Management of anemia of chronic disease in patients with the human immunodeficiency virus

Anemia is the most frequently encountered hematologic complication in human immunodeficiency virus (HIV) infection and acquired immunodeficiency syndrome. The prevalence estimates vary widely with the severity of HIV disease. Data suggest that treatment with highly active antiretroviral therapy may have a positive impact on reducing the prevalence of anemia of chronic disease in patients infected with HIV. Anemia consistently has been shown to be a predictor of decreased survival, and treatment plays an important role in improving patients' survival and quality of life (e.g., fatigue and dementia). Addressing potential underlying reversible causes and treating the chronic anemia are important strategies in the management of anemia. Erythropoietin therapy should be considered a first-line treatment, and blood transfusions should be limited to situations requiring immediate correction of hemoglobin levels.     

What is the optimal treatment for anemia in inflammatory bowel disease?

Anemia is common in inflammatory bowel disease (IBD), with a prevalence ranging from 8.8% to 73.7%. This wide range reflects the definitions used and the populations studied. Although many patients are reported to be asymptomatic, systematic studies have shown anemia to have a significant impact on quality of life. Consequently treatment should be instituted early. The commonest cause of anemia in IBD is iron deficiency, predominantly related to gastrointestinal blood loss. Anemia of chronic disease often occurs concomitantly, due to cytokine-mediated impaired erythropoiesis and dysregulated iron metabolism. Oral iron is a simple and effective method for treating iron deficiency, but requires long courses of treatment. It is also theoretically implicated with worsening intestinal inflammation, via the production of toxic reactive oxygen species. Intravenous iron avoids these concerns, especially with the development of ferric carboxymaltose, which allow up to 1000mg to be given rapidly. In patients failing to respond to intravenous iron, the anemia of chronic disease is most likely to be causative. In this setting evidence suggests that additional erythropoietin therapy can be effective. Blood transfusions should be avoided as part of routine management and reserved for patients with substantial acute gastro-intestinal bleeding, where there is a risk of hemodynamic compromise. This article discusses the underlying physiology of anemia in IBD, and presents the current evidence supporting treatment options available.     

亚急性肝衰竭贫血发生的临床特征及意义

摘要 目的：探讨亚急性肝衰竭贫血的发生及其与病情轻重及预后的关系。方法：回顾性分析1995年10月～2011年5月我院187例亚急性肝衰竭病人贫血发生的影响因素及其与病情、预后关系的资料。结果：187例患者中发生贫血者127例（67.9%）,贫血的发生与营养不良、反复出血及病情轻重明显相关,发生贫血者合并感染及病死率均增加,而且恢复期早期肝硬化和肝硬化的发生率也增加。结论：贫血是亚急性肝衰竭的并发症之一,与病情的轻重明显相关,并影响预后,预防和治疗贫血是亚急性肝衰竭治疗的重要环节。     

南宁市江南区托幼机构儿童贫血情况调查分析

目的分析南宁市江南区儿童贫血的原因,探讨降低贫血的措施。方法托幼机构健康体检,抽取儿童的外周血检测血红蛋白。结果贫血由2010年的17.63%降为2011年的3.76%,差异有统计学意义(χ2=194.4,P<0.01)。结论饮食中铁的供给不足为导致缺铁性贫血的重要原因,合理喂养可纠正大部分贫血。     

低氧诱导因子脯氨酰羟化酶抑制剂roxadustat

贫血是慢性肾病的重要并发症之一。随着慢性肾病的发展,贫血的发病率也随之不断升高。roxadustat是一种新型的口服低氧诱导因子脯氨酰羟化酶抑制剂,可诱导内源性红细胞生成素升高,无论是尚未接受透析的慢性肾病患者,还是需要透析治疗的末期肾病患者,roxadustat都能治疗贫血并保持一定的血红蛋白水平,且耐受良好,能够为肾性贫血患者提供更加安全便利的治疗。     

Managing anemia in the critically ill patient

Anemia of critical illness is a multifactorial condition caused by phlebotomy, ongoing blood loss, and inadequate production of red blood cells. It occurs early in the course of critical illness. Although red blood cell transfusion is the treatment of choice for immediate management of anemia in the intensive care unit, controversy surrounds the most appropriate hemoglobin concentration or hematocrit "trigger." Therapeutic options, including blood-conservation tools, minimization of phlebotomy, erythropoietic agents, and investigational oxygen-carrying agents, may be alternatives to red blood cell transfusions in critically ill patients with anemia. Patient selection for erythropoietic agents will depend on further work dealing with outcomes and the total cost of care in managing the anemia of critical illness.     

骨髓增生异常综合征贫血原因及治疗策略

骨髓增生异常综合征 （MDS） 是一组高度异质性疾病, 贫血是MDS常见的临床表现, 也是影响MDS患者生存及生活质量的重要因素。MDS贫血的发病机制复杂, 患者的贫血可以是多种因素的结果。本文论述了MDS常见的贫血原因, 包括异常克隆的扩增、 免疫异常、 5q-的造血异常、 无效造血和铁过载等。针对不同原因的贫血, 可以采用促红细胞生成素、 免疫抑制剂、 祛铁治疗、 免疫调节治疗、 转化生长因子-β （TGF-β） 通路阻断剂、 去甲基化药物治疗和造血干细胞移植等策略。     

Erythropoietin in heart failure and other cardiovascular diseases: hematopoietic and pleiotropic effects

Erythropoietin is a hypoxia-induced hormone that is a major regulator of normal erythropoiesis. Over the last decade, the production of recombinant human erythropoietin has revolutionized the treatment of anemia associated with chronic renal failure, and has led to a greater understanding of anemia pathophysiology and to the elucidation of the interactions of erythropoietin, iron, and erythropoiesis. Anemia has been shown to be independently associated with increased mortality and disease progression. Potential survival benefits associated with correction of anemia have expanded considerably the indications of erythropoietin use in various patient populations and are leading to consideration of earlier, more aggressive treatment of mild to moderate anemia. The results of such treatment are promising in a variety of new clinical settings, including anemia associated with congestive heart failure. Furthermore, the erythropoietin receptor is widely distributed in the cardiovascular system, including endothelial cells, smooth muscle cells and cardiomyocytes and preclinical studies have established erythropoietin to be a pleiotropic cytokine with anti-apoptotic activity and tissue-protective actions in the cardiovascular system, beyond correction of hemoglobin levels. Despite some potential adverse effects, such as hypertension, and the occurrence of erythropoietin resistance, early studies in heart failure patients with anemia suggest that erythropoietin therapy is safe and effective in reducing left ventricular hypertrophy, enhancing exercise performance and increasing ejection fraction. Anemia is found in about one-third of all cases of congestive heart failure (CHF). The most likely common cause is chronic renal insufficiency, which is present in about half of all CHF cases. However, anemia can occur in CHF without renal insufficiency and is likely to be due to excessive cytokine production. The anemia itself can worsen cardiac function, both because it causes cardiac stress through tachycardia and increased stroke volume, and because it can cause a reduced renal blood flow and fluid retention, adding further stress to the heart. Long-standing anemia of any cause can cause left ventricular hypertrophy, which can lead to cardiac cell death through apoptosis and worsen CHF. Therefore, a vicious circle, cardio-renal anemia syndrome, is set up wherein CHF causes anemia, and the anemia causes more CHF and both damage the kidneys worsening the anemia and the CHF further and increasing mortality. There is now evidence that early correction of the CHF anemia with subcutaneous erythropoietin and intravenous iron improves shortness of breath and fatigue, cardiac function, renal function and exercise capacity, reducing the need for hospitalization and improving quality of life. In the present review we discuss the data on current clinical use of erythropoietin in cardiovascular disease, with the main focus on the treatment of congestive heart failure, and summarize the advances and progress made in the understanding of the hematopoietic and pleiotropic effects of erythropoietin in the cardiovascular system.     

Clinical Guidelines for the Treatment of Cancer-Related Anemia

Defining clinical guidelines for the treatment of cancer-related anemia requires investigation into causes and characteristics of this malady, uses, benefits, and adverse effects of current treatments; and recognition of currently accepted guidelines set forth by the American College of Physicians and the American Association of Blood Banks. Anemia, the most common hematologic abnormality in patients with cancer, originates from a variety of causes, including occult blood loss, hypoproliferation, and hemolysis, and often involves more than one mechanism. Clinical manifestations include fatigue, dyspnea, tachycardia, dizziness, anorexia, and hypersensitivity to cold. Although the majority of cancer-related anemias are hypoproliferative, establishing their pathophysiology in individual patients is critical to effective treatment. Anemia usually, but not always, resolves with successful treatment of underlying disease. Symptomatic relief can be managed in accordance with established treatment guidelines.     

幽门螺旋杆菌与缺铁性贫血相关性研究

目的探讨幽门螺旋杆菌（HP）感染与缺铁性贫血（IDA）的相关性及清除HP治疗在缺铁性贫血治疗中的必要性。方法选择2003～2009年本院住院及门诊的83例缺铁性贫血患者,并随机抽取了100例无IDA的患者作对照,均行”C检查。将HP阳性的49例IDA患者随机分成两组,A组31例行抗HP治疗加铁剂治疗,B组18例行单纯铁剂治疗,动态观察,记录两组的血液学和铁代谢等指标变化,治疗前和治疗后3个月分别检测患者的血红蛋白（Hb）、血清铁（SI）、铁蛋白（SF）。结果观察组83例中49例HP阳性,感染率为59．03％;对照组100例中,24例HP阳性,感染率为24％。两组间差异有显著性意义（P〈0．05）,研究组A、B两组比较,治疗前后血液学指标改变及疗效差异有显著意义,P〈0．05。结论HP感染与IDA有一定相关性,对HP阳性的IDA患者,联合清除HP及铁剂治疗是行之有效的方法。     

Anemia of critical illness

Anemia of critical illness, a commonly encountered clinical situation, is hematologically similar to that of chronic anemia, except that the onset is generally sudden. The etiology is usually multifactorial, occurring as a consequence of direct inhibitory effects of inflammatory cytokines, erythropoietin deficiency, blunted erythropoietic response, blood loss, nutritional deficiencies, and renal insufficiency. Although anemia is not well tolerated by critically ill patients, aggressive treatment of anemia can be just as detrimental as no treatment. Different types of anemia may coexist in a patient in the intensive care unit, making diagnosis and differentiation among these anemias complex, therefore requiring good diagnostic skills. Although several therapeutic options are available to treat anemia, critically ill patients often receive a transfusion, and yet, most recent studies indicate that blood transfusions in critically ill patients are associated with worse outcomes, including higher morbidity and mortality. These studies have generated interest in the administration of exogenous erythropoietin and iron therapy. Unfortunately, the accurate determination of iron status can be a rather difficult task, an undertaking that is made even more difficult by the presence of comorbid conditions that can affect the commonly used parameters for guiding iron therapy. The use of erythropoiesis-stimulating agents is rapidly gaining acceptance, although they also present potential problems of their own.     

Anemia in chronic obstructive pulmonary disease: epidemiology and economic implications

ABSTRACT

Background: Anemia in chronic illness is associated with increased healthcare resource utilization (HRU) and costs. In COPD, it occurs frequently and influences both clinical and economic outcomes. Because no data studies have been performed either in a single center or a subpopula­tion of COPD patients, anemia's influence on the outcomes is not fully understood.

Research design and methods: We conducted a retrospective cohort study in a large healthcare database to quantify prevalence, HRU and costs of anemia in COPD. From 1997 to 2005, patients ≥?45 years of age with an ICD-9 diagnosis code for COPD and >?3.5 years of follow-up were included. Anemia was defined by the WHO criteria. Other disease states for which anemia is a known complication were excluded. We calculated the prevalence of anemia and compared annual HRU and costs between COPD patients with and without anemia. Multiple regression analysis adjusted for the effects of age, gender, race, length of enrollment, diagnosing physician specialty, co-morbidity burden, anemia and COPD severity.

Results: Of the 2404 patients with COPD, 33% (n = 788) had a diagnosis of anemia. Anemic patients were older, more likely to be male and non-Caucasian, and had a greater co-morbidity burden than non-anemic individuals. Annual costs for COPD patients with anemia were more than twice those for patients without anemia ($17?240 vs. 6492, p < 0.001, unadjusted). HRU was also significantly greater among anemic than non-anemic COPD patients (?p < 0.0001). In a multiple regression analysis, anemia accounted for $7929 per patient (95% CI: $5572–10?599) of the total costs of care.

Limitations: This is a retrospective cohort study and thus subject to multiple forms of bias. Although spirometric evidence of COPD was available only for a subgroup of patients, our case identification methods have been previously validated and found to be accurate in recognizing COPD.

Conclusions: Anemia is a common co-morbidity in COPD. It is significantly associated with an increase in HRU and costs of care for COPD, independent of demographic and clinical patient characteristics.     

Anemia from sleep deprivation with anticoagulants in rats with enhancement by PCPA

Profound anemia was observed to occur in 5 to 8 days in rats fed the anticoagulants phenylindanedione and dicumarol, when fast wave sleep (FWS) was prevented by the inverted flower pot technique. No anemia occured in groups of rats deprived of FWS or receiving anticoagulants only. Anemia was accelerated by parachlorophenylalanine (PCPA). Anemia was slight when limited FWS was allowed by use of a larger platform or a continuous feeding period. Red blood cell, hemoglobin and hematocrit values all fell dramatically. There was little evidence of hemorrhage grossly, such as occurs in anticoagulant-treated rats with stress. Histologic study failed to display bleeding or stress involution of lymphoid tissue but did show diminished splenic iron depots and diminished haemopoietic activity in the splenic red pulp. Electroencephalography showed with sleep deprivation, a greater amount of brain waves of the type normally associated with slow wave sleep. This effect was partially blocked by serotonin depletion through PCPA injections. It is suggested that the development of anemia is due to the combined effects of several mechanisms. The results support the view that FWS-deprivation is not a stress.     

Economic burden of anemia in an insured population

OBJECTIVE: Anemia is a common hematological disorder characterized by reduced hemoglobin concentrations. Despite information on prevalence and associated outcomes, little is known about the impact of anemia on health care utilization and costs. This study examines anemia prevalence and associated medical costs and utilization, using administrative claims for adults newly diagnosed with anemia, including up to 12 months of follow-up. METHODS: Patients predisposed to anemia, based on selected comorbid conditions (chronic kidney disease, human immunodeficiency virus, rheumatoid arthritis, inflammatory bowel disease, congestive heart failure, and solid-tumor cancers), were identified. Costs for anemic patients and a random sample of nonanemic patients with these conditions were compared. Associations were evaluated after adjustment for potential confounders using a regression model. Clinical care patterns were examined overall and by condition. RESULTS: Anemia was observed in 3.5% (81,423) of approximately 2.3 million health plan members in 2000; 15% of anemic patients received an identified treatment, with transfusion being the most frequent intervention. Utilization and costs were significantly higher for anemic patients (P < 0.001). Average annualized per-patient costs were 14,535 US dollars for anemic patients (55% outpatient, 33% inpatient, 13% pharmacy), 54% higher than the 9,451 US dollars average cost for nonanemic patients (45% outpatient, 36% inpatient, 19% pharmacy). After adjustment for age, other comorbidities (e.g., chronic kidney disease and cancer), sex, and insurance type (indemnity, preferred provider organization/point of service, or health maintenance organization, in the Medstat MarketScan database), anemic patients had average costs that were more than twice the adjusted costs of nonanemic patients. CONCLUSION: Medical costs for anemic patients are as much as twice those for nonanemic patients with the same comorbid conditions.     

重组人促红细胞生成素在肿瘤相关性贫血中的应用

贫血是肿瘤患者的常见合并症, 既往治疗肿瘤相关性贫血多用输血,存在诸多缺点及风险.近年来重组人促红细胞生成素在肿瘤相关性贫血中的应用日益受到重视.现简述重组人促红细胞生成素的药物类别、适应证、用法用量、临床应用、缺点、不良反应、使用现状及应用限制等.     

Assessment of chemotherapy-induced anemia in children with cancer

Anemia is a common cause of co-morbidity in children with cancer. We reviewed a series of 124 children with non-metastatic cancer to assess the relationship between chemotherapy intensity, severe anemia, and frequency of transfusion. In more than 60% of children who received intensive chemotherapy, transfusions were prescribed compared to 38% and 21% of children treated with standard and mild chemotherapy, respectively. In conclusion, our data suggest that the intensity and duration of chemotherapy constitute important factors in determining the onset of anemia.     

Highlights of the Pananemia National meeting of the Italian Southern Oncological Group (GOIM): pharmacological and molecular treatment of cancer-induced anemia

Anemia commonly occurs in cancer patients and results in symptoms such as fatigue which have a profound impact on quality of life. Anemia is also associated with poor treatment outcome and overall survival. Several studies in patients with solid tumors have shown that erythropoiesis-stimulating agents (ESA), such as recombinant erythropoietins, effectively increase hemoglobin levels and reduce the need for emergency blood transfusions, regardless of the type of concomitantly administered chemotherapy. This Italian meeting, sponsored by the Italian Southern Oncological Group (GOIM) and Southern Pananemia Study Group, focused on various aspects of cancer-related anemia and its treatment options.     

Emerging drugs for the treatment of kidney disease-induced anemia

Introduction: Anemia has been remained one of the most characteristic and visible manifestations of chronic renal failure. Correction of anemia requires two main treatment strategies: increased stimulation of erythropoiesis, and maintenance of an adequate iron supply to the bone marrow.

Areas covered: Erythropoiesis activating agents became a mainstay in the treatment of renal anemia for more than 25 years. Recently, there have been several attempts to introduce new drugs to stimulate erythropoiesis or affect the hepcidin-ferroportin pathway. Orally available hypoxia-inducible factor (HIF) stabilizing compounds are attractive alternatives. They not only increase hemoglobin, but also suppress hepcidin production and improve iron availability. Novel iron preparations, may also help to ameliorate anemia, with acceptable safety profile and other beneficial properties such a phosphate binding.

Expert opinion: One should be aware of potential risks and benefits of novel sophisticated therapies and their role in the management of renal anemia remain to be established. In particular HIF stabilizers needs to be proven safe, or even safer than ESAs, in large long-term safety studies testing hard end points, due its ubiquitous nature and the regulation of variety of biological processes potentially leading to unexpected side effects. Besides safety, cost-effectiveness appears the major issue in the modern world, including nephrology.     

1 型糖尿病患者伴发贫血的特征及危险因素分析简

目的 研究分析1型糖尿病患者并发贫血的发生率、特点和危险因素.方法 分别对入选患者临床和实验室指标进行分析.结果 1型糖尿病94例中,27.6%的患者伴有贫血.病程≥3年以上的患者血红蛋白（Hb）、肌酐（Cr）、糖化血红蛋白（HbA1c）、24 h尿微量白蛋白（24 hUMA）水平显著高于病程＜3年的患者,贫血的1型糖尿病患者Hb和Cr呈负相关,相关系数（r）为-0.400（P〈0.05）,Hb与肾小球滤过率（eGFR）呈正相关,r为0.551（P〈0.01）.结论 1型糖尿病患者中贫血的发生率较高,并且与Cr和eGFR密切相关.     

Anemia in Patients Undergoing Percutaneous Coronary Intervention

Anemia is common among patients with coronary artery disease (CAD) and portends a higher risk of short- and long-term mortality, major adverse cardiac events, and bleeding complications. Blood transfusion has long been the cornerstone of therapy for anemia; however, its benefit in patients with CAD is controversial and the appropriate threshold for transfusion has been widely debated. In this review, we summarize the studies evaluating the impact of anemia in patients with CAD undergoing percutaneous coronary intervention and address several issues regarding the use of transfusion in anemic patients. In addition, we discuss alternative options for the management of anemia, such as the use of erythropoietin, aqueous oxygen, and hemoglobin-based oxygen carriers.