Is Anemia a Serious Disease?



What is Anemia?

Anemia is a condition that manifests through a marked reduction in hemoglobin concentration or the number of RBCs’ (red blood cells) below their normal levels (WHO, 2020). The appropriate hemoglobin concentration is paramount to the transfer of oxygen to various body tissues. A reduction in hemoglobin or RBCs reduces the overall oxygen-carrying capacity of the blood. The affected patients could experience symptoms including shortness of breath, dizziness, weakness, and fatigue. The maintenance of appropriate hemoglobin concentration is highly needed to accomplish the body’s physiological requirements. Hemoglobin concentration varies in accordance with pregnancy status, smoking habits, the height of residence, gender, and age. Anemia usually develops under the influence of the following causes. Although, numerous other causes of anemia are widely reported in evidence-based clinical literature.  

  1. Parasitic infections 
  2. HIV (Human Immunodeficiency Virus) 
  3. Tuberculosis, malaria, and other infectious diseases  
  4. Hemoglobinopathies 
  5. Vitamin A/B12 deficiency 
  6. Folate/iron deficiency 

Approximately 40% of pregnant women and 42% of kids below five years of age reportedly experience anemia across the globe (WHO, 2020).         

Is Anemia a Disease?

Anemia is not regarded as a clinical diagnosis; however, its presence indicates an underlying disease condition (Turner, et al., 2020). Anemia symptoms vary following the presence of comorbidities and etiological factors. Anemia symptoms in some patients occur after a reduction in hemoglobin level beneath 7 grams per decilitre. The major chunk of RBCs inside the human body is produced under the influence of EPO (erythropoietin) of the kidney. EPO production is triggered by tissue hypoxia; however, hemoglobulin concentration is inversely proportional to the EPO concentration. This reveals that anemic patients exhibit an increased concentration of EPO along with a reduction in hemoglobulin level. Suboptimal EPO level elevation is commonly reported in anemia of chronic disease, thereby leading to a relative EPO deficiency. Any reduction in hemoglobin levels affirms the development of anemia. The normal lab ranges of hemoglobin are mentioned below. 

  1. 13.5-18g/dL (males) 
  2. 12-15g/dL (females) 
  3. 11-16g/dL (children)   
  4. Above 10g/dL in pregnant women 

What are the Commonly Reported Causes/Risk-Factors of Anemia?

Numerous pathophysiological processes and factors contribute to the development of anemia. Some of the potential causes are listed below (Warner & Kamran, 2020) (Johnson-Wimbley, 2011) (Miller, 2013). 

  1. The socioeconomic status, gender, and age of individuals elevate their risk of anemia and related complications. 
  2. Iron deficiency anemia develops under the impact of blood loss, reduced iron absorption, or limited iron intake. 
  3. The absence of breastfeeding in infants increases their risk of anemia to many folds. 
  4. Parasitic infection also increases the risk and prevalence of anemia. 
  5. The nutritional deficiencies based on the limited intake of vegetables and fruits leads to the development of anemia in various patient scenarios.   
  6. Reduction in the stomach’s acidic environment interferes with the iron absorption mechanism. 
  7. Reduction in transferrin levels. 
  8. Blood loss due to accidents, nosebleed, and blood donation. 
  9. Iron loss based on hemoglobinuria and intravascular hemolysis in malaria patients 
  10. Chronic physical exertion. 
  11. Hookworm infection that usually develops with mild eosinophilia and iron deficiency anemia. 
  12. Iron malabsorption and malnutrition. 
  13. History of chronic illness and underdevelopment. 

How Could You Investigate Anemia Through Physical Examination?

The following findings could help you to identify and track the development of anemia in high-risk individuals. 

Skin-Related Findings

The appearance of one or more of the below-mentioned changes will assist you to clinically correlate the anemia-related developments. 

  1. Pallor
  2. Abnormal pigmentation 
  3. Icterus 
  4. Spider nevi 
  5. Petechiae 
  6. Purpura 
  7. Angiomas 
  8. Ulcerations 
  9. Palmar erythema 
  10. Coarseness of hair 
  11. Puffy face
  12. Thinning of the eyebrows’ lateral aspects 
  13. Nail defects 
  14. Unusual venous prominences over the abdominal wall 

Optic Findings 

The sclera and conjunctiva (including conjunctival vessels) of the anemia suspected patients require an assessment to check and/or rule out the following conditions. 

  1. Pallor 
  2. Icterus 
  3. Splinter hemorrhages 
  4. Petechiae 
  5. Comma signs 
  6. Telangiectasia

Findings Related to Lymph Nodes 

Systemic assessment of lymph nodes is paramount to evaluating or ruling out the development of anemia. The following considerations could help you to understand the clinical causes of anemia (Walker, et al., 1990). 

  1. A palpable lymph node enlargement would indicate the development of neoplasia or infection requiring further investigation. 
  2. The presence of bilateral edema would indicate the development of hepatic, or renal, or cardiac diseases requiring clinical correlation. 
  3. The presence of unilateral edema would raise suspicion for malignancy-related lymphatic obstruction. 
  4. The presence of splenomegaly or hepatomegaly would require further investigation to understand the pathophysiology of the developing anemia.  
  5. The assessment of the firmness/tenderness of liver, kidneys, and nodules (if present) would also facilitate the clinical investigation for anemia 
  6. The non-tenderness and firmness or liver and kidneys could indicate the presence of a chronic disorder. 
  7. An infection could elevate the tenderness and softness of different organs. 
  8. Any infection or tumor in the pelvis and/or rectum could increase the risk of anemia 
  9. The neurological assessment for anemia could include the systematic evaluation of tendon reflexes, cranial nerves, vibratory sense, and position. 
  10. The severity and duration of anemia are directly proportional to the extent of cardiac enlargement. 
  11. Bacterial endocarditis manifests through murmurs that prove to be a significant clue for anemia. 

What are the Commonly Reported Symptoms/Signs of Anemia?

You may experience one or more of the following symptoms and/or signs related to anemia (Freeman, et al., 2020). 

  1. Fatigue 
  2. Weakness 
  3. Lightheadedness 
  4. Headache 
  5. Pallor 
  6. Jaundice 
  7. Tachycardia 
  8. Palpitations 
  9. Chest pain 
  10. Dyspnea 
  11. Cold distal extremities 
  12. Claudication 

What is the Pathophysiology of Anemia?

Anemia progresses under the influence of one or more of the following processes (Freeman, et al., 2020). 

  1. The thalassemia/sickle cell disease variants of beta and alpha chains of RBCs contribute to the development of anemia.  
  2. Genetic variations in cell morphology, cell metabolism, and cell membrane also contribute to the progression of anemia. 
  3. The absence of substrates including folate, vitamin B12, and iron deteriorates reticulocyte metabolism, thereby triggering the onset of anemia. 
  4. Radiation exposure, infections, toxins, and medications potentially deteriorate the function of bone marrow, thereby disrupting the production of RBCs. 
  5. The development of fibrosis or neoplasm across bone marrow also contributes to the development of anemia. 
  6. Kidney diseases potentially deteriorate the production of erythropoietin that eventually restricts the formation of proerythroblasts from pluripotent stem cells. 
  7. Acute blood loss and related anemia trigger the onset of hypertension that prompts stretch receptors to generate downstream effects through signaling via the vagus and glossopharyngeal nerves. These processes elevate the secretion of vasopressin or arginine vasopressin or antidiuretic hormone that reduces renal perfusion through increased water reabsorption. The subsequent activation of the renin-angiotensin system results in vascular tone elevation, aldosterone induction, and intravascular volume enhancement. 
  8. Acute blood loss anemia impacts the physiology of the pituitary gland, cerebral cortex, and medulla in a manner to elevate antidiuretic hormone secretion and sympathetic tone enhancement. This eventually triggers the brain volume changes. 
  9. The renal-mediated and CNS-directed responses to perfusion/volume loss arising from rapid hemolysis or blood loss attempt to compensate for the acute onset anemia and related complications. 
  10. 15% of blood volume loss results in class-I hemorrhage that does not impact vital signs. 
  11. 15-30% of blood volume loss causes class-II hemorrhage that potentially increases the risk of peripheral vasoconstriction, blood pressure reduction, and tachycardia. These outcomes warrant crystalloid-based volume repletion intervention. 
  12. 30-40% of blood volume loss leads to class-III hemorrhage that triggers shock, tachycardia, and hypotension. The clinical management of class-III hemorrhage relies on blood transfusion and crystalloid resuscitation. 
  13. The blood volume loss above 40% triggers class-IV hemorrhage in a manner that compromises the compensatory mechanism. The clinical management of class-IV hemorrhage is based on the administration of pressors, crystalloids, and blood products (i.e. aggressive resuscitation).       

What Laboratory Investigations Could You Deploy to Investigate Anemia? 

Anemia assessment relies on the combination of the following investigations (Freeman, et al., 2020). 

  1. Hemogram, including mean corpuscular hemoglobin concentration, mean corpuscular hemoglobin, mean corpuscular volume, hematocrit, and hemoglobin. 
  2. Iron profile based on total iron-binding content, ferritin, and serum iron. 
  3. Reticulocyte count for the assessment of bone marrow’s RBC output. 
  4. Serum creatinine for the assessment of kidney function. 
  5. Peripheral blood smear for the assessment of RBC morphology. 
  6. Coagulation screen for the assessment of thrombin time, international normalized ratio/prothrombin time, and activated partial prothrombin time. 
  7. Liver function test/panel for the assessment of 5'-nucleotidase, gamma-glutamyl transferase, lactate dehydrogenase, alkaline phosphatase, albumin, bilirubin, total protein, transaminases, and calcium. 
  8. Thyroid function panel for the assessment of thyroid-stimulating hormone and T-4 (thyroxine) levels. 
  9. Macrocytosis profile to evaluate the levels of homocysteine, methylmalonic acid, folate, and vitamin B-12. 
  10. Hemolysis profile for the assessment of indirect bilirubin, lactate dehydrogenase, and haptoglobin. 
  11. Hemoglobin electrophoresis for the assessment of amino acid chains 
  12. Bone marrow assessment 
  13. Abdominal sonogram for the assessment of spleen/liver size.  

How Could You Prevent Anemia? 

The assessment and mitigation of anemia’s causative factors are highly necessary for its prevention and treatment. The below-mentioned strategies could help you to reduce your risk of anemia (Medicine_Net, 2020) (IOM, 1993) (DeMaeyer, et al., 1989, p. 38). 

  1. Incorporation of folic acid and vitamin B12 in the diet
  2. Restriction in consumption of coffee and/or tea with meals 
  3. Elevated consumption of fluids and food items rich in vitamin C (ascorbic acid) 
  4. Elevated consumption of bread, iron-fortified cereals, beans, lentils, lean red meat, and green leafy vegetables. 
  5. Increased consumption of fruit juices 
  6. Increased consumption of meat 
  7. Administration of iron supplements to anemic women 
  8. The consumption of the iron-folate supplement is highly recommended for pregnant women (based on physician prescription) to reduce their risk of anemia 
  9. The coadministration of iron supplements is recommended with juice/water/milk at bedtime or between meals. 
  10. Anemia screening for females is highly recommended within the age range of 15-25 years 
  11. The regular consumption of the following vegetables and fruits also reduces the risk of anemia

a)     Boiled turnip 

b)     Raw tomato 

c)     Boiled spinach 

d)     Boiled sweet potato 

e)     Raw sweet potato 

f)      Boiled potato 

g)     Raw potato 

h)     Boiled cauliflower 

i)      Raw cauliflower 

j)      Boiled cabbage 

k)     Raw cabbage 

l)      Fresh mango 

m)   Fresh pineapple 

n)     Fresh orange 

o)     Fresh lemon juice 

p)     Fresh guava 

References

DeMaeyer, E. M. et al., 1989. Prevention and Controlling Iron Deficiency Anemia Through Primary Health Care. In: Geneva: s.n., pp. 1-61.

Freeman, A. M., Pandya, N. K. & Morando, D. W., 2020. Anemia Screening. Treasure Island (FL): StatPearls Publishing.

IOM, 1993. Recommended Guidelines For Preventing And Treating Iron Deficiency Anemia In Nonpregnant Women Of Childbearing Age. In: Iron Deficiency Anemia: Recommended Guidelines for the Prevention, Detection, and Management Among U.S. Children and Women of Childbearing Age. Washington (DC): National Academies Press.

Johnson-Wimbley, T. D., 2011. Diagnosis and management of iron deficiency anemia in the 21st century. Therap Adv Gastroenterol, 4(3), pp. 177-184.

Medicine_Net, 2020. Health Tip: Help Prevent Anemia. [Online]
Available at: https://www.medicinenet.com/a_visual_guide_to_anemia/article.htm
[Accessed 21 05 2020].

Miller, J. L., 2013. Iron Deficiency Anemia: A Common and Curable Disease. Cold Spring Harb Perspect Med, 3(7).

Turner, J., Parsi, M. & Badireddy, M., 2020. Anemia. In: StatPearls. Treasure Island (FL): StatPearls Publishing.

Walker, H. K., Hall, W. D. & Hurst, J. W., 1990. Anemia. Boston: Butterworths.

Warner, M. J. & Kamran, M. T., 2020. Anemia, Iron Deficiency. In: StatPearls. Treasure Island (FL): s.n.

WHO, 2020. Anaemia. [Online]
Available at: https://www.who.int/health-topics/anaemia#tab=tab_1
[Accessed 20 05 2020].

 

 

 


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