Anemia of critical illness

Intravenous iron for critically ill children. Comparison of three dose regimens

BACKGROUND

Anemia is extremely common among patients admitted to pediatric intensive care. Alternative treatments to transfusions such as intravenous iron must be considered. There are no published data for a prospective intravenous (IV) iron study focused in the critically ill children. The objective is to examine the safety and efficacy of intravenous iron sucrose infusion to manage anemia in pediatric critical care. A secondary objective is to examine the effect of different dose regimens of iron sucrose (3, 5, and 7 mg/kg dose).

PROCEDURE

Prospective investigation of intravenous iron sucrose utilization at a tertiary pediatric intensive care unit between October 2017 and November 2022.

RESULTS

In all 115 patients received a total of 616 infusions of IV iron. Transferrin saturation index (TSI) was the most common altered iron deficiency biomarker (91.8%). After IV iron treatment, hemoglobin showed a significant increase within a 30-day follow-up (9.2 vs. 11.6 g/dL, p < .001). There was also a significant improvement in TSI and serum iron (p < .001). Iron deficit replacement was higher in the 7 mg/kg dose group (94%) compared to 85.9% in the 5 mg/kg regimen and 77.5% in the lower dose group (p = .008), requiring less doses and a shorter time. Very few mild adverse reactions were reported (1.3% of infusions), with no differences between groups. The most frequent adverse effect was gastrointestinal in three cases. There were no anaphylaxis-like or other serious/life-threatening adverse effects.

CONCLUSIONS

This is the first study to evaluate intravenous iron therapy in pediatric critical care, providing preliminary evidence of safety and efficacy of IV iron sucrose. The 7 mg/kg dose regimen showed higher iron deficit replacement in a shorter time, which could be beneficial in critically ill children.

Zinc protoporphyrin levels in COVID-19 are indicative of iron deficiency and potential predictor of disease severity

Background

Coronavirus disease (COVID-19) has a severe impact on all aspects of patient care. Among the numerous biomarkers of potential validity for diagnostic and clinical management of COVID-19 are biomarkers at the interface of iron metabolism and inflammation.

Methods

The follow-up study included 54 hospitalized patients with laboratory-confirmed COVID-19 with a moderate and severe/critical form of the disease. Iron deficiency specific biomarkers such as iron, ferritin, transferrin receptor, hepcidin, and zinc protoporphyrin (ZnPP) as well as relevant markers of inflammation were evaluated twice: in the first five days when the patient was admitted to the hospital and during five to 15 days; and their validity to diagnose iron deficiency was further assessed. The regression and Receiver Operating Characteristics (ROC) analyses were performed to evaluate the prognosis and determine the probability for predicting the severity of the disease in the first five days of COVID-19.

Results

Based on hemoglobin values, anemia was observed in 21 of 54 patients. Of all iron deficiency anemia-related markers, only ZnPP was significantly elevated (P<0.001) in the anemic group. When patients were grouped according to the severity of disease, slight differences in hemoglobin or other anemia-related parameters could be observed. However, the levels of ZnPP were significantly increased in the severely ill group of patients. The ratio of ZnPP to lymphocyte count (ZnPP/L) had a discrimination power stronger than the neutrophil to lymphocyte count ratio (N/L) to determine disease severity. Additionally, only two markers were independently associated with the severity of COVID-19 in logistic regression analysis; D-dimer (OR (5.606)(95% CI 1.019–30.867)) and ZnPP/L ratio (OR (74.313) (95% CI 1.081–5108.103)).

Conclusions

For the first time ZnPP in COVID-19 patients were reported in this study. Among all iron-related markers tested, ZnPP was the only one that was associated with anemia as based on hemoglobin. The increase in ZnPP might indicate that the underlying cause of anemia in COVID-19 patients is not only due to the inflammation but also of nutritional origin. Additionally, the ZnPP/L ratio might be a valid prognostic marker for the severity of COVID-19.

Malnutrition and nutritional status in critically ill patients with enteral nutrition

BACKGROUND & OBJECTIVE: The prevention of malnutrition is an important factor in the survival of critically ill patients with enteral nutrition. The present study aims to assess the nutritional status and its association with some blood-related markers in critically ill patients with enteral nutrition during hospitalization in the intensive care units (ICUs). METHODS: Totally, 110 patients participated in this study from the time of admission to discharge at five ICUs. The patients’ nutritional status was assessed by subjective global assessment (SGA), Acute Physiology and Chronic Health Evaluation and Albumin, Total Iron Binding Capacity (TIBC), Hemoglobin (Hb), Hematocrit (HCT), Ferritin, and Feas biochemical indices and anthropometric parameters. RESULTS: Malnutrition prevalence increased significantly on the day of discharge (83.6%) compared to the day of admission (41.8%), according to SGA (P < 0.001). Hb, HCT, serum Fe decreased and ferritin, also TIBC were increased during hospitalization in ICU. The malnutrition risk predictors based on the logistic regression were low levels of Hb (OR = 0.6), HCT (OR = 0.9), Fe (OR = 0.9), Albumin (OR = 0.3) and High Ferritin level (OR = 1.006) on the admission day. Anemia of inflammation (AI) was observed during ICU stay. CONCLUSION: This study demonstrated that malnutrition is an increasing phenomenon in the ICU patients and the delay in patient’s enteral feeding had a direct influence in the prevalence of malnutrition on discharge day.

Hemoglobin Levels Across the Pediatric Critical Care Spectrum: A Point Prevalence Study

OBJECTIVES

To determine the prevailing hemoglobin levels in PICU patients, and any potential correlates.

DESIGN

Post hoc analysis of prospective multicenter observational data.

SETTINGS

Fifty-nine PICUs in seven countries.

PATIENTS

PICU patients on four specific days in 2012.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Patients' hemoglobin and other clinical and institutional data. Two thousand three hundred eighty-nine patients with median age of 1.9 years (interquartile range, 0.3-9.8 yr), weight 11.5 kg (interquartile range, 5.4-29.6 kg), and preceding PICU stay of 4.0 days (interquartile range, 1.0-13.0 d). Their median hemoglobin was 11.0 g/dL (interquartile range, 9.6-12.5 g/dL). The prevalence of transfusion in the 24 hours preceding data collection was 14.2%. Neonates had the highest hemoglobin at 13.1 g/dL (interquartile range, 11.2-15.0 g/dL) compared with other age groups (p < 0.001). The percentage of 31.3 of the patients had hemoglobin of greater than or equal to 12 g/dL, and 1.1% had hemoglobin of less than 7 g/dL. Blacks had lower median hemoglobin (10.5; interquartile range, 9.3-12.1 g/dL) compared with whites (median, 11.1; interquartile range, 9.0-12.6; p < 0.001). Patients in Spain and Portugal had the highest median hemoglobin (11.4; interquartile range, 10.0-12.6) compared with other regions outside of the United States (p < 0.001), and the highest proportion (31.3%) of transfused patients compared with all regions (p < 0.001). Patients in cardiac PICUs had higher median hemoglobin than those in mixed PICUs or noncardiac PICUs (12.3, 11.0, and 10.6 g/dL, respectively; p < 0.001). Cyanotic heart disease patients had the highest median hemoglobin (12.6 g/dL; interquartile range, 11.1-14.5). Multivariable regression analysis within diagnosis groups revealed that hemoglobin levels were significantly associated with the geographic location and history of complex cardiac disease in most of the models. In children with cancer, none of the variables tested correlated with patients' hemoglobin levels.

CONCLUSIONS

Patients' hemoglobin levels correlated with demographics like age, race, geographic location, and cardiac disease, but none found in cancer patients. Future investigations should account for the effects of these variables.

Pharmacotherapy in Acutely Anemic Jehovah’s Witnesses: An Evidence-Based Review

Objective: To determine the pharmacological treatment methods available to anemic Jehovah’s Witnesses (JW). Data Sources: MEDLINE and PubMed were searched from inception through February 2018 using the search terms Jehovah’s Witnesses, treatment, erythropoietin, hemoglobin-based oxygen carrier, Sanguinate, Hemopure, bleeding, and anemia. Study Selection and Data Extraction: All clinical trials, cohort studies, case-control studies, and observational trials involving pharmacotherapy in anemic JW patients were evaluated. Case reports and bibliographies were also analyzed for inclusion. Data Synthesis: Two studies involving the use of erythropoietin (EPO) and one study involving recombinant factor VIIa were included. Information was also included from other pharmacotherapeutic modalities that had case report data only. Current published evidence is limited with regard to evidence-based management of JW patients. High-dose EPO, intravenous iron supplementation, and hemostatic agents have demonstrated good clinical outcomes in case reports. EPO doses as high as 40 000 units daily have been advocated by some experts; however, pharmacokinetic studies do not support dose-dependent effects. Hemoglobin-based oxygen carriers (HBOCs) are currently not Food and Drug Administration approved. They are available through expanded access programs and may represent a lifesaving modality in the setting of severe anemia. Conclusions: There are currently not enough data to make definitive recommendations on the use of pharmacological agents to treat severe anemia in the JW population. Further evidence utilizing EPO and HBOCs will be beneficial to guide therapy.

Investigation of iron status and markers of inflammation in anaemic and non-anaemic hospitalised cats

OBJECTIVES

To measure iron parameters and markers of inflammation in anaemic cats presented for intensive care unit hospitalisation, and to compare these to cohorts of non-anaemic hospitalised cats and cats that develop hospital-acquired anaemia.

METHODS

Blood samples were collected for measurement of iron panel and serum amyloid A in addition to routine investigation in cats admitted to the intensive care unit. Medical records were reviewed to determine how many of the Systemic Inflammatory Response Syndrome criteria were met and to assign Acute Patient Physiologic and Laboratory Evaluation scores as a measure of illness severity.

RESULTS

Seventy-eight cats were enrolled. Anaemia was documented in 34·6% of cats on presentation and another 10·3% developed anaemia during hospitalisation. Compared with non-anaemic cats, animals that were anaemic on presentation had higher neutrophil and white blood cell counts, and longer hospitalisation. Iron status was consistent with anaemia of inflammation in most anaemic patients. Iron status, serum amyloid A concentration, and prevalence of systemic inflammatory response syndrome did not differ between anaemic and non-anaemic cohorts. All cause mortality was higher in anaemic cats.

CLINICAL SIGNIFICANCE

Anaemia is common in cats hospitalised in the intensive care unit. Systemic inflammation is also common in these cats. Iron status in anaemic cats suggests that anaemia of inflammatory disease may be a significant contributor to anaemia in this patient population.

Protective role of tocopherol and ascorbic acid in taxol-treated human erythrocytes in vitro

Taxol is a well-known anticancer agent. It is used for the treatment of several kinds of cancer, including breast cancer, lung cancer and ovarian cancer. In spite of being a good chemotherapeutic agent, taxol has several side effects. Drug-induced haemolytic anaemia is one of the most common side effects of taxol. This study investigated the haemolytic effect of taxol on normal erythrocytes and the protective effect of natural antioxidants ascorbic acid and tocopherol in the presence of taxol. We evaluated the osmotic fragility and the activity of enzymes superoxide dismutase and catalase of erythrocytes in the presence of taxol alone and taxol in combination with tocopherol and ascorbic acid. Taxol-induced haematological perturbation significantly caused haemolysis and reduced the activities of superoxide dismutase and catalase in erythrocytes. The antioxidants tocopherol and ascorbic acid demonstrated a protective effect when added to taxol. The combination of tocopherol with taxol significantly protected the osmotic lysis of erythrocytes and increased the activities of superoxide dismutase but had less effect on catalase. Ascorbic acid showed significant protection of erythrocytes from osmotic lysis but didn’t show any significant effect on superoxide and catalase. The results suggest that both antioxidants, especially tocopherol, could exhibit a protective effect against taxol-induced haematological toxicity.

Hematologic Complications

Critically ill patients are at high risk of developing various hematologic complications that may be present on admission or occur during their stay in the Intensive Care Unit (ICU). Often times the etiology of specific hematologic abnormalities is unclear and the diagnosis may be challenging due to the complexity of critically ill patients. This chapter will focus on diagnosis and management of the most commonly encountered hematologic problems in the critically ill such as anemia, neutropenia, thrombocytopenia, coagulopathy and thrombotic complications, with specific focus on diagnosis and management of these conditions.

Renal anemia of inflammation: the name is self-explanatory

BACKGROUND

Anemia is inevitable as chronic kidney disease (CKD) advances. With the advent of erythropoietin-stimulating agents (ESAs), considerable improvement has been achieved in the management of anemia. However, some patients show a reduced response to ESAs.

METHODS

Many factors affect the response to ESA treatment. CKD is now considered as an inflammatory disorder and this understanding led to the recognition of the central role of inflammation in ESA resistance. Inflammation is related to untoward outcomes, including atherosclerosis and anemia, in the CKD population. Furthermore, recognition of deleterious effects of proinflammatory markers at different levels of erythropoiesis led to a change in the name of 'anemia of chronic disease' to anemia of inflammation.

RESULTS

The discovery of hepcidin as the major controller of iron metabolism in anemia of inflammation answered many questions regarding the interaction of erythropoietin, iron and bone marrow. Hepcidin production in the liver is driven by three major factors: inflammation, iron overload and anemia/hypoxia. Hepcidin levels are increased in patients with CKD due to the interaction of many factors; a comprehensive understanding of these pathways is thus critical in the effort to alleviate anemia of inflammation and ESA resistance.

CONCLUSION

In this review, we discussed the epidemiology, determinants and consequences of anemia of inflammation in CKD patients with special emphasis on the central role of hepcidin along with molecular pathways driving its production.