What is the workup for normocytic anemia in a 71-year-old male with mild anemia (Hemoglobin level: 12.7 g/dL)?

From the Guidelines

For a 71-year-old male with hemoglobin of 12.7 g/dL and normocytic anemia, a focused workup should begin with a complete blood count with differential to assess other cell lines and indices, along with a reticulocyte count to evaluate bone marrow response. This level is only mildly decreased, as normal hemoglobin for elderly males is typically 13.2-16.6 g/dL. Initial testing should include a comprehensive metabolic panel to assess kidney and liver function, iron studies (ferritin, iron, TIBC, transferrin saturation) to evaluate for iron deficiency 1, vitamin B12 and folate levels to assess for megaloblastic anemia, and inflammatory markers like CRP and ESR to evaluate for chronic inflammation.

Key Tests

• Reticulocyte count to evaluate bone marrow response
• Comprehensive metabolic panel to assess kidney and liver function
• Iron studies (ferritin, iron, TIBC, transferrin saturation) to evaluate for iron deficiency
• Vitamin B12 and folate levels to assess for megaloblastic anemia
• Inflammatory markers like CRP and ESR to evaluate for chronic inflammation A peripheral blood smear should be examined for morphological abnormalities. Additional testing may include hemolysis evaluation (LDH, haptoglobin, bilirubin) 1, thyroid function tests, and serum protein electrophoresis to rule out multiple myeloma.

Considerations in Elderly Patients

• In elderly patients, consider occult blood loss through stool guaiac testing and potential GI evaluation, as malignancy must be excluded 1
• Medication review is essential as many drugs can cause anemia If these initial tests are inconclusive and anemia persists or worsens, bone marrow examination may be necessary to rule out myelodysplastic syndrome or other primary bone marrow disorders common in this age group 1.

From the Research

Workup for Normocytic Anemia

The workup for normocytic anemia in a 71-year-old male with a hemoglobin level of 12.7 g/dL involves several steps:

• A thorough history and physical examination to identify potential underlying causes of anemia 2
• Basic diagnostic studies, including:
  • Red blood cell distribution width (RDW) to assess for iron deficiency or other causes of anemia 3, 2
  • Corrected reticulocyte index to evaluate bone marrow response to anemia 2
  • Peripheral blood smear to examine red blood cell morphology 3, 2
• Further testing guided by the results of these studies, such as:
  • Serum ferritin level to assess for iron deficiency anemia 4
  • Reticulocyte hemoglobin content (CHr) to evaluate iron availability and diagnose iron deficiency anemia 5, 6
• Evaluation for underlying conditions, such as:
  • Chronic kidney disease 4
  • Chronic inflammation 4
  • Occult blood loss from gastrointestinal malignancy 4

Diagnostic Considerations

• Normocytic anemia can be caused by various factors, including anemia of chronic disease, normocytic megaloblastic anemia, and acquired immunodeficiency syndrome 3, 2
• Iron deficiency anemia is a common cause of normocytic anemia, and CHr can be a useful diagnostic tool in this setting 5, 6
• Serum ferritin level is an important diagnostic test in patients with normocytic or microcytic anemia, as a low level is associated with iron deficiency anemia 4

Treatment Considerations

• Treatment should be directed at correcting the underlying cause of the anemia 2, 4
• Symptomatic patients with severe anemia may require blood transfusion 4
• Patients with suspected iron deficiency anemia should be given a trial of oral iron replacement, with parenteral iron infusion reserved for those who do not respond to or cannot tolerate oral therapy 4