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Is 13 g·dL^–1 the threshold to correct anaemia in COPD?

Christian Medical College and Hospital, Ludhiana, India.

To the Editors:

I read with interest the recent article by Cote et al. 1, wherein the authors have beautifully highlighted the prevalence and association of abnormal haemoglobin with clinical outcomes in a cohort of stable chronic obstructive pulmonary disease (COPD) outpatients. However, there are certain points regarding their study that need discussion.

First, there may be overestimation of the anaemia prevalence, as patients with cancer, thyroid disease, liver disease, gastroinestinal haemorrhage or blood loss and vitamin B12 or folic acid deficiency were not excluded in the study and the prevalence of these diseases increases with age.

Secondly, the type and severity of anaemia was not categorised in the study. It was presumed that all the patients had anaemia of chronic diseases, and a wide range of other causes of anaemia in elderly people could have been missed.

Thirdly, the clinical symptoms of anaemia vary with the degree of severity of anaemia and, in the study, there was no correlation between severity of anaemia and increased dyspnoea and reduced exercise capacity.

Fourthly, it is important to note that anaemia of chronic disease (as in COPD) can be a reflection of a more progressive underlying disease 2, 3. However, the study by Cote et al. 1 could not associate this.

Finally, treatment of the underlying disease is the therapeutic approach of choice for anaemia of chronic diseases 2 and, in cases where the treatment of the underlying disease is not feasible, alternative strategies are necessary. Blood-transfusion therapy has been associated with increased survival rates in anaemic patients with myocardial infarction 4, but transfusion itself has also been associated with multiorgan failure and increased mortality in critically ill patients 5. Erythropoietic agents are approved for use in patients with anaemia of chronic disease as their beneficial effect involves counteracting the antiproliferative effects of cytokines 3, along with the stimulation of iron uptake and heme biosynthesis in erythroid progenitor cells 2.

Present data indicate that for patients receiving erythropoietic agents, target haemoglobin levels should be 11–12 g·dL^–1 6, and, in the study by Cote et al. 1, haemoglobin <13 g·dL^–1 was the cut-off level to define anaemia. Overcorrection of anaemia to normal haemoglobin levels 7 and insufficient treatment 8 have each been associated with unfavourable clinical courses. This elegant study by Cote et al. 1 has opened a new debate on ideal targeted haemoglobin levels in chronic stable chronic obstructive pulmonary disease patients.

REFERENCES

1. Cote C, Zilberberg MD, Mody SH, Dordelly LJ, Celli B. Haemoglobin level and its clinical impact in a cohort of patients with COPD. Eur Respir J 2007;29:923–929.[Abstract/Free Full Text]
2. Weiss G. Pathogenesis and treatment of anaemia of chronic disease. Blood Rev 2002;16:87–96.[CrossRef][Web of Science][Medline] [Order article via Infotrieve]
3. Spivak JL. Iron and the anemia of chronic disease. Oncology (Huntingt) 2002;16: Suppl. 10 25–11.
4. Goodnough LT, Bach RG. Anemia, transfusion, and mortality. N Engl J Med 2001;55:1272–1274.
5. Vincent JL, Baron JF, Reinhart K, et al. Anemia and blood transfusion in critically ill patients. JAMA 2002;288:499–507.
6. Rizzo JD, Lichtin AE, Woolf SH, et al. Use of epoetin in patients with cancer: evidence-based clinical practice guidelines of the American Society of Clinical Oncology and the American Society of Hematology. J Clin Oncol 2002;20:4081–4107.
7. Henke M, Laszig R, Rube C, et al. Erythropoietin to treat head and neck cancer patients with anaemia undergoing radiotherapy: randomised, double-blind, placebo controlled trial. Lancet 2001;162:1255–1260.
8. Besarab A, Bolton WK, Browne JK, et al. The effects of normal as compared with low hematocrit values in patients with cardiac disease who are receiving hemodialysis and epoetin. N Engl J Med 1998;119:584–590.

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