Decline In Hemoglobin Levels Research Articles

Predictors of hemoglobin decline in non-metastatic prostate cancer patients on androgen deprivation therapy: a matched cohort study

The extent and severity of hemoglobin decline after the initiation of androgen deprivation therapy (ADT) is unclear, and predictors of hemoglobin decline in older men with prostate cancer (PC) are not well-characterized. Three cohorts were recruited in this prospective study to evaluate the impact of ADT and other factors on hemoglobin decline. Cohorts included ADT users initiating continuous ADT, PC controls, and healthy controls, matched on age and education. All patients with PC had non-metastatic disease. Univariate and multivariable associations between changes in hemoglobin over 12 months and baseline characteristics were evaluated using linear regression models. We included 250 men (mean age 69 years). The baseline mean hemoglobin was 141 g/L in ADT users, 144 g/L in PC controls, and 149 g/L in healthy controls (p < 0.001). Over 12 months, the mean hemoglobin level declined in ADT users by 8.9 g/L, compared to 0.56 and 2.03 g/L among PC controls and healthy controls, respectively (p < 0.001). Statistically significant predictors of greater hemoglobin decline included ADT use (p < 0.001), lower activities of daily living score (p < 0.001), higher Charlson comorbidity score (p = 0.02), higher baseline hemoglobin level (p < 0.001), and non-White race (p = 0.04) but not age (p = 0.50). In men with non-metastatic prostate cancer, ADT was independently associated with a decline in hemoglobin level over 12 months. Other predictors of declining hemoglobin included comorbidity, functional status, baseline hemoglobin level, and race. These findings may help clinicians identify patients starting ADT who would benefit from closer hemoglobin monitoring.

High rates of sustained virological response in hepatitis C virus-infected injection drug users receiving directly observed therapy with peginterferon alpha-2a (40KD) (PEGASYS) and once-daily ribavirin

This retrospective study evaluated the efficacy and tolerability of directly observed therapy with peginterferon alfa-2a and once-daily ribavirin (RBV) for chronic hepatitis C in 49 opioid-addicted injection drug users (IDUs) participating in a drug treatment program at a specialized outpatient center. Patients also received prophylactic citalopram to minimize the risk of interferon-induced depression. Patients had daily access to and support from specialist physicians, nurses and counseling services at the center, and a 24-hour helpline. Sustained virological response was achieved by 48 of 49 patients (98%) overall, including 20 of 21 (95%) hepatitis C virus (HCV) Genotype 1/4-infected patients and 28 of 28 (100%) Genotype 2/3-infected patients. Treatment was well tolerated, and no unexpected side effects of peginterferon treatment were seen. The safety profile of once-daily RBV was not different from twice-daily dosing. Decline in hemoglobin levels was similar to those reported in clinical trials including once-daily RBV and did not lead to dose reduction or treatment withdrawal. Our data demonstrate that HCV-infected IDUs on stable L-polamidone (methadone) or buprenorphine maintenance can be successfully and safely treated with peginterferon alfa-2a and RBV in an optimal substitution setting.

Predictors of Cognitive Decline After Chemotherapy in Breast Cancer Patients

The objective of this study is to identify whether decline in cognitive functioning after chemotherapy in women with breast cancer is associated with health/disease, treatment, and psychological variables. Neuropsychological performance, health/disease, and treatment-related information of 136 women with breast cancer (age M = 49.38; SD = 7.92; range = 25.25-67.92) was assessed pre-chemotherapy and 1-month post-chemotherapy. The Reliable Change Index corrected for practice (RCIp) identified women whose performance significantly declined, while Pearson correlations assessed the relationship between cognitive change and predictor variables. A total of 16.9% of women showed significant decline post-chemotherapy, with affected domains including verbal learning and memory, abstract reasoning, and motor coordination. Decline in hemoglobin levels and increased anxiety over the course of chemotherapy was found to significantly predict impairment in multiple cognitive measures. Change in specific cognitive measures was significantly associated with baseline fatigue, depression, and functional well-being (r = 0.23 to 0.33; p = .01 to < .001). Although the effects are small, there is evidence that psychological and health factors may increase vulnerability to cognitive dysfunction after chemotherapy for breast cancer. Significant associations reported in this study may be useful in the identification and treatment of at-risk individuals.

Pulmonary Hemorrhage in Patients with Systemic Lupus Erythematosus

Pulmonary hemorrhage (PH) is a life-threatening complication in systemic lupus erythematosus (SLE) occurring in 0.5% to 5.7% of lupus patients. PH is more common in women. The mean age at onset is around 30 years. Most have an established diagnosis of SLE but in approximately 20% PH occurs at onset of diagnosis. PH should be suspected in lupus patients presenting new pulmonary infiltrates, a rapid decline in hemoglobin level and any of the following: hemoptysis, dyspnea, hypoxemia, paradoxical increase of carbon monoxide diffusing capacity, or bronchoscopic evidence of hemorrhage. Radiographic abnormalities are non-specific but commonly show alveolar infiltrates. Pulmonary infiltrates are usually bilateral, perihilar or basilar with sparing of apices. PH usually occurs in patients with active lupus presenting extra-pulmonary manifestations, the most common being renal involvement. Hematologic abnormalities, central nervous system involvement, mucocutaneous manifestations, elevated anti-dsDNA antibodies and low C3 and C4 complements are also frequently seen. PH can lead to a prompt death; thus, early diagnosis and aggressive therapy are crucial. Treatment includes high-dose corticosteroids, cyclophosphamide and plasmapheresis. Improved survival rates have been reported lately, which could be related to better management of ventilatory support and the use of broad-spectrum antibiotics, together with timely and aggressive therapy. Keywords: Systemic lupus erythematosus, pulmonary hemorrhage, clinical manifestations, outcome, treatment

Prevalence of Anemia in African-Americans with Diabetes Mellitus: Role of Angiotensin Converting Enzyme Inhibitors

Angiotensin Converting Enzyme Inhibitors (ACE-I) and Angiotensin Receptor Blockers (ARB) have long been considered standard therapy in the medical management of congestive heart failure and diabetes due to their beneficial effects in preventing progression of cardiac remodeling and diabetic nephropathy, respectively. The benefits of ACE-I, however, are tempered by their anti-erythropoietic effects and potential role in anemia. We conducted a retrospective study based on extraction of electronic medical records available through the Washington Veterans Affairs Medical Center. We compared hemoglobin levels of diabetic African-American and Caucasian patients on ACE-I or ARB, referred to the Hematology Section with a diagnosis of unexplained anemia within a 10-year span from January 1, 1998 to January 1, 2008. Additional sub-stratification analyses were performed on insulin dependence and renal function. Of the 102 African-Americans and 25 Caucasians evaluated, 60 African-Americans and 13 Caucasians were not anemic prior to initiation of ACE-I or ARB therapy. In this group, a greater decline from pretreatment hemoglobin levels were evident in African-Americans compared with Caucasians, with an average change in hemoglobin of −2.76 ± 1.34 g/dL compared with −2.04 ± 1.35 g/dL, respectively, though neither change was statistically significant. A greater decrease in hemoglobin levels was also evident depending on length of time on ACE-I therapy in African Americans. The average change in hemoglobin was −0.85 ± 1.87 g/dL at less than 5 years, −1.25 ± 1.55 g/dL at 5–10 years, and −3.15 ± 1.61 g/dL at 10–15 years after initiation of therapy. Limited data were available for Caucasians. Pearson correlation analyses also showed a weak positive correlation between decline in hemoglobin levels and decline in renal function. The average change in hemoglobin concentration after initiation of ACE-I or ARB therapy was greater in the subgroup of patients with estimated GFR less than 60cc/min in both African-Americans and Caucasians, with decrease of −1.85 ± 1.67g/dL and −1.60 ± 1.49g/dL, respectively. In African-Americans, decreases in hemoglobin were even greater for those patients with an estimated GFR less than 30cc/min, at 2.03 ± 2.19g/dL. Only one Caucasian patient had a GFR less than 30cc/min in our study. Greater decline in hemoglobin levels also correlated with insulin use even when renal function was accounted for, though this change was also not statistically significant. In diabetic African-Americans on ACE-I or ARB therapy, the change in hemoglobin was −2.03 ± 1.83 g/dL on insulin, compared with −1.64 ± 1.52 g/dL on no insulin. In diabetic Caucasians on ACE-I/ARB therapy, the change in hemoglobin was −1.38 ± 1.43 g/dL on insulin, compared with −1.11 ± 1.42 g/dL on no insulin. Our study is the first to include a large sub-population analysis of African-American diabetic patients to evaluate the effects of ACE-I and ARBs on the development or worsening of a hypoproliferative normocytic, normochromic anemia state. While results of this retrospective study were not statistically significant, due to small numbers, it does confirm ACE-I and ARB-mediated anemia may involve several downstream factors acting in concert and reinforces the need for additional large population studies.

The prognostic value of hemoglobin change after initiating androgen‐deprivation therapy for newly diagnosed metastatic prostate cancer

The objective of this study was to characterize changes in hemoglobin (HGB) levels after the initiation of androgen-deprivation therapy (ADT) in patients with previously untreated, metastatic prostate cancer who were enrolled in a large clinical trial. The multivariate associations between 3-month change in HGB and baseline characteristics were evaluated with a linear regression model. The associations between 3-month change in HGB level and time-to-event outcomes, including overall survival and progression-free survival, were evaluated by using proportional hazards regression models. Quartiles of baseline HGB levels were < or =12.0 g/dL, from 12.1 to 13.7 g/dL, from 13.8 to 14.7 g/dL, and >14.7 g/dL. Overall, 3 months after initiating ADT, the mean HGB level declined 0.54 g/dL (standard deviation [SD], 1.68 g/dL); however, the mean HGB level increased by 0.99 g/dL (SD, 1.83 g/dL) in patients who had baseline HGB levels <12 g/dL and decreased 1.04 g/dL (SD, 1.28 g/dL) in patients who had baseline HGB levels > or =12 g/dL. After adjusting for potential confounders, including baseline HGB level, a decline in HGB after 3 months of ADT was associated independently with shorter survival (hazards ratio [HR], 1.10 per 1 g/dL decline; P = .0035) and shorter progression-free survival (HR, 1.08 per 1 g/dL decline; P = .013). An unexpected finding was that the effect of baseline HGB on overall and progression-free survival varied significantly by race. In a sample of men with newly diagnosed, metastatic prostate cancer, a decline in HGB level after 3 months of ADT was associated with shorter survival and progression-free survival after adjusting for disease status and other baseline covariates. Although race alone was not a strong predictor of death or disease progression, the effect of the baseline HGB level on overall and progression-free survival varied significantly by race.

Platelet decline: An early predictive hematologic marker of simian immunodeficiency virus central nervous system disease

As the prevalence of human immunodeficiency virus (HIV)-induced central nervous system (CNS) disease has increased with antiretroviral treatment, there is a critical need for identifying biomarkers that predict HIV CNS disease. To identify novel hematologic markers that precede and predict CNS disease, the authors examined longitudinal hematology data from 47 simian immunodeficiency virus (SIV)-infected macaques. This study demonstrated that the magnitude of decline in circulating platelet counts beginning at day 28 post infection, during asymptomatic SIV infection, predicted the eventual development of SIV encephalitis. Univariate analysis performed on platelet values obtained day 56 post inoculation demonstrated that SIV-infected macaques with the greatest decline in platelet numbers were 18 times more likely to develop SIV CNS disease than SIV-infected animals with minimal to no decline in circulating platelet counts. Decline in platelet number was a more robust marker than decline in hemoglobin levels, a previously identified marker of HIV CNS disease. The identification of an association between decline in platelets and the development of encephalitis demonstrates that monitoring platelet decline in HIV-infected individuals may serve as a predictive marker for clinical progression to HIV-induced CNS disease. Identifying those HIV-infected individuals at risk for CNS disease during asymptomatic stages of infection would promote early interventive, neuroprotective therapy to prevent neuronal damage and loss.

A case of familial Mediterranean fever and polyarteritis nodosa complicated by spontaneous perirenal and subcapsular hepatic hemorrhage requiring multiple arterial embolizations

The association of familial Mediterranean fever (FMF) and polyarteritis nodosa (PAN) has been well established. These patients have been reported to have an overall better prognosis than other PAN patients. Herein we report a patient with FMF and PAN who died of sepsis following a severe course of recurrent bleeding episodes which required multiple embolization attempts. The 39-year-old Turkish male presented with abdominal pain of 1-month duration. He had been diagnosed with FMF at the age of 24. On admission, he had pallor with general ill appearance. Rebound tenderness was obtained in the right upper abdominal quadrant. He had mild anemia, leukocytosis, thrombocytosis, and hypoalbuminemia. On the 2nd day of his admission, he developed hypotension with a rapid decline in hemoglobin level. Abdominal angiography showed multiple aneurysms in the branches of renal arteries, superior mesenteric artery, and hepatic arterial system including left renal infarct, suggesting PAN. He was put on high-dose steroids and oral cyclophosphamide. Despite medical treatment, he developed intense abdominal pain, hypotension, tachycardia, and a rapid fall in hemoglobin on four occasions. Active bleeding sites were embolized in two different angiography sessions. Although the patient experienced no more recurrent bleeding, he died of multiorgan dysfunction syndrome resulting from sepsis 6 weeks after admission. Polyarteritis nodosa associated with FMF may follow a grave course despite immunosuppressive therapy. Arterial embolization should be considered in the presence of bleeding aneurysms in addition to immunosuppressive therapy.

Use of Recombinant Erythropoietin in Treatment of the Anemia of Prematurity

The anemia of prematurity is defined by a progressive decline in hemoglobin level occurring over the first 2 months of life. Unlike term newborns whose "physiologic anemia" rarely if ever necessitates any treatment, preterm infants may become anemic enough to have clinical symptoms that indicate a need for red blood cell transfusions. Various factors contribute to the development of this anemia. Some of these factors, such as the short life span of erythrocytes in preterm infants, increased sensitivity of the erythrocytes to oxidative injury, and the blood losses caused by repeated phlebotomies, would normally be expected to induce corrective reticulocytosis. Characteristically, however, this anemia is hyporegenerative. Thus, it is associated with relative reticulocytopenia, low serum erythropoietin levels, and bone marrow erythroid hypoplasia. The recent availability of recombinant human erythropoietin has opened new perspectives in the management of a variety of anemias. Based on current knowledge of the regulation and pathophysiology of fetal and neonatal erythropoiesis, recombinant erythropoietin may represent a logical and efficient alternative to giving red blood cell transfusions in the treatment of the anemia of prematurity. Clinical trials have been initiated in several countries using different approaches and methodology. At this early stage these trials do not yet fully affirm that recombinant erythropoietin can be used as the first-line therapy in infants with the anemia of prematurity. Our own observations, however, suggest that this agent is well tolerated by preterm infants and may exert a corrective effect on the anemia of prematurity.

Serum Immunoreactive Erythropoietin in HIV-Infected Patients

Serum immunoreactive erythropoietin (SIE) and hemoglobin levels were measured in 152 patients infected with the human immunodeficiency virus. Anemia was present in 18% of asymptomatic patients who tested positive for the human immunodeficiency virus, 50% of patients with a condition related to the acquired immunodeficiency syndrome (AIDS), and 75% of patients with AIDS. The mean SIE level for untreated AIDS patients (26.2 +/- 2.4 mU/mL) was greater than for patients who tested positive for human immunodeficiency virus or patients with an AIDS-related condition but not outside the normal range for SIE (4 to 26 mU/mL), and the incremental increase in SIE level for a given decline in hemoglobin level was much less in AIDS patients than in patients with uncomplicated iron deficiency anemia. Forty-two patients were treated with zidovudine, and the hemoglobin level fell 10 g/L or more in 48%. In contrast to the untreated patients, however, the mean SIE level rose 10-fold to 214 mU/mL, and the incremental change in SIE level for a given decline in hemoglobin level was markedly increased. In the zidovudine-treated patients, erythrocyte mean corpuscular volume also rose significantly from a mean of 88.1 fL to 102 fL. However, in only 1 patient was there a corresponding increase in reticulocytes and in none was there amelioration of anemia. The data indicate that SIE level is inappropriately low in anemic AIDS patients. The ability of these patients to produce erythropoietin is intact and can be expressed with zidovudine therapy. However, even very high levels of SIE fail to stimulate erythropoiesis adequately.

Hematologic studies of severe undernutrition of infancy. I. The anemia of prolonged caloric deprivation in the pig.

Hematologic studies of severe undernutrition of infancy. I. The anemia of prolonged caloric deprivation in the pig.