a kliewer journal_club_anemia
TRANSCRIPT
Prevalence of anemia and related deficiencies in the first year following laparoscopic gastric bypass for morbid
obesity
Aarts, E. O., van Wageningen, B., Janssen, I. M. C., & Berends, F. J. (2012).
Journal of ObesityAllison Kliewer
Literature : Evidence Analysis Manual
Accurate assumptions
No bias was introduced to the study
Appropriate conclusions made
No financial ties to disclose
No conflict of interests
Design: prospective cohort
Epidemiological analytical study: class B, Grade I: Good
Background
Laparoscopic Roux-en-Y Gastric Bypass (LRBGY) is most common bariatric surgery
Anemia associated with iron, folic acid, and vitamin B12 deficiencies after surgery are common
Restrictive, malabsorptive procedure
Bypassing stomach and duodenum, gastric acid, intake
Purpose
Limited studies addressing nutrient deficiencies and anemia
Prospective study to investigate the prevalence of anemia and deficiencies in iron, folate, and vitamin B12 in the first year after laparoscopic gastric bypass (LRYGB) in our patients.
Subjects
January 2005 – October 2009
416 pts LRYGB (Rijnstate Hospital, The Netherlands)
N= 377 ( 102: M, 275: F)
Average age: 43.4 (18-63)
Average wt (kg): 137.5 ± 22.6
Average BMI 46.8 ± 6.3
Inclusion/Exclusion criteria
Screened by multidisciplinary team
Met NIH Consensus Development Conference Panel for bariatric surgery
Unable to attend standard F/U protocol
Pt with laboratory evaluations that surpassed the 6 & 12 month evaluation by 2-3 months respectively
Methods
30 cc proximal gastric pouch
Connect 100-150 cm roux-en-y limb to jejunum 40 cm from the ligament of Treitz
2005-2007 BMI > 40 received 100 cm limb, BMI of >50 (or failing gastric band) received 150 cm limb
2007 all pt received 150 cm
Ligament of Treitz
30 cc proximal gastric pouch
40 cm
100 cm roux-en-limb
150 cm roux-en-limb
Vitamins and Minerals Absorption sites bypassed:
IronB vitaminsVitamin ACalciumPyridoxinePantothenic acidFolic Acid
Methods
F/U at 1,3,6 & 12 months post-op
Complete blood count, mean cell volume (MCV) and kidney function pre-op
After 6 & 12 months laboratory evaluations repeated, plus plasma levels of iron, total iron binding capacity (TIBC), serum folate levels and serum B12
Post-op Protocol
Standard multivitamin 3 x daily
7 mg iron
100 μg of folic acid
0.5 μg B12
Compliance was assessed
Limits
Anemia: Hemoglobin (Hb) in men < 8.4 mmol/L & Hb women <7.4 mmol/L
MCV 80-100 fL normal
TIBC > 80%
Serum iron < 9.0 μmol/L = Deficient
Serum folate < 9.0 nmol/L = Deficient
B12 < 150 pmol/L = Deficient
Results: Anemia
Pre-op 27 pt had anemia
After 12 months 66 pt developed anemia
Total prevalence of anemia including pre-op is 25%
93 developed anemia within first year
Results
239/377 (63%) were diagnosed with at least one of either iron, folic acid, or B12 deficiency
Male 45% risk of being diagnosed with iron, folic acid, or B12 deficiency vs. 68% of females
AGB prior to RYGB a 24% vs. 39% risk in B12 deficiencies
Male vs Female & AGB
Male Female
Anemia 20% 20%
Iron deficient 17% 38%
B12 deficient 21% 42%
Iron, Folate, B12Deficient
45% 68%
• AGB had lower % of anemia, folic acid, and B12 deficiency
Article Subjects Length Post-op protocol Results
Aarts et al.
2012
N= 377Male= 102Female= 275
January 2005-October 200912 months post-op
Standard MVI x 3 dailyAt least 7 mg iron100 μg folic acid0.5 μg B12
66 pt anemia de novo33% iron deficient15% folic acid deficient50% B12 deficient
Avgerinos et al.
2010
RYGBN= 206Male= 41Female= 165
January 2003-November 200786 wks
Standard chewable MVIFerrous sulfate tablets @ 320 mg daily
Anemia= 21 (10.2 %)serum ferritin, TIBC, MCV
Menstruating females and pt found to have marginal ulcer on endoscopy at significantly greater risk.
Drygalski et al.
2011
RYGBN= 1125Male= 126Female= 999
48 monthspostoperative
Daily MVI with 18 mg iron, 400 μg folic acid, 1000 μg B12Calcium citrate with vitamin 1500 mg vitamin D
Mean Hb lower after 24-48 mSignificantly lower Hb in premenopausal women than in postmenopausal women or men.Anemia greater in pre vs post menopausalFerritin continuously at 24-48mIron @ 24-48 mFolate @ 24-48 mB12 @ 24-48 m
Risk Factors
Decreased absorption surface = absorption capacity
ph due to gastric acid (proton pump inhibitors and calcium, other meds)
Intolerance for red meat and milk
Inadequate intake preoperatively
Menstruation
inflammatory response
Recommendations
40-65 mg/d of elemental iron for males
100 mg/d elemental iron for females
+ Vitamin C ?
400 μg/d of folic acid or 1 mg/d
300-500 μg/d of B12
Questions?
Based on the results from this study, what protocol should be followed with patients undergoing LRYGB?
Why would a folate deficiency be of concern for premenopausal women?
Is this information useful?
Application
Monitor anemia and deficiencies in pt following gastric bypass
Supplementation to avoid deficiency and anemia post-op needs to be determined
At risk pts would benefit from a higher supplementation level
References
Aarts, E., van Wageningen, B., Janssen, I. & Berends, F. (2012). Prevalence of anemia and related deficiencies in the first year following laparoscopic gastric bypass for morbid obesity. Journal of Obesity. 1-7. doi:10.1155/2012/193705.
Avgerinos, D., Llaguna, O., Seigerman, M., Lefkowitz, A. & Leitman, M. (2010). Incidence and risk factors for the development of anemia following gastric bypass surgery. World Journal of Gastroenterology. 16 (15): 1867-1870. doi:10.3748/wjg.v16.i15.1867
Gastrointestinal Surgery for Severe Obesity. NIH Consens Statement Online 1991 Mar 25-27 [16 October 2012];9(1):1-20.
Von Drygalski, A., Andris, D., Nuttleman, P., Jackson, S., Klein, J. & Wallace, J. (2011). Anemia after bariatric surgery cannot be explained by iron deficiency alone: results of large cohort study. Surgery for Obesity and Related Diseases. 7: 151-156. doi:10.1016/soard.2010.04.008.