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Schmidt WFJ, Ahlgrim C. Clinical importance of distinguishing true anemia from dilutional pseudo-anemia: Consequences of a 3-year follow-up volume assessment in a heart failure patient. Clin Case Rep 2024; 12:e9071. [PMID: 38863867 PMCID: PMC11164669 DOI: 10.1002/ccr3.9071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Revised: 02/15/2024] [Accepted: 05/25/2024] [Indexed: 06/13/2024] Open
Abstract
In chronic heart failure, dilutional anemia and hypervolemia may occur due to plasma volume expansion, the latter sometimes exacerbated by an increase in red cell volume. Diagnosis and a therapeutic strategy require determination of vascular volumes.
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Affiliation(s)
- Walter F. J. Schmidt
- Deptartment of Sports Medicine/Sports PhysiologyUniversity of BayreuthBayreuthGermany
| | - Christoph Ahlgrim
- Department of Cardiology and Angiology II, Heart Center Freiburg University, Faculty of MedicineUniversity of FreiburgFreiburg im BreisgauGermany
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Plumb JOM, Otto JM, Kumar SB, Bali S, Wakatsuki M, Schmidt WFJ, Montgomery HE, Grocott MPW, Levett DZ. Cardiopulmonary exercise testing before and after intravenous iron in preoperative patients: a prospective clinical study. Perioper Med (Lond) 2023; 12:31. [PMID: 37400931 DOI: 10.1186/s13741-023-00319-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Accepted: 06/16/2023] [Indexed: 07/05/2023] Open
Abstract
BACKGROUND Anemia is associated with impaired physical performance and adverse perioperative outcomes. Iron-deficiency anemia is increasingly treated with intravenous iron before elective surgery. We explored the relationship between exercise capacity, anemia, and total hemoglobin mass (tHb-mass) and the response to intravenous iron in anemic patients prior to surgery. METHODS A prospective clinical study was undertaken in patients having routine cardiopulmonary exercise testing (CPET) with a hemoglobin concentration ([Hb]) < 130 g.l-1 and iron deficiency/depletion. Patients underwent CPET and tHb-mass measurements before and a minimum of 14 days after receiving intravenous (i.v.) Ferric derisomaltose (Monofer®) at the baseline visit. Comparative analysis of hematological and CPET variables was performed pre and post-iron treatment. RESULTS Twenty-six subjects were recruited, of whom 6 withdrew prior to study completion. The remaining 20 (9 [45%] male; mean ± SD age 68 ± 10 years) were assessed 25 ± 7 days between baseline and the final visit. Following i.v. iron, increases were seen in [Hb] (mean ± SD) from 109 ± 14 to 116 ± 12 g l-1 (mean rise 6.4% or 7.3 g l-1, p = < 0.0001, 95% CI 4.5-10.1); tHb-mass from 497 ± 134 to 546 ± 139 g (mean rise 9.3% or 49 g, p = < 0.0001, 95% CI 29.4-69.2). Oxygen consumption at anerobic threshold ([Formula: see text] O2 AT) did not change (9.1 ± 1.7 to 9.8 ± 2.5 ml kg-1 min-1, p = 0.09, 95% CI - 0.13 - 1.3). Peak oxygen consumption ([Formula: see text] O2 peak) increased from 15.2 ± 4.1 to 16 ± 4.4 ml.kg.-1 min-1, p = 0.02, 95% CI 0.2-1.8) and peak work rate increased from 93 [67-112] watts to 96 [68-122] watts (p = 0.02, 95% CI 1.3-10.8). CONCLUSION Preoperative administration of intravenous iron to iron-deficient/deplete anemic patients is associated with increases in [Hb], tHb-mass, peak oxygen consumption, and peak work rate. Further appropriately powered prospective studies are required to ascertain whether improvements in tHb-mass and performance in turn lead to reductions in perioperative morbidity. TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT 033 46213.
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Affiliation(s)
- James O M Plumb
- Perioperative and Critical Care Theme, NIHR Southampton Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust/University of Southampton, Southampton, UK.
- Centre for Human Integrative Physiology, Faculty of Medicine, University of Southampton, Southampton, UK.
- Anaesthesia and Critical Care Research Unit, University Hospital Southampton NHSFT, Southampton, UK.
- Shackleton Department of Anaesthesia, University Hospital Southampton NHSFT, Southampton, UK.
| | - James M Otto
- Perioperative and Critical Care Theme, NIHR Southampton Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust/University of Southampton, Southampton, UK
- Centre for Human Integrative Physiology, Faculty of Medicine, University of Southampton, Southampton, UK
- Anaesthesia and Critical Care Research Unit, University Hospital Southampton NHSFT, Southampton, UK
- Shackleton Department of Anaesthesia, University Hospital Southampton NHSFT, Southampton, UK
| | - Shriya B Kumar
- Perioperative and Critical Care Theme, NIHR Southampton Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust/University of Southampton, Southampton, UK
| | - Sitara Bali
- Perioperative and Critical Care Theme, NIHR Southampton Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust/University of Southampton, Southampton, UK
| | - Mai Wakatsuki
- Shackleton Department of Anaesthesia, University Hospital Southampton NHSFT, Southampton, UK
| | - Walter F J Schmidt
- Department of, Sports Medicine/Sports Physiology, University of Bayreuth, Bayreuth, Germany
| | - Hugh E Montgomery
- Centre for Human Health and Performance/Institute of Sport, Exercise and Health, University College London, London, UK
- NIHR University College London Hospitals Biomedical Research Centre, London, UK
| | - Michael P W Grocott
- Perioperative and Critical Care Theme, NIHR Southampton Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust/University of Southampton, Southampton, UK
- Centre for Human Integrative Physiology, Faculty of Medicine, University of Southampton, Southampton, UK
- Anaesthesia and Critical Care Research Unit, University Hospital Southampton NHSFT, Southampton, UK
- Shackleton Department of Anaesthesia, University Hospital Southampton NHSFT, Southampton, UK
- Department of Anesthesiology, Duke University School of Medicine, Durham, NC, USA
| | - Denny Z Levett
- Perioperative and Critical Care Theme, NIHR Southampton Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust/University of Southampton, Southampton, UK
- Centre for Human Integrative Physiology, Faculty of Medicine, University of Southampton, Southampton, UK
- Anaesthesia and Critical Care Research Unit, University Hospital Southampton NHSFT, Southampton, UK
- Shackleton Department of Anaesthesia, University Hospital Southampton NHSFT, Southampton, UK
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Seiler F, Ahlgrim C, Birkner P, Wrobel N, Rilinger J, Grundmann S, Bode C, Pottgiesser T. Blood volume and hemoglobin mass in long-term heart transplant recipients with and without Anemia. J Cardiothorac Surg 2021; 16:159. [PMID: 34078389 PMCID: PMC8171054 DOI: 10.1186/s13019-021-01510-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Accepted: 05/05/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND In systolic chronic heart failure, a heterogeneous blood volume (BV) regulation can be found with plasma volume expansion in many cases, possibly leading to pseudoanemia. Little is known about the volume status after heart transplantation (HTX). So far, anemia of HTX recipients was solely investigated using hemoglobin-concentration that may be misleading in a clinical context. The objective of the study was whether a difference in plasma volume and red cell volume can be observed in clinically stable heart transplant recipients compared to matched control subjects. Secondary, the aim was to describe anemia in the long-term after HTX based on quantitative data. METHODS Blood volume and its constituents red cell volume and plasma volume were quantified using an abbreviated carbon monoxide rebreathing method (aCORM) with focus on its primary measure total hemoglobin mass (Hbmass) and coincidental anemia in 36 (7 women) heart transplant recipients. For comparison, a matched control group of 46 (5 women) healthy subjects was selected. RESULTS Neither Hbmass nor blood volumes were significantly different in HTX patients compared to matched healthy control group subjects. The prevalence of anemia 6.3 ± 4.3 years after transplantation was 19%. Hbmass and red cell volume were significantly lower in anemic HTX patients compared to non-anemic patients while plasma volume was not expanded. Various immunosuppressant regimens did not have an effect on Hbmass, plasma volume or red cell volume. CONCLUSIONS There was no difference in blood volumes and Hbmass between HTX patients and control subjects. The pathophysiologic blood volume regulation in chronic heart failure does not seem to be longer active in long-term HTX recipients. However, in the long-term after HTX, anemia occurs in a considerable number of patients as true anemia without a clear association with immunosuppression. TRIAL REGISTRATION German registry for clinical studies, DRKS00006078. Registered 09 May 2014, https://www.drks.de/drks_web/navigate.do?navigationId=trial . HTML&TRIAL_ID=DRKS00006078.
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Affiliation(s)
- Florian Seiler
- Department of Cardiology and Angiology I, Heart Center, Faculty of Medicine, University Medical Center Freiburg, University of Freiburg, Hugstetter Str. 55, 79106, Freiburg, Germany
| | - Christoph Ahlgrim
- Department of Cardiology and Angiology II, Heart Center, Faculty of Medicine, University Medical Center Freiburg, University of Freiburg, Bad Krozingen, Germany
| | - Philipp Birkner
- Department of Cardiology and Angiology I, Heart Center, Faculty of Medicine, University Medical Center Freiburg, University of Freiburg, Hugstetter Str. 55, 79106, Freiburg, Germany
| | - Nina Wrobel
- Center for Medicine, Institute for Exercise- and Occupational Medicine, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Jonathan Rilinger
- Department of Cardiology and Angiology I, Heart Center, Faculty of Medicine, University Medical Center Freiburg, University of Freiburg, Hugstetter Str. 55, 79106, Freiburg, Germany
| | - Sebastian Grundmann
- Department of Cardiology and Angiology I, Heart Center, Faculty of Medicine, University Medical Center Freiburg, University of Freiburg, Hugstetter Str. 55, 79106, Freiburg, Germany
| | - Christoph Bode
- Department of Cardiology and Angiology I, Heart Center, Faculty of Medicine, University Medical Center Freiburg, University of Freiburg, Hugstetter Str. 55, 79106, Freiburg, Germany
| | - Torben Pottgiesser
- Department of Cardiology and Angiology I, Heart Center, Faculty of Medicine, University Medical Center Freiburg, University of Freiburg, Hugstetter Str. 55, 79106, Freiburg, Germany.
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Krehl LM, Plumb JOM, Wachsmuth NB, Haupt S, Kumar SB, Otto JM, Schierbauer J, Grocott MPW, Montgomery HE, Schmidt WFJ. A carbon monoxide 'single breath' method to measure total haemoglobin mass: a feasibility study. Exp Physiol 2020; 106:567-575. [PMID: 33369791 DOI: 10.1113/ep089076] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2020] [Accepted: 12/14/2020] [Indexed: 12/20/2022]
Abstract
NEW FINDINGS What is the central question of this study? Is it possible to modify the CO-rebreathing method to acquire reliable measurements of haemoglobin mass in ventilated patients? What is the main finding and its importance? A 'single breath' of CO with a subsequent 30 s breath hold provides almost as exact a measure of haemoglobin mass as the established optimized CO-rebreathing method when applied to healthy subjects. The modified method has now to be checked in ventilated patients before it can be used to quantify the contributions of blood loss and of dilution to the severity of anaemia. ABSTRACT Anaemia is defined by the concentration of haemoglobin (Hb). However, this value is dependent upon both the total circulating haemoglobin mass (tHb-mass) and the plasma volume (PV) - neither of which is routinely measured. Carbon monoxide (CO)-rebreathing methods have been successfully used to determine both PV and tHb-mass in various populations. However, these methods are not yet suitable for ventilated patients. This study aimed to modify the CO-rebreathing procedure such that a single inhalation of a CO bolus would enable its use in ventilated patients. Eleven healthy volunteers performed four CO-rebreathing tests in a randomized order, inhaling an identical CO volume. In two tests, CO was rebreathed for 2 min (optimized CO rebreathing; oCOR), and in the other two tests, a single inhalation of a CO bolus was conducted with a subsequent breath hold of 15 s (Procnew 15s) or 30 s (Procnew 30s). Subsequently, the CO volume in the exhaled air was continuously determined for 20 min. The amount of CO exhaled after 7 and 20 min was respectively 3.1 ± 0.3 and 5.9 ± 1.1 ml for oCOR, 8.7 ± 3.6 and 12.0 ± 4.4 ml for Procnew 15s and 5.1 ± 2.0 and 8.4 ±2.6 ml for Procnew 30s. tHb-mass was 843 ± 293 g determined by oCOR, 821 ± 288 g determined by Procnew 15s (difference: P < 0.05) and 849 ± 311 g determined by Procnew 30s. Bland-Altman plots demonstrated slightly lower tHb-mass values for Procnew 15s compared with oCOR (-21.8 ± 15.3 g) and similar values for Procnew 30s. In healthy volunteers, a single inhalation of a CO bolus, preferably followed by a 30 s breath hold, can be used to determine tHb-mass. These results must now be validated for ventilated patients.
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Affiliation(s)
- Lisa-Marie Krehl
- Department of Sports Medicine/Sports Physiology, University of Bayreuth, Bayreuth, 95440, Germany
| | - James O M Plumb
- Respiratory and Critical Care Research Area, NIHR Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust/University of Southampton, Southampton, UK
| | - Nadine B Wachsmuth
- Department of Sports Medicine/Sports Physiology, University of Bayreuth, Bayreuth, 95440, Germany
| | - Sandra Haupt
- Department of Sports Medicine/Sports Physiology, University of Bayreuth, Bayreuth, 95440, Germany
| | - Shriya B Kumar
- Centre for Human Integrative Physiology, Faculty of Medicine, University of Southampton, Southampton, UK
| | - James M Otto
- Respiratory and Critical Care Research Area, NIHR Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust/University of Southampton, Southampton, UK
| | - Janis Schierbauer
- Department of Sports Medicine/Sports Physiology, University of Bayreuth, Bayreuth, 95440, Germany
| | - Michael P W Grocott
- Respiratory and Critical Care Research Area, NIHR Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust/University of Southampton, Southampton, UK
| | - Hugh E Montgomery
- Centre for Human Health and Performance/ Institute of Sport, Exercise and Health, University College London, and NIHR University College London Hospitals Biomedical Research Centre, London, UK
| | - Walter F J Schmidt
- Department of Sports Medicine/Sports Physiology, University of Bayreuth, Bayreuth, 95440, Germany
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