I Hate Dialysis Message Board
Dialysis Discussion => Dialysis: News Articles => Topic started by: okarol on July 20, 2008, 11:52:44 PM
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NEW YORK TIMES
July 19, 2008
Expert Q & A
The Challenges of Anemia: Defining It, and Living With It
By ERIC SABO
Dr. Allen Nissenson is a professor of medicine and director of the dialysis program for the David Geffen School of Medicine at the University of California, Los Angeles. He has written two medical textbooks on kidney disease treatment and was president of the National Anemia Action Council, a patient advocacy group.
Q: Anemia can result from a wide range of diseases and conditions. What are the most prominent causes?
A: The biggest categories are nutritional anemias, which are mainly iron deficiency, but also deficiencies in folic acid or vitamin B12. Another major cause is bleeding, usually from the gastrointestinal tract. Chronic diseases that have an inflammatory component, like rheumatoid arthritis, can also cause anemia.
And then there’s cancer itself, or the side effects from treating cancer, that can cause anemia. Another prominent cause is deficiencies in erythropoietin, or Epo, a hormone that stimulates red blood cell production, which is almost entirely a problem in people with kidney disease.
Q: A lot of symptoms of anemia share the same characteristics as being overworked or just tired. How do you tell the difference between normal fatigue and anemia?
A: You really can’t. One of the dilemmas with anemia is that the symptoms are pretty ubiquitous: tiredness, weakness, some difficulty in thinking clearly. They’re all kind of vague.
So what we tell people is if you have these symptoms and they go on for a long time or seem to be interfering with your ability to function normally, then you should see your doctor. One of the things you need to get checked is your hemoglobin level — the protein that carries oxygen in red blood cells — to see if that’s part of the anemia.
Q: Is there a specific cutoff point of hemoglobin that indicates whether someone is anemic?
A: One of the challenges is defining what normal is, and there’s no uniform acceptance of normal hemoglobin levels. The one most doctors use is from the World Health Organization. A hemoglobin level below 13 for men and below 12 for women is considered anemic.
Q: Nutritional deficiencies are a common cause of anemia. Do these arise from a poor diet or underlying disease?
A: Bleeding is one of the most prominent causes of iron deficiency, because when you bleed you lose red blood cells that contain iron. But there still is a significant prevalence of nutritional iron deficiencies, which is much more common in pregnant women and children because of their diets.
Nutritional iron deficiency is the biggest cause of anemia worldwide, and it’s a problem is some segments of the United States. For folate or vitamin B12, it’s much less common to be deficient.
Q: How difficult is to live with anemia?
A: It’s very tough. One of the things we learned, however, is that the ability of the body to adapt is tremendous. Over time, even people with moderately severe anemia say, “You know, I really don’t feel that bad.”
Although people are fatigued or can’t do as much as they could before, they slowly adapt their lifestyle. Instead of walking to the grocery store once a week, they may go once a month and buy everything they need because they’re too tired to keep going back. There’s a lot of adaptation that takes place, but anemia can be very debilitating.
Q: Is anemia life-threatening?
A: The only life-threatening anemia is if you have massive hemorrhaging. But chronic anemia can be life-threatening indirectly in the sense that prolonged, severe anemia can cause the heart to enlarge and overwork, leading to heart failure. So through that mechanism, anemia can lead to serious morbidity or mortality.
Q: The Food and Drug Administration has issued warnings on three similar anemia drugs: Procrit, Aranasep and Epogen. How safe are these to use?
A: The studies that raised the red flags were either in cancer patients or in people with kidney disease, and they all showed something similar: if you attempt to correct the anemia completely back up to normal hemoglobin levels, that’s not a good idea. You start getting strokes or heart attacks, blood-clotting problems or increased mortality.
The recent studies that the F.D.A. flagged were just studies. Kidney specialists weren’t practicing this way — they were waiting for the studies. So we’re going to continue practicing the way we were, which is to give modest doses of the drugs, with modest improvements in hemoglobin.
Q: Are the drugs potentially dangerous for the elderly or other groups?
A: There are no studies to help us figure that out. There’s no question that since cancer patients and kidney patients are so different, but the same problem has arisen, I think people need to be extremely cautious with the use of these drugs.
One dilemma now is that if someone wanted to do a study on normalizing hemoglobin levels in the elderly with these drugs, I think an institutional review board that has to approve the ethics of studies like this would have a very difficult time because of the concerns of the risks.
Q: The F.D.A. says the drugs are safe to use in small doses that keep oxygen-carrying hemoglobin just below a level that is considered normal. Is this enough to help anemia patients feel better?
A: The quality of life benefit is seen with pretty modest increases of hemoglobin. It looks like you get the biggest bang for the buck early on. If you push the doses, then you start to see the toxicity.
Q: Are red blood cell transfusions a potentially safer option given the new concerns about the drugs?
A: As long as you’re aiming for a moderate increase in hemoglobin, the drugs are so much simpler and have few or any side effects unless you start pushing them hard. Whereas with transfusions, you still have the risk of infectious diseases and other issues.
Q: Are there lifestyle measures, like diet or exercise, that can treat anemia?
A: In the chronic conditions, there is probably very little that can be done. Obviously for nutritional anemia, improving nutrition will help. Probably the only thing you can do is to go to a higher altitude, because there’s less oxygen available.
As a result, the cells that make Epo detect that and then stimulate Epo to make more red blood cells. Even people with chronic illnesses have slightly higher hemoglobin when they go to altitude for a period of time.
http://health.nytimes.com/ref/health/healthguide/esn-anemia-expert.html#
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This article was more informative than what I recently looked up on the internet
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If I thought my relatives and friends would read the whole article, I would send it to everyone. It really explains the whole problem with anemia and kidney disease. The explanation of changing your lifestyle hit the nail on the head. I do things different, pace myself and know when to stop. Great article--thanks Okarol.
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I really hate anemia. Everyone in my life understands it even though they don't have it.. and have always helped me... except my dad. He always thought/thinks I am just making it up, being lazy, or whatever else he can think of... especially when I slept like all day and was still so tired and drained... he just was like "there is no way it is that bad". If only I could make someone who don't want to believe, understand.
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My dad is like that also with anything healthwise about me. One reason I do not get along with him and just stay away or walk away from him.
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This article unfortunately does not combine three important facts -- first, that it is only safe to raise hemoglobin levels with EPO to 13 in men and 12 in women; second, that hemoglobin in dailysis patients often range around the 12 to 10 level; and third, that leaving anemia only partially corrected at these levels can be devastating to human productivity and energy. The sad fact is that modern medicine is helpless to deal effectively with most cases of renal anemia.
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Here's how I define anemia: I used to be too hot if the weather got above 72. Now I'm cold unless the weather is 77 or higher. Basically I wear sweaters and sweatshirts a lot longer than most other folks!
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Here's how I define anemia: I used to be too hot if the weather got above 72. Now I'm cold unless the weather is 77 or higher. Basically I wear sweaters and sweatshirts a lot longer than most other folks!
I wish that was my answer. Even when I do not have anemia, I still feel cold when it is 80 out especially if there is a breeze. Once I do get hot, take a rest, get one of my shirts off, or go into an air conditioned place, I get cold easily. I thought this was due to dialysis, but even after transplant I still feel this way. I forgot which doctor I was talking to in the many I see, but it was mentioned that it may have something to do with a form of neuropathy.. No other doctors look into the cause, they just know I will be cold waiting in the exam room shivering :banghead;
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I get cold severely easily due to my Lupus. Of course it got worse on dialysis, but back to the same now just from having Lupus. I have to wear sweatshirts in my house, even when i lived in Vegas and it was 120 out, because I get cold unless everyone else around me is sweating. hehe.. :)