Approccio clinico al paziente geriatrico con anemia...Distribution of the prevalence of anemia by...
Transcript of Approccio clinico al paziente geriatrico con anemia...Distribution of the prevalence of anemia by...
Giovambattista DesideriUO Geriatria e Lungodegenza
Università degli Studi di L’Aquila
Approccio clinico al paziente geriatrico con anemia
Approccio clinico al paziente geriatrico con anemia
Frequente
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
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.
Approccio clinico al paziente geriatrico con anemia
Frequente
Rilevante in chiave prognostica
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%
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
Relationship between the baseline levels of Hct and the cumulative incidence of ESRD
Iseki K et al. Kidney International (2007) 72, S4–S9
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
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.
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
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
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
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
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
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
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
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
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
Anker SD et al. N Engl J Med 2009;361:2436-48.
FAIR-HF: secondary endpoint: 6-Minute-Walk Test
Ponikowsky P et al. European Heart Journal (2015) 36, 657–668
CONFIRM-HF: 6-Min Walk Test Over Time
Ponikowsky P et al. European Heart Journal (2015) 36, 657–668
CONFIRM-HF: Patient Global Assessment and NYHA Functional Class over Time
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
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
Approccio clinico al paziente geriatrico con anemia
Frequente
Rilevante in chiave prognostica
Eterogenea nelle cause
Types of anemia and mild anemia in the elderly population
Tettamanti M et al. Haematologica 2010;95(11):1849-1856.
Main types of anemia in the elderly population
Causes of iron deficiency anemia
Zeller MP et al. CMAJ March 13, 2017 189 (10) E409; DOI: https://doi.org/10.1503/cmaj.160153
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
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
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
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.
Main types of anemia in the elderly population
Vitamin B12 and folate metabolism and function
Green R et al. Nat Rev Dis Primers. 2017 Jun 29;3:17040
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
Main types of anemia in the elderly population
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)
Main types of anemia in the elderly population
The origins of age-related proinflammatory state
Ferrucci L et al. Blood, 2005 105: 2294-2299
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
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
Approccio clinico al paziente geriatrico con anemia
Frequente
Rilevante in chiave prognostica
Eterogenea nelle cause
….e la gestione?
Evaluation and Management of Anemia in the Elderly
Goodnought LT e al. Am J Hematol. 2014 January ; 89(1): 88–96 (modified)
Iron deficiency
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
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
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
Evaluation and Management of Anemia in the Elderly
Goodnought LT e al. Am J Hematol. 2014 January ; 89(1): 88–96 (modified)
Iron deficiencyCKD
Approccio clinico al paziente geriatrico con anemia
Frequente
Rilevante in chiave prognostica
Eterogenea nelle cause
….e la gestione?
Approccio clinico al paziente geriatrico con anemia
Pensiamoci
Non trascuriamola
Interpretiamola
Trattiamola