inpatient population

Summary The causes of iron deficiency anemia in a population of adults admitted to two Jerusalem hospitals within a period of 7 years were examined. About one half of the 262 patients with iron deficiency anemia were over 70 years old. The ratio of males to females exclusive of young females with menorrhagia was 1:1.8. Despite the combined use of various diagnostic procedures, no definite cause of iron deficiency anemia could be established in 34% of patients. Benign gastrointestinal lesions were found in about one half of the cases in both hospitals. The prevalence of GI neoplasms in hospital B with a more intensive use of endoscopic procedures was significantly higher than in hospital A (18% vs 5%, p<0.001). The relative usefulness of barium contrast vs endoscopic studies is illustrated by the fact that 22 diagnoses established by endoscopy were missed by barium studies, whereas only 2 of those established by barium studies were not visualized by endoscopy. A particularly high risk group were anemic males aged 50 to 69 years in whom the prevalence of GI neoplasms was 30%. These data indicate that reliance on traditional contrast radioscopy may result in misdiagnosis of a high proportion of gastrointestinal neoplasms.     

Individualized treatment for iron-deficiency anemia in adults

Iron deficiency is one of the most common disorders affecting humans, and iron-deficiency anemia continues to represent a major public health problem worldwide. It is especially common among women of childbearing age because of pregnancy and menstrual blood loss. Additional patient groups include those with other sources of blood loss, malnutrition, or gut malabsorption. Iron-deficiency anemia remains prevalent despite the widespread ability to diagnose the disease and availability of medicinal iron preparations. Therefore, new approaches are needed to effectively manage these patient populations. In this review, the diagnosis and treatment of iron-deficiency anemia are discussed with emphasis placed on consideration of patient-specific features. It is proposed that all patients participate in their own care by helping their physician to identify a tolerable daily iron dose, formulation, and schedule. Dosing cycles are recommended for iron replacement based on the tolerated daily dose and the total iron deficit. Each cycle consists of 5000 mg of oral elemental iron ingested over at least 1 month with appropriate follow-up. This approach should assist physicians and their patients with the implementation of individualized treatment strategies for patients with iron-deficiency anemia.     

慢性病贫血的铁代谢研究

目的:探讨慢性病贫血(ACD)的铁代谢,有利于临床医师提高对该病的诊治水平。方法:对21例ACD和15例缺铁性贫血(IDA)患者进行Hb、血清铁(SI)、总铁结合力(TIBC)、血清铁蛋白(SF)、可溶性转铁蛋白受体(sTfR)、骨髓涂片铁染色、EPO、白细胞介素(IL)-1、IL-6、IL-8和肿瘤坏死因子-浕(TNF-浕)进行检测,并对结果进行分析。结果:①SI、TIBC、SF和骨髓涂片铁染色对区别ACD和单纯性IDA有很大帮助,2组数据比较差异有统计学意义,P<0.05;②ACD组中存在缺铁(占19.01);③ACD组和IDA组的sTfR水平分别为(2.41±1.20)mg/L和(6.38±3.24)mg/L,2组比较差异有统计学意义,P<0.05;④ACD组EPO水平低于IDA组,而IL-6、IL-8、TNF-浕水平高于IDA组,2组间数据比较除IL-1外,其他细胞因子差异有统计学意义,P<0.05。结论:sTfR是一种新的铁参数,有助于临床医师对ACD与IDA鉴别及合理用药,初步结果显示一些细胞因子在ACD疾病的致病因素中占重要地位。     

幽门螺杆菌感染与缺铁性贫血关系的研究进展

铁缺乏不但是发展中国家而且是发达国家最常见的一种营养物质缺乏状态，是贫血最常见的原因，同时是临床实践中最常见的器质性病变之一，对于缺铁性贫血（Iron deficiency anemia，IDA）患者，消化科医生常需行胃镜检查以了解有无导致慢性失血的粘膜损伤存在（包括恶性肿瘤、溃疡及血管发育不良等）、行粪潜血检查及寄生虫检查以除外钩虫病、行血清学及十二指肠粘膜活检以除外口炎性腹泻等，但虽经内镜及其它各种临床检查，     

Emerging causes of iron deficiency anemia refractory to oral iron supplementation

While oral iron supplementation is commonly used throughout many clinical setting,treatment with intravenous(IV) iron has historically been reserved for specific settings,such as chronic kidney disease,gynecologic issues,and anemia associated with cancer and its treatments.However,the use of IV iron has begun to gain popularity in the treatment of iron deficiency anemia(IDA) associated with two conditions that are being seen more frequently than in years past:patients who are status post gastric bypass procedure and those with inflammatory bowel disease(IBD).The Roux-en-Y procedure involves connecting a gastric pouch to the jejunum,creating a blind loop consisting of distal stomach,duodenum,and proximal jejunum that connects to the Roux limb to form a common tract.IDA occurs in 6%-50% of patients who have undergone a gastric bypass,the etiology being multifactorial.The proximal gastric pouch,the primary site of gastric acid secretion,is bypassed,resulting in a decreased ability to metabolize molecular iron.Once metabolized,most iron is absorbed in the duodenum,which is entirely bypassed.After undergoing bypass procedures,most patients significantly limit their intake of red meat,another factor contributing to post-bypass IDA.Chronic anemia occurs in approximately 1/3 of patients who suffer from IBD,and almost half of all IBD patients are iron deficient.IBD leads to IDA through multiple mechanisms,including chronic intestinal blood loss,decreased absorption capabilities of the duodenum secondary to inflammation,and an inability of many IBD patients to tolerate the side effects of oral ferrous sulfate.In this study,we reviewed the charts of all patients who received IV iron at Sylvester Comprehensive Cancer Center/University of Miami Hospital Clinic from January 2007 to May 2012.The most common indications for IV iron were for issues related to cancer and its treatment(21.9%),IBD(20.1%),and gastric bypass(15.0%).Of the 262 patients who received IV iron,230 received iron sucrose and 36 received iron dextran.While doses of 100,200,300,and 400 mg of iron sucrose were given,100 and 200 mg were by far the most common dosages used,122 and 120 times,respectively.The number of dosages of iron sucrose given ranged from 1 to 46,with a mean of 5.5 and a median of 4 doses.The average dose of iron dextran given was 870.5 mg,with 1000 mg being the most common dosage used.Most patients(22 of 36) who received iron dextran only received one dose.While patients with traditional indications for IV iron,such as gynecologic issues and kidney disease,still were represented in this study,we expect to see a continued increase in physicians using IV iron for emerging gastrointestinal indications,especially considering the increased safety of new low-molecular formulations.     

慢性疾病性贫血的发病机制

慢性疾病性贫血是一类以血清铁低，总铁结合力低，贮存铁增加为特征的贫血，其发病机制是多因素，多机制的，包括细胞因子，一氧化氮，急性时相反应蛋白及促红细胞生长素等所致的红细胞寿命缩短，铁代谢紊乱及骨髓对贫血失代偿等。     

Abnormal splenic uptake of red cells in long-lasting iron deficiency anemia due to self-induced bleeding (factitious anemia)

Summary The authors report on six cases of chronic iron deficiency anemia in which a diagnosis of factitious anemia was made. Erythrokinetic studies demonstrated iron deficiency and blood loss. Besides these features, two kinetic abnormalities are described: precocious splenic sequestration of red cells and excess hemolysis. This hemolytic syndrome seems to be correlated to the duration of anemia rather than to its severity.     

新疆阿克苏地区拜城县哺乳期妇女碘与铁营养现况调查

目的 了解新疆阿克苏地区拜城县碘缺乏重病区哺乳期妇女碘与铁营养现况,为缺碘地区重点人群碘缺乏病防治工作提供依据.方法 2007年在阿克苏地区碘缺乏病重病区拜城县,选取温巴什、察尔齐、大桥、托克逊4个乡作为调查点.每个乡分别选哺乳期妇女30～40人进行人户调查,采集一次随意尿样以及当地饮用水测定含碘量.静脉穿刺采集调查对象全血,放射免疫分析方法测定血清铁蛋白(SF),亚铁嗪比色法测定血清铁(SI)、总铁结合力(TIBC),化学发光免疫分析方法测定FT3、FT4、TSH.结果 共调查137名哺乳期妇女,尿碘中位数为134.99μg/L,但4个乡中,大桥(99.73 μg/L)和托克逊(44.17μg/L)乡的哺乳期妇女尿碘中位数<100μL;察尔齐[21.1%(8/38)]、大桥[21.4%(6/28)]、托克逊[47.8%(11/23)]乡尿碘<50μg/L者所占比例均>20%.居民饮用水共采集78份,水碘中位数为2.15 μg/L.检测血清SF、SI低于正常值的各占47.6%(59/124)、16.9%(21/124),TIBC高于正常值的占20.2%(25/124),n低于正常值的占11.8%(15/127),TSH高于正常值的占10.2%(13/127).结论 阿克苏地区拜城县部分哺乳期妇女同时存在碘缺乏与铁缺乏,建议对该部分重点人群采取有效的补碘、补铁干预措施.     

Relationship between glycosylated hemoglobin and iron deficiency anemia: A common but overlooked problem

IntroductionBoth diabetes mellitus (DM) and iron deficiency anemia (IDA) are prevalent in every area of the world, and so, the possibility of these two diseases co-existing is also very high. It is our belief that clinical results of any correlation between iron status of the body and glycosylated haemoglobin (HbA1c) would be beneficial to many patients, therefore in this study, the effect of IDA on HbA1c was investigated.Materials – methodsA total of 146 patients with DM and IDA were evaluated prospectively. While the patients were administered 270 mg/day of ferrous sulphate (80 mg elemental iron) orally for three months for the treatment of IDA, no interventions were made for the treatment of DM. Patient levels of hemoglobin (Hb), hematocrit, red blood cells (RBC), mean corpuscular volume (MCV), platelet, white blood cells (WBC), serum iron, serum iron binding capacity (SIBC), ferritin, fasting plasma glucose (FPG), HbA1c, body mass index (BMI), C-reactive protein (CRP) values were measured at baseline and at the third month of treatment with iron, and were compared.ResultsThe median age of our patients was 45 (40–50) and median duration of diabetes was 3 years (1,75–5). While the baseline median Hb was 10.4 (mg/dL) (9.5–11.1), MCV was 74 (fL) (70.8–77), ferritin was 4 (ug/L) (3–6) at three months, Hb was measured at 12.6 (mg/dL) (12.1–13.2), MCV was measured at 82 (fL) (80–86), ferritin was measured at 15 (ug/L) (9–21.2) and was significantly higher compared to baseline values (p < 0.001). The baseline median HBA1c of patients was 7.09 ± 0.51 (%) and three month HBA1c was 6.69 ± 0.53 (%), which was significantly lower than when comparing baseline values with values at third month (p < 0.001). Baseline and three month values for FPG were 118 (mg/dL) (108–132) and 116 (mg/dL) (106–125) respectively, and there was no significant difference (p:0.07). A 2.2 mg/dL (1.5–3.5) increase in median Hb level accompanied a 0.4 % (0.2–0.6) decrease in median HbA1c levels (Spearman rho = ?0.362; p < 0.001).ConclusionOur study has shown conclusivly that IDA is related to increased HbA1c concentrations and HbA1c decreases significantly following treatment with iron. IDA should be considered before making any decisions regarding diagnosis or treatment according to HbA1c.     

Successful response to alpha-interferon 2b in a refractory IgM autoagglutinin-mediated hemolytic anemia

Summary We describe the beneficial effect of recombinant alpha 2b interferon in a woman with an idiopathic and refractory IgM-mediated autoimmune hemolytic anemia due to low-titer, high-thermal-amplitude cold agglutinins. The response was partial but sustained, 2 months after interruption of interferon, with hemoglobin concentrations ranging between 8.5 and 10 g/dl. In the literature, such rarely encountered hemolyzing warm-reacting agglutinins are described as causing severe hemolysis with a frequently fatal clinical outcome.