Polycythemia

Polycythemia (also spelt polycythaemia) is a laboratory finding that the hematocrit (the volume percentage of red blood cells in the blood) and/or hemoglobin concentration are increased in the blood. Polycythemia is sometimes called erythrocytosis, and there is significant overlap in the two findings, but the terms are not the same: polycythemia describes any increase in hematocrit and/or hemoglobin, while erythrocytosis describes an increase specifically in the number of red blood cells in the blood.

Polycythemia has many causes. It can describe an increase in the number of red blood cells ("absolute polycythemia") or a decrease in the volume of plasma ("relative polycythemia"). Absolute polycythemia can be due to genetic mutations in the bone marrow ("primary polycythemia"), physiological adaptations to one's environment, medications, and/or other health conditions. Laboratory studies such as serum erythropoeitin levels and genetic testing might be helpful to clarify the cause of polycythemia if the physical exam and patient history do not reveal a likely cause. The definition is different for neonates and varies by age in children. is not a true increase in the number of red blood cells or hemoglobin in the blood, but rather an elevated laboratory finding caused by reduced blood plasma (hypovolemia, cf. dehydration). Relative polycythemia is often caused by loss of body fluids, such as through burns, dehydration, and stress. A specific type of relative polycythemia is Gaisböck syndrome; in this syndrome, primarily occurring in obese men, hypertension causes a reduction in plasma volume, resulting in (amongst other changes) a relative increase in red blood cell count. If relative polycythemia is deemed unlikely because the patient has no other signs of hemoconcentration and has sustained polycythemia without clear loss of body fluids, the patient likely has absolute or true polycythemia.

Absolute or true polycythemia (also erythrocytosis) can be split into two categories:

Primary polycythemia, that is the overproduction of red blood cells due to a primary process in the bone marrow (a so-called myeloproliferative disease; eg. polycythemia vera). These can be familial or congenital, or acquired later in life.
Secondary polycythemia, whenever additional red blood cells may have been received through another process — for example, being over-transfused (either accidentally or, as blood doping, deliberately).

Polycythemia in neonates

Polycythemia in newborns is defined as hematocrit > 65%. Significant polycythemia can be associated with blood hyperviscosity, or thickening of the blood. Causes of neonatal polycythemia include:

Hypoxia: Poor oxygen delivery (hypoxia) in utero resulting in compensatory increased production of red blood cells (erythropoeisis). Hypoxia can be either acute or chronic. Acute hypoxia can occur as a result of perinatal complications. Chronic fetal hypoxia is associated with maternal risk factors such as hypertension, diabetes and smoking.
Umbilical cord stripping: delayed cord clamping and the stripping of the umbilical cord towards the baby can cause the residual blood in the cord/placenta to enter fetal circulation, which can increase blood volume.

Pathophysiology

The pathophysiology of polycythemia varies based on its cause. The production of red blood cells (or erythropoeisis) in the body is regulated by erythropoietin, which is a protein produced by the kidneys in response to poor oxygen delivery. As a result, more erythropoietin is produced to encourage red blood cell production and increase oxygen-carrying capacity. This results in secondary polycythemia, which can be an appropriate response to hypoxic conditions such as chronic smoking, obstructive sleep apnea, and high altitude.

Primary polycythemia, on the other hand, is caused by genetic mutations or defects of the red cell progenitors within the bone marrow, leading to overgrowth and hyperproliferation of red blood cells regardless of erythropoeitin levels.

Evaluation

History and physical exam

The first step to evaluate new polycythemia in any individual is to conduct a detailed history and physical exam.

Blood smear to evaluate cell morphology
Iron panel to evaluate for concurrent iron deficiency
JAK2 mutation testing Often, excess white blood cells and platelets are also produced. A hallmark of polycythemia vera is an elevated hematocrit, with Hct > 55% seen in 83% of cases. A somatic (non-hereditary) mutation (V617F) in the JAK2 gene, also present in other myeloproliferative disorders, is found in 95% of cases. Symptoms include headaches and vertigo, and signs on physical examination include an abnormally enlarged spleen and/or liver. Studies suggest that mean arterial pressure (MAP) only increases when hematocrit levels are 20% over baseline. When hematocrit levels are lower than that percentage, the MAP decreases in response, which may be due, in part, to the increase in viscosity and the decrease in plasma layer width. Furthermore, affected individuals may have other associated conditions alongside high blood pressure, including formation of blood clots. Transformation to acute leukemia is rare. Phlebotomy is the mainstay of treatment.

Primary familial polycythemia, also known as primary familial and congenital polycythemia (PFCP), exists as a benign hereditary condition, in contrast with the myeloproliferative changes associated with acquired PCV. In many families, PFCP is due to an autosomal dominant mutation in the EPOR erythropoietin receptor gene. PFCP can cause an increase of up to 50% in the oxygen-carrying capacity of the blood; skier Eero Mäntyranta had PFCP, which is speculated to have given him an advantage in endurance events.

Secondary polycythemia

Secondary polycythemia is caused by either natural or artificial increases in the production of erythropoietin, hence an increased production of erythrocytes.

Secondary polycythemia in which the production of erythropoietin increases appropriately is called physiologic polycythemia. Conditions which may result in physiologic polycythemia include:

Altitude related – Polycythemia can be a normal adaptation to living at high altitudes (see altitude sickness). Many athletes train at high altitude to take advantage of this effect, which can be considered a legal form of blood doping, although the efficacy of this strategy is unclear.
Hypoxic disease-associated – for example, in cyanotic heart disease where blood oxygen levels are reduced significantly; in hypoxic lung disease such as COPD; in chronic obstructive sleep apnea;

Conditions where the secondary polycythemia is not caused by physiologic adaptation, and occurs irrespective of body needs include:

Post-transplant erythrocytosis – About 10–15% of patients after renal transplantation are found to have polycythemia at 24 months after transplantation, which can be associated with increased thrombotic (clotting) risk.

Testosterone replacement therapy (TRT) and secondary polycythemia

Testosterone replacement therapy (TRT) causes secondary polycythemia by stimulating the body's natural pathways that regulate red blood cell production, rather than from an inherent bone marrow disorder. Testosterone increases the production of erythropoietin (EPO) in the kidneys, a hormone that signals the bone marrow to make more red blood cells. At the same time, testosterone suppresses the liver hormone hepcidin, which normally limits the absorption and mobilization of iron. With less hepcidin, iron becomes more available for hemoglobin synthesis, further fueling red blood cell production. This combination of increased EPO signaling and enhanced iron supply amplifies erythropoiesis, leading to elevated hematocrit and hemoglobin levels. The effect is most pronounced with injectable forms of testosterone that create high peak serum levels, which strongly stimulate these pathways. Because the mechanism is driven by a hormonal stimulus and not by a primary bone marrow abnormality, the condition is classified as secondary polycythemia. Clinically, this distinction is important, as TRT-induced secondary polycythemia resolves or improves with dose adjustment, delivery method changes, or therapeutic phlebotomy, whereas primary polycythemia reflects a chronic clonal disorder of hematopoietic stem cells.

Altered oxygen sensing

Rare inherited mutations in three genes which all result in increased stability of hypoxia-inducible factors, leading to increased erythropoietin production, have been shown to cause secondary polycythemia:

Chuvash erythrocytosis or Chuvash polycythemia is an autosomal recessive form of erythrocytosis endemic in patients from the Chuvash Republic in Russia. Chuvash erythrocytosis is associated with homozygosity for a C598T mutation in the von Hippel–Lindau gene (VHL), which is needed for the destruction of hypoxia-inducible factors in the presence of oxygen. Clusters of patients with Chuvash erythrocytosis have been found in other populations, such as on the Italian island of Ischia, located in the Bay of Naples. Patients with Chuvash erythrocytosis experience a significantly elevated risk of events.
PHD2 erythrocytosis: Heterozygosity for loss-of-function mutations of the PHD2 gene are associated with autosomal dominant erythrocytosis and increased hypoxia-inducible factors activity.
HIF2α erythrocytosis: Gain-of-function mutations in HIF2α are associated with autosomal dominant erythrocytosis and pulmonary hypertension.

Symptoms

Polycythemia is often asymptomatic; patients may not experience any notable symptoms until their red cell count is very high. For patients with significant elevations in hemoglobin or hematocrit (often from polycythemia vera), some non-specific symptoms include:

Epidemiology

The prevalence of primary polycythemia (polycythemia vera) was estimated to be approximately 44–57 per 100,000 individuals in the United States.

Management

The management of polycythemia varies based on its etiology:

See polycythemia vera for management of primary polycythemia, which involves reducing thrombotic risk, symptom amelioration and monitoring for further hematologic complications. Treatment can include phlebotomy, aspirin, and myelosuppressive or cytoreductive medications based on risk stratification.