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Definition

Anemia is defined as too few red blood cells or red blood cells that don't work as well as they should.

Red blood cells contain hemoglobin which use iron to help transport oxygen throughout the body. Red blood cells pick up oxygen in the lungs, and carry it to the body's tissues. The red blood cells deliver the oxygen to the tissues and pick up carbon dioxide, a waste product. The red blood cells then bring the carbon dioxide back to the lungs where it is exhaled and released from the body.

If the number of red blood cells decreases quickly then the person with anemia can feel sick right away. If the red blood cell count falls slowly over a longer period of time, the body adjusts. In this case, the person may not feel sick - just tired or weak.

If there are not enough red blood cells, the tissues don't get enough oxygen. When the body's tissues don't get enough oxygen, then they aren't able to do their normal jobs. For example:

  • The body tells the heart to pump faster to get more oxygen to the tissues. As the anemia gets worse, the heart beats faster, called tachycardia. At first, it happens only with activity, but later the heart beats fast at rest. Sometimes, the heart can skip a beat or two. The irregular beat is called an arrhythmia.
  • If the person has heart disease, then the person may get chest pain if the heart muscle isn't getting enough oxygen.
  • The person may feel dizzy, or feel faint when moving from lying to standing positions. The person often feels tired, since oxygen is like energy. The muscles in the body need oxygen to walk, talk, and do any exercise. When anemia is slight, the person may just be a little more tired than usual after doing an activity. When the anemia is severe, it can make the person exhausted, or may prevent the person from doing anything at all.

The body also tells the lungs to breathe faster to bring in more oxygen, so if the anemia is severe, the person may have fast breathing, called tachypnea.

The brain also needs oxygen. If the anemia is severe, then the person may be indifferent or have trouble making decisions and thinking.

With severe anemia, the person will be very sensitive to cold temperatures, and have difficulty sleeping (insomnia). A blood test, called a complete blood count, can tell how many red blood cells and how much hemoglobin are in the blood. These laboratory values are shown below in Table 1.

 

Table 1. Laboratory values in anemia

 

NORMAL VALUES

VALUES IN ANEMIA

HEMOGLOBIN (measured in grams (g) per deciliter (dL)b

 

Mild: 9.5-10.9 g/dL (grade 1)
Moderate: 8-9.4 g/dL (grade 2)
Severe: 6.5-7.9 g/dL (grade 3)
Life-Threatening: less than 6.5 g/dL (grade 4)

-men

14-18 g/dL

Less than 14 g/dL

-women

12-16 g/dL

Less than 12 g/dL

HEMATOCRIT

 

Mild: 30 -36%
Moderate:25-30%
Severe: less than 25%

-men

42%-52%

Less than 42%

-women

36%-48%

Less than 36%

Anemia can also be described by the size and volume of the red blood cells, the amount of hemoglobin, and whether the body is making new red blood cells.

Causes

Normally, the body makes enough red blood cells with hemoglobin to replace the ones that the body has used up. A hormone called erythropoietin, which is made in the kidneys, tells the body when more red blood cells are needed. Red blood cells are produced in the bone marrow (inside the bones). Normal red blood cells live about 120 days, or 3 months.

Anemia can happen when the:

  • body can't make enough red blood cells (such as with chemotherapy)
  • body loses too many red blood cells (such as with bleeding)
  • red blood cells in the body are destroyed (such as with hemolytic anemia)
  • red blood cells don't work right (such as with sickle cell anemia)

The most common cause of cancer-related anemia is body's inability to make enough red blood cells (Arnold et al, 2001). This can happen because of the cancer itself (called anemia of chronic disease), treatment , or because cancer cells are in the bone marrow and, are crowding out the normal red blood cells.

Doctors and scientists are not sure what causes anemia of chronic disease. It seems like the body tries to fight the cancer by forming an army of immune cells. This causes an inflammatory reaction, like with an infection. The immune cells make chemical messengers called cytokines. Scientists know of two cytokines -- interleukin 1 (IL-1) and tumor necrosis factor (TNF). Cytokines may stop the iron from getting into the red blood cells, which prevents red blood cells from being made. Cytokines may also lower the level of the hormone erythropoietin, so that bone marrow is not told to make more red blood cells. If the red blood cells are made in a person with anemia of chronic disease, they don't seem to live as long as normal red blood cells.

Sometimes, cancer treatments such as chemotherapy or radiation can cause anemia by damaging healthy cells and organs. Radiation treatment to areas like the pelvis, which includes bones with bone marrow, can cause anemia. People who receive a combination of chemotherapy and radiation therapy usually develop anemia. Cisplatin, a chemotherapy drug, can injure the kidney, so it lowers the production of erythropoietin and red blood cells. Without erythropoietin, the bone marrow is never told to make more red blood cells. When the healthy red blood cells die after about 3 months, there are no new red blood cells to replace them and the person gets anemia. This is why some people get anemia months after treatment ends.

Another cause of anemia is f the body doesn't have the building blocks it needs to make red blood cells. One important building block is iron. Normally, the body gets enough iron from food, but iron can be lost if the person has bleeding from the stomach or intestines. If the body loses more iron than it takes in, it causes iron deficiency anemia. A lack of folic acid (folate) can also cause anemia.

Treatment

The treatment of anemia depends upon the cause. If the anemia is due to a lack of red blood cells, then red blood cells can be given through transfusions or treatment.

Red blood cell transfusions are used a lot of the time to treat anemia caused by cancer or its treatment when the hemoglobin is less than 8g/dL, the hematocrit less than 25%, or the person has symptoms. Red blood cells are looked at closely before they are given to someone to make sure that they match the person getting them. However, people can still have reactions to the red blood cell transfusion. To lower the chance that this happens, a special blood filters is usually used to administer the blood transfusion, or the red blood cells are irradiated. Some people donít want red blood cell transfusions for cultural reasons, such as people of the Jehovahís Witness faith.

PROCRIT can sometimes help these people become less anemic without red blood cell transfusions. This is made in the laboratory using special (recombinant DNA) methods so that it is identical to the bodyís erythropoietin. When epoetin alfa is given, it can take approximately four weeks to raise the hemoglobin and hematocrit.

For most people receiving chemotherapy that have been diagnosed with anemia, PROCRIT can be given to improve hemoglobin and reduce red blood cell transfusions (Cascinu et al, 1995).

Keeping a personís hemoglobin above 12 g/dL has other benefits as well. Cella (1998) studied patients with anemia at Rush-Presbyterian-St. Luke's Medical Center in Chicago and found that people with hemoglobin levels higher than 12 g/dL had fewer symptoms of anemia such as fatigue, shortness of breath, and fast heartbeat. Demetri from the Dana Farber Cancer Center and colleagues (1998) studied over 2200 people receiving chemotherapy, and found that PROCRIT improved hemoglobin values.

If a person has anemia due to iron or folate deficiency, then the person will need to take supplements and change their diet to eat more foods high in iron or folate. Foods high in iron are green leafy vegetables, organ meats including liver, nuts, egg yolks, molasses, whole grain cereals, shellfish, apricots, peaches, potatoes, prunes, and grapes. Foods high in folate are green leafy vegetables, asparagus, bananas, fish, oatmeal, beef liver, wheat bran, and peanut butter (Lynch, 2001).

Prevention

Iron supplements and erythropoietin are being studied in people receiving radiation and chemotherapy to prevent anemia and improve response. People at risk for nutritional problems can decrease the risk of anemia by eating foods high in iron, and folate.

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