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Nisa Maruthur, M.D., M.H.S.
02-03-2011
- Hemoglobin < 13 g/dL in men, < 12.0 g/dL in women (World Health Organization)
- Anemia is most commonly caused by chronic kidney disease in diabetes.
- Complete blood count with differential (includes mean corpuscular volume): electrical impedance
- Reticulocyte count: flow cytometry
- Peripheral blood smear: light microscopy
- Other laboratory tests: basic metabolic panel to assess glomerular filtration rate
- Symptoms of anemia: Fatigue, weakness, dizziness, shortness of breath, chest pain, coldness of the extremities
- Presence of diabetic nephropathy
- Bleeding, most commonly menstrual and gastrointestinal (hematemesis, hematochezia, or melena)
- Restrictive diets (e.g., vegetarian diets)
- A lower than expected level of hemoglobin A1c (based on plasma glucose levels) could indicate the presence of a hemolytic anemia.
- Iron deficiency has been associated with increased hemoglobin A1c in type 1 diabetes.
- Chronic kidney disease
- Inflammation ("anemia of chronic disease") including from acute infection, cancer, and autoimmune disease.
- Iron deficiency from bleeding (e.g., gastrointestinal) or malabsorption (e.g., celiac disease)
- Nutritional deficiency (e.g., vitamin B12 and folate)
- Bone marrow disorder
- Acquired hemolytic anemias (e.g. drug-induced)
- Hemoglobinopathies (e.g., thalassemia, sickle cell disease)
- Other: Thyroid disease, liver disease, HIV
- Low mean corpuscular volume with elevated red cell distribution width indicates iron deficiency
- Low mean corpuscular volume with normal red cell distribution width indicates thalassemia
- Elevated mean corpuscular volume suggests vitamin B12 deficiency, folate deficiency, hypothyroidism, alcohol abuse, or liver disease
- Normal mean corpuscular volume suggests chronic kidney disease, anemia of inflammation, or bone marrow disease
- Iron studies, reticulocyte count, and peripheral blood smear can help to evaluate for iron deficiency, anemia of inflammation, and bone marrow disease
- See Severity of Anemia table in "more" section.
- Dehydration can mask anemia.
- Recent transfusion can confuse interpretation of red blood cell indices and peripheral blood smear.
- Hemolytic anemias (i.e., shortened red blood cell lifespan) may be associated with falsely low hemoglobin A1c levels.
- Check complete blood count periodically (at least yearly or with decreases in kidney function) if glomerular filtration rate < 60 ml/min per 1.73 m2.
- There is a paucity of data to determine optimal transfusion levels in anemia.
- Symptomatic anemia and active bleeding should be treated with transfusion.
- In general, erythropoeitin treatment should only be used for chronic kidney disease-associated anemia (hemoglobin level to be maintained 11-12 g/dL).
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