Anemia, the false beliefs that cost us our health. (Part two)

Classification of Anemias

Anemias can be classified according to different schemes, but in medical practice, the Morphological (Cytometric) Classification of Anemia is used, which is based on the size of erythrocytes (MCV) and parameters of Hb content (MCH). It is easier and less costly.

1. Microcytic Hypochromic Anemia: reduced hemoglobin, MCV < 80 fl, MCH < 27 pg.
2. Normocytic Normochromic Anemia: reduced hemoglobin, MCV 80 - 100 fl, MCH 29.5 ± 2.5 pg.
3. Macrocytic Anemia: reduced hemoglobin, MCV > 100 fl, MCH > 32 pg.

Clinic (symptoms and signs) of Anemic Syndrome

The presence or absence of clinical signs of anemia is determined by 4 factors:

1. The speed of anemia onset. An anemia that sets in quickly (post-hemorrhagic, hemolysis) has a more pronounced clinic than when it develops gradually (The Cardiovascular System has more time to adapt).
2. The degree of anemia. The deeper the anemia, the more pronounced the clinic. The clinic of anemia appears when Hb is less than 9-10gr/dl. However, there are cases where the reduction in Hb is significant and still there are no signs or they are very minimal if it is installed gradually and the person has been healthy and young (as in iron deficiency anemia).
3. The age and overall condition of the patient. Older ages endure anemia more difficultly than the younger ones, and this is related to the cardiovascular system and accompanying cardiopulmonary diseases.
4. The curve of Hb dissociation from oxygen. Anemia is accompanied by a greater ease of releasing oxygen from Hb to tissues.

Symptoms - Weakness, general fatigue, more pronounced during physical exertion (more oxygen is consumed), difficulty in breathing, headache (in the back of it), flies before the eyes, noise in the ear. In older ages and when installed quickly, symptoms of angina pectoris (chest pain) etc. may appear.

Signs - these are divided into general and specific signs.

1. General signs include the paleness of the skin and mucous membranes (which appear when Hb is less than 9-10 gr/dl). Evaluation should be done in natural light. Anemia looks better in mucous membranes (lips, mouth, pharynx, conjunctiva), earlobe, nail bed, palms of the hands and soles of the feet (when Hb < 7 gr/dl).
   
   It should be noted that it is the iron pigment (Fe) that provides the red color of hemoglobin, thus of erythrocytes and consequently of the blood itself (the rest of the blood without erythrocytes does not have a red color). The color of hemoglobin (thus of iron) is also the main factor of skin color. In cases where anemia sets in quickly and is deep, we may have tachycardia, fast and pounding pulse, strong heart tones, systolic murmur, cardiomegaly.
2. Specific signs depend on the type of anemia e.g., in the case of hemolytic anemia there will be jaundice from the increase in indirect bilirubin. In other diseases, anemia may be accompanied by neutropenia, thrombocytopenia etc.

What are the most common problems we encounter in the assessment and treatment of anemia in our country?

1. There is always confusion about what we will call anemia. Some doctors evaluate it based on the number of erythrocytes, some on hematocrit, very few on the value of hemoglobin, which as explained above, is the basic criterion of assessment. Different populations have different ranges of normal values for the red series and since we do not have these values in our country, accept the values referred by WHO, that we rely on different criteria (according to laboratories, devices, hematological treaties).
2. The most common anemia in practice is "Deficiency Anemia". This includes Iron Deficiency Anemia (Ferriprive Anemia), Anemia from Vitamin Deficiencies (Vitamin B12 and Folic Acid = Megaloblastic Anemia). These are also the most misdiagnosed and mistreated anemias. Deficiency anemias are the result of the respective deficiencies (in some cases they may be combined).
   
   Iron deficiency (the most common in practice, especially for the female gender) can be assessed by Ferritinemia and is more widespread (the base of the iceberg) than anemia from iron deficiency (the tip of the iceberg) which is its consequence. For vitamin deficiency anemias we do not have a marker like Ferritinemia, but their principle is the same as for Ferriprive Anemia. The corresponding stores are depleted (or combined) and as a result, Megaloblastic Anemia appears.
   
   The doctor does not need to find the cause of the anemia (it is the deficiency), but the cause of the deficiency/deficiencies. And here is the biggest practical mistake. Medical personnel and the people themselves think it is malnutrition. A healthy organism has 8 years of iron reserves, 2-4 years of vitamin B12, and 2 months for Folic Acid. This means that if they are consumed normally for the respective needs, we should not take iron for 8 years, vitamin B12 for 2-4 years, and Folic Acid for 2 months to deplete the stores and as a result, the respective anemia appears.
   
   Iron and folic acid are found in plant and animal products, Vitamin B12 only in animal foods (and a certain amount is synthesized by the body itself). Almost does not exist in practice as a factor of depleting the respective stores the lack of intake of iron and vitamins in food.
   
   More is a secondary cause for other causes of depleting the stores which are these in order of importance: iron loss (small repeated hemorrhage which includes repeated blood donations), overconsumption, malabsorption, lack of intake in food for Iron Deficiency (hypoferremia) and overconsumption (malignant/benign cellular proliferation), malabsorption, lack of vitamin intake for Vitamin/Vitamins B12 and Folic Acid (B9) Deficiency. And another practical mistake “anemia is cured with food”. THERE IS NO ANEMIA THAT IS CORRECTED WITH FOOD.
   
   The maximum daily iron intake that a person can reach at the maximum of his nutrition is 10-14 mg. The therapeutic daily dose of iron is 200 mg of elemental iron per day for adults, a quantity found in 4.5 kg of red meat and this for at least 3 months in a row (1-1.5 months for correcting the anemia and 1.5 months plus for correcting the corresponding stores). The use of liver, red wine, spinach etc. is a real nonsense that we are not managing to eliminate. Doctors should learn to seek Ferritinemia, it would be ideal to have such a marker for vitamins as well.
3. To fight to find and if possible to eliminate not the cause of anemia (it is known that is the corresponding deficiency), but the cause of the deficiency/deficiencies (in the case of combined) which might be based on malignant diseases. So, doctors should not be satisfied with just treating the anemia, but with its complete correction, the correction of the stores (in our country after correcting the anemia doctors and people themselves stop the treatment) and the elimination or at least compensation of the cause of the deficiency/deficiencies. In case these are realized the hematological pathology is cured and there are not many diseases that are cured. Most of them are just treated.
   
   The way doctors assess and treat Deficiency Anemias in Albania, they try to treat it but never cure it. If the cause/causes of the deficiency/deficiencies are not eliminated or at least compensated, Deficiency Anemias can be completely corrected, but the deficiency with or without anemia will recur (depending on the magnitude of the cause. And for this, the hematologist is not to blame, nor is the preparation, but the fact that the cause/causes have not been eliminated or corrected and this requires cooperation with other specialties (gynecologist, gastroenterologist, urologist).
4. The word “I treat with iron” is abused and the pointless use of Vitamin B12 (“to increase strength” 5-10 days Vitamin B12 I/M. The treatment should be done with the optimal daily therapeutic dose for the specified time until the complete correction of the anemia (Hb≥ 12 gr/dl in females and ≥13 gr/dl in males (not its improvement as happens in our medical practice) and once the anemia is corrected, the treatment will continue until the correction of the stores and only then the task is done properly.
5. Mild, moderate, severe anemia are evaluated and treated the same. But this evaluation and treatment are valuable even when we discover the phase of the deficiency, without the anemia yet installed. Send mild anemias to the specialist to evaluate and treat them. A significant part of mild anemias in our country are congenital (Thalassemia Minor) which of course in most cases is not assessed properly.
6. If you want to be checked for a blood pathology start with: complete blood + platelet + reticulocyte, ferritinemia, hemoglobin electrophoresis (carriers of sickle cell disease are not detected with peripheral blood analysis).