Anemia at older age: etiologies, clinical implications, and management

Reinhard Stauder, Peter Valent and Igor Theurl

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  • RE: Multi-Organ-Ageing and the Risk to Develop Anemia
    • Peter Valent, Specialist in Internal Medicine; specialist in Haemato-Oncology Department of Internal Medicine I, Div of Hematology & Hemostaseology, Medical Univ of Vienna, Austria and Ludwig Boltz
    • Other Contributors:
      • Igor Theurl, Specialist in Internal Medicine; Specialist in Laboratory Medicine
      • Reinhard Stauder, Specialist in Internal Medicine; specialist in Haemato-Oncology

    Dear Sirs, Dear Editors,

    We like to thank Ahmed Al-Sharefi for discussing the important point of male hypogonadism as substantial risk factor and potential cause of anemia and of other relevant pathologies. We agree that testosterone replacement is an appropriate therapy in these patients, with recognition of potential side effects. We also agree that this therapy can lead to improvement or even resolution of anemia. Finally, we agree that hypogonadism is quite frequently seen in elderly patients and is therefore a relevant issue in older patients developing ´unexplained´ anemia.
    Several mechanisms may contribute to the development of anemia in elderly patients with hypogonadism. As outlined in previous articles and our manuscript1-3, one hypothesis is that hypogonadism with low testosterone leads to an impaired production of erythropoietin (EPO) in the kidney which is important, as in many older patients with ´unexplained´ anemia, decreased (inappropriately low) serum EPO levels are measured. However, there are also other mechanisms that contribute to the development of anemia in elderly patients with hypogonadism, such as a reduced response of multi-lineage or erythroid-committed hematopoietic progenitor cells to early-acting growth factors or EPO. In fact, it has been shown that testosterone augments the growth-stimulating effects of EPO on erythroid colony-forming progenitor cells (CFU-E and BFU-E).2,4 In addition, testosterone is per se capable of induc...

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    Conflict of Interest:
    None declared.
  • RE: Male hypogonadism, a treatable yet forgotten cause of unexplained anaemia
    • Ahmed Al-Sharefi, M.B.Ch.B MRCP, Specialist Registrar in Diabetes & Endocrinology Department of Endocrinology ,Royal Victoria Infirmary ,Newcastle-upon-Tyne Hospitals , Newcastle –upon-Tyne , United Kingdom
    • Other Contributors:
      • Richard Quinton, MA MD FRCP, Consultant & Senior Lecturer in Endocrinology

    Dear Sir,

    Stauder 1 et al highlighted that unexplained anemia is found in around one-third of the elderly population and may contribute to multiple adverse outcomes, but omitted male hypogonadism among the secondary causes. Testosterone stimulates erythopoeisis, hence adult male reference ranges for haemoglobin (Hb), haematocrit and red cells are higher than for females and prepubertal boys. Different mechanisms have been proposed, including increased erythroid cell mass and colony formation, stimulation of renal erythropoietin production, increased sensitivity of erythroid progenitor cells to erythropoietin 2, or via an effect on hepcidin concentrations 1.

    Hypogonadism can result from dysfunction of the testes - primary hypogonadism (PH) - or hypothalamo-pituitary axis - secondary hypogonadism (SH). Although SH can be hard to distinguish from the physiological profile of non-gonadal chronic illness, PH is readily apparent through low serum testosterone and raised LH and FSH levels. Untreated male hypogonadism carries an increased risk of anaemia, sarcopenia and osteoporosis, all of which respond to testosterone replacement, even when the hypogonadism is congenital and testosterone is not initiated until middle age 3. Although there is no male counterpart to menopause (complete gonadal insufficiency occurring in 100% of older women), the European Male Aging Study found raised LH and FSH levels in around 5% of older men, with 2% also having unequivocally...

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    Conflict of Interest:
    None declared.