Frequency and Classification of Anemia based on RBC Indices Among Patients Attended Benghazi Medical Center Randa Alfirjani Dietitian in General Surgery Department at Benghazi Medical Center 2016

Introduction Anemia is a major public health problem in developing countries, which affects people of all ages [1] . It has a negative impact on quality of life, associated with increase in morbidity and mortality rates [2,3] . WHO estimates that one-quarter of the world’s population are anemic [1] .

Anemia defined according to the World Health Organisation (WHO) criteria as heamoglobin concentration level < 12 g/dl in women and < 13 g/dl in men. The severity of anemia was categorized by WHO in to: Mild anemia (Hb 12.9 - 11 g/dl in men, 11.9 - 11 g/dl in women), Moderate (Hb 10.9 - 8 g/dl) and Severe (Hb < 8 g/dl ) in both sex [4].

Red Blood Cell (RBC) indices, which including: Mean Corpuscular Volume (MCV), Mean Corpuscular Hemoglobin(MCH), Mean Corpuscular Heamoglobin Concentration (MCHC) and the Red Cell Distribution width (RDW) index, are furthermore used to classify types of anemia [5] .

Anemia has been classified according to the morphology of RBCs based on (MCV) and (MCH) as Microcytic- Hypochromic (MCV< 80 fL, MCH < 27 pg), Normocytic-Normochromic (MCV 80-95 fL – MCH >27 pg), or Macrocytic ( MCV >95 fL)[6]. Red Cell Distribution width (RDW) is another useful diagnostic tool for anemic disorders based on combination with (MCV), which was proposed by Bessman classification[7] .

Table (1) : Proposed Classification of Anemic Disorders Based on Red Cell Mean (MCV) and Heterogeneity ( RDW) According to Bessman[ 7] . MCV high RDW high ( Macrocytic heterogeneous) RDW normal (Macrocytic homogeneous) MCV normal (Normocytic heterogeneous) (Normocytic homogeneous) MCV low (Microcytic heterogeneous) ( Microcytic homogeneous) Vitamin B12 and Folate deficiency A plastic anemia Preleukemia Mixed deficiency (Early Iron or Folate deficiency) Chronic disease Hemorrhage Iron deficiency Heterozygeous thalassemia Chronic diseases

There are limited studies about the frequency and the most common types of anemia among the patients attended healthcare facilities laboratory in Libya.

Objectives The aims of this study are to - Investigate the frequency of anemia. - Recognize the most common types of anemia among patients attended Benghazi Medical Center Laboratory.

METHODS Study setting The study was conducted in the hematology lab of Central Laboratory at Benghazi Medical Center (BMC). The BMC is a medical, surgical, oncology, a hematology as well as a renal, gynecology and pediatric clinics, departments and ER. It is a considered as the most referral hospital from several cities around Benghazi.

Study design A cross sectional study Study design A cross sectional study. Study procedures Data were collected by a questionnaire included : Complete Blood Count (CBC), Demographic data (Age, Gender, Sender of patient ) from hematology lab database. Peripheral Blood Film (PBF) results from patient’s report records during one month from (1st January to 31st January 2016).

Study Subjects Inclusion criteria All age groups, all outpatient clinics, inpatient departments and emergency room patients who had attended or received sample of patients to hematology lab BMC and had PBF in January 2016. Exclusion criteria Clotted samples, repeated samples of CBC and peripheral blood film results from repeated samples of patient to avoid overestimation the frequency of anemia.

Figure(1): Selection of sample Total number of patients (n= 5416) Exclusion Clotted samples (n= 70) Total number of patients (n= 5346) Exclusion Repeated samples (n= 3546) Total number of study sample (n= 1800) Unknown (n= 1672) In-patients (n= 69) Out –patients ( n= 56) ER (n= 3) Total No of patients (n= 1800) Figure(1): Selection of sample

Figure (2): Selection of peripheral blood film smear results Total number of peripheral blood film smear results (n= 188) Exclusion Results of repeated samples (n= 124) No Results (n= 9) Missing results (n= 7) Unmatched results( n= 10) Total number of study results peripheral blood film (n= 38) Figure (2): Selection of peripheral blood film smear results

Laboratory Studies A complete blood count (CBC) included: Hemoglobin concentration and Red blood cell indices (MCV, MCH, MCHC and RDW). White Blood cells (WBC) and Platelets Count were done by automated blood analyzer (Sysmex K X – 21 N, Japan) . Peripheral Blood Film smears were examined manually .

Statistical analysis Data was analyzed using Statistical Package for Social Sciences (SPSS) Version 18. Descriptive Statistics analysis used ( mean, standard deviations, frequencies and Percentages) were carried out for all variables. Then, statistical significance was tested by Chi-Square Test for a relationship between types of anemia and the age, gender of patients. P-values < 0.05 level was considered statistically significant. Notes : Treatment of missing data of age by Howell, D.C [8].

Ethical considerations This study has been approved by the Research Ethics Board (REB) at Benghazi Medical Center. Date of acceptation was on 31st July 2016.

Results Figure (3): The percent of frequency anemic patients.

Figure (4): Distribution percent of anemic patients by gender

Table (2): Category of anemia by gender and age according to WHO. Percent ( %) Frequency Category of anemia 10.4 134 Mild anemia Hb (12.9-11g/dl) for adult men (15 to ≥ 60 years of age) 20.2 260 Mild anemia Hb (11.9 - 11g/dl ) for adult women (15 to ≥ 60 years of age 56.3 725 Moderate anemia Hb (10.9 – 8 g/dl ) in both 5 to ≥ 60 years of age 12.3 158 Sever anemia Hb( < 8 g/dl ) in both from 5 to ≥ 60 years of age .5 6 Mild anemia Hb (10.9 – 10 g/dl) for children (6-59 months of age ) .2 3 Moderate anemia Hb (9.9 – 7 g/dl) for children 6-59 months of age .1 1 Sever anemia (Hb <7 g/dl) for children (<59 months of age) 100.0 1287 Total

Table (3): The minimum, maximum, mean, standard deviation, and normal range of hematological parameters of study of anemic patients Normal range Std. Deviation Mean Maximum Minimum Variables Male :>13 g/dl Female: >12 g/dl 1.6 9.9 12.9 3.6 Hb g/dl Male : 40- 52% Female : 36-48% 4.7 29.96 40.1 11 PCV % Male: 4.5-6.5 *106/mm3 Female: 3.9-5.6*106/mm3 0.7 3.8 5.9 1.2 RBCs count*106/mm3 80-95 fL 7.9 79 126.8 52.1 MCV fL 27-34 pg 26 44.2 12.3 MCH pg 30-35 % 2.0 32.9 38 20.3 MCHC % 11.6 – 14.6 % 3.1 15.6 31.5 11.2 RDW % 4-11 *109/L 30.6 10.7 1030 0.40 WBCs 109/L 150-400*103/mm3 132 256.4 1156 Platelets 103/mm3

Figure ( 5 ): Distribution percent types of anemia.

Normal RBC Microcytic –hypochromic Normocytic- normochromic Macrocytic Figure (6): Peripheral Blood Film Smear (under microscope).

Figure (7): Distribution percent of anemic disorders.

Table (4): Relationship between types of anemia and gender Significant P value χ2 value Total Gender Types of anemia Male Female .000 34.936 583 114 469 Microcytic-Hypochromic anemia 45.3% 8.9% 36.4% 520 177 343 Normocytic-Normochromic anemia 40.4% 13.8% 26.7% 23 11 12 Macrocytic -Normochromic anemia 1.8% .9% 62 16 46 Microcytic-Normochromic anemia 4.8% 1.2% 3.6% 99 25 74 Normocytic- Hypochromic anemia 7.7% 1.9% 5.7% 1287 944 Total n % 100.0% 73.3%

Table (5): Correlation between types of anemia and category of age anemic patients Significant P value χ2 value Total Both male &female >= 60 years of age Adult male 15-59 years of age Female 50-59 years of age Adult female 15-49 years of age Children 12-14 years of age 5-11 years of age Children 6-59 Months of age Types of anemia .000 95.694 321 48 41 27 192 9 4 Microcytic-Hypochromic anemia 41.5% 6.2% 5.3% 3.5% 24.8% .0% 1.2% .5% 325 90 66 134 3 5 Normocytic-Normochromic anemia 42.0% 11.6% 8.5% 17.3% .4% .6% 21 6 7 2 1 Macrocytic -Normochromic anemia 2.7% .8% .9% .3% .1% 42 11 8 Microcytic-Normochromic anemia 5.4% 1.4% 1.0% 64 29 23 Normocytic- Hypochromic anemia 8.3% 3.8% 3.0% 773 184 126 68 372 10 Total n % 100 % 23.8% 16.3% 8.8% 48.1% 1.3%

Table (6): Correlation between anemic disorders and category of age in anemic patients Significant P value χ2 value Total Both male &female >= 60 years of age Adult male 15-59 years of age Female 50-59 years of age Adult female 15-49 years of age Children 12-14 years of age Children 5-11 years of age Children 6-59 Months of age Anemic disorders .000 74.378 271 43 35 20 167 5 1 Iron deficiency 35.1% 5.6% 4.5% 2.6% 21.6% .0% .6% .1 % 321 75 58 30 144 4 6 Chronic diseases 41.5% 9.7% 7.5% 3.9% 18.6% .5% .8% 17 VitB12 or Folate deficiency 2.2% .1% 160 60 26 13 59 2 Mixed deficiency 20.7% 7.8% 3.4% 1.7% 7.6% .3% A plastic anemia or Preleukemia 773 184 126 68 372 9 10 Total N % 100% 23.8% 16.3% 8.8% 48.1% 1.2% 1.3%

Conclusion Anemia was highly frequent (71 Conclusion Anemia was highly frequent (71.5 %), among patients attended BMC during January 2016. Females were more commonly affected by anemia than males. The most common types of anemia were microcytic hypochromic anemia due to iron deficiency, followed by normocytic normochromic anemia due to chronic diseases.

Recommendations 1. The CBC should be measured at a regular intervals for each anemic patient. Other investigations include; Serum. Iron, S. Ferritin, TIBC, S.VitB12 and Folate, Reticulocyte count should be done as a routinely hospital diagnostic protocol . 2. There are a need for more nutritional health education and supplements especially among the reproductive age of females and old age for both sex.

3. Recommended of all physician to write diagnosis, age and department of patient on hematology request. 4. We need good quality work for Data Entry. 5. Hopefully, in future more research about causative factors and other types of anemia to help the health facilities to take appropriate measures for the prevention and treatment of anemia.

Limitations 1. Unavailability of the most data from database such as age and sender of patient’s. 2. This study has been done certainly at the lab in short period, So doesn't access to patient’s files records for all department of hospital. 3. This study didn’t cover all types of anemia such as hereditary anemia. 4.This study hasn’t done of PBF for all anemic patient’s. And results of some peripheral blood film samples did not correlate to RBC indices according to international reference(normal)values.

References 1. Mclean E, Cogswell M, Egli I, Wojdyla D, de Benoist B References 1. Mclean E, Cogswell M, Egli I, Wojdyla D, de Benoist B. Worldwide prevalence of anemia, WHO vitamin and mineral Nutrition Information System, 1993-2005. Public Health Nutr 2009;12:444-454. 2. Migone De Amicis M, Poggiali E, Motta I, Minonzio F, Fabio G, Hu C, Cappellini MD. Anemia in elderly hospitalized patients: prevalence and clinical impact. Intern Emerg Med. 2015;10(5):581-6. 3. Rachoin JS, Cerceo E, Milcarek B, Gerber DR. Prevalence and impact of anemia in hospital patients. South Med J.2013;106(3):202-6 . 4. World Health Organization. Heamoglobin concentrations for the diagnosis of anaemia and assessment of severity. Vitamin and Mineral Nutrition Information System. Geneva, World Health Organization; 2011.

5. Jadhav M V, et al. Utility of automated RBC parameters in evaluation of anemia. International J of Health and Biomedical Resear.2015;3(3):170-181. 6. Hoffbrand AV, Moss PAH, Pettit JE. Essential haematology. 5th ed. Oxford: Blackwell Publishing; 2006. 7. Bessman JD, Glimer PR, Gardner FH.Improved classification of anemia by MCV and RDW. Am J Clin Pathol 1983;80(3):322-326. 8. Howell, D.C. The analysis of missing data. In Outhwaite, W. &Turner, S. Handbook of social Science Methodology London :Sage.2008.

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