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Blood, 1 March 2008, Vol. 111, No. 5, pp. 2941. This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Rights and Permissions Citing Articles Citing Articles via CrossRef Citing Articles via Google Scholar Google Scholar Articles by Artz, A. Articles by Dong, X. Search for Related Content PubMed PubMed Citation Articles by Artz, A. Articles by Dong, X. Related Collections Related Article in Blood Online Social Bookmarking                   What's this?  Previous Article  |  Table of Contents  |  Next Article  CORRESPONDENCE Defining anemia by race using epidemiologic data To the editor: We laud Patel and colleagues' thoughtful analysis and important contribution to the sparse literature on the racial variation in the relationship of anemia and outcome in older adults.1 The authors suggest that "alternative criteria are warranted" for defining anemia in blacks. They intimate that we should consider a threshold lower in blacks than the World Health Organization anemia criteria of hemoglobin (Hb) less than 130 g/L for men and less than 120 g/L for women based on their observation that anemia did not predict for increased mortality in blacks. However, we believe lowering the Hb threshold defining anemia based on this epidemiologic study is premature. Because the data conflict with Denny and colleagues' report showing increased mortality in older blacks having anemia, we must consider study limitations.2 In the manuscript by Dr Patel, the recruitment strategies for blacks and whites differed (whites were randomly selected whereas blacks were recruited) as did the number of patients lacking baseline Hb values (56% in blacks compared with 39% in whites). This may have introduced bias that abrogated the mortality impact of anemia. The authors also state that restricting the analysis to well-functioning individuals strengthens the study by negating confounding factors. However, to redefine population-based Hb thresholds in a nonpopulation-based analysis is problematic. Finally, it remains unknown whether anemia in older blacks increases the risk of other health-related outcomes such as hospitalization, quality of life, or institutionalization. Even if anemia in older blacks is shown to have no impact on outcomes, defining anemia based solely on epidemiologic data may have unintended consequences. Anemia has long served as a clinically important sign of other conditions. Applying a lower Hb concentration to diagnose anemia would desensitize physicians and patients about when to evaluate anemia and/or may lead payors to refuse reimbursement for "mildly" low Hb values. As the authors point out, genetic traits, such as -thalassemia,3 probably reduce the median Hb in blacks. Using a lower Hb threshold for all black older adults runs a serious risk of missing important causes such as nutrient deficiencies, iron deficiency (and underlying gastrointestinal pathology), or other serious conditions. Clarifying the Hb concentration below which an etiologic evaluation can be safely deferred requires a rigorous study analyzing anemia etiology by race and Hb concentration. Although approximately one-third of older anemic adults lack an obvious cause,4,5 prospective studies using careful clinical evaluation are lacking. Finally, we would also like to emphasize that observational data on Hb and mortality do not necessarily inform Hb criteria for corrective therapy using erythropoietin stimulating agents (ESA). Prospective trials in older anemic adults will be needed to discern the risks and benefits of anemia correction as well as the optimal Hb concentration for initiation and targeting with ESA. Authorship Conflict-of-interest disclosure: A.A. has served on an advisory board to Amgen and has received research support from Amgen. X.D. declares no competing financial interests. Correspondence: Andrew Artz, University of Chicago, 5841 S Maryland Avenue, MC 2115, Chicago, IL 60637; e-mail: aartz{at}medicine.bsd.uchicago.edu. Andrew Artz, and XinQi Dong References Patel KV, Harris TB, Faulhaber M, et al. Racial variation in the relationship of anemia with mortality and mobility disability among older adults. Blood 2007; 109:4663–4670.[Abstract/Free Full Text] Denny SD, Kuchibhatla MN, Cohen HJ. Impact of anemia on mortality, cognition, and function in community-dwelling elderly. Am J Med 2006; 119:327–334.[CrossRef][Medline] [Order article via Infotrieve] Beutler E and West C. Hematologic differences between African-Americans and whites: the roles of iron deficiency and alpha-thalassemia on hemoglobin levels and mean corpuscular volume. Blood 2005; 106:740–745.[Abstract/Free Full Text] Artz AS, Fergusson D, Drinka PJ, et al. Mechanisms of unexplained anemia in the nursing home. J Am Geriatr Soc 2004; 52:423–427.[CrossRef][Medline] [Order article via Infotrieve] Guralnik JM, Eisenstaedt RS, Ferrucci L, Klein HG, Woodman RC. Prevalence of anemia in persons 65 years and older in the United States: evidence for a high rate of unexplained anemia. Blood 2004; 104:2263–2268.[Abstract/Free Full Text] CiteULike    Connotea    Del.icio.us    Digg    Reddit    Technorati    What's this? Related Article in Blood Online: Further epidemiologic research on anemia in older adults is needed Kushang V. Patel, Tamara B. Harris, Anne B. Newman, and Jack M. Guralnik Blood 2008 111: 2941-2942. [Full Text] [PDF] This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Rights and Permissions Citing Articles Citing Articles via CrossRef Citing Articles via Google Scholar Google Scholar Articles by Artz, A. Articles by Dong, X. Search for Related Content PubMed PubMed Citation Articles by Artz, A. Articles by Dong, X. Related Collections Related Article in Blood Online Social Bookmarking                   What's this?

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