Does aging have an impact on hemoglobin? Study in elderly population at rural teaching hospital

BACKGROUND

The prevalence of anemia increases with age. Some serious underlying conditions may lead to anemia in the old age. The present study was undertaken to detect and do morphological typing of anemia and further delineate etiological factors in elderly patients.

METHODS

In this hospital-based prevalence study carried out a tertiary care center over one and half years, a total of 90 patients were fully evaluated for etiology and typing of anemia in elderly (>60 years age) patients. Details of other significant medical and surgical history were noted. Laboratory investigations were conducted, which included complete hemogram, peripheral blood smear, reticulocyte count, erythrocyte sedimentation rate estimation, serum urea, serum creatinine and serum lactate dehydrogenase, bone marrow examination (with Prussian blue marrow iron staining), serum iron and serum total iron-binding capacity, serum ferritin, and stool and urine examination.

RESULTS

The mean hemoglobin as per age was 60-64 years- 5.95 gm%, 65-69 years - 6.7 gm%, 70-74 years - 6.58 gm%, and 75-79 years - 6.87 gm%. The difference not being significant (p = 0.33). Morphologically, 53 patients (24 males and 29 females) had microcytic anemia, 27 (17 males and 10 females) had normocytic anemia, and 10 (8 males and 2 females) had macrocytic anemia. Anemia of chronic disease (ACD) was the most common occurrence (50, 55.56%), followed by iron deficiency anemia (IDA) (27, 30%), macrocytic anemia (9, 10%), and others 4 (4.44%). The cause of anemia was found in 10 out of 27 (37.03%) patients in the IDA group, 28 out of 50 (56%) in the ACD group, whereas the etiology was discernible in only one out of nine cases (11.1%) of macrocytic anemias.

CONCLUSION

There was no significant difference observed in the mean hemoglobin levels as the age increased. Morphologically, the majority of the patients had microcytic anemia, followed by normocytic anemia. A population-based study is recommended for further assessment of the prevalence and causes of anemias in asymptomatic elderly subjects.

Effect of intra-cellular trafficking on flow cytometric measurement of neutrophil's oxidative status in iron deficient pregnant females

BACKGROUND

Iron deficiency and iron deficiency anemia are prevalent among pregnant women particularly in developing countries. This study aimed to evaluate the iron status among Egyptian pregnant women and its impact on their neutrophil's count and antimicrobial functions.

METHOD

Ninety pregnant females underwent complete blood count, iron profile, flow cytometric studies for neutrophil myeloperoxidase expression & oxidative burst using dihydrorhodamine 123 (DHR) after phorbol-12-myristate-13-acetate (PMA) stimulation as well as neutrophil phagocytic and lytic indices.

RESULTS

According to percent saturation 54/90 women (60%) were iron deficient (<15% saturation) (cases) and 36/90 (40%) were iron sufficient (controls). A higher proportion of iron deficient pregnant women were in their third trimester compared to controls. No significant difference was found between the iron deficient & sufficient groups as regards anemia despite a positive correlation between haemoglobin level and percent saturation (P=.02). Both the phagocytic and lytic indices were significantly lower among the cases compared to controls (P=.014 & .002 respectively). Cases and controls were comparable as regards flow cytometric studies of neutrophils' myeloperoxidase and oxidative burst (P>.05). No significant correlation was found between any of the iron profile parameters and the oxidative burst by flow cytometry.

CONCLUSION

Functional microphage assay (phagocytic and lytic indices) may be more relevant and cost effective than flow cytometry assays of myeloperoxidase and oxidative burst in reflecting either iron status or cellular immunity in pregnancy.

Iron deficiency anaemia and evaluation of the utility of iron deficiency indicators among healthy Nigerian children

The hemoglobin (Hb), serum iron (SI), total iron binding capacity (TIBC), transferrin saturation (TS) and serum ferritin (SF) values of 240 apparently healthy children were determined in a prospective cross-sectional study conducted in Port Harcourt, Nigeria. Standard colorimetric and enzyme immunoassay procedures were used for the estimation all variables. The mean values of all parameters in this study population were; Hb (11.2 +/- 1.83 gldl), TIBC (361.4 +/- 245.7 ugldl, log(c) SI (1.807 +/- 0.45), log(c) SF (1.51 +/- 0.47) and TS (29.3 +/- 18.5%). There was an age-dependent statistical significant difference in the Hb, TIBC and TS values (P < 0.01). Sex was not found to exert any significant influence on the parameters except TIBC. TS had the highest sensitivity and efficiency values of 48 and 95%, respectively. Positive predictive value (PPV), likelihood ratio (LR(+)) and post-test probability values were highest with SF (58%, 3.3 and 62.2%, respectively) as a diagnostic indicator. Hb values correlated positively and significantly with TS (P < 0.01), log(c) SI and log(c) SF concentrations (P < 0.05). Log(c) SF also correlated positively and significantly with Hb and TIBC (P < 0.05). The overall prevalence of iron deficiency anaemia among these children was 33.75%. We conclude that there is a high prevalence of iron deficiency anaemia among apparently healthy children under the age of five years in this part of the world and these results may justify the need for the introduction of a broad intervention programme for this highly vulnerable group. This study is also in support of the hypothesis that SF is the best test for diagnosing or excluding iron deficiency anaemia. The combination of SF, Hb and TS determinations may prove more useful in a resource-limited moderate setting.

Laboratory support of the clinical nutrition service

This article critically reviews the role of the laboratory services in assessment, monitoring and management of complications in patients requiring nutritional support. It has broadly been divided into three sections. (i) Assessment of protein and energy status: whilst it is stressed that clinical judgement and anthropometric measurements are the most effective methods of evaluation of nutritional requirements, laboratory tests which can be of use in assessment of protein energy status are discussed in detail, including an appraisal of the value of each test in various clinical situations. (ii) Assessment of micronutrient and electrolyte status: the clinical justification for assessment of the various micronutrients and electrolytes is considered. A few selected examples are discussed in detail including an evaluation of the tests of status available and examples of situations where measurement may be clinically helpful. (iii) Effective use of the laboratory: this section attempts to guide the clinician in the most appropriate use of laboratory tests, firstly in the assessment of requirement for aspects of nutritional support, secondly in the continued monitoring and evaluation of the support provided, and thirdly in prevention and treatment of metabolic complications. It is emphasised that clinical nutrition is a multidisciplinary topic requiring input from the laboratory in conjunction with other specialities to provide the best available patient care.

Iron and heart disease: the epidemiologic data

There has developed a general theory of chronic and degenerative disease causation--the Oxidative Stress Theory. This theory states that the production of tissue-damaging free radicals is an essential component in the pathogenesis of chronic diseases and that iron may help to catalyze the reactions producing free radicals. As a result, it has been suggested that the risk of coronary heart disease increases with increasing body iron stores. In support of that hypothesis, a prospective epidemiologic study of heart disease in Finnish men found that the risk of heart attack increased with increasing levels of serum ferritin. However, the vast majority of the epidemiologic data, including results from prospective, cross-sectional, and case-control and autopsy studies, published since that initial study have failed to support the original hypothesis that high body iron stores increase the risk of coronary heart disease.

Body iron stores, dietary iron intake and coronary heart disease mortality

OBJECTIVES

To assess whether increased body iron stores and dietary iron intake are associated with an increased risk of coronary heart disease mortality.

DESIGN

A prospective population study with a mean mortality follow-up time of 14 years.

SETTING

Participants attending a health screening examination carried out in several localities in Finland.

SUBJECTS

All 6086 men and 6102 women aged from 45 to 64 years at the baseline examination without known heart disease, who had had serum iron and total iron binding capacity (TIBC) assessed. In a random fifth of these people, dietary iron intake was assessed by a dietary history.

INTERVENTIONS

The study was observational without any interventions.

MAIN OUTCOME MEASURES

Mortality from coronary heart disease.

RESULTS

Altogether, 739 of the men and 245 of the women died from coronary heart disease. No relationship between TIBC and coronary mortality was observed in the men; in the women, an inverse although not significant association was found. Transferrin saturation was inversely but not significantly associated with coronary mortality in men; in women, the relationship was U-formed with a higher mortality at both the lower and higher ends of the distribution. Adjustment for other risk factors did not alter the results. No association was found with dietary iron intake and coronary mortality.

CONCLUSIONS

The results do not corroborate earlier findings that excess body iron stores and increased iron intake are associated with an elevated risk of coronary heart disease.

Anaemia in elderly patients. Incidence and causes of low haemoglobin concentration in a city general practice

Haemoglobin concentration was determined in all patients (530) over 70 years of age in a general practice in Oslo during an eight month period. 72 had anaemia and were investigated further. Iron deficiency was found in 13 patients and was most often caused by gastrointestinal blood loss. Chronic diseases, particularly chronic infections and rheumatoid arthritis, were responsible for anaemia in 34 patients. Renal failure caused anaemia in 14 patients. In 10 patients we found no explanation for the anaemia. Nine patients with a previously undiscovered disease were found, six of whom could be offered some kind of treatment. We conclude that anaemia in elderly patients in general practice is often caused by chronic diseases. The main cause of iron deficiency is blood loss, and routine prescription of iron is not justified in this age group. The therapeutic benefit from routine measurement of haemoglobin concentration is small and the test should be used selectively.

The value of serum iron studies as a test for iron-deficiency anemia in a county hospital

To evaluate the performance of serum iron studies as a diagnostic test for iron-deficiency anemia in a county hospital, the authors identified retrospectively all general medicine patients who had had bone-marrow aspirates for the work-up of non-macrocytic anemias from 1978 through 1983. Re-reading a sample of aspirates from the 254 study patients (42 with iron deficiency) verified the presence or absence of iron. Analysis with logistic regression, likelihood ratios, and receiver operating characteristic curves demonstrated that the total iron-binding capacity (TIBC) performed markedly better as a diagnostic test than did the transferrin saturation test. While no single TIBC level was diagnostic, the TIBC provided a good estimate of the probability of iron-deficiency anemia.

Iron status in hypogammaglobulinaemia

Iron, transferrin and ferritin were measured in serum samples from 16 patients with primary hypogammaglobulinaemia. Transferrin saturation was low in 12 patients (75%) and serum ferritin was low in 9 patients (56.25%). Both parameters were low, confirming the state of iron deficiency, in 6 patients (37.5%). These figures are highly significant (P less than 0.01) when compared with the prevalence of iron deficiency in the general population. Eight patients were maintained on intravenous immunoglobulin infusions and the rest on intramuscular immunoglobulin injections, their mean serum IgG being 4.4 g/l and 2.6 g/l respectively. There was no difference in the prevalence of iron deficiency between the two groups.

Measurement of ferritin in serum: application in diagnostic use

A sandwich-type radioimmunoassay for serum ferritin was developed using iron-rich human liver ferritin and evaluated for its clinical usefulness. In young healthy males and females, the mean serum ferritin concentrations were 44 micrograms/L (range 7-158) and 16 micrograms/L (range 4-56), respectively. In anemic patients lower serum ferritin concentrations were found, while in most patients with iron overload serum ferritin concentrations well above 1000 micrograms/L were measured. Comparison of our method with a commercially available radioimmunoassay kit revealed a good correlation, except for sera with very low ferritin concentrations. Comparison with serum iron and transferrin parameters in patients with iron deficiency demonstrated that serum ferritin concentrations might be subnormal in a majority of patients with otherwise normal iron indices. Up to 70% of the ferritin in serum of normal subjects could bind to concanavalin A-Sepharose, indicating its glycoprotein nature. It is concluded that our serum ferritin radioimmunoassay gave reliable results and was useful in the laboratory diagnosis of latent iron-deficiency and in the analysis of the heterogeneity of serum ferritin.

Nutritional support of the critically ill patient

Injury or stress generates a vigorous metabolic response designed to establish the metabolic priorities required for the repair of injured tissues. In this condition, hormones commonly found to be elevated in the plasma include glucagon, catecholamines, glucocorticoids, growth hormone, aldosterone, and antidiuretic hormone. This hormonal profile results in rapid lysis of body protein, an increased rate of fat oxidation, and water and salt conservation. Rates of gluconeogenesis and ureagenesis are accelerated and may result in significant losses in lean body mass, a process that, if allowed to progress, will adversely affect patient survival. Exogenous nutrients provided to the critically ill patient may be poorly tolerated and may result in complications. Dextrose and intravenous fat emulsions provide the major sources of parenteral, nonprotein energy. These energy sources may not be metabolized efficiently in these patients, even though energy expenditure in this condition is increased significantly. Measurement of urinary nitrogen losses yields evidence useful in assessing the patient's degree of stress. In this manner, the patient's energy and protein requirements may be estimated. Formulations of amino acids, including the branched-chain amino acids, in higher concentrations have been reported to have anticatabolic effects and may improve the maintenance of lean body mass in stressed individuals. The stressed patient is prone to metabolic complications and, therefore, requires more careful monitoring of fluid, electrolyte, and acid-base balance, as well as renal, pulmonary, and liver function. Nutritional status is difficult to assess, since negative nitrogen balance may persist and the visceral proteins such as transferrin become altered in stress and, therefore, may not respond to nutritional intervention alone. The goal of nutritional therapy is the preservation of lean body mass by the safe and efficacious provision of metabolic substrate, thus improving patient survival.