In a 68-year-old woman with hemoglobin 16 g/dL, hematocrit 47.7 % and serum sodium 145 mmol/L, what is the clinical significance and recommended management?

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Elevated Hemoglobin/Hematocrit Assessment in a 68-Year-Old Woman

These laboratory values (hemoglobin 16 g/dL, hematocrit 47.7%, sodium 145 mmol/L) are at the upper limit of normal for a woman and warrant clinical correlation with symptoms and baseline values, but do not automatically require extensive workup unless specific polycythemia vera (PV) features are present.

Initial Clinical Significance

The hemoglobin of 16 g/dL and hematocrit of 47.7% are borderline elevated for a woman. According to diagnostic guidelines, PV should be suspected only when hemoglobin/hematocrit exceeds the 95th percentile adjusted for sex and race (typically >16.5 g/dL hemoglobin or >48% hematocrit in women), when there is documented increase above the patient's baseline, or when PV-related features accompany borderline-high values 1.

The sodium of 145 mmol/L is within normal range (135-145 mmol/L) and does not suggest significant hemoconcentration or dehydration 2.

Diagnostic Algorithm

Step 1: Determine if Further Workup is Needed

Pursue diagnostic evaluation if ANY of the following are present:

  • Documented increase from this patient's historical baseline hemoglobin/hematocrit
  • PV-related features:
    • Thrombocytosis
    • Leukocytosis
    • Microcytosis from iron deficiency
    • Splenomegaly
    • Aquagenic pruritus (itching after water exposure)
    • Unusual thrombosis (Budd-Chiari syndrome, splanchnic vein thrombosis)
    • Erythromelalgia (burning pain in extremities)

If none of these features are present: Simply repeat complete blood count in 3 months 1.

Step 2: If Workup is Indicated

Order serum erythropoietin (EPO) level first 1:

  • Low EPO: Highly suggestive of PV (>90% specificity), proceed to bone marrow examination with cytogenetics
  • Normal EPO: PV remains possible (sensitivity of low EPO for PV is only ~70%), consider bone marrow examination if clinical suspicion remains high
  • High EPO: PV is unlikely; investigate secondary causes of polycythemia (hypoxia-driven conditions, medications, tumors)

Step 3: Additional Considerations

Assess for secondary causes:

  • Smoking history: Chronic carbon monoxide exposure causes real polycythemia 1
  • Medications: Testosterone, SGLT-2 inhibitors (erythrocytosis rates up to 22%), anti-angiogenic tyrosine kinase inhibitors 3
  • Hypoxia-related conditions: Sleep apnea, chronic lung disease, high altitude, cardiac right-to-left shunts
  • Obesity and alcohol use: Common in young adults with erythrocytosis (43% obese, 59% smokers in one cohort) 4

Common Pitfalls to Avoid

  1. Do not order red cell mass (RCM) measurement in routine practice. With hematocrit <60% and no other PV features, the likelihood of PV is extremely low and can be addressed more cost-effectively with serum EPO testing 1.

  2. Do not assume relative polycythemia (plasma volume contraction) without clinical evidence of dehydration, diuretic use, severe burns, or capillary leak syndrome. The concept of "stress polycythemia" or Gaisböck syndrome is poorly understood and controversial 1.

  3. Do not overlook medication-induced erythrocytosis, particularly in patients on testosterone (rates up to 66.7%) or SGLT-2 inhibitors 3.

Clinical Context

In healthy elderly individuals, mean hemoglobin values are approximately 14.8 g/dL in men and 13.6 g/dL in women 5. This patient's values are slightly elevated but not dramatically so. The key is determining whether this represents a change from her baseline or is associated with any PV-related clinical features.

The sodium level of 145 mmol/L does not suggest hemoconcentration as a cause of the borderline elevated hematocrit, as it sits at the upper limit of normal without evidence of hypernatremia 2.

Recommended Management

For this specific patient with isolated borderline values and normal sodium:

  • Review her previous hemoglobin/hematocrit values to assess for documented increase
  • Perform targeted history and physical examination for PV-related features listed above
  • Assess medication list (particularly testosterone, SGLT-2 inhibitors)
  • Evaluate for smoking, sleep apnea, chronic lung disease

If no concerning features are identified: Repeat CBC in 3 months 1.

If any PV-related features or documented increase from baseline: Proceed with serum EPO level and consider hematology referral 1.

References

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