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Alert Number 80

Anemia Can Be a Silent Killer

Date: February 23, 2005

All of us know by now that CLL can cause serious deficits in other cell lines, including red blood cells. Many CLL patients develop a variety of autoimmune diseases, where the immune system fails how to distinguish friend from foe and attacks perfectly good body cells and kills them. Patients with AIHA (Auto Immune Hemolytic Anemia) can have low red blood cell counts, even if the bone marrow is doing its job: the newly minted red blood cells are getting targeted and killed by antibodies in their blood. We have discussed AIHA at length in a recent article AIHA: Auto Immune Hemolytic Anemia. You might want to read it if you need a refresher on this very real complication of CLL. AIHA is one of several potential causes of low red blood cell counts - other reasons for anemia can be a packed bone marrow that is no longer able to make red blood cells or a spleen that is squirreling away red blood cells and keeping them out of circulation.

When your red blood cell counts start dropping, the resulting anemia can make difficult even simple actions such as climbing stairs. Since the red blood cells are the oxygen carriers in your body, chronic anemia can be likened to gradual strangulation and cutting off of your air supply. Fatigue and loss of quality of life are not the only problems associated with chronic anemia. As the Reuters report below points out, anemia is now shown to be strongly associated with coronary artery disease. Researchers point out that "having fewer red blood cells makes the heart work harder, and may therefore increase risk for developing heart failure." Even moderate anemia can increase the risk of heart disease two-fold, and severe anemia can increase the risk by more than 6-fold.

As we discussed, anemia can occur in CLL patients for a variety of reasons. For some patients, drugs such as Aranesp, Epogen and Procrit can be literally miracle drugs. These are man-made versions of a growth factor called erythropoietin that our body uses to send messages to the bone marrow to produce more red blood cells. If the trends on your monthly CBC show a clear pattern of dropping red blood cell counts and decreased hemoglobin and hematocrit levels, it is important that you discuss your options with your doctor. Toughing it out and putting up with the fatigue associated with anemia may be a dangerous option, especially if you are already at risk of heart disease.

Please remember, a single out-of-kilter CBC result does not make a trend. It is really important to track your monthly CBC results over time and keep an eye out for clear trends. May I suggest using a chart to keep track of all the numbers? We have a nice Excel template for charting your data on our website, under the heading Your Charts. You can download this template and save it on your own computer. Update it each month when you get your blood test results. Keeping all the CBC data on one chart makes it a lot easier to spot troublesome trends. Since anemia may occur due to variety of reasons, drugs such as Procrit and Aranesp may not be the answer for every case of anemia - that is up to your doctor to decide. Here are a couple of links where you can learn a lot more about anemia. These are links to pages on Anemia.org, the website of the National Anemia Action Council. I find them useful because they have all the numbers, acronyms and jargon all described in one place. The website has many other useful documents and is worth exploring.

Anemia FAQ;
Anemia of Cancer (Monograph in pdf form).

Epo drugs, like all growth factor dugs, need to be used with caution. Over-use is not a smart thing to do - but refusing to get the Procrit / Epogen / Aranesp shot when your doctor recommends it and your anemia clearly needs it is even more foolish. Managing your CLL is all about making pragmatic choices that are driven neither by panic nor neglect.

Be well.

Chaya
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Press Report

Anemia Tied to Diastolic Dysfunction in Heart Patients

Reuters Health Information 2005
2005 Reuters Ltd.

NEW YORK (Reuters Health) Feb 16 - Anemia appears to be strongly associated with diastolic dysfunction in patients with coronary artery disease, researchers report in the February 1st issue of the American Journal of Cardiology. It appears that "having fewer red blood cells makes the heart work harder, and may therefore increase risk for developing heart failure," lead author Dr. Mary A. Whooley told Reuters Health.

The association between anemia and heart failure has only recently been appreciated, Dr. Whooley of the VA Medical Center, San Francisco, and colleagues note. To further investigate, the researchers performed a cross-sectional study with 822 coronary artery disease patients, most of whom were elderly men. All had normal sinus rhythm and preserved systolic function.

The prevalence of diastolic dysfunction ranged from 8% in those without anemia to 24% in those with severe anemia. After multivariant adjustment, moderate anemia conferred an odds ratio of 2.0 for diastolic dysfunction. For severe anemia, the corresponding figure was 6.6. No significant association was seen between left ventricular hypertrophy and anemia. The researchers "hypothesize that adaptation to anemia leads to ventricular remodeling, diastolic dysfunction, and systolic dysfunction in patients who have coronary disease."

Am J Cardiol 2005;95:332-336.
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