Strategies for the Laboratory Diagnosis of Some Common Causes of Anaemia in Elderly Patients

Iron deficiency anemia in older adults: A review

Anemia in older adults is a risk factor for numerous negative outcomes. There is no standard definition, but in most studies, anemia is defined as a hemoglobin value <12 g/dL for women and <13 g/dL for men. Absolute iron deficiency anemia is defined as the combination of anemia and the absence of total body iron. Serum ferritin is the most frequently used diagnostic parameter, but its concentration increases with age and in the presence of inflammatory diseases. Other laboratory tests, such as transferrin saturation, soluble transferrin receptor and the soluble transferrin receptor/ferritin index might provide useful information, but there is a wide variety in the cut-off values and interpretation of the results. Recent research regarding hepcidin as a central regulator of iron homeostasis is promising, but it has not been used yet for the routine diagnosis of iron deficiency anemia. In older iron deficiency anemia patients, an esophagogastroduodenoscopy and colonoscopy should be initiated in order to identify the underlying bleeding cause. CT colonography can replace a colonoscopy, and in specific cases, a video capsule is recommended. It remains crucial to keep in mind which potential benefits might be expected from these investigations in this vulnerable population, taking into account the comorbidity and life expectancy, and one should discuss in advance the possible therapeutic options and complications with the patient, a family member or a proxy. Oral iron administration is the standard treatment, but parenteral iron is a convenient and safe way to provide the total iron dose in one or a few sessions. Geriatr Gerontol Int 2018; 18: 373-379.

Anemia in chronic heart failure: can we treat? What to treat?

Even though anemia is a significant comorbidity regularly observed in patients with chronic heart failure (HF), only in recent years systematic therapeutic research has been started. This article aims to review the aspects of anemia in chronic HF that are relevant for making treatment decisions, beginning with the definition of anemia and its incidence and prevalence of anemia in patients with chronic HF. Considering the etiology and prognostic impact of anemia in chronic HF, several treatment options will be considered. The latter are the application of erythropoiesis-stimulating agents (erythropoietin or darbepoetin alfa) or in the application of intravenous iron (e.g., iron carboxymaltose). According to the results seen in the FAIR-HF trial, iron supplementation should be particularly considered to improve symptoms and quality of life. Intravenous iron application may result in higher compliance and much faster treatment response than oral iron. The RED-HF study will show whether use of darbepoetin alfa in anemic patients with chronic HF will reduce the combined endpoint of death for any reason or hospitalization for heart failure.

Role of iron deficiency and anemia in cardio-renal syndromes

Chronic heart failure is a common disorder associated with unacceptably high mortality rates. Chronic renal disease and anemia are two important comorbidities that significantly influence morbidity and mortality in patients with chronic heart failure (CHF). Progress in CHF again may cause worsening of kidney function and anemia. To describe this vicious cycle, the term cardio-renal anemia syndrome has been suggested. Iron deficiency is part of the pathophysiology of anemia in both CHF and chronic kidney disease, which makes it an interesting target for treatment of anemia in cardio-renal anemia syndrome. Recently, studies have highlighted the potential clinical benefits of treating iron deficiency in patients with CHF, even if these patients are nonanemic. This article summarizes studies investigating the influence of iron deficiency with or without anemia in chronic kidney disease and CHF and gives an overview of preparations of intravenous iron currently available.

Micronutrient (Zn, Cu, Fe)-gene interactions in ageing and inflammatory age-related diseases: implications for treatments

In ageing, alterations in inflammatory/immune response and antioxidant capacity lead to increased susceptibility to diseases and loss of mobility and agility. Various essential micronutrients in the diet are involved in age-altered biological functions. Micronutrients (zinc, copper, iron) play a pivotal role either in maintaining and reinforcing the immune and antioxidant performances or in affecting the complex network of genes (nutrigenomic approach) involved in encoding proteins for a correct inflammatory/immune response. By the other side, the genetic inter-individual variability may affect the absorption and uptake of the micronutrients (nutrigenetic approach) with subsequent altered effects on inflammatory/immune response and antioxidant activity. Therefore, the individual micronutrient-gene interactions are fundamental to achieve healthy ageing. In this review, we report and discuss the role of micronutrients (Zn, Cu, Fe)-gene interactions in relation to the inflammatory status and the possibility of a supplement in the event of a micronutrient deficiency or chelation in presence of micronutrient overload in relation to specific polymorphisms of inflammatory proteins or proteins related of the delivery of the micronutriemts to various organs and tissues. In this last context, we report the protein-metal speciation analysis in order to have, coupled with micronutrient-gene interactions, a more complete picture of the individual need in micronutrient supplementation or chelation to achieve healthy ageing and longevity.

Serum ferritin and nutritional status in older adults at eldercare facilities

OBJECTIVES

To identify serum ferritin levels and their association with nutritional status determined by Body Mass Index in older adults at four eldercare facilities.

METHODS

An exploratory, cross-sectional study was carried out on 100 older adults residing at eldercare facilities in Colima, Mexico. Association between blood serum ferritin levels and nutritional status determined by Body Mass Index was evaluated. Ferritin levels were determined by means of chemiluminescence of blood samples obtained from subjects under control conditions. Descriptive statistics were used to analyze demographic characteristics. Student's t test and chi-square test were used to compare ferritin levels and Body Mass Index, respectively, between sexes. Statistical significance was considered to exist when P≤ 0.05. Pearson's correlation was used to establish the relation between Body Mass Index and serum ferritin levels.

RESULTS

Mean serum ferritin levels were 59.9489 ng/mL in women and 86.9266 ng/mL in men (P= 0.12). In regard to Body Mass Index there was statistical significance between normal vs overweight/obesity (P = 0.008), but not between normal vs underweight (P = 0.34). Body Mass Index/serum ferritin correlation was not statistically significant (Pearson's r = 0.003).

CONCLUSIONS

The quantification of a single serum indicator is insufficient for determining nutritional status in the older adult.

Anemia in heart failure: an overview of current concepts

Chronic heart failure is a substantial public health problem. Anemia is an important comorbidity frequently observed in patients with the disease and, in heart failure, anemia has only recently started to attract systematic epidemiological and therapeutical research endeavor. This article describes the many aspects of anemia in chronic heart failure, starting with the ongoing discussion of how to define anemia, which has important consequences for the estimation of its prevalence and incidence. Further, we discuss prognostic implications of anemia in patients with chronic or acute heart failure, the etiology of anemia in heart failure and treatment possibilities. Such therapeutic avenues embrace intravenous iron preparations and subcutaneous administration of erythropoietin and its derivatives, all of which have been extensively studied over the last several years. Finally, this article describes the potential costs incurred by treating anemic patients with heart failure.

The evolving clinical scenario of myelodysplastic syndrome: the need for a complete and up to date upfront diagnostic assessment

Until the beginning of the current millennium, few concrete therapeutic possibilities were available for myelodysplastic syndrome (MDS) patients. This situation has dramatically changed in the last decade when new knowledge, new drugs and new opportunities have become available for physicians and their MDS patients. A correct diagnostic and prognostic assessment of all MDS patients wherever they are first seen in a hematology or internal medicine department is mandatory to identify the best therapeutic option and the most appropriate resources allocation. This article will review modern diagnostic criteria and classification together with correlated new therapeutic opportunities.

Myelodysplastic syndrome in elderly patients: correlation of CBC with cytogenetic and FISH analysis

Unexplained anemia in the elderly could represent myelodysplastic syndrome (MDS). We assessed the utility of using a fluorescence in situ hybridization (FISH) panel for common chromosomal abnormalities seen in MDS. A total of 101 elderly outpatients with anemia of unknown etiology were evaluated. Complete blood count, bone marrow biopsy, conventional cytogenetic analysis (CC), and FISH panel were reviewed. A total of 21 (21%) of the 101 patients had MDS. A combination of CC and FISH identified chromosomal abnormalities in 17 (81%) of the patients with MDS. The remaining 4 (19%) were diagnosed with MDS based solely on morphologic criteria. Except in two cases, FISH did not reveal abnormalities not already detected by CC. Furthermore, MDS patients infrequently had isolated anemia (14%) as opposed to those without MDS (75%). A MDS FISH panel is not more sensitive than CC in elderly outpatients with unexplained anemia. MDS is more likely if in addition to anemia, leukopenia and/or thrombocytopenia are also present.

Malnutrition on the menu: nutritional status of institutionalised elderly Australians in low-level care

BACKGROUND

Most studies reporting malnutrition in the elderly relate to high-level care. However, one third of Australians in aged care reside in low-level care facilities. Data is limited on their nutritional status.

OBJECTIVE

To investigate the nutritional status of elderly in low-level care facilities.

DESIGN

A cross sectional study design.

SETTING

14 low-level aged care facilities in metropolitan Melbourne.

PARTICIPANTS

Convenience sample of 103 ambulatory elderly (86 +/- 6.6 years (mean +/- SD), 76% female, comprising 15% of the hostel population) able to perform daily functions of living.

MEASUREMENTS

Nutritional intake assessed by three-day weighed food records, and nutritional status by haematological and biochemical markers and body composition (dual energy X-ray absorptiometry).

RESULTS

FOOD served did not supply the estimated average requirements (EAR) for 5 of the 14 nutrients analysed. Compared with EAR, 34% of participants were protein malnourished and 62% had energy intake deficits. Micronutrient intake was low for calcium, magnesium, folate, zinc (for men) and dietary fibre. Vitamin D deficiency (serum 25OH Vitamin D < 50 nmol/L) was present in 58% of residents. More men than women had low haemoglobin (P < 0.000), low red blood cells (P < 0.000), and a raised white blood cell count (P = 0.004). Forty three percent of men and 21% women had sarcopenia, 28% of men and 44% women had excess body fat (> 28% and >40%, respectively) and 14% of men and 12 % of women were sarcopenic-obese. Only 12% showed no sign of undernutrition using seven different nutritional indicators. Around 65% had two or more indicators of undernutrition.

CONCLUSION

These findings highlight the need for the supply of more, better quality, nutrient dense food to residents and better detection of undernutrition in aged care facilities. Maintenance of nutritional status has the potential to reduce morbidity and delay the transition to high-level care.

Phagocytosis, oxidative burst, and produced reactive species are affected by iron deficiency anemia and anemia of chronic diseases in elderly

Iron and oxidative stress have a regulatory interplay. During the oxidative burst, phagocytic cells produce free radicals such as hypochlorous acid (HOCl). Nevertheless, scarce studies evaluated the effect of either iron deficiency anemia (IDA) or anemia of chronic disease (ACD) on phagocyte function in the elderly. The aim of the present study was to determine the oxidative burst, phagocytosis, and nitric oxide (*NO) and HOCl, reactive species produced by monocytes and neutrophils in elderly with ACD or IDA. Soluble transferrin receptor, serum ferritin, and soluble transferrin receptor/log ferritin (TfR-F) index determined the iron status. The study was constituted of 39 patients aged over 60 (28 women and 11 men) recruited from the Brazilian Public Health System. Oxidative burst fluorescence intensity per neutrophil in IDA group and HOCl generation in both ACD and IDA groups were found to be lower (p < 0.05). The percentages of neutrophils and monocytes expressing phagocytosis in ACD group were found to be higher (p < 0.05). There was an overproduction of *NO from monocytes, whereas the fundamental generation of HOCl appeared to be lower. Phagocytosis, oxidative burst, and *NO and HOCl production are involved in iron metabolism regulation in elderly patients with ACD and IDA.

CSF proteomic analysis reveals persistent iron deficiency-induced alterations in non-human primate infants

Iron deficiency (ID) anemia during infancy results in long-term neurological consequences, yet the mediating mechanisms remain unclear. Infant monkeys often become naturally anemic during the first 6 months of life, presenting an opportunity to determine the effect of developmental iron deficiency. After weaning, animals were chosen randomly for supplementation with oral iron or, fed a standard commercial chow diet. The control group was never iron deficient. ID anemia was corrected by 12 months in both groups, as indicated by hematological parameters. CSF was collected for proteomic analysis at 12 months of age to assess the impact of developmental ID on the brain. The CSF proteome for both formerly iron deficient groups was similar and revealed 12 proteins with expression levels altered at least twofold. These proteins were identified by matrix assisted laser desorption ionization time-of-flight spectrometry and included prostaglandin D synthase, olfactory receptors and glial fibrillary acidic protein. Thus the proteomic analysis reveals a persistent effect of ID and provides insights into reports of disturbed sleep, hypomyelination and other behavioral alterations associated with ID. Furthermore, alterations in the CSF proteome despite normal hematologic parameters indicate that there is a hierarchical system that prioritizes repletion of red cell mass at the expense of the brain.

Pernicious anemia in Chinese: a study of 181 patients in a Hong Kong hospital

To study the clinical and hematologic features of pernicious anemia in Chinese, we describe 181 Chinese with megaloblastic anemia and low serum cobalamin, in association with either classic Schilling test results (82 patients) or the presence of serum antibody to intrinsic factor (99 patients), encountered in a regional hospital in Hong Kong from May 1994 to May 2005. The median age was 75 years (range, 32-95 yr) and the male to female ratio was 1:1.5. The chief presenting feature was anemia, and fewer than 10% of patients presented predominantly with neurologic deficit. Gastric biopsies of 109 patients showed glandular atrophy in 73, endocrine cell hyperplasia in 5, polyps in 14, adenocarcinoma in 1, and chronic gastritis in the rest. Gastric adenocarcinoma occurred in 1.7% of patients after a median follow-up of 35 months (range, 0.5-132 mo). Diabetes mellitus occurred in 24% of patients and thyroid disease in 7%. No specific ABO blood group was associated with pernicious anemia. Serum antibody to intrinsic factor (73%) occurred more frequently than serum antibody to gastric parietal cell (65%) (p=0.353). The frequency of serum antibody to gastric parietal cell was higher in male (78%) than in female patients (53%) (p=0.018). Pernicious anemia is a major cause of megaloblastic anemia in Chinese.