A 65 male patient with diabete has the following serum biochemistry results.
blood glucose 120 mg/dl and taking glyclzide metformine and pitoz-Hemoglobin is 12g/dl which is low-serum iron is normal-serum ferritin is normal-RBC is 4.4,vitamine B12 is normal.What is the cause of Low hemoglobin.What is your suggestion for treatment for low hemoglobin?
Hb of 12 is not low it is in normal range. please check serum creatinine and e GFR Long standing diabetes may cause nephropathy
Is there any indication of bone marrow deficiency?
Creatinin usually increases in late stage diabetic nephropathy. Does the patient have proteinuria?
Finally, the question remains whether there is an indication for treatment. Probably not yet.
For men, anemia is typically defined as hemoglobin level of less than 13.5 gram/100 ml and in women as hemoglobin of less than 12.0 gram/100 ml. Many persons here are slightly anemic, and I was once the same.
Anemia is "common in seniors, especially those who have a decreased appetite. Studies have found that 13 percent of seniors older than 65 have a vitamin B12 deficiency, and about 5 percent of seniors have a folate deficiency. Vegetarians also have an increased risk of acquiring vitamin-deficiency anemia because meat is a main source of vitamin B12". (Hope this helps, but do see your doctor.)
http://www.everydayhealth.com/anemia/vitamin-deficiency-anemia.aspx
Does the patient have a chronic inflammatory syndrome, even discreet?
(sedimentation rate, electrophoresis ...).
Normal ferritin may correspond to an iron deficiency masked by this inflammation that will raise ferritin.
It is also important to know the corpuscular volume and mean corpuscular hemoglobin concentration and the reticulocyte count.
The patient's hemoglobin is slightly reduced and that is really worrying if you see in him a drop compared to previous values. Then seek occult blood loss
Thanx for the question that needs a book to be answered.
However at age 65, DM or no DM general causes of low Hb need be thought off. However, one must not forget the commonest cause in this age and DM range of patients. The commonest easy to diagnose cause is chronic blood loss, and within that the commonest is association with aspirin use for preventing CVD complications. In the western world, it is GI malignancy as a cause of such lowering of Hb, either chronically or sudden lowering due to fresh bleeding episode. Finally it is lowering of erythropoietin due to CRD/CKD.
Routine blood tests including iron studies and ferritin, renal function tests, CRP, LFT, esp CEA, intestinal cancer markers, occult blood (feces 3 consecutive), urine for RBCs/blood, TFT for hypothyroidism (a cause for low Hb) ...are all important besides all the routine tests for DM and its complications.
If one can't find anything, we still need to do GI endoscopy, very especially colonoscopy.
I am sure you would find the answer this way.
Happy searching
Suresh
Besides the above comment:
Medications?
Aassociated co-morbidities besides DM?
HgB is fine, I wouldn't worry about it unless there is a trend.
Yes, Sergio
For medicines, commonest is still chronic use of Aspirin as mentioned (prevention of CVD complications, AF, etc.). Certainly, general universal causes of Hb lowering need be ruled out if nothing gives a causal lowering of Hb.
Thanx Sergie, World stats still talk about the commonest cause of death as CVD and then Intestinal cancers (Developed World).
Suresh
And, Dear Ali
Please try to remember:
This much Hb should never be treated unless you are treating the cause, for which you should have found the cause. If the case is as you have mentioned, there has to be either nothing, in which case one must keep following the Hb and related common (iron studies) tests to see any changes over a period of time provided you have ruled out intestinal malignancy with all tests and GI endoscopy. The cause (if any) would be found out this way, if there is any needing appropriate management.
Regards
Suresh
Dear Colleagues
Thanks from all for your excellent explanations.There is no inflammatroy singns in this patient. only Hb and transferrin saturation is lower than normal values.As i mentioned ferritin level is in higher value normal level.No asprin is taken up.Metformin,glyclside and pitoz are taking by this patien.
Thanks all
Professor Ali
kindly tell the findings of general blood picture the most important information to classify anemia
Dear Narsingh
- The biochemistry results of this diabete patients show that Transferrin saturation is 17 percent,serum irom 68ug/dl ferritin 188ng/ml,vitamim B12 630 pg/ml Hb 12g/dl MCV 84 and MCH 28 MCHC 34 RBC is alittle low 4.21
- Many thanks
- Prof. Moshtaghie
Do have information from patient's past measurements?
If you have already exhausted all the common possibilities, including loss of blood through gastric ulcers, infections, other diseases and such, historical numbers may be useful. If the patient always ran a little low, it is possible that he may have inherited a mutated version of hemoglobin. Electrophoresis of hemoglobin will give you a fairly good idea, if that is the case... just a thought from a non-clinician.
I Know diabetic patients who take metformin, they suffering from anemia after 3 months of taking metformin , in my view this medication prevents absorption of many nutrients from the gut.
Yes Fatima
Metformin can contribute and so can hypothyroidism and many other factors, it is well documented.
Suresh
And, dear Ali
Please let us know the findings as they come in this case. Could you please tell me if you have done CRP, CEA and lower GI endoscopy (colonoscopy) and what these results are.
Cheers
Suresh
Anemia is relatively common in patients with diabetes mellitus, and low hemoglobin concentration contributes to many clinical aspects of diabetes mellitus or its progression. Low hemoglobin concentration in patients with diabetes mellitus is associated with a more rapid decline in glomerular filtration rate than that of other kidney diseases.For more please read at following link
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3443718/
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