approccio clinico al paziente geriatrico con anemia...distribution of the prevalence of anemia by...
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Giovambattista DesideriUO Geriatria e Lungodegenza
Università degli Studi di L’Aquila
Approccio clinico al paziente geriatrico con anemia
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Approccio clinico al paziente geriatrico con anemia
Frequente
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Tettamanti M et al. Haematologica 2010;95(11):1849-1856.
Prevalence, incidence and types of mild anemia in the elderly:the “Health and Anemia” population-based study
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Distribution of the prevalence of anemia by level in the elderly:the “Health and Anemia” population-based study
Tettamanti M et al. Haematologica 2010;95(11):1849-1856.
Mild anemia, Hb 10.0–11.9 g/dL in females and Hb 10.0–12.9 g/dL in males;
Moderate anemia, Hb 8.0–9.9 g/dL; Severe anemia, Hb< 8.0 g/dL.
Blanc B et al. World Health Organization; 1968.
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Approccio clinico al paziente geriatrico con anemia
Frequente
Rilevante in chiave prognostica
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Relationship between hemoglobin concentration and 5-year all-cause mortality in community-dwelling, disabled older women
Chaves PH et al. J Am Geriatr Soc. 2004; 52:1811–1816.
+20%
-25%D45%
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Anemia in Old Age Is Associated With Increased Hospitalization
Penninx BW et al. J Gerontol A Biol Sci Med Sci2006;61:474–9.
<12 g/dL in women<13 g/dL in men
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Relationship between the baseline levels of Hct and the cumulative incidence of ESRD
Iseki K et al. Kidney International (2007) 72, S4–S9
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Kaplan-Meier survival function of time to dementiadiagnosis by baseline anemia
Hong CH et al. Neurology 2013;81:528–533
<12 g/dL in women<13 g/dL in men
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Cahves PH et al. J Gerontol A Biol Sci Med Sci. 2005 Jun;60(6):729-35.
Cross-sectional relationship between Hb concentration and prevalentfrailty status, Women’s Health and Aging Studies I and II, 1992–1996.
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Difference in event-free survival rates between iron-deficient and non–iron-deficient patients with HF with or without anemia
Klip IT et al. Am Heart J 2013;165:575-582
<12 g/dL in women<13 g/dL in men
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ID commonly occurs even
without anaemia in HF
ID (with or without anaemia)
is present in 50% of HF
patients
Iron deficiency definition used:
− Serum ferritin <100 µg/L or
− Serum ferritin <299 µg/L if TSAT
<20%
Iron deficiency and/or anemia stratified by NYHA functional class.Prevalence of ID and/or anemia per NYHA functional class.
Klip IT et al. Am Heart J 2013;165:575-582
ID/A
ID
A
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ANAEMIA
Tissue hypoxia
Peripheral vasodilation
Blood pressure
Sympathetic activity
Renal blood flow
Renin-angiotensin aldosterone ADH
Salt & Fluid retention
Plasma volume
Oedema
LVdiameter
LV remodelling Apoptosis Necrosis
Worsening
HF
Vicious circle of Anemia and HF
HF
Anand IS et al. J Am Coll Cardiol 2008;52:501–11
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Swedberg K et al. N Engl J Med 2013;368:1210-9.
Treatment of Anemia with DarbepoetinAlfa in Systolic Heart Failure – RED HF study
Monthly Hemoglobin Levels through 60 MonthsAccording to Study Group
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Impact of iron status on exercise capacity (6-minute walk test) in patients with chronic heart failure
Enjunaes C et al. Rev Esp Cardiol. 2016;69(3):247–255
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Iron-dependent changes in cellular energy metabolism
Brown DA et al. Nat Rev Cardiol. 2017 April ; 14(4): 238–250.
The numbers of the heart:
100.800 beats/day
5-6 kg ATP/day
mitochondria: 40% cell volume
Bayeva M et al. J Am Coll Cardiol 2013;61:599–610
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Recommendations for iron replacement in HF
2017 ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the Management of HF1
COR LOE
In patients with NYHA class II and III HF and iron deficiency (ferritin <100 ng/mL or 100 to 300 ng/mL if transferrin saturation is <20%), intravenous iron replacement might be reasonable to improve functional status and QoL.
NEW: New evidence consistent with therapeutic benefit.
IIb B-R
(3,4)
2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure2
Class Level
Intravenous FCM should be considered in symptomatic patients (serum ferritin <100 μg/L, or ferritin between 100–299 μg/L and transferrin saturation <20%) in order to alleviate HF symptoms, and improve exercise capacity and quality of life.
IIa A
(3,4)
1Yancy CW et al. Circulation. 2017 Aug 8;136(6):e137-e1612Ponikowski P et al. European Heart Journal (2016) 37, 2129–2200
3Anker SD, et al. N Engl J Med 2009;361:2436–2448 FAIR-HF4Ponikowski P, et al. Eur Heart J 2015;36:657–668 CONFIRM
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Anker SD et al. N Engl J Med 2009;361:2436-48.
FAIR-HF: primary endpoint: Self-Reported Patient Global
Assessment at Wk 24
459 pts with chronic HF - NYHA class II or III, LVEF <40% (for patients with NYHA class II or <45% for NYHA class III)
Iron deficiency (ferritin level <100 μg/L or between 100 and 299 μg/L, if the transferrinsaturation was <20%), and a hemoglobin levelof 95 to 135 g/L.
FAIR-HF: primary endpoint: NYHA Functional Class at Wk 24
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FAIR-HF: primary endpoint: Self-Reported Patient Global Assessment and NYHA class at Wk 24 according to the presence or
absence of anaemia at baseline
Filippatos G et al. European Journal of Heart Failure (2013) 15, 1267–1276
Self-Reported Patient Global Assessment
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Anker SD et al. N Engl J Med 2009;361:2436-48.
FAIR-HF: secondary endpoint: 6-Minute-Walk Test
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Ponikowsky P et al. European Heart Journal (2015) 36, 657–668
CONFIRM-HF: 6-Min Walk Test Over Time
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Ponikowsky P et al. European Heart Journal (2015) 36, 657–668
CONFIRM-HF: Patient Global Assessment and NYHA Functional Class over Time
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Anker SD et al. Eur J Heart Fail. 2018 Jan;20(1):125-133.
Effects of FCM on CV hospitalisations and mortality rates iniron-deficient HF patients: an individual patient data meta-analysis
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Anker SD et al. Eur J Heart Fail. 2018 Jan;20(1):125-133.
Effects of FCM on CV hospitalisations and mortality rates iniron-deficient HF patients: an individual patient data meta-analysis
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Approccio clinico al paziente geriatrico con anemia
Frequente
Rilevante in chiave prognostica
Eterogenea nelle cause
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Types of anemia and mild anemia in the elderly population
Tettamanti M et al. Haematologica 2010;95(11):1849-1856.
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Main types of anemia in the elderly population
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Causes of iron deficiency anemia
Zeller MP et al. CMAJ March 13, 2017 189 (10) E409; DOI: https://doi.org/10.1503/cmaj.160153
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Oral anticoagulation among atrial fibrillation patients with anaemia: an observational cohort study
Bonde AN et al. European Heart Journal (2019) 0, 1–9
Mild anemia (MA): Hb 6.83–7.45 mmol/L for women and Hb 6.83–8.03 mmol/L formen)Moderate/severe anemia (MSA): Hb <6.83 mmol/L.
MSA 14% MA 20%
To convert mmol to mg: X 1/0.6206
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Diagnostic Blood Loss From Phlebotomy and Hospital-Acquired Anemia During Acute Myocardial Infarction
Salisbury AC et al. Arch Intern Med. 2011 Oct 10;171(18):1646-53
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Twelve-month mortality among patients with mild Hospital-AcquiredAnemia (HAA), moderate-severe HAA, and chronic anemia and AMI
Salisbury AC et al. Circ Cardiovasc Qual Outcomes. 2010;3:337-346
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Michels K et al. PLoS Pathog. 2015 Aug; 11(8): e1004998
Anemia of chronic disease
Ganz T. Physiol Rev 93: 1721–1741, 2013DeLoughery TG. N Engl J Med 2014;371:1324-31.
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Main types of anemia in the elderly population
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Vitamin B12 and folate metabolism and function
Green R et al. Nat Rev Dis Primers. 2017 Jun 29;3:17040
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The relationship between distribution of mean corpuscular volume (MCV), anisocytosis and red blood cell distribution width (RDW).
Danete E et al. J Thorac Dis 2015;7(10):E402-E411
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Main types of anemia in the elderly population
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Update on Anemia in ESRD and Earlier Stages of CKD
Fishbane S et al. Am J Kidney Dis. 71(3): 423-435. NEJM. 2017;376:1965-1971)
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Main types of anemia in the elderly population
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The origins of age-related proinflammatory state
Ferrucci L et al. Blood, 2005 105: 2294-2299
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Serum erythropoietin (EPO) levels by hemoglobin concentration among irondeficiency anemia, unexplained anemia in the elderly, and myelodysplastic
syndromes and acute myeloid leukemia.
Arts AS et al. J Gerontol A Biol Sci Med Sci. 2011 August;66A(8):925–932
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Association of Testosterone Levels With Anemia in Older Men: A Controlled Clinical Trial
JAMA Intern Med. 2017 April 01; 177(4): 480–490.
788 elderlyTestosterone <275 ng/dL
16% with anemia 6.3% myelodysplasia, 33.3% iron deficiency, 2.4% B12 deficiency 7.9% chronic inflammation
or disease 49.2% unexplained anemia
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Approccio clinico al paziente geriatrico con anemia
Frequente
Rilevante in chiave prognostica
Eterogenea nelle cause
….e la gestione?
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Evaluation and Management of Anemia in the Elderly
Goodnought LT e al. Am J Hematol. 2014 January ; 89(1): 88–96 (modified)
Iron deficiency
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Comparative efficacy of differentoral iron formulations for treating bleeding-induced
moderate-to-severe anemia.
Gómez-Ramírez S et al. Pharmaceuticals 2018, 11, 97; doi:10.3390/ph11040097
Ironpyrophosphate
Phospholipmembrane
SucresterenvelopeTricalcium
phosphate
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Condizione Motivazione
INTOLLERANZA INTESTINALE Nausea, vomito, stipsi, diarrea
MANCATO ASSORBIMENTO
Gastrectomia, by-pass duodenale, chir. bariatrica,
HP, gastrite atrofica, celiachia
Forme genetiche (IRIDA)
Flogosi: IBD, CKD, Neoplasie, Età avanzata
Mancato incremento Hb dopo 4 settimane
ANEMIA GRAVE (Hb < 7-8 g/dL) Necessità di un rapido miglioramento
TRATTAMENTO CON EPO Inefficace la terapia orale
PERDITE EMATICHE CRONICHE
Polimenorrea
Teleangectasia emorragica ereditaria
Angiodisplasie
ALTRE
Programmazione di chirurgia maggiore entro 6 settimane
Insufficienza cardiaca sistolica cronica
Secondo e terzo trimestre di gravidanza
Indicazioni al trattamento parenterale
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Toblli JE et al. Drug Design, Development and Therapy 2014:8 2475–2491
Optimizing iron delivery in the management of anemia: patient
considerations and the role of FCM
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Evaluation and Management of Anemia in the Elderly
Goodnought LT e al. Am J Hematol. 2014 January ; 89(1): 88–96 (modified)
Iron deficiencyCKD
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Approccio clinico al paziente geriatrico con anemia
Frequente
Rilevante in chiave prognostica
Eterogenea nelle cause
….e la gestione?
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Approccio clinico al paziente geriatrico con anemia
Pensiamoci
Non trascuriamola
Interpretiamola
Trattiamola
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