DISSERTATION ON

A STUDY ON LIPID PROFILE IN ANAEMIA

Dissertation Submitted To

THE TAMILNADU DR. M.G.R MEDICAL UNIVERSITY,

In partial fulfillment of the Rules and Regulations,

For the award of the M.D. Degree In General Medicine

BRANCH - I

THANJAVUR MEDICAL COLLEGE

THANJAVUR – 613004

THE TAMILNADU DR. M.G.R. MEDICAL UNIVERSITY

CHENNAI – 600032

APRIL - 2017
 CERTIFICATE

This is to certify that dissertation entitled A STUDY ON LIPID PROFILE IN

ANAEMIA is the bonafide record of work done by DR.P.SADHASIVAM in the

Department of General Medicine , Thanjavur Medical College, Thanjavur during his

Post Graduate Course from 2014 – 2017 . This is submitted as partial fulfillment for

the requirement of M.D. Degree Examinations – Branch I (General Medicine) to be held

in April 2017

Dr.C.Ganesan,M.D., Dr.S.Gopalakrishnan,M.D.,
Professor and Head of Department, Unit Chief,
Department of General Medicine, Department of General Medicine,
Thanjavur Medical College, Thanjavur Medical College,
Thanjavur. Thanjavur.

The Dean
Thanjavur Medical College,
Thanjavur.
 CERTIFICATE BY THE GUIDE

Certified that the thesis entitled “A STUDY ON LIPID PROFILE IN

ANAEMIA ” has been carried out by Dr.P.Sadhasivam, under my direct

supervision and guidance. All the observations and conclusions have been made

by the candidate himself and have been checked by me periodically.

Place: Thanjavur Dr.S.Gopalakrishnan,M.D.,

Unit Chief
Date : Department Of Internal Medicine
Thanjavur Medical College
Thanjavur
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 DECLARATION

I , DR.P.SADHASIVAM solemnly declare that dissertation titled A STUDY

ON LIPID PROFILE IN ANAEMIA is a bonafide work done by me at Thanjavur

Medical College Hospital during Jan 2016 – June 2016 under the guidance and

supervision of Prof.Dr.S.GOPALAKRISHNAN, M.D., Unit Chief., Department of

Internal Medicine.

The dissertation is submitted to THE TAMILNADU Dr. M.G.R. MEDICAL

UNIVERSITY, CHENNAI, TAMILNADU as partial fulfillment for the requirement

of M.D. Degree Examinations – Branch I (General Medicine) to be held in April 2017.

Place :Thanjavur Dr.SADHASIVAM .P

Date : Post graduate in General Medicine
Thanjavur Medical College
 ACKNOWLEDGEMENTS

I am extremely grateful to the Dean,Dr.M.VANITHAMANIM.S.,MCh.,

Thanjavur Medical College , for permitting me to do this dissertation in Thanjavur

Medical College Hospital,Thanjavur. With a deep sense of gratitude I remember the

Professor and Head of the Department of Medicine, Prof. C. GANESAN. M.D., for

allotting me this topic and for his constant encouragement in this venture.

I am very grateful to my Unit Chief Dr. S.GOPALAKRISHNAN. M.D., for

teaching me the essence of clinical medicine, knowledge of which is a prerequisite for

pursuing dissertation work of any sort.

I am extremely thankful to Prof.Dr.C.PARANTHAGAN, M.D., and my

Assistant Professors Dr.Sundararajan,M.D., Dr.Vinoth,M.D., Dr.Kavitha,M.D.,

Dr.Vetrivel,M.D., and Dr.Senthilkumar, M.D., D.M., for their thoughtful guidance

throughout the period of this study.

I am grateful to all the patients and volunteers who participated in this study. I

acknowledge my Family for their continuous encouragement. Finally I owe my thanks

to the ALMIGHTY for the successful completion of the study.

 ABBREVIATIONS

2,3-BPG 2,3-biphosphoglycerate

AIDS Acquired immune deficiency syndrome

Apo Apolipoprotein

BMI Body mass index

CETP Cholesteryl ester transfer protein

CHD Coronary heart disease

CoA Coenzyme A

DM Dimorphic anaemia

DNA Deoxyribo nucleic acid

FADH Reduced flavin adenine dinucleotide

FBS Fasting blood sugar

FH Familial hypercholesterolemia

G6PD Glucose 6 phosphate dehydrogenase

GIT Gastrointestinal tract

GM-CSF Granulocyte-macrophage colony stimulating factor

GPE General physical examination

Hb Haemoglobin

HCL Hairy cell leukemia

HDL High density lipoprotein

HMG CoA 3-hydroxy-3-methylglutaryl coenzyme

A HMP Hexose monophosphate

HSPG Heparan sulphate proteoglycans

IDL Intermediate density lipoproteins

JVP Jugular venous pulse

KIMS Kempegowda Institute of Medical Sciences

LCAT Lecithin:Cholesterol acyl transferase

LDL 1Low density lipoprotein

LP(a) Lipoprotein a

LPL Lipoprotein lipase

LRP Low density lipoprotein receptor related protein

MCH Mean corpuscular haemoglobin

MCHC Mean corpuscular haemoglobin concentration

MCP-1 Monocyte chemoattractant protein 1

MCV Mean corpuscular volume

MH Microcytic hypochromic anaemia

MPD Myeloproliferative disorder

MTP Microsomal transfer protein

NADH Reduced nicotinamide adenine dinucleotide

NCEP National cholesterol education program

NH Normocytic hypochromic anaemia

NN Normocytic normochromic blood picture

PPBS Post prandial blood sugar

RBC Red blood cell

RBS Random blood sugar

SAP Serum alkaline phosphatase

SD Standard deviation

SGOT Serum glutamate oxaloacetate aminotranferase

SGPT Serum glutamate pyruvate aminotransferase

T3 3,5,3’-Triiodothyronine

T4 Thyroxine

TSH Thyroid stimulating hormone

VLDL Very low density lipoprotein

 CONTENTS

PAGE
NUMBER CHAPTER
NUMBER

1 INTRODUCTION 1

2 OBJECTIVES 2

3 REVIEW OF LITERATURE 3

4 MATERIALS AND METHODS 60

5 RESULTS 65

6 DISCUSSION 90

7 SUMMARY 96

8 CONCLUSION 97

9 BIBLIOGRAPHY
ANNEXURE
1.PROFORMA

10 2. CONSENT FORM
3. INFORMATION SHEET
4. MASTER CHART
 INTRODUCTION

Research studies have generated considerable novel information about the

effect of serum lipids on heart disease and vascular disease. Elevated serum lipids

have a significant correlation with the risk of atherosclerosis which in turn causes

coronary artery disease, cerebrovascular disease & peripheral vascular disease, thus

increasing morbidity & mortality worldwide.

The most common nutritional disorder encountered in India is Iron

deficiency anaemia, although there are plenty of reasons attributable to anaemia.

There are studies reporting the beneficial effect of anaemia on lipid profile. Type

of anaemia does not influence the lowering of lipid levels. Decreased serum

cholesterol levels is not due to specific lowering of any particular lipoprotein

family, instead it is observed that there occurs a proportionate decrease in all major

lipoprotein families. Its interesting that this fall in serum lipids in anaemic patients

may decrease the risk of coronary artery disease – a disease which kills number of

Indians every year.

The mechanism by which anaemia causes a fall in serum lipid level is still a

grey area. It might be due to dilution effect, increased cholesterol utilization by

actively dividing cells, decreased liver oxygenation leading to reduced endogenous

cholesterol synthesis, increased levels GM – CSM & finally – in the bone marrow

– enhanced receptor mediated uptake of LDL . Once anaemia is corrected, Lipid

profile is normalized.

1
 OBJECTIVES

• To evaluate demography & clinical features in anaemia cases.

• To study Lipid profile of anaemic patients as compared with age & sex

matched controls.

• To correlate if type of anaemia has any effect on lipid profile.

• To study if severity of anaemia is associated with changes in various lipid

subfractions.

2
 REVIEW OF LITERATURE

Milestones in History

In 18th century Babington showed lipaemia causing milky plasma. In 1780,

Hawson explained alimentary Lipaemia and another pathological Lipaemia

occurring spontaneously. Later in 1903, Fischer listed the conditions resulting in

Lipaemia.

Diabetes mellitus is almost always associated with dyslipidemia. This was

first reported by Neisser, Derlin & Jonel. Conclusively, Klemperer & Umber

showed phospholipids, cholesterol and other sterols are frequently elevated in those

with diabetes. Now there is overwhelming evidence that hyperglycemia is the

major causes of high serum lipids which in turn causes increased risk of

cardiovascular complications of Diabetes Mellitus.

A rapid cholesterol assay method was first developed by Grigaurt in 1910.

In the 14th French Medical congress 1920, at Brussels-chaufford, Laroche &

Griguart put forward the theory of two types of Lipaemia : Masked and visible.

Widal, weill and Landet worked on this theory later on.

Frenchman Macheboef in 1920 first recognized plasma Lipoproteins.

(NH4)2SO4 treated serum, under specific circumstances lead to precipitation of

Lipids and proteins of constant composition.

Later in 1940s, cohn fraction technique to separate Lipoproteins was

applied by Oncley & his colleagues.

3
 The technique of preparative ultracentrifugation for isolation of

Lipoproteins was introduced by Havel, Eder & Bragdon. With the exception of

chylomicrons, ultracenrifugation is must to separate all lipoproteins. The use of

albuminated buffer in paper eletrophoretic separation of Lipoproteins further

improved the technique. The credit goes to Lees & Hatch for this contribution.

In order to classify Lipoprotein disorders based on which Lipoprotein

subfraction is particularly elevated, Frerickson, hevy & hees devised a system

where paper electrophoresis with Heparin or Manganese precipitation and

preparative ultracentrifugation was used.

Later, in the year 1967, Ritkind & Gale first showed the association of

anaemia with decreased cholesterol levels. This hypocholesterolemia was due to

proportional fall in the level of all major Lipoprotein subfractions rather than

specific decrease in any specific subfraction of Lipoprotein family.

In 1970, A study involving 4070 females found a mean difference of 30

mg/dl in the cholesterol levels between women with Haemoglobin levels above and

below 10.5 mg/dl. Treating anaemia resulted in increased cholesterol levels.

In the year 1975 Westermann established that regardless of the type of

anaemia, cholesterol level is related to the Hematocrit value.

4
Lipid – Biochemistry, Metabolism

What are Lipids?

Lipids are a heterogenous group of Hydrophobic organic molecules. Their

insolubility makes them compartmentalized – as membrane associated Lipids or

droplets of TAG inside fat cells or transportation as Lipoprotein particles or in

combination with albumin in plasma. Lipids are major energy source, and lipids in

the forms of fat soluble vitamins have regulatory or coenzyme functions and as

prostaglandins & steroid hormones – they have control over body’s homeostasis.

Classification of Lipids

Lipids can be classified as simple, complex, derived & other miscellaneous

lipids.

Simple Lipids

These are esters of fatty acids with alcohol. Fatty acids are classified based

on the number and position of double bonds. Saturated fatty acids have no double

bonds. Monounsaturated and polyunsaturated fatty acids have one and more double

bonds respectively. Fatty acids are a major source of energy. Triglycerides are

esters of fatty acids with glycerol. Waxes are esters of fatty acids other than

glycerol.

Complex lipids

Complex lipids possess additional groups like phosphate, carbohydrate,

protein or any nitrogenous base. They can be phospholipids, Glycerophospholipids,

Sphingophospholipids, Glycolipids, Lipoproteins, Sulfolipids, aminolipids,

Lipopolysaccharides, Triglycerides etc.,

5
Derived Lipids

There are derived by hydrolysis of simple & complex lipids and they bear

the characteristic features of Lipids . Glycerol, fatty acids, fat soluble vitamins etc.,

belong to this group.

Other Lipids

Substances like beewaxes, terpenes, squalene, etc which have the

characteristics of lipids are put under miscellaneous lipids.

Functions of Lipids

Lipids are dutiful within limits. But when consumed in excess, they

become a threat to health. Triacylglycerols are the concentrated (9 cal/g) fuel

source. Phospholipids and cholesterol make the cell membrane structure and

decides the membrane permeability. Lipids are the source of micronutrients-the

most important being fat soluble vitamins A, D, E, K. Steroid hormones and

prostaglandins act as regulators of cellular metabolism. Finally, lipids, by

surrounding the vital organs-gives them protection, provide insulation to our body

and also gives shape and smooth appearance to the physique.

6
 CHOLESTEROL

Cholesterol is exclusively present in animals. It is the most widely

distributed animal sterol. It was first isolated from bile. Cholesterol is synthesized

in the body which is the major source and it is also absorbed from the diet. Liver,

skin, adrenals gonads, brain and intestine produces cholesterol. Cholesterol is

present in plenty of amount in the nervous system. It functions as an insulating

cover and helps in transmission of electrical impulses within the nervous system.

Endogenous cholesterol biosynthesis begins with Acetate. Three acetate

molecules condense and form HMG-CoA. The enzyme HMG-CoA Reductase

converts this into mevalonic acid which in turn, through a number of steps, is

converted into cholesterol. The rate limiting enzyme is HMG-CoA Reductase

which is controlled by the amount of cholesterol inside cells. Cholesterol does not

get catabolised, instead it is excreted in bile as free cholesterol or converted into

bile acids and secreted into the gut. Both free cholesterol and bile acids undergo

enterohepatic circulation.

Bile Acid Synthesis

The step catalyzed by 7-alpha hydroxylase is the Rate limiting step.

Synthesis of Bile acids takes place in Liver. This enzyme is under the negative

feedback control of Bile Acids.

7
LDL Receptor

All cells contain low density lipoprotein receptors on their surface. It

regulates the uptake of cholesterol rich Lipoproteins from the circulation. LDL

receptor binds apolipoproteins B-100 and E. The cholesterol content inside cell

regulates the number of LDL receptors and thus keeps intracellular cholesterol

content almost relatively constant .

Acyl CoA-cholesterol Acyl Transferase

This enzyme is present in Endoplasmic Reticulum which esterifies free

cholesterol that enters the cell. The enzyme cholesterol ester hydrolase generates

free cholesterol again by hydrolysis for efflux from the cells or to use as substrate

for biosynthesis.

Digestion of Ingested Lipids

Ebners glands on the dorsum of tongue secrete lingual lipase which is not

of much significance, thus beginning the digestion of lipids in the oral cavity itself.

Gastric lipase, the main predeodenal lipase hydrolyses Triacyl glycerols

into water soluble short chain and Medium chain fatty acids which enter the portal

vein.

The major part of digestion of dietary lipids takes place in the Intestine by

pancreatic enzymes such as lipase, Co-lipase , cholesterol esterase, Bile salt

activated lipase and phospholipase A2. Bile salts helps in the digestion of lipids

because of their property of reducing surface tension and emulsification of fats.

8
 Pancreatic lipase hydrolyses triacyl glycerols into mono-acyl glycerol,

diacyl glycerol and fatty acids. Bile salt activated lipase hydrolyses cholesterol

esters, phospholipids, triglycerides and esters of fat soluble vitamins.

Cholesterol Esterase hydrolyses cholesterol esters into cholesterol and Fatty

acids. Phospholipase A2 hydrolyses Glycerophospholipids into Lysophospholipids

which in turn helps in emulsification of lipids and their digestion.

ABSORPTION OF LIPIDS

Hydrophilic products Such as Glycerol and SCFA formed after the digestion of

lipids are directly absorbed into the portal circulation.

The other products such as LCFA, 2-Mono Acyl Glycerols, cholesterol,

phospholipids and lysophospholipids needs micelles & liposomes as they are

hydrophobic. Micelles are spherical with a hydrophobic core which contains the

above mentioned hydrophobic products and a hydrophilic exterior to allow the

product of lipid digestion to be carried through aqueous surrounding of the

Intestinal lumen to the cells in the brush border of intestine from where they are

absorbed into interstesial cells.

Once inside the mucosal cells, fatty acids are again re-esterified into

triglycerides. Together with phospholipids, cholesterol, apoproteins A, C, E they

are incorporated into chylomicrons. These chylomicrons are produced in Golgi

bodies. Cholesterol and lysophospholipids also undergo re-esterification to form

cholesterol esters and phospholipids.

9
 Intestinal mucosa produces chyle loaded with chylomicrons which is

transported into thoracic duct via lacteals and finally into the systemic circulation.

Triglycerides & free Fatty Acids

Lipoprotein lipase in capillary Endothelium acts on triglycerides of

chylomicrons & VLDL and releases free fatty acids. Insulin the main fat storage

hormone – converts free fatty acids into triglycerides for storage in the adipose

tissue. Triglyceride synthesis is catalysed by enzyme-Acyl CoA-DGAT.

FFA release from storage depot – fat cells

Hormone sensitive lipase causes lipolysis and release of free fatty acids into

the blood stream. There are number of hormones that activate lipoprotein lipase

such as catecholamines, Glucagons, corticotrophins, placental lactogen,

Thyrotrophin, Prolactin, VIP, Growth hormone, Glucocorticoids, and vasopressin.

Those that inhibit hormone-sensitive lipase and thereby lipolysis include Insulin,

Oxytocin, prostaglandins, Gastric inhibitory peptide and somatomedins. Released

FFA circulate in plasma as albumin bound forms and are either taken up by liver or

muscle. Glycerol is used up for synthesis of triglycerides or Gluconeogenesis by

liver or kidney.

Ketogenesis and Fatty Acid Oxidation

Except for long chain fatty acids which are oxidized in peroxisomes, all

other fatty acid oxidation and ketogenesis takes place in the mitochondria. Fatty

acids by oxidation are converted into CoA derivatives which is further converted

into Acetyl CoA, FADH and NADH by beta oxidation. FADH and NADH enter

the electron transport system and Acetyl CoA into the citric acid cycle.

10
 In uncontrolled Diabetes Mellitus and in prolonged starvation, the influx of

free fatty acids into liver in large quantities exceeds liver’s capacity to metabolize

and accumulation of Acetyl CoA, FADH and NADH inside Mitochondria finally

results in ketogenesis.

Biosynthesis of Fatty acids

Fatty acid synthesis is the result of condensation of Acetyl CoA molecules

in the cellular cytoplasm. 8 Acetyl CoA molecules condenses and forms palmitic

acid. LCFA such as stearic acid and Oleic acid are synthesized by chain extension

from palmitic acid.

Apolipoproteins

These are protein components of Lipoproteins, which act as structural

component of lipoprotein and recognizes surface receptors in cell membranes.

They are involved in lipoprotein metabolism. Each lipoprotein have specific

apolipoprotein composition.

Apolipoprotein B

There are two forms – ApoB48 and ApoB-100. Liver produce apo B100

and it’s a structural component of VLDL, LDL, IDL. Its a ligand for LDL Receptor.

Apo B48 is a structural protein of chylomicron produced in intestine and it is unable

to bind to LDL receptor.

Apolipoprotein E

This is a component of chylomicron, chylomicron remnants, VLDL, IDL,

HDL1 and also serves as a ligand for LDL receptor and apo E receptor. This is

synthesised widely in many tissues including macrophages and liver. Apoprotein E

11
involves chylomicron and VLDL transport and also gets involved in the

redistribution of lipids among different cells in a tissue or organ.

Apolipoprotein AI

This is a component of chylomicrons and HDL synthesized in liver and

intestine. It activates LCAT which causes esterification of free cholesterol on HDL

molecules.

Apolipoprotein AII

This is found in combination with apoA1 on a subfamily of HDL known as

Lp AI/AII particles and is synthesized mainly in liver. This may activate hepatic

lipase and inhibit LCAT.

Apolopoproteins CI, CII, CIII

These are synthesized primarily in the liver and are readily exchanged

among different Lipoprotein families. HDL is a reservoir for these apolipoproteins

which are then transferred to Triglyceride rich Lipo-proteins. Apo CI and CIII

modulates remnant binding to receptors. Apo CI activates LCAT and Apo CII acts

as co-factor for Lipoprotein Lipase.

12
 LIPOPROTEIN RECEPTORS

LDL Receptor

This receptor binds apo B100 and apo E possessing Lipoproteins.

Cholesterol content inside the cell regulates the expression of LDL receptors on cell

surface.

LDL Receptor – related protein

This is an integral receptor of cell membrane. It has high affinity for apo E

enriched chylomicron remnants and VLDL remnants but does not bind with LDL.

VLDL Receptors

This receptors binds with apo E containing Lipoprotein. VLDL receptors

are found especially in muscle, brain and fat . It is not present in liver. It delivers to

the target organs triglyceride enriched Lipoproteins.

Apolipoprotein E Receptor

This receptor is expressed in Brain and placenta and helps in Lipoprotein

metabolism in CNS. It transduces extracellular signals and has an important role in

normal brain development.

Scavenger Receptors

Scavenger receptors gain significance because of their property to interact

with broad range of different kinds of ligands involved in various processes like

atherosclerosis, CNS disorders and host defense mechanisms. They are classified

into five subclasses – subclass A, B, C, D, E. Acetylated, Acetoacetylated and

Malondialdehyde attached LDL particles are taken up by scavenger receptors.

13
 VARIOUS ENZYMES AND TRANSFER PROTEINS

Hepatic Lipase

Hepatocytes synthesis hepatic lipase which is present on hepatic

endothelium and HSPG in the space of Disse. From the liver, this enzyme is

transported to the capillary endothelium of Gonads and adrenal glands. When

chylomicron remnants are finally processed this enzyme hydrolyses phospholipids

and triglycerides. It also binds with Heparan sulfate and causes interaction between

LRP and remnant Lipoproteins, thus facilitating internalization of these receptors

into Hepatocytes. IDL is processed into LDL by hepatic Lipase. Triglycerides and

phospholipids are removed from HDL2 by hepatic lipase and thus HDL2 is

converted to HDL3.

Lipoprotein lipase

Adipocytes, Myocytes and Macrophages synthesis lipoprotein Lipase. It is

then transported to capillary endothelium and gets attached to HSPG. Lipoprotein

Lipase then interacts with chylomicrons and VLDL in the circulation and helps in

Triglyceride hydrolysis.

LCAT

Lecithin – cholesterol Acyl transferase with HDL in circulation esterifies

cholesterol in its free form. Small HDL particle is the major substrate for this

enzyme. It mainly transfers LCFA from phosphatidyl choline to cholesterol.

14
CETP

Cholesterol ester transfer protein catalyses the transfer of cholesterol esters

from HDL to VLDL, IDL or remnant lipoproteins. Triglycerides from lipoproteins

is transfered to HDL in return.

PLASMA LIPOPROTEINS

Chylomicrons

The largest plasma lipoprotein composed of 99% lipid and 1% protein is

chylomicron. They are abundant in plasma after food. They contain apo B48,

apoA1, apoAIV, apoC and apoE apolipoproteins. The specific Lipoprotein is apo

B48 synthesized only in the intestinal epithelial cells.

Chylomicrons are synthesized in proximal Jejunum and duodenum. Inside

the cellular golgi apparatus, FFA and monoglycerides combine to form

triglycerides which in combination with cholesterol and phospholipids form

chylomicrons. These chylomicrons through mesenteric lymph reach thoracic duct

and ultimately emptied into the blood stream.

The action of LDL on chylomicron produces chylomicron remnant by the

release of FFA from Triglycerides, which are cleared by liver from the circulation

with the aid of LDL and LRP receptors.

15
VLDL

The density of VLDL is less than 1.006g/ml that they float on

ultracentrifugation. Composition is 85% Lipid and 15% protein. The specific

apolipoprotein is apo B100. They also have apo E & C apolipoproteins. They are

synthesized in liver and while in circulation additional apolipoprotein E is added

from HDL.

LPL and hepatic lipase hydrolyse Triglycerides resulting in IDL formation.

IDLS retain apoE and apo B-100. Again the above two enzymes convert IDL to

LDL. Half of VLDL is processed to LDL while remaining is cleared by liver.

IDL

Intermediate Density Lipoproteins possess a composition between LDL and

VLDL. They are present only in low concentration in plasma.

The specific apolipoproteins are apoE and apo B100. They are catabolic

products of VLDL metabolism and are the precursors of LDL. IDL is finally

processed by hepatic lipase or is cleared from circulation by the LDL receptor.

LDL

The major cholesterol bearing Lipoprotein in plasma is LDL, with a

composition of 75% Lipid and 25% protein. The specific protein is Apo B100 and

contains small amount of apoE.

16
 VLDL are finally processed into LDL by the process of Lipase hydrolysis.

The larger VLDL particles have a core rich in triglycerides which is removed and

then the excess surface constituents after remodeling are transferred to HDL

forming LDL rich in cholesterol and devoid of all Lipoproteins, the only exception

being apoB100.

LDL receptor and apoB100 mediates most of the uptake of LDL & almost

75% uptake is into the hepatocytes.

LDL is the source of cholesterol for many cells. Cholesterol is used for

Lipid bilayer biosynthesis, biosynthesis of VLDL, excretion in bile and conversion

into bile acids, for production of steroid hormone in gonads & adrenal glands.

Cholesterol plays an important role in cell proliferation as well as repair.

HDL

HDL floats at densities of 1.063 to 1.21 g/ml. HDL is subclassified as

HDL1, HDL2 and HDL3. HDL is composed of 50% Lipids and 50% protein.

The major aproproteins are apoA1, Apo AII and lesser amounts of C & E. HDL1

is present in very small amounts and contains ApoE.

There are 3 sources of HDL – Liver, Intestine & Lipolysis of surface

material of chylomicrons and VLDLs.

17
 The HDL precursor particles are known to excellently uptake free

cholesterol. LCAT esterifies free cholesterol and moves inside from the surface

resulting in cholesterol ester rich core (HDL-2). As more and more cholesterol is

accepted by HDL-2, it is converted to HDL-3. When HDL2 acquires apoE, it forms

HDL1.

Reverse cholesterol transport is an important function of HDLs. HDLs

receive the cholesterol from cells and transport it to other cells including

hepatocytes that are in need of cholesterol. Apo E on HDL1 makes this a target to

cells expressing LDL receptor. CETP transfers cholesterol ester to VLDL, LDL,

IDL remnants from HDL2. Thus HDL2 particles are depleted of cholesterol esters

and made enriched with triglycerides by the action of CETP.

HDL2 is then acted upon by hepatic lipase and gets converted to HDL3. Thus

HDL2-HDL3 cycle goes on perpetuating. It is a well known fact that high levels of

HDL is associated with decreased incidence of CHD. How this occurs is HDL

causes redistribution of cholesterol away from the walls of arteries.

18
 LIPIDS AND ATHEROSCLEROSIS

Atherosclerosis results in narrowing of vessels leading to decreased supply of

oxygen and nutrients to the affected organs. When oxygen is insufficient, it results

in ischemia or infarctions – Angina or MI in heart, stroke in brain, intermittent

claudication of lower limbs. CHD is more important because it ranks first as the

cause of death in most countries.

Lipid deposition and cellular proliferation causes narrowing of vessel walls

leading to plaque formation and obstruction. When plaques are susceptible to

fissuring and ulceration, it results in emboli and compromise of blood supply to

vital organs. Lipids deposited include plasma lipoproteins. High plasma

cholesterol is an important risk factor. The other significant risk factors include

male sex, Comorbidities like Diabetes, hypertension, obesity as well as life style

factors like lack of exercise, stress and smoking also contribute to atherosclerosis.

Cholesterol – Diet – Heart Hypothesis

1. Elevated plasma cholesterol increases CHD risk

2. High fat diet with saturated fat and cholesterol results in elevated

plasma cholesterol

3. Lowering plasma cholesterol results in decreased CHD risk.

19
Evidence from Human Study

Lipid lowering drugs invariably reduces CHD risk in humans as evidenced

by several studies. This clearly implies that reduction in plasma cholesterol levels

is protective against CHD risk.

Epidemiological evidence

Relationship between plasma cholesterol level and the risk of CHD is

evidenced from many epidemiological studies. The MRFIT trial showed that when

cholesterol levels are greater than 200 mg/dl, the risk increased several fold.

Similarly, the seven countries study showed association between increased plasma

cholesterol and CHD risk.

Epidemiological studies also have shown high intake of saturated fats in

diet tends to increase plasma cholesterol levels. Restriction of dietary fat may have

a therapeutic role in control of plasma cholesterol levels.

The Atherogenic Lipoproteins

Apo B containing Lipoproteins are atherogenic including LDL.

LP (a) has apo (A) which is atherogenic due to thrombosis related mechanisms.

LDL is of different densities. The large fluffy LDLs are safe while the small

dense LDLs are more atherogenic.

20
The LDL paradox

The LDL receptor pathway is highly regulated that only less amount of

normal plasma LDL is taken up by macrophages. This down regulates LDL

receptors expression and thus cells are protected from accumulation of LDL. As

only limited quantities are taken up by macrophages, the question arises why LDLs

contribute to atherosclerosis. Its because modified LDLs are taken up by

macrophages in an unregulated manner with the help of scavenger receptors which

are not related to LDL receptor. The chemical modification of LDL previously

mentioned as well as macrophages themselves can cause LDLs to be modified and

taken up by scavenger receptors.

21
 ATHEROGENESIS

The initial event in this process is accumulation of atherogenic lipoproteins

enriched with cholesterol in the subendothelial layers of arteries. Normal healthy

arteries are transformed to lesioned unhealthy arteries due to oxidation and other

modifications of lipoprotein accumulated.

Circulating monocytes gets attached to surface endothelium of vessels. The

retained atherogenic lipoprotein in surface endothelium and in regions of micro-

injury is the cause for this. After adherence these monocytes migrate between the

cells of endothelium and finally enter into the subendothelial space and are

converted into macrophages. The trapped LDL in the vessel wall undergoes

modifications and are taken up by macrophages forming foam cells.

Mcp-1 (Monocyle chemoattractant protein) which is synthesized by

endothelium and smooth muscle cells causes further recruitment of monocytes.

Other significant growth factors involved in atherosclerosis include PDGF, BFGF,

IF, IL-1, TNE, TGF B. All these factors enhance smooth muscle proliferation.

Cytokines of atherogenesis include IL-1, TFN, TNF, IL2 & CSF. These cytokines

act in autocrine or paracrine manner.

The first macroscopic lesion visible is Fatty streak due to foam cells. Based

on local stimuli in the arterial wall fatty streaks come and go.

22
 Fatty streak matures to form fibrous plaque. This extends into vessel

lumen. The already accumulated lipid is cytotoxic causing necrosis of foam cells

leading to lipid deposition extracellularly and collagen synthesis accompanied by

migration of smooth muscle cell and its proliferation.

As endothelial cells are lost, the surfaces of complicated lesions turn

thrombogenic, causing adherence of platelet and thrombus formation. Sometimes

plaque fissuring occur and blood dissects into the artery wall resulting in the

formation of a large thrombus. Calcification might occur. Advanced lesions makes

the artery wall weak resulting in aneurysm formation. Removal of atherogenic

stimulus results in regression of plaque leaving a scar with remnants devoid of

lipids.

23
 HYPERLIPIDEMIA

90th to 95th percentile of values from population distribution is considered

as hyperlipidemia. NCEP 2001 guidelines suggests plasma cholesterol of 200

mg/dl is desirable, 200-240 mg/dl is borderline, greater than 240 mg/dl is high.

Less than 130 mg/dl is considered Hypolipidemia.

The cause of hyperlipidemia is increased Lipoprotein concentration due to

increased production or increased secretion into the circulation, decreased clearance

or coexistence of both causes. Genetic defects are considered as primary disorder

in Lipid metabolism where as alterations in lipid metabolism due to Diabetes

mellitus and Hypothyroidism are classified as secondary disorders. These endocrine

disorders leads to increased concentration of plasma lipoproteins.

PRIMARY DISORDERS

Familial Hypercholesterolemia

Familial Hypercholesterolemia is due to LDL receptor gene mutation

resulting in LDL receptor dysfunction or total absence resulting in increased LDL

and total cholesterol levels. The clinical picture is presence of Tendon xanthomas

on extensor tendons of hands and Achilles tendon, Xanthelesma and premature

corneal arcus. Also premature coronary artery disease is known in increased

frequency. This disorder is mainly diagnosed clinically. Confirmation is by skin

fibroblasts culture and demonstration of decreased ability of LDL binding to its

celluar receptors. The mainstay of treatment is a low fat diet along with drug

therapy.

24
Familial defective apolipoprotein B-100

The LDL receptor ligand apo-B100 mutation results in elevated plasma

LDL and total cholesterol levels. Lipid profile reveals isolated increase in LDL-C

and other clinical picture of FH. Treatment is low fat, low cholesterol diet with

drug therapy.

Familial combined Hyperlipidemia

Here plasma cholesterol and triglyceride levels are elevated with increased

susceptibility to CHD. This Autosomal dominant trait is still of unknown genetic

cause. Moderate elevation of both plasma cholesterol, triglyceride or either one

associated with glucose intolerance, obesity or hyperuricemia is the feature here.

Management includes weight reduction and dietary modification. Drug

therapy is targeted only to correct lipid abnormality whereas associated metabolic

abnormalities are corrected by lifestyle modifications. Identifying affected family

members is important.

Type III Hyperlipoproteinemia

Hypertriglyceridemia and Hypercholesterolemia due to accumulation of

cholesterol rich remnants is the characteristic feature of Type III

Hyperlipoproteinemia. Apo E mutation results in defective binding to lipoprotein

receptors. The pathognomonic feature is palmar Xanthomas. Apart from this

tuberous or tuberoerective xanthomas are also seen. Premature CVD is also a

feature.

25
 A careful search should be done to identity the cause of obesity and treat it. The

other underlying causes like alcoholism, diabetes mellitus and Hypothyroidism

should be controlled. Dietary modification by restricting total fat, cholesterol and

saturated fat and restricting calories to promote weight loss must be practiced. Only

when treatment of underlying co-morbid illnesses and dietary therapy do not yield

expected results, drug therapy should be started.

Lipoprotein Lipase Deficiency

LPL gene mutation leads to LDL deficiency a rare disorder, Recessive in

nature. This is diagnosed usually in infancy as Chylomironemia syndrome.

Recurrent abdominal pain or pancreatitis with Hypertriglyceridemia is the feature

here. There may be lipemia retinalis and eruption xanthomas.

Heterozygous patients have decreased LDL activity with mild or moderate

hypertriglyceridemia .

Dietary therapy with fat free diet is adviced till the triglyceride levels are

within safety limits. This fat restriction should be continued lifelong. Medium

Chain Triglycerides can provide as source of dietary fat. Supplementation of fat

soluble vitamins is done. Drug therapy has no effect in LDL deficiency.

26
Apolipoprotein C II deficiency

This is also a autosomal recessive disorder causing chylomicronemia

syndrome involving pancreatitis and recurrent abdominal pain. After 12 hours fast,

the serum is lipaemic. Heterozygotes have mildly elevated triglyceride levels, but

no pancreatitis. Apo CII containing plasma transfusion is used to treat severe

hypertriglyceridemia and pancreatitis in apo CII deficient patient.

Familial Hypertriglyceridemia

Triglyceride rich VLDLs are increased in plasma. In this unknown genetic

defect, Insulin resistance and obesity is common. Dietary restriction of fat along

with treatment of underlying secondary causes like Diabetes mellitus,

administration of Estrogen or alcohol consumption should be searched for and

treated. Drugs lowering triglycerides are useful.

High plasma Lp(a) levels

Increased modified LDL particles in the plasma in which apo(a) is

covalently bonded to apo-B is the feature of this disorder. There are no special

features to suggest increased Lp(a) levels. It can be suspected in patients with

premature CHD. Niacin is known to lower Lp(a) levels.

Polygenic Hypercholesterolemia

This is a diagnosis of exclusion of other primary genetic disorders

characterized by absent Tendon Xanthomas . Hypercholesterolemia is present only

in less than 10% of first degree relatives.

27
Sporadic Hypercholesterolemia

Absence of Hypercholesterolemia in other family members helps in

distinguishing this from familial syndromes. Dietary restriction of fat along with

treating underlying secondary causes and drugs is the line of management.

PRIMARY DISORDERS INVOLVING HIGH DENSITY LIPOPROTEIN

METABOLISM

Apolipoprotein a mutation

Familial Hypo alpha lipoproteinemia

CETP deficiency

PRIMARY GENETIC HYPOLIPIDEMIAS

Familial Hypobetalipoproteinemia

Abetalipoproteinemia

SECONDARY DISORDERS

Diabetes Mellitus

Hypothyroidism

Alcohol intake

Protease inhibitors

Nephritic syndrome

28
Other agents

Other drugs causing hyperlipidemia includes beta blockers, Thiazide

diuretics and Glucocorticoids. Exogenous administration of androgens is known to

decrease HDL levels.

29
 ANAEMIA

Anemia is defined as a reduction below normal limits of total red cell mass. As

it is not easily measurable, it is defined as reduction below normal of hematocrit or

reduction in Haemoglobin concentration in blood

When Haemoglobin level < 13 g/dl (males)

Haemoglobin level < 12 g/dl (female) is Anemia according to WHO

Recommendation.

Prevalence

20% world population are affected by anemia. Most commonly, it affects

women of 15 – 44 years of age. It again increases in the elderly. Mainly, the cause

is iron deficiency. In India Estimates show that

30% adult males

45% adult females

80% pregnant females

60% children

have iron deficiency.

Pathology

Oxygen carrying capacity is reduced – there by arterio venous oxygen

difference is reduced.

30
The compensatory mechanism include

1. Intrinsic RBC compensation. 2, 3 – BPG concentration increases which

causes the oxygen dissociation curve to the right, thus enhancing the tissue

oxygen delivery by 40%.

2. Locally, shunting of blood from less to more vital organs, vasodilatation of

blood vessels of skin and kidney occur.

3. Cardiovascular system changes occur when Haemoglobin level falls below

7-8 g/dl, there will be increased stroke volume and cardiac output increases.

Hyperkinetic circulation occurs due to reduced velocity of blood and

vasodilatation due to reduced after load.

Clinical Manifestation

Acute blood loss Chronic anemia

Shock General – Easy fatiguabilility

Collapse pallor

Dyspnea cardio respiratory features :

Tachycardia Exertional dyspnea

Feeble pulse tachycardia

Hypotension palpitation

Peripheral vasoconstriction angina

Claudication

Night cramps

Cardiac murmurs

31
 Cardiomegaly

Features of CCF

Neuromuscular features

Headache, vertigo, light headedness, tinnitus,

Muscle cramps

GI symptoms

Loss of appetite, Nausea, constipation, diarrhea

Genitourinary

Menstrual irregularities, urinary frequency,

Loss of libido

Classification

It may be classified according to

Morphology

Underlying mechanism

1. Morphology

Hypochromic microcytic (MCV, MCH, MCHC decreased)

1.Acquired : Iron deficiency, sideroblastic anemia, Anemia of chronic disease

2. Genetic: thalassemia, sideroblastic anemia

2. Normocytic – normochromic

Chronic disorders: Infection, malignancy, collagen disease, Rheumatoid

arthritis

32
 Renal failure

Hypothyroidism

Hypopituitarism

Aplastic anemia

Red-cell hypoplasia

Disease of bone marrow : Leukemia, Malignant infiltration, Myelosclerosis.

3.Normochromic – macrocytic (MCV increased)

1. Normoblastic bone marrow : liver disease

Myelodysplasia

Chemotherapy

2. Megaloblastic marrow: Vitamin B12

Folate deficiency

4.Polychromatophilic – macrocytic (MCV increased)

Hemolysis

5.Leucoerythroblastic (Normal indices)

Myelosclerosis

Leukemia

Metastatic carcinoma

33
2. Underlying Mechanism

1. Blood loss – Acute – Trauma

Chronic – GIT lesions, Gynecological problem

2. Intrinsic RBC abnormalities

Intrinsic

a. RBC membrane disorders

Cytoskeleton disorder : Spherocytosis

Elliptocytosis

Lipid synthesis disorder : in membrane lecithin

b) Enzyme deficiencies

Glycolytic enzymes : Pyruvate kinase deficiency, Hexokinase deficiency

HMP shunt pathway: Glucose 6 Phosphate Dehydrogenase, Glutathione

synthetase deficiency

c) Hb synthesis – disorders

Globin synthesis : α – thalassemia

Β – thalassemia

Hemoglobinopathies : Sickle cell anemia

Haemoglobin D,

Unstable Haemoglobins

Acquired :

PNH - Paroxysmal nocturnal hemoglobinuria

34
Extrinsic abnormalities

a) Antibody mediated :

Isohemagluttinins : Transfusion reaction

Erythroblastosis fetalis

Auto antibodies : idiopathic

Drug – associated

SLE

Malignant neoplasm

mycoplasma infection

b) Mechanical Trauma

Micro angiopathic hemolytic anemia:

Thrombotic thrombocytopenic purpura, DIC

Cardiac traumatic Hemolytic anemia

c) Infection : Malaria

d) Chemical injury : Lead poisoning

e) Sequestration in mononuclear phagocyte system: Hypersplenism

3) Impaired RBC production

a) disturbed proliferation and differentiation of stem cells :

Aplastic anemia

Pure Red cell aplasia

Anemia of renal failure

Anemia of endocrine disorder

35
b) Disturbed proliferation and maturation of erythroblasts :

DNA synthesis : vitamin B12 deficiency

Folate deficiency

Defective hemoglobin synthesis:

1) Heme synthesis : Iron deficiency

2) Globin systhesis : Thalassemia

Unknown :

Sideroblastic anemia

Anemia of chronic infection

Myelophthisic Anemia due to infiltration of bone marrow

36
 PRINCIPLES IN ANEMIA MANAGEMENT

Cause of anemia should be found before the start of treatment. In most

cases of Iron – deficiency anemia further more investigations for blood loss are

required. Iron therapy may be started if there is clear cut history about the cause

without further investigation and Haemoglobin levels monitored before and after

therapy. If the Haemoglobin level increases by 1 g/dl per week, then there is full

response to therapy.

For megaloblastic anemia, blood samples have to be obtained for serum

folate, B12 levels and then treatment is to be initiated. In about 5 – 7 days,

Reticulocytosis will occur. Blood transfusion should be done only when

Haemoglobin level is dangerously low, in such cases, patient should be transfused

to attain safe level and then Haemoglobin has to be increased with appropriate

treatment of the specific cause.

In patients with severe congestive heart failure due to anemia, blood

transfusion has to be done to a level of Haemoglobin about 6 – 8 g% . Packed cells

should be transfused along with furosemide for fear of fluid overload. In patients

with more severe CCF, through one, arm packed cells are transfused and through

the other arm, equal amount of blood is removed.

37
 ANEMIA OF BLOOD LOSS

Acute Blood loss :

The response to blood loss is calculated by

- Rate of blood loss

- External or internal bleeding

If the patient survives after an acute blood loss, there occurs a

compensatory mechanism of shift of water from interstitial fluid to restore the lost

blood volume. This causes the hematocrit to fall, Erythropoietin levels are

increased causing increased erythropoietin levels. If there is internal bleeding, iron

can be reused but, if there is external bleeding, iron deficiency occurs in presence

of inadequate reserves. 10 – 15% reticulocytosis is observed after 7 days.

Chronic blood loss

If the rate of loss exceeds the regenerative capacity of RBC precursors, then

anemia is manifested. Iron deficiency anemia is the most common type in chronic

blood loss.

38
 HEMOLYTIC ANEMIA

The characteristic features include

- Premature destruction of RBCs

- Marked increase in erythropoetins

- Catabolic products of hemoglobin gets accumulated

Hemolytic anemia may be Intravascular or Extravascular

Intravascular hemolysis is caused when RBCs are damaged by mechanical

injury or complement fixation in mismatched transfusion or exogenous toxins.

There will be decreased haptoglobin level and hemoglobinemia, hemoglobinuria,

methemoglobinemia, unconjugated hyperbilirubinemia, hemosiderinuria etc.

When RBCs are injured or made foreign or become less deformable,

then RBCs get sequestered within the spleen. This causes extravascular hemolysis.

Hemoglobinemia, Hemoglobinuria, hemosiderinuria does not occur, but there will

be decreased haptoglobins.

On the whole, hemolytic anemia causes marked increase in both

marrow normoblasts and extramedullary hematopoises. Reticulocytosis occurs.

Due to high levels of bilirubin, pigment gallstones are formed. In chronic cases,

hemosiderosis of mononuclear – macrophage system occurs.

39
Hereditary spherocytosis

Autosomal dominant disorder, affecting the scaffolding proteins for RBCs

namely ankyrin, spectrin and protein 3. This causes loss of membrane stability

which results in decreased surface to volume ratio and a spherical shape due to

decreased deformability resulting in trapping and hemolysis of RBCs in spleen.

Characteristic features include anemia, splenomegaly and jaundice.

Aplastic crisis occurs when there is temporary suppression of anemia caused by

parvovirus infection, which results in sudden worsening of anemia and

disappearance of reticulocytes from the blood. Gallstones may form. The

diagnosis is done on the basis of family history, hematological findings and raised

osmotic fragility of RBCs. Splenectomy and folate supplementation finds helpful in

most patients.

Hereditary elliptocytosis

A genetically heterogenous disorder characterized by elliptical cells with

hemolysis. The disorder can be inherited both in autosomal dominant and

autosomal recessive forms. It occurs due to point mutations or deletions in α

spectrin or β spectrin genes. Characteristic features include anemia, splenomegaly

and reticulocytosis. Peripheral smear shows elliptocytes and pencil cells.

Management is same as that of hereditary spherocytosis.

40
G-6-PD deficiency

G6PD plays a main role in HMP shunt, which is responsible for protecting

cells from oxidative damage. It is an X linked recessive disorder. It is usually

asymptomatic, but in periods of oxidative stress due to drugs (primaquine,

Nitrofurans, chloramphenicol , analgesics, sulfonamides), chemicals, infectious

agents and favism due to a bean, severe hemolysis and anemia occur. Within 24

hours of exposure, intravascular hemolysis occur manifesting as malaise and

abdominal pain. Within 2-3 days, anemia, jaundice, hemoglobrinuria and acute

renal failure sets in. Anisocytosis, poikilocytosis, Heinz bodies are seen in

peripheral smear. Diagnosis is made by decreased G6PD activity. Avoidance of

precipitating factors and blood transfusion helps in the management of this disorder

Paroxysmal nocturnal hemoglobinuria

An acquired clonal stem cell disorder caused due to mutation in

phosphatidyl inositol glycan A gene, results in abnormal sensitivity of RBCs to

lysis by complement reaction. Episodic hemoglobinuria in the morning occurs

since complement activity is enhanced by respiratory acidosis occuring in sleep.

The other features include anemia, iron deficiency, thrombosis of hepatic, portal or

cerebral veins. The rare complications include aplastic anemia, AML and

myelodysplasia. Investigatory findings include anemia and hemosiderinuria.

Serum LDH, iron deficiency, leucopenia, thrombocytopenia, absence of CD 59 by

flow cytometry. Iron replacement, prednisolone steroid therapy and Allogenic

bone marrow transplant may be helpful.

41
Autoimmune Hemolytic anemia

It is an acquired disorder in which autoantibodies are generated against the

membrane of RBC. Mostly it is idiopathic, sometimes, it can be associated with

SLE, CLL or lymphomas. Anemia occurs very rapidly, present with angina or

CCF. Jaundice and splenomegaly may be present. Reticulocytosis, coincident

immune thrombocytopenia (Evans syndrome), positive direct coombs test are

findings. Treatment consists of blood transfusion, splenectomy and drugs such as

prednisolone, rituximab, danazol, cyclophosphamide and azathioprine.

Mechanical trauma

It occurs in cardiac valve prosthesis, in conditions of narrowing and

obstruction of vasculature. Mechanical damage to RBC occur when they squeeze

through abnormally narrowed vessels. It is occurs in DIC, malignant hypertension,

SLE, thrombotic thrombocytopenic purpura, HUS and disseminated cancer.

Peripheral smear shows Burr cells, helmet cells, triangle cells. Due to continuous

low-grade hemoglobinuria, iron deficiency occurs.

Hypersplenism

Destruction of formed elements of the blood takes place due to pooling of

blood in spleen. Splenectomy may be helpful.

42
 HEMOGLOBINOPATHIES

Condition may be inherited or acquired. Its subdivided into 5 classes

I. Structural : a) Abnormal polymerization of Haemoglobins

b) Altered O2 affinity : familial polycythemia, cyanosis,

pseudoanemias

c) Readily oxidized hemoglobin

II. Thalassemias : α thalassemias, β thalassemia,

III. Thalassemic hemoglobin variants : HbE, Hb constant spring, Hb lepore

IV. Hereditary persistence of HbF

V. Acquired : Methemoglobin, sulphemoglobin, Carboxyhemoglobin, HbH in

erythroleukemias, HbF in states of erythroid stress and bone marrow dysplasia

Sickle cell anemia

It is an autosomal recessive disorder with single DNA base change leading

to an amino acid substitution of valine for glutamine in 6th position on the β globin

chain. HbS forms polymers that damage the RBC membrane in the deoxygenated

form, causing jaundice, pigment gall stones, splenomegaly, poorly healing ulcers as

the clinical manifestation. When hemolytic or aplastic crisis occurs, life threatening

anemia occurs. Due to vaso – occlusion, infarction occurs in a large number of

organs which is painful. Peripheral smears shows sickle cells, reticulocytosis,

43
nucleated RBCs, Howell-Jolly bodies and target cells. Electrophoresis reveals the

condition.

Treatment include folate supplementation, blood transfusion, pneumococcal

vaccination, adequate hydration and oxygenation during acute painful episodes,

hydroxyurea as well as allogenic bone marrow transplantation.

Thalassemias

It is characterized by reduction in globin chains which causes reduced

hemoglobin synthesis. Peripheral smear shows microcytic hypochromic anemia. α

thalassemia occurs due to gene deletion. β - thalassemias are caused by point

mutations. It causes relative increase in HbA2 and HbF due to reduced globin

synthesis. The excess α chains precipitate and damage RBC membranes which in

turn causes hemolysis. Normally, there are four α – globin gene. Usually there are

4 genes. when 3 - functioning α-globin genes are there, individuals are silent

carriers. α –thalassemia trait occurs when there is 2 α- globin gene. When only one

is present, then it is called Hb-H disease. They may require blood transfusion

during exacerbation caused by infection or other stresses. When all 4 globin genes

are deleted, the fetus is known as hydrops fetalis which is still born. Thalassemia

major is when patient is homozygous for bela-thalassemia.

When Hb synthesis switches from HbF to HbA at 6 months of age severe

anemia develops which is manifested by growth failure, bony deformities,

hepatosplenomegaly and jaundice.

44
 Transfusion therapy will cause hemosiderosis and jaundice with heart

failure, cirrhosis endocrinopathies etc. Thalassemia intermedia is said to exist when

the patient is homozygous for milder form of beta – thalassemia. They have

chronic hemolytic anemia, but they don’t require transfusion. Heterozygous

patients have thalassemia minor and they are clinically insignificant.

Peripheral smear shows hypochromic microcytic anemia, target cells,

poikilocytosis, reticulocytosis, Basophilic stippling and nucleated RBCs. Mild

forms of thalessemia does not require intervention except genetic counselling.

Severe form require blood transfusion, folate supplementation with iron chelation

theraphy. Splenectomy and allogenic bone marrow transplantation also helps in

thalassemia.

45
 ANEMIAS OF IMPAIRED RBC PRODUCTION

Aplastic anemia

It results from failure or suppression of myeloid stem cells which causes

decreased production and release of differentiated cell lines. Anemia, neutropenia,

thromcytopenia can occur in inherited or acquired forms.

Causes

Acquired

a) Idiopathic – Immune mediated, primary disorders of stem cells

b) Chemical agents

(i) Idiasyncratic – chloramphenicol, phenylbutazone, organic, arsenicals,

streptomycin

(ii) Dose – related – alkylating agents, antimetabolities, benzene

c) Physical agents – irradiation

d) Viral infection – Non – A non – B hepatitis, CMV, EBV virus

e) Miscellaneous

Inherited – Fanconi’s anemia

Onset is usually gradual, but can present at any age. Symptom occurs due

to the decreased 3 formed elements of blood. Bone Marrow examination shows

hypocellularity. Idiopathic type carries poor prognosis. Antithymocyte globulin

46
combined with cyclosporine, Allogenic bone marrow transplantation and

withdrawal of toxic drugs are helpful.

Pure red cell aplasia

Marrow failure occurs due to aplasia of erythroid precursors. It is classified

primary and secondary to thymoma and leukemia. Therapy consists of immune

suppressive therapy, resection of thymic tumour and plasmapheresis .

Anemia of Renal failure

Any etiology which causes chronic renal failure may have associated

anemia. The severity varies. The cause is usually multifactorial. Extracorpuscular

defect causes chronic hemolysis due to bleeding and uremia. Iron deficiency

occurs. Reduced erythropoietin synthesis will lead to decreased RBC production.

Therapy consists of correction of iron deficiency with recombinant erythropoietin

administration.

Megaloblastic anemia

This occurs due to impaired DNA synthesis resulting in distinctive

morphological changes in blood and bone marrow. The precursors are abnormally

large due to defective cell maturation and division.

Peripheral smear shows normochromic anisocytosis, macro ovalocytes,

reduction in reticulocytes, nucleated RBCs and hypersegmented neutrophils. Bone

Marrow examination shows hypercellularity. Megaloblastic changes are seen in all

47
stages of RBC development. Nuclear – cytoplasmic asynchrony with giant

metamyelocytes, band –forms are seen. Large megakaryocytes having bizarre,

multilobate nuclei are seen. Intramedullary hemolysis causes ineffective

erythropoiesis.

Causes

I Vitamin B12 deficiency

a) Reduced intake, inadequate diet, vegetarian diet

b) impaired absorption

Intrinsic factor deficiency – pernicious anemia, gastrectomy

Malabrosption states

Diffuse intestinal lesions – lymphoma, systemic sclerosis

ileal resection, ileitis

Fish tapeworm infection

Bacterial overgrowth in blind loops

c) Increased requirement – pregnancy, hyperthyroidism, disseminated

cancer

II Folic acid deficiency

a) Decreased intake – alcoholism, infancy

b) impaired absorption – malabsorption, intrinsic intestinal disease,

anticonvulsants, oral contraceptives

c) Increased loss, hemodialysis

48
 d) Increased Requirement – pregnancy, infancy, disseminated cancer

e) impaired use – folic acid antagonists

III other causes

a) Metabolic inhibitors – mercaptopurine, cytosine

b) Unexplained disorder – pyridoxine and thiamine responsive

megaloblastic anemia, acute erythroleukemia

Pernicious anemia

Immunologically mediated destruction of gastric mucosa with diffuse

chronic gastritis occurs in pernicious anemia. Myeline degeneration of dorsal and

lateral tracts of spinal cord may be seen.

It is usually insidious. Megaloblastic anemia, leucopenia with

hypersegmented granulocytes, thrombocytopenia, involvement of posterolateral

spinal tracts, achlorhydria, inability to absorb an oral dose of cobalamine, decreased

serum levels of vitamin B12, excretion of methylmalonic acid in urine,

reticulocytosis, improvement of anemia after parenteral administration of vitamin

B12 are all the main features.

Folic acid deficiency

Same features as that of vitamin B12 deficiency except there is absence of

neurological changes. Diagnosis depends on the decreased serum folate levels and

increased urinary excretion of FIGLU after histamine intake.

49
 IRON DEFICIENCY ANEMIA

This is the Most common cause of anemia. In normal individuals iron

metabolism is balanced between absorption and loss of 1 mg/day. From Dietary

intake – 10% of iron is absorbed.

Causes

Deficient diet

Decreased absorption

Requirement increased – pregnancy, lactation

Blood loss – GI loss, menstruation , resulting from blood donation

Hemoglobinuria

Iron sequestration – pulmonary hemosiderosis

Patient presents with easy fatiguability, palpilations, breathlessness, pica,

dysphagia (esophageal webs). The findings include glossitis, brittle nails, cheilosis.

Initially there is lower serum ferritin levels and elevated serum TIBC.

Then MCV falls, blood smear showing hypochromic microcytic anisocytosis,

poikilocytosis. In severe forms, target cells, pencil cells, nucleated RBCs are seen.

Treatment consists of identification of cause. Iron replacement may be done orally

or parenterally. Within 3 weeks return of hematocrit level halfway toward normal

with full return to baseline after 2 months indicate good response. Iron therapy

should be continued for next 3-6 months.

50
Sideroblastic anemia

Hemoglobin synthesis is reduced due to failure of heme incorporation into

protoporphyrin to form, Haemoglobin. Iron deposits in the mitochondria. Usually

acquired, in which causes include alcoholism, lead poisoning, transitional stage of

myelodysplasia.

Moderate anemia with normal MCV, dimorphic picture in smear with

marked erythroid hyperplasia and ringed sideroblasts are seen. Iron store is

increased. Pyridoxine helps along with blood transfusion and iron chelation

therapy.

Anemia of chronic disease

This occur in cases such as chronic microbial infection, osteomyelitis,

bacterial endocarditis, lung abcess, chronic immune disorders (Rheumatoid

arthritis), Neoplasm and alcoholism. There will be low serum iron with reduced

TIBC and abundant stored iron in mononuclear – phagocytic cells showing a defect

in recycling of iron. Marrow hypoproliferation due to inadequate erytheopoietic

synthesis is the main cause. Administration of recombinant erythropoietin along

with treatment of underlying condition helps.

51
HYPOCHOLESTEROLEMIA AND ANEMIA

It is important to determine the extent of relationship between cholesterol

and Haemoglobin levels, because cholesterol level is a risk factor for

atherosclerosis and CHD studies revealed the significance of hypocholestrolemia

related to anemia.

CLINICAL REPORTS & OUTCOME

Rifkind and Gale in 1967 showed that hypocholestrolemia was associated

with proportional reduction in all the major lipoprotein families. This was

compatible with plasma volume – dependent effect. It also showed that

splenectomy lead to doubling of cholesterol in a patient with microspherocytosis

and vitamin B12 administration in pernicious anemia causes rise in serum

cholesterol.

In 1970, a study was conducted in 4,070 women in which 124 were found

to have Haemoglobin below 10.5 g/dl. In females with Haemoglobin level >

10.5g/dl, serum cholesterol were 241 plus or minus 2.5mg/dl and in females with

Haemoglobin < 5g/dl, serum cholesterol were 211 plus or minus 3.9 mg/dl.

Mean difference of 30 mg/dl were found to be significant.

A clinical trial was conducted in which women with level of

Haemoglobin< 10.5 g/dl received 0, 30, 90 mg/day iron daily for 12 weeks. Rise

in serum cholesterol is observed. Dilution effect is the explanation for the observed

relation between hemoglobin and cholesterol levels. Difference in packed – cell

52
volume between the groups in the study was proportionally similar to difference in

cholesterol levels. This proved a highlight in this hypothesis.

Westermann conducted a study to show the relationship between

hypocholesterolemia and various types of anemia. After B12 / folic acid therapy in

pernicious anemia, after splenectomy in hereditary spherocytosis, after transfusion

in sickle cell anemia there is increase in both hematocrit and serum cholesterol.

Similar picture is observed in aplastic anemia after transfusion.

Plasma cholesterol level is closely related to Hematocrit levels, throughout

the study, anemias associated with hypocholestrolemia regardless of the type, low

hematocrit is the cause of low cholesterol levels. This association appears due to

changes in cholesterol distribution or plasma dilution because of the rapidity with

which the cholesterol change occurred after transfusion.

El.Hazmi et al study also shows the theory of plasma dilution. Study

conducted among 45 patients with sickle cell anemia and 45 age plus sex matched

controls and investigated plasma levels of both triglycerides and cholesterol.

Cholesterol level is lower in patients with sickle cell anemia than in control but

there is no significant change in triglyceride level. This hypocholesterolemia may

be due to idiopathic decrease in endogenous production of cholesterol, utilization of

cholesterol, decreased liver function, functional defects of liver or plasma volume

expansion.

53
 In contrast to the above studies Seip & Skrede considered hemodilution

only as a part of explanation for decreased cholesterol levels. The study consisted

of 17 children, 9 with hemolytic anemia, 3 with congenital hypoplastic anemia, 2

with congenital sideroblastic anemia, 2 with iron – deficiency anemia. All patients

have low levels of cholesterol irrespective of hemolytic anemia with very active

erythropoiesis or anemia with low erythropoitic activity. But there is no association

between triglyceride and Haemoglobin levels. There is increase in cholesterol

levels after treatment irrespective of type of anemia.

Dessi et al conducted a study in which children with G6PD during

hemolysis induced by favism due to favabean ingestion showed that total

cholesterol, LDL, HDL were reduced and it is associated with maximal Bone

Marrow hyperplasia. He concluded that these changes are due to increased

utilization of cholesterol by proliferating cells.

This same result was drawn by El-Hazmi et al, who investigated 400

normal individuals, 100 patients with sickle –cell disease, 220 sickle heterozygotes

(HbAS ) and 100 patients with G6PD deficiency. Sickle cell patients had

significantly lower cholesterol when compared with normal people. On the other

hand there is no significant difference between HbAS and G6PD deficient groups.

The results showed that utilization or production might account for the decreased

cholesterol levels in severe anemia patients. This study is supported by another

study conducted by Akinyanju & Akinyanju.

54
 In 1986 au et al suggested that due to increased shunting of substrates to

non-sterol pathway, there is reduced endogenous cholesterol production in anemia.

In an animal model, a study conducted which showed that cholesterol levels were

well lower in anemia than in non – anemia.

Choi conducted a study in which he showed that lipid levels in patients

with iron deficiency anemia were directly related to the level of iron. In patients

with Haemoglobin 8g/dl, the total cholesterol level is significantly lower (148+

16mg/dl vs 170 + 17 mg/dl). Triglyceride level was 2-fold lower than in patients

with Haemoglobin 14 g/dl.

The result of above study were contradicted by Tanzer et al. He conducted

a study in which 70 children suffer from iron deficiency anemia and 20 healthy

children were taken and the results showed that there is higher serum total

triglyceride and total cholesterol , VLDL levels in iron deficiency patients than in

healthy controls.

Nimer et al conducted a study to show the use of human GM-CSF to

improve hematopoiesis in patient with moderate to severe aplastic anemia. In all

patients serum cholesterol levels decreased by 27% - 53% from baseline except

one.

Vitols et al conducted a study in patients with AML and showed that

lowest cholesterol concentration is present in these patients because of high LDL –

receptor activity of leukemic cells. 59 patients were taken into account. The study

showed that in patients with leukemia and other neoplastic disorders due to elevated

55
LDL receptor activity, uptake and degradation of LDL occurs, thus causing

hypocholesterolemia.

Juluisson et al analyzed the relationship between LDL receptor activity and

cholesterol in hairy cell leukemia, 66 patients were taken into study. They were

treated with cladribine for 7 days. After therapy HDL and LDL levels rise, but

triglyceride levels didn’t. Also because of splenomegaly, they concluded that

hypocholesterolemia was not due to increased LDL receptor activity but to

increased size of spleen.

Gilbert and Ginsberg conducted a study in which 23 patients with

polycythemia vera and 9 with angiogenic myeloid metaplasia were taken. There

was lower values of total plasma cholesterol, LDL cholesterol and HDL. But the

removal rate of LDL was significantly increased in MPD patients which was

attributed to both non-specific, low affinity processes such as fluid endocytosis and

specific high-affinity interactions with cell-surface receptors.

Deiana et al conducted a study in sardinian population to evaluate the

influence of β-thalassemia on the phenotypic expression of heterozygous familial

hypercholesterolemia. There was lower total and LDL cholesterol levels in subjects

with FH plus β (o) thalassemia trait than those with FH only but there is no

significant difference in HDL cholesterol and triglyceride levels. It may be due to

expression of LDL receptor in excess and secretion of erythropoietin or due to

activation of monocyte macrophage system due to release of some cytokines.

56
Pathophysiology

In general, hypocholesterolemia occurs due to decreased absorption,

decreased synthesis, increased excretion, shift of plasma into other tissues or some

combination of these factors. Dietary absorption or altered absoption are unlikely

factors.

Gilbert and Ginsberg study showed that LDL removal from plasma occurs

only due to fluid endocytosis. High receptor mediated uptake and degradation of

LDL by leukemic cells was the reason in MPD patients. On the other hand,

Julliuson showed there was no increased LDL uptake due to monophage-

macrophage system. Deiana et al study also supported this study.

Due to decreased oxygenation of blood in anemia coupled with

spontaneous oxygen production with catabolism of modified lipoproteins by

macrophage scavenger receptors results in hypocholesterolemia. The studies are

limited to those type of anemia where an elevated level of erythropoietin is present.

Hypocholesterolemia could be due to indirect effect of erythropoietin. But Mat et al

showed that long-term treatment with recombrinant human erythropoietin does not

significantly change lipid levels in hemodialysis patients.

Decreased Serum cholesterol may occur due to increased utilization of

plasma lipids for compensatory erythrocyte production or due to increased use of

cholesterol by newly proliferated cells. Therefore, hemolysis causes increase

turnover of plasma total cholesterol.

57
 It may also be due to the effect of plasma dilution but the rise in cholesterol

level after treatment is not of the same relative increase as the observed rise in

hematocrit. So a change in serum cholesterol may not be a true reflection of total

body cholesterol.

Other factors also contribute to change in cholesterol level like liver disease

that change hepatic cholesterol synthesis and absorption, because cholesterol levels

do not always return to normal in patients treated with transfusion. The theory

behind increased serum cholesterol with iron supplementation is not known.

Conclusion

Patients with anemia may also have relative hypocholesterolemia regardless

of the cause and correction leads to increase in serum cholesterol.

There is positive correlation between serum cholesterol and Haemoglobin

and Hematocrit.

Patients with anemia may have lower risk of developing ischemic heart

disease not only due to hypocholesterolemia but also due to the theory of iron

induced free radical damage . This may explain the difference in the occurrence of

ischemic heart disease between the sexes, premenopausal and post – menopausal

and between developed versus under – developed countries. However, data

regarding the incidence of coronary heart disease is not shown in any study.

Prospective cohort studies are needed for this data.

58
 Few studies have been designed to understand the basis of this relationship.

Further studies are needed to find relationship between anemia of various etiologies

and levels of specific lipoprotein families along with concurrent measurement of

hematocrit. In patients with leukemia, LDL receptor activity may be inversely

correlated with plasma cholesterol. So this was studied only by Ginsberg &

Gilbert. So the precise degradation of VLDL and LDL should be determined to

clarify the role of LDL receptor mediated removal by macrophages since

splenectomy was associated with an increase in cholesterol level. Follow – up

study has to be done to determine the true effect of anemia on cholesterol after

specific treatment.

59
 MATERIALS AND METHODS

This is a study which has been carried out in the Department of

Internal Medicine, TMCH,Thanjavur.

Source of Data

The data for this study was collected from patients who presented to

TMCH,Thanjavur either on inpatient or outpatient basis.

Sample Size

50 cases, 50 controls

Study duration

Jan 2016 to June 2016

Inclusion Criteria

All proven cases of anaemia. Men: Hb < 13 gm%, Women: Hb < 12 gm%.

Exclusion Criteria

1.Children below 14 years

2.Obesity/Overweight: BMI > 25 kg/m2

3.Malnutrition: BMI < 19 kg/m2 or Serum Total Protein < 6 gm/dl

or Serum Albumin < 3.5/dl

60
 4. Known case of Diabetes Mellitus or RBS > 200mg/dl or FBS > 126 mg/dl

or PPBS > 200 mg/dl

5. Known Hypertensives or Blood Pressure persistently more than 140/90 mm of

Hg on three consecutive readings taken on different days.

6. Alcoholics

7. Smokers

8. Known case of AIDS.

9. Known case of Ischaemic Heart Disease/ Cerebrovascular Accident.

10. History of recent blood loss.

11. History of use of steroids, oral contraceptives, diuretics, beta-blockers.

12. Urine Albumin ≥ +

13. Blood Urea > 40 mg% or Serum Creatinine > 1.4 mg%

14. SGOT > 40 U/L or SGPT > 40 U/L or Serum Alkaline Phosphatase > 250 U/L

15. TSH > 7.0 µU/ml or TSH < 0.3 µU/ml

Clinical evaluation

A detailed history was obtained from the subjects of the study, with

special emphasis on age, sex and occupation; non specific symptoms of anaemia

like fatiguability, dyspnoea, giddiness, palpitations and angina; symptoms

suggestive of a specific cause for anaemia like pica, dysphagia, abdominal pain,

bony pain, fever, loss of appetite, weight loss, jaundice, bleeding, malaena,

haemoglobinuria, menorrhagia, pregnancy and post menopausal bleeding. Past

history of disorders associated with dyslipidemia or anaemia was obtained,

61
including diabetes mellitus, hypertension, ischemic heart disease, cerebrovascular

accident, AIDS, recent blood loss and gall stones. Dietary habits and habits like

alcoholism and tobacco smoking was ascertained. History of intake of drugs

affecting lipid levels, such as oral contraceptives, beta blockers, diuretics,

steroids and NSAIDs was obtained. Family history of anaemia, jaundice and

gallstones was also obtained.

Each patient was subjected to a detailed general physical examination, with

special emphasis on pallor, koilonychias, icterus, pedal edema, lymphadenopathy,

glossitis, angular stomatitis, petechiae, haemolytic facies, ankle ulcers, perioral

pigmentation and knuckle pigmentation. Pulse, blood pressure, weight, height and

body mass index was measured.

Thorough systematic examination was made of the cardiovascular system

to look for the presence of elevated JVP, venous hum, cardiomegaly, S3 and flow

murmur. The respiratory system was examined to look for evidence of pulmonary

congestion. Abdomen was examined to look for organomegaly. The central

nervous system was examined for confusion, muscular weakness, deep tendon

reflexes, vibration sense, position sense and romberg’s sign.

Investigations

Venous blood was drawn for investigations like complete haemogram,

random blood sugar, blood urea, serum creatinine, liver function tests, and thyroid

stimulating hormone levels. A urine sample was obtained for urine analysis,

including albumin, sugar and microscopy. Fasting venous blood sample (> 12

62
hours) was obtained for estimation of lipid profile. T3 and T4 levels, fasting and

post prandial (two hours after an oral dose of 75gms of glucose) blood sugar

levels, and bone marrow aspiration cytology was done in selected cases based on

clinical assessment.

Complete haemogram was performed using the Sysmax automated analyzer.

Haemoglobin levels were confirmed by the colorimetric method. Differential count

and peripheral smear was done manually using Leishmann’s stain by a qualified

pathologist. Urine albumin and sugar was estimated by dipstick method. Urine

microscopy was done manually by a qualified pathologist. Biochemical analyses

were done using the fully automated Technicon RA-XT system by Bayer. TSH, T4

and T3 were estimated using the chemiluminescence method on the fully

automated ADVIA Centaur system by Bayer.

Estimation of total cholesterol, HDL and triglycerides was done with the

commercially available Autopak cholesterol kit on Technicon RA-XT system.

VLDL was calculated using the formula, VLDL = Triglyceride/5. LDL

cholesterol was calculated using the Friedewald’s equation. LDL = Total

cholesterol – [(Triglycerides/5) + HDL] mg/dl.

Controls

Fifty non anemic age and sex matched subjects were selected and screened

for compliance with the exclusion criteria. Complete haemogram, lipid profile and

other investigations were performed on them.

63
Statistical Methods80,81

Student t test has been used to test the homogeneity of age between

case and control. Chi-square test has been used to find the homogeneity of sex

between case and control. Student t test has been used to find the significance

of Lipid profiles between case and controls. Analysis of Variance has been used

to find the significance of mean lipid profiles when there are more than 2 groups.

Mann Whitney U test has been carried to find the significance between case and

control for TC/HDL and LDL/HDL ratio. Kruskal Wallis test has been used to find

significance of TC/HDL and LDL/HDL ratio when there are more than 2 groups.

Effect Size due to Cohen d has been computed to find the extent of effect of

anemia on Lipid profiles.

0 < d < 0.20 No effect

0.20 < d < 0.50 Mild Effect

0.50 < d < 0.80 Moderate effect

0.80 < d < 1.20 Large effect

d > 1.20 Very Large effect

Statistical software

The statistical software used for the analysis of the data was SPSS 11.0

and Systat8.0. Microsoft Word and Excel have been used to generate figures and

tables.

64
 RESULTS

Study Design

A case - control study consisting of 50 anaemic cases and 50 normal subjects

was undertaken to study the clinical presentation of anaemic cases and also to

investigate the relationship between anaemia and lipid profile.

Age

The cases and controls were matched for age. Majority of the cases were

middle aged (30-60). The youngest case was 14 years old. The oldest was 75 years

old.

Table 1
Age distribution with Haemoglobin levels in cases and controls
Case
Age in
Haemoglobin levels (in gm/dl) n=80 Control
Years
<6 6-9 >9 Total (n=50)
(n=9) (n=19) (n=22) (n= 50)
≤20 1 1 2
4 4
(11.17) (5.3) (9.1)
21-30 2 5 3
10 10
(22.2) (26.3) (13.4)
31-40 2 5 4
11 11
(22.2) (26.3) (18.2)
41-50 1 3 2
6 6
(11.1) (15.7) (9.1)
51-60 1 2 7
10 10
(11.1) (10.5) (31.8)
61-70 1 2 3
6 6
(11.1) (10.5) (13.6)
>70 1 1 1
3 3
(11.1) (2.3) (4.5)

Inference :
Samples are age matched (p>0.05) Anaemic cases <50 years of are 2.42 times more to
have Hb levels < 6 gm/dl (p=0.107) and Anamic cases >50 years of age are 4.31 times
more likely to have > 9Hb gm/dl (p<0.01)

65
 Figure 1
Age distribution in cases and controls

Age distribution (in years)

12 11 11
10 10 10 10
10

8
6 6 6 6
6
4 4
4 3 3

0
< 20 21-30 31-40 41-50 51-60 61-70 >70
Case Control

Figure 2
Age distribution with Haemoglobin levels

Age and Hb Level

12

10
4
3
8
7
6
2
5 5 3
4
3
2
3
2 2 2
1 1
2 2
1 1 1 1 1
0
<21 21-30 31-40 41-50 51-60 61-70 >70
Hb >9 gm/dl Hb 6-9 gm/dl Hb < 6gm/dl

66
Sex

The cases and controls were matched for sex. The cases consisted of 22

males and 28 females. Sex was not associated with haemoglobin levels

Table 2

Sex distribution between case and controls

Case Haemoglobin levels (in gm/dl)

Control
Sex
<6 6-9 >9 Total (n=50)
(n=9) (n=19) (n=22) (n=100)
3 9 10
Male 22 22
33.3 47.4 95.5
6 10 12
Female 28 28
66.7 52.6 54.5

Inference

Samples are sex matched (P>0.05) sex is not statistically associated with
haemoglobin levels (P>0.05)

Figure 3
Sex distribution between case and controls

Male, Male,
44% Female 44% Female
56% 56%

Female Male Female Male

Case Control

67
Distribution of cases according to type and severity of Anaemia

A total of 50 cases were included in this study. 20 cases had dimorphic

anaemia (DM) according to peripheral smear, 1 2 cases had microcytic

hypochromic anaemia (MH), 9 cases had normocytic hypochromic anaemia (NH)

and 5 cases had a normocytic normochromic blood picture (NN). Out of the 4

cases grouped together as ‘others’ for the purpose of analysis, 3 cases had

megaloblastic anaemia, 2 cases had pancytopenia, and one case each had chronic

myeloid leukemia and leukoerythroblastic blood picture. A total of 9 cases had

haemoglobin less than 6 gm/dl, 19 cases had haemoglobin between 6 and 9 gm/dl,

and 22 cases had haemoglobin more than 9 gm/dl.

Table -3

Distribution of cases according to type and severity of Anaemia

Hb
Type of Anaemia
(in gm/dl)
DM MH NH NN Others Total

<6 7 3 - - 2 12

6-9 10 7 1 - 2 20

>9 3 2 8 5 0 18

Total 20 12 9 5 4 50

68
Symptoms

The most common presenting symptom was easy fatiguability, which was

present in 25 cases. The next common symptoms were dyspnoea (15 cases),

palpitations (16 cases) and giddiness (12 cases). Other symptoms were loss of

appetite (4 cases), fever (2 cases), weight loss (2 cases), angina(2 cases), dysphagia,

jaundice and menorrhagia (3 cases each), bony pain and bleeding (1 case) each. Not

seen in the study group were pica, abdominal pain, malaena, haemoglobinuria and

pregnancy.

Figure 4

Symptoms
30 A: Fatigue
B: Dyspnoea
25 C: Giddiness
D:Palpitations
20 E:Angina
F:Dysphagia
15 G:Body pain
H:Fever
10 I:Loss of appetite
J: weight loss
5 K:Jaundice
L:Bleeding
0 M:Menorrhagia
A B C D E F G H I J K L M

Symptoms

69
Symptoms and severity of anaemia

Cases with more severe anaemia were found to be more likely to have

symptoms. All cases with haemoglobin less than 6 gm/dl had at least one

symptom, while out of 22 cases with haemoglobin more than 9 gm/dl, only 8 cases

(36.4%) had at least one symptom. Most symptoms were found more

frequently in cases with more severe anaemia. 88.9 % of cases with

haemoglobin less than 6 gm/dl complained of fatigue, compared to just 13.6 % of

cases with haemoglobin more than 9 gm/dl. Fever, bony pain and bleeding were

the only symptoms which were found more frequently in cases with less severe

anaemia. Cases with severe anaemia also had more number of symptoms. Cases

with haemoglobin less than 6 gm/dl had an average of 3.7 symptoms, compared to

cases with haemoglobin more than 9 gm/dl, who had only an average of 0.6

symptoms.

Symptoms and type of anaemia

Non specific symptoms such as fatigue, dyspnoea, giddiness,

palpitations, fever, loss of appetite and loss of weight were equally frequent

in the different types of anaemia, except normocytic hypochromic anaemia and

cases with normocytic normochromic blood picture. This is possibly due to the

fact that these cases had less severe anaemia. Symptoms like angina, dysphagia

and menorrhagia were seen only in patients with dimorphic anaemia and

microcytic hypochromic anaemia. Bony pain and bleeding was seen only in one

patient with chronic myeloid leukemia.

70
 Table -4
Symptoms and severity of Anaemia

Haemoglobin levels in cases (in gm/dl)

Presenting
Total <6 6-9 >9
illness
(n=50) (n=9) (n=19) (n=22)
8 73.7 3
Fatigue 25
(88.9) (14) (13.6)
7 2
Dyspnoea 15 31.2
(77.8) (9.09)
6 5 1
Giddiness 12
(66.7) (26.3) (4.5)
8 5 3
Palpitation 16
(88.9) (26.3) (13.6)
2
Angina 2 - -
(22.2)
Pica - - - -
2
Dysphagia 2 - -
(22.2)
1
Abd pain 1 - -
(11.1)
2
Bony pain 2 - -
(9.0)
1 1 2
Fever 4
(11.1) (5.3) (9.0)
2 1 1
Loss of appetite 4
(22.2) (5.3) (4.5)
2 1
Wt loss 3 -
(22.2) (5.3)
1 1
Jaundice 2 -
(11.1) (5.3)
1 1
Bleeding 1 -
(11.1) (2.7)
Malaena - - - -
Haemoglobinuria - - - -
2 1
Menorrhagia 2 -
(22.2) (5.3)
Pregnancy - - - -
Post menopausal 1
1 - -
bleed (11.1)

71
Past history

None of the cases was a known case of diabetes mellitus, hypertension,

ischaemic heart disease or AIDS. None of the cases had a past history of

cerebrovascular accident, recent blood loss or gall stones.

Personal history

8 cases were vegetarian. 44.5% (4 cases out of 9) of all cases with

haemoglobin less than 6 gm/ dl were vegetarian, compared to 27.3.8% (6

cases out of 22) of all cases with haemoglobin more than 9 gm/ dl.

Vegetarians were more likely to have dimorphic anaemia (55.6%) compared to

the other types of anaemia (5.6% to 22.2%). None of the cases had a history of

alcohol use or tobacco smoking.

Drug History

None of the cases had a history of intake of oral contraceptives, beta

blockers, diuretics, steroids or non steroidal anti inflammatory drugs.

Family history

Four cases had a family history of anaemia, out of whom three had

microcytic hypochromic anaemia. Five cases had a family history of jaundice,

out of whom four had dimorphic anaemia.

72
General physical examination

The most common finding on general physical examination was pallor,

which was present in 30 cases. Also seen were glossitis (10 cases), koilonychia

(7 cases), angular stomatitis (5 cases), knuckle pigmentation (3 cases), pedal

oedema (4 cases), icterus (1 cases), lymphadenopathy (1 case) and perioral

pigmentation (1 case). None of the cases had petechiae, haemolytic facies or

ankle ulcers.

73
General physical examination and severity of anaemia

Cases with more severe anaemia were found to be more likely to have

findings on general physical examination. All cases with haemoglobin less

than 6 gm/dl had at least one sign, while out of 2 2 cases with

haemoglobin more than 9 gm/dl, only 6 cases (21.6%) had at least one

sign. All signs were found more frequently in cases with more severe

anaemia. 100 % of cases with haemoglobin less than 6 gm/dl had pallor

and 66.7% had glossitis, compared to just 21.1 % and 0% in cases with

haemoglobin more than 9 gm/dl. Cases with severe anaemia also had more

number of signs on general physical examination. Cases with haemoglobin

less than 6 gm/dl had an average of 2.8 signs, compared to cases with

haemoglobin more than 9 gm/dl, who had only an average of 0.2 signs.

General physical examination and type of anaemia

Pallor was equally frequent in the different types of anaemia, except

normocytic hypochromic anaemia and cases with normocytic normochromic

blood picture. This is possibly due to the fact that these cases had less severe

anaemia. Koilonychia, lymphadenopathy, glossitis and angular stomatitis

were seen only in cases with dimorphic anaemia and microcytic

hypochromic anaemia. Knuckle pigmentation and preioral pigmentation was

seen only in cases with megaloblastic anaemia and dimorphic anaemia.

74
 TABLE 6

GPE and severity of Anaemia

Haemoglobin levels in cases (in gm/dl)

GPE Total <6 6-9 >9
(n=50) ( n=9) (n=19) (n=23)
9 17 4
Pallor 30
(100.0) (89.5) (18.2)
8 2
Kollonyehia 10 -
(88.9) (10.5)
1 1
Leterus 2 -
(11.1) (5.3)
3 1
Pedal oedema 4 -
(38.3) (5.3)
1
Lymphadenopathy 1 - -
(5.3)
6 4
Glossitis 10 -
(66.7) (21.1)
4 1
Angular stomatitis 5 -
(44.4) (5.3)
Peterchiae 0 0 0 -

Haemolytis facies 0 0 0 -

Ankle ulcers 0 0 0 -
Peri oral 1
1 0 -
Pigmentation (11.1)
Knuckle 2
3 1 -
Pigmentation (22.2)

75
 TABLE 7

GPE and Type of Anaemia

Symptoms Types of Anaemia

DM MH NH NN Others
(n=20) (n=12) (n=9) (n=5) 4
Pallor 18 10 3 4
30 -
(90.0) (83.3) (33.3) (100)
Koilonychia 6 4
10 - - -
(30.5) (33.3)
Ictercs 1 1 0
2 - -
(5.0) (8.3) (14.3)
Pedal oedema 3 1 0
4 - -
(15.0) (8.3) (28.6)
Lymphadenopathy 1
1 - - -
(8.3)
Glossitis 6 4
10 - - -
(30.0) (33.3)
Angulaer stomatitis 3 2
5 - - -
(15.0) (16.7)
Petechiae
0 - - - - -
Haemolytis facies
0 - - - - -
Ankle ulcers
0 - - - - -
Peri 0ral 0
1 5.0 - - -
Pigmentation (14.3)
Knuckle 2 1
3 - - -
Pigmentation (10.05) (25.0)

76
Pulse Rate

The mean pulse rate was 85.4/ minute in cases and 83.7/ minute in

controls. The mean pulse rate was significantly increased (89.3/ minute) in

cases with haemoglobin less than 6 gm/dl. There was no difference in mean

pulse rate between the different types of anaemia except in the ‘others’ group,

in whom in was significantly raised (96.3/ minute).

Blood Pressure

The mean blood pressure was 121.2/ 76.3 mm of Hg in cases and

122.1/ 76.5 mm of Hg in controls. It was less in cases with haemoglobin

less than 6 gm/dl (118.7/ 75.2 mm of Hg), compared to cases with

haemoglobin more than 9 gm/dl (122.7/ 77.3 mm of Hg). There was no

significant difference in mean blood pressure in the different types of anaemia.

Body Mass Index

The mean body mass index was 21.5 kg/m2 in cases and 21.6 kg/m2 in

controls. It was significantly decreased (20.9 kg/m2) in cases with

haemoglobin less than 6 gm/dl. There was no significant difference of mean

BMI among the various types of anaemia.

77
 TABLE -8

Pulser rate, Blood pressure and BMI with severity of

Anaemia
Case
Haemoglobin levels (in gm/dl) Control
<6 6-9 >9 Total (n=50)
(n=9) (n=19) (n=22) (n=50)
Mean pulse rate 89.3 ± 12.8 83.6 ± 9.8 84.9 ± 7.5 85.4 ± 10.0 83.7± 16.9
Mean systolic
118.7 ± 9.7 121.3 ±8.5 122.7 ± 10.4 121.2 ± 9.6 122.1 ± 15.2
blood pressure
Mean diastolic
75.2 ± 7.9 76.1 ± 7.7 77.3 ± 9.0 76.3 ± 8.2 76.5 ± 8.4
blood pressure
Mean BMI 20.9 ± 1.5 22.0 ± 1.7 21.4 ± 1.6 21.5 ± 1.7 21.6 ± 1.6

Inference

Increased mean pulse rate (p=0.082) as well an signigicantly decreased mean BMI
(P<0.01) m is seen in cases with HB < 6 gm/ml. Mean systolic and diastolic blood
pressure are not significantly different. (p>0.05)

Pulse rate

89.3
90
89
88
87 85.4
86 84.9
Mean (/ minute)

85 83.7 83.6
84
83
82
81
80
Controls Cases Hb<6 gm/dl Hb 6-9 Hb > 9
gm/dl gm/dl

Pulse rate

78
 Blood Pressure
140
122.1 121.2 118.7 121.3 122.7
120
100
76.5 76.3 75.2 76.1 77.3
80
60
40
20
0
Controls Cases Hb < 6 gm/dl Hb 6-9 gm/dl Hb > 9 gm/dl
Systolic BP Diastolic BP

Body Mass Index

22
22
21.8 21.6
21.5
21.6 21.4
21.4
Mean (/ minute)

21.2 20.9
21
20.8
20.6
20.4
20.2
Controls Cases Hb<6 gm/dl Hb 6-9 Hb > 9
gm/dl gm/dl

Pulse rate

79
 TABLE -9
Pulse rate, Blood pressure and BMI with type of Anaemia

Types of Anaemia
DM MH NH NN Others
(n=40) (n=25) (n=18) (n=10) (n=7)
Mean pulse rate 85.0 ± 8.5 82.3 ±12.0 87.0 ± 7.5 84.1 ± 5.2 96.3 ± 14.9

Mean systolic 120.1 ± 9.8 122.3 ± 8.9 118.9 ± 8.3 126 ± 11.7 122.9 ± 9.5
Mean diastolic 75.1 ± 6.7
75.6 ± 10.0 77.2 ± 8.3 79.0 ± 8.8 80.0 ± 8.2
blood pressure
Mean BMI 21.5 ± 1.7 21.4 ± 1.7 21.6 ± 1.8 21.4 ± 1.4 21.8 ± 1.9

Inference

Mean pulse rate significantly higher in the other group (P<0.05). Mean
systolic and diastolic blood pressures are not significantly different (P>0.05)
Mean BMI is not significantly different (P>0.05)

Pulse rate, Blood pressure and BMI with type of Anaemia

140

120

100

80

60

40

20

0
DM MH NH NN Others
Pulse (per mt) SBP(mm Hg) DBP (mm Hg) BMI (kg/m2)

80
 Systemic examination

The most common findings on systemic examination were venous hum

and flow murmurs (4 cases each). Abdominal examination revealed 3 cases

with splenomegaly and 2 cases with hepatomegaly. CNS findings were

impairment of vibration sense (2 cases) and joint position sense (1 cases),

suggestive of peripheral neuropathy. Elevated JVP, cardiomegaly, and basal

crepitations were seen in 2 cases each.

Systemic Examination

4.5
4
A: JVP
4 4 B: Venous Hum
3.5 C: Cardiomegaly
3 D:Gallop Rhythm
3 E:Flow murmers
2.5
F:Basal cepitations
2 G:Hepatomegaly
2 2 2 2 H:Splenomegaly
1.5
I:Confusion
1 J: Motor Weakness
1 1
0.5 K:Abnormal DTRs
0 0 0 0 0 L:Vibration Sense
0
M:Joint Position Sense
A B C D E F G H I J K L M N
N: Romber’s Sign
Systemic Examination

Systemic examination and severity of anaemia

Cardiovascular and respiratory findings such as elevated JVP, venous

hum, cardiomegaly, flow murmurs and basal crepitations were found only in

cases with haemoglobin less than 6 gm/ dl, with the exception of one

case with haemoglobin between 6 and 9 gm/ dl, who had a flow murmur.

Impairment of vibration and joint position sense were also found only in cases

81
 with severe anaemia. Hepatomegaly and splenomegaly were found in all

groups of cases equally.

TABLE 10

Systemic examination and severity of Anaemia

Systemic Haemoglobin levels in cases (in gm/dl)

Examination Total <6 6-9 >9
(n=50) (n=9) N=19 22
CVS
1 1
JVP 2
(11.1) (5.3)
3 1
Venous hum 4
(33.3) (5.3)
1
Cardiomegaly 1 -
(11.1)
Gallop rhythm - - -
3 1
Flow murmur 4
(33.3) (5.3)
2
RS: Basal crepts 2 -
(22.2)
P/A

1 1
Hepatomegaly 2 0
(11.1) (5.3)
2 1
Splennomegaly 3 0
(22.2) (5.3)
CNS
Confusion - - - -

Power - - - -

DTRs - - - -
2
Vibration - -
(22.2)
1
Position 2 - -
(11.1)
Romberg’s 1 - - -

82
 Systemic examination and type of anaemia

Elevated JVP, venous hum, cardiomegaly, flow murmurs and basal

crepitations were not found in cases with normocytic hypochromic anaemia

and normocytic normochromic blood picture. This is possibly due to the fact

that these cases had less severe anaemia. Hepatomegaly and splenomegaly was

seen in all types of anaemia except cases with normocytic normochromic

blood picture. Impairment of vibration and joint position sense was seen

only in cases with dimorphic anaemia and megaloblastic anaemia.

Table 11

Systemic examination and type of Anaemia

Types of Anaemia
Symptoms DM MH NH NN Others
(n=20) (n=10) (n=9) (n=5) (n=4)
CVS
2 0
JVP 2 - - -
(10.0) (28.6)
3 1 1
Venous hum 4 - -
(15.3) (8.3) (26.0)
1 0
Cardiomegaly 1 - - -
(5.0) (28.6)
2 1 1
Flow murmur 4 - -
(10.0) (8.3) (50.0)
2 2
RS- Basal crepts 2 - - -
(10.0) 28.6
P/A
1 1 1
Hepatomegaly 2 - 1
(5.0) (8.3) (5.6)
1 1
Splenomegaly 3 0 - 25.0
(5.0) (8.3)
CNS
2
Vibration 2 - - - -
(10.0)
1
Position 1 - - - -
(5.0)

83
 Anaemia and Lipid profile

The mean serum total cholesterol levels were significantly lower

(P<0.01) in cases (130.2 mg/dl) as compared to controls (172.4 mg/dl). The

effect of anaemia on the total cholesterol levels was very large.

The mean serum HDL levels were significantly lower (P<0.01) in

cases (30.0 mg/dl) as compared to controls (38.9 mg/dl). The effect of

anaemia on the HDL levels was large.

The mean serum LDL levels were significantly lower (P<0.01) in

cases (78.7 mg/dl) as compared to controls (111.1 mg/dl). The effect of

anaemia on the LDL levels was very large.

The mean serum VLDL levels were significantly lower (P<0.01) in cases

(20.6 mg/dl) as compared to controls (24.0 mg/dl). The effect of anaemia on

the VLDL levels was mild.

The mean serum triglyceride levels were significantly lower (P<0.01) in

cases (109.1 mg/dl) as compared to controls (123.5 mg/dl). The effect of anaemia

on the triglyceride levels was mild.

The mean total cholesterol / HDL ratio was significantly lower (P<0.05) in

cases (4.34) as compared to controls (4.43). The effect of anaemia on TC/HDL ratio

was mild.

The mean LDL / HDL ratio was significantly lower (P<0.01) in cases

(2.6) as compared to controls (2.85). The effect of anaemia on LDL/HDL ratio

was mild.

84
 Table -12

Anaemia and liqid profile

Lipid profile Controls Significance Effect size

Cases (n=50)
(mean ± SD) (n= 50) by student t (d)
1.64
Total Cholesterol 130.2 ± 28.0 172.4 ± 20.4 P <0.01**
(V. Large)
1.12
HDL 30.0 ± 6.3 38.2 ± 7.0 P <0.01**
(Large)
1.43
LDL 78.7 ± 24.0 111.1 ±16.5 P<0.01**
(V. Large)
0.46
VLDL 20.6 ±6.2 24.0 ± 6.2 P<0.01**
(Mild)
0.46
Triglycerides 102. 1± 31.4 123.5 ± 30.8 P<0.01**
(Mild)
0.27
TC/HDL ratio 4.34 ± 0.5 4.43 ± 0.7 P<0.05*M
(Mild)
0.45
LDL / HDL ratio 2.6 ± 0.7 2.85 ± 0.6 P<0.01*M
(Mild)
*Significant at 5% **Significant at 1% M-Mean Whitney U test

Anaemia and Lipid Profile

250

200

150
mg/dl

100

50

0
TC HDL LDL VLDL TG
Case Control

85
Severity of Anaemia and Lipid profile

The mean serum total cholesterol levels were significantly lower (P<0.01) in

cases with haemoglobin less than 6 gm/dl (105.0 mg/dl), as compared to

cases with haemoglobin more than 9 gm/dl (154.7 mg/dl).

The mean serum HDL levels were significantly lower (P<0.01) in cases with

haemoglobin less than 6 gm/dl (25.3 mg/dl), as compared to cases with

haemoglobin more than 9 gm/dl (35.5 mg/dl).

The mean serum LDL levels were significantly lower (P<0.01) in cases with

haemoglobin less than 6gm/dl (62.0 mg/dl), as compared to cases with

haemoglobin more than 9 gm/dl (96.8 mg/dl).

The mean serum VLDL levels were significantly lower (P<0.01) in cases

with haemoglobin less than 6 gm/dl (18.0 mg/dl), as compared to cases with

haemoglobin more than 9 gm/dl (23.4 mg/dl).

The mean serum triglyceride levels were significantly lower (P<0.01) in cases

with haemoglobin less than 6 gm/dl (94.4 mg/dl), as compared to cases with

haemoglobin more than 9 gm/dl (116.6 mg/dl).

The mean serum total cholesterol/HDL ratio was significantly lower (P<0.05)

in cases with Hb less than 6 gm/dl (4.15), as compared to cases with Hb more than

9 gm/dl (4.35).

The mean serum LDL/HDL ratio was significantly lower (P<0.01) in cases

with Hb less than 6 gm/dl (2.45), as compared to cases with Hb more than 9 gm/dl

(2.72).

86
 TABLE 13

Severity of Anaemia and liqid profile

Liqid profile Hb < 6 gm/dl HB 6-9 gm/dl Hb > 9 gm/dl P value

(mean ± SD) (n=9) (n=19) (n=22) (ANOVA)

TC 105.0 ± 21.3 128.5 ± 22.6 154.7 ± 23.6 P <0.01**

HDL 25.3 ± 6.2 30.5 ± 6.4 35.5 ± 5.2 P <0.01**
LDL 62.0 ± 19.3 75.0 ± 21.5 96.8 ± 22.0 P <0.01**
VLDL 18.0 ± 7.4 21.8 ± 5.5 23.4 ± 5.9 P <0.01**
TG 94.5 ± 36.7 102.1 ± 27.9 116.6 ± 28.8 P <0.01**
TC/HDL 4.15 ± 0.7 4.21 ± 0.09 4.35 ± 0.7 P <0.05*K
LDL/HDL 2.45 ± 0.7 2.45 ± 0.7 2.72 ± 0.7 P <0.01*K
*Significant at 5% **Significant at 1% K- Kruskal Wallies test

Severity of Anaemia and Lipid Profile

200
180
160
140
120
Units in

100
80
60
40
20
0
TC HDL LDL VLDL TG
Hb < 6 gm/dl Hb 6-9 gm/dl Hb > 9 gm/dl

87
Type of Anaemia and Lipid Profile

Since the severity of anaemia was found to have a significant effect on the

lipid profile, analysis of the effect of type of anaemia on lipid profile was done by

further subdividing the types of anaemia on the basis of severity and comparing

the lipid profile in groups having varying types of anaemia with similar severity.

There was no significant difference (P>0.05) in the mean total cholesterol

levels in different types of anaemia with similar levels of haemoglobin.

There was no significant difference (P>0.05) in the mean HDL levels in

different types of anaemia with similar levels of haemoglobin.

There was no significant difference (P>0.05) in the mean LDL levels in

different types of anaemia with similar levels of haemoglobin.

There was no significant difference (P>0.05) in the mean VLDL levels in

different types of anaemia with similar levels of haemoglobin.

There was no significant difference (P>0.05) in the mean triglyceride levels

in different types of anaemia with similar levels of haemoglobin.

There was no significant difference in the mean total cholesterol / HDL ratio

(P>0.05) and mean LDL / HDL ratio (P>0.05) in different types of anaemia with

similar levels of haemoglobin.

88
 Table 14

Type of Anaemia and lipid profile

Lipid Type of Anaemia

Profile Hb (in P Value
(mean gm/dl) (ANOVA)
DM MH NH NN OTHERS
± SD)
TC <6 108.4 ± 19.3 106.6± 23.6 - - 93.3 ± 25.9 P > 0.05
In
Mg/dl 6-9 125.8 ± 20.9 132.6 ± 26.2 113.0 ± 18.3 - 118.5 ± 2.1 P > 0.05
158.6 ± 22.5 143.6 ± 31.2 151.8 ± 23.6 163.6 ± 107.0± 0 P > 0.05
>9
13.0
HDL <6 21.6 ± 6.6 25.6 ± 3.6 - - 248± 7.4 P > 0.05
(in
mg/dl) 6.9 30.3 ± 6.1 28.2 ± 7.2 31.0 ± 0 - 30.0 ±9.9 P > 0.05

>9 36.4 ± 4.2 32.8 ± 4.0 32.4 ± 4.9 36.4 ± 4.1 24. 0 ± 08 P > 0.05
LDL >6 65.7 ± 16.0 64.4 ± 22.5 - - 44.5 ±22.4 P > 0.05
(in
6-9 74.3 ± 17.7 78.4 ±27.2 58.0 ±14.1 - 75.5 ±12.0 P > 0.05
mg/dl)
>9 79.3 ± 18.7 40.6 ± 32.3 93.0 ±23.0 104.4± 12.4 60.0 ± 08 P > 0.05
VLDL <6 18.6 ± 7.3 17.6 ± 5.3 - - 25.0 ± 8.4 P > 0.05
(in
6-9 21.2 ± 5.5 23.1 ± 5.8 25.0 ± 4.2 - 21.0 ±0 P > 0.05
mg/dl)
>9 24.0 ± 5.0 20.2 ± 4.4 25.4 ±6.7 21.8 ±5.2 23.0 ± 08 P > 0.05
TG( in <6 81.6 ± 36.3 89.0 ± 27.3 - - 124.8 ±41.1` P > 0.05
mg/dl)
6-9 102.5 ± 27.8 115.7 ± 29.3 125.0 ± 21.2 - 103.5 ± 0.7 P > 0.05

>9 113.2 ± 26.4 101.4 ± 23.4 126.6 ±32.4 109.5 ±25.7 114.0 ± o8 P > 0.05
TC <6 5.0 ± 0.007 2.2± 1.0 - - 3.8 ± 0.4 P > 0.05K
/HDL
6-9 4.1 ±0.08 4.3 ± 0.9 - - 4.0 1.5 P > 0.05K

>9 4.4 ± 0.7 4.4 ± 1.1 3.8 ±0.06 4.5 ± 0.5 4.5 08 P > 0.05K
LDL <6 3.0 ± 0.6 2.8 ± 1.0 4.7 ± 0.8 - 1.8 ±0.6 P > 0.05K
HDL
6-9 2.5 ± 0.06 4.7 ± 0.7 0.5 - 2.6 ± 1.2 P > 0.05K

>9 2.1 ± 0.6 1.23 ± 1.1 2.9 ± 0.7 2.9 ± 0.5 2.5 ± 0# P > 0.05K

Inference:
There is no statistically significant difference in lipid fractions between
different types of anemia (P>0.05)
# - p value could not be computed as there was only one case. K –Kruskal Wallies Test

89
 DISCUSSION

The observations made in 50 cases of anaemia and 50 non anaemic controls,

who presented to Department of Medicine, Thanjavur Medical College,Thanjavur

from Jan 2016 to June 2016 is discussed here and results have been

compared with other similar studies.

Age

All cases in this study were between 14 and 75 years. Majority of the cases

were middle aged (30-60 years). Anaemic cases younger than 50 years were

more likely to have more severe anaemia, as compared to cases older than 50 years,

who were more likely to have less severe anaemia. This is probably due to younger

individuals having a higher risk of worm infestations, and also the onset of

menopause with cessation of menstrual blood loss after the age of 50 years.

Sex

The cases consisted of 22 males and 28 females. There was no correlation

between sex and severity of anaemia.

Type and severity of Anaemia

Dimorphic anaemia was the most commonly seen type of anaemia in this

study. Microcytic hypochromic anaemia was the second most common, followed by

normocytic hypochromic anaemia, and those with normocytic normochromic blood

picture. Only a few cases of megaloblastic anaemia and pancytopenia, and one case

90
of chronic myeloid leukemia were seen. This is consistent with standard

textbooks of medicine, which describe nutritional deficiencies, especially iron

deficiency, to be the most common cause for anaemia25,26.

Most cases had mild to moderate anaemia, as defined by a haemoglobin level

above 6 gm/dl. None of the cases with normocytic hypochromic anaemia or

normocytic normochromic blood picture had severe anaemia.

Symptoms

Cases commonly presented with non specific symptoms of anaemia, such

as fatigue, dyspnoea, palpitations and giddiness. Symptoms suggestive of a

specific cause for anaemia were rarely seen.

Cases with more severe anaemia were more likely to have symptoms and had

more number of symptoms. Patients with haemoglobin more than 10 gm/dl were

usually asymptomatic, and incidentally detected to have on anaemia on routine

evaluation. This is consistent with standard textbooks of medicine which state that

mild anaemias of insidious onset are usually asymptomatic26.

Non specific symptoms such as fatigue, dyspnoea, giddiness, palpitations,

fever, loss of appetite and loss of weight were equally frequent in the

different types of anaemia, except normocytic hypochromic anaemia and cases

with normocytic normochromic blood picture.

91
This is possibly due to the fact that these cases had less severe anaemia.

Personal history

8 cases were vegetarians. Vegetarians were more likely to have more severe

anaemia and to have dimorphic anaemia. Vegetarians are likely to have more severe

anaemia as dietary iron of plant origin has less bioavailability.

General physical examination

Pallor was the most common finding on general physical examination. Cases

with more severe anaemia were found to be more likely to have findings on general

physical examination. Signs were usually not seen in cases with haemoglobin less

than 10 gm/dl. Koilonychia, lymphadenopathy, glossitis and angular stomatitis were

seen only in cases with dimorphic anaemia and microcytic hypochromic anaemia.

Knuckle pigmentation and perioral pigmentation was seen only in cases with

megaloblastic anaemia and dimorphic anaemia. This is consistent with descriptions

given in standard textbooks of medicine25.

Pulse Rate

The mean pulse rate was higher in anaemic cases when compared to non

anaemic controls. The mean pulse rate was higher in cases with more severe

anaemia. The pulse rate has been described to be higher in case of anaemia,

in standard textbooks of medicine. This is part of a compensatory mechanism to

raise cardiac output and maintain tissue oxygenation34.

92
 Ickx, Rigolet and Linden33, in 2000, demonstrated that anaemia causes a

rise in pulse rate and stroke volume in patients whose haemoglobin was lowered

from 13 gm/dl to 8 gm/dl.

Blood Pressure

The mean blood pressure was comparable in cases and controls. It was

lower in cases with more severe anaemia. This is due to peripheral vasodilatation,

another compensatory mechanism to raise cardiac output and maintain tissue

oxygenation.

Duke and Abelmann31, in 1969, demonstrated that redistribution of blood

volume and vasodilatation played a dominant role in the hyperkinetic circulatory

response to chronic anaemia.

Body Mass Index

The mean body mass index was comparable in cases and controls. It was lower

in cases with more severe anaemia.

Systemic examination

The most common findings on systemic examination were venous hum and

flow murmurs. Features suggestive of hyperdynamic state of circulation and

congestive cardiac failure were only seen in cases with severe anaemia. Features

suggestive of peripheral neuropathy were seen only in cases with megaloblastic

anaemia and dimorphic anaemia.

93
 This was consistent with a study done by Graettinger, Parsons and

Campbell35 in 1983, which demonstrated that anaemia leads to significant

haemodynamic changes only when it is severe.

Anaemia and Lipid profile

The results of this study confirm the findings of previous investigators

that the mean serum total cholesterol, HDL, LDL, VLDL and triglyceride levels are

decreased in anaemia.

The mean total cholesterol was found to be lower in anaemic cases when

compared to controls. The decrease in mean serum cholesterol was not due to a

specific lowering of any of the serum lipoprotein families; hypocholesterolemia was

caused by a reduction in all the major lipoprotein families, including mean HDL,

LDL, VLDL and triglycerides. There was a very large decrease in mean total

cholesterol and LDL levels, and a large decrease in mean HDL levels, resulting in a

mild fall in mean TC/HDL and LDL/HDL ratios. There was a mild decrease in

mean VLDL and triglyceride levels.

Rifkind and Gale4,5 in 1967 showed that anaemia was associated with

hypocholesterolemia and the decrease in serum cholesterol was not due to a specific

lowering of any of the serum lipoprotein families, and that hypocholesterolemia was

caused by a proportional reduction in all the major lipoprotein families.

Elwood and Mahler6, in 1970, conducted a study 4,070 women, and

demonstrated a significant difference in cholesterol between women with

haemoglobin levels above and below 10.5g/dL.

94
Severity of Anaemia and Lipid profile

Patients with more severe anaemia were found to have a larger fall in mean

total cholesterol and all the lipid sub fractions. This suggests that the severity of

anaemia is responsible for the hypocholesterolemia seen in anaemia.

A study conducted by Choi61 et al in 2001 showed that lipid levels in patients

with iron deficiency anaemia were directly related to the hemoglobin levels.

Type of Anaemia and Lipid Profile

The type of anaemia did not have a significant effect on the mean lipid levels.

This suggests that it is anaemia per se, and not the type of anaemia that is

responsible for the lowering of lipid levels in anaemia.

A study by Westerman7 in 1975 examined the relationship between

hypocholesterolemia and various types of anaemia, including megaloblastic

anaemia, hereditary spherocytosis, homozygous sickle cell disease, aplastic

anaemia, and liver associated anaemia. The study showed that the plasma

cholesterol level is closely related to haematocrit levels, both initially and

throughout the course of the anaemias associated with hypocholesterolemia. This

association was maintained regardless of the cause of changes in haematocrit

levels. The authors concluded that low haematocrit, not the type of anaemia, is the

cause of low cholesterol levels.

Seip and Skrede56, in 1967, found an association between serum

cholesterol and haemoglobin in all cases, regardless of cause of anaemia.

95
 SUMMARY

This study was done on 50 anaemic cases and 50 non anaemic controls to

study the clinical presentation and effect on lipid profile of anaemia.

Younger individuals are more likely to have severe anaemia. Cases with

severe anaemia have more symptoms. They have higher mean pulse rate, lower

mean blood pressure and mean BMI. Vegetarians are more likely to have severe

anaemia. Cases with severe anaemia also have more signs on examination.

Anaemia is associated with significant hypocholesterolemia, with lowering in

all lipid subfractions. The extent of hypocholesterolemia is proportional to the

severity of anaemia. The type of anaemia has no effect on the hypocholesterolemia

seen in anaemia.

Further studies are required to study the long term effect of anaemia on the

risk of developing atherosclerosis, and to study the long term effect of treatment of

anaemia on lipid levels and cardiovascular morbidity and mortality1.

96
 CONCLUSION

50 cases of anaemia and 50 controls who presented to the Department of

Medicine, T M C H ,Thanjavur from Jan 2016 to June 2016 are presented here.

They were studied regarding demographic characteristics, clinical presentation and

biochemical changes with special reference to lipid profile in relation to severity

and type of anaemia. The following conclusions were arrived at.

1) Majority of cases with anaemia were in the age group of 30-60 years.

Younger cases were more likely to have more severe anaemia.

2) There was no relation between sex and severity of anaemia

3) Dimorphic anaemia was the most commonly seen type of anaemia.

4) Most cases had mild to moderate anaemia.

5) The most common presenting symptom was fatigue. Patients with severe

anaemia were more likely to be symptomatic.

6) Vegetarians were more likely to have more severe anaemia.

7) Pallor was the most common finding on general physical examination. Cases

with more severe anaemia were more likely to have findings on general

physical examination.

8) The mean pulse rate was higher in cases. The mean pulse rate was higher in

cases with severe anaemia. The mean blood pressure and BMI were lower in

cases with severe anaemia.

97
 9) The most common findings on systemic examination were venous hum and

flow murmurs. Features suggestive of hyperdynamic state of circulation and

congestive cardiac failure were only seen in cases with severe anaemia.

10) The mean total cholesterol, HDL, LDL, VLDL and triglyceride levels, along

with TC/HDL and LDL/HDL ratios were significantly decreased in cases

compared to controls.

11) There was a larger reduction in mean total cholesterol, HDL, LDL, VLDL

and triglyceride levels, along with TC/HDL and LDL/HDL ratios with

increased severity of anaemia.

12) The type of anaemia did not have a significant effect on the mean lipid levels.

98
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 Annexures

Proforma

A Study of Lipid Profile in Anaemia

Case/Control No: Matched with Case/Control

No:

Preliminary data of the Patient

Name: Age: years Sex: M/F

Occupation:

OP/IP No: Unit: Med Date:

History of Presenting Illness:

Fatigue Yes/ No

Dyspnoea Yes/ No

Giddiness Yes/ No

Palpitations Yes/ No

Angina Yes/ No

Pica Yes/ No

Dysphagia Yes/ No

Abd pain Yes/ No

Bony pain Yes/ No

Fever Yes/ No

Loss of appetite Yes/ No

Weight loss Yes/ No

Jaundice Yes/ No

Bleeding Yes/ No

Malaena Yes/ No

Haemoglobinuria Yes/ No

Menorrhagia Yes/ No

Pregnancy Yes/ No

Post menopausal bleeding Yes/ No

Past History:

Diabetes Mellitus Yes/ No

Hypertension Yes/ No

IHD Yes/ No

CVA Yes/ No

AIDS Yes/ No

Recent blood loss Yes/ No

Gall stones Yes/ No

Personal History:

Diet: Veg/ Non veg

Smoking Yes/ No

Alcohol Yes/ No

Drug History:

Oral Contraceptives Yes/ No

Beta blockers Yes/ No

Diuretics Yes/ No

Steroids Yes/ No

NSAIDs Yes/ No

Family History

Anaemia Yes/ No

Jaundice Yes/ No

Gallstones Yes/ No

On Examination:

Pallor Yes/ No

Koilonychia Yes/ No

Icterus Yes/ No

Pedal edema Yes/ No

Lymphadenopathy Yes/ No

Glossitis Yes/ No

Angular stomatitis Yes/ No

Petechiae Yes/ No

Haemolytic facies Yes/ No

Ankle ulcers Yes/ No

Perioral pigmentation Yes/ No

Knuckle pigmentation Yes/ No

Pulse: /min Rhythm Volume

BP: mm of Hg
Weight: kgs

Height: cms

Body Mass Index: kg/m2

Cardiovascular system

JVP Yes/ No cms

Venous hum Yes/ No

Cardiomegaly Yes/ No

S3 Yes/ No

Flow murmer Yes/ No

Respiratory system

Basal crepitations Yes/ No

Abdomen

Hepatomegaly Yes/ No

Splenomegaly Yes/ No

Central nervous system

Confusion Yes/ No

Power

DTRs

Vibration Normal/ Impaired

Position Normal/ Impaired

Romberg’s Present/ Absent

Investigations:

1. Complete Haemogram

Hb g/dl

PCV %,

TC * 103 /mm3

DC %P %L %E %M %B,

ESR mm/hr

RBC *106 /mm3

MCV fL

MCH pg

MCHC g/dl

Peripheral Smear:

2. Lipid Profile

Total Cholesterol mg/dl

HDL mg/dl

LDL mg/dl

VLDL mg/dl,

Triglycerides mg/dl

TC/ HDL Ratio

LDL/ HDL Ratio

3. Urine Routine

Albumin

Sugar

Microscopy PC / HPF

EPC / HPF

RBC / HPF

4. Random Blood Sugar mg/dl

5. Blood Urea mg/dl

6. Serum Creatinine mg/dl

7. Liver Function Tests

Serum total bilirubin mg/dl

Serum direct bilirubin mg/dl

SGOT U/L

SGPT U/L

SAP U/L

Serum total protein gm/dl,

Serum albumin gm/dl

Albumin/ Globulin Ratio

8. Thyroid Profile

TSH μU/ml

T3 ng/dl

T4 μg/dl

9. FBS mg/dl

PPBS mg/dl

10. Bone Marrow Aspiration Cytology

 CONSENT FORM

I __________________________________________ hereby give consent to

participate in the study conducted by DR.SADHASIVAM.P, Post graduate in the

Department of General Medicine ,Thanjavur Medical College & Hospital, Thanjavur

– 613004 and to use my personal clinical data and result of investigation for the purpose

of analysis and to study the nature of disease. I also give consent for further

investigations.

Place :

Date : Signature of participant

 INFORMATION SHEET

• We are conducting a prospective A STUDY OF LIPID PROFILE IN

ANAEMIA, in THANJAVUR MEDICAL COLLEGE in the Department of

General Medicine , Thanjavur Medical College & Hospital, Thanjavur – 613004.

• At the time of announcing the results and suggestions, name and identity of the

patients will be confidential.

• Taking part in this study is voluntary. You are free to decide whether to

participate in this study or to withdraw at any time; your decision will not result

in any loss of benefits to which you are otherwise entitled.

• The results of the special study may be intimated to you at the end of the study

period or during the study if anything is found abnormal which may aid in the

management or treatment.

Signature of Investigator Signature of Participant

Date:
 PATIENTS
*ANAEMIA
Sl.No Ip.No. Unit Patient's name A/S HB TC DC RBC PCV RBS UREA CR TC TGL HDL LDL VLDL
TYPES
1 36297 M4 Mr.Panchavarnam 70/M 3.8 5,200 59,30,11 1.5 12 94 28 0.8 101 175 28 38 35 DM
2 37308 M3 Mr.Veeramuthu 40/M 6.0 6,600 56,40,04 2 12 121 22 0.7 136 130 19 91 26 NH
3 34943 M5 Mr.Stalin 16/M 8.4 7,100 65,20,15 1.5 12 80 18 0.8 124 100 26 78 20 MH
4 34586 M3 Mr.Murugayyan 70/M 9.2 6,100 80,14,06 3 22 150 17 0.9 156 130 22 108 26 NH
5 33992 M5 Mr.Sutharathinam 76/M 6.8 6,300 78,20,02 2.4 16 84 16 0.6 112 95 24 69 19 DM
6 34009 M6 Mr.Kasinathan 52/M 5 7,300 68,30,02 2 14 90 16 1 72 110 28 22 22 DM
7 36978 M4 Mr.Natarajan 65/M 9.0 7,600 48,30,22 3.2 24 89 41 1.1 124 130 25 73 26 MH
8 36005 M3 Mr.marimuthu 62/M 8.6 6,100 78,20,02 2.9 22 86 18 0.9 88 130 19 43 26 DM
9 39564 M3 Mr.Gobinath 29/M 7.2 4,200 54,40,06 2.6 18 76 29 0.6 128 130 21 81 26 MH
10 37332 M3 Mr.Manickam 65/M 9.4 7,100 68,28,04 3.4 28 110 31 0.9 141 145 23 89 29 DM
11 39044 M4 Mr..Govindaraj 65/M 9.6 5,800 45,50,05 3.6 30 83 39 0.8 135 115 24 88 23 DM
12 34278 M1 Mr.Backiyaraj 37/M 8 3,600 64,34,02 2.8 20 109 21 0.6 99 160 30 37 32 OTHERS
13 39579 M3 Mr.Selvakumar 37/M 5.6 7,200 58,38,04 2 14 78 21 0.8 119 130 23 70 26 MH
14 36238 M4 Mr..Muruganandam 35/M 6.0 6,900 62,36,02 2.2 18 92 36 0.6 105 100 24 61 20 DM
15 36333 M4 Mr.Raman 60/M 9.4 8,100 68,30,02 3.3 26 93 42 1.2 142 145 21 92 29 DM
16 34588 M3 Mr.Kannan 38/M 9.6 6,300 60,28,12 3.5 28 124 20 0.8 94 85 16 61 17 NH
17 35537 M1 Mr.Rengasamy 40/M 10.2 7,100 78,18,04 3.6 26 112 26 1.2 120 125 21 74 25 NH
18 36131 M3 Mr.Ezhumalai 37/M 9.6 5,400 68,31,01 3.3 24 78 22 0.5 60 90 22 20 18 NH
19 35702 M1 Mr.Shanmugam 65/M 7.6 8,700 68,30,02 2.9 20 76 42 0.9 105 140 23 55 27 DM
20 38966 M4 Mr.Yesudass 45/M 9.6 8,000 64,28,08 3.2 24 95 42 1.2 144 130 26 92 26 MH
21 34854 M4 Mr.Kathayyan 80/M 10.8 7,000 82,16,02 3.6 26 130 28 0.9 160 140 31 101 28 MH
22 34814 M4 Mr.Sethu 38/M 11 11600 78,18,04 3.8 30 91 20 1 157 165 29 95 33 NH
 PATIENTS
*ANAEMIA
Sl.No Ip.No. Unit Patient's name A/S HB TC DC RBC PCV RBS UREA CR TC TGL HDL LDL VLDL
TYPES
1 34956 M5 Ms.Nirmala 18/F 6.4 8,400 68,30,02 2.4 20 88 18 0.7 116 110 26 68 22 DM
2 33101 M2 Ms.Ranjitha 20/F 9.6 7,800 56,40,04 3.6 28 94 15 0.7 158 105 24 113 21 NN
3 35051 M6 Mrs.Samuthiravalli 29/F 9 6,100 38,60,02 3.2 24 89 22 0.9 140 110 31 87 22 MH
4 40575 M5 Mrs.Lillismary 45/F 3 4,200 54,40,06 1.1 10 184 16 0.9 133 85 25 91 17 OTHERS
5 39731 M1 Mrs.Mariyammal 40/F 9.2 7,800 68,22,10 1.2 10 99 31 0.8 104 140 16 60 28 DM
6 39780 M1 Mrs.Kanga 40/F 6.3 8,300 74,20,06 3.2 10 102 38 0.9 119 125 22 72 25 NH
7 38154 M8 Mrs.Sathiyavani 25/F 3.2 3,800 78,20,02 1.2 10 85 16 1 108 155 19 58 31 OTHERS
8 36326 M4 Ms.Akila 16/F 9.5 7,300 65,32,03 3.6 10 76 33 0.9 91 125 26 40 25 DM
9 40311 M4 Mrs.Annakili 28/F 8.4 4,600 40,56,04 3 10 111 29 1 121 135 24 70 27 DM
10 39776 M1 Mrs.Masilamani 30/F 4.3 4,900 54,36,10 1.2 10 96 27 0.6 102 90 18 65 19 DM
11 36417 M2 Mrs.Sumithira 35/F 7.4 7,000 44,50,06 2.8 20 78 19 1 132 120 25 83 24 MH
12 36172 M3 Mrs.Arockiyamary 40/F 4.6 4,400 70,28,02 1.3 10 99 35 0.6 110 100 24 66 20 DM
13 36222 M4 Ms.Pavithira 16/F 8.6 6,400 52,38,10 3 14 86 24 0.8 123 130 34 63 26 MH
14 39872 M2 Mrs.Arockiyamary 47/F 5.6 3,400 58,39,03 2.1 14 157 35 1.2 132 155 21 80 31 OTHERS
15 39605 M3 Mrs.Jayam 37/F 9.4 13,000 60,38,02 3.4 24 86 28 0.5 133 145 28 76 29 DM
16 39459 M6 Mrs.Banumathi 35/F 9.6 5,600 60,28,12 3.6 28 82 34 1.3 151 130 33 92 26 NN
17 229320 OP Mrs.Amaravathy 55/F 6.8 7,600 72,26,02 2.6 20 95 28 0.5 153 115 33 97 23 DM
18 223949 OP Ms.Sobana 13/F 10.8 8,000 60,34,06 3.8 30 100 14 1.2 169 120 39 106 24 NN
19 223966 OP Mrs.Nagalakshmi 37/F 7.8 6,400 60,32,08 3 20 89 27 0.7 148 140 34 86 28 DM
20 36486 M5 Mrs.Chinnaponnu 45/F 7.4 5,600 60,36,04 3 22 152 21 0.8 156 125 29 102 25 DM
21 224026 OP Mrs.Vetriselvi 45/F 9.8 9,800 56,40,04 3.4 26 89 33 0.6 155 130 29 100 26 MH
22 224147 OP Ms.Thaiyalnayaki 13/F 9.4 9,300 58,38,04 3.5 26 101 29 0.9 144 165 36 75 33 DM
23 224173 OP Mrs.manimekalai 45/F 8.6 7,200 56,40,04 3 24 202 21 1.1 164 200 37 87 40 MH
24 39605 M3 Mrs.Santhi 37/F 10.4 13,000 60,38,02 3.6 24 86 28 0.5 133 145 28 76 29 NN
25 39459 M6 Mrs.banumathi 35/F 9.8 5,600 60,28,12 3.2 28 82 34 1.3 151 130 33 92 26 DM
26 229622 OP Mrs.Vasantha 45/F 8.2 9,800 56,40,04 3.1 24 89 33 0.6 155 130 29 100 26 MH
27 229482 OP Mrs.Sangeetha 18/F 11.2 9,300 58,38,04 3.9 30 101 29 0.9 144 165 36 75 33 NN
28 229433 OP Ms.Chitra 20/f 8.6 7,200 56,40,04 3.2 24 202 21 1.1 164 200 37 87 40 NH
 CONTROL
Sl.No OP.NO Unit Patient's name A/S HB TC DC RBC PCV RBS UREA CR TC TGL HDL LDL VLDL
1 201313 OP Mrs.Raji 59/f 11.8 7,300 68,20,12 3.9 30 88 18 0.8 160 135 30 103 27
2 201343 OP Mrs.Kangam 50/F 12 8,500 59,37,04 4 32 99 54 1.6 187 125 41 121 25
3 201089 OP Mrs.Gunavathi 35/F 12.2 6,300 72,26,02 4.1 34 95 28 0.5 153 115 33 97 23
4 201215 OP Mrs.Veerammal 51/F 11.8 8,100 64,32,04 3.8 30 157 18 0.7 128 115 22 83 23
5 201226 OP Mrs.Vasantha 50/F 12.2 6,200 49,44,07 4.2 36 146 27 0.6 113 145 22 62 29
6 119461 OP Ms.Priyanka 18/F 12.4 6,300 72,26,02 4.2 36 95 28 0.5 153 115 33 97 23
7 203355 OP Mrs.Vallinayaki 29/F 12 8,500 59,37,04 4 34 99 54 1.6 187 125 41 121 25
8 205493 OP Mrs.Anjukam 28/F 11.8 6,900 64,33,03 4 32 89 18 1 262 385 34 151 77
9 2055633 OP Mrs.Amusu 38/F 12.8 3,800 78,20,02 4.5 38 85 16 1 108 155 19 58 31
10 206175 OP Mrs.Gunapathi 25/F 12 8,000 64,28,08 4.4 38 95 42 1.2 144 130 26 92 26
11 206278 OP Mrs.Asha 29/F 11.6 4,800 59,40,01 4.1 34 122 25 0.9 98 130 18 54 26
12 128123 OP Ms.Ragini 20/F 12 3,800 78,20,02 4 32 85 16 1 108 155 19 58 31
13 186131 OP Mrs.Rani 45/F 12.4 8,000 64,28,08 4.2 36 95 42 1.2 144 130 26 92 26
14 206897 OP Mrs.megaraj 40/F 12.2 5,600 60,28,12 4.2 38 82 34 1.3 151 130 33 92 26
15 207082 OP Mrs.Saroja 55/F 12.2 6,400 69,23,08 4.3 34 99 46 1.5 122 155 26 65 31
16 207753 OP Mrs.Thangam 70/F 12.6 6,800 70,28,02 4.4 34 88 14 1 170 120 39 107 24
17 195717 OP Mrs.Shanthi 40/F 12.4 6,100 48,50,02 4.3 36 152 21 0.8 156 125 29 102 25
18 223090 OP Mrs.manimekalai 58/F 12 6,900 52,46,02 4.1 32 202 21 1.1 164 200 37 87 40
19 223144 OP Ms.Punitha 18/F 12 5,900 64,30,06 4 32 96 23 0.8 159 145 29 101 29
20 227529 OP Mrs.Suseela 70/F 11.8 8,200 44,48,08 3.9 30 95 18 0.9 118 130 20 72 26
21 227659 OP Mrs.maheswari 59/F 12.8 6,100 48,50,02 4.6 38 152 21 0.8 156 125 29 102 25
22 238851 OP Mrs.Chandra 48/F 12.2 6,500 64,33,03 4.2 34 194 33 1.2 143 155 24 88 31
23 245803 OP Mrs.Saroja 20/F 12.8 8,600 56,40,04 4.7 40 89 33 0.6 155 130 29 100 26
24 248497 OP Mrs,Sagarabanu 27/F 12.8 7,700 58,38,04 4.8 40 101 29 0.9 144 165 36 75 33
25 250186 OP Mrs.josepin 36/F 12.6 7,200 56,40,04 4.4 38 115 25 0.8 152 185 29 86 37
26 252750 OP Mrs.Saraswathy 50/F 12.6 8,400 65,30,05 4.4 38 202 21 1.1 164 200 37 87 40
27 252688 OP Ms.Shanmugapriya 23/F 12.6 7,200, 54,40,06 4.2 34 130 28 0.9 160 140 31 101 28
28 252474 OP Mrs.Sobiya 35/F 11.8 6,100 48,50,02 3.9 32 152 21 0.8 156 125 29 102 25
 CONTROL
Sl.No OP.NO Unit Patient's name A/S HB TC DC RBC PCV RBS UREA CR TC TGL HDL LDL VLDL
1 192494 OP Mr.Rajeshkanna 14/m 13.6 6,100 48,50,02 4.6 40 152 21 0.8 156 125 29 102 25
2 192495 OP Mr.Subramanian 60/M 13.8 6,900 52,46,02 4.5 38 202 21 1.1 164 200 37 87 40
3 193437 OP Mr.Siraj 40/M 14.2 8,000 63,36,01 4.8 40 134 23 0.8 122 125 19 78 25
4 193580 OP Mr.Paulraj 40/M 13.8 4,800 59,40,01 4.6 40 122 25 0.9 98 130 18 54 26
5 195471 OP Mr.Selvaraj 40/M 13.8 5,800 45,50,05 4.5 38 83 39 0.8 135 115 24 88 23
6 198083 OP Mr.Pandian 46/M 13.2 4,200 54,40,06 4.4 38 76 29 0.6 128 130 21 81 26
7 199729 OP Mr.Regan 29/M 14 7,100 48,42,10 4.8 40 114 20 0.9 102 90 18 66 18
8 202420 OP Mr.Saminathan 60/M 13.6 8,400 56,45,09 4.4 38 96 24 0.7 160 110 27 111 22
9 202408 OP Mr.Raja 18/M 14 5,600 50,38,12 4.6 40 142 28 1.2 140 125 21 94 25
10 202396 OP Mr.David 43/M 14.2 9,600 58,41,01 4.6 38 119 28 0.8 140 165 29 78 33
11 205432 OP Mr.Vicky kumar 14/M 13.6 11,000 82,16,02 4.2 38 132 33 1 165 140 32 105 28
12 205487 OP Mr.Senthilkumar 28/M 14.2 8,300 68,30,02 4.9 42 199 38 1.5 147 135 27 93 27
13 205534 OP Mr.Vijayakumar 43/M 13 6,300 60,28,12 4.1 42 124 20 0.8 94 85 16 61 17
14 207114 OP Mr.Gobinath 15/M 13.8 6,100 80,14,06 4.5 40 150 17 0.9 156 130 22 108 26
15 209685 OP Mr.Dinesh 15/M 13.4 7,100 48,42,10 4.4 40 114 20 0.9 102 90 18 66 18
16 153223 OP Mr.Durairaj 50/M 13.8 8,400 56,45,09 4.5 40 96 24 0.7 160 110 27 111 22
17 245742 OP Mr.Shiyamprasad 15/M 13.6 9,800 56,40,04 4.5 38 89 33 0.6 155 130 29 100 26
18 181001 OP Mr.Vishnuvarthan 17/M 13.4 9,300 58,38,04 4.3 38 101 29 0.9 144 165 36 75 33
19 245740 OP Mr.Ramesh 22/M 14.6 7,200 56,40,04 4.9 44 202 21 1.1 164 200 37 87 40
20 245810 OP Mr.Moorthy 31/M 14.4 13,000 60,38,02 4.9 44 86 28 0.5 133 145 28 76 29
21 245801 OP Mr.naveen 30/M 13.6 7,200 56,40,04 4.4 40 202 21 1.1 164 200 37 87 40
22 249722 OP Mr.Karthikleyan 36/M 14.6 13,000 60,38,02 5 46 86 28 0.5 133 145 28 76 29