The cause of the sharp reduction in the haemmoglobin may be as a result of increased destruction fibroblasts in the kidney leading to reduced production of erythropoietin needed in the production of red cells. Please check the serum erythropoeitn level. The cause could also be immunological like disbalance in the inlammatory and antinflammatory cytokines which may even hinder improvement during the cause of the treatment. Please advice the haematologists there to do a thorough blood film reading of the patient.

It would be necessary to look at other causes of anemia , rather than renal disease , as the stage is CKD stage 3 . She is also getting Erythropoietin weekly. What is her age ? It would be preferable to check for blood loss for eg. from GI tract or look for a source of infection . What is the serum Fe & TIBC ?

Interesting question. I chanced on these resources which may be helpful. Best regards

Thank you Dr Emmanuel and Dr Adom for you kind suggestion

Dr. Singh Shivakumar Sir: Thanks for your comment,

Mother is about 71 year

The TIBC value is 195.00 µg/dL

Ferritin :3662 ng/ml

A detailed pathology report is attached here with

So sir kindly suggest for same so that my mother can recover with this problem.

IRON STUDIES, SERUM

(Spectrophotometry). Reference

Iron 146.00 µg/dL 50.00 - 170.00

TIBC. 195.00 µg/dL 250.00 - 425.00

Transferrin Saturation 74.87 % 15.00 -50.00

HEMOGLOBIN; Hb, BLOOD

(Cyanmethemoglobin Method). Reference

Hb. 4.00 g/dL 11.50 - 15.00

FOLATE (FOLIC ACID), SERUM #

(Chemiluminescent Immunoassay)

>20.0

Interpretation

--------------------------------------

|RESULT IN ng/mL |REMARKS |

|----------------|---------------------|

| 0.35-3.37 |Deficient |

|----------------|---------------------|

| 3.38-5.38 |Indeterminate |

|----------------|---------------------|

|>5.38 |Normal |

Comments

Iron is an essential trace mineral element which forms an important component of hemoglobin, metallocompounds and Vitamin A. Deficiency of iron, leads to microcytic hypochromic anemia. The toxic

effects of iron are deposition of iron in various organs of the body and hemochromatosis.

Total Iron Binding capacity (TIBC) is a direct measure of the protein Transferrin which transports iron from the gut to storage sites in the bone marrow. In iron deficiency anemia, serum iron is reduced and TIBC increases.

Transferrin Saturation occurs in Idiopathic hemochromatosis and Transfusional hemosiderosis where no

unsaturated iron binding capacity is available for iron mobilization. Similar condition is seen in congenital

deficiency of Transferrin.

Hi Hariom,,, from the investigations anemia is very unlikely to be because of CKD or iron defficency. Whether your mother is taking metformin that can cause vit B12 defficency. Peripheral smear and reticulocyte count will be very useful to exclude megaloblastic and haemolytic anaemia. Wheather there is any hepatosplenomegally or lympadenopathy, that can give some clues to haematological disorder or chronic inflammatory disorder. ANA or dsDNA can be done to exclude collagen vascular disease. Lastly examination of bone marrow by experienced haematologist is required to exclude myelodysplatic syndrome and plasma cell disorder. Wheather total WBC and platelet count are within normal limit that is also very important.. Thanks

Good resource for you: Article Anemia, Diabetes, and Chronic Kidney Disease

Professor Emmanuel gave the appropriate answer and very informative conversation.

Thank you Dr. Majumdar Sir,

Bone marrow test (attached herewith) has been already done just a month before of above Iron Profile. We had consulted with hematologist and conclude that bone marrow is normal with respect to age....

Same bone marrow test is performed again in SGPGI, Lucknow

So kindly suggest for the same

Thanks and Regards

@ Hariom Gupta,

Thanks for the detailed data . Your mother has low WBC & Platelet count along with anemia with Macrocytosis . As Biswajit Majumder suggested vitamin B 12 deficiency is possible , as this can cause lowering of TC , Hb & platelets . Please measure vitamin B 12 levels , as this is a common cause of anemia in India & can be due to nutritional cause or Metformin therapy .

@ Dr. Singh Shivakumar

Thank you sir for kind suggestion and valuable guidance

Serum B12 level is 324 pg/ml Normal reference range: 211 - 911 pg/ml

she is also taking folic acid and B12 supplements as a medicines however her Hb level is still decreasing within span of about two months.

report of B12 is attached herewith.

thanks and regards

Follow question

@Pro. Singh Sivakumar and @ DrBishvajit Majumdar

Thanks for your kind responses and support

I checked the medicine and found that she is taking zoryl M1 (Glimepiride 1mg and Metformin Hydrochloride - 500 mg) for controlling the sugar level (type 2 Diabetes).

So please suggest some alternative of above medicine.

with thanks and regards

@ Hariom Gupta ,

Thanks for the laboratory data . Please send all the clinical & non hematological data . The serum ferritin levels are high suggesting chronic inflammatory disease .

Hi Hariom,,, peripheral smear showed macrocytes and large platelet along with lower level of WBC and platelet count, megaloblastic anaemia needs strong exclusion. Serum B12 is also lower side of normal. Bone marrow should be reviewed to exclude megaloblastic changes. Some time oral replacement of B12 may not be sufficient and needs injectable preparation specially in pernicious anaemia. Is there is any neurological changes of your mother? Regarding therapy, you can use gliptins like (vildagliptin, sitagliptin or linagliptin ) in place of metformin.. Also ask to look for hypersegmented nutrophil in peripheral smear which is very suggestive of megaloblastic anemia.. Thanks

I also recommend that you should investigate if the abnormal proteins synthesis through bone marrow expert assay. This could be a serious problem. I advise she should replenish her total protein level.

The results are related to chronic hepatic disease, a condition that can affect diabetic patients in the form of steatohepatitis. It usually increases transferrin saturation and deposits iron in the liver, while increasing ferriting. Macrocytosis can be found also in chronic liver disease, but can also be due to megaloblastic anemia, even though B12 and folate levels are normal. As RDW is increased, the patient has mixed anemia. A peripheral smear would be interesting to see; it probably may show macrocytes and normocytes. It seems to be a case of anemia due to erythropoietin deficiency, chronic inflammation, and maybe some B12 deficiency. I suggest liver sonogram with elastography, gammaglutamiltranspeptidase, liver function tests for chronic hepatic disease evaluation. As ferritin is extremely elevated it would be advisable to test c-reactive protein and procalcitonin levels to determine the possibility of an occult infection or other inflammatory process