losartan-potassium and Folic-Acid-Deficiency

Anemia, a common complication associated with inflammatory bowel disease (IBD), is frequently overlooked in the management of IBD patients. Unfortunately, it represents one of the major causes of both decreased quality of life and increased hospital admissions among this population. Anemia in IBD is pathogenically complex, with several factors contributing to its development. While iron deficiency is the most common cause, vitamin B12 and folic acid deficiencies, along with the effects of pro-inflammatory cytokines, hemolysis, drug therapies, and myelosuppression, have also been identified as the underlying etiology in a number of patients. Each of these etiological factors thus needs to be identified and corrected in order to effectively manage anemia in IBD. Because the diagnosis of anemia in IBD often presents a challenge, combinations of several hematimetric and biochemical parameters should be used. Recent studies underscore the importance of determining the ferritin index and hepcidin levels in order to distinguish between iron deficiency anemia, anemia due to chronic disease, or mixed anemia in IBD patients. With regard to treatment, the newly introduced intravenous iron formulations have several advantages over orally-administered iron compounds in treating iron deficiency in IBD. In special situations, erythropoietin supplementation and biological therapies should be considered. In conclusion, the management of anemia is a complex aspect of treating IBD patients, one that significantly influences the prognosis of the disease. As a consequence, its correction should be considered a specific, first-line therapeutic goal in the management of these patients.

Topics: Anemia; Anemia, Iron-Deficiency; Cytokines; Dietary Supplements; Erythropoietin; Ferritins; Folic Acid Deficiency; Hemolysis; Hepcidins; Humans; Inflammatory Bowel Diseases; Iron; Prognosis; Quality of Life; Vitamin B 12 Deficiency

PTH may participate in the genesis of the anemia of uremia through at least three pathways. These include inhibition of erythropoiesis, shortening survival of RBCs and inducing fibrosis of bone marrow cavity. A possible fourth mechanism through which PTH may contribute to the anemia of uremia is its effect on platelets. PTH inhibits platelet aggregation [53] and, as such, may play an important role in the genesis of the bleeding tendencies and the consequent blood loss in uremia.

Topics: Anemia; Anemia, Hypochromic; Anemia, Sideroblastic; Animals; Colony-Forming Units Assay; Erythrocyte Aging; Erythropoiesis; Erythropoietin; Folic Acid Deficiency; Hematopoietic Stem Cells; Hemolysis; Hemorrhage; Humans; Hyperparathyroidism, Secondary; In Vitro Techniques; Mice; Parathyroid Hormone; Uremia

Uremia interferes with erythropoiesis, granulocyte, platelet, and immune functions. As a result, uremic patients are almost invariably anemic, and have a high incidence of infections and hemorrhagic complications. The anemia of renal failure, which is caused primarily by damage to the site of erythropoietin production is often complex, and complicated by hemolysis from a variety of mechanisms, iron deficiency, and so forth. Although hemodialysis ameliorates some of the hematologic complications to a variable degree, they remain a serious hinderance to the well being of this group of patients. Progress in understanding the mechanism of these problems and their therapy has been reviewed here.

Topics: Anemia; Anemia, Hemolytic; Anemia, Hypochromic; Blood Transfusion; Erythrocytes; Erythropoiesis; Erythropoietin; Folic Acid Deficiency; Hemorrhage; Humans; Kidney; Kidney Failure, Chronic; Renal Dialysis; Testosterone; Testosterone Congeners

Topics: Anemia, Hemolytic; Anemia, Neonatal; Bilirubin; Birth Weight; Blood Group Antigens; Diet; Erythrocytes; Erythrocytes, Abnormal; Erythropoiesis; Erythropoietin; Folic Acid Deficiency; Gestational Age; Hemoglobinometry; Hemorrhage; Humans; Immunization; Infant; Infant, Newborn; Isoantigens; Kinetics; Rh-Hr Blood-Group System; Thalassemia; Vitamin E Deficiency

In many elderly patients with anemia, a specific cause cannot be identified. This study investigates whether erythropoietin levels are inappropriately low in these cases of "anemia of unknown etiology" and whether this trend persists after accounting for confounders.. This study includes all anemic patients over 60 years old who had erythropoietin measured between 2005 and 2013 at a single center. Three independent reviewers used defined criteria to assign each patient's anemia to one of ten etiologies: chronic kidney disease, iron deficiency, chronic disease, confirmed myelodysplastic syndrome (MDS), suspected MDS, vitamin B12 deficiency, folate deficiency, anemia of unknown etiology, other etiology, or multifactorial etiology. Iron deficiency anemia served as the comparison group in all analyses. We used linear regression to model the relationship between erythropoietin and the presence of each etiology, sequentially adding terms to the model to account for the hemoglobin concentration, estimated glomerular filtration rate (eGFR) and Charlson Comorbidity Index.. A total of 570 patients met the inclusion criteria. Linear regression analysis showed that erythropoietin levels in chronic kidney disease, anemia of chronic disease and anemia of unknown etiology were lower by 48%, 46% and 27%, respectively, compared to iron deficiency anemia even after adjusting for hemoglobin, eGFR and comorbidities.. We have shown that erythropoietin levels are inappropriately low in anemia of unknown etiology, even after adjusting for confounders. This suggests that decreased erythropoietin production may play a key role in the pathogenesis of anemia of unknown etiology.

Topics: Aged; Aged, 80 and over; Anemia; Anemia, Iron-Deficiency; Biomarkers; Chronic Disease; Comorbidity; Erythropoietin; Female; Folic Acid Deficiency; Glomerular Filtration Rate; Hematologic Tests; Hemoglobins; Humans; Linear Models; Male; Middle Aged; Myelodysplastic Syndromes; Renal Insufficiency, Chronic; Retrospective Studies; Vitamin B 12 Deficiency

Laboratory indices are often poorly diagnostic of folate deficiency (FD). Compared with iron depletion in hemodialysis (HD) populations, the impact of FD is less appreciated. The composite scoring of hematologic indices of FD may facilitate a prompt and accurate diagnosis, and enhance operational research on folic acid therapy.. Our objectives were to (1) validate composite scores of folate diagnostic indices, and (2) determine the reliability index of the diagnostic tool.. A cohort of 30 subjects, with a mean age of 16 (SD +/- 3.2 years), on HD and erythropoietin (EPO) for a minimum of 3 months was studied. After a baseline hematologic assessment, routine folates were administered for 6 months. Composite FD scores (FDS) of baseline mean corpuscular volume (MCV), mean corpuscular hemoglobin (MCH), mean corpuscular hemoglobin concentration (MCHC), random distribution width (RDW), and hemoglobin were determined. Validation and reliability statistics were then analyzed, using the quantitative change in red blood cell folate/plasma homocysteine, or EPO requirement after 6 months of folate use, as diagnostic criteria.. The mean FDS for FD and non-FD subsets were 3.0 +/- 1.3 and 1.4 +/- 0.9, respectively (analysis of variance; P = .0001). The correlation coefficient, r(2), between FD total and FDS was 0.61 (P = .001), and the coefficient between 2 (weekly) values of RDW, MCV, MCH, and MCHC was >0.84 (P = .0001). Scoring tools derived from the first (P = .002) and second (P = .01) halves of the laboratory indices remained discriminatory for the FD and non-FD groups. Baseline serum folate is poorly specific for FD, whereas FD score >or=3 had sensitivity, specificity, and positive and negative predictive values close to 90%.. Composite scoring of erythrocyte indices was predictive of the FD diagnosis, as defined by the quantitative response of red blood cell folate, homocysteine, and EPO dose to folate therapeutic intervention. The diagnostic items yielded a high reliability coefficient. The FDS scheme is a potential tool for the diagnosis and surveillance of FD, particularly in at-risk populations (e.g., dialysis subjects).

Topics: Adolescent; Analysis of Variance; Cohort Studies; Diagnosis, Differential; Erythrocytes; Erythropoietin; Female; Folic Acid; Folic Acid Deficiency; Hemoglobins; Homocysteine; Humans; Iron; Kidney Failure, Chronic; Male; Predictive Value of Tests; Recombinant Proteins; Renal Dialysis; Sensitivity and Specificity

While folic acid deficiency causes macrocytic anaemia in non-renal patients, the relevance of altered folate metabolism in anaemia of end-stage renal disease and its response to rHu-EPO is less clear.. Ten haemodialysis patients with macrocytic anaemia due to dietary folic acid deficiency were compared to 10 matched (age, duration of dialysis, degree of anaemia) patients with normocytic normochromic anaemia. Nineteen patients received erythropoietin-alpha intravenously thrice weekly. The study design was a prospective crossover (ABA) comparison of the effects of intravenously administered high doses of folic acid on haemoglobin levels and EPO doses, with 6 months active supplementation (B) and two periods of 6 months duration each without folic acid supplementation (A).. The two patient groups did not differ at recruitment. Red blood cell folate levels were normal in patients with normocytic anaemia, but they were subnormal in all patients with macrocytic anaemia. Compared to the first period without folic acid supplementation, patients with macrocytic anaemia had significantly higher haemoglobin levels despite lower EPO doses after 6 months high-dose folic acid, and red cells had become normocytic. The removal of folic acid supplementation resulted in re-occurrence of macrocytosis and in a significantly lower response to rHu-EPO. In contrast, high-dose folic acid supplementation had no effect on response to rHu-EPO in patients with normocytic anaemia.. Folic acid deficiency may occur in elderly haemodialysis patients with poor dietary folate intake without regular oral supplementation and may cause hyporesponsiveness to rHu-EPO. Macrocytosis is a simple and cheap indicator for folate deficiency in end-stage renal disease patients on maintenance dialysis.

Topics: Adult; Aged; Anemia, Macrocytic; Case-Control Studies; Erythropoietin; Female; Folic Acid Deficiency; Follow-Up Studies; Hematopoiesis; Humans; Kidney Failure, Chronic; Kidney Function Tests; Male; Middle Aged; Probability; Recombinant Proteins; Reference Values; Risk Assessment; Severity of Illness Index; Statistics, Nonparametric; Treatment Outcome

Topics: Aged; Erythropoietin; Female; Folic Acid; Folic Acid Deficiency; Hemoglobins; Humans; Kidney Failure, Chronic; Kidney Function Tests; Male; Middle Aged; Recombinant Proteins; Renal Dialysis

Unlike iron therapy, folate use is not a standard of care in hemodialysis (HD) patients. Despite iron repletion, poor response to erythropoietin (EPO) treatment is common. Theoretical evidence for folate deficiency (FD) includes chronic blood loss, inflammation, malnutrition, and nutrient loss during dialysis. Due to poor diagnostic standards, early studies failed to establish a role for FD in EPO resistance. Given that hematological response to therapeutic intervention is the gold standard for FD, its diagnosis was therefore based on composite scoring of RBC and/or folate indices. Fifteen subjects (8-20 years) on chronic HD were enrolled in this study. No folate supplement was given in the first six months. Thereafter, 5-mg folic acid was administered orally after HD sessions over a six-month period. Folate indices before and after treatment were compared using percentage differences and paired t-tests. After folate use, the mean Hb increased by 11.4%, while MCV and RDW were reduced. Similarly, 4 of the 15 subjects each had a > or = 20% rise in Hb and a > or = 5% reduction in MCV, while 46.7% had a > or = 2.5% reduction in RDW. Mean RBC folate increased by 24%, while FD scores reduced from 3.8+/-1.2 to 0.4+/-0.7, and the EPO requirement by 90%. In contrast to previous studies, 26.7% of study subjects met the criteria for FD. Furthermore, the substantial (post-folate) reduction in the EPO requirement validates the need for therapeutic intervention, and therefore the presence of functional FD in the population.

Topics: Adolescent; Adult; Anemia, Iron-Deficiency; Child; Drug Resistance; Erythropoietin; Female; Folic Acid; Folic Acid Deficiency; Hemoglobins; Humans; Kidney Failure, Chronic; Male; Recombinant Proteins; Renal Dialysis; Vitamin B 12

Topics: Anemia, Hypochromic; Antirheumatic Agents; Autoimmune Diseases; Blood Loss, Surgical; Christianity; Crohn Disease; Erythropoietin; Folic Acid Deficiency; Hepatitis C, Chronic; Hip Fractures; Humans; Iron; Male; Middle Aged; Paraproteinemias; Premedication; Proteus Infections; Recombinant Proteins; Spondylitis, Ankylosing; Sulfasalazine; Urinary Tract Infections; Vitamins

To examine the possible relationships between recombinant human erythropoietin (rhEPO) therapy, serum folic acid and homocysteine levels in a cohort of stable, chronically hemodialyzed patients.. The study was cross-sectional in its first phase and consisted of 3 groups of subjects (group 1:6 healthy controls; group 2:7 dialyzed patients not receiving rhEPO; group 3: 14 patients on rhEPO therapy). Hematological and biochemical parameters were taken after an overnight fast in all subjects. The second phase of the study was prospective, and included 8 dialyzed patients, and investigated the effects of a 6-month period of folic acid supplementation (10 mg, 3 times a week) on the same parameters examined in the first phase of the study.. In the first part of the study hemoglobin levels were near-normal, or normal, in all patients. No differences in hemoglobin or hematocrit values were observed in the 3 groups. 80% of all hemodialyzed patients had low serum folic acid levels, irrespective of whether they were receiving rhEPO. Serum erythropoietin level was elevated in group 3 (23.3+/-10.4 mIU/ml). In group 2, serum erythropoietin level was not different from that of the healthy controls (13.5+/-11.2 vs. 8.0+/-5.4 mIU/ml, p = n.s.). Total serum homocysteine levels were elevated in all dialyzed patients (group 2: 24.7+/-9.2 micromol/l; group 3: 31.6+/-14.4 micromol/l), with a significant difference seen when comparing controls and those dialyzed patients on rhEPO therapy (8.7+/-2.2 vs. 31.6+/-14.4 micromol/l; p<0.05). Significant correlations (ANOVA) were observed between serum erythropoietin and folic acid levels (r = -0.382; p = 0.049), and between folic acid and homocysteine levels (r = -0.560; p = 0.002). In the second part of the study folic acid supplementation led to a highly significant reduction in homocysteine levels (20.9+/-4.9 vs. 11.9+/-2.5 micromol/l; p<0.0005). Two of 3 patients receiving rhEPO therapy, had rhEPO discontinued after commencing folic acid, as hemoglobin levels remained adequate, even without rhEPO.. In hemodialyzed patients, the presence of a near-normal hemoglobin level, irrespective of rhEPO therapy, implies efficient erythropoiesis. Without adequate folic acid reserves, folic acid deficiency may develop in these patients and this will aggravate already high homocysteine levels. Therefore, folic acid supplementation is warranted in hemodialyzed patients, especially in those patients with hemoglobin levels approaching normal. This treatment is safe and effective in reducing homocysteine levels, especially when given in high doses for prolonged periods of time.

Topics: Analysis of Variance; Case-Control Studies; Cross-Sectional Studies; Erythropoietin; Female; Folic Acid; Folic Acid Deficiency; Humans; Hyperhomocysteinemia; Male; Middle Aged; Prospective Studies; Recombinant Proteins; Renal Dialysis

Patients on regular hemodialysis treatment may develop megaloblastic anemia caused by folate deficiency, but whether folate supplementation is required is still controversial, particularly during erythropoietin administration. Erythrocyte folate concentration is a better indicator of folate status than serum folate, although the latter is the variable generally measured. We measured serum and erythrocyte folate in blood samples from 112 regular hemodialysis patients (57 men, 55 women, 50 treated with erythropoietin, and 62 not) by Stratus Folate immunoenzymatic assay (Dade). Patients with very low serum (<2.87 ng/mL) but normal erythrocyte folate were reinvestigated 4 months later without receiving folate supplementation meanwhile. Serum folate concentrations were 0.48 to 12.76 ng/mL (median, 3.40) and erythrocyte folate 0.19 to 1.85 microg/mL (median, 0.42). Only 37% serum folate values were in the relevant reference interval compared with 80.2% erythrocyte folate values (3.08 to 17.65 ng/mL and 0.24 to 0.64 microg/mL, respectively). A significant correlation was found between serum and erythrocyte folate concentrations, without clinical relevance caused by the wide scatter around the regression line. Serum and erythrocyte folate did not vary significantly between patients given erythropoietin and those not so treated. The folate status of the 24 patients with very low serum folate was almost unchanged 4 months later. According to the serum folate test, 63% of patients needed folate supplementation, whereas the erythrocyte folate test, a better indicator of folate status, suggested that only 1.8% of patients needed folate supplementation. Erythropoietin therapy appears not to be an indication for standard folate supplementation in hemodialysis patients.

Topics: Adult; Aged; Aged, 80 and over; Edetic Acid; Erythrocyte Indices; Erythrocytes; Erythropoietin; Female; Folic Acid; Folic Acid Deficiency; Hematologic Tests; Humans; Male; Middle Aged; Recombinant Proteins; Renal Dialysis; Reproducibility of Results; Uremia

Human recombinant erythropoietin (rHu-Epo) is now extensively used in chronic renal failures; this treatment, resulting in a correction of the severe anemias seen in hemodialysed patients, may in turn lead to a resistance to rHu-Epo therapy by reason of the shortage of erythropoiesis factors, such as iron, vitamin B12 and folates. The utility of the red cell indices (MCV, MCH, RDW) for detection of early iron, folate and B12 deficiencies was studied in eighteen hemodialysed patients with end-stage renal failure treated with rHu-Epo; Microcytosis (MCV < 80 fl) was found ineffective in detecting iron deficiencies as well as macrocytosis (MCV > 100 fl) in folate and B12 deficiencies, partly due to the high incidence of associated iron and folate deficiencies. Lowered MCH (< 27 pg) was not more efficient than microcytosis in detecting early iron deficiencies. Increased RDW was the most sensitive feature for folate, iron and B12 deficiencies with respective sensitivities of 62.5%, 72% and 75%. The global specificity for detecting all deficiencies was 74%. However, high RDW values were not indicative of any type of deficiency; it may thus be concluded that RDW is a non expensive, non invasive and sensitive test, which allows a selection of hemodialysed patients treated with rHu-Epo for a complete investigation program, in order to detect early iron, B12 and folate deficiencies.

Topics: Anemia, Hypochromic; Drug Resistance; Erythrocyte Indices; Erythropoietin; Female; Ferritins; Folic Acid Deficiency; Hemoglobins; Humans; Kidney Failure, Chronic; Male; Renal Dialysis; Treatment Failure; Vitamin B 12 Deficiency

Iron deficiency involvement in the results of long-term replacement therapy of renal anemia with recormon, a preparation of recombinant human erythropoietin, has been studied in chronic renal failure patients on programmed hemodialysis. The effect of recormon subcutaneous administration to 51 patients was found reduced in 9 patients; in 5 of them the decreased sensitivity to recormon was attributed to iron deficiency. During a year of treatment the percentage of iron-deficient patients rose from 9.1% to 45% as a result of intensive uptake of iron in the course of erythropoiesis. Iron preparation as a corrective treatment contributed to hematocrit increment reducing effective doses of erythropoietin. In addition to routine control of ferritin and iron it is recommended to trace the degree of transferrin saturation in the course of recombinant erythropoietin therapy.

Topics: Anemia, Hypochromic; Drug Evaluation; Erythropoietin; Ferritins; Folic Acid; Folic Acid Deficiency; Humans; Iron; Kidney Failure, Chronic; Recombinant Proteins; Renal Dialysis; Transferrin; Vitamin B 12; Vitamin B 12 Deficiency

Erythroid alterations were studied in 136 patients with rheumatoid arthritis (RA). Anemia was present in 75 cases. A definite diagnosis was determined in 65. The most frequent anemia was that of chronic disease (ACD) (43 cases); 14 patients with ACD presented with moderate to severe anemia. Prevalence of deficiencies were also high (15 cases had iron deficiency anemia, IDA). Serum erythropoietin levels were different in patients with RA compared with a healthy control group (p < 0.00001). Serum erythropoietin was increased in ACD (49 +/- 28.8 U/l) with respect to both RA (38.6 +/- 12.7 U/l, p = 0.0036) and controls (18.2 +/- 7.6 U/l, p < 0.00001). Although hemoglobin (Hb) was similar in ACD and IDA, serum erythropoietin in ACD was lower than in IDA (p = 0.01). There was a negative relationship between Hb and serum erythropoietin in ACD (r = -0.42, p = 0.005). In conclusion, almost 50% of patients with RA have anemia and ACD is the most frequent. As serum erythropoietin in ACD is blunted, patients with moderate to severe ACD are possible candidates for erythropoietin treatment.

Topics: Adult; Aged; Aged, 80 and over; Anemia; Arthritis, Rheumatoid; Chronic Disease; Erythropoietin; Female; Folic Acid Deficiency; Humans; Male; Middle Aged; Prevalence; Prospective Studies; Vitamin B 12 Deficiency

Topics: Anemia; Animals; Arthritis, Rheumatoid; Chronic Disease; Erythrocyte Aging; Erythropoietin; Female; Folic Acid Deficiency; Humans; Lupus Erythematosus, Systemic; Male; Recombinant Proteins; Vitamin B 12 Deficiency

Thirty six patients with rheumatoid arthritis (RA) (25 with anaemia) were studied to establish the role of iron, vitamin B12, and folic acid deficiency, erythropoietin responsiveness, and iron absorption in the diagnosis and pathogenesis of anaemia in RA. Iron deficiency, assessed by stainable bone marrow iron content, occurred in 13/25 (52%), vitamin B12 deficiency in 7/24 (29%), and folic acid deficiency in 5/24 (21%) of the anaemic patients. Only 8/25 (32%) had just one type of anaemia. The iron deficiency of anaemia of chronic disease (ACD) was distinguished by ferritin concentration, which was higher in that group. Mean cell volume (MCV) and mean cell haemoglobin (MCH) were lower in both anaemic groups, but most pronounced in iron deficient patients. Folic acid, and especially vitamin B12 deficiency, masked iron deficiency by increasing the MCV and MCH. Iron absorption tended to be highest in iron deficiency and lowest in ACD, suggesting that decreased iron absorption is not a cause of ACD in RA. No specific causes were found for vitamin B12 or folic acid deficiency. Haemoglobin concentration was negatively correlated with erythrocyte sedimentation rate in the group with ACD. Erythropoietin response was lower in ACD than in iron deficient patients. It was concluded that generally more than one type of anaemia is present simultaneously in anaemic patients with RA. The diagnosis of each type may be masked by another. Studies on pathogenesis of the anaemia are difficult as deficiencies generally coexist with ACD. Disease activity and, possibly, erythropoietin responsiveness are major factors in ACD pathogenesis.

Topics: Aged; Anemia; Anemia, Hypochromic; Arthritis, Rheumatoid; Bone Marrow; Chronic Disease; Erythropoietin; Female; Folic Acid Deficiency; Humans; Iron Deficiencies; Male; Middle Aged; Vitamin B 12 Deficiency

Various factors are involved in the pathogenesis of anemia in dialysis patients. Reduced erythropoiesis is mainly attributed to erythropoietin deficiency. Stimulation of erythropoiesis may be promoted by androgens. Substitution of iron is recommended in case of iron deficiency. As a rule, supplementation of vitamin B12 is not necessary, but administration of folic acid is recommended. Treatment of anemia in renal failure is rendered more effective by increased technical efficiency in hemodialysis permitting a relatively protein-rich diet. Blood transfusions are not necessary during routine treatment of dialysis. Since bilateral nephrectomy will always provoke severe anemia, it should be reserved to special cases of severe hypertension. Until now, no conservative therapy has been developed which would allow optimal treatment of anemia in dialysis patients. Successful renal transplantation still is, and will be, the best therapeutic intervention.

Topics: Androgens; Anemia, Hypochromic; Blood Transfusion; Erythrocytes; Erythropoiesis; Erythropoietin; Folic Acid; Folic Acid Deficiency; Hemoglobins; Hemolysis; Histidine; Humans; Iron; Kidney Failure, Chronic; Renal Dialysis; Splenectomy; Vitamin B 12 Deficiency

Topics: Anemia, Neonatal; Biological Transport; Birth Weight; Cell Survival; Erythrocyte Count; Erythrocytes; Erythropoiesis; Erythropoietin; Female; Folic Acid Deficiency; Hemoglobins; Humans; Infant Nutritional Physiological Phenomena; Infant, Newborn; Infant, Premature; Iron Deficiencies; Oxygen Consumption; Pregnancy; Reticulocytes; Vitamin B 12 Deficiency; Vitamin E Deficiency

Topics: Adenosine Triphosphatases; Anemia, Hemolytic; Blood Urea Nitrogen; Bone Marrow Cells; Cell Membrane; Erythrocytes, Abnormal; Erythropoiesis; Erythropoietin; Folic Acid Deficiency; Glycolysis; Hemolysis; Humans; Hydrogen-Ion Concentration; Iron; Kidney; Oxygen Consumption; Phosphoric Monoester Hydrolases; Uremia

Topics: Anemia; Anemia, Hypochromic; Anemia, Iron-Deficiency; Anemia, Macrocytic; Blood Platelets; Bone Marrow Cells; Drug Therapy; Epoetin Alfa; Erythropoietin; FIGLU Test; Folic Acid; Folic Acid Deficiency; Glutamates; Hemoglobins; Humans; Infant; Infusions, Parenteral; Injections, Intravenous; Iron; Iron-Dextran Complex; Megakaryocytes; Reticulocytes; Thrombocytopenia; Thrombocytosis; Vitamin B 12