Introduction
Anemia of chronic diseases is a group of anemias that occurs with a long course of various chronic infectious, inflammatory, oncological, and autoimmune diseases and having the features of iron deficiency. In the development of the disease, a set of factors of iron metabolism play a role, as a result of which it bears the features of iron-deficiency anemia. At the same time, treatment with iron preparations can even worsen the condition, in light of which the differential diagnosis of this form from true iron deficiency anemia is of great practical importance.
Anemia of chronic diseases is a pathogenetic component of the body’s response to a prolonged tumor, infection, inflammatory or autoimmune process. It is based on the disrupted proliferation of erythroid progenitors. Anemia is the result of distorted iron metabolism, a reduced response to erythropoietin, and significant activity of pro-and anti-inflammatory cytokines.
Problem
The problem is anemia of chronic diseases, which is prevalent among the patients of a transitional nurse who primarily deals with people with chronic diseases. Highlights of the pathogenesis of anemia of chronic conditions include iron metabolism. Iron is an essential element that plays a large role in many cellular and tissue functions, including oxygen transport, nucleotide synthesis, mitochondrial respiration, and immune defense (Fraenkel, 2015). Iron is absorbed from the food by enterocytes of the duodenum and from them enters the plasma in a complex way. In plasma, iron, through soluble transferrin receptors located on the surface of a number of macrophages, binds to the iron transporting protein – transferrin, undergoes a series of changes, after which it returns to the bloodstream and is used for the synthesis of hemoglobin and other needs of the body.
Significance
The issue is highly significant among transitional nurses and their patients because anemia of chronic diseases can be a ramification of other health issues. Clinical manifestations in a patient with anemia are determined by the pathology that causes anemia, and the severity of tissue hypoxia. Anemia of chronic diseases is one of the symptoms of general illness, often masking or masking the underlying disease. There is a direct relationship between the degree of anemia of chronic diseases and the severity of the underlying disease (Shu et al., 2015). Anemia enhances the clinical manifestations in the case of damage to the arteries supplying the brain and lower extremities, worsens heart failure, and in the occurrence of lung diseases, anemia exacerbates hypoxic syndrome. The body adapts to low levels of hemoglobin and red blood cells, and patients often get used to their malaise, explaining it by overwork at work, psycho-emotional overload, and other factors.
Purpose
The main purpose of the research is to identify and outline the diagnostic factors associated with each trigger disease. The basis of diagnosis is the presence of a long-term chronic disease in a patient. Usually, its nature is tumorous, infectious-inflammatory, or autoimmune. If there is no underlying disease, then a diagnosis of anemia of chronic diseases is unlikely. The clinical manifestations of anemia of chronic diseases are largely dependent on the disease with which it is associated. Ferritin levels do not reflect iron stores in patients with inflammatory processes as they do in individuals without inflammation. As for tumor and autoimmune diseases, the inflammatory component is usually also present here. Successful treatment of the underlying disease that caused the development of anemia, as a rule, allows nurses to normalize the existing hematological disorders (Murawska et al., 2016). If effective treatment of the underlying disease is not possible, use therapy aimed at correcting anemia.
A meta-analysis of a large number of studies is being used more and more often, and its results are usually the subject of wide discussion. However, even though statistical methods are constantly being improved, the approach that attempts to summarize the results of studies in different patient populations continues to raise doubts. In addition to the fact that the people are different, the studies themselves have different goals and objectives and initially use a different methodology. Evaluation of the results of such work is difficult. This is reminiscent of the anecdotal situation of measuring the average temperature of all patients in a hospital. It probably makes sense to analyze studies with similar groups of patients, even if these groups are significantly smaller.
Research Questions
The research questions are primarily focused on understanding the overall anemia’s likelihood of occurrence after a certain form of health problem.
- How is anemia of chronic diseases linked to chronic renal insufficiency?
- What is the relationship between anemia of chronic diseases and viral infections, such as HIV?
- What mechanisms give rise to anemia of chronic diseases among patients with liver cirrhosis?
Master’s Essentials
Master’s essentials related to the topic revolve around evidence-based practice, clinical prevention, and program evaluation in order to improve patient outcomes. Evidence-based practice is a core element of the given research because the main goal is to gather the most up-to-date data regarding the issue. In addition, the research will manifest itself in clinical prevention, which is the main goal of transitional nurses. Improving patient outcomes is also critical in order to reduce the chances of acquiring anemia of chronic diseases after treatment.
The Review of Literature
The research on the topic of anemia of chronic diseases (ACD) has already generated vital discoveries that save people’s lives, but its complexity and issues with timely diagnoses signal for more required effort. ACD is a common disease, and it is often overlooked as it can be masked by other underlying conditions (Ganz, 2019). In-depth knowledge about this disease is necessary for a nurse who has a chance to encounter patients with high risks of developing it. In the past decade, there was a surge of studies about ACD that is linked with rising concerns about the aging population. This essay surveys the literature related to the topic and analyzes the information provided by several recent studies.
The first article, “Risk factors for incident anemia of chronic diseases: A cohort study” by Lee et al., is a correlational study on the relationship between ACD and comorbidities. Authors note that most studies of this disease focus on a specific single disease or population, therefore, they were limited in terms of risk factors in patients with anemia (Lee et al., 2019). Moreover, many studied groups had patients with existing heart conditions, for whom anemia is a risk factor that could cause cardiovascular arrest and death (Besarab & Hemmerlich, 2018). Lee et al. (2019) acknowledge that “population-based studies have shown that 17% of the elderly are anemic”, but their study includes people from 18 years and older who were monitored for 20 years. The paper examines what factors could cause ACD in patients with common chronic diseases. The occurrence of ACD will increase as the population ages, therefore, it is necessary to define risk groups accurately.
The second article called “Anemia in the long-term care setting” is a meta-analysis done by Abid et al. It focuses on concerns about ACD occurrence in long-term care settings, its prevalence, and the significance of the in-depth knowledge of this disease for people who work in these facilities. This disease is related to a higher risk of dementia, delirium, falls, it decreases the quality of life and patients have higher chances of dying from other causes when suffering from ACD (Abid et al., 2019). Besarab and Hemmerich (2018) argue that “the aging process itself might be an intrinsic factor in the development of anemia, possibly through the age-related dysregulation of certain pro-inflammatory cytokines” (p. 61). Therefore, nurses who work at elderly care facilities should be knowledgeable about the issue and have the necessary means to diagnose it at their disposal.
The third scholarly paper “Evaluation of serum hepcidin as a biochemical marker in the diagnosis of anemia of chronic disease” is an experimental study conducted by Vyas et al. It discusses how anemia affects people worldwide and provides an insight into the research of the new marker for diagnosing ACD at lower costs without damaging its accuracy. Vyas et al. (2018) aimed to “explore the use of a biomarker i.e. hepcidin in detection and diagnosis in early-stage anemia,” and concluded that the chosen marker for infection correlates with hepcidin expression (p. 1974). This pioneering study gives a new tool for a simple and non-invasive way to diagnose ACD.
The fourth article is “Targeting hypoxia-inducible factors for the treatment of anemia in chronic kidney disease patients” by Locatelli et al. It is a review of multiple sources of data on the safety and effectiveness of prolyl hydroxylase inhibitors (HIF-PHIs) in ACD treatment. While seven different HIF-PHIs have been created, none of them have passed clinical trials yet (Besarab & Hemmerich, 2018). Locatelli et al. (2017) conclude that “HIF-PHIs need to be proven safe,” and highlight the need for controlled trials that “will provide a comprehensive summary of the safety of this interesting approach to the treatment of anemia in CKD” (p. 198). The paper ushers the introduction of new, cheaper, and more efficient treatment protocols and medications, which are necessary for such widespread diseases as ACD.
The fifth paper is a chapter by Thomas Ganz called “Anemia of chronic disease” from Molecular Hematology. It provides a thorough introduction to the topic, gives detailed instructions on diagnosis and treatment of ACD, and highlights how to distinguish its underlying problems in different settings accurately. Ganz (2019) points out that “hypoferremia, a decrease in serum iron concentration, is the defining feature of anemia of inflammation” (p. 165), which supports previously mentioned articles. This chapter gives a clear set of symptoms for ACD, defines all modern treatment methods, and describes difficulties in the diagnosis of ACD. In conclusion, each of these articles provides crucial knowledge about the disease. This information is of utmost importance for nurses who will encounter patients from high-risk groups and must be included in educational courses as vital knowledge to nursing practitioners. Further studies about this disease are necessary for raising the standards of living of many patients, especially older people since their percentage grows rapidly in many countries. Research on the new diagnosis and treatment methods is essential and must be funded for quicker development.
Implementation
The previous two papers outlined the importance of research into anemia of chronic disease (ACD) and the steps necessary to further our understanding of the condition. This final paper represents the final step of the planning phase for the study: outlining the specific details of its implementation. These specifics include determining the type of the study, designing it, budgeting time and resources, and finally, conducting a pilot study, if possible and feasible.
Step 1: Determine the Type of Study
The research problem posed for this study is determining the likelihood of ACD developing following precursor conditions. Thus, the ultimate purpose of this research is to identify conditions that can be precursors of ACD, and inform further research towards altering the treatment of these precursor conditions to minimize the risk of ACD’s development. The research question for the study can be formulated as “Which health conditions correlate with a patient developing ACD within 5 years of initial diagnosis?” The research by Lee, et al. (2019), and Weiss, et al. (2018) identifies chronic kidney disease (CKD), chronic pulmonary disease (CPD), immune disease, and diabetic status as precursor conditions for ACD. Therefore, the study should primarily focus on these conditions and the factors associated with them.
Having established the research question and conditions associated with ACD, it is possible to start designing a study. Since the goal of this study is to compare the incidence of pre-existing precursor conditions with the later incidence of ACD, a comparative study design is suitable for acquiring the required data (Nieswiadomy & Bailey, 2018). Furthermore, there is no need to examine any ongoing processes, the study can be retrospective, treating the incidence of ACD as the dependant variables and precursor conditions as independent variables (Nieswiadomy & Bailey, 2018). Having determined the type of the study, we can proceed to design it.
Step 2: Design the study
The key factors to designing a retrospective comparative study are obtaining the sample and determining the specific conditions that need to be evaluated as precursors to ACD. Designing this list of precursor conditions is challenging since factors such as age and body mass index (BMI) need to be considered as possible contributors to the development of ACD. These factors are not necessarily related to the conditions being studied, and, therefore, fall outside of the scope of this study. Thus, the study design needs to account for these factors.
The sample choice for this study is straightforward: patients who have developed ACD after being diagnosed with a condition identified as a precursor. Evaluating all the patient records that satisfy the study’s broad conditions is not feasible; therefore, a representative randomized sample is necessary. Nonetheless, due to the multitude of possible uncontrolled factors, the sample size should be as large as feasible (Nieswiadomy & Bailey, 2018). However, the challenges related to factors outside of the scope of the study complicate the choice of scope. Therefore, the selection of participants may be limited to certain ages or presenting a BMI within a certain range. The time frame of the ACD’s development is also outside of this study’s scope. To summarize, this step of the study’s implementation should answer two crucial questions. First, it must identify a comprehensive list of precursor conditions. Second, it must isolate confounding factors that can contribute to developing ACD despite not having a direct relation to precursor conditions and determine ways to control for them (Polit & Beck, 2017). Based on these answers, specifics of sample selection and research metrics can be determined, informing the study’s design.
Step 3: Budget Time and Resources
As a retroactive comparative study, this research does not carry any particular instruments, tools, or procedures. Therefore, the monetary budget for this study is determined by the time and effort required to collect and interpret the significant amount of data. Consequently, the time requirement primarily depends on the sample size. However, the process for obtaining and analyzing the data is relatively straightforward and presents no obvious complications, thus allowing the study to be finished within a reasonably short time frame.
Step 4: Conduct the Study
Before conducting the research at full scale, a pilot study is preferable. Doing so will allow to fine-tune the sample eligibility criteria or uncover any issues in the planned research methodology that need to be amended before the study can produce valuable results. The pilot study can be limited to the patients of a single hospital or localized to a single town. Although a pilot study involves additional time and effort that must be devoted to the research, it can save resources in the future by eliminating unfeasible or impossible avenues of research. Finally, if the pilot study shows promising results, i. e. suggests a causal relationship between any of the precursor conditions and subsequent development of ACD, the full-scale study can be launched. As an additional benefit of the pilot study, its results can be used to adjust the list of precursor conditions used in the final study. After the study concludes, a follow-up can be considered, or further studies, for instance, examining specific precursor conditions and non-condition related factors.
Results
After addressing the random sample of patients who were 18 years old or older, the researcher established three groups intended to help them conduct the pilot study and obtain the first viable results. The three groups designed to participate in the project were patients with (a) chronic renal insufficiency, (b) HIV, and (c) liver cirrhosis. Despite the potential existence of unmodifiable factors affecting the study outcomes, the researcher decided not to limit the existing sample and make sure that the three conditions in question are going to be associated with the anemia of chronic diseases. As a retroactive comparative study, the current pilot project turned out to be evidence-based because the researcher focused on the collection of data and aligned the current research projects against the procedures that they completed within the pilot study. There were no significant complications that would deteriorate the quality of the study or contribute to adverse patient outcomes.
General Discussion
There were three research questions that the researcher intended to answer with the help of the proposed pilot study. The first one investigated the link between chronic renal insufficiency and anemia of chronic diseases. It was found that there is a strong association between the two because EPO deficiency in both conditions is relatively similar. This connection is also supported by the literature on the subject where the key concepts related to chronic renal insufficiency suggest a shortened erythrocyte survival and disordered iron homeostasis (Lee et al., 2019). The study also allowed the researcher to disclose the fact that anemia of chronic renal insufficiency was linked to the lack of healthy dietary iron absorption in the majority of study participants, with iron mobilization also diminishing due to the excess of hepcidin. These findings support the idea that there should be additional studies focusing on how molecular mechanisms related to anemia of chronic renal insufficiency are “built.” The fundamental pathogenic mechanisms causing anemia should be investigated by researchers to deploy innovative pharmacologic agents aimed to improve the efficiency of the proposed treatment and evade adverse outcomes.
The relationship between anemia and HIV has also been found to be valid due to the complex etiology of anemia in the latter. The findings of the existing pilot study allow for the suggestion that anemia is an independent predictive indicator that is inherent in HIV. These instances of evidence are also in line with information from the literature on the subject because Abid et al. (2019) pointed out atypical cytokine regulation to be one of the essential reasons causing anemia in patients with HIV. The context of aging has also been taken into consideration, as the participants of the study proved that HIV infection only accelerates processes within the human organism when age is most vulnerable. There is a need to investigate the mechanisms that drive anemia in patients with HIV further (mostly including the elderly population). The decreasing quality of life of patients with HIV cannot be separated from the context of anemia because it could be the only way to reduce mortality in the most vulnerable populations. Abid et al. (2019) proposed a therapy intended to protect patients that are most exposed to the adverse outcomes of anemia and claimed that the field of hematology should expand further to investigate the close link between HIV and anemia.
After conducting the pilot study, the author may be able to conclude that anemia of chronic diseases may be associated with liver cirrhosis as well. The main reason why it is possible is that patients with hematological abnormalities are susceptible to having issues with the liver. Many of such patients may be exposed to diverse types of anemia due to the existence of additional factors (bleeding, for example) (Weiss et al., 2018). A high occurrence of anemia in patients with liver cirrhosis turned out to be one of the most severe comorbidities, with blood coagulation also being directly related to the advent and development of anemia. It is crucial to invest in future research on the subject because previous hepatitis (according to (Weiss et al., 2018)) might lead to aplastic anemia, too. The process of treatment should be carefully aligned against the potential side effects characteristic of the proposed medication due to the negative outcomes that follow toxic effects and malnutrition. The key problem with future studies is that they might not be able to consider the correct therapy from the beginning due to the complex pathogenesis of the anemia.
Study Limitations
The biggest study limitation that would have to be addressed in future studies is the researcher’s failure to include unexplained anemia in the research process and investigate its etiology at the same time as (a) chronic renal insufficiency, (b) HIV, and (c) liver cirrhosis. On the other hand, a large number of clonal or unexplained anemia cases could have become a possibility due to the lack of younger participants within the proposed sample. Additionally, it would be crucial to collect more data on the connection between anemia and chronic liver disease in an attempt to expand the existing evidence on liver cirrhosis and proinflammatory factors that could affect the human body. Overall, impending studies should feature a richer sample and more related conditions (including unexplained anemia cases) in order to help the author gain extensive insights on the nature of anemia of chronic diseases.
Learning Experiences
Learning Experience: Master Essentials of Nursing Education
The knowledge obtained in the course of the learning process linked to the Master Essentials in Nursing Education was immeasurable as the basis for further learning and management of patients’ needs. Namely, the learning experience allowed understanding how theoretical knowledge can be transformed into strategies for evidence-based practice (EBP). In fact, EBP itself was a life-changing experience since it enabled me to see how observations and analysis of specific cases, including the isolation of key symptoms and identification of changes in well-being, helps to create strategies for clinical prevention.
Therefore, the learning experience obtained in the course of gaining the Master’s Degree in Nursing Education has shaped my understanding of how various nursing techniques can be used to improve health issues in specific populations. The described discoveries also relate to how a Master in Nursing Education can participate in changing health policies so that appropriate health services could be made more affordable and available to the target demographic. Namely, embracing the needs of vulnerable groups and communities has turned out to be of especially high importance.
Learning Experience: Master Research Class
Another essential experience gained in the course of learning, attending the Master research Class has given me insight into how health issues can be studied to produce homogenous strategies for managing public health issues. The Master Research Class allowed me to expand my frame of perception concerning research in healthcare, particularly, the application of EBP tools in it. Furthermore, after attending the class, I gained a better idea of how research can be performed when tending to the needs of a particular group, while also keeping the research results relevant to other populations. The class has shown how to increase the applicability of study results, thus creating a system in which theoretical tenets and practical approaches are interrelated.
Overall, the Master’s research Class has given me an impetus for studying the area of my choice with particular diligence. By applying the developed knowledge to specific settings, I will be able to improve the efficacy and quality of care with the help of a well-developed leadership strategy and properly directed research. Therefore, the class has been a crucial addition to my knowledge system and a valuable opportunity to expand my skill set.
Conclusion
Affecting iron metabolism in patients, anemia of chronic diseases leads to a significant reduction in the efficacy of the immune function, as well as the overall rise in fatigue levels, which is why it has to be addressed from a nursing perspective by connecting it to the problems such as renal insufficiency, infections, and liver cirrhosis. The study has established that anemia of chronic diseases affects the specified conditions directly, aggravating them and causing a patient to experience additional health issues. Therefore, the problem of anemia of chronic diseases needs to be confronted directly by building a corresponding awareness program for nurses and patients.
Moreover, with the development of anemia of chronic diseases, a patient is likely to view fatigue as a natural response to health issues, which will further obfuscate the identification and management of the said conditions. Therefore, as a nurse, one has to develop prevention measures and strategies for handling the cases of anemia of chronic diseases effectively. Using an evidence-based program for mitigating the effects of anemia of chronic diseases, as well as educating both nurses and patients about the subject matter, one will be able to mitigate the detrimental outcomes of anemia of chronic diseases.
References
Abid, S. A., Gravenstein, S., & Nanda, A. (2019). Anemia in the long-term care setting. Clinics in Geriatric Medicine, 35(3), 381–389. Web.
Besarab, A., & Hemmerich, S. (2018). Anemia of chronic disease. In R. Provenzano et al. (Eds.), Management of anemia. Springer.
Ganz, T. (2019). Anemia of chronic disease. In D. Provan & J. Gribben (Eds.), Molecular hematology (4th ed.). Wiley-Blackwell.
Fraenkel, P. G. Understanding anemia of chronic disease. Hematology ASH Education Program, 2015(1), 14-18.
Lee, Y. G., Chang, Y., Kang, J., Koo, D. H., Lee, S. S., Ryu, S., & Oh, S. (2019). Risk factors for incident anemia of chronic diseases: A cohort study. PloS one, 14(5). Web.
Locatelli, F., Fishbane, S., Block, G. A., & Macdougall, I. C. (2017). Targeting hypoxia-inducible factors for the treatment of anemia in chronic kidney disease patients. American Journal of Nephrology, 45, 187-199. Web.
Neswiadomy, R. M., & Bailey, C. (2018). Foundations of Nursing Research. Pearson, 2018.
Murawska, N., Fabisiak, A., & Fichna, J. (2016). Anemia of chronic disease and iron deficiency anemia in inflammatory bowel diseases: Pathophysiology, diagnosis, and treatment. Inflammatory Bowel Diseases, 22(5), 1198-1208.
Shu, T., Jing, C., Lv, Z., Xie, Y., Xu, J., & Wu, J. (2015). Hepcidin in tumor‐related iron deficiency anemia and tumor‐related anemia of chronic disease: Pathogenic mechanisms and diagnosis. European Journal of Haematology, 94(1), 67-73.
Polit, D. F., & Beck, C. T. (2017). Nursing Research: Generating and Assessing Evidence for Nursing Practice. Wolters Kluwer Health.
Vyas, S., Suman, S., Kapoor, A., & Nema, S. (2018). Evaluation of serum hepcidin as a biochemical marker in diagnosis of anemia of chronic disease. International Journal of Research in Medical Sciences, 6(6), 1971-1976. Web.
Weiss, G., Ganz, T., & Goodnough, L. T. (2018). Anemia of inflammation. Blood, 133(1), 40-50.