Anemia

In this condition factsheet:

• The Facts
• Causes
• Symptoms and Complications
• Making the Diagnosis
• Treatment and Prevention

The Facts

Anemia is a condition where the number of healthy red blood cells (RBCs) in the blood is lower than normal. RBCs transport oxygen throughout the body, so a shortage of these cells can be serious.

Iron-deficiency anemia is the most common type of anemia. It can affect children and adults of all ages – especially people who are menstruating. It's estimated that at least 1 out of every 10 people who menstruate in North America does not have enough iron in their blood. It can also seriously affect those who do not menstruate when it is caused by colon polyps, colon cancer, or other gastrointestinal (GI) malignancies (cancers). Iron-deficiency anemia is often one of the first warning signals that a person may have a GI malignancy.

Sickle cell anemia is another well-known type of anemia. This condition affects millions of people worldwide. It is a hereditary disease, passed on to children by parents with the altered genetic material. People most commonly affected include those of African, Middle Eastern, Mediterranean, or Indian descent. Every year, about 1 in 10 babies of African descent are born with a genetic potential to pass sickle cell anemia on to their children. It's estimated that 1 out of 300 babies of African descent will have the disease.

Aplastic anemia is a form of anemia where the bone marrow stops producing all types of blood cells. This type of anemia is very serious, but fortunately rare. It affects 2 to 12 out of every 1 million people each year. Aplastic anemia occurs in both adults and children.

Anemia of chronic disease is the second most common form of anemia worldwide. It is a mild form of anemia that occurs with people who have diseases that last more than 1 to 2 months. Such diseases include tuberculosis, HIV, cancer, kidney disease, rheumatologic disorders, and liver disease.

Pernicious anemia is a form of anemia more common in elderly people and is caused by either a lack of dietary intake or poor absorption of vitamin B12 or folic acid from their diet. It is also a common condition seen in alcoholics.

Causes

Anemia is not an actual disease – it's a condition that's caused by some other problem. Even mild anemia should be assessed by your doctor to determine the underlying cause. There are three basic ways you can develop anemia:

Blood loss

The most common cause of anemia in North America is blood loss. Many people who menstruate are borderline anemic, usually because their diets lack the proper nutrients to replace their monthly blood loss from menstrual flow. Another frequent cause is gastrointestinal (GI) bleeding due to illnesses like ulcerative colitis, diverticulitis, and colon cancer. Use of certain medications such as acetylsalicylic acid* (ASA) and nonsteroidal anti-inflammatory drugs (NSAIDs) may also cause GI bleeding.

Other conditions that can cause bleeding include:

• gastric ulcers
• hemophilia
• hemorrhoids
• hookworms

Low production of healthy RBCs

The body needs iron to make hemoglobin, a protein on RBCs that carries oxygen from the lungs to the rest of the body. Hemoglobin also gives blood its red colour. In addition to lack of iron, there can be a lack of vitamin B12 and folic acid in the diet as well. These deficiencies are less common in North America, but they still occur. People with increased iron requirements include infants, pregnant people, and teenagers going through a growth spurt.

Slow bleeding can also cause iron-deficiency anemia. Even healthy people lose a small amount of blood in their stool. A slightly larger amount can easily go unnoticed and yet be enough to cause anemia.

The cause of anemia of chronic disease is not completely understood. It is related to a decreased production of RBCs.
Individual RBCs only last about 4 months and must be replaced by new ones, which are made in the bone marrow. Aplastic anemia is caused when the marrow is destroyed or so badly damaged that it can't produce enough RBCs. Some medications and radiation therapy can kill bone marrow, but the most common cause is an autoimmune reaction. This occurs when cells that normally protect you against disease attack your own tissue instead. In 50% of cases the cause of the autoimmune reaction is unknown.

Other conditions that can destroy bone marrow and cause aplastic anemia include viral hepatitis and severe rheumatoid arthritis. Fanconi anemia is a rare inherited aplastic condition in which the bone marrow is deficient. Anemia is common for people who have severe kidney disease. This is because healthy kidneys make a hormone called erythropoietin, a natural hormone that causes the bone marrow to produce more RBCs as they are needed by the body. Diseased kidneys cannot produce enough of this hormone to keep the body supplied with RBCs, leading to anemia.

Rapid destruction of RBCs

Healthy bone marrow can only produce so many RBCs a month. If the body is destroying cells faster than they are made, anemia will result. Old, "worn out" RBCs are mostly broken down in the spleen, which is the organ that filters the blood, checks it for infection, and removes undesirable substances. Some conditions can cause the spleen to grow larger. A variety of conditions may cause hypersplenism (enlarged spleen), including liver disease, malaria, lupus, or tuberculosis. An oversized spleen can trap and destroy even healthy RBCs, causing anemia

Sickle cell anemia and thalassemia are inherited diseases in which the RBCs are deformed. Sickle cell anemia is widespread among people of African descent, while thalassemia tends to run in families of Mediterranean descent. Sickle cell anemia is a genetic disease that occurs when individuals receive a copy of the sickle cell gene from both parents, resulting in misshapen or crescent-shaped RBCs. The spleen recognizes them as abnormal, and it grows to cope with the extra workload of destroying them. This destruction of RBCs causes anemia. Interestingly, the gene that causes sickle cell disease also gives people resistance to, or protection from, a parasite that causes malaria.

Anemia can also be caused by a combination of factors. Anemia is very common in people with cancer. In fact, about half of people with cancer develop anemia. It can have a variety of different causes, including chemotherapy or radiation therapy that damages the bone marrow where RBCs are produced, tumours in the bone marrow, blood loss, poor nutrition, or a combination of these reasons.

In people with severe kidney disease, anemia is caused by a combination of decreased production of RBCs, decreased RBC lifespan, and blood loss related to dialysis.

Symptoms and Complications

The symptoms of anemia vary, depending on the degree of RBC loss or shortage.

Menstrual bleeding or iron deficiency tends to cause mild chronic anemia with symptoms of fatigue, pallor (pale skin colour), shortness of breath, and weakness. Those with iron deficiency may experience a craving to eat ice, clay, dirt, or other substances. This is known as pica. Treating the iron deficiency will resolve pica.

If anemia is due to major blood loss, such as in cases of severe GI bleeding caused by ulcers, you may feel dizzy and very weak, especially if you stand up suddenly.
Severe anemia can cause tissues and organs to be completely starved of blood and oxygen. When this happens, cells rapidly die in a process called ischemia.

In sickle cell anemia, RBCs, which are normally disc-shaped, become sickle-shaped. This abnormal shape of the cells causes them to get lodged in small blood vessels, blocking normal blood flow. People with this disease may get serious ischemia in their feet, sometimes requiring amputation, or in other organs, causing pain. People with sickle cell anemia are at a high risk of stroke, since the sickle-shaped cells can easily bunch together, forming masses (clots) that block blood flow in the brain's blood vessels.

For those with cancer, the most common symptoms of anemia are usually fatigue and shortness of breath. This makes it difficult to keep up usual energy levels and activities, and can have very negative effects on daily life.

Making the Diagnosis

Your doctor will ask for a blood sample that will be sent to the laboratory for a hemoglobin level. This measures the number of grams of hemoglobin per litre of your blood. Your blood will also be checked for levels of white blood cells, platelets, and various other blood components. The laboratory will also look at the size and shape of your RBCs.

The different levels, and how the blood cells look, can tell the doctor a lot about what's causing the anemia. For instance, low red and white cells suggest a condition involving the bone marrow or spleen. The doctor will then test for other conditions, depending on the results of your initial blood test.

Treatment and Prevention

The treatment for anemia depends on the underlying illness causing it. Severe bleeding is usually treated with blood transfusions. You may also need regular transfusions of blood if you have a serious chronic type of anemia (e.g., Fanconi anemia or sickle cell anemia).

There has been a great improvement in lifespan for people with sickle cell anemia. In the past, those with the disease often did not survive to adulthood. The expected life span has now surpassed 50 years of age. The disease is managed by general health maintenance, vaccinations, folate supplementation, and the medication hydroxyurea. Currently, the only cure is a hematopoietic stem cell transplant (a procedure which replaces the abnormal bone marrow). This procedure has many risks, and it is generally used only for those with advanced complications of the disease.

Iron supplements are used to treat iron-deficiency anemia. Infants who have this problem tend to be bottle-fed. A baby is able to absorb more iron from breast milk than from cow's milk. You may want to take iron supplements for yourself when breast-feeding your child. Iron supplements will also help in cases of mild anemia that's due to GI or menstrual bleeding. It may take 3 to 6 weeks of taking iron supplements to replenish the iron your body needs.

Vitamin B12, vitamin C, and folic acid are all crucial to RBC production; therefore, a deficiency in any one of these vitamins puts you at risk for anemia. Good sources of vitamin B12 include beef and fish. Vegetables don't contain this vitamin, so if you don't eat meat, fish, or dairy products, you'll need to take vitamin B12 supplements. Sources of folic acid include spinach, green peas, oranges, and cantaloupe. Iron from vegetables is not as well absorbed by the body as iron from meat sources, so you may also need to take iron supplements. For people with pernicious anemia, vitamin B12 injections are given into a muscle. These injections are given regularly until the cause can be corrected.

When anemia is caused by decreased production of RBCs, such as in cancer or severe kidney disease, medications such as epoetin alfa and darbepoetin alfa can be used. These medications mimic the action of erythropoietin, the natural hormone that causes the bone marrow to produce more RBCs.

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*All medications have both common (generic) and brand names. The brand name is what a specific manufacturer calls the product (e.g., Tylenol®). The common name is the medical name for the medication (e.g., acetaminophen). A medication may have many brand names, but only one common name. This article lists medications by their common names. For information on a given medication, check our Drug Information database. For more information on brand names, speak with your doctor or pharmacist.

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