What is the clinical significance of the patient's laboratory results showing anemia (low Red Blood Cell (RBC) count, low Hemoglobin (Hb) level, and low Hematocrit (Hct) level), leukopenia (low White Blood Cell (WBC) count), and thrombocytopenia (low Platelet count) over the past three years?

From the Guidelines

The patient's lab results indicate a persistent and worsening macrocytic anemia, and I strongly recommend immediate evaluation by a hematologist to determine the underlying cause and guide treatment. The most recent labs from February 2025 show a hemoglobin level of 10.6 g/dL, which is significantly below the reference range of 13.5-17.5 g/dL. The elevated Mean Corpuscular Volume (MCV) in most readings suggests a macrocytic anemia. Common causes of macrocytic anemia include vitamin B12 deficiency, folate deficiency, alcohol use disorder, certain medications, or myelodysplastic syndrome 1.

Key Findings and Recommendations

• The patient's anemia has been persistent for years and appears to be worsening recently, with a current hemoglobin level of 10.6 g/dL.
• The white blood cell counts have fluctuated but are currently normal, though there was a period of lymphopenia (low lymphocyte percentage) in the most recent reading.
• The platelet counts have remained within normal range.
• Complete testing should include serum B12, folate, methylmalonic acid, homocysteine, liver function tests, thyroid function, and possibly bone marrow examination to determine the underlying cause of the anemia.
• Treatment will depend on the underlying cause but may include vitamin supplementation (B12 injections or oral folate), dietary changes, or addressing any underlying conditions.

Rationale for Recommendations

The patient's lab results and medical history suggest a complex anemia that requires thorough evaluation and treatment. The use of epoetin or darbepoetin may be considered in patients with chemotherapy-associated anemia, but the patient's current situation does not indicate chemotherapy as the cause of anemia 1. The KDIGO guideline recommends investigating anemia in patients with CKD, including tests for iron deficiency, vitamin B12 and folate levels, and reticulocyte count 1. The European evidence-based consensus on the diagnosis and management of ulcerative colitis also recommends evaluating anemia in patients with inflammatory bowel disease, considering iron deficiency, vitamin B12 and folate deficiency, and anemia of chronic disease 1.

Prioritization of Morbidity, Mortality, and Quality of Life

The patient's anemia has been persistent and worsening, which can significantly impact their quality of life and increase the risk of morbidity and mortality. Prompt evaluation and treatment of the underlying cause of the anemia are essential to improve the patient's outcomes and quality of life. The recommendations prioritize the patient's morbidity, mortality, and quality of life by addressing the underlying cause of the anemia and guiding treatment to improve their overall health and well-being.

From the Research

Anemia Diagnosis and Evaluation

• The diagnosis of anemia can be complicated, and most tests have drawbacks 2.
• A complete blood count (CBC) with reticulocyte count is typically the first step in evaluating anemia 3, 4, 5.
• The CBC provides important clues to the classification and cause of anemia, including mean corpuscular volume (MCV) 4.
• Supplemental tests may include a peripheral blood smear, iron panel, and levels of vitamin B12, folate, lactate dehydrogenase, haptoglobin, and bilirubin 4, 5.

Reticulocyte Parameters

• Reticulocytes are the youngest erythrocytes released from the bone marrow into the blood and circulate for 1-2 days before becoming mature erythrocytes 6.
• Reticulocyte parameters, such as reticulocyte hemoglobin content (CHr), can help in the differential diagnosis of iron deficiency anemia (IDA), vitamin B12 deficiency anemia, and mixed anemia 2, 6.
• CHr is a good indication of iron availability and an early marker of iron-deficient erythropoiesis 2.
• MCVr (Reticulocyte mean corpuscular volume) and CHCMr (Corpuscular mean hemoglobin concentration of reticulocyte) can also be useful in differentiating mixed anemia from vitamin B12 deficiency, IDA, and healthy controls 6.

Laboratory Evaluation

• Laboratory evaluation of anemia should be approached logically, with a complete blood count and red cell indices offering clues to diagnosis 3, 5.
• Examination of the bone marrow may be required for diagnosis in some cases 5.
• Molecular testing is increasingly being used to aid in the diagnostic process 5.
• A rational approach to determining the etiology of a patient's anemia is essential, and may involve a combination of laboratory tests and clinical evaluation 5.