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Home , Anemia, Hematology

NUTRITIONAL DEFICIENCIES AND

HEMATOLOGY

Noah Carpenter, MD Dr. Noah Carpenter is a Thoracic and Peripheral Vascular Surgeon practicing in Brandon, Manitoba. He is known for the development of surgical techniques. He attended the University of Manitoba where he graduated with the B.Sc. in chemistry, completed and did his surgical and at the University and Affiliated in Edmonton, Alberta. Dr. Carpenter did an additional fellowship at the University of Edinburgh, Scotland in Adult Cardiovascular and Thoracic , and has specialized in microsurgical techniques, vascular , laser and laparoscopic surgery in Vancouver, British Columbia, Canada and Colorado, Texas, Vancouver, and Los Angeles. He has an Honorary Doctorate of Law from the University of Calgary, and was appointed a Citizen Ambassador to China, and has served as a member of the Native Association of Canada, the Canadian College of Health Service Executives, the Science Institute of the Northwest Territories, the Canada Science Council, and the International Society of Endovascular Surgeons, among others. He has been an inspiration to youth, motivating them to understand the importance of achieving higher education.

ABSTRACT

Anemia can occur for many different reasons. These include chronic disease, nutritional deficiencies, malignancy, medications, loss, and disorders. An understanding of the different causes of will help clinicians to better decide upon proper treatment and to avoid complications caused by anemia. Grading of the severity of anemia is also a critical aspect of diagnosis and treatment. The effect of nutritional deficiencies and related anemia as well as how anemia and nutritional deficiencies are treated is discussed.

nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com 1 Policy Statement

This activity has been planned and implemented in accordance with the policies of NurseCe4Less.com and the continuing education requirements of the American Nurses Credentialing Center's Commission on Accreditation for registered nurses. It is the policy of NurseCe4Less.com to ensure objectivity, transparency, and best practice in clinical education for all continuing nursing education (CNE) activities.

Continuing Education Credit Designation

This educational activity is credited for 2 hours. Nurses may only claim credit commensurate with the credit awarded for completion of this course activity. Pharmacology content 0.5 hours (30 minutes).

Statement of Learning Need

Although it is easily identified and treated, anemia can be missed or the cause confused with another condition. Anemia is a health problem that affects vulnerable individuals such as children, pregnant women, and elderly, as well as economically disadvantaged regions of the world. Any prevention and treatment of anemia depends on proper diagnosis and surveillance of affected people. This includes appropriate utilization of diagnostic testing that focuses on factors affecting clinical outcomes.

Course Purpose

To provide health clinicians with an understanding of the diagnosis and treatment of anemia related to nutritional deficiencies.

nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com 2 Target Audience

Advanced Practice Registered Nurses and Registered Nurses

(Interdisciplinary Health Team Members, including Vocational Nurses and Medical Assistants may obtain a Certificate of Completion)

Course Author & Planning Team Conflict of Interest Disclosures

Noah Carpenter, MD, William S. Cook, PhD, Douglas Lawrence, MA, Susan DePasquale, MSN, FPMHNP-BC – all have no disclosures.

Acknowledgement of Commercial Support

There is no commercial support for this course.

Please take time to complete a self-assessment of knowledge, on page 4, sample questions before reading the article. Opportunity to complete a self-assessment of knowledge learned will be provided at the end of the course.

nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com 3 1. ______will raise a patient’s concentration of .

a. Smoking and living at higher altitudes b. c. deficiency d. Blood donations

2. In men and postmenopausal women, ______is the most common source of

a. a vegetarian diet b. menorrhagia c. gastrointestinal d. low socioeconomic status

3. Elevated ______is a good sign of B12 deficiency.

a. homocysteine levels b. methylmalonic acid c. d. iron levels

4. Cobalamin, a water-soluble , that is important in the production of red blood cells, is also known as ______.

a. Iron b. Vitamin E c. d.

5. True or False: Folic acid deficiency causes neurological symptoms, even in the absence of a .

a. True. b. False.

Introduction nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com 4 Anemia is often indicative of an underlying disease condition and can be multifactorial. There are three different etiologies of anemia with iron deficiency being the leading cause. The underlying anemia involves a reduction in the concentration of hemoglobin or red blood cells in the blood and may require treatment depending on severity. The level of anemia often depends upon an individual’s age and gender, lifestyle patterns, and the altitude of a person’s residence.

Anemia: An Overview

Red blood cells (erythrocytes) are a type of produced in the bone marrow. They start off as immature cells and are released into the bloodstream after approximately seven days. The (RBC) is shaped like a biconcave disk and the average RBC lifespan is about 120 days. Production of RBCs is controlled by , a created mostly in the kidneys. RBCs do not have a nucleus. This is important because it helps the RBCs to vary their shape easily in order to travel through different blood vessels.1

Hemoglobin is a protein carried by red blood cells. Hemoglobin transports from the lungs to other parts of the body. It also brings back carbon dioxide to the lungs so that it can be released through exhalation.1

The complete blood cell count (CBC) laboratory test ranges for what is considered normal can vary depending on the source. Anemia is typically based on the hemoglobin value in the CBC. In addition to RBC count and hemoglobin, there are a number of other CBC laboratory values that are important in helping to diagnose anemia. The mean cell volume (MCV) is the average size of the RBCs. If a patient with anemia has a normal MCV, it is

nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com 5 called . If the MCV is less than normal, it is considered microcytic, and an MCV greater than normal is considered macrocytic.

The mean cell hemoglobin (MCH) is the average amount of hemoglobin in an average RBC. If the MCH is normal, it is considered normochromic. Likewise, a decreased value is considered hypochromic while an elevated value is considered hyperchromic. The red cell distribution width reveals the variability of RBC size.2 Below is a table displaying the normal ranges for blood cell values.1,2

NORMAL BLOOD CELL VALUES WOMEN MEN BOTH GENDERS Red Blood Cell 4.1 - 5.1 4.5 - 5.9 Hemoglobin (g/dL) 12.3 - 15.3 14 - 17.5 Mean cell volume (MCV) 80- 96.1

Mean cell hemoglobin (MCH) 27.5 - 33.2

Mean cell hemoglobin 33.4 - 35.5 concentration (MCHC)

Red cell distribution width 11.5 - 14.5 (RDW) (%)

Definition of Anemia

Anemia is defined as a condition occurring when the number of red blood cells is inadequate to meet the physiologic needs of the body. A patient’s age, gender, smoking status, pregnancy state, and place of residence (altitude above sea level) can all affect the patient’s physiologic needs. For example, living and smoking at higher altitudes raises the concentration of hemoglobin.4-7,11 On the other hand, pregnant women usually experience a nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com 6 drop in hemoglobin, which starts in the first trimester and worsens in the second trimester.4

National Institute Terminology Criteria for Adverse Events: Anemia4,11 Grade 1 2 3 4 5 Hemoglobin Hgb <10 - 8 Hgb <8 g/dL Life- Death (Hgb) g/dL threatening

*LLN (lower limit of normal).

Etiology

The cause of anemia can be multifactorial. There are three main causes of anemia: 1) Decreased production of red blood cells, 2) Increased destruction of red blood cells, and 3) Blood loss.5-7

When considering the three major causes of anemia, it is important to note that blood loss to iron deficiency (discussed in a later section). The main focus here however is on acquired causes of decreased RBC production. The bone marrow needs certain ingredients to make RBCs, which include iron, vitamin B12, and .

Iron Deficiency Anemia

The most common nutritional deficiency in the world is iron deficiency. Greater than one-fourth of the global population is anemic with iron deficiency being approximately one-half of the total burden.10 In the United States, iron deficiency is noted in approximately 2% of adult men and 9%- 12% of Caucasian women. The incidence is even higher in minority women, estimated at close to 20%. Risk factors for iron deficiency include vegetarian nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com 7 diet, , and low socioeconomic status in conjunction with being postpartum.6

Causes of Iron Deficiency

Adequate dietary iron may be missing in infants and children when consuming milk, including breast milk, or formula not supplemented with iron. In women, the most common cause of iron deficiency is chronic blood loss in the form of menorrhagia. In men and postmenopausal women, gastrointestinal bleeding is the most common source of iron deficiency.3,6

Iron deficiency is generally higher in women, children, and individuals in low-income countries. In world regions where the availability of meat and iron-supplemented grains exist there is less incidence of iron deficiency anemia.10 The major causes of iron deficiency are:

• Insufficient dietary intake of iron (occurs mainly in infants and children) • Averting iron to fetus/infant during pregnancy and/or lactation • Chronic blood loss (respiratory, gastrointestinal, genitourinary tracts, phlebotomy) • Iron (found in subtotal , gastric bypass) • Intravascular • A combination of the above

In the geriatric population iron deficiency anemia may occur for a variety of reasons. There may be a cancerous growth or a person may have developed an intolerance or poor absorption to oral iron supplements, which occurs more commonly when a person is taking antacid medication or low production of gastric acid.10 Symptoms and Diagnosis nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com 8 Symptoms of iron deficiency anemia include , on exertion, and . Headaches and irritability can also occur. Cold hands and feet, as well as tingling sensations in the legs may also happen. Patients with iron deficiency anemia can develop strange cravings to eat ice or clay, known as .3,7,10

Low attention spans, developmental delays, and behavioral problems may be found in children with iron deficiency anemia. It is important to note that the severity of symptoms does not always match up with the severity of iron deficiency. During physical examination, anemic patients may be found to have and a smooth red tongue. , or spoon-shaped nails, is usually only seen in very severe, chronic cases of deficiency.3,7

The CBC is very important to diagnosing iron deficiency. Microcytic (decreased MCV), hypochromic (decreased MCHC) anemia is usually evident. The red cell distribution width (RDW) is often elevated. The (WBC) count is usually normal. Most of the time, the count will be normal. However, it is not uncommon to see elevated platelet count, which is usually related to chronic blood loss.3

Iron studies include concentration, total iron binding capacity (TIBC), and serum . The serum iron level is usually low. TIBC is usually elevated. However, in mild cases the TIBC is in the higher range of normal. Iron saturation, which is a calculation based on iron and TIBC, is decreased. In patients with iron deficiency, the iron saturation is usually less than fifteen percent. It is important to note that patients with chronic inflammation can also have a low iron saturation value even though they are not iron deficient.

nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com 9 The serum ferritin is a measurement of iron stores. Low ferritin levels are seen in iron deficiency. However, patients with iron deficiency can have elevated ferritin levels. This is because serum ferritin is an acute phase reactant and is often increased during inflammatory states, such as , malignancy, and hepatitis.3

Once a patient is diagnosed with iron deficiency, the investigation of cause and the treatment plan begins. The reason for iron deficiency must be discovered. Since gastrointestinal loss is the most common cause of iron deficiency, stools should be checked for occult blood. Further workup, including esophagogastroduodenoscopy (EGD) and , may be required. Women with menorrhagia will need to follow-up with a gynecologist. They may require further testing, such as pelvic ultrasound.3,7

Complications of Iron Deficiency

Iron deficiency can become quite severe and to very serious problems if it goes untreated. In pregnant females, the incidence of premature births and low birth weight babies is higher with iron deficiency. Infants and children with iron deficiency may experience growth and developmental delays.

Cardiac problems, including and can also occur. The is under more stress and works harder to pump blood throughout the body. This increased work can lead to cardiomegaly.7

Prevention and Treatment

Challenges in the treatment of iron deficiency include diagnosing and treating the underlying cause and deciding upon the type of iron nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com 10 replacement that addresses the needs of an individual patient. Usually oral iron replacement is the first step in treating iron deficiency. Increasing iron in the diet is not adequate. There is a plethora of oral iron supplements. Ferrous sulfate is the least costly option. The daily dose of elemental iron is outlined in the table below.3

Iron deficiency anemia, Menstruating women: (anemia prevalence ≥40%) 30 to 60 mg daily for 3 months

Iron deficiency anemia 100 to 200 mg orally, daily in 2 to 3 divided doses.

Extended release tablets: once daily use.

Restless legs syndrome (off- 65 mg (325 mg ferrous label use) sulfate) orally, twice daily taken with vitamin C (for ferritin level ≤75 mcg/L)

Ferrous sulfate oral liquids are available in multiple doses. Attention to ferrous sulfate liquid selection or substitution is important to avoid inappropriate dosing. The oral iron, immediate release is preferred for treatment of iron deficiency anemia whereas enteric coated and slow or sustained release oral preparations should be avoided due to poor absorption. Also, ferrous sulfate contains approximately 20% elemental iron and ferrous sulfate exsiccated (dried) contains approximately 30% elemental iron.3

Lower doses of iron have been studied in a randomized trial that compared 15, 50, or 150 mg daily in 90 hospitalized individuals age of 80 years and

nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com 11 had iron deficiency anemia (hemoglobin 8 to 11.9 g/dL; ferritin <40 ng/mL). Interestingly, all doses were found to be effective with improved hemoglobin levels and with a significantly lower rate of gastrointestinal . In runners and blood donors iron repletion can improve athletic performance, sleep disturbance, and fingernail breakage.10

Patient Education

Some important aspects are highlighted below related to patients take iron supplementation.

• Do not take iron with meals • Do not take iron with antacids or anything that reduces acid • Iron can often cause . Laxatives or stool softeners may be taken as needed. • Iron is best absorbed with vitamin C. • Iron supplementation can cause dark-colored stools. • Store iron supplements in a safe place, away from children.

The average time to normalization of hemoglobin levels is two to four months. Patients should continue oral iron for approximately one year after hemoglobin normalizes. In patients who continue to have blood loss, they may need to be on iron replacement for as long as the bleeding continues. The expected response may not occur if bleeding persists. If bleeding has been controlled but response is poor, other things to consider include malabsorption or other causes of anemia.3,10

Parenteral iron is also available for the treatment of iron deficiency. The reasons for using parenteral iron include very severe deficiency, malabsorption, and inability to tolerate oral iron (usually gastrointestinal

nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com 12 symptoms, such as colitis or severe constipation). There are a number of different preparations. Dosing and frequency of treatment differ based on the specific iron product. Some products can be given intravenously or intramuscularly. Allergic reactions, including anaphylaxis, can occur.3,10

In extremely severe cases of iron deficiency anemia associated with blood loss, patients may require transfusion of PRBCs (). Transfusions should only be administered to patients with hemoglobin less than 7 - 8 and who are symptomatic (i.e., , shortness of breath, palpitations). Patients should be properly counseled about the risks of transfusion.3,6,10

Vitamin B12 Deficiency

Vitamin B12, also known as cobalamin, is a water-soluble vitamin that is important in the production of red blood cells. Vitamin B12 also has a role in the health of the central nervous system. Vitamin B12 can be stored in the liver for months to years. The average American diet is plentiful in vitamin B12. It is found in various foods, including meat, shellfish, eggs, milk, and dairy products. Many other foods, such as cereal, have added B12. However, B12 is absorbed more efficiently from animal-based foods.8

Causes of B12 Deficiency

Individuals following a vegan diet may be at risk for B12 deficiency. However, the most common cause of B12 deficiency is malabsorption. is required for the absorption of B12. Malabsorption can be due to several different factors, including:8,13

• Pernicious anemia (most common reason for malabsorption) • Gastric Bypass nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com 13 • History of gastrectomy (total and subtotal) • Ileal resection • Diseases/trauma to ileum (sprue, Crohn’s disease, radiation) • Zollinger-Ellison Syndrome • Pancreatic Disease • Blind Loop Syndrome • Diphyllobothrium latum infestation (intestinal parasites)

As mentioned above, pernicious anemia is the most common cause of malabsorption. Pernicious anemia is actually an . The immune system destroys cells in the stomach. Because of this damage, the gastric mucosa does not produce intrinsic factor adequately and B12 deficiency occurs.8,13

Symptoms and Diagnosis

Patients who develop anemia secondary to B12 deficiency usually develop anemia slowly. Patients may experience fatigue, weakness, palpitations, and . Because pernicious anemia can cause damage to the nervous system, these patients may present with neurological symptoms. Sometimes neurological symptoms occur before symptoms of anemia. Neurological symptoms include numbness and tingling in the hands and feet, as well as changes in position and vibration sense. If the brain is affected, patients may experience sleepiness as well as changes in taste, smell, and vision. Physical examination may reveal pallor and smooth, beefy red tongue.8,13

The CBC again is very useful in diagnosing B12 deficiency. This type of anemia is usually a , meaning that the red blood cells are larger than normal. The size of red blood cells varies and they can be oddly nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com 14 shaped. This type of anemia is known as megaloblastic, meaning that the red blood cells are large and have immature nuclei. The MCV is increased, usually 100 or more. However, if there is also an iron deficiency or inflammation, the MCV may not be elevated. Oftentimes, patients will also have low WBC and platelet count.8,13

In order to confirm B12 deficiency, further testing is imperative. Serum B12 level is low, but this alone is not sufficient to diagnose a deficiency. Sometimes the B12 level will be normal despite the presence of a deficiency. Elevated methylmalonic acid is a good sign of B12 deficiency. The homocysteine level is also elevated. The homocysteine level is not as reliable as the methylmalonic acid level because homocysteine may also be elevated in and .8,13

As mentioned previously, pernicious anemia is a common cause of B12 deficiency. In order to diagnose pernicious anemia, further testing is required. Serum are usually present in these patients, though this test is not specific. Serum intrinsic factor antibodies is a specific test that will be elevated in these patients.8,13

Complications of B12 Deficiency

If B12 deficiency goes untreated, complications can ensue. Neurological symptoms, such as numbness and tingling in the hands and feet, can sometimes be irreversible. Lack of muscle control and muscle stiffness, known as spastic ataxia, may ensue. Dementia and psychosis are other serious complications.8,13

nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com 15 Treatment

Patients who have B12 deficiency due to poor dietary intake (such as vegans) may benefit from oral or sublingual B12 supplementation. Sublingual B12 is more readily absorbed. However, B12 deficiency is usually due to malabsorption issues. In those cases, parenteral B12 is used to treat deficiency. The injection is normally given intramuscularly.

When initiating B12 replacement, there is a series of loading doses (1,000 micrograms daily or weekly for several doses). The maintenance dose is usually 1,000 micrograms monthly. In some cases, this dose may not be sufficient and higher doses will be required. B12 is not toxic but excess B12 will be excreted through the urine. Patients who have had total gastrectomy or terminal ileum resection should be started on B12 treatment after surgery. It is important to monitor potassium levels in patients receiving B12 replacement as hypokalemia can develop.8,13

Once treatment is started, patients often notice improvement quickly. The marrow starts to produce normal red cells within a day of starting treatment. It takes about one to two months for the hemoglobin to return to normal range. Most of these patients will not require as they have likely adjusted to anemia over time. If and were present, these values also return to normal rather quickly.8,13

Folate Deficiency

Folate, or folic acid, is a B vitamin that is important in the production of red blood cells. Folic acid also creates and fixes DNA. Folic acid is found in many different foods, including green leafy vegetables, liver, poultry, shellfish, citrus, beans, legumes, and eggs. Folic acid is water-soluble. Excess folic nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com 16 acid is eliminated and only a limited amount is stored in the body. Deficiency can occur after just a few weeks of not eating enough folic acid.9

Causes of Folate Deficiency

The major causes of folate deficiency can be separated into three main categories, which include decreased intake, increased need, and problems with absorption. A diet low in folic acid is the most common cause of deficiency.9,13

Decreased intake could be related to:

• Poor • • Elderly • Children on synthetic diets • • Hyperalimentation • Spinal cord • Premature infants

Increased need could be a result of:

• Chronic • Pregnancy • Exfoliative dermatitis

Problems with absorption may occur from:

• Sprue, celiac disease • Other diseases of the intestine, such as Crohn’s disease nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com 17 There are also a number of medications that can cause folic acid deficiency. Some of these medications include , aminopterin, sulfasalazine, trimethoprim, triamterene, pemetrexed, hydroxyurea, phenytoin, and some oral contraceptives. In some cases, it may be necessary for patients on these medications to take supplemental folic acid.9,13

Symptoms and Diagnosis

Symptoms of folate deficiency may include fatigue and weakness. The anemia usually progresses gradually. Folic acid deficiency does not cause neurological symptoms unless a vitamin B12 deficiency is also present. On physical exam, patients may have gray hair, red swollen tongue, and mouth sores. Children with folic acid deficiency may have stunted growth.9,13

The CBC is an important element in diagnosing folate deficiency. Just like with B12 deficiency, this type of anemia is usually a macrocytic anemia, meaning that the red cells are larger than normal. This will result in an elevated MCV. Patients who present with macrocytic anemia should be tested for both folic acid and vitamin B12 deficiencies. The serum folic acid level will be low. However, it is important to remember that folic acid has limited stores in the body. A low folic acid level may just signify decreased intake in the few days before testing.12,13

Complications of Folate Deficiency

In severe cases of deficiency, patients may also experience and thrombocytopenia. Folic acid deficiency in pregnant women may lead to neural tube defects in the baby.12

nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com 18 Treatment

Folic acid deficiency is treated with oral supplementation. The dose is usually betweem1mg and 5mg daily. Pregnant women should take 1mg of folic acid daily during the entire pregnancy.12

Case Study of Anemia

A 25-year-old female arrives to an outpatient with no significant past medical history. She is premenopausal and has heavy menstrual cycles lasting seven days on average. She is not taking any kind of hormonal contraceptives. The symptoms she reported to her primary medical clinician included excessive fatigue, headaches, leg muscle cramps, and cravings for ice. The primary care clinician requested laboratory blood testing and scheduled the patient for a return medical appointment in one week to discuss the test results.

Upon the patient’s return visit, her laboratory testing was reviewed. A (CBC) showed a normal white blood cell count (WBC) of 6.7. The platelet count was on the higher end of normal at 448,000. The hemoglobin was decreased at 9.9. The MCV (mean corpuscular volume) was also decreased at 77. The complete metabolic panel (CMP) was within normal limits. Thyroid studies were also normal. However, the iron studies revealed a significant deficiency with a ferritin level of 5 and iron saturation of 4 percent.

The patient’s medical clinician started her on an and referred her to a hematologist for further evaluation. The patient’s hemoglobin of 9.9 would be considered Grade II anemia. The most important thing for the clinician to observe is that the patient reported being nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com 19 symptomatic, including fatigue and muscle cramps. She also had cravings for ice, known as pica.

A hematologist evaluated the patient and performed a thorough history and physical examination. The hematologist’s impression was that the patient appeared somewhat pale, but otherwise her exam was unremarkable. Although the patient’s primary medical clinician evaluated the iron studies, the hematologist proceeded with an extensive anemia work up to ensure there were no other causes of anemia. The hematologist evaluated blood levels of B12 and folic acid and ordered stool testing for occult blood.

Because the patient’s iron deficiency was severe and her menorrhagia was ongoing, the hematologist recommended intravenous iron. He discussed intravenous iron with the patient, including the risks and possible side effects. He scheduled a return visit in one week to discuss results and to start treatment. In the meantime, he advised the patient to continue the oral iron supplement.

At the patient’s next visit, her workup was overall negative except for severe iron deficiency caused by menorrhagia. The hematologist referred her back to her gynecologist for evaluation of menorrhagia. The gynecologist started the iron infusion that same day and the patient tolerated it very well. The patient completed her iron infusion treatment and the gynecologist started her on oral contraceptives.

Following completion of iron infusions, the patient was continued on oral iron supplement every day. The patient’s menorrhagia improved after several months. When the iron studies were repeated three months later, results showed resolution of the iron deficiency. The hemoglobin was normal at 13.1 nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com 20 and the platelet count also normalized at 355. The patient had no fatigue or other symptoms of anemia. She continued to follow up regularly and had iron studies evaluated every three months thereafter.

Summary

The causes of anemia are multifactorial and nutritional deficiencies can often lead to anemia. Iron, folic acid, and vitamin B12 are all important in the production of red blood cells and in the prevention and treatment of anemia. When patients are evaluated to have anemia, it is imperative that the cause of anemia is identified early on so that adequate treatment can be provided. Severe anemia can lead to serious complications, including heart problems and irreversible neurological changes. Patients with severe anemia may even require blood transfusion. An important aspect of patient encounters involves health education for patients to know the proper supplementation to prevent anemia and lifestyle prevention strategies and complications that can occur.

Please take time to help NurseCe4Less.com course planners evaluate the nursing knowledge needs met by completing the self-assessment of Knowledge Questions after reading the article, and providing feedback in the online course evaluation.

Completing the study questions is optional and is NOT a course requirement.

nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com 21 1. ______will raise a patient’s concentration of hemoglobin.

a. Smoking and living at higher altitudes b. Pregnancy c. Iron deficiency d. Blood donations

2. In men and postmenopausal women, ______is the most common source of iron deficiency

a. a vegetarian diet b. menorrhagia c. gastrointestinal bleeding d. low socioeconomic status

3. Elevated ______is a good sign of B12 deficiency.

a. homocysteine levels b. methylmalonic acid c. mean corpuscular volume d. iron levels

4. Cobalamin, a water-soluble vitamin, that is important in the production of red blood cells, is also known as ______.

a. Iron b. Vitamin E c. Vitamin C d. Vitamin B12

5. True or False: Folic acid deficiency causes neurological symptoms, even in the absence of a vitamin B12 deficiency.

a. True. b. False.

nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com 22 1. ______will raise a patient’s concentration of hemoglobin.

a. Smoking and living at higher altitudes

“A patient’s age, gender, smoking status, pregnancy state, and place of residence (altitude above sea level) can all affect the patient’s physiologic needs. For example, living and smoking at higher altitudes raises the concentration of hemoglobin.”

2. In men and postmenopausal women, ______is the most common source of iron deficiency

c. gastrointestinal bleeding

“In men and postmenopausal women, gastrointestinal bleeding is the most common source of iron deficiency.”

3. Elevated ______is a good sign of B12 deficiency.

b. methylmalonic acid

“Elevated methylmalonic acid is a good sign of B12 deficiency.”

4. Cobalamin, a water-soluble vitamin, that is important in the production of red blood cells, is also known as ______.

d. Vitamin B12

“Vitamin B12, also known as cobalamin, is a water-soluble vitamin that is important in the production of red blood cells. Vitamin B12 also has a role in the health of the central nervous system.”

5. True or False: Folic acid deficiency causes neurological symptoms, even in the absence of a vitamin B12 deficiency.

b. False.

“Folic acid deficiency does not cause neurological symptoms unless a vitamin B12 deficiency is also present.”

nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com 23 References Section

The References below include published works and in-text citations of published works that are intended as helpful material for your further reading. [References are for a multi-part series on ].

1. American Society of Hematology. (2015). Blood basics. Retrieved from http://www.hematology.org/Patients/Basics/ 2. Gersten, T. (2014). RBC indices. In Medline Plus. Retrieved from http://www.nlm.nih.gov/medlineplus/ency/article/003648.htm 3. Lexicomp (2018). Ferrous Sulfate Drug Information. UpToDate. Retrieved from https://www.uptodate.com/contents/ferrous-sulfate-drug- information?search=ferrous%20sulfate&source=search_result&selected Title=1~45&usage_type=default&display_rank=1 4. National Cancer Institute. (2017). Common terminology criteria for adverse events v4.0 (NIH Publication No. 09-7473). Retrieved from https://ctep.cancer.gov/protocoldevelopment/electronic_applications/do cs/CTCAE_v5_Quick_Reference_5x7.pdf. 5. Lee, G., et al. (2018). Association of Hemoglobin Concentration and Its Change With Cardiovascular and All-Cause Mortality. Journal of the American Heart Association. 2018;7:e007723. 6. Carson, J. and Kleinman, S. (2018). Indications and hemoglobin thresholds for red blood cell transfusion in the adult. UpToDate. Retrieved from https://www.uptodate.com/contents/indications-and- hemoglobin-thresholds-for-red-blood-cell-transfusion-in-the- adult?search=red%20blood%20cell%20transfusion&source=search_res ult&selectedTitle=1~150&usage_type=default&display_rank=1. 7. Mayo Clinic. (2014). Diseases and conditions: Iron deficiency anemia. Retrieved from http://www.mayoclinic.org/diseases-conditions/iron- deficiency-anemia/basics/definition/con-20019327 8. Evert, A. (2013). Vitamin B12. In Medline Plus. Retrieved from http://www.nlm.nih.gov/medlineplus/ency/article/002403.htm 9. Gersten, T. (2013). Folate deficiency. In Medline Plus. Retrieved from http://www.nlm.nih.gov/medlineplus/ency/article/000354.htm 10. Schrier, S. and Auerbach, M. (2018). Treatment of iron deficiency anemia in adults. UpToDate. Retrieved from https://www.uptodate.com/contents/treatment-of-iron-deficiency- anemia-in-adults 11. Savarese, D. (2018). Common terminology criteria for adverse events. UpToDate. Retrieved from https://www.uptodate.com/contents/common-terminology-criteria-for- adverse-events.

nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com 24 12. Lexicomp (2018). Folic Acid. UpToDate. Retrieved from https://www.uptodate.com/contents/folic-acid-drug- information?search=folic%20acid&source=search_result&selectedTitle= 1~148&usage_type=default&display_rank=1. 13. Schrier, S. (2018). Clinical manifestations and diagnosis of vitamin B12 and folate deficiency. UpToDate. Retrieved from https://www.uptodate.com/contents/clinical-manifestations-and- diagnosis-of-vitamin-b12-and-folate- deficiency?search=folic%20acid&source=search_result&selectedTitle=3 ~148&usage_type=default&display_rank=6.

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