Chronic Anemia Treatment & Management
- Author: Christopher D Braden, DO; Chief Editor: Barry E Brenner, MD, PhD, FACEP more...
EDs rarely treat anemia beyond the emergent needs. Discharging the patient on iron, vitamin B-12, or folate may mask other problems and cloud the correct diagnosis.
Unless cardiopulmonary or cerebrovascular disease is present, transfusion is rarely needed in patients who have chronic anemia with an Hgb greater than 7 g/dL.
The American College of Obstetricians and Gynecologists has guidelines available on the treatment of anemia in pregnancy.
Emergent Care of Chronic Anemia
Most patients presenting with chronic anemia are not in distress.
Prehospital care most often is initiated for patients in extremis. Attention to ABCs is most appropriate. All such patients should have intravenous (IV) placement, fluid resuscitation, and airway management as necessary.
The initial status and appearance of the patient may hold useful information and should be elicited from prehospital personnel.
Patients with chronic anemia usually do not require intervention in the ED. Ultimate treatment requires investigation into the etiology of the anemia and correction of the underlying cause.
Records of previous hospitalizations or ED visits are invaluable in many aspects of patient management. Such patients frequently have undergone previous workup, and previous Hgb or hematocrit trends indicate the time course of the illness.
Patients with chronic anemia requiring admission include the following:
Patients presenting with hypovolemia, active bleeding, angina, tachypnea, altered mental status, transient ischemic attack (TIA), or exacerbation of congestive heart failure (CHF) 
Patients who demonstrate a considerable drop in Hgb and hematocrit values when compared with previous values or who have new-onset or worsening pancytopenia
Patients with an initial Hgb of less than 10 g/dL or a hematocrit of less than 30%
Patients who may not comply with follow-up or those in whom the clinician anticipates the need for an extensive workup
Patients can be admitted to a ward bed, a monitored bed, or an intensive care unit (ICU) bed, depending on their condition.
Patients with chronic anemia seldom require transfer to another facility for definitive care. Transfers are only acceptable if the patient is hemodynamically stable.
One conspicuous exception in the treatment of chronic anemia is the use of transfusion therapy. Unless cardiopulmonary or cerebrovascular disease is present, transfusion is rarely needed in patients who have chronic anemia with an Hgb greater than 7 g/dL. Multiple situations that may require transfusion include angina, chronic heart failure, transient ischemic attack (TIA), and signs of tissue hypoxia.
It is important to weigh the risks and benefits of blood transfusion.
Many adverse reactions are associated with transfusion therapy. Most frequently encountered is a febrile nonhemolytic reaction. Patients who have had previous transfusion or patients who are pregnant are at greatest risk. Treatment is supportive with antipyretics. The clinician should maintain a high level of suspicion for a hemolytic reaction, because fever may the first symptom.
Many patients fear infection. Hepatitis C occurs in 1 of 103,000 transfusions, hepatitis B occurs in 1 of 200,000 transfusions, and human immunodeficiency virus (HIV) occurs in 1 of 490,000 transfusions.
In a retrospective study of patients with chronic refractory anemia who were transfusion-dependent for more than 1 year, 10 of the 13 patients had abnormal liver function. The CT Hounsfield units in the liver were proportional to serum ferritin levels and were increased significantly in 11 patients. In the nine patients with serum ferritin >3,500 ng/mL, eight of whom died, skin pigmentation, liver dysfunction, and endocrine dysfunction were observed. Serum ferritin levels did not decrease significantly in the nine patients treated with 15-60 days of iron-chelating therapy.
Graft versus host reaction
The graft versus host reaction is rare but is especially dangerous in patients who are immunocompromised. It carries a mortality rate of greater than 90%. Pathogenesis in this reaction involves donor T lymphocytes attacking host human leukocyte antigens (HLA). High fever, erythematous rash, diarrhea, and abnormal LFTs associated with recent or concurrent transfusion may herald the severe reaction. Symptoms may not appear until 8 days after transfusion, and death occurs in 3-4 weeks.
Using irradiated blood can decrease the incidence of graft versus host reaction and should be considered in all patients deemed immunocompromised, as well as in fetuses receiving intrauterine transfusions, patients receiving units from a blood relative, and patients transplanted with marrow. Care should be taken when transfusing patients with CHF. Preferably, transfusion should occur over 3-4 hours in the sitting position.
Patients with chronic anemia most often are treated in the outpatient setting. Clear instructions must be given to the patient regarding proper follow-up.
Consideration of the patient’s financial situation and ability to comply with follow-up care is imperative. The key to minimizing complications from chronic anemia is ongoing reassessment and patient compliance with proposed medical therapy.
All efforts should be made to arrange for follow-up. When all avenues for outpatient evaluation fail, patients should be instructed to return to the ED for reassessment in 2-3 weeks.
Upon discharge, instruct the patient to watch for signs and symptoms of worsening anemia. The patient should be advised to return to the ED if such symptoms develop.
Generally, patients with chronic anemia can be treated on an outpatient basis, and referral to a primary care provider is appropriate.
Consultation with the patient's primary care provider or an available internist should begin in the ED.
Symptomatic patients with an underlying medical condition that requires surgical consultation, such as chronic GI bleeding from colon cancer, should be evaluated by a surgeon in the ED.
McLennan JD, Steele M. Extent of microcytic anemia among children in a low-income, peri-urban community in the Dominican Republic using different cut-points. J Trop Pediatr. 2015 Apr. 61 (2):86-91. [Medline].
[Guideline] American College of Obstetricians and Gynecologists (ACOG). Anemia in pregnancy. 2008 Jul. [Full Text].
Zittermann A, Jungvogel A, Prokop S, Kuhn J, Dreier J, Fuchs U, et al. Vitamin D deficiency is an independent predictor of anemia in end-stage heart failure. Clin Res Cardiol. 2011 Apr 7. [Medline].
Omar N, Salama K, Adolf S, El-Saeed GS, Abdel Ghaffar N, Ezzat N. Major risk of blood transfusion in hemolytic anemia patients. Blood Coagul Fibrinolysis. 2011 Apr 19. [Medline].
Gao C, Li L, Chen B, Song H, Cheng J, Zhang X, et al. Clinical outcomes of transfusion-associated iron overload in patients with refractory chronic anemia. Patient Prefer Adherence. 2014. 8:513-7. [Medline].