Adult Congenital Heart Disease: Symptoms, Diagnosis & Treatments

Overview

Congenital heart disease is a type of defect in one or more structures of the heart or blood vessels that occur before birth. The heart structures, or vessels, do not form as they should during pregnancy, while the fetus is developing in the uterus.

In the United States:

• They affect about 8 to 10 out of every 1,000 children. Congenital heart defects may produce symptoms at birth, during childhood and sometimes not until adulthood.
• 800,000 adults in the United States have grown into adulthood with congenital heart disease. This number increases by about 20,000 each year.
• Adult congenital heart disease is not uncommon. 1 in 150 adults are expected to have some form of congenital heart disease.
• Heart Disease and Stroke Statistics–2017 Update

The most common congenital heart disorders affecting adults are:

Symptoms and Causes

Symptoms of Congenital Heart Disease

Congenital heart defects may be diagnosed before birth, right after birth, during childhood or not until adulthood. It is possible to have a defect and no symptoms at all. In adults, if symptoms of congenital heart disease are present, they may include:

• shortness of breath
• poor exercise tolerance

Diagnosis and Tests

Diagnosis of Congenital Heart Disease

Congenital heart disease is diagnosed by a murmur on a physical exam and several diagnostic tests:

Management and Treatment

Treatment of Congenital Heart Disease

Treatment is based on the severity of the congenital heart disease. Some mild heart defects do not require any treatment.Others can be treated with medications, invasive procedures or surgery. Most adults with congenital heart disease should be monitored by a congenital heart specialist and may need to take precautions to prevent endocarditis (an infection of the heart) throughout their life.

Surgical Treatment Options

Resources

How to find a doctor if you have adult congenital heart disease

Doctors vary in quality due to differences in training and experience; hospitals differ in the number of services available. The more complex your medical problem, the greater these differences in quality become and the more they matter.

Clearly, the doctor and hospital that you choose for complex, specialized medical care will have a direct impact on how well you do. To help you make this choice, read more about our Sydell and Arnold Miller Family Heart & Vascular Institute outcomes.

The Center for Adult Congenital Heart Disease in the Sydell and Arnold Miller Family Heart, Vascular & Thoracic Institute is a specialized center involving a multi-disciplinary group of specialists, including cardiologists, cardiac surgeons and nurses from Cardiovascular Medicine, Pediatric Cardiology, Pediatric and Congenital Heart Surgery, Cardiothoracic Surgery, Diagnostic Radiology, Pulmonary, Allergy and Critical Care Medicine, and Transplantation Center, who provide a comprehensive approach to diagnosing and treating adult congenital heart disease.

Learn more about specialized teams of doctors who treat congenital heart disease.

You may also use our MyConsult second opinion consultation using the Internet.

For younger patients with congenital heart disease:

See About Us to learn more about the Sydell and Arnold Miller Family Heart, Vascular & Thoracic Institute.

Contact

If you need more information,click here to contact us, chat online with a nurse or call the Miller Family Heart, Vascular & Thoracic Institute Resource & Information Nurse at 216.445.9288 or toll-free at 866.289.6911. We would be happy to help you.

Becoming a Patient

Treatment Options

Treatment Guides

Diagnostic Tests

Congenital heart disease is diagnosed by a murmur on a physical exam and several diagnostic tests:

Anatomy

Webchats

Our webchats and video chats give patients and visitors another opportunity to ask questions and interact with our physicians.

Videos

Interactive Tools

Resource Links

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The inclusion of links to other websites does not imply any endorsement of the material on those websites nor any association with their operators.

Why choose Cleveland Clinic for your care?

Our outcomes speak for themselves. Please review our facts and figures and if you have any questions don’t hesitate to ask.

Elevated Hemoglobin and Macrocytosis: A Neglected Association to Become a Diagnostic Tool (A Case Report) – The Permanente Journal

Elevated Hemoglobin and Macrocytosis: A Neglected Association to Become a Diagnostic Tool (A Case Report)

Leonid L Yavorkovsky MD, PhD1

Perm J 2021;25:20.262

https://doi.org/10.7812/TPP/20.262

E-pub: 05/12/2021

Introduction: The landmark value of mean corpuscular volume (MCV) in the diagnosis and classification of anemias has been established more than a century ago. In contrast, the importance of MCV assessment in patients with elevated hemoglobin and hematocrit is not nearly as appreciated.

Case Presentation: This case describes a patient who exhibited long-standing macrocytosis (elevated MCV) that contributed to elevated hemoglobin and hematocrit levels thus mimicking a diagnosis of polycythemia vera.

Conclusion: The case demonstrates that discounting the MCV effect on hemoglobin/hematocrit levels can lead to potential errors in interpretation of blood tests and misdiagnosis.

INTRODUCTION

The hemoglobin (Hb), hematocrit (Hct), and red blood cells (RBCs) have been historically essential in morphologic classification and diagnosis of anemias. Likewise, the RBC indices (RBCI) such as mean corpuscular Hb (MCH, picograms per cell), MCH concentration (MCHC, grams Hb per deciliter), and, especially, mean corpuscular volume (MCV) that defines the size (volume) of RBCs have been equally important in anemia assessment.¹ While MCV represents perhaps the most valued index in hematological practice,² its exact effects on Hct and Hb levels, especially in polycythemia cases, have long been underappreciated and completely disregarded in clinical practice. An illustrative case is presented. This case report follows the CARE Guidelines.³

CASE REPORT

A 79-year-old man with a history of congestive heart failure, atrial fibrillation, bladder cancer, lumbar spondylosis, gout, and depression was referred for evaluation of elevated Hb and Hct (Table 1). His Hb and Hct levels have fluctuated over a 2-year period from 17.4 to 18.1 g/dL (reference range, 13.0-17.0 g/dL) and from 52.7% to 54.4% (reference range, 39%-51%), correspondingly. The RBCs varied from 4.28 to 5.03 × 10¹²per liter (reference range, 4.10-5.70 × 10¹² per liter). At the time of evaluation, the patient’s RBC distribution width was 12.8% (reference range, 12.0%-16.5%) and mean corpuscular volume (MCV) was elevated at 110 fL (reference range, 80-100 fL). MCH was 36.3 pg Hb per cell (reference range, 27-31 pg per cell) and MCHC was 33 g Hb per deciliter (reference range, 31-37 g Hb per deciliter). He had a normal white blood cell count of 4. 5 × 10⁹ per liter (reference range, 3.7-11.1 × 10⁹ per liter), normal differential and platelet count of 124 × 10⁹ per liter (reference range, 140-400 × 10⁹ per liter). The reticulocyte count was 1.72% (reference range, 0.70%-2.40%), absolute count 80 × 10⁹ per liter (reference range, 25-115 × 10⁹ per liter). The patient never smoked and had normal oxygen saturation and no evidence of lung disease or sleep apnea. Additional tests were performed but failed to confirm the diagnosis of polycythemia vera (PV). There was no splenomegaly, his erythropoietin level was normal, and JAK2 V617F gene was unmutated. The patient’s treatment consisted of metoprolol, clonazepam, hydrocodone, venlafaxine, trazodone, allopurinol, tamsulosin, and furosemide.

Table 1. The case timeline

A 79-year-old man with a history of congestive heart failure, atrial fibrillation, bladder cancer, lumbar spondylosis, gout and depression, an unremarkable family and psychosocial history has been evaluated for a long-standing macrocytosis and temporary elevation of hemoglobin and hematocrit suggestive of polycythemia vera diagnosis.
Date	Summaries from initial and follow-up visits	Diagnostic testing (including dates)	Interventions
2000	Patient with multiple medical problems noticed to have borderline macrocytosis (MCV, 100 fL) and transient thrombocytopenia (136 × 109 per liter).	Evaluation of macrocytosis with bone marrow biopsy (01/19/01) showed no apparent signs of myelodysplasia, normal cytogenetics and flow cytometry.	Complete blood cell count monitoring without further diagnostic intervention was recommended.
2001-2015	Gradual increase of MCV without other RBC parameter changes was noticed: 102 fL in 2006, 104 fL in 2009, 106 fL in 2013 and 110 fL in 2015.	Several evaluations over the years failed to elucidate the cause of elevated MCV (see text).	The patient’s RBC parameters were observed without the treatment or any dietary or lifestyle changes.
	The treatment with diuretic for CHF initiated in 2015.
March 2016-Nov 2017	An asymptomatic elevation of Hb and Hct in addition to macrocytosis was identified.	A thorough evaluation with multiple blood tests and spleen ultrasound (see text) failed to establish the cause of elevated Hb and Hct.	A hematology consultation was requested for an indeterminate cause of elevated Hb/Hct.
Nov 2017	An initial evaluation of the patient’s medical, family and social history, medications and physical exam by hematologist failed to reveal an apparent cause of elevated Hb/Hct.	A comprehensive, longitudinal and comparative review of the RBC counts and RBC indices was performed.	The cause of elevated Hb/Hct was identified as a combined effect of relative RBC elevation due to diuretic use and elevated MCV. Discontinuation of the diuretic was recommended.
2017-2019	Following discontinuation of the diuretic, the patient’s RBC count returned to previous baseline with concomitant Hb/Hct normalization.	No further testing was recommended.	No further interventions were recommended.

CHF = congestive heart failure; Hb = hemoglobin; Hct = hematocrit; MCV = mean corpuscular volume; RBC = red blood cell.

The patient’s records showed that his MCV was slowly rising over 20 years. Of note, while the MCV was elevated during the entire follow-up period (Table 2), the increase in total Hb/Hct was observed for only 2 years preceding the evaluation. During that time, the patient was receiving a loop diuretic that, upon careful review, caused his RBC count to increase from a mean baseline of 4.54 × 10¹² per liter prior to the diuretic use to 4.79 × 10¹² per liter during the treatment. The patient was observed for 18 months. Following the diuretic cessation, the RBC count, while remaining normal, declined to the patient’s previous baseline with concomitant Hb/Hct normalization.

Table 2. Patient’s laboratory values

Laboratory test	Values				Reference range
	3.5 y before presentation (10/13/14)	At the time abnormal RBCI recorded (09/15/16)	At presentation (03/20/18)	1 y after presentation (03/19/19)
RBCs, × 1012/L	4. 45	4.85	4.80	4.68	4.10-5.70
Hb, g/dL	15.9	17.8	17.4	16.6	13.0-17.0
Hct, %	46.7	53.3	52.7	50.7	39-51
MCV, fL	105	110	110	108	80-100
MCH, pg/cell	35.7	36.7	36.3	35.4	27-31
MCHC, g Hb/dL	34. 0	33.3	33.0	32.7	31-37
White blood cells, × 109/L	4.8	4.4	4.5	5.3	3.7-11.1
Platelets, × 109/L	161	137	124	141	140-400

Hb = hemoglobin; Hct = hematocrit; MCH = mean corpuscular hemoglobin; MCHC = mean corpuscular hemoglobin concentration; MCV = mean corpuscular volume; RBCs = red blood cells; RBCI = red blood cell indices.

The cause of increased MCV, although extraneous to the issue under discussion, was addressed by extensive and repeated diagnostic procedures over the years. Seventeen years prior to the patient’s presentation, a bone marrow study showed normal trilineage hematopoiesis with mild relative erythroid predominance and focal mild increase in reticulin staining. Cytogenetic studies were normal and flow immunophenotyping failed to identify abnormal cell populations. The patient had no known history of drug or alcohol abuse, or kidney, thyroid or liver disease. He had a normal testosterone level and lipid profile [cholesterol 4.73 mmol per liter (reference range, < 5.17 mmol per liter), triglycerides 1.74 mmol per liter (reference range, < 5.63 mmol per liter)], and took no medications known to cause macrocytosis. He demonstrated no conditions that can cause spurious macrocytosis such as cold agglutinins, monoclonal proteins, hyperglycemia or hyperleukocytosis. The diagnosis of pernicious anemia was repeatedly dismissed based on the patient’s normal vitamin B12 (and folate) levels, lack of anemia, and macrocytosis persisting for as long as 20 years.

DISCUSSION

The cause of elevated Hb/Hct, the laboratory finding in question, was patently nontrivial in this case and necessitated an unconventional approach. As noted above, the patient’s Hb/Hct elevation occurred concomitantly with macrocytosis (Table 2). When present together, these abnormalities can pose a clinical challenge. The ordinary cause of high Hct is elevated RBC count.⁴ Because it was normal, the lasting increase in MCV was felt to be pertinent to the patient’s Hct elevation. Indeed, the high Hct ought to be attributed to the large RBC size as the classical formula Hct = RBC × MCV overtly demonstrates: the higher the MCV (the larger the RBC size), the higher the Hct (and vice versa).

Curiously, this fact, though obvious and rightly emphasized previously,⁵ has been completely overlooked and discounted in practice. It is also important to point out that MCV affects not only Hct, but also Hb. The fundamental link between MCV and Hb was established almost a century ago⁶ but remained completely obscured. This link was validated in a more recent study where MCV was shown to vary in a strict linear relationship with average content of Hb of RBCs (MCH).⁷ As the result, macrocytes accommodate a greater amount of Hb compared with normocytes or microcytes. Such a congruence of MCV with Hb content of RBCs (MCH) is sustainable owing to essentially constant Hb concentration per RBC (MCHC)⁷ (Table 2). While these findings proved to be important for evaluation of anemias, it has not been previously recognized that, by contributing to a total Hb/Hct level, MCV could be clinically relevant in the cases of elevated Hb/Hct.

The MCV elevation was not the only factor that triggered Hb/Hct raise in this case. The treatment with loop diuretic for 2 years was deemed to have caused chronic dehydration leading to relative RBC elevation. The latter in conjunction with elevated MCV forced the Hb/Hct levels upward of normal range and was masquerading polycythemia vera (PV). It is worth noting that, while the World Health Organization’s (WHO) classification of PV identifies erythrocytosis with high levels of Hb/Hct,⁸ this case corroborates that the latter may not be a reliable surrogate marker for absolute erythrocytosis.⁹

Although the etiology of elevated MCV presents a separate issue and is peripheral to its effect on Hb/Hct, it was of special interest in this case. Macrocytosis of such a long duration is rarely seen. Additionally, its cause remained hard to determine despite the extensive and repeated diagnostic procedures over the years. The likelihood of a normal variant or genetic predisposition^10,11 appeared to be low because the macrocytosis evolved over time. An acquired myelodysplastic syndrome, however, remained a plausible cause of the macrocytosis despite its remarkably long timespan.¹⁰

The present case illustrates a common scenario of how elevated MCV can contribute to high Hb/Hct levels, but it requires awareness and clinical acumen to resolve. While the described modifying MCV effect may have little clinical significance when short-lived, it caused a lasting diagnostic dilemma in this case. Such subtle RBC parameter dynamics may not be routinely perceived as important, but they are common and vastly underappreciated. Because macrocytosis occurs frequently in practice, and because RBC count tends to fluctuate for various reasons, their joint effect on Hb/Hct is clinically more prominent than generally recognized. In fact, even minor upward or downward trends in MCV readings can affect Hb/Hct in a clinically significant way.

As RBCI have become readily available with automated cell counters, their accurate assessment is paramount, especially in cases like this, and requires exclusion of the false readings due to spurious macrocytosis (SM) and/or spurious erythrocytosis. As mentioned before, the potential causes of SM such as RBC clumping (cold agglutinins or monoclonal proteins), RBC swelling (blood sample dilution from hyperglycemia),¹² and increased blood turbidity (hyperleukocytosis)¹³ were ruled out. A simple review of a peripheral blood smear can reliably identify SM in most instances. Spurious erythrocytosis may be caused by hemoconcentration due to burns, emesis, diarrhea, or diuretics as occurred in this case. A comprehensive history will usually identify the cause of spurious erythrocytosis, thus obviating the need for costly RBC mass measurements with radioisotope studies. One of the limitations of this case presentation is that the macrocytosis remained incompletely explained even after excluding all conceivable causes. On the other hand, if not for the durable macrocytosis, the long-hidden cause of Hb/Hct elevation could have been overlooked.

CONCLUSION

The essential link between the size (volume) of RBCs and the RBC cellular Hb content, despite its far-ranging clinical applications, has been discounted for almost a century. This case opportunely highlights the fact that macrocytes, by virtue of their larger volume, display a higher Hb content per cell than normocytes, and, as the result, contribute to overall higher Hb/Hct readings. In addition, the case demonstrates that macrocytosis is capable of forcing Hb/Hct above the normal range even in the absence of erythrocytosis (elevated RBC count). Because the described effect has a profound importance in clinical practice, general physicians and hematologists must be mindful about the MCV in every case of abnormally high Hb/Hct that can cause potential errors in interpretation of blood tests, misdiagnosis of PV, and unwarranted and costly workup.

Disclosure Statement

The author(s) have no conflicts of interest to disclose.

Funding

No funding has been provided for this study.

Acknowledgments

Kathleen Louden, ELS, of Louden Health Communications performed a primary copy edit.

Author Affiliations

¹Department of Oncology, Kaiser Permanente San Jose Medical Center, San Jose, CA

Corresponding Author

Leonid L Yavorkovsky, MD, PhD (Leonid. [email protected])

Author Contributions

Leonid L Yavorkovsky, MD, PhD, contributed entirely to this study including identifying the case and writing the manuscript.

Statement of Ethics

The patient has given his written informed consent to publish his case.

Abbreviations

Hb, hemoglobin; Hct, hematocrit; JAK2, Janus kinase 2 tyrosine kinase; MCH, mean corpuscular hemoglobin; MCHC, mean corpuscular hemoglobin concentration; MCV, mean corpuscular volume; PV, polycythemia vera; RBC, red blood cell; RBCI, red blood cell indices; SM, spurious macrocytosis

References

1. Wintrobe MM. Classification of the anemias on the basis of differences in the size and hemoglobin content of the red corpuscles.(Proc Soc Exp Biol Med) 1930 Jun;27(9):1071-3. DOI: https://doi.org/10.3181/00379727-27-5119

2. Davidson RJ, Hamilton PJ. High mean red cell volume: Its incidence and significance in routine haematology. J Clin Pathol 1978 May;31(5):493-8. DOI: https://doi.org/10.1136/jcp.31.5.493, PMID:649776

3. Riley DS, Barber MS, Kienle GS, et al. CARE guidelines for case reports: Explanation and elaboration document. J Clin Epidemiol 2017 Sep;89:218-35. DOI: https://doi.org/10.1016/j.jclinepi.2017.04.026

4. Billett HH. Hemoglobin and hematocrit. In: Clinical methods: The history, physical, and laboratory examinations. Walker HK, Hall WD, Hurst JW, editors. 3rd ed. Boston: Butterworths; 1990; Chapter 151. PMID: 21250102.

5. Doig K, Zhang B. A methodical approach to interpreting the red blood cell parameters of the complete blood count. Clin Lab Sci 2017 Jul;30(3):173-85. DOI: https://doi.org/10.29074/ascls.30.3.173

6. Haden RL. Clinical significance of volume and hemoglobin content of the red blood cell. Arch Intern Med 1932 Jun;49(6):1032-57. DOI: https://doi.org/10.1001/archinte.1932.00150130155013

7. Fischer SL, Fischer SP. Mean corpuscular volume. Arch Intern Med 1983 Feb;143(2):282-3. DOI: https://doi.org/10.1001/archinte.1983.00350020108020

8. Arber DA, Orazi A, Hasserjian R, et al. The 2016 revision to the World Health Organization classification of myeloid neoplasms and acute leukemia. Blood 2016 May;127(20):2391-405. DOI: https://doi.org/10.1182/blood-2016-03-643544, PMID:27069254

9. Johansson PL, Safai-Kutti S, Kutti J. An elevated venous haemoglobin concentration cannot be used as a surrogate marker for absolute erythrocytosis: A study of patients with polycythaemia vera and apparent polycythaemia. Br J Haematol 2005 Jun;129(5):701-5. DOI: https://doi.org/10.1111/j.1365-2141.2005.05517.x, PMID:15916693

10. Valent P, Jäger E, Mitterbauer-Hohendanner G, et al. Idiopathic bone marrow dysplasia of unknown significance (IDUS): Definition, pathogenesis, follow up, and prognosis. Am J Cancer Res 2011;1(4):531-41, PMID:21984971.

11. Sechi LA, De Carli S, Catena C, Zingaro L, Bartoli E. Benign familial macrocytosis. Clin Lab Haematol 1996 Mar;18(1):41-3. DOI: https://doi.org/10.1111/j.1365-2257.1996.tb00736.x, PMID:9118603

12. van Duijnhoven HL, Treskes M. Marked interference of hyperglycemia in measurements of mean (red) cell volume by Technicon H analyzers. Clin Chem 1996 Jan;42(1):76-80. DOI: https://doi.org/10.1093/clinchem/42.1.76, PMID:8565238

13. Francis DA, Francis JL, Roath OS. Improved assessment of haemoglobin and red cell indices in blood samples with high white cell counts. Med Lab Sci 1985 Jul;42(3):285-6, PMID:4046772.

Keywords: case report, hemoglobin, macrocytosis, mean corpuscular volume

Secondary Polycythemia: Practice Essentials, Pathophysiology, Epidemiology

Author

Srikanth Nagalla, MD, MS, FACP Chief of Benign Hematology, Miami Cancer Institute, Baptist Health South Florida; Clinical Professor of Medicine, Florida International University, Herbert Wertheim College of Medicine

Srikanth Nagalla, MD, MS, FACP is a member of the following medical societies: American Society of Hematology, Association of Specialty Professors

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Alexion; Alnylam; Kedrion; Sanofi; Dova<br/>Serve(d) as a speaker or a member of a speakers bureau for: Dova; Sanofi.

Coauthor(s)

Emmanuel C Besa, MD Professor Emeritus, Department of Medicine, Division of Hematologic Malignancies and Hematopoietic Stem Cell Transplantation, Kimmel Cancer Center, Jefferson Medical College of Thomas Jefferson University

Emmanuel C Besa, MD is a member of the following medical societies: American Association for Cancer Education, American Society of Clinical Oncology, American College of Clinical Pharmacology, American Federation for Medical Research, American Society of Hematology, New York Academy of Sciences

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Ronald A Sacher, MBBCh, FRCPC, DTM&H Professor of Internal Medicine and Pathology, Director, Hoxworth Blood Center, University of Cincinnati Academic Health Center

Ronald A Sacher, MBBCh, FRCPC, DTM&H is a member of the following medical societies: American Association for the Advancement of Science, American Association of Blood Banks, American Clinical and Climatological Association, American Society for Clinical Pathology, American Society of Hematology, College of American Pathologists, International Society of Blood Transfusion, International Society on Thrombosis and Haemostasis, Royal College of Physicians and Surgeons of Canada

Disclosure: Nothing to disclose.

Chief Editor

Sara J Grethlein, MD, FACP Professor of Clinical Medicine, Indiana University School of Medicine; Medical Director of Cancer Services, Indiana University Health, Adult Academic Health Center, IU Simon Cancer and IU North Hospital, Joe and Shelly Schwarz Cancer Center

Sara J Grethlein, MD, FACP is a member of the following medical societies: Alpha Omega Alpha, American College of Physician Executives, American College of Physicians, American Medical Women’s Association, American Society of Clinical Oncology, American Society of Hematology, Gold Humanism Honor Society, Leukemia and Lymphoma Society

Disclosure: Nothing to disclose.

Additional Contributors

Karen Seiter, MD Professor, Department of Internal Medicine, Division of Oncology/Hematology, New York Medical College

Karen Seiter, MD is a member of the following medical societies: American Association for Cancer Research, American College of Physicians, American Society of Hematology

Disclosure: Received honoraria from Novartis for speaking and teaching; Received consulting fee from Novartis for speaking and teaching; Received honoraria from Celgene for speaking and teaching.

A Patient Walks Into A Sleep Clinic With Too Many Red Blood Cells…

Read this article on the The Huffington Post

Joseph M. Ojile, M.D., D.ABSM, F.CCP
Chief Executive Officer, Clayton Sleep Institute

Over the last few months we’ve seen a spike in patients who’ve come to see us because “my  blood count is too high.”  The patients are puzzled.  Why am I seeing sleep specialists when “I have too many red blood cells?”  They’re seeing us because they have very smart, deeply caring primary care physicians.

So let’s look at the possible ties between an elevated hematocrit (the measurement of red blood cell count relative to blood volume) and sleep disorders.

One example patient, a 68-year-old gentleman, had a hematocrit measurement above the normal range despite as well as a hemoglobin measurement above normal range. Hemoglobin is the protein contained in red blood cells that delivers oxygen to tissues.  Elevated hemoglobin and hematocrit are important markers for erythrocytosis—“too many red blood cells. ”

Our patient had been diagnosed with Obstructive Sleep Apnea several years prior, and was using a CPAP, but reported that he had excessive daytime sleepiness and that he did not feel rested despite the CPAP treatment.

Our patient looked like he was in the ranks of the subjects in a study published in Sleep Breath in 2006,* which concluded that sleep apnea alone is a risk factor for an increased hematocrit.

Why are “too many red blood cells”—a condition called erythrocytosis—a bad thing?  Because it usually means that there is a shortage of oxygen in the system and the body is creating more red blood cells to carry more oxygen to make up for the shortage.  An elevated hematocrit is a risk marker for some very serious illnesses: heart disease, kidney disease and stroke.  And less threatening but really unpleasant symptoms include pain, weakness, fatigue, headache, blurred vision and mental fuzziness.

That Sleep Breath study showed that as the average oxygen (O2) saturation dropped, hematocrit rose.   The low-oxygen—hypoxic—environment created by sleep apnea is one possible mechanism for dropping O2 and elevating hematocrit. And as oxygen falls, your body has two main ways to compensate:  (1) take in more air—not usually possible if you have sleep apnea; (2) make more red blood cells to carry more oxygen and/or concentrate the red blood cells by decreasing the other elements that make up your blood.

Over time, the body becomes more and more accustomed to low oxygen levels and the hematocrit stays elevated.  Enter those very smart primary care physicians!  In a patient with a consistently elevated hematocrit and other risk factors such as large neck circumference, high blood pressure, overweight and symptoms such as snoring and excessive daytime fatigue, it’s time for a sleep specialist to make an evaluation.

A sleep study will reveal if a patient is suffering from obstructive sleep Apnea (OSA) and decreased oxygen levels at night.  One treatment for OSA is for the patient to use a continuous positive airway (CPAP) machine.   CPAPs enable better airflow and oxygenation during sleep.  A study published in Chest** showed that small group of patients treated with CPAP experienced significant decreases in hematocrit levels.  A larger study from the European Respiratory Journal followed patients for over a year and demonstrated a similar decrease in hematocrit levels. ***

So what was going on with our patient who was using CPAP, but was excessively tired and unrested and had persistently elevated hematocrit?  We put him on a program of optimized settings for his CPAP and a new mask better suited to him, combined with recommendations to be a “side-sleeper” not a back sleeper, to reach ideal body weight and to avoid alcohol around bedtime.

Results?  We tested his blood levels again within 30 days of modifying his treatment, and his hematocrit tested normal, as did his hemoglobin.  His red blood cells were just right!

Keep in mind, an elevated hematocrit does not necessarily mean you have sleep apnea.   Nevertheless, over the years we have diagnosed and treated patients for OSA who have suffered at length with the effects of hypoxia because their health care providers did not consider a sleep disorder as the secondary source of their elevated hematocrit.  So cheers for those perceptive and caring primary care physicians who get their patients with “too many red blood cells” evaluated for OSA!

Captain John Koch, MD, was recently a 4th-year medical student at Saint Louis University School of Medicine who engaged in a sleep and pulmonary specialty rotation with Dr. Ojile. Dr. Koch contributed greatly to the research and development of this review of elevated hematocrit and obstructive sleep apnea.  We recognize his participation with gratitude.

* “Does obstructive sleep apnea increase hematocrit?”  Jong Bae Choi, Jose S. Loredo, Daniel Norman, Paul J. Mills, Sonia Ancoli-Israel, Michael G. Ziegler, Joel E. Dimsdale;  Sleep Breath (2006) 10: 155-160

** “Overnight Decrease in Hematocrit After Nasal CPAP Treatment in Patients with OSA,” Jean Krieger, M. D.; Emilia Sforza, M.D.; Mariette Barthelmebs, Ph.D.; Jean-Louis Imbs, M.D.; Daniel Kurtz, M.D.;  CHEST, 97. 3  March 1990; pp 729-730

*** “Decrease in haematocrit with continuous positive airway pressure treatment in obstructive sleep apnoea patients”  J. Krieger, E. Sforza, C. Delanoe, C. Petiau;  European Respiratory Journal, 1992, 5, 228-233

How Is Hemolytic Anemia Diagnosed?

Your doctor will diagnose hemolytic anemia based on your medical and family histories, a physical exam, and test results.

Specialists Involved

Primary care doctors, such as a family doctor or pediatrician, may help diagnose and treat hemolytic anemia. Your primary care doctor also may refer you to a hematologist. This is a doctor who specializes in diagnosing and treating blood diseases and disorders.

Doctors and clinics that specialize in treating inherited blood disorders, such as sickle cell anemia and thalassemias, also may be involved.

If your hemolytic anemia is inherited, you may want to consult a genetic counselor. A counselor can help you understand your risk of having a child who has the condition. He or she also can explain the choices that are available to you.

Medical and Family Histories

To find the cause and severity of hemolytic anemia, your doctor may ask detailed questions about your symptoms, personal medical history, and your family medical history.

He or she may ask whether:

• You or anyone in your family has had problems with anemia
• You’ve recently had any illnesses or medical conditions
• You take any medicines, and which ones
• You’ve been exposed to certain chemicals or substances
• You have an artificial heart valve or other medical device that could damage your red blood cells

Physical Exam

Your doctor will do a physical exam to check for signs of hemolytic anemia. He or she will try to find out how severe the condition is and what’s causing it.

The exam may include:

• Checking for jaundice (a yellowish color of the skin or whites of the eyes)
• Listening to your heart for rapid or irregular heartbeats
• Listening for rapid or uneven breathing
• Feeling your abdomen to check the size of your spleen
• Doing a pelvic and rectal exam to check for internal bleeding

Diagnostic Tests and Procedures

Many tests are used to diagnose hemolytic anemia. These tests can help confirm a diagnosis, look for a cause, and find out how severe the condition is.

Complete Blood Count

Often, the first test used to diagnose anemia is a complete blood count (CBC). The CBC measures many parts of your blood.

This test checks your hemoglobin and hematocrit (hee-MAT-oh-crit) levels. Hemoglobin is an iron-rich protein in red blood cells that carries oxygen to the body. Hematocrit is a measure of how much space red blood cells take up in your blood. A low level of hemoglobin or hematocrit is a sign of anemia.

The normal range of these levels may vary in certain racial and ethnic populations. Your doctor can explain your test results to you.

The CBC also checks the number of red blood cells, white blood cells, and platelets in your blood. Abnormal results may be a sign of hemolytic anemia, a different blood disorder, an infection, or another condition.

Finally, the CBC looks at mean corpuscular (kor-PUS-kyu-lar) volume (MCV). MCV is a measure of the average size of your red blood cells. The results may be a clue as to the cause of your anemia.

Other Blood Tests

If the CBC results confirm that you have anemia, you may need other blood tests to find out what type of anemia you have and how severe it is.

Reticulocyte count. A reticulocyte (re-TIK-u-lo-site) count measures the number of young red blood cells in your blood. The test shows whether your bone marrow is making red blood cells at the correct rate.

People who have hemolytic anemia usually have high reticulocyte counts because their bone marrow is working hard to replace the destroyed red blood cells.

Peripheral smear. For this test, your doctor will look at your red blood cells through a microscope. Some types of hemolytic anemia change the normal shape of red blood cells.

Coombs’ test. This test can show whether your body is making antibodies (proteins) to destroy red blood cells.

Haptoglobin, bilirubin, and liver function tests. When red blood cells break down, they release hemoglobin into the bloodstream. The hemoglobin combines with a chemical called haptoglobin. A low level of haptoglobin in the bloodstream is a sign of hemolytic anemia.

Hemoglobin is broken down into a compound called bilirubin. High levels of bilirubin in the bloodstream may be a sign of hemolytic anemia. High levels of this compound also occur with some liver and gallbladder diseases. Thus, you may need liver function tests to find out what’s causing the high bilirubin levels.

Hemoglobin electrophoresis. This test looks at the different types of hemoglobin in your blood. It can help diagnose the type of anemia you have.

Testing for paroxysmal nocturnal hemoglobinuria (PNH). In PNH, the red blood cells are missing certain proteins. The test for PNH can detect red blood cells that are missing these proteins.

Osmotic fragility test.  This test looks for red blood cells that are more fragile than normal. These cells may be a sign of hereditary spherocytosis (an inherited type of hemolytic anemia).

Testing for glucose-6-phosphate dehydrogenase (G6PD) deficiency. In G6PD deficiency, the red blood cells are missing an important enzyme called G6PD. The test for G6PD deficiency looks for this enzyme in a sample of blood.

Urine Test

A urine test will look for the presence of free hemoglobin (a protein that carries oxygen in the blood) and iron.

Bone Marrow Tests

Bone marrow tests show whether your bone marrow is healthy and making enough blood cells. The two bone marrow tests are aspiration (as-pi-RA-shun) and biopsy.

For a bone marrow aspiration, your doctor removes a small amount of fluid bone marrow through a needle. The sample is examined under a microscope to check for faulty cells.

A bone marrow biopsy may be done at the same time as an aspiration or afterward. For this test, your doctor removes a small amount of bone marrow tissue through a needle. The tissue is examined to check the number and type of cells in the bone marrow.

You may not need bone marrow tests if blood tests show what’s causing your hemolytic anemia.

Tests for Other Causes of Anemia

Because anemia has many causes, you may have tests for conditions such as:

• Kidney failure
• Lead poisoning
• Vitamin or iron deficiency

Newborn Testing for Sickle Cell Anemia and G6PD Deficiency

All States mandate screening for sickle cell anemia as part of their newborn screening programs. Some States also mandate screening for G6PD deficiency. These inherited types of hemolytic anemia can be detected with routine blood tests.

Diagnosing these conditions as early as possible is important so that children can get proper treatment.

Source: National Heart, Lung, and Blood Institute, National Institutes of Health.

Hemoglobin Blood Level – an overview

Treatment of Cancer-Related Anemia

Hemoglobin levels typically decrease early in the course of chemotherapy treatment; with greater than half of patients experience a greater than 1 g/dL drop over the course of the first 9 weeks of therapy. The treatment of anemia related to malignancy depends upon correct identification of the underlying etiology. As noted previously, iron-deficiency anemia is very common in patients with malignancy. Among those patients with cancer who have an absolute iron deficiency (transferrin saturation <20%, ferritin <30 ng/mL), there is evidence that they may benefit from a short course of either oral or low-dose intravenous iron. In this setting, the addition of erythropoiesis stimulating agents (ESAs) is not necessary.

For many patients, transfusion of blood products is an effective therapeutic intervention. Red cell transfusion provides rapid symptomatic relief and is also a source of iron; one unit of packed red blood cells (RBCs) contains roughly 200 mg of iron. Logistic limitations with RBC transfusion, and transfusion-related morbidities have spurred the incorporation of ESAs as alternative agents for treating anemia in cancer patients. The use of ESAs during myelosuppressive treatment increases the hemoglobin level and decreases transfusion requirements by approximately 50%; however, ESA use is associated with an increased rate of cardiovascular and thrombotic events, and may be associated with poorer overall survival and time to cancer progression. This relationship between ESA use and thrombosis may be related to the target hemoglobin concentration as higher hemoglobin targets are associated with increased rates of thrombotic events in cancer patients.

In addition to thrombotic events, a number of concerns have been raised about ESA use and potential worsening of overall survival or time to disease progression. Data regarding ESAs and progression of disease are conflicting; some studies in patients with breast cancer and patients with head and neck cancer suggested worsening progression-free survival or local control of disease with ESA use. The mechanism behind tumor progression is unknown but may relate to decreased chemosensitivity in the setting of ESA use or relate to tumor vascularity and oxygen supply. One study isolated breast cancer stem-like cells, which are thought to promote tumor progression and relapse, and identified expression of the EPO receptor on the cell surface of these chemoresistant cells. Moreover, the concurrent administration of ESAs during chemotherapy had a chemoprotective effect. Other mechanisms that may underlie the association of EPO administration with tumor progression include augmentation of red cell mass and effects on tumor oxygenation.

Because of concerns about thrombotic events, as well as the potential for worsened overall survival and time to disease progression, ESA use is generally restricted to certain indications in patients with cancer. In general, transfusion of blood products and, if indicated, iron therapy, remain the standard of care for anemia associated with malignancy. Future studies considering the safety of ESAs for lower target hemoglobin levels, as well as alternative preparations of iron therapy may provide viable treatment options for cancer patients with anemia. There are some instances where ESAs may be useful adjuncts, specifically among patients with moderate or severe chronic kidney disease, or in palliative settings. In such situations, reversible causes of anemia should be ruled out before ESA use, and the minimal amount of EPO be used to avoid RBC transfusion.

Hemoglobin – Complete Blood Count

Hemoglobin – Complete Blood Count

Hemoglobin

Hemoglobin
is a molecule comprised of four subunits. Each subunit contains an iron containing
pigment (heme) and a protein (globulin). There are two types of subunits, alpha
and beta. Each gram of hemoglobin can carry 1.34 ml of oxygen. The oxygen carrying
ability of blood is directly proportional to its hemoglobin concentration. The
numbers of red blood cells does not indicate blood’s oxygen content because
some cells may contain more hemoglobin than others. Hemoglobin determination
is used to screen for anemia, to identify the severity of anemia, and to assist
in evaluating the patient’s response to anemia therapy. Hemoglobin also serves
as an important pH buffer in the extracellular fluid.

Decreased hemoglobin:

Blood loss and bone marrow
suppression reduce total RBC count and therefore lower total hemoglobin content.
Hemoglobin levels are also lowered in patients who have abnormal
types of hemoglobin or hemoglobinopathies. Red blood cells with abnormal types
of hemoglobin are often fragile and damaged or destroyed easily in the vascular
system. Hemoglobin electrophoresis can distinguish among specific types of abnormal
hemoglobin.

Thalassemia is an inherited
recessive hemoglobinopathy. It results from a failure to produce sufficient
globin molecules. The failure can be in either the alpha or beta portion. In
sickle cell anemia, the patient has an abnormally shaped hemoglobin known as
sickle hemoglobin (hgbS). Sickle hemoglobin creates misshapen RBCs which form
blockages in the vessels.

Other patients have a normal
RBC count but a low hemoglobin level. This situation occurs with iron-deficiency
anemia, in which red blood cells have less hemoglobin than normal. Iron deficiency
anemia is also referred to as hypochromic anemia. Hypochromic is a term that
means “less than normal color.” In general, women need more iron in
their diets than men, due to the regular loss of iron in the menstrual flow.
During pregnancy a woman’s need for iron to build more hemoglobin increases.
If a woman becomes pregnant when she has low iron reserves, she is at risk of
becoming severely anemic. Regular hemoglobin testing is an important part of
prenatal care. During the last trimester of pregnancy, a condition known as
“physiological anemia of pregnancy” occurs. This normal drop in hemoglobin
values results from an increase in the plasma volume. Multiple blood draws in
premature infants is a common cause of anemia.

Instant
Feedback:

Red
blood cells that have abnormal hemoglobin are damaged or destroyed more easily
than cells with normal hemoglobin.

Hemoglobin: critical low
and high values

• A hemoglobin value under
  5 g/dl may cause
  heart failure
• A hemoglobin value over
  20 g/dl may cause clogging of capillaries
  due to hemoconcentration

Increased levels of hemoglobin
are found in any condition in which the number of circulating red blood cells
rises above normal. Examples of conditions associated with increases in hemoglobin
are polycythemia vera , severe burns, chronic obstructive pulmonary disease,
and congestive heart failure.

For more
information about anemia, consider visiting the AMERICAN SOCIETY of HEMATOLOGY

http://www.hematology.org/Patients/Other-Resources/Education-Book/5302.aspx

© RnCeus.com

90,000 🧬 How to understand the results of a general blood test?

Muscovites in a test mode were given access to an electronic medical record – the history of visits to doctors for three years. This practice may soon spread across the country and people will study how health indicators have changed. More often than others, a general blood test is found in the card. It includes about two dozen parameters: some are vital, others deviate from the norm only in rare diseases. Together with Andrey Besedin, Candidate of Medical Sciences, GMS Clinic family doctor, we will tell you what a change in the level of the main ones means and why he is almost always prescribed first.

When is one test sufficient?

In some cases, the doctor, having received the result of the analysis from the finger, already understands what the problem is and how to solve it.

“Blood very often helps to identify different signs of a disease by the balance of blood cells and the ratio of cells,” says Andrey Besedin, candidate of medical sciences, family doctor at GMS Clinic. – For example, a deficiency of red blood cells coupled with low hemoglobin is a typical picture of anemia and it is imperative to look for and eliminate its cause.Sometimes, this is enough to prescribe iron supplements right at the reception. ”

A blood test allows you to understand, for example, that a patient has a serious infectious disease, and not a common cold. The level of leukocytes will scream about this.

“With a banal acute respiratory disease or acute respiratory viral infection, you can do without analysis,” says Viktor Shcherbina, therapist of polyclinic No. 2 in the city of Sergiev Posad. – But often there are additional signs: prolonged fever, severe cough, etc.For example, a patient comes with a cold, but the temperature is 37.2-37.5 ° C for more than a week. It turned out that it was caused by an inflammatory process from pyelonephritis – the patient had a cold in the pelvic area.

General analysis is also the primary oncological screening of diseases of the hematopoietic organs. If suspected, the therapist will immediately refer you to a hematologist or oncologist.

“In case of serious pathology, several parameters at once may differ from the norm,” says Besedin.- There are exceptions – a woman’s temperature “jumped” for no reason during the day from 35.5 ° to 38.5 ° C, severe weakness. All analysis indicators were in order, but the relative and absolute levels of lymphocytes were many times overestimated. This made it possible to detect blood oncological diseases at an early stage ”.

What to look at first?

According to therapists, the main parameters are the level of hemoglobin, platelets, leukocytes and ESR, it is also the erythrocyte sedimentation rate.And also the leukocyte formula – the percentage of different types of leukocytes.

Hemoglobin – an iron-containing protein in red blood cells that is responsible for gas exchange and metabolism – is the first thing that therapists look at. The hemoglobin level in women is lower than in men due to the difference in muscle mass. An increased level is much less common than a lower one and can hint at pathologies of the heart, kidneys, or bone marrow. He is referred to a hematologist with him, unless the patient is a donor.After a transfusion, their erythrocytes recover sharply, so their number increases dramatically and they have to continue donating blood to maintain balance. But the decrease is most often caused by an unbalanced diet, physical overload and liver disease. A severely reduced rate is a sign of more serious problems.

“If a man has very low hemoglobin, I suspect bleeding,” Shcherbina shares her experience. – Perhaps the smallest drops of blood are secreted in the stomach or intestines, it may be a hemorrhoid, or the ureter is bleeding due to urolithiasis.In women, this, coupled with pallor, indicates serious anemia. ”

Platelets are responsible for blood clotting. With their low level, the patient will not be accepted for surgery – it will not be easy to stop the blood. At elevated levels, there is a high risk of blood clots – blood clots that clog a vessel and cause a heart attack or stroke. The level of platelets indicates the state of blood vessels, and in combination with others helps to understand the nature of many diseases.

Leukocytes protect the body from infections, viruses and allergens.Before the health care reform in Russia, the norm was considered to be (6-8) * 109 / l, now (4-11) * 109 / l. A deficiency of leukocytes can indicate problems with immunity, a lack of B vitamins, or disruption of the bone marrow. An increased level indicates inflammation in the body, and the degree of its intensity helps to understand the rate of erythrocyte sedimentation.

“If the leukocytes are less than 4 * 109 / l, the ESR is more than 30 mm / h, and in the leukocyte formula neutrophils are increased to 70-80%, I am looking for a focus of inflammation,” says Viktor Shcherbina.- At temperatures below 40 ° C it can be pneumonia or acute prostatitis. In the opposite situation – an excess of leukocytes and a lack of neutrophils, I suspect lymphocytic leukemia, and refer to a hematologist. ”

So, the leukocyte formula helps to understand the source of problems in the immune response: viruses, as a rule, respond to some cells, for example, lymphocytes, to bacteria – neutrophils. According to Andrey Besedin, for example, inflammation can be caused by both viruses and bacteria, and leukocyte counts are needed to determine the tactics of treatment and monitor the patient.

What influences the results and when can they lie?

The numbers almost do not depend on age, weight and skin color. 80-year-olds have values ​​better than other young ones. If the parameters are slightly outside the norm, but there are no serious complaints, doctors do not prescribe anything for normalization, except for advice on maintaining a healthy lifestyle. Indicators are considered valid for no more than 1-2 weeks, and even less in case of a fleeting illness or recovery.

“In a patient with erysipelas of the limb while taking antibiotics, the parameters of leukocytes improved twice per day,” says Besedin.However, over-the-counter drugs usually do not affect results. What can not be said about dietary supplements: not all of them undergo clinical trials and can not only distort the test results, but also become the cause of the disease themselves.

Doctors admit that sometimes the readings look almost normal in an apparently unhealthy person. This happens in patients with gastritis, pancreatitis, cholelithiasis, and often in those suffering from hypertension. An experienced specialist can suspect some diseases already by the appearance of the tongue, while for the diagnosis of others one cannot do without fibrogastroscopy or ECG and EchoCG.

“A general analysis is prescribed if obvious symptoms are not visible on visual examination,” says Shcherbina. Often in the first 1-2 days of illness, a general analysis does not help to identify, for example, acute appendicitis: the level of leukocytes does not sharply increase. If a person begins to smoke in adulthood and at the same time leads a sedentary lifestyle, hemoglobin in his blood will remain at a normal level for several months or even be slightly increased, while the state of health may deteriorate sharply.And for the diagnosis of the notorious coronavirus, a general analysis is useless. But there is also a downside to the coin: a change in readings due to physiological processes.

“Ladies who have several indicators outside the normal range often come to me,” says Viktor Shcherbina. – It turns out that the analysis was given against the background of a large loss of blood during menstruation, but in fact everything is in order. So it is better for women to take it at least a week after the end of menstruation, and if this is not possible, warn the doctor. “

A general blood test is almost never the only one, it is prescribed as a hint – in which direction to think, and which pathologies to exclude. Therefore, without medical education, it is possible to interpret it, or the dynamics of results in an electronic map, only in general terms. It is better to understand what was happening to the body and consult an experienced doctor.

Source: EAPTEKA.RU

Automated blood test: Hemoglobin concentration

The article will analyze the indicators of 3-diff hematological analysis with a description of the technologies for their determination based on the automatic hematological analyzer BC-30s manufactured by Mindray .In particular, methods of determination, possible causes of false indicators and their clinical and diagnostic values.

1. HGB (Hb,

hemoglobin ) – hemoglobin concentration

Most accurate method

Mindray systems use the cyanide-free methemoglobin method using imidazole as a ligand. The method is fast (10 seconds) and sensitive, much less affected by high levels of leukocytes in the blood than hemiglobincyanide.The reagent (NaOH and lauramine oxide) dissolves all cell particles and lipids and destroys bilirubin – thus eliminating the interference due to hemoglobin turbidity. Therefore, this method provides more reportable results than any other.

False indicators

Clinical and diagnostic value

2.MCH (Mean Corpuscular Hemoglobin) – the average content of hemoglobin in the erythrocyte

Interchangeable parameters

MCH reflects the mass of hemoglobin in the “average” erythrocyte. This parameter can be calculated by the hemoglobin index and the number of erythrocytes:

MCH (pg) = Hb (G / L) / RBC (1012 / L).

MCH in the erythrocyte and the previously used CP (color indicator) express the same characteristic of cells – the average amount of hemoglobin in erythrocytes. But the first indicator gives the absolute value in picograms, and the second – the hemoglobin content in erythrocytes in arbitrary units.

Since these two metrics completely replace each other, there is no need to calculate the CPU. (Of course, if the laboratory has a hematology analyzer, it will calculate the MCH automatically). In addition, MCH in the erythrocyte is a more objective parameter than CP. After all, the second does not reflect the synthesis of hemoglobin and its content in the erythrocyte.

Independent indicator

An increase in MCH over 34 pg (hyperchromia) depends solely on an increase in the volume of red blood cells, and not on an increased saturation with hemoglobin.SIT in the erythrocyte is an extremely stable indicator and for adults does not depend on age, gender, race. The coefficient of variation of this parameter in patients is 5-6%.

As a diagnostic parameter, MCH is secondary and has no independent diagnostic value. It correlates with the values ​​of MCV and MCSU. All conditions that contribute to a decrease in volume, an overestimation of the number of erythrocytes and an underestimation of hemoglobin, lead to a decrease in the content of hemoglobin in the erythrocyte.

Clinical and diagnostic value

3. MCHC (Mean Corpuscular Hemoglobin Concentration)

– Average concentration of hemoglobin in the erythrocyte

Calculation of the parameter

MCHC reflects the concentration of hemoglobin in the “average” content of hemoglobin cell volume) and characterizes the degree of saturation of the erythrocyte with hemoglobin in percent.This parameter can be calculated using indicators of hemoglobin and hematocrit:

MCHC = Hb (g / dL) · 100 / Ht (%).

Genetically determined indicator

The average hemoglobin content in an erythrocyte is the most stable, genetically determined indicator and for adults does not depend on age, sex, race. The coefficient of variation of this parameter in patients in the clinic is 4–5%.

Of all the erythrocyte indices, MCHS is the least susceptible to fluctuations in pathological conditions.Therefore, its reduction is of great value in diagnostics:

• iron deficiency anemia,
• thalassemia,
• lead intoxication,
• some hemoglobinopathies.

Error indicator

For the same reason, the parameter can be used as an indicator of an instrument error or inaccuracy made when preparing a sample for examination. The stability of the calibrations, the correct functioning of the equipment – all of this is useful to monitor against the current average value of the MCSU.It should fluctuate within 34 ± 2 units.

Clinical and diagnostic value

When to repeat the analysis

The upper limit of the solubility of hemoglobin in water is 37 g / dl.therefore, an increase in ICSU is extremely rare. Results above 37 g / dL. – a clear indication of the need to repeat the analysis. One of the possible reasons for the increase in MCHC is hemolysis in the sample.

Vladimir Lazun,

Head of the KDL Product Division

Khimlaborreaktiv LLC

Complete blood count with reticulocytes

What are reticulocytes and when is their analysis prescribed?

Reticulocytes are young red blood cells present in the peripheral blood in small numbers.Erythroid cells are the precursors of reticulocytes. Determination of these cells in the blood is considered an important indicator because it determines the activity of the bone marrow. This study can be performed at any age, it is carried out for both men and women. In infants and women, reticulocyte counts are slightly increased during pregnancy.

Explanation of results. Standards

If a person is healthy, then the number of reticulocytes as a whole does not change. In the case when the hematocrit or the number of erythrocytes is reduced, the percentage of reticulocytes may increase in comparison with the total number of erythrocytes, that is, an artificial overestimation of the number of reticulocytes occurs.Therefore, in order to accurately assess the severity of anemia in this case, it is better to use the reticulocyte index, which determines the absolute number of reticulocytes. In this case, the patient’s hematocrit is compared with the normal hematocrit level.

Rate (RI) – 1-3%.
RI <1 - is a manifestation of the hypoproliferative form of anemia.
RI> 3 – means enhanced activation of erythropoiesis.

Normal indicators of RI:

• children under 1 month- 0.2 – 2.0%; 2 – 12 months – 0.2 – 1.5%; 1 – 14 years – 0.2 – 1.7%
• in adults: for women — 0.5 – 2.1%; for men – 0.2 – 1.7% 90,097

Reasons for an increase in the number of reticulocytes

• Bleeding. In the case of chronic blood loss, the level of reticulocytes will be constantly increased
• Inflammatory processes in the body
• Hemolysis (the indicator rises to 300% of the normal indicator)
• Treatment of B12-deficiency anemia affects the onset of reticulocytic crisis
• Erythropoietin intake
• Oncological diseases of the bone marrow and with metastases of other neoplasms in the bone marrow
• Restoration of bone marrow activity after radiation and chemotherapy
• Polycythemia of any genesis

Causes of reduced reticulocyte count

• Folic deficiency or iron deficiency anemia
• Myxedema resulting from decreased thyroid function
• Alcoholism
• Aplastic anemia
• Chronic kidney disease
• Uremia
• Chronic infections in the body
• Chloramphenicol and carbamazepine intake

We offer to undergo a full examination in our medical center, including laboratory and instrumental diagnostics services.We guarantee our patients a full range of medical services, friendliness and professionalism of the staff.

Clinical blood test – price in St. Petersburg, transcript in adults

When is it recommended to do UAC

A general blood test is taken in order to quickly and comprehensively assess the functions of vital systems and the state of the whole organism as a whole. The study is prescribed in the following situations:

• preventive examination;
• diagnostics of diseases of infectious, inflammatory, tumor, allergic origin;
• dynamic assessment of the course of chronic pathologies;
• hospitalization in a therapeutic / surgical hospital;
• preoperative preparation;
• evaluation and monitoring of the effectiveness of therapy.

Children are assigned to pass the AOK as part of a medical examination before entering kindergarten, school, as well as when applying for sports clubs and specialized educational institutions.

Preparation

For the results of a general blood test to be reliable and objective, the patient needs to properly prepare for delivery. On the eve of the study, you should limit the use of fatty, sweet, salty foods. The last meal should take place 8-12 hours before blood sampling.If the patient cannot comply with this interval, a light snack is allowed 3 hours before visiting the laboratory.

It is advisable to exclude any stress, intense psycho-emotional and physical stress. Smokers should refrain from cigarettes for at least 30 minutes before donating blood.

In some situations, a general blood test is performed urgently, then preparation is neglected, because it is important to assess the state of the body at the moment.

How to take the test

A general blood test can be taken in the multidisciplinary medical center of St. Petersburg “MEDIONA PARNAS”.The cost of a general blood test includes the collection of biomaterial and the test itself.

Adults donate venous blood. Capillary blood (from a finger) is taken from children under 7 years of age. Taking the test takes no more than 5 minutes. Results are ready within a day.

What shows the UAC

The laboratory test measures the following indicators:

• Erythrocytes are red blood cells that contain hemoglobin and exchange gas in tissues.An increased level is observed against the background of the pathological state of the hematopoietic organs, diseases of the respiratory system. A decreased level of red blood cells is detected in patients with anemia (anemia).
• Leukocytes are white blood cells that have a protective function. An increase in their number indicates an inflammatory process in the body. A reduced amount may indicate a violation of the immune system.
• Platelets are cells that provide blood clotting.A low level indicates a tendency to bleeding. High may indicate a risk of blood clots.
• Indicators MCV, MCH, MCHC, MCV reflect the hemoglobin content in erythrocytes and are used in the differential diagnosis of anemia. 12 cells / l) MCV, mean erythrocyte volume 80-101 fl 78-101 fl RDV 11.6-14.8% MCH, color index 27-35 pg 27-34 pg Platelets 150-400 thousand / μl 150-400 thousand / μl Leukocytes 4.5-9 thousand / μl

  Changes in the composition and characteristics of blood are not a specific symptom of any disease.Indicators can change under the influence of various factors (pregnancy, dietary habits, bad habits, stress) and pathological changes in the body.

  A doctor will help to objectively evaluate the results of a general blood test. To decipher the test, you can contact a therapist or the attending physician who ordered the study. The specialist interprets the results taking into account the patient’s condition, existing symptoms, history data and the results of other diagnostic procedures.

  It is possible to make a general blood test in a high-quality, objective and reliable way in St. Petersburg in the MEDIONA PARNAS clinic, which is equipped with modern laboratory equipment. Sign up for an examination at a convenient time without queues!

  blood hemoglobin indicators | MRI Expert

  “We need to do a hemoglobin test.” Probably almost everyone has heard a similar phrase (often supported by a written direction for research).It is also done for preventive purposes – when a person is not worried about anything.

  Why is this very hemoglobin so important? What is this in general and what can he tell about? What are the reasons for the increased and decreased levels?

  Who is and what does

  Hemoglobin is a protein substance contained in erythrocytes. Consists of two parts, reflected in its name – heme (non-protein part) and a simple protein globin. The terms “hemoglobin” and “iron” are connected with each other so strongly that perhaps everyone knows about it.So iron is just part of the heme.

  The function of hemoglobin is fundamental: it carries oxygen from the lungs to the tissues, and back from them carries carbon dioxide. Contained in red blood cells.

  Read the material on the topic: William Harvey vs. Claudius Galen: how does the human circulatory system work?

  Normal

  In textbooks and manuals, you can see the differing figures for the norm of hemoglobin in the blood.Perhaps this is due to the fact that, depending on the time period and country, its content was measured in different ways.

  Normal fluctuations in an adult, according to various sources, are – regardless of gender – from 120 g / l to 177 g / l. However, the level of hemoglobin is normally higher in men than in women. This is due to a number of factors, including the stimulating effect of male sex hormones (primarily testosterone) on hematopoiesis, as well as regular menstrual blood loss in women.

  Limits of the norm: 120-172 g / l – for women, and 130-177 g / l – for men.

  It is important to remember that standards may differ depending on the laboratory used.

  More often – below

  Why do we need to know how much hemoglobin is in the blood? Based on its function, the answer is on the surface: its amount will affect the gas transport function of the blood.

  NORMAL VIBRATIONS IN AN ADULT,
  FOR DIFFERENT SOURCES, MAKE UP –
  WITHOUT DEPENDENCE ON THE FLOOR – FROM 120 G / L TO 177 G / L

  A decrease in the level of hemoglobin can be observed with anemia.It is a condition characterized by a decrease in hemoglobin concentration and hematocrit. Usually, this also decreases the number of red blood cells.

  Why can low hemoglobin levels be found? This happens with various diseases.

  HEMOGLOBIN LEVEL IN NORMAL
  MEN HIGHER THAN WOMEN

  The so-called iron deficiency anemias have a significant share in the structure of anemias. Already from the name it is clear that in this case the body is experiencing a lack of this element.The reasons may vary. These are periods of rapid growth in children, helminthic diseases, pregnancy (when the child “takes” part of the iron from the mother). The most common cause is frequent minor bleeding. Is the stomach ulcer bleeding or see blood in the stool due to hemorrhoids? Or maybe you are worried about heavy menstruation or uterine bleeding? Iron “leaves” the body for these and other reasons.

  A separate article – fasting days, self-administered diets, dietary style.It is necessary to understand that iron is acquired from the outside. This means that in relation to him, the figurative “I am what I eat” is quite right. Here, we can additionally mention the lack of protein in food (do not forget about the structure of the hemoglobin molecule).

  Read the material on the topic: Vegetarianism: fashion, philosophy or good for the body?

  The next mechanism for the development of iron deficiency is poor absorption. Iron and protein are sufficient, and hemoglobin is below normal. Why? It is possible that the problem is in the absorption of food components.This can occur, in particular, with some diseases of the gastrointestinal tract.

  Read the material on the topic: What is gastritis and how to treat it?

  The level of hemoglobin also decreases with other types of anemias (vitamin B12-deficient, hemolytic, aplastic, etc.). They are characterized by their own mechanisms leading to a decrease in the hemoglobin content in the blood.

  Suspect

  In some cases, even when the process of reducing the amount of hemoglobin is already underway, there may be no complaints.As the pathology worsens, signs begin to appear.

  Symptoms arising from a low hemoglobin level are many. Among them:

  – general weakness;

  – fatigue;

  – dizziness and headaches are possible;

  – tinnitus;

  – shortness of breath;

  – heart palpitations.

  Skin and visible mucous membranes pale. When determining the level of hemoglobin, its decrease is noted.

  In addition to general symptoms, there may be specific ones characteristic of various types of anemias.

  For example, with iron deficiency anemia, there may be changes in the mucous membranes of the gastrointestinal tract, a decrease in the acidity of gastric juice, muscle weakness, including sphincters.

  There is a hypothesis that iron deficiency can lead to a deterioration in cognitive processes. This is especially evident in children. Also, the lack of this element is presumably capable of leading to a weakening of the immune system.

  Is a lot always good?

  Sometimes in the analysis you can see that the hemoglobin level is not lowered, but on the contrary, increased.What does it mean?

  As it turned out, this condition can also indicate pathology. Some of them are: polycythemia vera (erythremia, Vakez’s disease), kidney disease – in particular, in violation of their blood supply and insufficient supply of oxygen to them; smoking; lung diseases; a decrease in the volume of the liquid part of the blood.

  There are reports that an increase in hemoglobin can be noted while in the mountains; a number of malignant neoplasms; heart failure.

  How to find out

  The diagnosis of anemia is specified and confirmed / excluded by determining the amount of hemoglobin in a unit of blood volume (g / l). Usually this study is part of a general blood test, which also clarifies a number of other important parameters – in particular, the number of erythrocytes, the concentration of hemoglobin in the erythrocyte, etc. In addition, a biochemical blood test can be performed to determine the level of ferritin and other indicators.

  Since there are many causes of anemia, instrumental research methods can be used according to indications: ultrasound, gastro- and colonoscopy.

  Read the material on the topic: Where to get the courage to decide? Gastroscopy – WITHOUT fear!

  The range of necessary studies is determined by the attending physician depending on the specific situation.

  What’s Next

  Appropriate treatment is prescribed depending on the diagnosis. It is often asked whether it is possible to increase hemoglobin levels through nutrition. The answer is not always. This largely depends on the reason that led to its decline.
  EFFECTIVE SOURCE OF IRON
  THERE MAY BE NOT ALL PRODUCTS.
  MANY FRUITS AND VEGETABLES, PULSES
  REALLY RICH IN IRON,
  HOWEVER IT GETS BAD

  But what if we are talking about iron deficiency anemia, when insufficient intake of iron in the body has been proven? Of course, a balanced and competent diet will increase the level of hemoglobin. However, it should be remembered that clinically apparent iron deficiency should only be treated by a doctor with the necessary medication.Food alone is not able to completely eliminate its deficiency, even when it comes to a relatively unexpressed decrease in hemoglobin levels. Therefore, appropriate medications may be needed until iron levels in the body are normalized.

  What foods increase hemoglobin? You probably had to meet with advice to eat liver dishes, carrots, beets, walnuts, apples, pomegranate juice.

  However, not all foods can be an effective source of iron.Many fruits and vegetables, legumes are actually rich in iron, but it is poorly absorbed. The leaders in digestibility are iron from lean meat and poultry.

  What matters is what meat is consumed with. Pasta, milk porridge reduce its absorption, but a side dish of zucchini, broccoli, onions, herbs are quite acceptable “companions” of meat. Vitamins will also help to assimilate the iron – especially ascorbic acid.

  Read the material on the topic: Ascorbic acid, familiar from childhood: why does the body need vitamin C?

  It is also recommended to use vegetable oils, and if there are no contraindications – and butter.

  Do not drink tea immediately after eating. Limit your coffee intake.

  It is also recommended to exclude fat and fatty fish from the diet. Regarding the latter, discuss this issue with your doctor: perhaps this is a temporary measure, since the fish itself is good for the body.

  If you need to take a blood test for hemoglobin, the cost of the study can be found by calling the phone number listed on the contacts tab

  Can I handle it myself?

  If a low or high hemoglobin level was found in a blood test, this is always a reason to consult a doctor.Now you know that there are many reasons for changing its content. Therefore, self-medication is unacceptable: you can not only harm yourself, but also waste valuable time, especially when it comes to a serious illness.

  Text: Enver Aliyev

  You may also be interested in:

  You and I are of the same blood. How to become a donor in Russia?

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  90,000 Efficiency of donor erythrocyte transfusions in patients with hemoblastosis with anemia

  N.A. Romanenko, R.A. Golovchenko, S.S. Bessmeltsev, N.A. Potikhonova, A.V. Chechetkin, K.M. Abdulkadyrov

  FGBU “Russian Research Institute of Hematology and Transfusiology of the Federal Medical Biological Agency of Russia”, St. Petersburg

  Transfusiology No. 2, 2015

  Summary

  The article presents an analysis of the results of anemia correction using erythrocyte (TE) transfusions in 190 patients with various forms of hemoblastosis.The effectiveness of TE was determined by a decrease in the clinical symptoms of anemia and an increase in the hemoglobin content per one infused dose of erythrocytes. A complete response to TE in the form of an increase in hemoglobin content by 10 g / l (11.4 ± 0.6 g / l) was observed in 57 (30%) patients, whose Hb concentration increased from 70.4 ± 1.7 to 103.4 ± 0.9 g / L after transfusion of 2.9 ± 0.2 doses of erythrocytes. Overall survival (OS) over a period of 4 months was 94.7%. A partial response to TE in the form of an increase in Hb content by 5–9.9 g / l (6.6 ± 0.2 g / l) for each transfused dose of erythrocytes was recorded in 71 (37.4%) patients.Their Hb level increased from 68.7 ± 1.4 to 97.6 ± 1.2 g / l, 4.5 ± 0.3 units of erythrocytes were transfused. OS within 4 months was 84.5%. The minimum response in the form of an increase in hemoglobin for each dose of erythrocytes by <5 g / l (2.6 ± 0.2 g / l) was found in 62 (32.6%) patients. Their Hb concentration increased from 72.5 ± 1.6 to 89.2 ± 1.8 g / l, 6.4 ± 0.8 doses of erythrocytes were transfused. OS within 4 months was 66.1%, which is significantly lower than in the groups of patients with complete and partial response. Low efficiency of TE was observed in patients with severe depression of erythropoiesis, hemolysis of erythrocytes due to disease progression and the toxic effect of chemotherapy.Stratification of patients into groups depending on the effectiveness of TE allows predicting the course of the underlying disease and differentiated approach to the treatment of anemia in hemoblastosis.

  Keywords: anemia, erythrocytes, erythrocyte transfusion, hemoglobin content, hematocrit, hemoblastosis, donor erythrocytes.

  Introduction

  Anemic syndrome in oncohematological diseases is a frequent manifestation of the disease, worsens its prognosis and the quality of life of patients.This syndrome is characterized by numerous clinical symptoms, leading to maladjustment of the patient in the emotional, social, family spheres [1, 2]. The frequency of anemia varies depending on the variant, as well as the phase of the tumor process and ranges from 20 to 90%, and during the period of chemotherapy (CT) can increase by 1.5–2 times [3–7].

  The main method for correcting anemia in patients with tumor diseases of the blood system is erythrocyte (TE) transfusion, which allows to ensure the adequate functioning of organs and body systems and the quality of life of patients.However, transfusions of donor blood components are often complicated by immune reactions with hemolysis, transmissible infections, vascular thrombosis, and multiple TEs can lead to hemosiderosis of internal organs [8–12]. Therefore, in recent years, a restrictive tactic has been adopted for the use of blood transfusions [13–15]. The rules for transfusion of donor erythrocytes are determined by the Orders of the Ministry of Health of the Russian Federation No. 363 dated November 25, 2002 “On approval of the Instructions for the use of blood components” and No. 183n dated April 2, 2013.”On the approval of the rules for the clinical use of donor blood and (or) its components” [14, 15]. According to the instructions of regulatory documents, the indication for transfusion of donor erythrocytes in acute anemia due to massive blood loss is the loss of 25-30% of the circulating blood volume, accompanied by a decrease in hemoglobin levels below 70-80 g / l and hematocrit below 25%, as well as the occurrence of circulatory disorders. For patients with chronic anemia, donor erythrocytes are transfused according to more stringent indications, which is due to the compensatory mechanisms of the recipient’s body (an increase in cardiac output, a shift in the oxyhemoglobin dissociation curve to the right, an increase in oxygen release in the tissues).These patients are transfused with erythrocytes only to correct the most important symptoms associated with anemia [15].

  However, in patients with oncohematological diseases during the period of chemotherapy, the hemoglobin content in the blood often decreases by 10–40 g / l, aggravating the existing anemia and the functions of vital organs and systems. The course of anemia is also aggravated by erythrocyte hemolysis, bone marrow hypoplasia (BM), and intoxication due to the breakdown of tumor cells [16]. In addition, chronic anemia can often lead to dystrophic changes in the myocardium with the development of heart failure, which is reflected, among other things, in the prognosis of the disease and the patient’s quality of life [2].Therefore, such patients need to ensure an adequate gas transport function of the blood to avoid complications from the cardiovascular system. The optimal response to each transfused dose of donor erythrocytes containing 180–260 ml of erythrocytes is considered to be an increase in peripheral blood Hb content by 10 g / L in a patient weighing 70–80 kg [16–18]. However, in patients with erythropoiesis defect, BM hypoplasia, erythrocyte hemolysis, it is not always possible to achieve an optimal response, which poses the task of identifying the reasons for the low efficiency of TE and its effect on the overall survival (OS) of patients with hemoblastosis.

  Materials and Methods

  The efficacy of TE was investigated in 190 patients (aged 18 to 81) with hematological malignancies who were treated in the hematology clinic of the Federal State Budgetary Institution “RosNII GT” in the period 2006–2013. Among the studied there were 39 patients with myelodysplastic syndrome (MDS), 28 – acute myeloid leukemia (AML), 21 – primary myelofibrosis (PMF), 10 – chronic myeloid leukemia (CML) in the blast crisis phase, 42 – multiple myeloma (MM) in III stages, 19 – non-Hodgkin’s lymphomas (NHL) in stages III-IV, 22 – chronic lymphocytic leukemia (CLL) in stage C (according to J.L. Binet), 9 – acute lymphoblastic leukemia (ALL). The study group consisted of young patients with a stable status and elderly patients (over 65 years old) with concomitant cardiac and pulmonary insufficiency, as well as patients with an unstable course of the underlying disease (sepsis, unstable peripheral blood parameters, hemorrhagic syndrome, hemolysis). According to the severity of anemia (according to the WHO classification), 3 groups of patients were identified: with moderate anemia (n = 49), with severe anemia (n = 61) and with anemia of threatening severity (n = 80).

  Transfusions of donor erythrocytes and assessment of their effectiveness were carried out in accordance with the “Instructions for the use of blood components” [15]: after each blood transfusion of erythrocytes, a hemogram and a general urine analysis were examined. TE was prescribed in the presence of complaints of severe weakness, palpitations, shortness of breath with minimal physical activity, a sharp decrease in working capacity, tachycardia, as well as with a hemoglobin content of 90,088 <80 g / l, hematocrit <25%. The transfusion of erythrocytes was stopped when the hemoglobin content reached 85–95 g / l and above.The indications were extended (hemoglobin content <95 g / l and hematocrit <30%) in elderly patients with heart or pulmonary insufficiency. The effectiveness of TE was assessed by a decrease in the clinical symptoms of anemia and an increase in hemoglobin concentration. Depending on the increase in Hb concentration per dose of transfused donor erythrocytes, patients were divided into three groups: with a positive (complete) response (increase in Hb level 10 g / l), partial (by 5-9.9 g / l) and minimal ( by <5 g / l).

  Filtered erythrocyte mass (FEM), washed erythrocytes (EE), thawed and washed erythrocytes (SEM), and erythrocyte mass (EM) were prescribed to correct anemia. Considering that some patients received multiple transfusions of donor erythrocytes (for> 2 months), their blood was examined for the presence of allo- and autoanti-erythrocyte antibodies and, if there was a suspicion of possible incompatibility (n = 16), TE was performed after individual selection of donor erythrocytes, taking into account a complex of antigens according to the Rhesus system.

  When correcting anemia, not only the symptoms of anemia, hemogram indices, but also the genesis of the development of anemia were taken into account. Thus, in the course of the study, it was revealed that the main causes of anemia were tumor infiltration of BM and a decrease in the bridgehead of the erythroid lineage (in 41 patients, the number of erythroid precursors in the sternal punctate ranged from 0.2 to 9.8%), hemolysis of erythrocytes (in 25 patients, an increase in indirect fraction of bilirubin from 19.2 to 41.9 μmol / l), sometimes iron deficiency was detected (in 24 patients serum iron ranged from 4.0 to 8.8 μmol / l), hemorrhagic syndrome was observed (in 16 patients, including gastrointestinal and nosebleeds) due to disseminated intravascular coagulation or thrombocytopenia.In the presence of iron deficiency, iron supplements were prescribed in addition to TE. To stop bleeding, fresh frozen plasma, platelet concentrate in therapeutic doses in combination with hemostatic drugs were used.

  The results were statistically processed using Microsoft Windows (Microsoft Excel, Ver. 2007) and STATISTICA 7.0 for Windows. Differences were considered significant at p <0.05.

  Study results

  In the course of the analysis, it was revealed that the most demanded was the filtered erythrocyte mass (tab.1), which was used 5.5 times more often compared with OE or SEM (p <0.02) and 15 times more often than EM (p <0.0001).

  On the background of TE, the patients showed positive clinical dynamics – the symptoms of anemia significantly decreased and the peripheral blood parameters improved (Table 2). At the same time, the hemoglobin content in the group as a whole increased from 70.4 ± 0.9 to 98.6 ± 1.0 g / l (p <0.001), and its increase was stated on average 28.9 ± 1.2 g / l , which corresponded to 8.0 ± 0.4 g / l (1–30 g / l) based on each infused dose of erythrocytes.Similarly, there was an increase in the number of erythrocytes by an average of 0.92 ± 0.03 × 10¹² / l and the level of hematocrit by an average of 8.3 ± 0.3%.

  Comparative analysis revealed that the number of doses of erythrocytes, depending on the age of the patients, did not differ significantly; Thus, young patients (from 18 to 65 years old) and older patients (from 66 to 81 years old) required an average of 5.1 ± 0.5 and 4.3 ± 0.4 doses to correct anemia, respectively (p> 0, 05).

  However, against the background of TE, not all patients had the same increase in peripheral blood indices, which made it possible to divide patients into groups depending on the increase in Hb level per erythrocyte transfusion (Table 1).3).

  The group of patients with a complete response to TE was 30.0% (n = 57). The Hb level increased by 10 g / l (on average by 11.4 ± 0.6 g / l) after each erythrocyte transfusion, the symptoms of anemia decreased (shortness of breath, weakness, dizziness, palpitations, hypotension, hypodynamia, etc.) … This group included patients with oncohematological diseases with a favorable prognosis for the underlying disease and responding well to anticancer therapy. These patients received an average of 2.9 ± 0.2 (1–7) doses of erythrocytes.As a result, the hemoglobin content increased (Fig. 1) from 70.4 ± 1.7 to 103.4 ± 0.9 g / l. It should be emphasized that after erythrocyte transfusions in 41 patients, erythron parameters (Hb> 100 g / l, Ht> 30%) rapidly increased not only due to the high efficiency of TE, but also to the regenerative activity of BM patients. In this group of patients within four months after TE, the overall survival rate was 94.7%. Lethal outcomes in this group were stated in 3 (5.3%) of 57 patients; at the same time, 2 patients with MM developed acute renal failure (1 patient with MM III stage.B) and acute heart failure (1 patient with MM III stage A), and in 1 patient with CLL C stage according to J.L. Binet – Severe bilateral pneumonia developed.

  The group of patients with partial response to TE was 37.4% (n = 71). In these patients, after each erythrocyte transfusion, there was an increase in hemoglobin content by 5.0-9.7 g / l (on average by 6.6 ± 0.2 g / l), a decrease in the symptoms of anemia, and after the cancellation of transfusions after 10-15 days, a moderate decrease in erythron parameters was observed, usually not requiring repeated transfusions.This group mainly included patients with a favorable prognosis (n = 47) and with relapses and refractory forms of the disease: MDS (n = 8) – refractory anemia with an excess of blasts (RAEI I and II), AML from previous MDS (n = 5) and AML caused by previous treatment (n = 3), CML blast crisis (n = 3), MM resistant to chemotherapy (n = 4), Richter’s syndrome in chronic lymphocytic leukemia (n = 1). These patients received an average of 4.5 ± 0.3 (1–10) doses of erythrocytes. During blood transfusions, the hemoglobin content increased from 68.7 ± 1.4 to 97.6 ± 1.2 g / l.OS within 4 months was 84.5%. The lethal outcomes of patients (11 out of 71, or 15.5%) were due to refractoriness to antitumor therapy and progression of the underlying disease.

  The group of patients with a minimal response to erythrocyte transfusion was 32.6% (n = 62). Patients of this group, as a rule, needed repeated blood transfusions in 10-14 days. The increase in hemoglobin after each erythrocyte transfusion did not exceed 4.9 g / l (on average, 2.6 ± 0.2 g / l). An increase in hemoglobin concentration was noted from 72.5 ± 1.6 to 89.2 ± 1.8 g / l.A low increase in the Hb level in this group, and subsequently its rapid decrease after TE, are mainly due to hemolysis (an increase in total bilirubin 20.5 μmol / L – in 19 patients), pronounced inhibition of hematopoiesis (a decrease in BM erythroid elements of less than 5% – in 17 patients) due to the refractoriness of the disease to antitumor therapy, as well as the toxic effect of chemotherapy (hematological toxicity of III – IV grade). To improve their condition, these patients were subsequently transfused with a significantly larger number of doses of donor erythrocytes – on average 6.4 ± 0.8 (2–32), due to which it was possible to increase the hemoglobin level and hematocrit.This group included patients with refractory forms of hemoblastosis. RH within 4 months was 66.1%. The lethal outcomes of patients within four months in this group of patients (21 of 62 – 33.9%) were due to refractoriness to chemotherapy and progression of the underlying disease.

  In the course of the comparative analysis, it was revealed that the increase in the level of hemoglobin was significantly different, reaching respectively 103.4 ± 0.9; 97.6 ± 1.2 g / L (p = 0.004) and 89.2 ± 1.8 g / L (p <0.001), although the initial Hb concentrations were practically the same (70.4 ± 1.7; 68, 7 ± 1.4 g / L and 72.5 ± 1.6 g / L; p> 0.3).Overall survival was also significantly different (Fig. 2) within 4 months (from the beginning of blood transfusions).

  So, if in the 1st group the overall survival was 94.7% (out of 57, 3 patients died), in the 2nd – 84.5% (11 out of 71 patients died) – without a statistically significant difference (p = 0, 12), then in the 3rd – 66.1% (out of 62, 21 died), which significantly differed from the 1st and 2nd groups (p = 0.0003 and p = 0.023, respectively). However, during the study period, the median OS was not reached.

  The relationship between overall survival and a number of factors has been investigated.The method of multiple regression established the influence of the volume (R = 0.183; p = 0.036; n = 130) and the number of infused doses (R = 0.162; p = 0.029; n = 190) of donor erythrocytes, as well as a low increase in the hemoglobin level (R = – 0.180; p = 0.017; n = 190) on the overall survival of patients. This indicates the fact that the longer the patient’s anemia is stopped and the higher the need for transfusions of donor erythrocytes for adequate correction of anemia, the worse the prognosis of the underlying disease, which allows patients to be stratified into risk groups.In the group of low-risk patients (with a complete response to transfusion of donor erythrocytes – the hemoglobin level increased by × 10 g / l), the overall survival rate was 94.7%. In the group of patients of intermediate risk (partial response – the Hb level increased by 5–9.9 g / l), overall survival was stated at 84.5%; in the high-risk group of patients (minimal response – the Hb level increased by <5 g / l), the overall survival rate was 66.1%.

  At the same time, no relationship was found between overall survival for 4 months either with the age of the patients (R = 0.05; p = 0.51; n = 190) or with gender (R = 0.011; p = 0.89; n = 186), nor with the initial hemoglobin content (R = 0.017;
  p = 0.81; n = 190).

  Discussion

  Anemia in hemoblastosis is often the leading symptom of the disease (in 20–98% of cases), reduces the antitumor effect of chemotherapy, worsens the prognosis and quality of life of patients [2–7, 19]. During the period of diagnosis with lymphogranulomatosis, anemia is detected in 22% of patients, increasing against the background of anticancer treatment to 54.5%; with NHL – in 34.9%, increasing against the background of chemotherapy to 73.7%; with CLL – in 30.1%, rising to 72.9%; with MM – in 56%, increasing to 77.4% [6, 7].Even more often, anemia is detected in patients with acute myeloid and lymphoid leukemia, MDS. In the initial diagnosis of PMF, anemia occurs in 38% of patients with a gradual increase in frequency during the progression of the disease; with essential thrombocythemia in the phase of blast crisis – in 74% of patients; in CML during therapy with tyrosine kinase inhibitors – from 40 to 83% [5, 19–23]. Moreover, anemia in patients with indolent forms of lymphoproliferative diseases is often regarded as an “indicator” for starting chemotherapy [24].

  When choosing the tactics of correcting anemia treatment of such patients, it is necessary to take into account the risk of developing life-threatening complications arising from the action of chronic hypoxia due to inadequate oxygenation of vital organs, primarily the brain, heart, liver, as well as the mechanisms of anemia development, taking into account which it is possible stop anemia or significantly improve the general condition of the patient. In patients with oncohematological diseases, several factors can take part in the genesis of anemia at once: a) tumor infiltration of bone marrow with displacement of erythroid elements; b) hemolysis of erythrocytes; c) suppression of the erythroid lineage by proinflammatory cytokines; d) low production of endogenous erythropoietin; e) functional iron deficiency due to increased production of hepcidin; f) free radical oxidation of phospholipids of cell membranes during chemotherapy; g) hemorrhagic syndrome [3, 25–30].Taking into account the identification of factors involved in the development of anemia, it is currently possible to correct it by pathogenetic methods, for example, by prescribing erythropoietin preparations [1, 3]. However, pathogenetic therapy may not be acceptable for all patients, since its effectiveness, as a rule, does not exceed 60–70%, and a response to therapy is expected in 2–3 months [25, 31]. Expectant tactics for patients with hemoblastosis is not always justified due to the danger of progression of the tumor process and the risk to the patient’s life from hypoxia of the myocardium and other vital organs, especially in old age with concomitant ischemic heart disease.At the same time, TEs are a universal and urgent method for correcting anemia, regardless of the nosological form of the disease. Consequently, hemocomponent replacement therapy remains a priority, especially when the patient’s life is threatened, since it allows to achieve an improvement in the patient’s general condition in the shortest possible time.

  Indications for TE are a pronounced clinical picture of anemia and a decrease in hemoglobin and hematocrit. Currently, there are two tactics: restrictive, in which transfusions of donor erythrocytes are carried out with a hemoglobin content of less than 70 g / l, maintaining it within 70-90 g / l, and liberal – erythrocyte transfusions are carried out with a hemoglobin content of less than 100 g / l [ 32].When choosing one or the other tactics for correcting chronic anemia in patients with hemoblastosis, it is necessary to carefully weigh the potential risk and benefit of blood transfusions. So, despite the increased requirements for the selection of donors, the use of high-tech methods for the diagnosis of transmissible infections, the individual selection of donors, nevertheless, there remains a risk of transmission of infections (viral hepatitis B, C, HIV, etc.) from the donor to the recipient, alloimmunization of the patient with antigens, as well as the risk of overloading the body with iron with the development of hemosiderosis of internal organs [8–12, 14, 15].In this regard, in recent years, donor erythrocytes have been transfused in patients with chronic anemia only to correct the most important symptoms of anemia that are not amenable to the main pathogenetic therapy [15].
  However, with oncohematological diseases, patients are characterized by the instability of the general somatic state and the variability of the course of the main tumor process, they receive cytostatic therapy, which is toxic not only to hematopoiesis, but also to other vital organs and systems, including the cardiovascular system, which leads to a decrease in tolerance organism to hypoxia [2, 16].Therefore, restrictive tactics with regard to erythrocyte transfusion in this category of patients, especially in old age with concomitant heart failure, is unsafe.

  In this work, it was demonstrated that 30% of oncohematological patients received a complete response to erythrocyte transfusions, and the increase in Hb content was more than 10 g / l; they quickly recovered their own hematopoiesis after courses of anticancer therapy, and the effect of erythrocyte transfusions persisted for a long period.In such patients without signs of heart failure, anemia was corrected at an Hb level <80 g / L. A stable state was achieved after transfusion of 2.9 ± 0.2 doses of erythrocytes. In 37.4% of patients with a partial response, there was also a satisfactory effect of TE with an increase in hemoglobin per transfused dose of erythrocytes of 5–9.7 g / l. Improvement of the condition in this group of patients was achieved through the transfusion of 4.5 ± 0.3 doses of erythrocytes. In both the first and the second group of patients, the hemoglobin content decreased slightly after 10-14 days.At the same time, insufficient efficiency from transfusion of donor erythrocytes was observed in the third group with a minimal response. The increase in Hb level per one dose of erythrocytes infused was found to be less than 5 g / l. Improvement of the condition and an increase in Hb concentration> 80 g / l in such patients could be achieved only after transfusion of 6.4 ± 0.8 doses of donor erythrocytes. In these patients, not only the advanced stage of the disease with depression of erythropoiesis due to the progression of the tumor process and the toxic effect of cytostatic therapy were detected, but often hemolysis of erythrocytes as a manifestation of the underlying disease.

  When determining the tactics of hemocomponent replacement therapy, one should also take into account the age of the patients and the presence of cardiac or respiratory pathology due to the risk of hypoxic complications. Elderly patients, even with higher peripheral blood (hemoglobin content 80–100 g / l, hematocrit 26–30%), were more likely to have tachycardia (pulse over 90–110 beats / min), hypotension (blood pressure less than 120 / 70 mm Hg), shortness of breath with moderate exertion, and sometimes at rest.At the same time, after transfusion of erythrocytes, they showed a significant improvement in their general condition and relief or significant reduction in clinical symptoms. Therefore, to correct anemia in elderly patients, as well as in patients with heart or pulmonary insufficiency, with signs of ineffective erythropoiesis, erythrocyte transfusions should be performed with Hb <90–95 g / l and hematocrit <30%.

  In the course of replacement therapy for anemia with the help of blood transfusions, we took into account not only the indices of peripheral blood, but also the genesis of its development.In the course of the study, it was revealed that the main causes of anemia were tumor infiltration of BM, impaired hematopoiesis, hemolysis of erythrocytes, as well as the toxic effect of chemotherapy. At the same time, some patients had iron deficiency, hemorrhagic syndrome caused by disseminated intravascular coagulation and / or thrombocytopenia. Therefore, in addition to transfusions of donor erythrocytes, such patients were prescribed iron preparations; to stop bleeding, the patients received fresh frozen plasma, platelet concentrate in combination with hemostatic drugs.In recent years, for the correction of anemia, primarily due to the toxic effect of anticancer therapy, as well as the negative effect of tumor cells on erythropoiesis, much attention has been paid to pathogenetic therapy with the appointment of erythropoiesis-stimulating agents. Their use allows achieving a positive result in 24–85% of patients [1, 25, 31]. Erythropoiesis-stimulating therapy is especially effective if anemia is caused by a low synthesis of endogenous erythropoietin [1, 3, 31]. Nevertheless, patients with severe anemia with Hb <80 g / l, Ht <25% require TE, even if they are being treated with recombinant erythropoietin.

  Anemia, difficult to correct with donor erythrocyte transfusions, was often caused by hemolysis, which did not allow the hemoglobin and hematocrit levels to rise to the required levels. These patients had an increase in indirect bilirubin (19.2–41.9 μmol / l). As a pathogenetic therapy, such patients are shown the appointment of corticosteroid hormones and immunosuppressive drugs, which was previously shown by us in a patient with NHL with Evans syndrome, who received more than 60 transfusions of donor erythrocytes and was treated with glucocorticoid hormones without effect.However, a positive response was obtained to the use of anti-CD20 monoclonal antibodies (rituximab) with subsequent long-term remission [33].

  It should also be noted that overall survival within 4 months from the start of transfusion therapy significantly differed in the group with a minimal response to transfusion of donor erythrocytes (Fig. 2), amounting to 66.1% versus 94.7 and 84.5%, respectively, in the groups with full and partial answers. This confirms the version that the more difficult it is to stop anemia in a patient, i.e.That is, the lower the efficiency of TE, the worse the prognosis of the underlying disease, which makes it possible to stratify patients into risk groups. In the group of low-risk patients (with a complete response to TE – the hemoglobin level increased by 10 g / l), the overall survival rate was 94.7%. In the group of patients of intermediate risk (partial response – the Hb level increased by 5-9.9 g / l) OS – 84.5%; in the group of high-risk patients (minimal response – the Hb level increased by <5 g / l) OS - 66.1%. Patient stratification into risk groups can be taken as
  prognostic marker.

  Thus, the main causes of anemia in the analyzed patients were pronounced depression of erythropoiesis caused by the manifestation of a tumor disease, the toxic effect of chemotherapy, hemolysis of erythrocytes, as well as iron deficiency and hemorrhagic syndrome. Replacement erythrocyte transfusions can correct anemia, restore hemoglobin and hematocrit levels in most patients. However, after cessation of transfusions, hemoglobin levels may decrease, which requires repeated transfusions.Stratification of patients into risk groups, depending on the efficiency of transfusion of donor erythrocytes, allows predicting the course of the underlying disease and a differentiated approach to the treatment of anemia in hemoblastosis.

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  Norm of hemoglobin

  We often hear or read about an athlete being pulled out of competition for high hemoglobin levels, as well as advice on how to raise hemoglobin levels in the blood. What’s good? High or Low? What is the norm? And what is hemoglobin?

  Hemoglobin is a blood protein containing iron, with its help oxygen is transported in the blood from the respiratory organs to the tissues, and it also participates in the reverse process – the delivery of carbon dioxide from the tissues to the respiratory organs.

  Accordingly, the more hemoglobin in a person’s blood, the better his oxygen delivery to the cells, the higher the muscle performance. Therefore, athletes are so chasing a high level of hemoglobin, because with its help they are able to endure a large load.

  What is the norm of hemoglobin in human blood? The norm is different for men and women, depending on age, separate norms for newborns and pregnant women.

  The norm of hemoglobin in the blood in men is 140-160 grams per liter (16-18 years old – 117-166 g / l, 19-45 years old – 132-173 g / l, 46-65 years old – 131-172 g / l, 66-90 years old – 126-174 g / l), in women – 120-150 g / l (15-18 years old – 117-153 g / l, 19-45 years old – 117-155 g / l, 46-65 years – 117-160 g / l, 66-90 years – 117-161 g / l)

  Increased hemoglobin can be observed after physical exertion, in residents of the highlands, in pilots after flights at altitude, in climbers.That is, in conditions of lack of oxygen.

  Decreased hemoglobin (anemia) can occur with a lack of iron or vitamins (B12, folic acid). Therefore, it is important to maintain the vitamin and mineral balance in the body. For example, use the vitamin complex Doppelherz® active from A to Zinc, which will help to avoid a decrease in hemoglobin, since it contains both iron and essential vitamins. Anemia can also occur after blood loss, with blood diseases that destroy red blood cells, which contain hemoglobin, during blood transfusion.

  If there is an increased hemoglobin that goes beyond the upper limit of the norm, then this may indicate various diseases. For example, an increase in erythrocytes in the blood – erythrocytosis, blood clotting, congenital heart defects, intestinal obstruction, cardiopulmonary insufficiency. And a high level of one of the types of hemoglobin (glycated) is a symptom of diabetes mellitus and iron deficiency.

  That is, it is good when hemoglobin is normal, bad when we see increased and decreased hemoglobin.Get a blood test from time to time, take vitamins, and you can avoid big problems.