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Abstract
Anemia is a very common complicating feature of chronic kidney disease (CKD) in the elderly. Noninvasive assessment of renal function in the elderly may include several equations although they may actually underestimate the true glomerular filtration rate (GFR). In summary, anemia in the setting of CKD in the elderly is generally underrecognized and undertreated, leading to associations of increased morbidity and mortality. The likelihood of benefits of treatment of anemia in this rapidly increasing subset of patients with CKD remains very high.
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Affiliation(s)
- Franco Musio
- Nephrology Section, Department of Medicine, Inova Fairfax Hospital, Annandale, VA, USA; Nephrology Associates of Northern Virginia, 13135 Lee Jackson Memorial Highway, Suite 135, Fairfax, VA 22033, USA.
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2
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Abstract
Although gene sequencing has elucidated several mutations associated with mild cytopenias in older individuals, iron deficiency remains the most common cause of anemia. Oral iron has remained the frontline standard despite evidence that it is poorly tolerated, often ineffective, and frequently harmful. Studies of different formulations of intravenous iron have shown it effective, with marginal to no toxicity. Serious adverse events have not been described and the failure to address its administration in iron-deficient elderly patients is an unmet clinical need. This article outlines situations in which oral iron should be proscribed and offers an approach to administration of available formulations.
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Affiliation(s)
- Michael Auerbach
- Auerbach Hematology and Oncology, 5233 King Avenue #308, Baltimore, MD 21237, USA; Georgetown University School of Medicine, Washington, DC, USA.
| | - Jerry Spivak
- Johns Hopkins University School of Medicine, 720 Rutland Avenue, Baltimore, MD 21205, USA
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3
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Abstract
Erythropoietin (EPO) has been linked to cardioprotective effects. However, its effects during the aging process are little known. We investigated the effect of EPO administration on hemodynamic parameters, cardiac function, oxidative damage, and erythropoietin receptor (EPOR) expression pattern in the hypovolemic state. EPO was administered (1000 IU/kg/3 days) and then acute hemorrhage (20% blood loss) was induced in young and adult rats. There was no difference in plasmatic EPO in either age group. The hemodynamic basal condition was similar, without alterations in renal function and hematocrit, in both age groups. After bleeding, both EPO-treated age groups had increased blood pressure at the end of the experimental protocol, being greater in adult animals. EPO attenuated the tachycardic effect. Ejection fraction and fractional shortening were higher in adult EPO-treated rats subjected to hemorrhage. In the left ventricle, young and adult EPO-treated rats subjected to bleeding showed an increased EPOR expression. A different EPOR expression pattern was observed in the adult right atrial tissue, compared with young animals. EPO treatment decreased oxidative damage to lipids in both age groups. EPO treatment before acute hemorrhage improves cardiovascular function during the aging process, which is mediated by different EPOR pattern expression in the heart tissue.
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4
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Abstract
BACKGROUND Anemia is an issue of concern in the management of older patients with cancer. In this age group, the incidence and prevalence of both cancer and anemia increase with age. METHODS The clinical consequences and the management of anemia, a common comorbid condition in older patients with cancer, are explored. RESULTS Common causes of chronic anemia include iron deficiency and anemia of chronic disease. The prevalence of vitamin B12 deficiency due to reduced absorption of food-bound vitamin B12 also increases with aging. Although in many cases the cause of anemia is not found, a primary deficiency of erythropoietin may be at fault in at least some of these cases since the response of erythropoietin to anemia may decrease in individuals over age 70. CONCLUSIONS Anemia should not necessarily be ascribed to cancer or aging. The causes of anemia should be pursued and reversed, and hemoglobin levels should be maintained at a minimum of 12 g/dL in cancer patients undergoing chemotherapy who are responsive to erythropoietin. The reversal of anemia may offset or delay the accumulation of catabolic cytokines that may be responsible for functional decline in aging individuals.
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Affiliation(s)
- Lodovico Balducci
- Senior Adult Oncology Program, H. Lee Moffitt Cancer Center Research Institute, Tampa, FL 33612, USA.
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5
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Guo W, Li M, Bhasin S. Testosterone supplementation improves anemia in aging male mice. J Gerontol A Biol Sci Med Sci 2013; 69:505-13. [PMID: 23974081 DOI: 10.1093/gerona/glt127] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Whether aging alone causes anemia is still controversial. In this study, we show that 28-month-old male C57BL/6 mice, maintained in a pathogen-free environment, had significantly lower hemoglobin, hematocrit, and erythrocyte counts than young mice. The anemic condition aggravated further from 28 to 30 months. Old mice displayed increased erythropoietic activity, evidenced by an increase in reticulocyte counts, serum erythropoietin, and splenic expression of erythropoietic genes. An increase in late-stage erythroid progenitors was detected in spleen but not in bone marrow of the old mice. However, old mice also had lower serum iron and transferrin saturation, as well as lower erythrocyte iron incorporation rate. Testosterone supplementation restored serum iron status in old mice to levels similar to that of young adults, further upregulated splenic expression of erythropoietic genes, increased splenic erythroid progenitors, and significantly improved the red cell index. In conclusion, we found that mice can become anemic at very old age without apparent illness. The endogenous compensatory erythropoietic activity was insufficient to normalize the red cell index in old mice, either due to impaired iron homeostasis, ineffective erythropoiesis, or other unknown factors. Testosterone supplementation normalized the iron status and further stimulated splenic erythropoietic activity; both may contribute to improve the anemic condition in the old mice.
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Affiliation(s)
- Wen Guo
- Research Program in Men's Health: Aging and Metabolism, Brigham and Women's Hospital, 221 Longwood Avenue, #347J, Boston, MA 02115.
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6
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Rottembourg JB, Dansaert A. Faisabilité de la stratégie d’administration de la darbepoetin alfa tous les 15 jours : expérience 2005–2007 d’un centre de dialyse. Nephrol Ther 2011; 7:549-57. [DOI: 10.1016/j.nephro.2011.03.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2010] [Revised: 03/15/2011] [Accepted: 03/27/2011] [Indexed: 10/15/2022]
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7
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Olivieri NF, Pakbaz Z, Vichinsky E. HbE/β-thalassemia: basis of marked clinical diversity. Hematol Oncol Clin North Am 2011; 24:1055-70. [PMID: 21075280 DOI: 10.1016/j.hoc.2010.08.008] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Hemoglobin E thalassemia accounts for about one-half of all cases of severe beta thalassemia. There is marked variability in its clinical severity ranging from an asymptomatic to a transfusion-dependent phenotype. The phenotypic variability and inadequate longitudinal data present challenges in determining the optimal management of patients. This article summarizes findings on the natural history of Hemoglobin E thalassemia and some factors responsible for its clinical heterogeneity. Major genetic factors include the type of beta thalassemia mutation, the co-inheritance of alpha thalassemia, and polymorphisms associated with increased synthesis of fetal hemoglobin. Other factors, including response to anemia, and the influence of infection with malaria and other environmental influences, may be important. The remarkable variation and instability of clinical phenotypes in Hemoglobin E thalassemia require individual management plans for each patient, which should be reassessed over time.
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Affiliation(s)
- Nancy F Olivieri
- Pediatrics Medicine and Public Health Sciences, University of Toronto, Toronto, Ontario, Canada.
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8
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Kalantar-Zadeh K, Aronoff GR. Hemoglobin variability in anemia of chronic kidney disease. J Am Soc Nephrol 2009; 20:479-87. [PMID: 19211716 DOI: 10.1681/asn.2007070728] [Citation(s) in RCA: 72] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Hemoglobin levels in individuals with chronic kidney disease fluctuate frequently above or below the recommended target levels within short periods of time even though the calculated mean hemoglobin remains within the target range of 11 to 12 g/dl. Both pharmacologic features and dosing of erythropoiesis-stimulating agents may lead to cyclic pattern of hemoglobin levels within the recommended range. Several longitudinal studies highlight the complexity of maintaining stable hemoglobin levels over time. As a consequence, patients may risk increased hospitalization and mortality, because both low and high hemoglobin levels are associated with increased cardiovascular events and death. The duration of time that hemoglobin remains higher or lower than the target thresholds may be important to adverse outcomes. It is not clear whether adverse effects of hemoglobin variability are because of the therapy with erythropoiesis-stimulating agents and/or iron or despite such a therapy. Several factors affect hemoglobin variability, including those that are drug related, such as pharmacokinetic parameters, patient-related differences in demographic characteristics, and factors affecting clinical status, as well as clinical practice guidelines, treatment protocols, and reimbursement policies. Strategies that consider each of these factors and reduce hemoglobin variability may be associated with improved clinical outcomes.
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Affiliation(s)
- Kamyar Kalantar-Zadeh
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Los Angeles Biomedical Research Institute at Harbor-UCLA, and UCLA David Geffen School of Medicine, Los Angeles, CA 90502, USA.
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9
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Abstract
Among the elderly, anemia occurs with increasing frequency with each advancing decade. Unlike when anemia occurs in younger adults, the cause of anemia in the elderly is oftentimes not readily apparent or attributable to a single cause. However, this commonly observed form of anemia in the elderly (termed unexplained anemia [UA]) can generally be dissected to its root causes, which include renal insufficiency, inflammation, testosterone deficiency, and stem cell proliferative decline. Myelodysplasia (MDS) occurs commonly in this age group but can and should, for both diagnostic and therapeutic considerations, be distinguished from UA.
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Affiliation(s)
- Sasan Makipour
- Clinical Research Branch, Intramural Research Program, National Institute on Aging, National Institutes of Health, Baltimore, MD, USA
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10
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Hubbard RE, Sinead O'Mahony M, Woodhouse KW. ERYTHROPOIETIN AND ANEMIA IN AGING AND FRAILTY. J Am Geriatr Soc 2008; 56:2164-5. [DOI: 10.1111/j.1532-5415.2008.01997.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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11
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O'Donnell A, Premawardhena A, Arambepola M, Allen SJ, Peto TEA, Fisher CA, Rees DC, Olivieri NF, Weatherall DJ. Age-related changes in adaptation to severe anemia in childhood in developing countries. Proc Natl Acad Sci U S A 2007; 104:9440-4. [PMID: 17517643 PMCID: PMC1890513 DOI: 10.1073/pnas.0703424104] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2007] [Indexed: 12/30/2022] Open
Abstract
Severe forms of anemia in children in the developing countries may be characterized by different clinical manifestations at particular stages of development. Whether this reflects developmental changes in adaptation to anemia or other mechanisms is not clear. The pattern of adaptation to anemia has been assessed in 110 individuals with hemoglobin (Hb) E beta-thalassemia, one of the commonest forms of inherited anemia in Asia. It has been found that age and Hb levels are independent variables with respect to erythropoietin response and that there is a decline in the latter at a similar degree of anemia during development. To determine whether this finding is applicable to anemia due to other causes, a similar study has been carried out on 279 children with severe anemia due to Plasmodium falciparum malaria; the results were similar to those in the patients with thalassemia. These observations may have important implications both for the better understanding of the pathophysiology of profound anemia in early life and for its more logical and cost-effective management.
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Affiliation(s)
- Angela O'Donnell
- Weatherall Institute of Molecular Medicine, University of Oxford, John Radcliffe Hospital, Headington, Oxford OX 3 9DS, United Kingdom.
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12
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Balducci L, Ershler WB, Krantz S. Anemia in the elderly—Clinical findings and impact on health. Crit Rev Oncol Hematol 2006; 58:156-65. [PMID: 16387511 DOI: 10.1016/j.critrevonc.2005.09.003] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2003] [Revised: 08/30/2005] [Accepted: 09/08/2005] [Indexed: 11/30/2022] Open
Abstract
Anemia is common in older people and it becomes more so with advancing decades. Because the older population is increasing, the prevalence of anemia and consequently its impact on health and healthcare expenditure is expected to rise. Although the causes and consequences of anemia have not been fully elucidated and its etiology is occasionally elusive, clinical evidence has indicated that anemia itself is a cause of morbidity and it can complicate other health conditions. The clinical approach to anemia is evolving. In the past, anemia was mainly seen as a sign of underlying disease; today, anemia is considered to be a cause of severe deterioration of quality of life, morbidity, and decline in physical function, and a risk factor for death. A better understanding of anemia in the elderly will lead to improved treatment strategies, including the more judicious use of transfusion and appropriate use of erythropoietic agents.
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Affiliation(s)
- L Balducci
- H. Lee Moffitt Cancer & Research Institute, University of South Florida, 12902 Magnolia Dr. Tampa, FL 33612, USA.
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13
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Ershler WB, Sheng S, McKelvey J, Artz AS, Denduluri N, Tecson J, Taub DD, Brant LJ, Ferrucci L, Longo DL. Serum Erythropoietin and Aging: A Longitudinal Analysis. J Am Geriatr Soc 2005; 53:1360-5. [PMID: 16078962 DOI: 10.1111/j.1532-5415.2005.53416.x] [Citation(s) in RCA: 103] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVES To determine the changes in serum erythropoietin with age in patients with and without anemia and to assess the importance of certain comorbidities on changes in erythropoietin level and the development of anemia. DESIGN Clinical history, hematological parameters, and serum erythropoietin levels were examined at 1- to 2-year intervals for 8 to 30 years. SETTING Baltimore Longitudinal Study on Aging (BLSA), National Institute on Aging. PARTICIPANTS One hundred forty-three BLSA participants. MEASUREMENTS Complete blood count and serum chemistries were performed at the time of each visit, and archived serum samples were used for erythropoietin level. RESULTS Although all subjects were healthy and without anemia at the time of initial evaluation, some developed chronic illness-most notably hypertension and diabetes mellitus. Erythropoietin levels rose significantly for the group as a whole, and the slope of the rise was found to be greater for those who did not have associated diabetes mellitus or hypertension. During the subsequent years, subjects who developed anemia but did not have hypertension or diabetes mellitus had the greatest slope in erythropoietin rise over time, whereas those with hypertension or diabetes mellitus and anemia had the lowest erythropoietin slope. CONCLUSION The increase in serum erythropoietin with aging may be compensation for subclinical blood loss, increased red blood cell turnover, or increased erythropoietin resistance of red cell precursors. It is suspected that, with very advanced age, or in those with compromised renal function (e.g., diabetes mellitus or hypertension), the compensatory mechanism becomes inadequate and anemia results.
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14
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Artz AS, Fergusson D, Drinka PJ, Gerald M, Bidenbender R, Lechich A, Silverstone F, McCamish MA, Dai J, Keller E, Ershler WB. Mechanisms of Unexplained Anemia in the Nursing Home. J Am Geriatr Soc 2004; 52:423-7. [PMID: 14962159 DOI: 10.1111/j.1532-5415.2004.52116.x] [Citation(s) in RCA: 83] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To characterize anemia in elderly nursing home residents. DESIGN Prospective multiinstitutional cohort study. SETTING Five nursing homes. PARTICIPANTS From retrospective analysis, residents found to be anemic using chart review were prospectively randomized. Of the 81 residents enrolled, 60 were anemic. MEASUREMENTS Chart review for medical history and factors related to treatment or history of anemia, extensive laboratory evaluation for causes of anemia, and classification of anemia by two hematologists. RESULTS Among the 60 anemic residents, the causes of anemia were idiopathic (n=27), iron-deficiency (n=14), anemia associated with chronic disease (n=8), anemia of renal insufficiency (n=6), and other (n=5). The eryrthropoietin (EPO) response to anemia was lower in residents with idiopathic anemia (IA) than in those with iron-deficiency anemia, and this correlated with renal function as estimated using calculated creatinine clearance. In this elderly population, advancing age was not correlated with lower EPO response. CONCLUSION IA is common in nursing home residents. A lower EPO response contributes to the high prevalence of anemia in this setting and may be due, in part, to occult renal dysfunction.
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Affiliation(s)
- Andrew S Artz
- Institute for Advanced Studies in Aging and Geriatric Medicine, Washington, DC, USA.
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15
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Abstract
A rise in the aging population has been predicted, and, as a result, it is expected that the incidence of age-related health conditions will also increase. Although common in the elderly, anemia is often mild and asymptomatic and rarely requires hospitalization. However, untreated anemia can be detrimental, because it is associated with increased mortality, poor health, fatigue, and functional dependence and can lead to cardiovascular and neurological complications. Several factors have been suggested to cause anemia in this population, for example, blood loss or chronic disease. In some cases, the cause is unknown. It has been suggested that this is a result of the presence of comorbid conditions that can mask the symptoms of anemia. Therefore, appropriate diagnosis and management strategies of anemia in the elderly need to be identified, particularly because anemia may indicate the presence of other serious diseases.
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Affiliation(s)
- Lodovico Balducci
- H. Lee Moffitt Cancer Center and Research Institute, University of South Florida, Tampa 33612, USA.
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16
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Ifudu O, Uribarri J, Rajwani I, Vlacich V, Reydel K, Delosreyes G, Friedman EA. Gender modulates responsiveness to recombinant erythropoietin. Am J Kidney Dis 2001; 38:518-22. [PMID: 11532683 DOI: 10.1053/ajkd.2001.26842] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Several investigators reported that individuals with diabetes and women on hemodialysis treated with recombinant erythropoietin (EPO) attained lower hematocrits than individuals without diabetes and men. It is unclear whether these observed differences in achieved hematocrits are caused by inherent biological differences in responsiveness to EPO or undetected differences in modifiable factors that affect response to EPO. Also potentially modulating response to EPO is diurnal variation in the bioavailability of serum iron. To address these issues, we studied 309 patients undergoing hemodialysis in two large facilities in New York City. Retrospective data collected monthly for 3 months included patients' hematocrit, dose of EPO, urea reduction ratio (URR), total amount of intravenous iron administered, serum albumin concentration, transferrin saturation, and time of day patient underwent dialysis. The 309 study subjects (165 women, 144 men) included 207 blacks (67%), 74 Hispanics (24%), 23 whites (7%), and 5 Asians (2%) with a mean age of 55.4 +/- 15.6 (SD) years. Despite a greater mean URR (74% +/- 6.4% versus 71% +/- 6%; P = 0.001) and a 39% greater dose of EPO (97 +/- 65 versus 59 +/- 53 U/kg; P = 0.001), women (36% +/- 3.5%) had hematocrits equivalent with men (36.5% +/- 3.7%; P = not significant [NS]). There was no difference in the amount of intravenous iron administered to men (375 +/- 389 mg) and women (377 +/- 413 mg; P = NS). Diabetes mellitus (P = 0.48) did not significantly affect the odds of attaining a hematocrit greater than 33% after adjustment for URR, EPO dose, and amount of intravenous iron administered. The time of day a patient underwent dialysis (P = 0.93) had no effect on their response to EPO. We conclude that gender, but not diabetes status or time of dialysis, modulates response to EPO in hemodialysis patients.
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Affiliation(s)
- O Ifudu
- Renal Disease Division, State University of New York Downstate Medical Center, Brooklyn, NY 11203, USA.
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17
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Abstract
Anemia, usually mild, is one of the more common problems of the aged, especially in men. Although the anemia is often multifactorial, the specific entities can be grouped into three broad categories: (a) anemias due to causes more common in the elderly; (b) anemias without special predilection for the elderly; (c) anemias of unknown cause. The major biological questions concern the third category, which accounts for 14-17% of the anemias, and whether senescence itself contributes to anemia. Current opinion favors a diminished erythropoietic reserve with aging, but the data are inconsistent and the mechanism has not been established. It may be that cytokine modulation of erythropoiesis is abnormal. Some findings in unexplained anemia bear partial resemblance to the changes of anemia of chronic disease, suggesting the possibility that subtle unidentified inflammatory responses of unknown origin may be operative in many elderly people. Of the anemias of known cause that are especially common in the elderly, anemia of chronic disease is an important entity but is sometimes obscured or overlooked and its diagnosis rests on crude tests. Cobalamin deficiency is very common also, although most cases are mild and not accompanied by anemia. Because the basic diagnostic approach to anemia is neither complex nor very invasive and anemia may be a marker of poor prognosis, attribution of anemia to senescence is not advisable until other causes have been ruled out.
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Affiliation(s)
- R Carmel
- Department of Medicine, New York Methodist Hospital, Brooklyn, New York 11215-9008, USA
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18
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Pham I, Andrivet P, Sediame S, Defouilloy C, Moutereau S, Wirquin V, Chouaïd C, Housset B, Adnot S. Increased erythropoietin synthesis in patients with COLD or left heart failure is related to alterations in renal haemodynamics. Eur J Clin Invest 2001; 31:103-9. [PMID: 11168446 DOI: 10.1046/j.1365-2362.2001.00774.x] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
The mechanisms controlling erythropoietin (EPO) synthesis by the kidney in patients with chronic obstructive lung disease (COLD) or congestive left heart failure (CLHF) remain incompletely understood. Renal dysfunction occurs as a consequence of decreased renal blood flow (RBF) in these diseases. Because alterations in renal haemodynamics may affect EPO synthesis and red blood cell production, we investigated the potential relationships between renal function and plasma EPO synthesis in patients with COLD or CLHF. Thirty-two patients with COLD and 13 with CLHF underwent determination of renal physiology parameters, plasma EPO levels and haemoglobin levels. Plasma EPO concentrations were increased in patients with COLD or CLHF as compared to normal subjects, and were inversely correlated to haemoglobin concentrations. In patients with COLD or CLHF, plasma EPO was negatively correlated with both RBF and renal oxygen delivery (ROD) and positively correlated with filtration fraction. Plasma EPO was not correlated with glomerular filtration rate, fractional excretion of sodium, PO2 or PCO2. Among the patients with COLD, those with polycythemia (haemoglobin > 150 g L-1) had lower plasma EPO and higher RBF and ROD values than those with normocythemia (haemoglobin < or = 150 g L-1). Taken together, our data suggest that in patients with COLD or CLHF the critical determinant for EPO production is impairment of renal haemodynamics.
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Affiliation(s)
- I Pham
- Centre Hospitalier Intercommunal de Créteil, Service de Physiologie-Explorations Fonctionelles, CHU Henri Mondor, 51 avenue du Maréchal de Lattre de Tassigny, F-94000 Créteil, France
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19
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Misra S, Moore TB, Ament ME, Vargas JH, Busutill RW, McDiarmid SV. Profile of anemia in children after liver transplantation. Transplantation 2000; 70:1459-63. [PMID: 11118090 DOI: 10.1097/00007890-200011270-00011] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Clinical and hematological profile of chronic anemia in children after orthotopic liver transplantation (OLT) is unknown. METHODS We prospectively studied children after orthotopic liver transplantation (OLT) with hemoglobin levels < 2 standard deviation of age appropriate mean for > 6 months. Investigations included hemogram, reticulocyte count, peripheral blood smear, serum vitamin B-12, folic acid levels, iron studies, Coomb's tests, serum erythropoietin (EPO) levels, and stool and urine tests for occult blood. RESULTS Fifty-six participants (22 male and 34 female, mean age 82.9 months, range 20-232, mean post-OLT duration 48.8 months, range 6-132) were studied. The causes of anemia were idiopathic (32), iron deficiency (4), viral infections (2, HIV=1, parvovirus=1), and lymphoproliferative disease (2). Fifteen participants showed spontaneous recovery within 1-6 months. Thirty-one children with idiopathic anemia had low or normal EPO levels (mean 7.33 mmicro/L, range <2.5 to 15.9, normal 4-24). When outliers (iron deficiency=4, HIV disease= 1) were excluded, there was no statistical correlation between hematocrits and EPO levels. Serum vitamin B-12 levels (n=52) were elevated (normal 110-930 pg/ml) (mean=1,186 pg/ml) in 32 (61.5%) and were significantly higher in those with abnormal liver function tests. CONCLUSION Anemia is a common problem in children after OLT. More than half the participants had anemia of unknown etiology with an inappropriate EPO response for the degree of anemia. The normal negative correlation between hematocrit and EPO was lost in these children. The observation regarding serum vitamin B-12 levels requires further study.
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Affiliation(s)
- S Misra
- Department of Pediatrics, and Dumont-UCLA Liver Transplant Center, Los Angeles, California 90095-1752, USA
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20
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Yun YS, Lee HC, Yoo NC, Song YD, Lim SK, Kim KR, Hahn JS, Huh KB. Reduced erythropoietin responsiveness to anemia in diabetic patients before advanced diabetic nephropathy. Diabetes Res Clin Pract 1999; 46:223-9. [PMID: 10624788 DOI: 10.1016/s0168-8227(99)00097-2] [Citation(s) in RCA: 23] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
We often encounter diabetic patients with anemia in whom the causes of anemia were not clearly identified despite differential hematologic studies. We therefore studied the clinical and biochemical characteristics of diabetic patients with anemia of uncertain cause and measured erythropoietin (Epo) concentrations in 35 diabetic subjects without significant diabetic renal disease. Among 62 medical records of diabetic patients with anemia, showing no evidence of advanced diabetic nephropathy (creatinine clearance > or = 30 mg/kg/1.73 m2), the causes of the anemia were not able to be identified in 28 cases (45.2%). In addition, we enrolled 35 diabetic patients with uncertain causes of anemia in order to evaluate the serum Epo responsiveness to anemia, and compared levels to a group of non-diabetic subjects also with anemia. The serum Epo concentrations of diabetic patients (17.6 +/- 8.1 mIU/ml) were significantly lower than those of non-diabetic patients with similar degree of decrease in hemoglobin concentrations (144.9 +/- 108.0 mIU/ml, P<0.001). The hemoglobin concentrations of diabetic patients correlated with creatinine clearance (r = 0.34, P = 0.03), serum creatinine (r = -0.49, P = 0.003) and albumin excretion rate (r = -0.44, P = 0.009), but showed no relation to age, duration of diabetes, glycated hemoglobin, presence of retinopathy or neuropathy. We concluded that reduced Epo responsiveness to anemia could explain the anemia present in diabetic patient but without advanced diabetic nephropathy. This may reflect early renal interstitial damage.
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Affiliation(s)
- Y S Yun
- Department of Endocrinology and Metabolism, Diabetes Center, Yonsei University College of Medicine, Seoul, South Korea
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Lindstedt G, Lundberg PA. Are current methods of measurement of erythropoietin (EPO) in human plasma or serum adequate for the diagnosis of polycythaemia vera and the assessment of EPO deficiency? Scand J Clin Lab Invest 1998; 58:441-58. [PMID: 9832336 DOI: 10.1080/00365519850186247] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
Current methodology for the immunoassay of erythropoietin (EPO) in human plasma or serum is reviewed, with an emphasis on measurement of EPO concentrations in the low and normal ranges, analytical interference and blood sampling requirements. In only 2 out of 8 research or in-house immunoassays reported since 1987 was there evidence that patients with polycythaemia vera (PV) could be identified, PV being an EPO-independent form of polycythaemia in which EPO concentrations are low in untreated cases. The same was true for only 1 out of 13 currently available kit methods. Remarkable differences in sample stability have been observed with different methods. Measurement of EPO in serum is recommended in most published articles. However, only EDTA plasma seems to be acceptable for the one generally available method with proven high diagnostic sensitivity for PV. It is concluded that most EPO assay methods have not been shown to be adequate for the measurement of the low EPO concentrations, and thus have poor diagnostic sensitivity for PV. It is inferred that they might not be appropriate to assess states of EPO deficiency. Only when a sufficiently sensitive diagnostic method becomes generally available will it be possible to define the various causes of low EPO concentrations. As in other fields of polypeptide hormone measurement, further developments in the field of EPO assay may be expected to be important in diagnostic medicine.
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22
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Spivak JL. The Physiologic Basis for the Pharmacologic Use of Recombinant Erythropoietin. Cancer Control 1998; 5:22-25. [PMID: 10762463 DOI: 10.1177/107327489800502s05] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
While many growth factors influence erythroid progenitor cell proliferation, the hematopoietic growth factor erythropoietin has the most impact on the production of erythrocytes.
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Affiliation(s)
- JL Spivak
- Division of Hematology, The Johns Hopkins University School of Medicine, Baltimore, Maryland 21205, USA
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Kamenetz Y, Beloosesky Y, Zeltzer C, Gotlieb D, Magazanik A, Fishman P, Grinblat J. Relationship between routine hematological parameters, serum IL-3, IL-6 and erythropoietin and mild anemia and degree of function in the elderly. AGING (MILAN, ITALY) 1998; 10:32-8. [PMID: 9589749 DOI: 10.1007/bf03339631] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
To investigate the influence of functioning on unexplained senile anemia, we measured commonly used hematological parameters (serum iron, transferrin, iron saturation and ferritin) in addition to specific erythropoietic factors, such as interleukin-3 (IL-3), interleukin-6 (IL-6), and erythropoietin (EPO) in 48 elderly subjects aged 65-90 years. The subjects were divided into 3 groups: 1) 17 patients with unexplained mild anemia; 2) 17 non-anemic patients with newly acquired stroke and who previously were functionally active; 3) 14 functionally active patients with no major disease who served as controls. Anemia was defined as hemoglobin (Hb) values under 12.0 g/dL. The degree of functional ability was defined and scored by the "functional independence measure" (FIM) test. Data are presented as mean values +/- SD. The results revealed a correlation between the functional state and levels of Hb, iron and transferrin with unchanged iron saturation. Patients in the mild anemia group were found to be functionally declined (FIM = 57 +/- 19.4) with the relatively lowest mean iron (75.1 +/- 17 micrograms/dL) and transferrin levels (243 +/- 42.6 micrograms/dL). The stroke group (FIM = 62 +/- 17.7) had intermediate levels of iron (85.4 +/- 20.3 micrograms/dL) and transferrin (245 +/- 45.2), and with the continuation of the declined functional state the Hb level decreased significantly (13.7 +/- 0.9 to 12.0 +/- 1.0 g/dL, p < 0.001). The highest mean values of iron (102 +/- 27.9 micrograms/dL) and transferrin (322 +/- 42.7 micrograms/dL) were found in the control group (FIM = 122.7 +/- 5.8). The ferritin levels showed an opposite trend. IL-3 values were undetectable in the anemic and control groups, and were elevated in some patients in the stroke group. The lowest IL-6 level was observed in the anemic group, and the highest in the control group. Serial IL-6 assays in the stroke group showed an upward trend. Erythropoietin levels in all groups showed no difference.
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Affiliation(s)
- Y Kamenetz
- Department of Geriatrics, Rabin Medical Center, Petah-Tiqva, Israel
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24
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Joosten E, Van Hove L, Lesaffre E, Goossens W, Dereymaeker L, Van Goethem G, Pelemans W. Serum erythropoietin levels in elderly inpatients with anemia of chronic disorders and iron deficiency anemia. J Am Geriatr Soc 1993; 41:1301-4. [PMID: 8227911 DOI: 10.1111/j.1532-5415.1993.tb06479.x] [Citation(s) in RCA: 25] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
OBJECTIVE To analyze the relationship between serum erythropoietin levels and hemoglobin levels in elderly patients with anemia of chronic disorders related to cancer or acute infection when compared with anemic patients with iron deficiency. DESIGN Prospective survey with comparison groups. SETTING Tertiary care center. PATIENTS An elderly group aged 70 and above (mean 84, range 70-96) was divided into subgroups of 45 with anemia of chronic disorders (23 with cancer and 22 with acute infection), 24 with iron-deficiency anemia, and 27 with no anemia. Thirty non-anemic younger adults were also studied. MEASUREMENTS Serum erythropoietin (radioimmunoassay), complete blood count, serum iron, B12, folate and ferritin, liver and kidney function tests, blood gas analyses, and bacteriological and radiological tests. RESULTS The serum erythropoietin levels were significantly lower in the elderly non-anemic hospitalized group than in the healthy younger group. A significant negative relationship between the log serum erythropoietin and hemoglobin levels was found in patients with iron deficiency, but not in the other groups. For any given hemoglobin level, the response of erythropoietin was significantly higher in anemic patients with iron deficiency when compared with the neoplastic and infectious group. CONCLUSION Erythropoietin response to anemia is blunted in elderly patients with anemia of chronic disorders related to cancer or acute infection. Erythropoietin level is lower in non-anemic elderly inpatients than in healthy younger persons.
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Affiliation(s)
- E Joosten
- Department of Internal Medicine, University Hospitals K.U. Leuven, Belgium
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25
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Nafziger J, Pailla K, Luciani L, Andreux JP, Saint-Jean O, Casadevall N. Decreased erythropoietin responsiveness to iron deficiency anemia in the elderly. Am J Hematol 1993; 43:172-6. [PMID: 8352231 DOI: 10.1002/ajh.2830430303] [Citation(s) in RCA: 27] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
The prevalence of anemia in the elderly raises the question of an inappropriate secretion of erythropoietin in response to increased demands. Therefore, the serum erythropoietin concentration of elderly patients (74-95 years) with iron deficiency anemia was measured and compared to that of iron deficiency anemic adults (25-60 years). A lowered erythropoietin secretion in response to anemia was observed in elderly patients in comparison with adults. However, the serum erythropoietin of the anemic elderly was inversely correlated with hemoglobin levels as shown for the anemic adults. The progressive reduction of the renal function observed with aging could explain the decreased capacity of erythropoietin secretion in elderly patients.
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Affiliation(s)
- J Nafziger
- Laboratoire d'Hématologie, Hôpital Charles Foix, Ivry Sur Seine, France
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Salive ME, Cornoni-Huntley J, Guralnik JM, Phillips CL, Wallace RB, Ostfeld AM, Cohen HJ. Anemia and hemoglobin levels in older persons: relationship with age, gender, and health status. J Am Geriatr Soc 1992; 40:489-96. [PMID: 1634703 DOI: 10.1111/j.1532-5415.1992.tb02017.x] [Citation(s) in RCA: 158] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
OBJECTIVE To determine the relationship of hemoglobin levels and anemia with age and health status in older adults. DESIGN Survey. SETTING Community. PARTICIPANTS AND METHODS Hematologic tests were obtained from 3,946 adults aged greater than or equal to 71 years in three communities (East Boston, MA; Iowa and Washington counties, IA; and New Haven, CT). RESULTS Hemoglobin level was inversely associated with age, although this was more pronounced in men than in women. The proportion anemic was equal for men and women aged 71-74 years (8.6%) and increased differentially with age, reaching 41% and 21% for men and women aged greater than or equal to 90 years, respectively. Hemoglobin and anemia were independently associated with age, race, body-mass index, smoking, cancer, hospitalization, renal insufficiency, and hypoalbuminemia. The adjusted relative odds of anemia for a 5-year increase in age was 1.5 (95% confidence interval [CI] 1.3-1.8) for men and 1.2 (95% CI 1.1-1.4) for women. CONCLUSIONS Age is significantly associated with both hemoglobin levels and anemia, with a stronger effect in men compared with women, even after simultaneously adjusting for demographic characteristics and health status. The decline of hemoglobin and concomitant increased anemia with age is not necessarily a result of "normal aging" so the detection of anemia in an older person should prompt appropriate clinical attention.
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Affiliation(s)
- M E Salive
- Epidemiology, Demography, and Biometry Program, National Institute on Aging, National Institutes of Health, Bethesda, Maryland 20892
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Abstract
Anemia is one of the most common disorders in elderly patients. The pathophysiology of anemia is the same in the young as well as the old. However, the common presence of multiorgan dysfunction or disease in elderly patients can alter the clinical presentation, response to treatment, and prognosis of anemia in this group.
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Affiliation(s)
- A Mansouri
- Geriatric Research, Education and Clinical Center, John L. McClellan Memorial Veterans Hospital, Little Rock, Arkansas
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