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CHARACTERIZATION OF ANEMIA IN MULTIPLE MYELOMA WITH THE HELP OF ERYTHROCYTE CONSTANTS

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Analele Ştiinţifice ale Universităţii Alexandru Ioan Cuza, Secţiunea Genetică şi Biologie Moleculară, TOM XIV, 13 CHARACTERIZATION OF ANEMIA IN MULTIPLE MYELOMA WITH THE HELP OF ERYTHROCYTE CONSTANTS MIHAI
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Analele Ştiinţifice ale Universităţii Alexandru Ioan Cuza, Secţiunea Genetică şi Biologie Moleculară, TOM XIV, 13 CHARACTERIZATION OF ANEMIA IN MULTIPLE MYELOMA WITH THE HELP OF ERYTHROCYTE CONSTANTS MIHAI BULARDA MOROZAN 1, COSTICĂ MISĂILĂ 2 Keywords: anemia, multiple myeloma, VEM, HEM, CHEM. Abstract: This paper intends to shed extra light on different types of anemia as caused by multiple myeloma in patients registered at Elena Beldiman Municipal Emergency Hospital from Barlad, between In order to complete this characterization, the values of derived erythrocyte constants have been used: the average volume of erythrocytes (VEM); mean erythrocyte hemoglobin (HEM) and the average concentration of erythrocyte hemoglobin (CHEM). Moreover, this paper aims to compare the different types of anemia in patients with multiple myeloma, according to their gender and age. The 34 identified patients were divided into four study groups, men and women aged under, respectively over years. It has been noticed that the incidence of macrocytic anemia (increased VEM) coexists with hypochromia (decreased CHEM), and the values from the four study groups are comparable, both types of anemia having mollified levels of severity, both in male patients and female patients. INTRODUCTION The literature data including our previous results confirmed the fact that both the diminution of hemoglobin synthesis and the reduction of erythropoiesis intensity and efficiency represent hematological disorders, associated with multiple myeloma. That is why, anemia in its different stages of severity can be found in all patients with multiple myeloma. For example, in the casuistry of Elena Beldiman Municipal Emergency Hospital from Barlad, between 1-12 (BULARDA şi MISĂILĂ, 13a), out of 34 studied patients, 5% showed a mild anemia, 41,2% a moderate anemia, and 8,8% presented values of hemoglobin (Hb) and hematocrit (Ht) typical for severe anemia. When it s about patients with multiple myeloma, the presence of tumor cells contributes to anemia through different ways: disturbing the renal function, inhibiting the erythropoiesis production, and inducing cellular apoptosis through cell-cell contact (SAN MIGUEL and others, 1998). Thus, the presence of anemia in multiple myeloma is given by a multifactorial complex and constitutes the result of a hematopoietic suppression. As a result of tumor cells extension into the hematopoietic space, multiple myeloma can be also characterized by medullary insufficiency or even aplasia (NICKERING and others, 1; BULARDA and MISAILA, 11). Generally speaking, today s practice defines anemia as a decrease of the value of parameters which appreciate the quantity of erythrocytes from blood, as well as the number (E), volume (Ht) and their content in Hb. The main data necessary to classify the anemia according to its erythrocyte constants refers to: erythrocytes size (VEM the average volume of erythrocytes) and Hb loading with erythrocytes (HEM- mean erythrocyte hemoglobin and CHEM average concentration of erythrocyte hemoglobin). By the aid of erythrocyte constants, it is possible to make a morphological classification of anemia: µcytic, macrocytic and microcytic according to VEM values, respectively normochromic and hypochromic according to HEM and CHEM values. The functional classification of anemia is based on the appreciation of the erythrocytes yield in the bone marrow (COLIŢĂ, 1997). The present paper aims to characterize the anemia stage in multiple myeloma patients admitted to Elena Beldiman Municipal Emergency Hospital from Barlad, between 1 and 112, according to their age and gender in terms of values of derivative -erythrocyte constants. MATERIALS AND METHODS The casuistry available in the inventory of Elena Beldiman Municipal Emergency Hospital in Barlad for 1-12 consisted of 34 multiple myeloma patients domiciled in Barlad and its surroundings, and aged between 34 and 81 years. Venous blood samples were collected in hematology vacuum containers, and the lab analyses were performed with NIHON ROHDEN F Celltac Mek 6318K, the automated hematology analyzer existent in the hospital. Apart from showing the individual values of the main hemoglobin indices, especially of hemoglobin concentration, hematocrit and all the types of existent elements, the analyzer also performs the calculation of the derivative-erythrocyte constants, such as: VEM average volume of erythrocytes (µm 3 / erythrocyte), HEM mean erythrocyte hemoglobin (pg Hb / erythrocyte) and CHEM - average concentration of erythrocyte hemoglobin (g Hb/1mL erythrocytes). The mean of 21 Mihai Bularda Morozan et al Characterization of anemia in multiple myeloma with the help of erythrocyte constants these real individual values (tab.1) was compared for each group to the mean of normal physiological (ideal) values, in order to evaluate the severity of the pointed out anemia (fig.1, 3 and 5). These values can be achieved by calculation, starting from the results regarding the hemoglobin levels (Hb), hematocrit (Ht) and erythrocyte count (E), (MISĂILĂ şi COMĂNESCU, 1999). The average volume of erythrocyte (VEM): VEM is calculated from the ratio between Ht and E by using the following equation: VEM (µm3/eritrocit) = Ht x 1 / E, where: Ht represents the value of hematocrit expressed in percentage (%), and E- represents the number of erythrocytes expressed in millions / µl The mean erythrocyte hemoglobin (HEM): HEM is calculated from the ratio between Hb and E, by using the following equation: HEM (pg Hb/ erythrocyte) = Hb x 1 / E, where: Hb represents the concentration of hemoglobin expressed in g/dl The average concentration of erythrocyte hemoglobin (CHEM): CHEM is calculated from the ratio between Hb and Ht, by using the following equation: CHEM (g Hb/ 1 ml erythrocytes) = Hb x 1/Ht RESULTS AND DISCUSSION Apart from the quantitative variations where the main blood test indices are both involved and aimed at in multiple myeloma, the laboratory investigations may be completed with the study of the variations occurred on the level of derivative-erythrocyte constants. Table 1: The values of erythrocyte constants analyzed in patients with multiple myeloma Gender / Age Men / years Men / years Women / Case no Age (years) VEM (µm 3 /erythrocyte) HEM (pg Hb/erythrocyte) CHEM (g Hb/1 ml erythrocyte) ,8 3,7 33, ,1 27,4 29, ,6 31,8 31, ,3 28,9 29, ,8 26,5 32, ,1 3,2 32,7 7 11,2 29,2 32, , , ,9 3,6 32, ,9 31,3 33, ,6 3,5 3, , , ,2 28,9 34, ,4 3,5 32, , 27,6 31, ,4 38,7 33, ,5 29,4 32, ,1 31, ,6 28,8 33, ,2 3,9 32, ,9 29,1 3,7 22 Analele Ştiinţifice ale Universităţii Alexandru Ioan Cuza, Secţiunea Genetică şi Biologie Moleculară, TOM XIV, 13 years ,2 3,3 33, ,3 26, 3, ,8 31,3 33, ,3 3,6 32, ,6 3,6 31, ,6 29,4 32, ,8 29,3 32,3 Women / ,1 3, 34,4 years ,5 31, 35, ,6 31,2 29, ,8 28,6 34, ,4 31,7 31, ,1 3,3 According to the morphological classification of anemia (COLIŢĂ, 1997), in terms of VEM values, there can be distinguished, on the one hand, normocytic anemias with VEM values between 8 and 93 µm 3 / erythrocyte and on the other hand there ar macrocytic anemias (VEM 94), respectively microcytic anemias (VEM 8). Form our analyses (fig.1), it can be noticed that on every variations the real mean values exceed with several percentages (4-8%) the mean of the ideal values (physiological normal), with no significant differences between age groups or gender. 1 MVI - the average of the ideal values MVR - the average of the real values VEM (cubic micrometers/ erythrocyte) ,8 93,1 9, % 15% 1% 14% 1% 1% 1% 94 18% MVI MVR MVI MVR MVI MVR MVI MVR B years B years F years F years Fig. 1: VEM mean values in patients with multiple myeloma 23 Mihai Bularda Morozan et al Characterization of anemia in multiple myeloma with the help of erythrocyte constants This behavior of VEM values of the patients suggests, on the one hand, a tendency towards macrocytic anemia of an incipient type, and on the other hand suggests a general manifestation, that means one that is on every group of patients, having no connection with their age or gender. The statement that macrocytic anemia noted on every group of patients is an incipient one is based on the fact that the means of the real values are situated below 94 µm 3 / erythrocyte, although it can be noticed from table 1 that there are isolated individual values within each group that go beyond 94 µm 3 / erythrocyte, but the differences are insignificant ,7 VN - normal values VSN - supranormal values % of the total number of cases ,1 42,9 21,3 54,5 45,5 1 VN VSN VN VSN VN VSN VN VSN B years B years F years F years Fig. 2: The weighting factor of VEM individual normal values in patients with multiple myeloma Also, the data from fig.2 show that on men 57,1-72,7% of cases have VEM normal individual values and only 21,3-42,9% exceed this range of values. The same for women, the weighting of the normal individual values is of 54,5-% of cases, without having the rest of the cases exceeding too much the limit of the normal values, meaning 94 µm 3 / erythrocyte. 24 Analele Ştiinţifice ale Universităţii Alexandru Ioan Cuza, Secţiunea Genetică şi Biologie Moleculară, TOM XIV, 13 HEM (pg Hb / erythrocyte) MVI - the average of the ideal values 3,6 MVR - the average of the real 29, % 1% 12% 1% 1% 1% 1% 3,5 15% 5 MVI MVR MVI MVR MVI MVR MVI MVR B years B years F years F years Fig. 3: Mean values of HEM in patients with multiple myeloma Regarding the HEM values, although the variation of this constant goes along with the variation of the average volume of erythrocyte (VEM), in the case of multiple myeloma these constants show a somehow independent evolution. In the case of the studied patients, our data point out an average Hb loading of every erythrocyte which can be comparable to the mean of the normal physiological values. From this point of view, we point out an insignificant exceed of the ideal values mean (fig.3), and this taking into account the fact the mean of the real values of HEM is with 2-6% higher than the reference value for men, and -5% for women. 25 Mihai Bularda Morozan et al Characterization of anemia in multiple myeloma with the help of erythrocyte constants 1 1 VN - normal values % of the total number of patients 8 VN VN VN VN B years B years F years F years Fig. 4: The weighting factor of HEM individual normal values in patients with multiple myeloma The finding from above suggests a normochromic stage for all the four groups of patients. This thing is also highlighted in fig.4 which demonstrated that the HEM individual values from all the 43 patients are situated within the limits of normal physiological values (25-33 pg Hb / erythrocytes). According to (COLIŢĂ, 1997), macrocytosis can coexists in megaloblastic anemia, carential and non carential anemias, macrocytic non-megaloblastic anemias, myelodysplastic anemias as well as in chronic liver disease, myxedema, etc. The average concentration of erythrocyte hemoglobin (CHEM) is the erythrocyte constant with an important value in appreciating the type of anemia, because the real dilution of hemoglobin in the erythrocytic cytoplasma correlated with the size of the red globe (VEM) represent elements that define the efficiency of the expiratory exchanges in the studied patients. 26 Analele Ştiinţifice ale Universităţii Alexandru Ioan Cuza, Secţiunea Genetică şi Biologie Moleculară, TOM XIV, MVI - the average of the ideal values (normal physiological) MVR - the average of the real values (individual) CHEM (g Hb / 1 ml erythrocyte) ,7 32,1 32,6 1% 1% 1% 1% 93,2% 97,% 94.4% 95.9% 5 MVI MVR MVI MVR MVI MVR MVI MVR B years B years F years F years Fig. 5: Mean values of CHEM in patients with multiple myeloma As it results from fig.5, the mean values of CHEM are situated below the mean of the ideal values, both for men with 3-6,8% and for women with 4,1-5,6%. These data suggest a slight tendency towards hypochromia - an aspect that is certain, although is not too ample ,8 VsN - subnormal values VN - normal values % of the total number of patients ,9 57,1 18,2 36,4 63,6 1 VsN VN VsN VN VsN VsN VN B years B years F years F years Fig. 6: The weighting factor of CHEM individual normal values in patients with multiple myeloma VN 27 Mihai Bularda Morozan et al Characterization of anemia in multiple myeloma with the help of erythrocyte constants As it results from fig.6, hypochromia must be accepted, especially when for 18,2-42,9% of all male subjects and 36,4-% of all the female subjects, the CHEM individual values are situated below the normal limits, that means under 32 g Hb/dL erythrocytes. Moreover, our previous data (BULARDA şi MISĂILĂ, 13a) have shown an important hematologic failure in these patients whose real values mean of Hb is inferior to the ideal mean with more than 35% for men and 15% for women. When it s about Ht, the increases are over 38% for men and % for women, and the mean values of E are inferior to the normal limit with 37% for men and 14% for women. On the basis of the values of the studied erythrocyte constants, one can conclude that in the patients with multiple myeloma, the anemia macrocytic incidences coexist with hypochromia, and the values from all the four groups are comparable, without any strict delimitations in terms of gender or age. Medullary failure or even medullary aplasia caused by the presence of tumor cells in the hematopoietic space in multiple myeloma patients contributes to an increase in blood dilution and appearance of hypochromia by diminishing the red cell count and hematocrit, and also of macrocytosis by increasing the weighting of immature cells with a higher volume (VEM increase) and a more diluted citoplasma (CHEM decrease). CONCLUSIONS In the investigated patients with multiple myeloma, the anemia incidences of macrocytic type coexist with hypochromia, and the values from all the four groups are comparable, without any strict delimitations in terms of gender and age. Both macrocytic anemia disorders and hypochromia behave mild levels of severity in both men and women. In patients with multiple myeloma, the red cells are more sizeable than the ideal mean, for both men and women; a percentage of 32% of men and 43% of women revealing supranormal values of VEM, meaning 94 µm 3 / erythrocyte. The concentration of Hb in red cells citoplasma (CHEM) is inferior to the normal limit with 3-6,8% in men and 4,1-5,6 in women, a percentage of 31% of men and 38% of women revealing subnormal values of CHEM, that means below 32 g Hb /dl erythrocytes. REFERENCES Bularda Morozan Mihai, Misăilă Costică., (11): Hematological changes in multiple myeloma. Analele Ştiinţifice ale Universităţii,, Al. I. Cuza Iaşi. Secţiunea Genetică şi Biologie Moleculară, TOM XII, fasc.1: Coliţă, D, (1997), Anemiile. Generalităţi, clasificare, în: Tratat de Medicină Internă. Hematologie Partea I, sub.red. Radu Păun, Editura Medicală, Bucureşti. Misăilă, C., Comănescu, G., (1999): Elemente de hematologie generală, Editura Corson. p-126, 141, 155. Nickenig C., Lang N.K., Schoch C., Hiddemann W., Haferlach T., (1): New insights into the biology of multiple myeloma using a combination of May-Grünwald-Giemsa staining and fluorescence in situ hybridization techniques at the single cell level, Ann Hematol.8: San Miguel J.F., García-Sanz R., (1998): Recombinant human erythropoietin in the anaemia of multiple myeloma and non-hodgkin s lymphoma. Med Oncol.15 (Suppl 1):S29 S34. *) Universitatea Alexandru Ioan Cuza Iaşi *) Universitatea Alexandru Ioan Cuza Iaşi *) Aknowledgements: This work was supported by the the European Social Fund in Romania, under the responsibility of the Managing Authority for the Sectoral Operational Programme for Human Resources Development 7-13 [grant POSDRU/CPP 17/DMI 1.5/S/78342] . 28
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