ANEMIA: causes, symptoms and treatment

Anemia is a very common condition. Diagnosis is made through the analysis ofblood count: the finding of low hemoglobin, low red blood cells you hate low hematocrit to blood tests means to suffer from anemia. The main ones causes of anemia they are macrocytic and iron deficiency anemias, hemoglobinopathies such as thalassemia and sickle cell anemia. The main symptoms of anemia are the skin pallor, tiredness (asthenia), shortness of breath after small efforts.

Anemia

What is the meaning of the term anemia? Being anemic means having an insufficient amount of hemoglobin, together with or without a reduction in red blood cells orhematocrit. The finding of anemia in blood tests always arouses great concern, and is a fairly frequent finding, being the most common alteration of the blood count. The causes of anemia they are manifold, and in most cases they are easily correctable. Often the drop in hemoglobin o The reduction in red blood cells is not accompanied by any specific symptoms, and is only detected after routine blood tests, such as those carried out on the advice of the treating physician or employer. Let's analyze what anemia is, what is its classification and its main causes, as well as the symptoms that usually distinguish it.

Values of anemia

Usually the diagnosis of anemia is placed by observing the hemoglobin values. Hemoglobinemia is not the same for all people, as it differs based on gender, age, and particular conditions such as pregnancy. In the course of anemia there will be alow hemoglobin.

According to the criteria of the World Health Organization WHO, we talk about anemia values:

  • In the adult men, when the hemblobin values are lower than i 13 g / dl (130 g / L), i.e. 13 grams per deciliter or 130 grams per liter.
  • In the women non-pregnant adults, when the hemoglobin values are less than 12 g / dl (120 g / L), i.e. 12 grams per deciliter or 120 grams per liter.
  • In the women pregnant adults, when the hemoglobin values are less than 11 g / dL (110 g / L), i.e. 11 grams per deciliter or 110 grams per liter.
  • In the children aged 12 - 14, when the hemoglobin values are less than 12 g / dl (120 g / L), i.e. 12 grams per deciliter or 120 grams per liter.
  • In the children aged 5 - 11 years, when the hemoglobin values are less than 11.5 g / dL (115 g / L), i.e. 11.5 grams per deciliter or 115 grams per liter.
  • We talk about anemia in children aged 6 months to 5 years, when the hemoglobin values are less than 11 g / dL (110 g / L), i.e. 11 grams per deciliter or 110 grams per liter.
  • In infants, the normal hemoglobin concentration is 17.1-21.5 / dL, with a hematocrit of 54-78%, values that continue to increase until reaching a maximum after about 2 hours after birth. Below 17.1 g / dl of hemoglobin we can speak of anemia in the newborn.

The diagnosis of anemia can also be made by analyzing the number of Red blood cells, more properly called erythrocytes or red blood cells. In the course of anemia they will be found low red blood cells.

According to the American Society of Leukemia and Lymphomas (LLS):

  • Normal normal red blood cell values for men are between 4.7 and 6.1 million cells per microliter (µL).
  • Normal RBC values for non-pregnant women are 4.2 to 5.4 million per microliter (µL).
  • The normal range of red blood cell values in children is 4.0 to 5.5 million per microliter (µl).

We speak of anemia in the presence of red blood cells less than 4.7 million / microliter in adults, less than 4.2 million / microliter in non-pregnant women, less than 4.0 million / microliter in children up to 12 years. These ranges may vary depending on the laboratory or physician interpreting them.

In pregnancy there is a progressive hemodilution of the blood, due to the overall increase in body fluids. THE red blood cell values in pregnant women, as already seen for the hemoglobin values, they progressively decrease. Here is that, in order to speak of anemia in pregnancy you need to have red blood cell values:

First trimester of pregnancy: less than 3.42 million per microliter (µL).
Second trimester of pregnancy: less than 2.81 million per microliter (µL).
Third trimester of pregnancy: less than 2.72 million per microliter (µL)

Hemoglobin and red blood cells

Hemoglobin is a macromolecule contained in ours Red blood cells (also called erythrocytes or red blood cells). Hemoglobin is commonly abbreviated with the abbreviation Hb or with Hbg, and consists of 4 polypeptide chains of globin equal to two by two. The hemoglobin tetramer is in fact composed of two alpha chains and two beta chains, and is called HbA. This is the conformation most present in our body: other less represented variants of hemoglobin are the HbA2, consisting of two alpha chains and two gamma chains, and the HbS, that is thefetal hemoglobin, which is a predominant hemoglobin during the gestational period and the first months of life, which is then replaced by hemoglobin HbA in youth and adult life.

Anemia

Structure of a hemoglobin macromolecule, we note the tetramer of globin chains linked to protoporphyria and to iron to form heme, units with binding capacity for oxygen molecules. The presence of low hemoglobin concentrations in the blood leads to the diagnosis of anemia.

The globin chains are by themselves insoluble in the blood, but joined together in the structure of hemoglobin (hemoglobin tetramer) become ad high solubility. Hemoglobin works in the bloodstream, absorbing oxygen present in our pulmonary alveoli, tying it to if and carrying it up to the peripheral tissues where it is released.

THE Red blood cells are produced from bone marrow, together with other cells circulating in the blood such as platelets, granulocytes, lymphocytes and monocytes macrophages. They have a biconcave disc shape, that is a discoid shape with the two faces hollowed inwards, and have no nucleus. Red blood cells are not actually born in this form yet, as their precursors, the erythroblasts nucleated (proerythroblasts) produced by the bone marrow are rounded and have a cell nucleus, which then lose within 24-48 hours taking the name of reticulocytes. The reticulocytes are therefore without nucleus but have ribosomal RNA filaments within them that form a sort of reticulum between them: maturing in the medulla (3-4 days) and then in the bloodstream (1-2) they also lose this finally the name of erythrocyte or mature red blood cell.

anemia: low red blood cells or low hemoglobin

The lack of red blood cells and therefore of hemoglobin in the bloodstream is called anemia.

 

Anemia: classification

The various types of anemia can also be distinguished based on the size and content of red blood cells. We will therefore speak of microcytic anemia in the presence of small red blood cells, macrocytic anemia in the presence of large red blood cells, and of normocytic anemia in case of normal sized red blood cells.

Also, we will talk about normochromic anemia when the hemoglobin content of each red blood cell is normal, but the total number of red blood cells is reduced. We will speak instead of hypochromic anemia when the hemoglobin content of each red blood cell is reduced.

The combinations of these two types of hemoglobin classification will lead to identifying conditions of:

  • normocytic normochromia anemia, with normal red blood cells and containing normal amounts of hemoglobin.
  • microcytic normochromic anemia, with small red blood cells but containing a normal amount of hemoglobin.
  • macrocytic normochromic anemia, with large red blood cells but containing a normal amount of hemoglobin.
  • microcytic hypochromic anemia, with small red blood cells containing little hemoglobin.
  • macrocytic hypochromic anemia, with large red blood cells but containing little hemoglobin.

Usually thenormochromic normocytic anemia it is a mild type of anemia, with values slightly below the norm. L'macrocytic normochromic anemia on the other hand, it is often linked to red blood cell synthesis deficiency, as in the case of bone marrow diseases or in the presence of reduced vitamin B12 and folic acid introids (vegans, alcoholics, malnourished). L'microcytic hypochromic anemia is the typical anemia from martial deficiency (anemia hyposideremica or anemia ferropriva), that is linked to values of low iron in the blood.

L'hypochromic macrocytic anemia it is a very rare type of anemia, mainly linked to infrequent hereditary diseases, such as acquired idiopathic sideroblastic anemia (ASIA).

Anemia: causes

What are the main ones causes of anemia? The finding of anemia is quite frequent in blood tests. There are women who spend most of the years of their life with lower than normal hemoglobin levels. Having said that, however, a drop in hemoglobin can be the alarm bell of an underlying disease, and it must be investigated promptly to recognize the cause and establish a possible treatment. The main ones causes of anemia I'm:

  • Hypoproliferative anemia
    • Iron deficiency anemia (microcythemic anemia): is probably the type of chronic anemia more frequent, characterized by small red blood cells, develops in the presence of low iron in the blood (iron deficiency is also called iron deficiency). The main causes of iron deficiency are inadequate dietary intake, reduced intestinal absorption or increased loss. Often the red blood cells in addition to being small, are also deficient in hemoglobin: in this case iron deficiency anemia will be a hypochromic microcytic anemia.
    • Chronic inflammation / infection anemia
    • Renal failure anemia, secondary to reduced EPO production
    • Chronic disease anemia, such as in the course of cirrhosis or other long-term pathologies
    • Malnutrition anemia
    • Anemia secondary to cirrhosis
    • Endocrine deficiency anemia
  • Hemoglobinopathies
    • Alpha thalassemia
    • Beta thalassemia or Mediterranean anemia: it is distinguished in beta thalassemia major or Cooley's disease in which both genes that synthesize hemoglobin are mutated, and thalassemia minor or thalassemia trait, in which only one allele has changed. In the latter case we speak of a healthy carrier of Mediterranean anemia, as there are no symptoms but in the case of a child conceived with another healthy carrier, in 25% of cases a newborn affected by thalassemia major may be born.
    • Sickle cell anemia or sickle cell disease
    • Methemoglobin
    • Structural thalassemic variants such as hemoglobin Lepore, hemoglobin E or congenital persistence of fetal hemoglobin HbF
    • Carbon monoxide poisoning

As is known, some hemoglobinopathies such as sickle cell anemia and thalassemias are protective for malaria, a pathology caused by parasitic protozoa of the genus Plasmodium, which use red blood cells as a stage in the reproductive cycle within the body. Having malformed erythrocytes, sickle-shaped as in sickle cell disease or small in size as in thalassemia, paradoxically makes the organism less hospitable for malarial infection. This is why in the areas of Italy that in the past were swampy such as the province of Rovigo, in Veneto, or Sardinia, there is a high prevalence of Mediterranean anemia and sickle cell anemia, genetically selected because they are resistant to Plasmodium falciparum and other malarial protozoa. In some geographical areas, therefore, hemoglobinopathies are by far the most frequent causes of low hemoglobin.

  • Megaloblastic anemia (macrocytic anemia):
    • Pernicious anemia
    • Poor absorption I have reduced intake of vitamin B12 and / or folic acid (folate)
    • Pregnancy
    • Use of drugs that alter DNA metabolism and therefore the synthesis of red blood cells (methotrexate, sulfonamides such as sulfasalazine and many others)

Megaloblastic anemia with red cell macrocytosis was once defined hyperchromic anemia, even if this term has now fallen into disuse.

  • Anemia in pregnancy: often, in pregnancy there are hemoglobin levels a little lower than normal, so much so that even the normal values of hemoglobin in pregnancy have been corrected by lowering the references a little. Anemia in pregnancy has multiple causes, including a greater amount of body fluids that dilute the substances present in the blood, a lack of iron, common during pregnancy, and a reduction in absorption and a greater consumption of vitamin B12 and folate.
  • Hemolytic anemias
    • Autoimmune hemolytic anemia: is a type of autoimmune anemia with hemolysis (destruction) of hemaziesis
    • Paroxysmal nocturnal hemoglobinuria
    • Acanthocyte anemia
    • Hereditary spherocytosis anemia
    • Microangiopathic hemolysis anemia o microangiopathic hemolytic anemiaMicroangiopathic Haemolytic Anemia (MAHA), also called runner's anemia or runner's anemia
    • Disseminated intravascular coagulation
    • Favism, G6PD deficiency
    • Cryoagglutinin diseases cryoglobulinemia
    • Thrombotic thrombocytopenic purpura and haemolytic uremic syndrome
    • Prosthetic hemolysis, for example in the presence of mechanical heart valve prostheses
    • Anemia secondary to drugs
  • Anemia due to reduced bone marrow synthesis
    • Aplastic anemia
    • Myelodysplastic anemia: it is found in the course of myelodysplasia (myelodysplastic syndromes): within the myelodysplasia we recognize:
      • Refractory anemia (RA): bone marrow blasts less than 5% and absence of blasts in peripheral blood;
      • Refractory anemia with ring sideroblasts (ARSA): medullary blasts less than 5%, more than 15% of medullary erythroid precursors are ring sideroblasts;
      • Refractory anemia with excess blasts (AREB): bone marrow blasts between 5-20% and less than 5% blasts in peripheral blood;
      • Refractory anemia with excess transforming blasts (AREB-t): marrow blasts 20-30%, 5-29% peripheral blood blasts or presence of Auer's bodies (recently, in 2008, WHO has included AREB-t in myeloid leukemias acute, excluding it from myelodysplasia)
      • Chronic myelomonocytic leukemia (CML): bone marrow blasts less than 20%, peripheral blood blasts less than 5%, monocytes greater than 1000 / mm3 in peripheral blood.
    • Leukemia
    • Lymphomas
    • Myelofibrosis
    • Fanconi anemia
    • Sideroblastic anemia, characterized by ring sideroblasts in the bone marrow and hypochromic erythrocytes
    • Saturnine anemia or Franke's anemia (lead poisoning anemia)
    • Diamond-Blackfan anemia (DBA), also known as BlackfanDiamond or hereditary erythroblastopenia
  • Increased loss anemias
    • Acute hemorrhage anemia
    • Chronic bleeding anemia
    • Menorrhagia anemia, i.e. secondary to heavy menstruation
  • Hemodilution anemia: they are all those anasarcatic states characterized by the presence of a large amount of liquids in the body tissues, which lead to a dilution of the substances dissolved in the blood including hemoglobin.

Anemia: classification

The various types of anemia can also be distinguished based on the size and content of red blood cells. We will therefore speak of microcytic anemia in the presence of small red blood cells, macrocytic anemia in the presence of large red blood cells, and of normocytic anemia in case of normal sized red blood cells.

Also, we will talk about normochromic anemia when the hemoglobin content of each red blood cell is normal, but the total number of red blood cells is reduced. We will speak instead of hypochromic anemia when the hemoglobin content of each red blood cell is reduced.

The combinations of these two types of hemoglobin classification will lead to identifying conditions of:

  • microcytic normochromic anemia, with small red blood cells but containing a normal amount of hemoglobin.
  • macrocytic normochromic anemia, with large red blood cells but containing a normal amount of hemoglobin.
  • normocytic normochromia anemia, with normal red blood cells and containing normal amounts of hemoglobin.
  • microcytic hypochromic anemia, with small red blood cells containing little hemoglobin.

Anemia: symptoms

But what symptoms to expect in the presence of anemia? Some symptoms are fairly obvious others are a little more subtle. In general, the clinical manifestations that can be observed or perceived in parallel with the finding of a reduction in hemoglobin values are symptoms of anemia. Furthermore, some pathologies have specific symptoms which are those of the pathology that has caused, among other things, a reduction in hemoglobin values. For example, in the presence of iron deficiency anemia, the symptoms could be very different from symptoms of pernicious anemia or come on symptoms of Mediterranean anemia, as the underlying pathology is different.

Let's see the main ones together signs is symptoms of anemia:

  • Skin pallor
  • Nail pallor
  • Eye symptoms such as conjunctival pallor
  • Asthenia (tiredness, weakness)
  • Hypotension (low blood pressure)
  • Tachycardia (rapid heartbeat)
  • Fainting (syncope)
  • Shortness of breath after modest efforts
  • Reduced tolerance to cold
  • Signs of bleeding in the case of post-haemorrhagic anemia,
    • Hematuria
    • Melena, i.e. black stools due to the presence of old blood, a sign of bleeding in the upper digestive tract
    • Rectorrhagia, that is, abundant bright red bleeding with the stool
    • Hematochezia, i.e. stool minimally streaked with bright red blood
    • Epistaxis, which is the common bleeding from the nose
    • Gingivorrhagia, bleeding from the gums
    • Hemoftoe, that is, the emission of blood from the respiratory tract with coughing
  • Painful seizures in the presence of sickle cell anemia due to peripheral vascular microocclusions, with secondary ischemia causing widespread acute pain
  • Cutaneous jaundice, caused by the increase of bilirubin in the blood, due to the massive destruction of hemoglobin such as occurs in haemolytic crises or in the acute phases of paroxysmal nocturnal hemoglobinuria
  • Chest pain: Discrepancy infarcts are not uncommon, which are cardiac ischemias of varying magnitude secondary to reduced oxygen supply to the coronary arteries caused by low blood hemoglobin levels.

From the point of view of laboratory analyzes, often anemia, in addition to reduced hemoblobin, is accompanied by other blood count changes such as

  • an alteration of the Red blood cells (for example: high red blood cells in the case of thalassemia trait, low erythrocytes in the case of acute or chronic blood loss anemia)
  • an alteration of the mean corpuscular volume or MCV: High MCV in case of megaloblastic anemia, low MCV in case of iron deficiency microcytic anemia
  • an alteration of theRDW (Red Cell Distribution Width), i.e. the variability of the volume of red blood cells: often in the presence of more than one cause of anemia, red blood cells of very different sizes coexist in the circulation, causing a concomitant finding of high RDW.
  • An alteration of theMCHC, that is of the average cellular concentration of hemoglobin (in English mean corpuscular hemoglobin concentration): obviously in the presence of reduced hemoblobin, we will also have low MCHC.

Furthermore, it will be possible to encounter one low ferritin as in the presence of anemia due to lack of iron in the blood, or of ferritin high, such as in the presence of anemia from chronic diseases or alcoholism.

Anemia: risks

Which ones are they risks is consequences a reduction in hemoglobin?

First of all, we need to distinguish the timing of the drop in hemoglobin. In case of acute anemia, as a hemorrhage or a crisis of haemolytic anemia, the loss of even a few points of hemoglobin will be enough to induce tangible symptoms. On the contrary, in the presence of a constant but minor loss of hemoglobin, such as in a chronic bleeding in a patient using anticoagulant drugs or in a woman with heavy menstruation, the human body has more time to get used to, and therefore they are tolerated. very low hemoglobin values without showing any signs or symptoms.

The main consequences of anemia are related to the reduction of oxygen supply to the body tissues. For example, the ability to carry out physical exertion is reduced, and people who even a moderate degree of arterial atherosclerosis could experience ischemic problems such as ischemia in the heart or in other parts of the body. Another example is frequent fainting, caused by a momentary under-flow of blood and oxygen to the brain.

Anemia: treatment and remedies

But what to do in presence of anemia? Exist care or remedies for anemia?

The first thing to do is to contact your GP to another doctor to whom we have entrusted the care of our health. Your doctor will evaluate your symptoms, and hemoglobin levels, depending on the presence of severe anemia you hate mild anemia, will decide if it is necessary to use one transfusion of blood (blood transfusion) or if it is possible to wait until the cause of anemia is recognized and treated, the hemoglobin levels return to within values of reference. In this second case, surely the first things to do will be a careful medical history (which is the past and present medical history) and a thorough physical examination.

Secondly, in addition toblood count (including red blood cell count, hemoglobin, MCV, white blood cells and leukocyte formula, platelets), which we would have already performed, it will be essential to add other blood tests such as renal function (creatinine, urea, sodium and potassium), the indices of hepatic cytolysis and cholestasis (transaminase, GGT, alkaline phosphatase), direct and indirect bilirubin, protein profile (protein electrophoresis) including albumin and total proteins, indices of inflammation such as ESR and C reactive protein, and a urine test. Carrying out these investigations, the picture will certainly be a little clearer, since most of the anemia have an easy origin to identify.

There treatment of anemia it can therefore pass through:

  • iron supplementation, called martial therapy, in case of microcytic anemia with iron deficiency.
  • integration of vitamin B12 (cyanocobalamin) and / or of folic acid in the presence of macrocytic anemia with deficiency of these nutrients.
  • Investigations such as the search for the fecal occult blood, and secondly, gastroscopy (EGDS) e colonoscopy, to identify possible sources of chronic gastrointestinal blood loss.
  • Immunosuppressive therapy (e.g. with cortisone) in case of autoimmune haemolytic anemia.
  • In-depth study with lymphocyte subpopulations, beta2-microglobulin, Bence Jones rpoteinuria and subsequent haematological examination in case of suspected oncohematological pathology.

Anemia: what to eat?

Often, in the presence of low hemoglobin values in the blood, one wonders if something in our diet is not correct. Undoubtedly, a varied and complete diet helps to reduce the chances of developing deficiency anemia. For example, the intake of iron-rich foods, such as legumes, spinach, cocoa and chocolate, red meats, shellfish can help keep iron stores (ferritin) and circulating iron concentrations (sideremia) within the normal range. A diet rich in fruit and vegetables and low in alcohol, on the other hand, can help to provide our body with an adequate amount of cyanocobalamin (vitamin B12) and folate (folic acid).

To the diet for anemia deficient type therefore includes fruit and vegetables, but also an adequate quantity of red meat or vegetables with a high iron content such as spinach, legumes (beans, chickpeas, lentils), fruits such as figs, chestnuts, dates, walnuts.

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