| Anemia
What is anemia and why is it important?
Anemia is a common bone marrow condition that is characterized by
a lack of red blood cells (called erythrocytes). Red blood cells
are produced in the bone marrow and carry oxygen from the lungs
to the rest of the body. In order to produce the proper amount of
red blood cells, the bone marrow needs erythropoietin (a natural
hormone produced by the kidneys), iron, vitamin B-12, and folic
acid.
Anemia is very common and can develop during any stage of HIV-infection.
It is estimated that anemia is already present in 10-20% of people
who test HIV-positive. Anemia is later diagnosed in 70-80% of patients
over the course of their HIV infection.
Anemia is associated with an increased risk of death in HIV-positive
individuals. A recent study showed that the risk of death was 148%
higher for persons with anemia who entered the study with CD4 cells
above 200 than for persons in the same CD4 cell range without anemia.
The risk of death was also increased by 58% for people who started
the study with less than 200 cells and then developed anemia. The
risk of death decreased for all people who recovered from anemia.
What causes anemia?
In HIV-positive people the leading causes of anemia are opportunistic
infections (OIs) and HIV-related cancers which impair bone marrow
function. These include mycobac-terium avium complex (MAC), tuberculosis
(TB), cytomegalovirus (CMV), candidaisis (thrush), Kaposi's sarcoma
(KS), and Non-Hodgkin's lymphoma (NHL).
Anemia is also caused by lack of essential nutrients such as iron,
vitamin B-12, and folic acid; inadequate erythropoietin production;
excessive menstrual bleeding; and medications including AZT (zidovudine,
Retrovir®), Combivir®, hydroxyurea (Hydrea), and trimethoprim-sulfamethoxazole
(Bactrim®, Septra®).
What are the signs & symptoms of anemia?
Signs and symptoms of anemia include fatigue, weakness, heart palpitations,
shortness of breath, dizziness (especially when rising from a lying
or sitting position), pale skin color, and a tendency to feel cold.
While fatigue can be due to a number of reasons, it is the most
noticeable symptom of anemia and you should call your doctor if
severe fatigue does not go away after a few days.
How is anemia diagnosed?
Anemia is diagnosed using standard blood tests to check levels of
hemoglobin and hematocrit.
Hemoglobin is the main element of red blood cells. It is a protein
containing iron that allows the red blood cells to carry oxygen
and waste products. Normal hemoglobin ranges between 14-18 grams
per deciliter (g/dl) in men and 12-16 g/dl in women. A hemoglobin
level of 10 -14g/dl in men and 10-12g/dl in women is a sign of moderate
anemia, while any number under 10g/dl signals severe anemia in men
and women.
Hematocrit measures the volume percentage of red blood cells in
whole blood. Normal hematocrit levels range between 40-52% in men
and 35-46% in women. Anemia is considered to be moderate when the
hematocrit is between 35-40% in men and 30-35% in women and severe
when the hematocrit falls below 35% in men and 30% in women.
Can anemia be treated?
Yes. There are a number of ways to treat anemia. Levels of essential
nutrients such as iron, vitamin B-12, and folic acid should be monitored
and replaced if low.
Epoetin alfa (Epogen®, Procrit®) is commonly used to treat
HIV-positive people with anemia. Epoetin alfa is a synthetic form
of the body's natural erythropoietin. It can help stimulate bone
marrow production of red blood cells and increase hemoglobin. Studies
show that the use of epoetin alfa decreases the number of blood
transfusions needed and enhances overall quality of life.
The beginning level of erythropoietin in your blood can predict
how well you will do using epoetin alfa. People with erythropoietin
levels of 500 international units per liter (IU/L) or less usually
respond to epoetin alfa, while people with erythropoietin levels
over 500 IU/L usually do not respond.
Epoetin alfa is given by injection under the skin 3 times a week
until red blood cell counts go back to normal. People can learn
to give themselves injections at home. It is recommended that epoetin
alfa be used for a minimum of 8 weeks since it can take up to 6
weeks to get a good response.
Rash is the most common side effect seen with epoetin alfa.
Another effective therapy for anemia is blood transfusions. Blood
transfusions are generally used in cases of severe anemia when rapid
treatment is required. Because risks associated with blood transfusions
include infection with other viruses such as hepatitis and temporary
increases in viral loads, routine use of blood transfusions to treat
chronic anemia is not recommended for HIV-positive people.
If you have anemia caused by medications, it might be necessary
to switch the drug to one that does not cause anemia. It may also
be possible to lower the dose of the particular drug to see if this
stops the anemia. Check with your doctor to see if either option
is right for you.
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