hemolytic anemia

  My grandfather underwent surgery in september 98 to have a ring replaced
  in his heart valve.  Since the surgery, he has been losing a considerable
  amount of blood.  He has been taking 3.5-4 units of blood a month as his
  Hemoglobin often drops as low as 6.1.  He has had several tests, all of which
  have been normal: ANA titer, folic acid and B-12, Bili Ruben, leukemia,
  GI bleed, platelets, and white cell tests have revealed nothing.  There is  
  no loss of blood in the urine or stool.
       These blood transfusions are all that have been done.  The only other
  thing mentioned by the doctors is that the anemia may be caused by some sort
  of a reaction to the valve ring.  They have also mentioned Waring Blender(?)
  Syndrome and the possibilty of using prednisone or immuno suppresants.
    There seems to be no relief for him in site, and the doctors have little to
  offer.  Could you please shed some light?
                          Thanks
  

[CCF CARDIO MD APS]

_
Dear Corbin,
If the work-up to rule out common causes of anemia has been done (including a bone marrow biopsy that shows normal red blood cell production), then MOST likely it is the valve ring that is causing the problem-ESPECIALLY if the blood loss coincides with the placement of the valve ring (i.e. we are not just talking coincidence here.)
When it comes to blood loss there are basically only three ways that it can be happening: 1)your losing it in your intestine, urine, out your nose, etc.  These are obvious blood losses.  2) you are not producing enough in your bone marrow  or 3)you are destroying it somehow within the vascular space; either by shear forces of a foreign body in the heart/vascular space, or destruction by your own immune system.  The body may also decide to store a lot of blood in the spleen, the organ in the left upper quadrant of your abdomen, however that too is usually obvious on exam.  
Sometimes the foreign body will exert significant shear forces on the red blood cells such that they rip apart in passing through or near, this I believe is what you are calling the waring blender phenomenon and it has been known to happen after a valve replacement and or repair.  If this is the case, you have to remove the source of the shearing, i.e. the valve or valve ring.
However, if you believe it is the patient's immune system that is destroying the red blood cells (in reaction to whatever), you can try to suppress this activity with prednisone, a steroid, or some other immunosuppressent.
Basically, there really needs to be a blood specialist (hematologist) taking care, participating in your father's care, as this is obviously a very serious problem that is not common and mind you, immunosupressents in elderly patients are not without their potential side effects (i.e. susceptibility to infection.)
The answer is not "just keep transfusing him", rather, it is try the immunosuppressents and if that doesn't work, the foreign body must come out, i.e. it must be implicated as the cause when all else turns up negative.
I hope this information is useful. Information provided in the heart forum is for
general purposes only.  Only your physician can provided specific diagnoses and therapies.
Feel free to write back with further questions. Good luck!
If you would like to make an appointment at the Cleveland Clinic Heart Center, please
call 1-800-CCF-CARE or inquire online by using the Heart Center website at
www.ccf.org/heartcenter. The Heart Center website contains a directory of the
cardiology staff that can be used to select the physician best suited to address your
cardiac problem.