[Sickle cell disease, a genetic haemoglobin disease]

Sickle cell disease is the number one genetic disease in France in terms of the number of children diagnosed each year in the neonatal period. Throughout their lives, people with sickle cell disease are likely to develop acute complications that require urgent treatment. Chronic complications are more common amongst adults than in children.

[Anemia in blood donors and criteria of hemoglobin level control at the national blood transfusion center (NBTC) of Lomé, Togo]

INTRODUCTION

The aim of this study was to evaluate the prevalence of anemia among blood donors at Lomé national blood transfusion center (NBTC) and to identify criteria for controlling hemoglobin level in blood donation candidates.

METHODS

We determined the hemoglobin level using HemoCue® 201+. To identify the hemoglobin level control criteria, the judgment parameters were the proportion of anemic donors based on the number of blood donations in the last 12 months and the staining of the conjunctiva. One parameter is considered "critical" and used as a control criterion when more than 30% of donors meeting this parameter are anemic.

RESULTS

A total of 1 291 blood donor candidates, predominantly male (89.70%), were included in this study. The prevalence of anemia was 28.12%. This prevalence was 38.71% among women who made 2 donations and 32.27% among men who made 3 donations and who came for a new donation in the year. Anemia was observed in 59.45% of men and 51.56% of women who had slightly colored conjunctiva.

CONCLUSION

The prevalence of anemia was high among blood donors at NBTC Lomé. Hemoglobin control is indicated in blood donation candidates with conjunctiva judged to be slightly colored and / or on their 2nd donation (female) and 3rd blood donation (male) within 12 months.

Examining the decay in serum ferritin following intravenous iron infusion: a retrospective cohort analysis of Olympic sport female athletes

The long-term decay rate of serum ferritin post-iron infusion in athletic populations is currently unknown. Here, we modelled the decay rate of serum ferritin in female athletes after an intravenous iron infusion (n = 22). The post-infusion serum ferritin response and the rate of decay was highly variable between athletes; however, we demonstrate that follow-up blood testing at 1 (154 μg/L; 77-300 μg/L) and 6 months (107 μg/L; 54-208 μg/L) post-infusion is appropriate to observe treatment efficacy and effectiveness. Novelty Female athletes should have serum ferritin assessed at 1 and 6 months following an intravenous iron infusion to determine efficacy and effectiveness.

[Intravenous iron supplementation in the elderly patient]

Iron deficiency, absolute or functional, is a common pathology in elderly patients and the way of iron replacement therapy is a recurrent issue. It seems to be necessary to treat by intravenous iron instead of oral therapy because of defective iron absorption or side effects. Depending on the molecule chosen, the modes of administration, whether dilution, dose or rhythm, vary. The major risk of intravenous iron replacement is anaphylaxis, which is very rare, this is why it has to be an hospital administration.

Use of pre-ART laboratory screening to identify renal, hepatic and haematological abnormalities in Côte d'Ivoire

BACKGROUND

High demand for HIV-services and extensive clinical guidelines force health systems in low-resource settings to dedicate resources to service delivery at the expense of other priorities. Simplifying services may reduce the burden on health systems and pre-antiretroviral therapy (ART) laboratory screening is among the services under consideration for simplification.

METHODS

We assessed the frequencies of conditions linked to ART toxicities among 34,994 adult, ART-naïve patients with specimens referred to the RETRO-CI laboratory in Abidjan, Côte d'Ivoire between 1998 and 2017. Screening included tests for serum creatinine, alanine aminotransferase (ALT) and haemoglobin (Hb) to identify renal dysfunction (estimated glomerular filtration rate < 50 mL/min), hepatic abnormalities (ALT > 5× upper limit of normal) and severe anaemia (Hb < 6.5 g/dL), respectively. We considered screening results across four eras and identified factors associated with the conditions in question.

RESULTS

The prevalence of renal dysfunction, hepatic abnormalities and severe anaemia were largely unchanged over time and just 8.4% of patients had any of the three conditions. Key factors associated with renal dysfunction and severe anaemia were age > 50 years (adjusted odds ratio (aOR): 2.53; 95% confidence interval (CI): 2.19-2.92; P < 0.001) and CD4 < 100 cells/µl (aOR: 2.57; 95% CI: 2.30-2.88; P < 0.001).

CONCLUSION

The relative infrequency of conditions linked to toxicity in Côte d'Ivoire supports the notion that simplification of pre-ART laboratory screening may be undertaken with limited negative impact on identification of adverse events. Targeted screening may be a feasible strategy to balance detection of conditions associated with ART toxicities with simplification of services.

Menstrual blood losses and body mass index are associated with serum ferritin concentrations among female varsity athletes

Preventing and treating iron deficiency are important components in the nutritional care of female varsity athletes, as these interventions may improve aerobic endurance and athletic performance. We examined the factors associated with ferritin concentration in 30 female varsity athletes (18-30 years) at the University of British Columbia in Vancouver, Canada. Biochemical indicators of iron and inflammation status, dietary intake, supplementation practices, weight, height, and menstrual blood losses were assessed. Iron deficiency prevalence was 20% (n = 6/30; inflammation-adjusted ferritin <15 μg/L). Multiple linear regression was used to assess the associations of a number of independent explanatory variables with log-transformed serum ferritin (μg/L) as the continuous outcome variable. A 1-unit increase in body mass index (BMI; kg/m²) was associated with 22% (95% CI: 9%-37%) higher mean ferritin concentrations, and a 1-point increase in menstrual loss score was associated with 1% (95% CI: 1%-2%) lower ferritin concentrations. Hemoglobin and hepcidin concentrations, inflammation biomarkers, consumption of iron supplements in any form or dose for ≥3 days/week, and age were not significantly associated with ferritin concentrations in the final adjusted model. Novelty Estimated monthly menstrual losses and BMI were associated with serum ferritin concentrations in female athletes in our study. These are easy-to-measure, noninvasive measurements that should be considered in the assessment of risk of iron deficiency in female athletes.

Temporal trends and differential patterns in the prevalence of severe anaemia in India: observations from country-wide haemoglobin determinations 2008-2018

OBJECTIVES

To assess temporal trends in the occurrence of severe anaemia in India over the past decade, encompassing every state and union territory.

METHODS

For the period 2008-09 to 2017-18, annual estimates (%) of severe anaemia (haemoglobin < 7 g/dl) for India were derived from Health Management Information System datasets, along with 95% confidence intervals (CIs) to construct temporal trends. Differential patterns in the distribution of severe anaemia by geography, epidemiological transition level and socio-demographic index values were also investigated.

RESULTS

Severe anaemia occurred in 3.29% (95% CI: 3.28-3.30%) of all haemoglobin determinations in India in 2017-18, which was less than a third of the number in 2008-09. This decline (overall 7.8% or 0.78% per year) over the past decade was consistent (χ² _trend  = 1 557 296, P < 0.001). Distribution of severe anaemia was heterogeneous between states and union territories (in 2017-18), ranged from < 1% (in Kerala and Lakshadweep) to > 8% (in Telangana). Significant variations were observed according to geographical region (highest in Central zone), epidemiological transition level (highest at higher middle epidemiological transition level) and socio-demographic index (highest at middle socio-demographic index). Severe anaemia burden between rural and urban areas also differed significantly.

CONCLUSION

Although the prevalence of severe anaemia has decreased in India over the last decade, it remains substantial and differs widely with respect to geography, epidemiological transition level, and socio-economic conditions. A detailed assessment of the various aetiologies and documentation of their spatial epidemiology is desirable to understand their relative contribution to the severe anaemia burden and to design appropriate interventions.

Consequences of prenatal geophagy for maternal prenatal health, risk of childhood geophagy and child psychomotor development

OBJECTIVE

To investigate the relationship between prenatal geophagy, maternal prenatal haematological indices, malaria, helminth infections and cognitive and motor development among offspring.

METHODS

At least a year after delivery, 552 of 863 HIV-negative mothers with singleton births who completed a clinical trial comparing the efficacy of sulfadoxine-pyrimethamine and mefloquine during pregnancy in Allada, Benin, responded to a nutrition questionnaire including their geophagous habits during pregnancy. During the clinical trial, helminth infection, malaria, haemoglobin and ferritin concentrations were assessed at 1st and 2nd antenatal care visits (ANV) and at delivery. After the first ANV, women were administered daily iron and folic acid supplements until three what? post-delivery. Singleton children were assessed for cognitive function at age 1 year using the Mullen Scales of Early Learning.

RESULTS

The prevalence of geophagy during pregnancy was 31.9%. Pregnant women reporting geophagy were more likely to be anaemic (AOR = 1.9, 95% CI [1.1, 3.4]) at their first ANV if they reported geophagy at the first trimester. Overall, prenatal geophagy was not associated with maternal haematological indices, malaria or helminth infections, but geophagy during the third trimester and throughout pregnancy was associated with poor motor function (AOR = -3.8, 95% CI [-6.9, -0.6]) and increased odds of geophagous behaviour in early childhood, respectively.

CONCLUSIONS

Prenatal geophagy is not associated with haematological indices in the presence of micronutrient supplementation. However, it may be associated with poor child motor function and infant geophagy. Geophagy should be screened early in pregnancy.

High folate levels are not associated with increased malaria risk but with reduced anaemia rates in the context of high-dosed folate supplements and intermittent preventive treatment against malaria in pregnancy with sulphadoxine-pyrimethamine in Benin

OBJECTIVES

To investigate whether high-dosed folate supplements might diminish the efficacy of malaria intermittent preventive treatment in pregnancy (IPTp) with sulphadoxine-pyrimethamine (SP) in a cohort of pregnant women in Benin, where malaria is holoendemic.

METHODS

We followed 318 women during the entire pregnancy and analysed haematological and Plasmodium falciparum indicators in the context of an intermittent preventive treatment trial in Benin. During the follow-up, women received two-dose IPTp (1500/75 mg of SP per dose) at the maternity clinic and 600 mg of albendazole, 200 mg ferrous sulphate and 5 mg folic acid per day for home treatment.

RESULTS

High folate levels were not associated with increased malaria risk (adjusted OR (aOR) = 0.51 (95% CI: 0.17; 1.56, P-value = 0.24)), nor with increased P. falciparum density (beta coefficient = -0.26 (95% CI: -0.53; 0.02), P-value = 0.07) in a randomised trial of IPTp in Benin. On the contrary, higher iron levels were statistically associated with increased odds of a positive blood smear (aOR = 1.7 95% CI (1.2; 2.3), P-value < 0.001) and P. falciparum parasite density (beta coefficient = 0.2 95% CI (0.1; 0.3), P-value < 0.001). High folate levels were statistically associated with decreased odds of anaemia (aOR = -0.30 95% CI (0.10; 0.88), P-value = 0.03).

CONCLUSIONS

High folate levels are not associated with increased malarial risk in a prospective longitudinal cohort in the context of both iron and high-dosed folate supplements and IPTp. They are associated with reduced risk of anaemia, which is particularly important because iron, also given to treat anaemia, might be associated with increased malaria risk.

Malaria exacerbates inflammation-associated elevation in ferritin and soluble transferrin receptor with only modest effects on iron deficiency and iron deficiency anaemia among rural Zambian children

OBJECTIVE

In 4- to 8-year-old Zambian children (n = 744), we evaluated the effects of adjusting for inflammation (α1-acid glycoprotein >1 g/l), with or without additional adjustment for malaria, on prevalence estimates of iron deficiency (ID) and iron deficiency anaemia (IDA) during low malaria (LowM) and high malaria (HighM) transmission seasons.

METHODS

To estimate adjustment factors, children were classified as: (i) reference (malaria negative without inflammation), (ii) inflammation without malaria (I), (iii) malaria without inflammation (M) and (iv) inflammation with malaria (IM). We estimated the unadjusted ID or IDA prevalence, and then adjusted for inflammation alone (ID_I or IDA_I ) or inflammation and malaria (ID_IM or IDA_IM ).

RESULTS

Mean ferritin was 38 (reference), 45 (I), 43 (M) and 54 μg/l (IM) in LowM, increasing to 44, 56, 96 and 167 μg/l, respectively, in HighM. Corresponding mean sTfR was 6.4, 6.9, 7.9 and 8.4 mg/l in LowM, increasing to 8.2, 9.2. 8.7 and 9.7 mg/l in HighM. Ferritin-based ID, ID_I and ID_IM were 7.8%, 8.7% or 9.1%, respectively, in LowM and 4.6%, 10.0% or 11.7%, respectively, in HighM. Corresponding soluble transferrin receptor (sTfR)-based estimates were 27.0%, 24.1% and 19.1%, respectively, in LowM, increasing to 53.6%, 46.5% and 45.3%, respectively, in HighM. Additional adjustment for malaria resulted in a ~1- to 2-percentage point change in IDA, depending on biomarker and season.

CONCLUSIONS

In this population, malaria substantially increased ferritin and sTfR concentrations, with modest effects on ID and IDA prevalence estimates.

Short-term effects of hemodiafiltration versus conventional hemodialysis on erythrocyte performance

Hemodiafiltration (HDF) is a renal replacement therapy that is based on the principles of diffusion and convection for the elimination of uremic toxins. A significant and increasing number of end-stage renal disease (ESRD) patients are treated with HDF, even in the absence of definite and conclusive survival and anemia treatment data. However, its effects on red blood cell (RBC) physiological features have not been examined in depth. In this study, ESRD patients under regular HDF or conventional hemodialysis (cHD) treatment were examined for RBC-related parameters, including anemia, hemolysis, cell shape, redox status, removal signaling, membrane protein composition, and microvesiculation, in repeated paired measurements accomplished before and right after each dialysis session. The HDF group was characterized by better redox potential and suppressed exovesiculation of blood cells compared with the cHD group pre-dialysis. However, HDF was associated with a temporary but acute, oxidative-stress-driven increase in hemolysis, RBC removal signaling, and stomatocytosis, probably associated with the effective clearance of dialyzable natural antioxidant components, including uric acid, from the uremic plasma. The nature of these adverse short-term effects of HDF on post-dialysis plasma and RBCs strongly suggests the use of a parallel antioxidant therapy during the HDF session.

Prevalence of unexplained anaemia in Inuit men and Inuit post-menopausal women in Northern Labrador: International Polar Year Inuit Health Survey

OBJECTIVE

To identify correlates of hemoglobin (Hb) and anaemia unexplained by iron deficiency (UA) in Canadian Inuit adults.

METHODS

A cross-sectional survey assessed diet, demographic information, anthropometry, fasting Hb, ferritin, soluble transferrin receptor (on a subset), high-sensitivity C-reactive protein (hs-CRP) in serum, red blood cell (RBC) fatty acid composition, blood lead, and antibodies to Helicobacter pylori in non-pregnant, Inuit adults (n = 2550), ≥18 years of age from randomly selected households in 36 Inuit communities in Inuvialuit Settlement Region, Nunavut Territory and Nunatsiavut of Northern Labrador, Canada.

RESULTS

Hb concentrations were lower and UA prevalence higher in Inuit men after 50 years of age. Rate of anaemia was constant among Inuit women but changed from primarily iron deficiency anaemia pre-menopause, to primarily UA in post-menopause. Low education levels and hs-CRP were associated with increased risk of UA. For Inuit men, % RBC eicosapentaenoic acid (EPA) and elevated blood lead were also associated with increased risk of UA. Frequency of traditional food intake was positively associated with Hb.

CONCLUSION

Age patterns and regional variation of anaemia suggest that ethnicity-related physiological differences cannot explain anaemia prevalence for Inuit. High RBC EPA status, inflammation and infections, and lower education levels may contribute to the prevalence of anaemia in this population, which is not related to iron status. Thus, traditional lifestyle may protect Inuit from nutritional anaemia but contribute to lower Hb through environmental exposures. The clinical significance of UA for older Inuit adults requires further investigation, as the prevalence represents a moderate public health problem.

Anaemia in HIV-infected pregnant women receiving triple antiretroviral combination therapy for prevention of mother-to-child transmission: a secondary analysis of the Kisumu breastfeeding study (KiBS)

OBJECTIVE

The prevalence of anaemia during pregnancy is estimated to be 35-75% in sub-Saharan Africa and is associated with an increased risk of maternal mortality. We evaluated the frequency and factors associated with anaemia in HIV-infected women undergoing antiretroviral (ARV) therapy for prevention of mother-to-child transmission (PMTCT) enrolled in The Kisumu Breastfeeding Study 2003-2009.

METHODS

Maternal haematological parameters were monitored from 32 to 34 weeks of gestation to 2 years post-delivery among 522 enrolled women. Clinical and laboratory assessments for causes of anaemia were performed, and appropriate management was initiated. Anaemia was graded using the National Institutes of Health Division of AIDS 1994 Adult Toxicity Tables. Data were analysed using SAS software, v 9.2. The Wilcoxon two-sample rank test was used to compare groups. A logistic regression model was fitted to describe the trend in anaemia over time.

RESULTS

At enrolment, the prevalence of any grade anaemia (Hb < 9.4 g/dl) was 61.8%, but fell during ARV therapy, reaching a nadir (7.4%) by 6 months post-partum. A total of 41 women (8%) developed severe anaemia (Hb < 7 g/dl) during follow-up; 2 (4.9%) were hospitalised for blood transfusion, whereas 3 (7.3%) were transfused while hospitalised (for delivery). The greatest proportion of severe anaemia events occurred around delivery (48.8%; n = 20). Anaemia (Hb ≥ 7 and < 9.4 g/dl) at enrolment was associated with severe anaemia at delivery (OR 5.87; 95% CI: 4.48, 7.68, P < 0.01). Few cases of severe anaemia coincided with clinical malaria (24.4%; n = 10) and helminth (7.3%; n = 3) infections.

CONCLUSION

Resolution of anaemia among most participants during study follow-up was likely related to receipt of ARV therapy. Efforts should be geared towards addressing common causes of anaemia in HIV-infected pregnant women, prioritising initiation of ARV therapy and management of peripartum blood loss.

[Pancytopenia, Hemolytic Anemia and Schizocytes: a Pragmatic Approach]

A 58 year old woman presents with a progressive fatigue and dyspnea associated with paresthesia. Laboratory tests show pancytopenia with hypersegmented neutrophiles, macrocytic hyporegenerative anemia and arguments for hemolysis, in particular highly increased LDH. This constellation strongly suggests vitamin B12 deficiency, which was confirmed with an undetectable cobalamine concentration in the blood of our patient. The etiologic work up shows the presence of anti-parietal cells antibodies at a titer of 1/640, diagnostic of Biermer anemia.

[A WHO concept- patient blood management]

Blood transfusions are in general considered as lifesaving. Current data and evidence show, that blood transfusions are associated with increased morbidity and mortality, and this apparently dose-dependent. Basic research and results from randomized controlled trials show a causal relationship between blood transfusion and adverse outcome. Based on the current state of knowledge it has to be questioned that blood transfusions are "life-saving" as patients are exposed to an increased risk of disease or death. Furthermore, blood transfusions are more costly than previously assumed. For these reasons novel approaches in the treatment of anemia and bleeding are needed. Patient Blood Management (PBM) allows reduction of transfusion rates by correcting anemia by stimulating erythropoiesis, minimizing perioperative blood loss and optimizing the physiological tolerance of anemia. In 2010 the World Health Organization has claimed PBM to be considered as golden standard. PBM reduces morbidity and mortality by lowering the excessive use of blood transfusions. This concept has partially and successfully been implemented in the University Hospital Balgrist in Zurich.

Reproductive risk factors assessment for anaemia among pregnant women in India using a multinomial logistic regression model

OBJECTIVE

To assess reproductive risk factors for anaemia among pregnant women in urban and rural areas of India.

METHOD

The International Institute of Population Sciences, India, carried out third National Family Health Survey in 2005-2006 to estimate a key indicator from a sample of ever-married women in the reproductive age group 15-49 years. Data on various dimensions were collected using a structured questionnaire, and anaemia was measured using a portable HemoCue instrument. Anaemia prevalence among pregnant women was compared between rural and urban areas using chi-square test and odds ratio. Multinomial logistic regression analysis was used to determine risk factors.

RESULTS

Anaemia prevalence was assessed among 3355 pregnant women from rural areas and 1962 pregnant women from urban areas. Moderate-to-severe anaemia in rural areas (32.4%) is significantly more common than in urban areas (27.3%) with an excess risk of 30%. Gestational age specific prevalence of anaemia significantly increases in rural areas after 6 months. Pregnancy duration is a significant risk factor in both urban and rural areas. In rural areas, increasing age at marriage and mass media exposure are significant protective factors of anaemia. However, more births in the last five years, alcohol consumption and smoking habits are significant risk factors.

CONCLUSION

In rural areas, various reproductive factors and lifestyle characteristics constitute significant risk factors for moderate-to-severe anaemia. Therefore, intensive health education on reproductive practices and the impact of lifestyle characteristics are warranted to reduce anaemia prevalence.