Anemia and Blood Malignancies

Anemia and Blood Malignancies

Overview of Anemia

  • Anemia is not considered normal as one ages.

  • Possible causes include chronic illnesses and malignancies.

  • Symptoms are dependent on the severity of anemia, impacting the oxygen-carrying capacity of the blood.

Causes of Anemia

  • Anemia can be caused by:
      - Blood loss
      - Inadequate production of red blood cells (RBCs)
      - Increased destruction of RBCs
      - Vitamin deficiency

  • Categorized by:
      - Microcytic anemia: Mean Corpuscular Volume (MCV) < 80   - Macrocytic anemia: MCV > 100
      - Normocytic anemia: MCV between 80 and 100

  • Classified by:
      - Cause or cell size
      - Shape and substance of RBCs

Classifications of Anemia

e according to MCV

Macrocytic Anemia (MCV > 100)

  • Nutritional deficits (Vitamin B12 and folic acid)
      - Intrinsic factor deficiency, hypothyroidism, alcoholism, liver disease, drugs inhibiting DNA replication (e.g., methotrexate, zidovudine)

Normocytic Anemia (80 < MCV < 100)

  • Causes:
      - Acute blood loss
      - Chronic diseases
      - Bone marrow failure
      - Hemolysis

Microcytic Anemia (MCV < 80)

  • Hemoglobin synthesis defects (e.g., iron deficiency anemia, chronic diseases, thalassemia)

  • Globin synthesis defects (e.g., sideroblastic anemia)

Testing for Anemia

  • Tests include:
      - Complete Blood Count (CBC)
        - Red blood cell (RBC) count
        - MCV: Mean Corpuscular Volume
      - Iron studies include:
        - Serum Ferritin: total iron (FE) stores in the body (bone marrow)
        - Serum FE: total FE in the blood
        - Transferrin saturation: racextSerumFEimes100extTotalIronBindingCapacity(TIBC)rac{ ext{Serum FE} imes 100}{ ext{Total Iron Binding Capacity (TIBC)}}
        - TIBC: measures the protein that binds FE for transport and storage
      - Bone marrow aspiration if leukemia is suspected

Iron Deficiency Anemia

  • Characteristics:
      - MCV < 80, small and pale RBCs
      - Most common type of anemia
      - Depleted iron stores necessary for hemoglobin (HGB) function

  • Causes include:
      - Acute or chronic blood loss
      - Inadequate nutritional intake

  • Initial assessments should consider:
      - Gastrointestinal (GI) sources (occult blood, GI workup)

Symptoms of Iron Deficiency Anemia

  • Gradual onset; typically when Hgb drops to 7-8 g/dL, patients seek medical attention.

  • Early nonspecific symptoms:
      - Fatigue, weakness, shortness of breath
      - Pale appearance (earlobes, palms, conjunctiva)

  • Severe symptoms may include:
      - Brittle concave fingernails
      - Soreness and redness of the tongue
      - Dry and cracked corners of the mouth

  • Further progression may lead to:
      - Gastritis
      - Neuromuscular changes
      - Irritability and headaches
      - Numbness and tingling in the feet and hands
      - Vasomotor disturbances
      - In elderly individuals: mental confusion, memory loss, disorientation

Treatment of Iron Deficiency Anemia

  • Important not to treat anemia without understanding the underlying cause.

  • Condition often reversible with 1-2 weeks of treatment.

  • Ferrous sulfate dosage:
      - Generally prescribed at 325 mg for 6-12 months post-bleeding cessation

  • Patient education on ferrous sulfate:
      - Vitamin C enhances absorption (requires acidic environment for tablet breakdown)
      - Taken on an empty stomach if tolerated, otherwise with food
      - Patients may experience dark green to black stool

Normocytic Anemia

  • Types include:
      - Anemia of chronic disease (hypoproliferative)
      - Hemolytic anemia
      - Aplastic anemia

  • Characteristics include normal-sized cells with decreased production and survival of RBCs and either premature or rapid destruction.

Anemia of Chronic Disease

  • Causes include:
      - Inflammation, Infection, Tissue injury
      - Results in:
        - Low iron levels
        - Low bone marrow production
        - Normal or increased ferritin levels
        - Decreased TIBC

  • Contributing factors:
      - Malnutrition (deficiency of folic acid and Vitamin C) impacts RBC production
      - Chronic infections/inflammation decrease erythropoietin (EPO) production and RBC survival
      - Cancers may reduce nutrition and bone marrow suppression
      - Renal insufficiency decreases erythropoiesis and RBC survival
      - Chronic liver diseases can lead to toxic effects on bone marrow, impacting iron stores and binding capacity

Hemolytic Anemia

  • Can occur at any age but is more prevalent in aging populations.

  • Involves hemolysis or premature destruction of RBCs.

  • Associations include autoimmune antibodies, Hodgkin's disease, non-Hodgkin's lymphoma, traumatic injuries, heart valves, burns, exposure to toxic chemicals, drugs, and sickle cell anemia.

Medications Linked to Hemolytic Anemia

  • Ibuprofen

  • L-Dopa

  • Penicillin (PCN)

  • Cephalosporins

  • Tetracyclines

  • Acetaminophen

  • ASA

  • Erythromycin (PCE)

  • Hydralazine

  • Hydrochlorothiazide (HCTZ)

  • Insulin

  • Noteworthy: Hemolysis ceases upon withdrawal of the implicated drug.

  • Increased folic acid intake is necessary for enhanced RBC production.

Aplastic Anemia

  • This rare disorder is more common in younger populations.

  • Associated with a high overall mortality rate (> 50%).

  • Characterized by suppression of the bone marrow and decreased RBCs with a low reticulocyte count.

  • Causes can include unknown factors, radiation, or chemical substances.

  • Bone marrow transplants for patients over 65 are often ineffective.

Factors Affecting Iron Absorption

Inhibitors of Iron Absorption

  • Coffee, tea, milk, cereals, high dietary fiber, carbonated beverages

  • Supplements containing calcium, zinc, manganese, copper

  • Medications such as antacids, H2 blockers, and proton pump inhibitors (PPIs)

Facilitators of Iron Absorption

  • Vitamin C

  • Acidic foods

Macrocytic Anemias

  • Key types include pernicious anemia (Vitamin B12 deficiency) and folate deficiency.

  • Defined as having a mean cell volume (MCV) greater than 100 with abnormally large and thickened red blood cells due to defective DNA synthesis.

Macrocytic Anemia: Vitamin B12 Deficiency

  • Vitamin B12 (pernicious anemia) required intrinsic factor located in the stomach.

  • Causes of deficiency include:
      - Gastrectomy, small bowel disease, H. pylori infection, prolonged use of antacids, strict vegetarian diet
      - Heavy alcohol consumption
      - Autoimmune disorders affecting the endocrine system.

  • Treatment typically involves B12 injections.

  • Neurologic deficits often do not reverse; ongoing treatment necessary due to the condition being incurable.

Signs and Symptoms of B12 Deficiency

  • Symptoms may develop slowly over a 20-30 year period.

  • Early signs:
      - Infections, mood swings, GI, cardiac, and kidney issues

  • As Hgb drops to 7-8 g/dL, classical signs of anemia emerge:
      - Weakness, fatigue, paresthesia of feet and fingers, weight loss, sore mouth, beefy red tongue, difficulty walking, abdominal pain

Macrocytic Anemia: Folate Deficiency

  • Causes include:
      - Malabsorption syndromes, poor nutrition, alcoholism, malignancies

  • Folate is essential for RBC and DNA synthesis.

  • Human nutrition dependencies increase risk of deficiency, particularly among alcoholics and malnourished individuals on restrictive diets.

Symptoms of Folate Deficiency

  • Present with:
      - Scales and fissures in the mouth
      - Stomatitis
      - Painful ulceration of the buccal mucosa and tongue
      - Dysphagia
      - Flatulence and watery diarrhea

Treatment for Folate Deficiency

  • Treatment options include oral and parenteral folic acid.

  • Caution against excessive folic acid supplementation, which may mask B12 deficiency and result in dark yellow urine.

Blood Malignancies

  • Definition: Hematologic malignancies occur with the over-production of immature lymphoid and myeloid cells leading to bone marrow failure.

  • Classification is based on:
      1. Cell of origin
      2. Degree of differentiation

Types of Leukemia

  • Acute Lymphocytic Leukemia (ALL) - Not covered in this test

  • Chronic Lymphocytic Leukemia (CLL)

  • Acute Myelogenous Leukemia (AML)

  • Chronic Myelogenous Leukemia (CML)

Acute Myelogenous Leukemia (AML)

  • Characterized by the presence of immature myeloblasts in the bone marrow.

  • Rarely occurs before age 40, with a peak incidence at age 67.

  • Symptoms may include:
      - Fever and infection due to neutropenia
      - Fatigue and weakness due to anemia
      - Bleeding tendencies due to thrombocytopenia (petechiae and bruising)
      - Painful enlarged liver or spleen (engorgement)
      - Bone pain due to marrow expansion

Diagnosis and Treatment of AML

  • Diagnosis involves CBC showing decreased erythrocytes and platelets; leukocytes may be normal, high or low.

  • Bone marrow aspiration will display excessive immature blast cells.

  • Treatment focuses on inducing remission via aggressive interventions (e.g., cytarabine for younger patients).

  • Older patients may use hydroxyurea to increase quality of life.

  • Bone marrow transplants (BMT) are increasingly common.

Complications of Treatment

  • Tumor lysis syndrome (review Cancer Lecture):
      - Cell lysis leads to flooding of intracellular contents in the body.

  • Possible complications include electrolyte imbalances, renal calculi, and renal failure.

  • Prevention strategies include pre-hydration and monitoring for imbalances.

Chronic Leukemia

  • Chronic leukemias progress more slowly and often have a longer life expectancy, dependent on the stage.

  • Cells are often better differentiated, compromising 25-40% of all leukemia cases.

  • The exact cause is unknown but may involve a link to the Epstein-Barr virus and familial predispositions.

Chronic Lymphocytic Leukemia (CLL)

  • Typically occurs in individuals over age 72.

  • Characterized by malignant transformation of B cells, resulting in the proliferation of small abnormal lymphocytes in various sites (bone marrow, peripheral blood, body tissues).

Symptoms of CLL

  • Present with systemic symptoms:
      - B symptoms: fever, night sweats, unintentional weight loss, infections
      - Initial onset: weakness, fatigue, painful lymphadenopathy, anemia, and thrombocytopenia
      - Enlarged spleen and elevated WBC counts (20,000 - 100,000)

Diagnosis and Treatment of CLL

  • Diagnosis through bone marrow biopsy.

  • Treatment starts only after symptoms develop or become severe.

  • Although not curable, treatment focuses on inducing periods of remission through combination therapies, radiation, and nutritional support as the disease progresses.

Chronic Myelogenous Leukemia (CML)

  • Characterized by the presence of the Philadelphia chromosome in 95% of patients.

  • Defined by the overproduction of abnormal myeloid and blast cells, resulting in uncontrolled proliferation of granulocytes that may cause bone marrow and organ enlargement.

  • Age significantly increases risk, and life expectancy in chronic stages can exceed 5 years.

Symptoms of CML

  • Symptoms may be asymptomatic until leukocytosis is noted.

  • Chronic symptoms include:
      - Fatigue, weakness, anorexia, and weight loss
      - Prominent splenomegaly
      - Respiratory distress from high leukocyte counts; lymphadenopathy typically absent.

Treatment and Management of CML

  • Goals include controlling WBC proliferation and inducing remission.

  • Chemotherapy may suppress early stages; medications may include hydroxyurea, busulfan, and imatinib (Gleevec).

  • Aggressive treatment is necessary in blast phases, and prognosis in these cases is typically poor (2-4 months).

  • Bone marrow transplants may be viable if the disease is caught early and the patient is under 50 years old and in good health; leukophoresis can be employed for leukocytes exceeding 300,000, which can be life-threatening.

Nursing Care for Patients with Leukemia

  • Key considerations include monitoring for:
      - Bleeding (via CBC and assessment)
      - Infection (WBC and assessment)
      - Pain levels

  • Nurses also assist with end-of-life discussions and support.

Lymphomas

  • Lymphomas are neoplastic tumors affecting lymphoid tissue, classified into:
      - Hodgkin's lymphoma
      - Non-Hodgkin's lymphoma

Hodgkin’s Lymphoma

  • Typically peaks in individuals in their 20s and over the age of 50; more common in immunosuppressed patients.

  • Possible links include exposure to Agent Orange and the Epstein-Barr virus (EBV).

  • Characteristics include:
      - Propagation from one lymph node group to another
      - Development of systemic symptoms
      - Presence of Reed-Sternberg cells (malignant lymph cells).

Symptoms of Hodgkin’s Lymphoma

  • Often starts with enlarged cervical nodes, progressing to axillary and inguinal nodes.

  • Symptoms may include:
      - Enlarged, painless lymph nodes
      - Asymptomatic mediastinal masses visible on chest x-ray
      - Systemic symptoms: fever, night sweats, weight loss, fatigue, pruritus, early mild anemia that can worsen, indicating a poor prognosis if accompanied by weight loss.

  • Laboratory findings include increased sedimentation rates, leukocytosis, eosinophilia, and in advanced stages, leukopenia.

Diagnosis of Hodgkin’s Lymphoma

  • Diagnosis can be delayed as symptoms may remain painless for years.

  • Diagnostic procedures include lymph node biopsy, PET scans, CT scans, and chest x-rays.

Treatment of Hodgkin’s Lymphoma

  • Treatment depends on staging:
      - Early stages: Radiotherapy (80% cure rate)
      - Late stages: Combination chemotherapy and radiotherapy, with remission rates of 80% but high toxicity rate potential.

Non-Hodgkin’s Lymphoma

  • Incidence has doubled since 1970, may relate to immune deficiencies (5th most common type of cancer).

  • Progresses from a single node to systemic involvement including bones, CNS, and GI tract, replacing lymphoid tissues, causing infection and immune deficiencies.

  • Prognosis is often poorer than Hodgkin’s lymphoma.

  • Associated causes include impaired immune systems, prior cancer treatment, EBV/HIV, and chemical exposures.

Diagnosis and Treatment of Non-Hodgkin’s Lymphoma

  • Diagnomed with lymph node biopsy and PET scans, staged based on nodular or diffuse cytology.

  • Treatment efficacy is stage-dependent, including radiotherapy or chemotherapy initiated upon symptom development.

  • Bone marrow transplants can be considered for patients under the age of 60.

Multiple Myeloma

  • Prognosis: 5-year survival rate for newly diagnosed patients is approximately 33%.

Presentation of Multiple Myeloma

  • Infiltration of bone marrow aggregates into tumor masses within the skeletal system.

  • Most common presentation includes bone pain and related lesions due to destructive bone issues.

  • Associated with hypercalcemia leading to renal failure, and anemia due to impaired erythropoiesis.

Symptoms of Multiple Myeloma

  • Presenting symptoms may include:
      - Pathological fractures, particularly in vertebrae, ribs, pelvis, femur, clavicle, and scapula
      - 10% may experience spinal cord compression
      - Increased susceptibility to infections due to humoral response suppression (e.g., pneumonia, pyelonephritis)
      - Additional symptoms: fever, weight loss, night sweats, and bone breakdown that leads to renal failure.

Diagnosis of Multiple Myeloma

  • Diagnosis involves detecting a sudden spike in protein levels in blood/urine, end-organ damage classified by:
      - C: Elevated calcium levels
      - R: Renal insufficiency
      - A: Anemia
      - B: Bone lesions

  • Confirmed through bone marrow aspiration, X-rays, and nuclear bone scans.

Treatment of Multiple Myeloma

  • Prognosis remains poor with no available cure.

  • Treatments include chemotherapy for intermediate to high grades, radiation, and plasmapheresis when blood viscosity is high.

Nursing Interventions for Multiple Myeloma

  • Nursing care may be challenging due to comorbid conditions in the older adult population.

  • Regular 6-8 months of aggressive treatment may be needed, focusing on:
      - Pain control
      - Assistance with activities of daily living (ADLs)
      - Nutritional support
      - Symptom control.