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Anemia Associated
With
Nutritional Deficiencies
Elisabeth Sosa, MSN, ARNP, AOCNP
Elisabeth Sosa, MSN, ARNP, AOCNP is a certified
adult oncology nurse practitioner. She practices
within a large private practice
hematology/medical oncology group in Central
Florida. She has previously been published in
the Clinical Journal of Oncology Nursing (CJON).
ABSTRACT
Anemia can occur for many different reasons. These include chronic disease,
nutritional deficiencies, malignancy, medications, blood loss, and bone
marrow disorders. It is important that nurses understand how anemia is
caused by nutritional deficiencies, as well as how anemia and nutritional
deficiencies are treated. Health care personnel with an understanding of
anemia are better prepared to ensure that affected individuals obtain
appropriate treatment and avoid complications. This course will discuss the
definition of anemia, as well as grading the severity and complications of
anemia.
Keywords: Anemia, Hematology, Red blood cells, Iron deficiency, Pernicious
Anemia, Vitamin B12, Folic acid.
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Continuing Nursing Education Course Planners
William A. Cook, PhD, Director, Douglas Lawrence, MA, Webmaster,
Susan DePasquale, MSN, FPMHNP-BC, Lead Nurse Planner
Policy Statement
This activity has been planned and implemented in accordance with the
policies of NurseCe4Less.com and the continuing nursing education
requirements of the American Nurses Credentialing Center's Commission on
Accreditation for registered nurses. It is the policy of NurseCe4Less.com to
ensure objectivity, transparency, and best practice in clinical education for
all continuing nursing education (CNE) activities.
Continuing Education Credit Designation
This educational activity is credited for 1.5 hours. Nurses may only claim
credit commensurate with the credit awarded for completion of this course
activity.
Statement of Learning Need
An understanding of anemia due to nutritional deficiencies, as well as how
anemia and nutritional deficiencies are treated, is essential for health
professionals to support patients diagnosed with anemia.
Course Purpose
To help nurses develop an understanding of the treatment of anemia related
to nutritional deficiencies, and to learn about treatment options for types of
anemia as well as reasons why patients would require blood transfusions.
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Target Audience
Advanced Practice Registered Nurses and Registered Nurses
(Interdisciplinary Health Team Members, including Vocational Nurses and
Medical Assistants may obtain a Certificate of Completion)
Course Author & Planning Team Conflict of Interest Disclosures
Elisabeth Sosa, MSN, ARNP, AOCNP, William S. Cook, PhD,
Douglas Lawrence, MA, Susan DePasquale, MSN, FPMHNP-BC –
all have no disclosures.
Acknowledgement of Commercial Support
There is no commercial support for this course.
Activity Review Information
Reviewed by Susan DePasquale, MSN, FPMHNP-BC
Release Date: 1/1/2016
Termination Date: 7/1/2018
Please take time to complete a self-assessment of knowledge, on
page 4, sample questions before reading the article.
Opportunity to complete a self-assessment of knowledge learned
will be provided at the end of the course.
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1. ____________ will raise a patient’s concentration of hemoglobin.
a. Smoking and living at higher altitudes
b. Pregnancy
c. Iron deficiency
d. Blood donations
2. In men and postmenopausal women, ______________ is the
most common source of iron deficiency
a. a vegetarian diet
b. menorrhagia
c. gastrointestinal bleeding
d. low socioeconomic status
3. Elevated ______________ is a good sign of B12 deficiency.
a. homocysteine levels
b. methylmalonic acid
c. mean corpuscular volume
d. iron levels
4. Cobalamin, a water-soluble vitamin, that is important in the
production of red blood cells, is also known as _________________.
a. Iron
b. Vitamin E
c. Vitamin C
d. Vitamin B12
5. True or False: Folic acid deficiency causes neurological symptoms,
even in the absence of a vitamin B12 deficiency.
a. True.
b. False.
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Introduction
The presence of anemia in an indivdiual often is indicative of an underlying
diseas-state. It is important for health professionals to understand the
pathology underlying anemia for both men and women. Anemia involves a
reduction in the concentration of hemoglobin or red blood cells in the blood
and, depending on the severity, may require treatment. The level of anemia
often depends upon the age and gender of individuals, including lifestyle
patterns and altitude of the person’s residence. This course introduces a
case study at the start and end of the study relative to nursing care.
Case Study: Vanessa
The following case study may be seen in the outpatient primary care setting.
The objective of this case study is to illustrate how patients with anemia may
present. Suggestions will be made later in this course on how the patient
should be treated, including appropriate diagnostic testing, pharmacological
treatment, and supportive care.
Vanessa is a 25-year-old female with no significant past medical history.
She is premenopausal and has heavy menstrual cycles lasting seven days
on average. She is not taking any kind of hormonal contraceptives. She
develops symptoms including excessive fatigue, headaches, muscle
cramps in her legs, and cravings for ice. She presents to her primary care
physician for further evaluation. The PCP sends Vanessa for blood work
and schedules a return appointment in one week to discuss results. Upon
Vanessa’s return visit, her physician reviews her lab studies. Vanessa’s
complete blood count (CBC) notes a normal white blood cell count (WBC)
of 6.7.
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The platelet count is on the higher end of normal at 448,000. The
hemoglobin is decreased at 9.9. The MCV (mean corpuscular volume) is
also decreased at 77. The CMP is within normal limits. Thyroid studies are
also normal. However, the iron studies note significant deficiency with a
ferritin level of 5 and iron saturation of 4 percent. Her PCP starts her on
an iron supplement for the time being but refers Vanessa to a
hematologist for further evaluation.
Definition Of Anemia
Red blood cells (RBCs), which are also called erythrocytes, are a type of
blood cell produced in the bone marrow. They start off as immature cells and
are released into the bloodstream after approximately seven days. The
average lifespan of these cells, which are shaped like a biconcave disk, is
about 120 days. Production of RBCs is controlled by erythropoietin, a
hormone created mostly in the kidneys. RBCs do not have a nucleus. This is
important because it helps the cells to vary their shape easily so that they
can travel through different blood vessels.1
Hemoglobin is a protein carried by red blood cells. Hemoglobin transports
oxygen from the lungs to other parts of the body. It also brings back carbon
dioxide to the lungs so that it can be released through exhalation.1
The ranges for what is considered normal can vary depending on the source.
Anemia is typically based on the hemoglobin value. In addition to red blood
cell count and hemoglobin, there are a number of other laboratory values
that are important in helping to diagnose anemia. The mean cell volume is
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the average size of the RBCs. If a patient with anemia has a normal MCV, it
is called normocytic anemia. If the MCV is less than normal, it is considered
microcytic. If the MCV is greater than normal, it is considered macrocytic.
The mean cell hemoglobin is the average amount of hemoglobin in an
average RBC. If the MCH is normal, it is considered normochromic. Likewise,
a decreased value is considered hypochromic while an elevated value is
considered hyperchromic. The red cell distribution width reveals the
variability of RBC size.2 Below is a table displaying the normal ranges for
blood cell values.3
Table 1. Normal Blood Cell Values
WOMEN
MEN
BOTH
GENDERS
Red Blood Cell
4.1- 5.1
4.5- 5.9
Hemoglobin (g/dL)
12.3- 15.3
14- 17.5
Mean cell volume (MCV)
80- 96.1
Mean cell hemoglobin (MCH)
27.5- 33.2
Mean cell hemoglobin
33.4- 35.5
concentration (MCHC)
Red cell distribution width
11.5- 14.5
(RDW) (%)
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Anemia is defined as a condition occurring when the number of red blood
cells is inadequate to meet the physiologic needs of the body. A patient’s
age, gender, smoking status, pregnancy state, and place of residence
(altitude above sea level) can all affect the patient’s physiologic needs. For
example, smoking and living at higher altitudes raise the concentration of
hemoglobin. On the other hand, pregnant women usually experience a drop
in hemoglobin, which starts in the first trimester and worsens in the second
trimester.4
Table 2. National Cancer Institute Common Terminology Criteria for Adverse Events:
Anemia5
Grade
1
2
Hemoglobin
Hgb <10 - 8
(Hgb) <LLN-
g/dL
3
Hgb <8 g/dL
4
Life-
5
Death
threatening
10 g/dL*
consequences.
Urgent
treatment
required.
*LLN- lower limit of normal.
Causes Of Anemia
In some cases, anemia is multifactorial. There are three main causes of
anemia:
 Decreased production of red blood cells
 Increased destruction of red blood cells
 Blood loss
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When thinking about the three major causes of anemia, it is important to
note that blood loss leads to iron deficiency, which will be discussed shortly.
However, this course will mainly focus on acquired causes of decreased RBC
production. The bone marrow needs certain ingredients to make red blood
cells, which include iron, vitamin B12, and folate.3
Iron Deficiency Anemia
The most common nutritional deficiency in the world is iron deficiency. In
the United States, iron deficiency is noted in approximately two percent of
adult men and nine to twelve percent of Caucasian women. The incidence is
even higher in minority women, estimated at close to 20%. Risk factors for
iron deficiency include vegetarian diet, blood donation, and low
socioeconomic status in conjunction with being postpartum.6
Causes
The major causes of iron deficiency are listed below:
 Insufficient dietary intake of iron (occurs mainly in infants and children)
 Averting iron to fetus/infant during pregnancy and/or lactation
 Chronic blood loss (respiratory, gastrointestinal, genitourinary tracts,
phlebotomy)
 Iron malabsorption (patients who have had subtotal gastrectomy, gastric
bypass)
 Intravascular hemolysis
 Mixture of the above
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In women, the most common cause of iron deficiency is chronic blood loss in
the form of menorrhagia. In men and postmenopausal women,
gastrointestinal bleeding is the most common source of iron deficiency.3, 6
Symptoms and Diagnosis
Symptoms of iron deficiency anemia include fatigue, shortness of breath on
exertion, and palpitations. Headaches and irritability can also occur. Cold
hands and feet, as well as tingling sensations in the legs may also happen.
Strange cravings to eat ice or clay, known as pica, may occur. Children can
have low attention spans, developmental delays, and behavioral problems. It
is important to note that the severity of symptoms does not always match
up with the severity of iron deficiency. Physical examination of patients with
anemia may be positive for pallor and smooth red tongue. Koilonychia, or
spoon-shaped nails, is usually only seen in very severe, chronic cases of
deficiency.3, 7
The CBC is a very important part of the puzzle in diagnosing iron deficiency.
Microcytic (decreased MCV), hypochromic (decreased MCHC) anemia is
usually seen. The RDW (red cell distribution width) is often elevated. WBC is
usually normal. Most of the time, the platelet count will be normal. However,
it is not uncommon to see elevated platelet count, which is usually related to
chronic blood loss.3
Iron studies include serum iron concentration, total iron binding capacity
(TIBC), and serum ferritin. The serum iron level is usually low. TIBC is
usually elevated. However, in mild cases the TIBC is in the higher range of
normal. Iron saturation, which is a calculation based on iron and TIBC, is
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decreased. In patients with iron deficiency, the iron saturation is usually less
than fifteen percent. It is important to note that patients with chronic
inflammation can also have a low iron saturation value even though they are
not iron deficient.
The serum ferritin is a measurement of iron stores. Low ferritin levels are
seen in iron deficiency. However, patients with iron deficiency can have
elevated ferritin levels. This is because serum ferritin is an acute phase
reactant and is often increased during inflammatory states, such as chronic
kidney disease, malignancy, and hepatitis.3
Once a patient is diagnosed with iron deficiency, the work does not stop
there. The reason for iron deficiency must be discovered. Since
gastrointestinal loss is the most common cause of iron deficiency, stools
should be checked for occult blood. Further workup, including
esophagogastroduodenoscopy (EGD) and colonoscopy, may be required.
Women with menorrhagia will need to follow with a gynecologist. They may
require further testing, such as pelvic ultrasound.3, 7
Complications
Iron deficiency can become quite severe and lead to very serious problems if
it goes untreated. In pregnant females, the incidence of premature births
and low birth weight babies is higher with iron deficiency. Infants and
children with iron deficiency may experience growth and developmental
delays. Cardiac problems, including tachycardia and arrhythmias can also
occur. The heart is under more stress and works harder to pump blood
throughout the body. This increased work can lead to cardiomegaly.7
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Treatment
Usually oral iron replacement is the first step in treating iron deficiency.
Increasing iron in the diet is not adequate. There are a plethora of oral iron
supplements. Ferrous sulfate is the least costly option. The daily dose of
elemental iron should be 150 mg to 200 mg, divided into three or four
doses.3
Educating Patients About Oral Iron Supplementation
Below are some important items to discuss with patients who are taking
iron.
 Do not take iron with meals
 Do not take iron with antacids or anything that reduces acid
 Iron can often cause constipation. Laxatives or stool softeners may be
taken as needed.
 Iron is best absorbed with vitamin C.
 Iron supplementation can cause dark-colored stools.
 Store iron supplements in a safe place, away from children.
The average time to normalization of hemoglobin levels is two to four
months. Patients should continue oral iron for approximately one year after
hemoglobin normalizes. In patients who continue to have blood loss, they
may need to be on iron replacement for as long as the bleeding continues.
The expected response may not occur if bleeding persists. If bleeding has
been controlled but response is poor, other things to consider include
malabsorption or other causes of anemia.3
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Parenteral iron is also available for the treatment of iron deficiency. The
reasons for using parenteral iron include very severe deficiency,
malabsorption, and inability to tolerate oral iron (usually gastrointestinal
symptoms, such as colitis or severe constipation). There are a number of
different preparations. Dosing and frequency of treatment differ based on
the specific iron product. Some products can be given intravenously or
intramuscularly. Allergic reactions, including anaphylaxis, can occur.3
In extremely severe cases of iron deficiency anemia associated with blood
loss, patients may require transfusion of PRBCs (packed red blood cells).
Transfusions should only be administered to patients with hemoglobin less
than 7 - 8 and who are symptomatic (i.e., weakness, shortness of breath,
palpitations). Patients should be properly counseled about the risks of
transfusion.3 For more detailed information about blood transfusions, please
see the course list.
Vitamin B12 Deficiency
Vitamin B12, also known as cobalamin, is a water-soluble vitamin that is
important in the production of red blood cells. Vitamin B12 also has a role in
the health of the central nervous system. Vitamin B12 can be stored in the
liver for months to years. The average American diet is plentiful in vitamin
B12. It is found in various foods, including meat, shellfish, eggs, milk, and
dairy products.
Many other foods, such as cereal, have added B12. However, B12 is
absorbed more efficiently from animal-based foods.8
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Causes
Individuals following a vegan diet may be at risk for B12 deficiency.
However, the most common cause of B12 deficiency is malabsorption.
Intrinsic factor is required for the absorption of B12. Malabsorption can be
due to several different factors, including:
 Pernicious anemia (most common reason for malabsorption)
 Gastric Bypass
 History of gastrectomy (total and subtotal)
 Ileal resection
 Diseases/trauma to ileum (sprue, Crohn’s disease, radiation)
 Zollinger-Ellison Syndrome
 Pancreatic Disease
 Blind Loop Syndrome
 Diphyllobothrium latum infestation (intestinal parasites)
As mentioned above, pernicious anemia is the most common cause of
malabsorption. Pernicious anemia is actually an autoimmune disease. The
immune system destroys cells in the stomach. Because of this damage, the
gastric mucosa does not produce intrinsic factor adequately and B12
deficiency occurs.3, 8
Symptoms and Diagnosis
Patients who develop anemia secondary to B12 deficiency usually develop
anemia slowly. Patients may experience fatigue, weakness, palpitations, and
lightheadedness. Because pernicious anemia can cause damage to the
nervous system, these patients may present with neurological symptoms.
Sometimes neurological symptoms occur before symptoms of anemia.
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Neurological symptoms include numbness and tingling in the hands and feet,
as well as changes in position and vibration sense. If the brain is affected,
patients may experience sleepiness as well as changes in taste, smell, and
vision. Physical examination may reveal pallor and smooth, beefy red
tongue.3, 8
The CBC again is very useful in diagnosing B12 deficiency. This type of
anemia is usually a macrocytic anemia, meaning that the red blood cells are
larger than normal. The size of red blood cells varies and they can be oddly
shaped. This type of anemia is known as megaloblastic, meaning that the
red blood cells are large and have immature nuclei. The MCV is increased,
usually 100 or more. However, if there is also an iron deficiency or
inflammation, the MCV may not be elevated. Oftentimes, patients will also
have low WBC and platelet count.3
In order to confirm B12 deficiency, further testing is imperative. Serum B12
level is low, but this alone is not sufficient to diagnose a deficiency.
Sometimes the B12 level will be normal despite the presence of a deficiency.
Elevated methylmalonic acid is a good sign of B12 deficiency. The
homocysteine level is also elevated. The homocysteine level is not as reliable
as the methylmalonic acid level because homocysteine may also be elevated
in folate deficiency and hypothyroidism.3
As mentioned previously, pernicious anemia is a common cause of B12
deficiency. In order to diagnose pernicious anemia, further testing is
required. Serum parietal cell antibodies are usually present in these patients,
though this test is not specific. Serum intrinsic factor antibodies is a specific
test that will be elevated in these patients.3
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Complications
If B12 deficiency goes untreated, complications can ensue. Neurological
symptoms, such as numbness and tingling in the hands and feet, can
sometimes be irreversible. Lack of muscle control and muscle stiffness,
known as spastic ataxia, may ensue. Dementia and psychosis are other
serious complications.3
Treatment
Patients who have B12 deficiency due to poor dietary intake (such as
vegans) may benefit from oral or sublingual B12 supplementation.
Sublingual B12 is more readily absorbed. However, B12 deficiency is usually
due to malabsorption issues. In those cases, parenteral B12 is used to treat
deficiency. The injection is normally given intramuscularly. When initiating
B12 replacement, there is a series of loading doses (1,000 micrograms daily
or weekly for several doses). The maintenance dose is usually 1,000
micrograms monthly. In some cases, this dose may not be sufficient and
higher doses will be required. B12 is not toxic but excess B12 will be
excreted through the urine. Patients who have had total gastrectomy or
terminal ileum resection should be started on B12 treatment after surgery. It
is important to monitor potassium levels in patients receiving B12
replacement as hypokalemia can develop.3, 8
Once treatment is started, patients often note improvement quickly. The
marrow starts to produce normal red cells within a day of starting treatment.
It takes about one to two months for the hemoglobin to return to normal
range. Most of these patients will not require blood transfusion as they have
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likely adjusted to anemia over time. If neutropenia and thrombocytopenia
were present, these values also return to normal rather quickly.3
Folate Deficiency
Folate, or folic acid, is a B vitamin that is important in the production of red
blood cells. Folic acid also creates and fixes DNA. Folic acid is found in many
different foods, including green leafy vegetables, liver, poultry, shellfish,
citrus, beans, legumes, and eggs. Folic acid is water-soluble. Excess folic
acid is eliminated and only a limited amount is stored in the body. Deficiency
can occur after just a few weeks of not eating enough folic acid.9
Causes
The major causes of folate deficiency can be separated into three main
categories, which include decreased intake, increased need, and problems
with absorption. A diet low in folic acid is the most common cause of
deficiency. The list below provides more detail.3, 9
Decreased Intake:

Poor Nutrition

Alcoholism

Elderly

Children on synthetic diets

Hemodialysis

Hyperalimentation

Spinal cord injury

Premature infants
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Increased Need:

Chronic hemolytic anemia

Pregnancy

Exfoliative dermatitis
Problems with Absorption:

Sprue, celiac disease

Other diseases of the intestine, such as Crohn’s disease
There are also a number of medications that can cause folic acid deficiency.
Some of these medications include methotrexate, aminopterin, sulfasalazine,
trimethoprim, triamterene, pemetrexed, hydroxyurea, phenytoin, and some
oral contraceptives. In some cases, it may be necessary for patients on
these medications to take supplemental folic acid.3
Symptoms and Diagnosis
Symptoms of folate deficiency may include fatigue and weakness. The
anemia usually progresses gradually. Folic acid deficiency does not cause
neurological symptoms unless a vitamin B12 deficiency is also present. On
physical exam, patients may have gray hair, red swollen tongue, and mouth
sores. Children with folic acid deficiency may have stunted growth.9
The CBC is an important element in diagnosing folate deficiency. Just like
with B12 deficiency, this type of anemia is usually a macrocytic anemia,
meaning that the red cells are larger than normal. This will result in an
elevated MCV. Patients who present with macrocytic anemia should be
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tested for both folic acid and vitamin B12 deficiencies. The serum folic acid
level will be low. However, it is important to remember that folic acid has
limited stores in the body. A low folic acid level may just signify decreased
intake in the few days before testing.3
Complications
In severe cases of deficiency, patients may also experience leukopenia and
thrombocytopenia. Folic acid deficiency in pregnant women may lead to
neural tube defects in the baby.9
Treatment
Folic acid deficiency is treated with oral supplementation. The dose is usually
betweem1mg and 5mg daily. Pregnant women should take 1mg of folic acid
daily during the entire pregnancy.3
Summary
There are many different causes of anemia. Nutritional deficiencies can often
lead to anemia. Iron, folic acid, and vitamin B12 are all important in the
production of red blood cells. When patients present with anemia, it is
imperative that the cause of anemia is identified early on so that adequate
treatment can be provided.
Severe anemia can lead to serious complications, including heart problems
and irreversible neurological changes. Patients with severe anemia may even
require blood transfusion.
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On Reflection: Vanessa (case study at the beginning of the course)
Vanessa’s hemoglobin is 9.9, which would be considered Grade II anemia.
However, the most important thing to note is that Vanessa is symptomatic, with
complaints of fatigue and muscle cramps. She also has cravings for ice, known
as pica. She presents to the hematologist for further evaluation. The
hematologist performs a thorough history and physical examination. She is
somewhat pale, but otherwise her exam is unremarkable.
Although Vanessa’s PCP evaluated the iron studies, the hematologist proceeds
with an extensive anemia work up to ensure there are no other causes of
anemia. The hematologist evaluates levels of B12 and folic acid and orders stool
testing for occult blood.
Because Vanessa’s iron deficiency is severe and her menorrhagia is ongoing, the
hematologist recommends intravenous iron. He discusses intravenous iron
therapy with Vanessa, including the risks and possible side effects. He schedules
a return visit in one week to discuss results and start treatment. In the
meantime, he advises Vanessa to continue the oral iron supplement.
At Vanessa’s next visit, her workup is overall negative except for severe iron
deficiency caused by menorrhagia. The hematologist refers her back to her
gynecologist for evaluation of menorrhagia. Vanessa starts her IV iron that day
and tolerates it very well. Vanessa completes her iron treatment and her
gynecologist starts her on oral contraceptives. After she completes IV iron, she
continues on daily, oral iron supplement. Vanessa’s menorrhagia improves after
several months. When the iron studies are repeated three months later, results
show resolution of the iron deficiency. Her hemoglobin is normal at 13.1. Her
platelet count has also normalized at 355. Vanessa has no fatigue or other
symptoms of anemia. She continues to follow up regularly and has her iron
studies evaluated every three months.
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Nurses play a crucial role in caring for patients with anemia and to keep
them safe. Part of the nursing role is to administer the treatments for
anemia. They often assist in educating patients and their families about the
treatments and possible side effects. As part of the healthcare team, nurses
are in an excellent place to improve patient outcomes.
Please take time to help NurseCe4Less.com course planners evaluate
the nursing knowledge needs met by completing the self-assessment
of Knowledge Questions after reading the article, and providing
feedback in the online course evaluation.
Completing the study questions is optional and is NOT a course
requirement.
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1._____________ will raise a patient’s concentration of hemoglobin.
a. Smoking and living at higher altitudes
b. Pregnancy
c. Iron deficiency
d. Blood donations
2. In men and postmenopausal women, _________________ is the
most common source of iron deficiency
a. a vegetarian diet
b. menorrhagia
c. gastrointestinal bleeding
d. low socioeconomic status
3. Elevated ______________ is a good sign of B12 deficiency.
a. homocysteine levels
b. methylmalonic acid
c. mean corpuscular volume
d. iron levels
4. Cobalamin, a water-soluble vitamin, that is important in the
production of red blood cells, is also known as _________________.
a. Iron
b. Vitamin E
c. Vitamin C
d. Vitamin B12
5. True or False: Folic acid deficiency causes neurological symptoms,
even in the absence of a vitamin B12 deficiency.
a. True.
b. False.
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Correct Answers:
1. a
2. c
3. b
4. d
5. b
References Section
The reference section of in-text citations include published works intended as
helpful material for further reading. Unpublished works and personal
communications are not included in this section, although may appear within
the study text.
1. American Society of Hematology. (2015). Blood basics. Retrieved from
http://www.hematology.org/Patients/Basics/
2. Gersten, T. (2014). RBC indices. In Medline Plus. Retrieved from
http://www.nlm.nih.gov/medlineplus/ency/article/003648.htm
3. Lichtman, M. A., Kaushansky, K., Kipps, T. J., Prchal, J. T., & Levi, M. M.
(2011). Disorders of red cells. In J. Shanahan & H. Lebowitz (Eds),
Williams manual of hematology eighth edition (pp.9-58). New York:
McGraw Hill Medical.
4. National Cancer Institute. (2009). Common terminology criteria for
adverse events v4.0 (NIH Publication No. 09-7473). Retrieved from
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6. Killip, S., Bennett, J. M., & Chambers, M. D. (2007). Iron deficiency
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