IN
ANAEMIA
by
In partial fulfillment
of the requirements for the degree of
Doctor of Medicine
in
General Medicine
2005
Anaemia is a bonafide and genuine research work carried out by me under the
guidance of Dr. Chikkalingaiah M.D., Professor of Medicine, Kempegowda Institute of
Medical Sciences, Bangalore and Dr. Mahadevappa PhD, Professor of Biochemistry,
Kempegowda Institute of Medical Sciences, Bangalore.
Date :
Place : Bangalore
II
Date :
Place : Bangalore
III
Date :
Place : Bangalore
IV
Anaemia is a bonafide research work done by Dr. Zayed Abdulla under the guidance
of Dr. Chikkalingaiah M.D., Professor of Medicine, Kempegowda Institute of Medical
Sciences, Bangalore.
Principal,
Department of Medicine,
Kempegowda Institute of
Kempegowda Institute of
Date :
Place : Bangalore
Place: Bangalore
COPYRIGHT
Declaration by the Candidate
I hereby declare that the Rajiv Gandhi University of Health Sciences, Karnataka shall
have the rights to preserve, use and disseminate this dissertation / thesis in print or
electronic format for academic / research purpose.
Date :
Place : Bangalore
VI
ACKNOWLEDGEMENT
I would like to take this opportunity to express my deep sense of gratitude towards
Dr. Chikkalingaiah. M.D., Professor of Medicine, Kempegowda Institute of Medical
Sciences, Bangalore, for his invaluable guidance, constant encouragement, and expert
suggestions, in spite of his busy schedule, which was most crucial in overcoming various
difficulties.
I would not have been able to complete this undertaking without Dr. K.L.
Mahadevappa PhD, Professor of Biochemistry, whose guidance and suggestions were of
utmost help.
I am deeply indebted to Dr. V. Channaraya. M.D., DNB, F.I.C.C., Professor and HoD,
Department of Medicine for his invaluable suggestions and insight.
I am extremely grateful to Dr. M.V Poornachandra. M.D., Professor and former
HoD, Department of Medicine for his supervision and keen interest in academic
activities.
I am grateful to Dr. Gowri Shankar M.D., Dr. H.V. Nataraju M.D., Dr. R. Manjunath
M.D., and Dr. Shivalingaiah M.D., Professors of Medicine, for their guidance and timely
help.
I am indebted to Dr. N.C. Srinivas Prabhu M.D., Dr. K.P. Balraj M.D., Dr. G.N.
Nagesh M.D. and Dr. R. Srinivas M.D., Associate Professors of Medicine for their
encouragement, valuable suggestions and healthy criticisms.
VII
I sincerely thank Dr. R. Vedavathi M.D. and Dr. K.C. Channappa M.D., Assistant
Professors of Medicine for their guidance and help given to me in this study. I am
grateful to Dr. H.D. Ramachandra Prabhu M.D. and Dr. C. Jagadish M.D., Lecturers in
Medicine, and Dr. H. Rajeev M.D., Dr. N. Venkataswamy M.D. and Dr. Ramakrishna M.D.,
Senior Residents in Medicine for their moral support during my study period.
My thanks are due to the staff of the Departments of Pathology and Biochemistry
for helping me carry out the required investigations. I am indebted to Mr. K.P Suresh,
Statistician, National Institute of Animal Nutrition and Physiology, Bangalore for his
generous help. I am grateful to all my friends and colleagues for their untiring support. I
thank all others who have assisted me in some form or the other in the preparation of this
work. Last but not the least, I am grateful to all those patients who were the subjects for
this study, without whose co-operation this work would not have been possible.
Date :
Place : Bangalore
VIII
2,3-biphosphoglycerate
AIDS
Apo
Apolipoprotein
BMI
CETP
CHD
CoA
Coenzyme A
DM
Dimorphic anaemia
DNA
FADH
FBS
FH
Familial hypercholesterolemia
G6PD
GIT
Gastrointestinal tract
GM-CSF
GPE
Hb
Haemoglobin
HCL
HDL
HMG CoA
3-hydroxy-3-methylglutaryl coenzyme A
HMP
Hexose monophosphate
IX
HSPG
IDL
JVP
KIMS
LCAT
LDL
LP(a)
Lipoprotein a
LPL
Lipoprotein lipase
LRP
MCH
MCHC
MCP-1
MCV
MH
MPD
Myeloproliferative disorder
MTP
NADH
NCEP
NH
NN
PPBS
RBC
RBS
SAP
SD
Standard deviation
SGOT
SGPT
T3
3,5,3-Triiodothyronine
T4
Thyroxine
TSH
VLDL
XI
ABSTRACT
Background & Objectives: Anaemia is reported to be associated with lowering in all
lipid subfractions. This study was conducted to study the clinical features of anaemia,
effect of anaemia on lipid profile, and effect of severity and type of anaemia on lipid
profile
Methods: The data for this study was collected from patients who presented to KIMS
hospital from June to June 2005. 100 anaemic cases and 100 non anaemic age and sex
matched controls underwent clinical assessment and relevant investigations, including
lipid profile estimation.
Results: Cases younger than 50 years were found to be more likely to have severe
anaemia. Fatigue and pallor were the most common clinical features. Clinical features
were more common among cases with severe anaemia. The mean total cholesterol (132.2
29.0 vs 173.4 20.3, P<0.01), HDL (31.0 6.7 vs 38.8 7.1, P<0.01), LDL (79.7
25.0 vs 110.1 16.6, P<0.01), VLDL (21.6 6.3 vs 24.5 6.2, P<0.01) and triglyceride
(108.1 31.3 vs 122.5 30.6, P<0.01) levels, along with TC/HDL (4.4 0.8 vs 4.6
0.7, P<0.05) and LDL/HDL (2.6 0.7 vs 2.9 0.6, P<0.01) ratios were significantly
decreased in cases compared to controls. There was a larger reduction in mean total
cholesterol, HDL, LDL, VLDL and triglyceride levels, along with TC/HDL and
LDL/HDL ratios with increased severity of anaemia (P<0.05). Type of anaemia did not
have a significant effect on the lipid levels (P>0.05).
XII
Interpretation
&
Conclusion:
Anaemia
is
associated
with
significant
Keywords
Anaemia; Cholesterol; Hypocholesterolemia; Lipid Profile
XIII
TABLE OF CONTENTS
Page No.
1. Introduction
01
2. Objectives
02
3. Review of Literature
03
a) Historical review
03
05
c) Anaemia
33
54
4. Methodology
65
5. Results
70
6. Discussion
96
7. Conclusion
103
8. Summary
105
9. Bibliography
106
10. Annexures
115
I. Proforma
115
122
XIV
LIST OF TABLES
Sl.No
Table
Page No
70
72
73
76
77
81
82
84
86
10
88
11
89
12
91
13
93
14
95
XV
LIST OF FIGURES
Sl.No
Figure
Page No
71
71
72
Symptoms
74
79
Pulse rate
84
Blood pressure
85
85
86
10
Systemic examination
87
11
91
12
93
XVI
1. Introduction1
Current data indicate that serum lipid levels are significantly correlated with the risk
of atherosclerosis, which causes coronary artery disease, cerebrovascular disease and
peripheral vascular disease, important causes for mortality and morbidity worldwide2.
The exact mechanism by which anaemia causes a fall in serum lipids is not known.
The simplest explanation is a dilution effect (the increased volume of serum in anaemia
carrying the same total load of cholesterol). Other possibilities are increased utilization of
cholesterol by proliferating cells, decreased endogenous synthesis of cholesterol by the
liver due to decreased liver oxygenation, elevated levels of granulocyte-macrophage
colony stimulating factor and enhanced receptor mediated removal of LDL in the bone
marrow. Correction of anaemia is associated with a rise in serum lipids.
2. Objectives
The following were the objectives of the study.
1) To study the demographic characteristics and clinical features in cases with
anaemia.
2) To study the lipid profile in anaemia as compared with that in age and sex
matched controls.
3) To correlate the extent of changes, if any, in the various lipid sub fractions with
the severity of anaemia.
4) To correlate the changes in the lipid profile to different types of anaemia.
3. Review of Literature
a) Historical Review3
Babington in 18th century showed that fat gives a milky appearance to plasma. In
1780, Hawson described two forms of lipemia, one the alimentary and the other
spontaneous and pathological. Fischer revived the subject in 1903 and listed the
conditions in which milky appearance of blood was observed.
Neisser, Derlin and later Janel reported increased lipid levels in diabetic patients.
Klemperer and Umber showed conclusively that other lipids like phospholipids, sterols
and steroids are frequently increased in diabetic patients.
Havel, Eder and Bragdon introduced the procedure of preparative ultracentrifugation to separate and isolate lipoproteins. Ultracentrifugation is needed to
separate all lipoproteins except chylomicrons.
Frerickson, Levy and Lees used paper electrophoresis in conjunction with heparin
or manganese precipitation and preparative ultacentrifugation to establish a system for
classifying plasma lipoprotein disorders based on which family or families of lipoproteins
were elevated.
Rifkind and Gale4,5 in 1967 showed that anaemia was associated with
hypocholesterolemia, and that the decrease in serum cholesterol was not due to a specific
lowering of any of the serum lipoprotein families, and that hypocholesterolemia was
caused by a proportional reduction in all the major lipoprotein families.
In 1970, a study was conducted in 4,070 women6, which found a mean difference in
cholesterol between women with haemoglobin levels above and below 10.5 g/dL of 30
mg/dL. Treatment of anaemia led to rise in serum cholesterol levels. A study by
Westermann7 in 1975 examined the relationship between hypocholesterolemia and
various types of anaemia. This study showed that plasma cholesterol level is closely
related to haematocrit levels, regardless of the type of anaemia.
Classes of Lipids8
Fatty Acids
Fatty acids vary in length and in the number and position of double bonds.
Saturated fatty acids lack double bonds, monounsaturated fatty acids have one double
bond, and polyunsaturated fatty acids have two or more. They are a major source of
energy and can be esterified to form complex lipids.
Cholesterol
Cholesterol is a four-ring hydrocarbon with an eight-carbon side chain. It is a
major component of cell membranes and a precursor of steroid hormones and bile acids.
Complex Lipids
Triglycerides (Triacylglycerol)
Triglycerides consist of three fatty acid molecules esterified to a glycerol
molecule. Diglycerides contain two fatty acids, and monoglycerides have only one fatty
acid per glycerol molecule. Triglycerides serve to store fatty acids.
Phospholipids
Phospholipids have fatty acids esterified at two of the three hydroxyl groups of
glycerol. The third hydroxyl group is esterified to phosphate (phosphatidic acid).
Phosphatidic acid is esterified to the hydroxyl group of a hydrophilic molecule, such as
choline, serine, or ethanolamine.
Cholesterol Metabolism9
Cholesterol Biosynthesis
Cholesterol is either absorbed from the diet or synthesized in the body. It is
produced in many organs including liver, skin, adrenals, gonads, brain and intestine.
Cholesterol 7-Hydroxylase
This enzyme converts free cholesterol to 7-hydroxycholesterol. This is the ratelimiting step in bile acid synthesis, and it is under feedback regulation by bile acids.
The stomach secretes gastric lipase, which is the main preduodenal lipase. It
initiates lipid digestion by hydrolyzing triacylglycerols. The released hydrophilic shortand medium-chain fatty acids are absorbed via the stomach wall and enter the portal vein.
Absorption
The water-soluble products of lipid digestion are absorbed directly into the portal
vein. These include glycerol and fatty acids with chain length of less than 10-12 carbon
atoms.
The other products of lipid digestion are 2-monoacylglycerols, long chain fatty
acids, cholesterol, phospholipids and lysophospholipids. They diffuse into micelles and
liposomes consisting of bile salts, phosphatidylcholine, and cholesterol, furnished by the
bile. Micelles are spherical particles with a hydrophilic exterior and hydrophobic core.
They allow the products of lipid digestion to be transported through the aqueous
environment of the intestinal lumen to the brush border of the mucosal cells, where they
are absorbed into the intestinal cells.
Within the intestinal mucosal cells, fatty acids are re-esterified to form
triglycerides and along with cholesterol, phospholipids, apoproteins C, E and A, are
incorporated into chylomicrons. Cholesterol and lysophospholipids are also re-esterified
with fatty acids to form cholesterol esters and phospholipids. Chylomicrons are formed in
golgi bodies.
fatty acids to triglycerides for storage. Triglyceride synthesis is catalyzed by the enzyme
acyl-CoA: diacylglycerol Acyltransferase (DGAT).
prolactin,
thyrotropin, vasoactive
intestinal
polypeptide,
vasopressin,
glucocorticoids and growth hormone promote lipolysis and release of fatty acids into the
bloodstream. These hormones activate hormone-sensitive lipase. Insulin, gastric
inhibitory polypeptide, oxytocin, prostaglandin and somatomedins act to inhibit
hormone-sensitive lipase and lipolysis.
Fatty acids formed by lipolysis are released into the bloodstream from adipocytes.
They bind to albumin and circulate in the plasma. Glycerol is taken up by the liver and
kidney for triglyceride synthesis or for gluconeogenesis. Fatty acids are taken up by
either the liver or muscle.
10
If the free fatty acid flux to the liver is massively increased, as in uncontrolled
diabetes mellitus or prolonged fasting, it exceeds the livers ability to synthesize VLDL,
resulting in accumulation of acetyl-CoA, FADH and NADH in the mitochondria. This
leads to ketogenesis.
Apolipoproteins12
Apolipoproteins are the protein moiety of lipoproteins. They act as structural
components of lipoproteins, activate and inactivate enzymes involved in lipoprotein
metabolism, and bind lipoproteins to cell surface receptors. Each lipoprotein has a
particular, nearly constant apolipoprotein composition.
Apolipoprotein B13
In human plasma, apo-B occurs in two forms, apo-B100 and apo-B48. Apo B-100
is synthesized in the liver and serves as a structural protein of VLDL, IDL and LDL.
Each of these particles contains one molecule of apo B-100. Apo B-100 serves as a ligand
for the LDL receptor. Apo-B48 is a structural constituent of chylomicrons. It is
synthesized in the intestine. It cannot bind to the LDL receptor.
11
Apolipoprotein E
Apolipoprotein E is a constituent of chylomicrons, chylomicron remnants, VLDL,
IDL and HDL1. It serves as the ligand for LDL receptor and chylomicron remnant (apoE) receptor. It is synthesized in various tissues, including the liver and macrophages.
Apo-E functions in two aspects of lipid transport. The first involves chylomicron and
VLDL transport. The second aspect involves the redistribution of lipids among cells
within a tissue or organ.
Apolipoprotein AI
Apo-AI is synthesized by the human intestine and liver and is a constituent of
chylomicrons and HDL. In addition to its role as a structural protein in HDL, apo-AI
activates lecithin: cholesterol acyltransferase, which esterifies free cholesterol on HDL
particles.
Apolipoprotein AII
Apo-AII is synthesized primarily in the liver. It is found together with apo-AI on
a subfraction of HDL referred to as LpAI/AII particles. Apo-AII may play a role in the
activation of hepatic lipase and the inhibition of LCAT.
C Apolipoproteins
They are apo-CI, apo-CII and apo-CIII. They are synthesized primarily by the
liver and readily exchange among various lipoproteins. HDL serves as a reservoir for the
C apolipoproteins, which can then be transferred to triglyceride-rich lipoproteins. Apo-CI
12
modulates remnant binding to receptors and activates LCAT. Apo-CII acts as a cofactor
for lipoprotein lipase. Apo-CIII modulates remnant binding to receptors.
Lipoprotein Receptors12
Low Density Lipoprotein Receptor
The LDL receptor functions in the uptake of apo-B100 and apo-E containing
lipoproteins, including LDL, chylomicron remnants, VLDL, VLDL remnants, IDL, and
HDL1. The expression of LDL receptors on the cell surface is regulated by the
intracellular cholesterol concentration.
Apolipoprotein E Receptor 2
The apo-E receptor 2 is expressed primarily in the brain and to a lesser extent in
the placenta. It plays a role in lipoprotein metabolism in the central nervous system. It
also plays a role in normal brain development by transducing extracellular signals.
13
Scavenger Receptors
The scavenger receptors are a large family of receptors with specificities for a
broad range of unrelated ligands and involvement in a spectrum of physiologic processes,
including atherosclerosis, host defense and central nervous system disorders. These
receptors are characterized by their ability to interact with chemically modified LDL but
not with native LDL. LDL particles that are modified by acetylation, acetoacetylation, or
malondialdehyde are taken up by these receptors present on the macrophages, resulting in
marked cholesterol accumulation. Currently, there are five subclasses (A to E) of the
scavenger receptor family.
Hepatic Lipase
Hepatic lipase is synthesized by hepatocytes and is present on liver endothelial
cells and on HSPG in the space of Disse. It is transported from liver to the capillary
endothelium of the adrenals, ovaries and testes. It hydrolyzes triglycerides and excess
phospholipids in the final processing of chylomicron remnants. It binds heparan sulfate
14
and facilitates the interaction of remnant lipoproteins with LRP, thereby delivering these
lipoproteins to the receptor for internalization by hepatocytes. It completes the processing
of IDL to LDL. It converts HDL2 to HDL3 by removing triglyceride and phospholipids
from HDL2.
Plasma Lipoproteins12
Chylomicrons
Chylomicrons are the largest of the plasma lipoproteins. They are composed of
98% to 99% lipid and 1% to 2% protein. Chylomicrons are present in postprandial
plasma and contain several apolipoproteins, including apo-B48, apo-AI, apo-AIV, apo-E
and the C apolipoproteins. The distinctive apolipoprotein is apo-B48, which is
synthesized only in the intestine.
15
LPL catalyzes the release of fatty acids from chylomicron triglycerides and
converts them into chylomicron remnants. These are cleared rapidly from the plasma by
the liver. The actual uptake of these particles by hepatocytes involves the LDL and LRP
receptors.
VLDL triglycerides are hydrolyzed by the actions of LPL and hepatic lipase. The
products of VLDL catabolism are IDLs. IDLs retain apo-B100 and apo-E. IDLs are
processed to LDLs by LPL with final processing by hepatic lipase. Approximately half of
16
VLDLs are converted to LDLs, and the remainder is cleared directly by the liver as
VLDL remnants and IDLs.
17
LDL serves as a source of cholesterol for many cells. Cholesterol taken up by the
liver has several fates: membrane biosynthesis, VLDL biosynthesis, excretion in bile and
conversion to bile acids. Cholesterol is used as a precursor for steroid hormone
production in the adrenals, ovaries, and testes. In other tissues, cholesterol is used in
membrane biosynthesis for cell repair and proliferation.
HDLs originate from three sources. First, the liver secretes an apo-AIphospholipid disc called precursor HDL. Second, the intestine directly synthesizes a
small apo-AI containing HDL particle. Third, HDLs are derived from surface material
that comes from chylomicrons and VLDLs during lipolysis.
The precursor HDL particles are excellent acceptors of free cholesterol, which
gets esterified by LCAT and moves away from the surface of the particle, forming a
cholesterol ester-rich core (HDL2). As HDL2 accepts more cholesterol, it enlarges and
gets converted to HDL3. HDL2 can also acquire apo-E to form HDL1.
18
19
fissuring. The deposited lipids are derived from plasma lipoproteins, and elevated plasma
cholesterol is a major risk factor. Other important risk factors include low HDL levels,
cigarette smoking, hypertension, male sex, diabetes mellitus, obesity, stress, and lack of
exercise.
CholesterolDietHeart Hypothesis
The cholesterol-diet-heart hypothesis states (1) that increased plasma cholesterol
concentrations increase the risk of CHD, (2) that diets high in fat (especially saturated
fat) and cholesterol result in increased levels of plasma cholesterol, and (3) that lowering
plasma cholesterol levels results in a decreased risk of CHD.
Epidemiological evidence
Several epidemiological studies have demonstrated a relation between plasma
cholesterol level and the risk of CHD14. The Multiple Risk Factor Intervention Trial15
showed that there is increased risk at levels above 200 mg/dl. The Seven Countries Study
also demonstrated a relation between an increased incidence of CHD and high plasma
cholesterol levels16.
Epidemiological studies have linked the intake of high levels of dietary fats,
especially saturated fats, with increased plasma cholesterol levels. Diets high in
cholesterol also tend to increase plasma cholesterol levels17. Therefore, restriction of
saturated fat and cholesterol is the cornerstone of dietary therapy to reduce elevated blood
cholesterol levels18.
20
Atherogenic Lipoproteins
In addition to LDL, almost all classes of lipoproteins that contain apo-B (VLDL,
-VLDL, IDL, Lp(a), and oxidized LDL) are atherogenic. Lp(a) contains apo(a), which
may contribute to atherogenesis by mechanisms related to thrombosis. The atherogenic
potential of LDL differs among the various LDL size and density subclasses, with the
small, dense LDL subclass being the most atherogenic.
21
Atherogenesis20,21
The key early event in atherosclerosis is the retention of atherogenic, cholesterolrich lipoproteins in the arterial sub endothelium. Oxidation22 and other modifications of
the retained lipoproteins initiate a series of responses that lead to the transformation of
healthy arteries into diseased, lesioned arteries.
22
The first grossly visible atherosclerotic lesion is the fatty streak. Macrophages
accumulate in the sub endothelial space and are converted to foam cells. Fatty streaks
come and go, depending on the local stimuli present in the artery wall.
The fatty streak matures into a proliferative or fibrous plaque, which is raised and
begins to extend into the lumen of the vessel. The foam cells begin to necrose because of
the cytotoxicity of the accumulated lipid, leading to extracellular lipid deposition,
accompanied by collagen synthesis and smooth muscle cell migration and proliferation.
Hyperlipidemia23
Hyperlipidemia has been defined from population distributions as the upper 5% to
10% of values (i.e., the 90th to 95th percentile). Guidelines from the 2001 National
Cholesterol Education Program18 (NCEP) suggest that plasma cholesterol levels less than
23
200 mg/dl are desirable, that those between 200 and 240 mg/dl are borderline elevated,
and that levels greater than 240 mg/dl are high. Hypolipidemia can be defined as plasma
cholesterol concentrations less than 130 mg/dl.
24
Weight reduction and dietary management can help correct associated metabolic
abnormalities. Drug therapy should be directed at the predominant lipid abnormality.
Affected family members should be identified.
25
The cause is mutations in apo-E that result in defective binding to lipoprotein receptors.
The presence of palmar xanthomas, which are planar xanthomas in the palmar creases, is
virtually pathognomic for this disorder. Tuberous or tuberoeruptive xanthomas are also
common. Premature vascular disease is common.
subjects
have
reduced
LPL
activity
and
mild
to
moderate
hypertriglyceridemia.
Initial treatment consists of a fat-free diet till plasma triglycerides reach a safe
level. Dietary fat restriction needs to be continued life long. Medium-chain triglycerides
can provide a source of fat in the diet. Fat-soluble vitamins should be supplemented.
Drug therapy for primary LPL deficiency is largely ineffective.
26
Familial Hypertriglyceridemia
Familial hypertriglyceridemia is characterized by increased plasma concentrations
of triglyceride-rich VLDLs. Obesity and insulin resistance is common. The genetic defect
is unknown.
27
Polygenic Hypercholesterolemia
Polygenic hypercholesterolemia is diagnosed by excluding other primary genetic
causes, by the absence of tendon xanthomas, and by demonstrating that
hypercholesterolemia is present in no more than 10% of first degree relatives.
Sporadic Hypertriglyceridemia
Sporadic hypertriglyceridemia can be distinguished from familial syndromes by
the absence of hypertriglyceridemia in relatives. The condition is treated with dietary fat
restriction, treatment of secondary conditions that exacerbate hypertriglyceridemia, and
drugs that lower triglyceride levels.
autosomal
dominant
disorder
familial
hypoalphalipoproteinemia
is
manifested by low plasma HDL-C levels and an increased risk for premature CHD. There
are no characterictic physical findings, but there is often a family history of low HDL-C
levels and premature CHD. The genetic and metabolic defects that lead to low plasma
HDL-C levels are unknown.
Apolipoprotein AI mutations
Mutations in the apo-AI gene can decrease HDL formation and result in low
plasma HDL-C levels. Manifestations include a predisposition to premature CHD,
xanthomas, and corneal opacities.
28
Homozygotes should be treated with large doses of vitamin E orally (100 to 300
mg/kg/day) in order to prevent neurologic complications.
Abetalipoproteinemia
This is a rare autosomal recessive disorder caused by a deficiency in MTP, which
results in a virtual absence of apo-B containing lipoproteins in the plasma. Features are
malabsorption of fat and fat-soluble vitamins from the intestine, which leads to
neurologic disease secondary to vitamin E deficiency. It is treated with large oral doses of
vitamin E.
29
Mellitus
exerts
profound
effects
on
lipid
metabolism.
In type 1 diabetes, insulin deficiency and poor glycemic control are associated
with increases in the plasma levels of triglycerides and apo-B-containing lipoproteins
because of effects on plasma lipid metabolism in peripheral tissues and the liver.
In type 2 diabetes the metabolic defect is related to insulin resistance and relative
insulin deficiency. The most common lipid abnormality in type 2 diabetes is a moderate
hyperlipidemia characterized by an increase in VLDL, accompanied by various degrees
of chylomicronemia. Plasma triglyceride and cholesterol levels are elevated, HDL-C
concentration may be low and IDLs are also increased. The hyperlipidemia in type 2
diabetes is accompanied by an increase in small dense LDLs which are particularly
atherogenic.
30
Hypothyroidism
The classical manifestation of hypothyroidism is elevation of LDL-C, but it can
also cause elevation of plasma triglycerides. Levels of HDL-C are unchanged or slightly
lower. Hyperlipidemia with hypothyroidism responds dramatically to thyroid hormone
replacement. In patients with ischemic heart disease, rapid thyroxine replacement may
exacerbate the condition.
Estrogen Therapy
Estrogen therapy increases plasma triglyceride levels by increasing synthesis of
VLDL, occasionally causing marked hypertriglyceridemia, resulting in pancreatitis.
Estrogen therapy also enhances LDL clearance and reduces LDL-C levels. Estrogens also
increase HDL-C levels.
Alcohol Consumption
The regular consumption of large quantities of alcohol leads to increased
triglyceride synthesis, fatty liver, and enhanced VLDL synthesis, occasionally causing
massive hypertriglyceridemia and pancreatitis. Alcohol consumption is also associated
with higher plasma levels of HDL-C.
Nephrotic Syndrome
Total cholesterol, VLDL, LDL-C, triglycerides and plasma apo-B are all
elevated in patients with nephrotic syndrome. Plasma Lp(a) levels can also be elevated.
Hyperlipidemia is secondary to increased production of LDL and VLDL.
31
Protease inhibitors
Combination therapy with protease inhibitors for human immunodeficiency virus
infection is associated with hyperlipidemia, lipodystrophy and insulin resistance.
Other drugs
Other therapeutic agents causing hyperlipidemia include glucocorticoids, thiazide
diuretics and -adrenergic blockers. Exogenous androgens can reduce HDL-C levels.
32
c) Anaemia25
Definition26,27
Anaemia may be defined as a reduction below normal limits of the total red cell
mass. This value is not easily measurable and anaemia has been defined as a reduction
below normal of the haematocrit or a reduction in the haemoglobin concentration of the
blood. The World Health Organization28 recommends that anaemia should be considered
to exist in adults whose haemoglobin levels are lower than 13 g/dl (males) or 12 g/dl
(females).
Prevalence
Anaemia is a major world health problem. It is estimated to affect at least 20% of
the world population28. It is most common in women between the ages of 15 and 44
years, and the prevalence increases again in the elderly. The majority of cases are due to
iron deficiency. In India, 30% adult males, 45% adult females, 80% pregnant females and
60% children have iron deficiency29.
Adaptation to Anaemia30,31
Anaemia reduces the oxygen carrying capacity of blood and thereby reduces the
arteriovenous oxygen difference. This is compensated by three mechanisms:
33
Clinical Manifestations26
Anaemia due to acute blood loss is characterized by shock, with collapse, dyspnoea,
tachycardia, feeble pulse, hypotension, and marked peripheral vasoconstriction32,33.
Cardio
respiratory
features34,35
include
exertional
dyspnoea,
tachycardia,
and loss of libido. Previously undiagnosed coronary artery narrowing maybe unmasked
by the onset of angina.
Classification of Anaemias26
Anaemias maybe classified according to underlying mechanism or RBC
morphology.
35
Acquired
a) Membrane defect: paroxysmal nocturnal haemoglobinuria
2) Extrinsic abnormalities
Antibody mediated
a) Isohaemagglutinins: transfusion reactions, erythroblastosis fetalis
b) Autoantibodies: idiopathic, drug-associated, systemic lupus
erythematosus, malignant neoplasms, mycoplasmal infection
Mechanical trauma to RBCs
a) Microangiopathic haemolytic anaemias: thrombotic thrombocytopenic
purpura, disseminated intravascular coagulation
b) Cardiac traumatic haemolytic anaemia
Infections: malaria
Chemical injury: lead poisoning
Sequestration in mononuclear phagocyte system: hypersplenism
III. Impaired RBC production
1) Disturbed proliferation and differentiation of stem cells: aplastic anaemia,
pure red cell aplasia, anaemia of renal failure, anaemia of endocrine disorders
2) Disturbance of proliferation and maturation of erythroblasts
Defective DNA synthesis: vitamin B12 and folate deficiency (megaloblastic
anaemia)
Defective haemoglobin synthesis
36
38
Patients who present with severe congestive cardiac failure due to profound
anaemia require transfusing up to a safe level, i.e., a haemoglobin level of 6 to 8 g/dl.
This is done by transfusing two to three units of packed cells along with frusemide.
Patient should be monitored for fluid overload during the transfusion. In patients with
very severe failure, packed cells maybe transfused through one arm while removing an
equal amount of blood from the other.
39
Haemolytic Anaemias39
The haemolytic anaemias are characterized by the following features:
40
Hereditary Spherocytosis40
Hereditary spherocytosis is an autosomal dominant disorder of the RBC membrane,
with defective spectrin, ankyrin or protein 3, the proteins providing the scaffolding for
RBC membranes. This results in loss of membrane with decreased surface to volume
ratio and a spherical shape with decreased deformability, causing trapping and
haemolysis of RBCs in the spleen.
The characteristic clinical features are anaemia, splenomegaly and jaundice. The
severity of the disease is variable. Aplastic crisis is due to temporary suppression of RBC
production, usually by parvovirus infection, manifested by sudden worsening of anaemia
and disappearance of reticulocytes from the blood. Gallstones may be found. Diagnosis is
based on family history, haematological findings and demonstrating the raised osmotic
fragility of RBCs. Most patients are benefited by splenectomy and folate
supplementation.
Hereditary Elliptocytosis40
Hereditary elliptocytosis is a genetically heterogeneous disorder characterized by
elliptical cells and haemolysis. Both autosomal dominant and autosomal recessive forms
have been identified. It is usually due to point mutations or deletions in the -spectrin or
-spectrin genes. It is characterized by anaemia, splenomegaly and reticulocytosis. The
peripheral smear contains elliptocytes and pencil cells. Management is similar to that of
hereditary spherocytosis.
41
Patients present with episodic haemoglobinuria in the morning urine since mild
respiratory acidosis of sleep leads to enhanced complement activity. Anaemia,
thrombosis of hepatic, portal or cerebral veins and iron deficiency are other features.
PNH may progress either to aplastic anaemia, myelodysplasia or acute myelogenous
leukemia.
42
Mechanical Trauma
Haemolytic anaemias may be associated with cardiac valve prosthesis and with
narrowing and obstruction of the vasculature. Microangiopathic haemolytic anaemia is
chaacterised by mechanical damage to RBCs as they squeeze through abnormally
narrowed vessels. It is commonly due to disseminated intravascular coagulation,
43
Hypersplenism
In cases of splenomegaly, increased destruction of formed elements of the blood
takes place due to pooling of blood in the spleen. Patients with cytopenia sufficient to
cause symptoms benefit from splenomegaly.
Haemoglobinopathies42
Haemoglobinopathies are a heterogeneous group of conditions which may be either
inherited or acquired. They may be subdivided into 5 major classes
I.
Structural haemoglobinopathies
a. Abnormal polymerization HbS, haemoglobin sickling
b. Altered O2 affinity familial polycythemia, cyanosis, pseudoanaemia
c. Readily oxidized haemoglobin
II.
Thalassemias
a. Thalassemias
b. Thalassemias
c. , , Thalassemias
III.
44
c. Hb Lepore
IV.
V.
Acquired haemoglobinopathies
a. Methaemoglobin
b. Sulfhaemoglobin
c. Carboxyhaemoglobin
d. HbH in erythroleukemia
e. Elevated HbF in states of erythroid stress and bone marrow dysplasia
Peripheral smear reveals sickled cells, reticulocytosis, nucleated RBCs, HowellJolly bodies and target cells. The diagnosis is confirmed by haemoglobin electrophoresis.
Treatment options include folate supplementation, blood transfusions, pneumococcal
45
Thalassemias44
The thalassemias are hereditary disorders characterized by reduction in the
synthesis of globin chains, causing reduced haemoglobin synthesis and a microcytic,
hypochromic anaemia. Alpha thalassemia is due to gene deletion causing reduced globin chain synthesis. Beta thalassemias are usually caused by point mutations resulting
in reduced or absent -globin chain synthesis, resulting in a relative increase in HbA2 and
HbF. The excess alpha chains precipitate and damage RBC membranes, leading to
haemolysis.
Normal adults have four copies of the -globin gene. People with three functioning
-globin genes are silent carriers. When two -globin genes are present, the patient has
alpha thalassemia trait, with mild microcytic anaemia. When only one -globin gene is
present, the patient has Haemoglobin H disease, with chronic haemolytic anaemia, pallor
and splenomegaly. Patients may require blood transfusions during periods of haemolytic
exacerbation caused by infection or other stresses. When all four -globin genes are
deleted, the affected fetus is stillborn as a result of hydrops fetalis.
Patients homozygous for beta thalassemia have thalassemia major. Severe anaemia
develops at the age of 6 months, when haemoglobin synthesis switches from HbF to
HbA. It is characterized by growth failure, bony deformities, hepatosplenomegaly and
jaundice. Transfusion therapy can cause haemosiderosis with heart failure, cirrhosis and
46
Acquired
a) Idiopathic Primary stem cell defect, Immune mediated
b) Chemical agents
47
Aplastic anaemia may present at any age, onset is usually gradual. Symptoms are
due to decrease in all the three formed elements of blood. Bone marrow examination
reveals hypocellular marrow. Withdrawal of toxic drugs may lead to complete recovery.
Idiopathic form has poor prognosis. Therapy consists of antithymocyte globulin with
cyclosporine or allogenic bone marrow transplantation.
48
Megaloblastic Anaemias49
Megaloblastic anaemias are a diverse group of entities, having in common impaired
DNA synthesis and distinctive morphologic changes in the blood and bone marrow. The
erythroid precursors and erythrocytes are abnormally large, due to defective cell
maturation and division.
49
Causes
I. Vitamin B12 deficiency
a) Decreased intake Inadequate diet, vegetarianism
b) Impaired absorption
i. Intrinsic factor deficiency Pernicious anaemia, gastrectomy
ii. Malabsorption states
iii. Diffuse intestinal disease lymphoma, systemic sclerosis
iv. Ileal resection, ileitis
v. Fish tapeworm infection
vi. Bacterial overgrowth in blind loops
c) Increased requirement pregnancy, hyperthyroidism, disseminated cancer
II. Folic acid deficiency
a) Decreased intake alcoholism, infancy
b) Impaired absorption malabsorption states, intrinsic intestinal disease,
anticonvulsants, oral contraceptives
c) Increased loss haemodialysis
d) Increased requirement pregnancy, infancy, disseminated cancer, increased
haematopoesis
e) Impaired use folic acid antagonists
III. Other causes
a) Metabolic inhibitors mercaptopurines, fluorouracil, cytosine
b) Unexplained disorders pyridoxine and thiamine responsive megaloblastic
anaemia, acute erythroleukemia
50
Pernicious anaemia50
Pernicious anaemia is due to immunologically mediated destruction of gastric
mucosa with diffuse chronic gastritis. Myelin degeneration of the dorsal and lateral tracts
of the spinal cord is seen.
51
Causes
I.
Deficient diet
II.
Decreased absorption
Haemoglobinuria
Iron deficiency develops in stages. The first is depletion of iron stores with low
serum ferritin levels and elevated serum total iron-binding capacity. In early stages, MCV
remains normal. Subsequently MCV falls and blood smear shows hypochromic
microcytic cells. With further progression, anisocytosis and poikilocytosis develop. In
severe iron deficiency, severely hypochromic cells, target cells, hypochromic pencilshaped cells and nucleated red blood cells are seen.
52
weeks with full return to baseline after 2 months. Iron therapy should continue for 3-6
months after restoration of normal hematological values.
Sideroblastic Anaemia52
Sideroblastic anaemias are a heterogenous group of conditions in which
haemoglobin synthesis is reduced because of failure to incorporate heme into
protoporphyrin to form haemoglobin. Iron accumulates, particularly in the mitochondria.
Sideroblastic anaemias are usually acquired. It may be a transitional stage of
myelodysplasia, other causes are alcoholism and lead poisoning. Hereditary forms are
also seen. Investigations reveal moderate anaemia, normal MCV, dimorphic picture in the
peripheral smear, with marked erythroid hyperplasia and ringed sideroblasts in the
peripheral smear. Iron stores are increased. Treatment is with pyridoxine, blood
transfusions and iron chelation.
53
In 1970, a study was conducted in 4,070 women6, of whom 124 were found to have
haemoglobin levels below 10.5 g/dl. In the women with haemoglobin levels 10.5g/dl,
the serum cholesterol levels were 241 2.5 mg/dl; in the women with haemoglobin
<10.5g/dl, the serum cholesterol levels were 211 3.9 mg/dl. The mean difference in
cholesterol between women with haemoglobin levels above and below 10.5g/dl was
found to be significant (30 mg/dl).
54
The women with haemoglobin levels < 10.5g/dl were admitted to a clinical trial in
which they received 0, 30 or 90 mg iron daily for 12 weeks. Anaemia treatment led to a
rise in serum cholesterol. The simplest explanation for the observed relation between
haemoglobin and cholesterol levels was a dilution effect (the increased volume of serum
in anaemia carrying the same total load of cholesterol). This hypothesis was attractive,
particularly as the difference in packed-cell volume between the groups in the study was
proportionally similar to the difference in cholesterol levels.
The study showed that the plasma cholesterol level is closely related to haematocrit
levels, both initially and throughout the course of the anaemias associated with
hypocholesterolemia. This association was maintained regardless of the cause of changes
in haematocrit levels. The authors concluded that low haematocrit, not the type of
anaemia, is the cause of low cholesterol levels. The authors pointed out that the
55
56
hypoplastic and aplastic anaemia. There was no difference in cholesterol levels between
hemolytic anaemias with very active erythropoiesis and anaemias with low erythropoietic
activity. Cholesterol levels increased after treatment in patients with hemolytic or aplastic
anaemia.
The same conclusion was drawn by El-Hazmi58 et al, who investigated 400 normal
individuals, 100 patients with sickle cell disease (HbSS), 220 sickle heterozygotes
(HbAS), and 100 patients with G6PD deficiency. Sickle cell patients had significantly
lower cholesterol compared to the normal individuals, whereas no significant differences
were found between the HbAS and G6PD deficient groups. Analysis showed a
statistically significant positive correlation between plasma cholesterol and total
hemoglobin in each group, particularly the HbSS group. The results suggested that
increased utilization or decreased production might account for the lower cholesterol
levels in severely anaemic patients. In support of this finding are the results of a study
conducted by Akinyanju and Akinyanju59 who showed that subjects with sickle cell
disease had lower total cholesterol levels than normal subjects.
57
A study conducted by Choi61 et al showed that lipid levels in patients with iron
deficiency anaemia were directly related to the level of iron. The authors assigned
patients with blood haemoglobin of < 8.0g/dl to the severely anaemic group and
compared their serum lipid levels with those of patients with haemoglobin levels >
14.0g/dl. The total cholesterol level in the severely anaemic group was significantly
lower than that found in the other group (148 16 mg/dl versus 170 17mg/dl). The
triglyceride level was twofold higher in subjects with haemoglobin > 14.0g/dl than in
subjects with haemoglobin < 8.0g/dl. The serum lipid concentrations in the females with
severe anaemia were significantly higher after iron supplementation. Overall, the study
showed that blood haemoglobin levels correlated significantly with serum cholesterol
concentrations.
The results of the above study were contradicted by a study done by Tanzer62 et al,
which aimed to determine the effect of iron deficiency on lipid metabolism. The study
group consisted of 70 children suffering from iron deficiency anaemia and 20 healthy
58
children. The results of the study indicated higher serum total triglyceride, total
cholesterol, and VLDL levels in iron deficient patients than in healthy controls.
59
lipids, hypocholesterolemia was thought to be due to the large spleen size and not to
increased LDL receptor activity.
60
Pathophysiology
In general, five possibilities exist for hypocholesterolemia: decreased absorption,
decreased synthesis, increased excretion, shift of plasma cholesterol into other tissues, or
some combination of these factors. Dietary intake and altered absorption are unlikely
causes of hypocholesterolemia in the previously mentioned studies.
The Gilbert and Ginsberg66 study showed that LDL removal from plasma via fluid
endocytosis was the only reason for reduced LDL cholesterol levels in patients with
MPD. The high receptor-mediated uptake and degradation of LDL by leukemic cells was
the cause of hypocholesterolemia in patients with acute leukemia. On the other hand,
Juliusson65 et al proved there was no increased LDL receptor activity in hairy cells in
patients with HCL. In the patients with MPD66,68,69, spleen and liver size were found to be
significantly and inversely related to plasma concentrations of total, LDL, and HDL
cholesterol; it was suggested that the mechanism involved macrophages. Deiana67 et al
proposed that the action of the monocyte/macrophage system through the release of
cytokines is one mechanisms of reducing plasma cholesterol levels. Splenectomy results
in increased plasma cholesterol levels and in the elevation of serum cholesterol level in
diseases associated with hypersplenism4,7.
61
patients. Some of the studies relating hypocholesterolemia and anaemia are limited to
those types of anaemia where an increased level of erythropoietin is present. Therefore,
hypocholesterolemia could be considered an indirect result of erythropoietin treatment.
However, Mat71 et al concluded that long-term treatment with recombinant human
erythropoietin does not significantly change lipid blood values in haemodialysis patients.
Another contributing factor may be that the abnormalities in cholesterol levels are
related to the effect of plasma dilution, since in most anaemic states the plasma volume is
increased due to a reduction in the haematocrit6,74. A shortcoming of this theory is that
the rise in cholesterol level that follows treatment of anaemia is the not of the same
relative size as the observed rise in haematocrit. Therefore, a change in serum cholesterol
may not be a true reflection of the absolute change in total body cholesterol.
Other factors must also contribute to changes in the serum cholesterol, since
cholesterol levels do not always return to normal in patients whose anaemia is treated
with transfusion. These factors can include modest liver disease that might change
62
hepatic cholesterol synthesis and absorption7. It is not known how iron supplementation
in patients with iron deficiency anaemia increases cholesterol levels61.
Conclusion
Patients with anaemia may also have relative hypocholesterolemia, which is present
regardless of the cause of anaemia7, and correction of anaemia leads to a rise in serum
cholesterol levels. Serum cholesterol is closely related to the haematocrit level. There is
also a positive relation between cholesterol and haemoglobin75,76. Various investigators
have suggested that the patients with anaemia may have a lower risk of developing
ischemic heart disease compared with subjects with normal haemoglobin levels. This
may be due not only to the lower cholesterol levels seen in patients with anaemia, but
also due to iron induced free radical damage to the heart in patients with adequate iron
reserves. Rifkind and Gale4,5 suggested that anaemia may explain the differences in the
incidence of ischemic heart disease between the sexes, between premenopausal and
postmenopausal women, and between developed and underdeveloped countries.
However, none of these studies provide any data regarding the incidence of coronary
artery disease in patients with anaemia. Prospective cohort studies are needed in which
the development of coronary artery disease over time is compared in patients with
anaemia and controls.
Many studies have shown that serum cholesterol levels are reduced in anaemic
patients. However, few studies have been designed to understand the basis of this
phenomenon. Altered intake of absorption, abnormal synthesis, and altered excretion,
dilution, and redistribution are some of the mechanisms suggested to produce changes in
63
serum cholesterol levels. Further studies that are based on a greater number of cases of
anemia with various etiologies and that include measurements of specific lipoprotein
families (HDL, LDL, VLDL) are needed. To delineate some of the contributing factors
responsible, concurrent measurements of haematocrit and total cholesterol, including the
specific lipoprotein family, are also necessary. Furthermore, the rates of production and
degradation of VLDL and LDL in anaemic patients should be determined, since LDL
receptor activity in patients with anaemia may be inversely correlated with plasma
cholesterol concentration, as is the case in patients with acute leukemia64. Till date, only
the study conducted by Ginsberg and Gilbert has made this determination68,69. The
finding that splenectomy was associated with an increase in cholesterol levels indicates
that more studies are needed to clarify the role of LDL receptor-mediated removal from
plasma by macrophages. Finally, studies must follow-up patients to understand the true
effect of anaemia on cholesterol after a specific treatment.
64
4. Methodology
This is a study which has been carried out in the Department of Medicine,
Kempegowda Institute of Medical Sciences, Bangalore.
Source of Data
The data for this study was collected from patients who presented to Kempegowda
Institute of Medical Sciences, Bangalore, either on inpatient or outpatient basis.
Sample Size
100 cases, 100 controls
Study duration
June 2003 to June 2005
Inclusion Criteria
All proven cases of anaemia. Men: Hb < 13 gm%, Women: Hb < 12 gm%.
Exclusion Criteria
1. Children below 14 years
2. Obesity/Overweight: BMI > 25 kg/m2
3. Malnutrition: BMI < 19 kg/m2 or Serum Total Protein < 6 gm/dl or Serum
Albumin < 3.5/dl
4. Known case of Diabetes Mellitus or RBS > 200mg/dl or FBS > 126 mg/dl or
PPBS > 200 mg/dl
65
Clinical evaluation
A detailed history was obtained from the subjects of the study, with special
emphasis on age, sex and occupation; non specific symptoms of anaemia like fatigability,
dyspnoea, giddiness, palpitations and angina; symptoms suggestive of a specific cause for
anaemia like pica, dysphagia, abdominal pain pain, bony pain, fever, loss of appetite,
weight loss, jaundice, bleeding, malaena, haemoglobinuria, menorrhagia, pregnancy and
post menopausal bleeding. Past history of disorders associated with dyslipidemia or
anaemia was obtained, including diabetes mellitus, hypertension, ischemic heart disease,
cerebrovascular accident, AIDS, recent blood loss and gall stones. Dietary habits and
habits like alcoholism and tobacco smoking was ascertained. History of intake of drugs
affecting lipid levels, such as oral contraceptives, beta blockers, diuretics, steroids and
66
NSAIDs was obtained. Family history of anaemia, jaundice and gallstones was also
obtained.
Each patient was subjected to a detailed general physical examination, with special
emphasis on pallor, koilonychias, icterus, pedal edema, lymphadenopathy, glossitis,
angular stomatitis, petechiae, haemolytic facies, ankle ulcers, perioral pigmentation and
knuckle pigmentation. Pulse, blood pressure, weight, height and body mass index was
measured.
Investigations
Venous blood was drawn for investigations like complete haemogram, random
blood sugar, blood urea, serum creatinine, liver function tests, and thyroid stimulating
hormone levels. A urine sample was obtained for urine analysis, including albumin, sugar
and microscopy. Fasting venous blood sample (> 12 hours) was obtained for estimation
of lipid profile. T3 and T4 levels, fasting and post prandial (two hours after an oral dose of
75gms of glucose) blood sugar levels, and bone marrow aspiration cytology was done in
selected cases based on clinical assessment.
67
Estimation of total cholesterol, HDL and triglycerides was done with the
commercially available Autopak cholesterol kit on Technicon RA-XT system. VLDL
was calculated using the formula, VLDL = Triglyceride/5. LDL cholesterol was
calculated using the Friedewalds equation. LDL = Total cholesterol [(Triglycerides/5)
+ HDL] mg/dl.
Controls
One hundred non anemic age and sex matched subjects were selected and screened
for compliance with the exclusion criteria. Complete haemogram, lipid profile and other
investigations were performed on them.
Statistical Methods80,81
Student t test has been used to test the homogeneity of age between case and
control. Chi-square test has been used to find the homogeneity of sex between case and
control. Student t test has been used to find the significance of Lipid profiles between
68
case and controls. Analysis of Variance has been used to find the significance of mean
lipid profiles when there are more than 2 groups. Mann Whitney U test has been carried
to find the significance between case and control for TC/HDL and LDL/HDL ratio.
Kruskal Wallis test has been used to find significance of TC/HDL and LDL/HDL ratio
when there are more than 2 groups. Effect Size due to Cohen d has been computed to find
the extent of effect of anemia on Lipid profiles.
No effect
Mild Effect
Moderate effect
Large effect
d > 1.20
Statistical software
The statistical software used for the analysis of the data was SPSS 11.0 and Systat
8.0. Microsoft Word and Excel have been used to generate figures and tables.
69
5. Results
Study Design
A case - control study consisting of 100 anaemic cases and 100 normal subjects was
undertaken to study the clinical presentation of anaemic cases and also to investigate the
relationship between anaemia and lipid profile.
Age
The cases and controls were matched for age. Majority of the cases were middle
aged (30-60). The youngest case was 14 years old. The oldest was 75 years old.
Table 1
Age distribution with Haemoglobin levels in cases and controls
Case
Haemoglobin levels (in gm/dl)
Control
Age in years
(n=100)
<6
6-9
>9
Total
(n=23)
(n=40)
(n=37)
(n=100)
3
3
2
8
8
20
(13.0)
(7.5)
(5.40)
6
10
3
21-30
19
19
(26.1)
(25.0)
(8.1)
4
11
7
31-40
22
22
(17.4)
(27.5)
(18.9)
4
6
3
41-50
13
13
(17.4)
(15.0)
(8.1)
2
4
17
51-60
23
23
(8.7)
(10.0)
(45.9)
3
5
3
61-70
11
11
(13.0)
(12.5)
(8.1)
1
1
2
>70
4
4
(4.3)
(2.5)
(5.4)
Samples are age matched (P>0.05). Anaemic cases < 50 years
of age are 2.42 times more likely to have Hb levels < 6 gm/dl
Inference
(p=0.107) and Anaemic cases > 50 years of age are 4.31 times
more likely to have > 9 Hb gm/dl (P<0.01)
Figures in parenthesis are percentages
70
Figure 1
Age distribution in cases and controls
Age distribution (in years)
25
Case
15
Control
10
0
</=20
21-30
31-40
41-50
51-60
61-70
>70
Figure 2
Age and Severity of Anaemia
Percentages
20
15
Hb > 9 gm/dl
10
Hb 6-9 gm/dl
Hb < 6 gm/dl
5
0
< 21 21-30 31-40 41-50 51-60 61-70 >70
Age (in years)
71
Sex
The cases and controls were matched for sex. The cases consisted of 48 males and
52 females. Sex was not associated with haemoglobin levels.
Table 2
Sex distribution between case and controls
Case
Haemoglobin levels(in gm/dl)
Control
(n=100)
<6
6-9
>9
Total
(n=23)
(n=40)
(n=37)
(n=100)
10
19
19
48
48
(43.5)
(47.5)
(51.4)
13
21
18
52
52
(56.5)
(52.5)
(48.6)
Samples are sex matched (P>0.05). Sex is not statistically
associated with haemoglobin levels (P>0.05)
Sex
Male
Female
Inference
Figure 3
Sex distribution in cases and controls
Female
52%
Female
52%
Male
48%
Male
48%
Control
Case
72
Table 3
Distribution of cases according to type and severity of Anaemia
Type of Anaemia
Hb (in
gm/dl)
DM
MH
NH
NN
Others
Total
<6
14
23
6-9
21
15
40
>9
16
10
37
Total
40
25
18
10
100
73
Symptoms
The most common presenting symptom was easy fatigability, which was present in
51 cases. The next common symptoms were dyspnoea (29 cases), palpitations (27 cases)
and giddiness (24 cases). Other symptoms were loss of appetite (9 cases), fever (7 cases),
weight loss (5 cases), angina, dysphagia, jaundice and menorrhagia (3 cases each), bony
pain and bleeding (1 case) each. Not seen in the study group were pica, abdominal pain,
malaena, haemoglobinuria and pregnancy.
Figure 4
Symptoms
60
No of cases
50
A: Fatigue
B: Dyspnoea
C: Giddiness
D: Palpitations
E: Angina
F: Dysphagia
G: Bony pain
H: Fever
I : Loss of appetite
J: Weight loss
K: Jaundice
L: Bleeding
M: Menorrhagia
40
30
20
10
0
A
Symptoms
74
75
Table 4
Symptoms and severity of Anaemia
Presenting
Haemoglobin levels in cases (in gm/dl)
Illness
Total
<6
6-9
>9
(n=100)
(n=23)
(n=40)
(n=37)
23
23
5
Fatigue
51
(100.0)
(57.5)
(13.5)
19
10
Dyspnoea
29
(82.6)
(25.0)
10
11
3
Giddiness
24
(43.5)
(27.5)
(8.1)
14
9
4
Palpitation
27
(60.9)
(22.5)
(10.8)
3
Angina
3
(13.0)
Pica
3
Dysphagia
3
(13.0)
Abd pain
1
Bony pain
1
(2.7)
1
2
4
Fever
7
(4.3)
(5.0)
(10.8)
4
2
3
Loss of appetite
9
(17.4)
(5.0)
(8.1)
4
1
Wt loss
5
(17.4)
(2.5)
2
1
Jaundice
3
(8.7)
(2.5)
1
Bleeding
1
(2.7)
Malaena
Haemoglobinuria
2
1
Menorrhagia
3
(8.7)
(2.5)
Pregnancy
Post menopausal
bleed
Figures in parenthesis are percentages
76
Symptoms
Fatigue
Dyspnoea
Giddiness
Palpitation
Angina
Table 5
Symptoms and type of Anaemia
Types of Anaemia
DM
MH
NH
NN
(n=40)
(n=25)
(n=18)
(n=10)
31
14
1
(77.5)
(56.0)
(5.6)
15
9
1
(37.5)
(36.0)
(5.6)
13
6
2
1
(32.5)
(24.0)
(11.1)
(10.0)
14
8
3
(35.0)
(32.0)
(16.7)
2
1
(5.0)
(4.0)
Others
(n=7)
5
(71.4)
4
(57.1)
2
(28.6)
2
(28.6)
-
Pica
Dysphagia
1
(2.5)
2
(8.0)
Abd pain
Bony pain
1
(2.5)
3
(7.5)
1
(2.5)
1
(2.5)
2
(8.0)
2
(8.0)
3
(12.0)
1
(4.0)
2
(11.1)
2
(11.1)
1
(10.0)
Bleeding
Malaena
Haemoglobinuria
Menorrhagia
2
(5.0)
1
(4.0)
Pregnancy
Post menopausal
bleed
Fever
Loss of appetite
Wt loss
Jaundice
77
1
(14.3)
1
(14.3)
2
(28.6)
1
(14.3)
1
(14.3)
1
(14.3)
Past history
None of the cases was a known case of diabetes mellitus, hypertension, ischaemic
heart disease or AIDS. None of the cases had a past history of cerebrovascular accident,
recent blood loss or gall stones.
Personal history
19 cases were vegetarian. 34.8% (8 cases out of 23) of all cases with haemoglobin
less than 6 gm/ dl were vegetarian, compared to 15.8% (6 cases out of 38) of all cases
with haemoglobin more than 9 gm/ dl. Vegetarians were more likely to have dimorphic
anaemia (55.6%) compared to the other types of anaemia (5.6% to 22.2%). None of the
cases had a history of alcohol use or tobacco smoking.
Drug History
None of the cases had a history of intake of oral contraceptives, beta blockers,
diuretics, steroids or non steroidal anti inflammatory drugs.
Family history
Four cases had a family history of anaemia, out of whom three had microcytic
hypochromic anaemia. Five cases had a family history of jaundice, out of whom four had
dimorphic anaemia.
78
Figure 5
General physical examination
70
60
A: Pallor
B: Koilonychia
C: Icterus
D: Pedal oedema
E: Lymphadenopathy
F: Glossitis
G: Angular stomatitis
H: Petechiae
I : Haemolytic facies
J: Ankle ulcers
K: Perioral pigmentation
L: Knuckle pigmentation
No of cases
50
40
30
20
10
0
A
79
80
Table 6
GPE and severity of Anaemia
Haemoglobin levels in cases (in gm/dl)
GPE
Total
(n=100)
Pallor
67
Koilonychia
11
Icterus
Pedal oedema
Lymphadenopathy
Glossitis
20
Angular stomatitis
Petechiae
<6
(n=23)
23
(100.0)
9
(39.1)
2
(8.7)
6
(26.1)
6-9
(n=40)
36
(90.0)
2
(5.0)
1
(2.5)
>9
(n=37)
8
(21.6)
13
(56.5)
7
(30.4)
1
(2.5)
7
(17.5)
2
(5.0)
Haemolytis facies
Ankle ulcers
5
(21.7)
Peri oral
pigmentation
Knuckle
pigmentation
81
1
(2.5)
2
(5.0)
Table 7
GPE and type of Anaemia
Types of Anaemia
Symptoms
Pallor
Koilonychia
Icterus
Pedal oedema
DM
(n=40)
37
(92.5)
5
(12.5)
1
(2.5)
4
(10.0)
MH
(n=25)
20
(80.0)
6
(24.0)
1
(4.0)
NH
(n=18)
3
(16.7)
NN
(n=10)
Others
(n=7)
7
(100.0)
1
(14.3)
2
(28.6)
12
(30.0)
4
(10.0)
1
(4.0)
8
(32.0)
5
(20.0)
Petechiae
Haemolytis facies
Ankle ulcers
5
(12.5)
Lymphadenopathy
Glossitis
Angular stomatitis
Peri oral
pigmentation
Knuckle
pigmentation
82
1
(14.3)
2
(28.6)
Pulse Rate
The mean pulse rate was 85.4/ minute in cases and 83.7/ minute in controls. The
mean pulse rate was significantly increased (89.3/ minute) in cases with haemoglobin less
than 6 gm/dl. There was no difference in mean pulse rate between the different types of
anaemia except in the others group, in whom in was significantly raised (96.3/ minute).
Blood Pressure
The mean blood pressure was 121.2/ 76.3 mm of Hg in cases and 122.1/ 76.5 mm
of Hg in controls. It was less in cases with haemoglobin less than 6 gm/dl (118.7/ 75.2
mm of Hg), compared to cases with haemoglobin more than 9 gm/dl (122.7/ 77.3 mm of
Hg). There was no significant difference in mean blood pressure in the different types of
anaemia.
83
Table 8
Pulse rate, Blood Pressure and BMI with severity of Anaemia
Case
Haemoglobin levels(in gm/dl)
Control
(n=100)
<6
6-9
>9
Total
(n=23)
(n=40)
(n=37)
(n=100)
Mean pulse
89.3 12.8 83.6 9.8
84.9 7.5
85.4 10.0
83.7 16.9
rate
Mean systolic
118.7 9.7 121.3 8.5 122.7 10.4 121.2 9.6 122.1 15.2
blood pressure
Mean diastolic
75.2 7.9
76.1 7.7
77.3 9.0
76.3 8.2
76.5 8.4
blood pressure
Mean BMI
20.9 1.5
22.0 1.7
21.4 1.6
21.5 1.7
Inference
Figure 6
Pulse rate
Mean ( /minute)
21.6 1.6
90
89
88
87
86
85
84
83
82
81
80
Controls
Cases
Hb < 6
gm/dl
84
Hb 6-9
gm/dl
Hb > 9
gm/dl
Figure 7
Blood Pressure
140
120
mm of Hg
100
Systolic BP
Diastolic BP
80
60
40
20
0
Controls Cases Hb < 6
gm/dl
Hb 6-9 Hb > 9
gm/dl gm/dl
Figure 8
Body Mass Index
23
22.5
kg/ m 2
22
21.5
21
20.5
20
Controls
Cases
Hb < 6
gm/dl
85
Hb 6-9
gm/dl
Hb > 9
gm/dl
Table 9
Pulse rate, Blood Pressure and BMI with type of Anaemia
Types of Anaemia
DM
MH
NH
NN
Others
(n=40)
(n=25)
(n=18)
(n=10)
(n=7)
Mean Pulse rate 85.0 8.5
82.3 12.0
87.0 7.5
84.1 5.2
96.3 14.9
Mean systolic
120.1 9.8 122.3 8.9 118.9 8.3 126 11.7 122.9 9.5
blood pressure
Mean diastolic
75.1 6.7
75.6 10.0
77.2 8.3
79.0 8.8
80.0 8.2
blood pressure
Mean BMI
21.5 1.7
21.4 1.7
21.6 1.8
21.4 1.4
21.8 1.9
Mean pulse rate significantly higher in the others group (P<0.05).
Inference
Mean systolic and diastolic blood pressures are not significantly
different (P>0.05). Mean BMI is not significantly different (P>0.05)
Figure 9
Pulse, Blood pressure & BMI with types of Anaemia
140
120
100
Pulse (per mt)
80
60
40
20
0
DM
MH
NH
NN
Type of Anaemia
86
Others
Systemic examination
The most common findings on systemic examination were venous hum and flow
murmurs (9 cases each). Abdominal examination revealed 8 cases with splenomegaly and
5 cases with hepatomegaly. CNS findings were impairment of vibration sense (4 cases)
and joint position sense (2 cases), suggestive of peripheral neuropathy. Elevated JVP,
cardiomegaly, and basal crepitations were seen in 2 cases each.
Figure 10
Systemic Examination
10
9
A: JVP
B: Venous Hum
C: Cardiomegaly
D: Gallop Rhythm
E: Flow murmers
F: Basal Cepitations
G: Hepatomegaly
H: Splenomegaly
I : Confusion
J: Motor Weakness
K: Abnormal DTRs
L: Vibration Sense
M: Joint Position Sense
N: Romberg's sign
8
No of cases
7
6
5
4
3
2
1
0
A B C D
G H
M N
Systemic examination
between 6 and 9 gm/ dl, who had a flow murmur. Impairment of vibration and joint
position sense were also found only in cases with severe anaemia. Hepatomegaly and
splenomegaly were found in all groups of cases equally.
Table 10
Systemic examination and severity of Anaemia
Haemoglobin levels in cases (in gm/dl)
Systemic
Total
<6
6-9
>9
Examination
(n=100)
(n=23)
(n=40)
(n=37)
CVS
JVP
Venous hum
Cardiomegaly
Gallop rhythm
Flow murmur
RS: Basal
crepts
2
(8.7)
9
(39.1)
2
(8.7)
8
(34.8)
2
(8.7)
1
(2.5)
2
(8.7)
2
(8.7)
1
(2.5)
3
(7.5)
2
(5.4)
3
(8.1)
4
(17.4)
2
(8.7)
-
P/A
Hepatomegaly
Splenomegaly
CNS
Confusion
Power
DTRs
Vibration
Position
Romberg's
88
Others
(n=7)
CVS
JVP
Venous hum
5
(12.5)
1
(4.0)
Cardiomegaly
Flow murmur
6
(15.0)
1
(4.0)
2
(5.0)
2
(5.0)
1
(4.0)
2
(8.0)
1
(5.6)
2
(11.1)
2
(28.6)
3
(42.6)
2
(28.6)
2
(28.6)
2
(28.6)
P/A
Hepatomegaly
Splenomegaly
1
(14.3)
2
(28.6)
CNS
Vibration
Position
3
(7.5)
1
(2.5)
89
1
(14.3)
1
(14.3)
The mean serum HDL levels were significantly lower (P<0.01) in cases (31.0
mg/dl) as compared to controls (38.8 mg/dl). The effect of anaemia on the HDL levels
was large.
The mean serum LDL levels were significantly lower (P<0.01) in cases (79.7
mg/dl) as compared to controls (110.1 mg/dl). The effect of anaemia on the LDL levels
was very large.
The mean serum VLDL levels were significantly lower (P<0.01) in cases (21.6
mg/dl) as compared to controls (24.5 mg/dl). The effect of anaemia on the VLDL levels
was mild.
The mean serum triglyceride levels were significantly lower (P<0.01) in cases
(108.1 mg/dl) as compared to controls (122.5 mg/dl). The effect of anaemia on the
triglyceride levels was mild.
The mean total cholesterol / HDL ratio was significantly lower (P<0.05) in cases
(4.4) as compared to controls (4.6). The effect of anaemia on TC/HDL ratio was mild.
90
The mean LDL / HDL ratio was significantly lower (P<0.01) in cases (2.6) as
compared to controls (2.9). The effect of anaemia on LDL/HDL ratio was mild.
Table 12
Anaemia and Lipid Profile
Lipid Profile
(mean SD)
Cases (n=100)
Controls (n=100)
Significance by
Student t
Total Cholesterol
132.2 29.0
173.4 20.3
P<0.01**
HDL
31.0 6.7
38.8 7.1
P<0.01**
LDL
79.7 25.0
110.1 16.6
P<0.01**
VLDL
21.6 6.3
24.5 6.2
P<0.01**
Triglycerides
108.1 31.3
122.5 30.6
P<0.01**
TC/HDL ratio
4.4 0.8
4.6 0.7
P<0.05*M
LDL/HDL ratio
2.6 0.7
2.9 0.6
P<0.01**M
Figure 11
Anaemia and Lipid profile
Case
250
Control
mg/dl
200
150
100
50
0
TC
HDL
LDL
91
VLDL
TG
Effect size
(d)
1.64
(V.Large)
1.12
(Large)
1.43
(V.Large)
0.46
(Mild)
0.46
(Mild)
0.27
(Mild)
0.45
(Mild)
92
The mean serum LDL/HDL ratio was significantly lower (P<0.01) in cases with Hb
less than 6 gm/dl (2.4), as compared to cases with Hb more than 9 gm/dl (2.8).
Lipid Profile
(mean SD)
Table 13
Severity of Anaemia and Lipid Profile
Hb < 6 gm/dl
Hb 6-9 gm/dl
Hb > 9 gm/dl
(n=23)
(n=40)
(n=37)
P value
(ANOVA)
TC
106.0 21.3
127.5 22.5
153.7 23.6
P<0.01**
HDL
26.3 6.2
30.4 6.4
34.5 5.2
P<0.01**
LDL
61.0 19.3
75.6 21.5
95.8 22.0
P<0.01**
VLDL
18.9 7.4
21.6 5.5
23.3 5.9
P<0.01**
TG
94.4 36.7
108.1 27.9
116.5 28.8
P<0.01**
TC/HDL
4.1 0.7
4.4 0.9
4.5 0.7
P<0.05*K
LDL/HDL
2.4 0.7
2.6 0.7
2.8 0.7
P<0.01**K
Figure 12
Severity of Anaemia and Lipid Profile
Hb < 6 gm/dl
Hb 6-9 gm/dl
Hb > 9 gm/dl
200
180
Units in
160
140
120
100
80
60
40
20
0
TC
HDL
LDL
93
VLDL
TG
94
Table No 14
Type of Anaemia and Lipid Profile
Lipid
Profile
(mean
SD)
TC
(in
mg/dl)
HDL (in
mg/dl)
LDL (in
mg/dl)
VLDL
(in
mg/dl)
TG
(in
mg/dl)
TC/
HDL
LDL/
HDL
Inference
Hb (in
gm/dl)
Type Of Anemia
P value
(ANOVA)
DM
MH
NH
NN
Others
<6
109.419.3
107.623.6
92.325.9
p>0.05
6-9
126.820.9
131.626.2
112.018.3
119.52.1
p>0.05
>9
159.622.5
144.631.2
150.823.6
164.613.0
106.00#
p>0.05
<6
22.66.6
24.63.6
23.87.4
p>0.05
6-9
31.36.1
29.27.2
30.00
30.09.9
p>0.05
>9
37.44.2
31.84.0
33.44.9
37.44.1
23.00#
p>0.05
<6
64.716.0
65.422.5
44.522.4
p>0.05
6-9
75.317.7
79.427.2
57.014.1
18.512.0
p>0.05
>9
19.218. 7
42.632.3
92.023.0
105.412.4
60.00#
p>0.05
<6
17.67.3
17.65.3
25.08.4
p>0.05
6-9
20.25.5
23.15.8
25.04.2
21.00
p>0.05
>9
23.05.0
20.24.4
25.46.7
21.85.2
23.00#
p>0.05
<6
87.636.3
89.027.3
124.841.1
p>0.05
6-9
101.527.8
115.729.3
125.021.2
103.50.7
p>0.05
>9
114.226.4
101.423.4
126.632.4
109.525.7
114.00#
p>0.05
<6
4.00.7
4.41.0
3.90.4
p>0.05K
6-9
4.10.8
4.90.9
3.70.6
4.21.5
p>0.05K
>9
4.30.7
4.61.1
4.60.8
4.40.5
4.60#
p>0.05K
<6
2.40.6
2.71.0
1.90.6
p>0.05K
6-9
2.50.6
2.90.7
1.90.5
2.51.2
p>0.05K
>9
2.70.6
2.91.1
2.80.7
2.90.5
2.60#
p>0.05K
95
6. Discussion
The observations made in 100 cases of anaemia and 100 non anaemic controls, who
presented to Department of Medicine, Kempegowda Institute of Medical Sciences,
Bangalore, from June 2003 to June 2005 is discussed here and results have been
compared with other similar studies.
Age
All cases in this study were between 14 and 75 years. Majority of the cases were
middle aged (30-60 years). Anaemic cases younger than 50 years were more likely to
have more severe anaemia, as compared to cases older than 50 years, who were more
likely to have less severe anaemia. This is probably due to younger individuals having a
higher risk of worm infestations, and also the onset of menopause with cessation of
menstrual blood loss after the age of 50 years.
Sex
The cases consisted of 48 males and 52 females. There was no correlation between
sex and severity of anaemia.
96
describe nutritional deficiencies, especially iron deficiency, to be the most common cause
for anaemia25,26.
Most cases had mild to moderate anaemia, as defined by a haemoglobin level above
6 gm/dl. None of the cases with normocytic hypochromic anaemia or normocytic
normochromic blood picture had severe anaemia.
Symptoms
Cases commonly presented with non specific symptoms of anaemia, such as
fatigue, dyspnoea, palpitations and giddiness. Symptoms suggestive of a specific cause
for anaemia were rarely seen.
Cases with more severe anaemia were more likely to have symptoms and had more
number of symptoms. Patients with haemoglobin more than 10 gm/dl were usually
asymptomatic, and incidentally detected to have on anaemia on routine evaluation. This
is consistent with standard textbooks of medicine which state that mild anaemias of
insidious onset are usually asymptomatic26.
97
Personal history
19 cases were vegetarians. Vegetarians were more likely to have more severe
anaemia and to have dimorphic anaemia. Vegetarians are likely to have more severe
anaemia as dietary iron of plant origin has less bioavailability.
Pulse Rate
The mean pulse rate was higher in anaemic cases when compared to non anaemic
controls. The mean pulse rate was higher in cases with more severe anaemia. The pulse
rate has been described to be higher in case of anaemia, in standard textbooks of
medicine. This is part of a compensatory mechanism to raise cardiac output and maintain
tissue oxygenation34.
98
Ickx, Rigolet and Linden33, in 2000, demonstrated that anaemia causes a rise in
pulse rate and stroke volume in patients whose haemoglobin was lowered from 13 gm/dl
to 8 gm/dl.
Blood Pressure
The mean blood pressure was comparable in cases and controls. It was lower in
cases with more severe anaemia. This is due to peripheral vasodilatation, another
compensatory mechanism to raise cardiac output and maintain tissue oxygenation.
Systemic examination
The most common findings on systemic examination were venous hum and flow
murmurs. Features suggestive of hyperdynamic state of circulation and congestive
cardiac failure were only seen in cases with severe anaemia. Features suggestive of
peripheral neuropathy were seen only in cases with megaloblastic anaemia and dimorphic
anaemia.
99
This was consistent with a study done by Graettinger, Parsons and Campbell35 in
1983, which demonstrated that anaemia leads to significant haemodynamic changes only
when it is severe.
The mean total cholesterol was found to be lower in anaemic cases when compared
to controls. The decrease in mean serum cholesterol was not due to a specific lowering of
any of the serum lipoprotein families; hypocholesterolemia was caused by a reduction in
all the major lipoprotein families, including mean HDL, LDL, VLDL and triglycerides.
There was a very large decrease in mean total cholesterol and LDL levels, and a large
decrease in mean HDL levels, resulting in a mild fall in mean TC/HDL and LDL/HDL
ratios. There was a mild decrease in mean VLDL and triglyceride levels.
Rifkind and Gale4,5 in 1967 showed that anaemia was associated with
hypocholesterolemia and the decrease in serum cholesterol was not due to a specific
lowering of any of the serum lipoprotein families, and that hypocholesterolemia was
caused by a proportional reduction in all the major lipoprotein families.
100
Elwood and Mahler6, in 1970, conducted a study 4,070 women, and demonstrated a
significant difference in cholesterol between women with haemoglobin levels above and
below 10.5g/dL.
A study conducted by Choi61 et al in 2001 showed that lipid levels in patients with
iron deficiency anaemia were directly related to the hemoglobin levels.
study
by
Westerman7
in
1975
examined
the
relationship
between
101
changes in haematocrit levels. The authors concluded that low haematocrit, not the type
of anaemia, is the cause of low cholesterol levels.
Seip and Skrede56, in 1967, found an association between serum cholesterol and
haemoglobin in all cases, regardless of cause of anaemia.
102
7. Conclusion
100 cases of anaemia and 100 controls who presented to the Department of
Medicine, Kempegowda Institute of Medical Sciences, Bangalore, from June 2003 to
June 2005 are presented here. They were studied regarding demographic characteristics,
clinical presentation and biochemical changes with special reference to lipid profile in
relation to severity and type of anaemia. The following conclusions were arrived at.
1) Majority of cases with anaemia were in the age group of 30-60 years. Younger
cases were more likely to have more severe anaemia.
5) The most common presenting symptom was fatigue. Patients with severe anaemia
were more likely to be symptomatic.
7) Pallor was the most common finding on general physical examination. Cases with
more severe anaemia were more likely to have findings on general physical
examination.
103
8) The mean pulse rate was higher in cases. The mean pulse rate was higher in cases
with severe anaemia. The mean blood pressure and BMI were lower in cases with
severe anaemia.
9) The most common findings on systemic examination were venous hum and flow
murmurs. Features suggestive of hyperdynamic state of circulation and congestive
cardiac failure were only seen in cases with severe anaemia.
10) The mean total cholesterol, HDL, LDL, VLDL and triglyceride levels, along with
TC/HDL and LDL/HDL ratios were significantly decreased in cases compared to
controls.
11) There was a larger reduction in mean total cholesterol, HDL, LDL, VLDL and
triglyceride levels, along with TC/HDL and LDL/HDL ratios with increased
severity of anaemia.
12) The type of anaemia did not have a significant effect on the mean lipid levels.
104
8. Summary
This study was done on 100 anaemic cases and 100 non anaemic controls to study
the clinical presentation and effect on lipid profile of anaemia.
Younger individuals are more likely to have severe anaemia. Cases with severe
anaemia have more symptoms. They have higher mean pulse rate, lower mean blood
pressure and mean BMI. Vegetarians are more likely to have severe anaemia. Cases with
severe anaemia also have more signs on examination.
Further studies are required to study the long term effect of anaemia on the risk of
developing atherosclerosis, and to study the long term effect of treatment of anaemia on
lipid levels and cardiovascular morbidity and mortality1.
105
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114
10. Annexures
I. Proforma
A Study of Lipid Profile in Anaemia
Case/Control No:
Age:
years
Sex:
Occupation:
OP/IP No:
Unit: Med
Yes/ No
Dyspnoea
Yes/ No
Giddiness
Yes/ No
Palpitations
Yes/ No
Angina
Yes/ No
Pica
Yes/ No
Dysphagia
Yes/ No
Abd pain
Yes/ No
Bony pain
Yes/ No
Fever
Yes/ No
Loss of appetite
Yes/ No
Weight loss
Yes/ No
115
Date:
M/F
Jaundice
Yes/ No
Bleeding
Yes/ No
Malaena
Yes/ No
Haemoglobinuria
Yes/ No
Menorrhagia
Yes/ No
Pregnancy
Yes/ No
Yes/ No
Past History:
Diabetes Mellitus
Yes/ No
Hypertension
Yes/ No
IHD
Yes/ No
CVA
Yes/ No
AIDS
Yes/ No
Yes/ No
Gall stones
Yes/ No
Personal History:
Diet:
Smoking
Yes/ No
Alcohol
Yes/ No
Drug History:
Oral Contraceptives
Yes/ No
116
Beta blockers
Yes/ No
Diuretics
Yes/ No
Steroids
Yes/ No
NSAIDs
Yes/ No
Family History
Anaemia
Yes/ No
Jaundice
Yes/ No
Gallstones
Yes/ No
On Examination:
Pallor
Yes/ No
Koilonychia
Yes/ No
Icterus
Yes/ No
Pedal edema
Yes/ No
Lymphadenopathy
Yes/ No
Glossitis
Yes/ No
Angular stomatitis
Yes/ No
Petechiae
Yes/ No
Haemolytic facies
Yes/ No
Ankle ulcers
Yes/ No
Perioral pigmentation
Yes/ No
Knuckle pigmentation
Yes/ No
Pulse:
/min
Rhythm
BP:
mm of Hg
Volume
117
Weight:
kgs
Height:
cms
kg/m2
Cardiovascular system
JVP
Yes/ No
Venous hum
Yes/ No
Cardiomegaly
Yes/ No
S3
Yes/ No
Flow murmer
Yes/ No
cms
Respiratory system
Basal crepitations
Yes/ No
Abdomen
Hepatomegaly
Yes/ No
Splenomegaly
Yes/ No
Yes/ No
Power
DTRs
Vibration
Normal/ Impaired
Position
Normal/ Impaired
Rombergs
Present/ Absent
118
Investigations:
1. Complete Haemogram
Hb
g/dl
PCV
%,
TC
* 103 /mm3
DC
%P
%L
%E
ESR
mm/hr
RBC
*106 /mm3
MCV
fL
MCH
pg
MCHC
g/dl
Peripheral Smear:
2. Lipid Profile
Total Cholesterol
mg/dl
HDL
mg/dl
LDL
mg/dl
VLDL
mg/dl,
Triglycerides
mg/dl
119
%M
%B,
3. Urine Routine
Albumin
Sugar
Microscopy
PC / HPF
EPC / HPF
RBC / HPF
mg/dl
5. Blood Urea
mg/dl
6. Serum Creatinine
mg/dl
mg/dl
mg/dl
SGOT
U/L
SGPT
U/L
SAP
U/L
gm/dl,
Serum albumin
gm/dl
120
8. Thyroid Profile
9.
TSH
U/ml
T3
ng/dl
T4
g/dl
FBS
mg/dl
PPBS
mg/dl
121
Diabetes mellitus
HTN
Hypertension
IHD
CVA
Cerebrovascular accident
AIDS
OCs
Oral contraceptives
BP
Blood pressure
Wt
Weight
Ht
Height
BMI
CVS
Cardiovascular system
JVP
RS
Respiratory system
P/A
Per Abdomen
CNS
DTRs
Hb
Haemoglobin
PCV
Haematocrit
TC
Total count
Polymorphs
Lymphocytes
122
Eosinophils
Monocytes
Basophils
ESR
MCV
MCH
MCHC
STC
HDL
LDL
VLDL
TG
Triglycerides
PCs
Pus cells
EPCs
Epithelial cells
RBCs
RBS
FBS
PPBS
STB
SDB
SGOT
SGPT
SAP
123
A/G
TSH
T3
3,5,3-Triiodothyronine
T4
Thyroxine
124