Polycythemia vera

Polycythemia vera is a bone marrow disease that leads to an abnormal increase in the
number of blood cells. The red blood cells are mostly affected.
Causes
Polycythemia vera is a disorder of the bone marrow. It mainly causes
too many red blood cells to be produced. The numbers of white blood
cells and platelets may increase as well..
This is a rare disorder that occurs more often in men than in women. It
is not often seen in people under age 40. The problem is often linked to
a gene defect called JA!"#$%&. The cause of this gene defect is
unknown.
Symptoms
Trouble breathing when lying down
'i((iness
)*cess bleeding
&ull feeling in the left upper abdomen +due to enlarged spleen,
-eadache
Itchiness. especially after a warm bath
/ed skin coloring. especially of the face
0hortness of breath
0ymptoms of blood clots in veins near the skin surface +phlebitis,
1ther symptoms that may occur with this disease2
3luish skin color
&atigue
/ed skin spots
"ision problems
Exams and Tests
The health care provider will perform a physical e*am. 4ou may also
have the following tests2
3one marrow biopsy
5omplete blood count with di6erential
5omprehensive metabolic panel
)rythropoietin level
7enetic test for the JA!"#$%& mutation
1*ygen saturation of the blood
/ed blood cell mass
"itamin 3$! level
Treatment
The goal of treatment is to reduce the thickness of the blood and
prevent bleeding and clotting.
A method called phlebotomy is used to decrease blood thickness. 1ne
unit of blood +about $ pint, is removed each week until the number of
red blood cells drops. The treatment is continued as needed.
1ther treatments may include2
5hemotherapy +speci8cally hydro*yurea, to reduce the number
of red blood cells made by the bone marrow. This option may
used when the numbers of other blood cell types are also high.
Interferon to lower blood counts.
Anagrelide to lower platelet counts
Taking aspirin to reduce the risk of blood clots may be an option for
some people. -owever. aspirin increase the risk of stomach bleeding.
When to Contact a Medical Professional
Polycythemia vera is a slow9growing type of blood cancer in which
your bone marrow makes too many red blood cells. Polycythemia vera
may also result in production of too many of the other types of blood
cells : white blood cells and platelets. These e*cess cells thicken your
blood and cause complications. such as such as a risk of blood clots or
bleeding.
Polycythemia vera isn;t common. It usually develops slowly. and you
may have it for years without noticing signs or symptoms. 1ften.
polycythemia vera is found during a blood test done for some other
reason.
Symptoms
&or many people. polycythemia vera may not cause any signs or
symptoms. -owever. some people may e*perience2
Itchiness. especially following a warm bath or shower
-eadache
'i((iness
<eakness
)*cessive sweating
Painful swelling of one =oint. often the big toe
0hortness of breath
3reathing di>culty when you lie down
?umbness. tingling. burning or weakness in your hands. feet.
arms or legs
A feeling of fullness or bloating in your left upper abdomen due
to an enlarged spleen
When to see a doctor
3ecause polycythemia vera causes your blood to thicken and slows
blood @ow. it increases your risk of developing blood clots. If a blood
clot occurs in your head. it can cause a stroke. 0eek emergency
medical care if you have any of the following signs or symptoms of a
stroke2
0udden numbness. weakness. or paralysis of your face. arm or
leg : usually on one side of your body
0udden di>culty speaking or understanding speech +aphasia,
0udden blurred. double or decreased vision
0udden di((iness. loss of balance or loss of coordination
A sudden. severe headache or an unusual headache. which may
or may not be accompanied by a sti6 neck. facial pain. pain
between your eyes. vomiting or altered consciousness
5onfusion. or problems with memory. spatial orientation or
perception
Causes
Polycythemia vera occurs when a mutation in a bone marrow cell
causes a problem with blood cell production. ?ormally. your body
carefully regulates the number of each of the three types of blood cells
you have. 3ut in polycythemia vera. the mechanism your body uses to
control the production of blood cells becomes damaged. and your bone
marrow makes too many of some blood cells.
The mutation that causes polycythemia vera is thought to a6ect a
protein switch that tells the cells to grow. 0peci8cally. it;s a mutation in
the protein JA! +the JA! "#$%& mutation,. Aost people with
polycythemia vera have this mutation. There are other mutations
found in people with polycythemia vera. but it;s not yet known what
role these mutations play in the development of the disease or what
the implications of these mutations might mean for treating the
disease.
It;s not clear what causes the mutations seen in polycythemia vera.
/esearchers believe the mutation occurs after conception : meaning
that your mother and father don;t have it : so it;s acBuired. rather
than inherited from a parent.
/isk factors
The risk of polycythemia vera increases with age. It is more common in
adults older than #0. though the disease can occur at any age.
Complications
Possible complications of polycythemia vera include2
Blood clots. Polycythemia vera causes your blood to be thicker
than normal. which can slow the rate of blood @ow through your
veins and arteries. Increased blood thickness and decreased
blood @ow. as well as abnormalities in your platelets. increase
your risk of blood clots. 3lood clots can cause a stroke. a heart
attack. or blockage of an artery in your lungs +pulmonary
embolism, or in a vein deep within a muscle +deep vein
thrombosis,.
Enlarged spleen (splenomegaly). 4our spleen helps your body
8ght infection and 8lter unwanted material. such as old or
damaged blood cells. The increased number of blood cells
caused by polycythemia vera makes your spleen work harder
than normal. which causes it to enlarge.
Skin problems. Polycythemia vera may cause your skin to itch.
especially after a warm bath or shower. or after sleeping in a
warm bed. 4ou may e*perience a burning or tingling sensation in
your skin. particularly on your arms. legs. hands or feet. 4our skin
may also appear red. especially on your face.
Problems due to high levels of red blood cells. Too many
red blood cells can lead to a number of other complications.
including open sores on the inside lining of your stomach. upper
small intestine or esophagus +peptic ulcers, and in@ammation in
your =oints +gout,.
ther blood disorders. In rare cases. polycythemia vera may
lead to other blood diseases. including a progressive disorder in
which bone marrow is replaced with scar tissue +myelo8brosis,. a
condition in which stem cells don;t mature or function properly
+myelodysplastic syndrome,. or cancer of the blood and bone
marrow +acute leukemia,.
Blood tests
'octors most freBuently use blood tests to diagnose polycythemia
vera. If you have polycythemia vera. blood tests may reveal2
!n increase in the number of red blood cells and. in some
cases. an increase in platelets or white blood cells.
Elevated hematocrit measurement" the percentage of red
blood cells that make up total blood volume.
Elevated levels of hemoglobin" the iron9rich protein in red
blood cells that carries o*ygen.
#ery lo$ levels of erythropoietin" a hormone that stimulates
bone marrow to produce new red blood cells.
Bone marro$ aspiration or biopsy
If your doctor suspects you have polycythemia vera. he or she may
recommend a bone marrow aspiration or biopsy to collect a sample of
your bone marrow. A bone marrow biopsy involves taking a sample of
solid bone marrow material. A bone marrow aspiration is usually done
at the same time as a biopsy. 'uring an aspiration. your doctor
withdraws a sample of the liBuid portion of your marrow.
If an e*amination of your bone marrow shows that it;s producing higher
than normal numbers of blood cells. it may be a sign of polycythemia
vera.
Treatments and drugs
Polycythemia vera is a chronic condition that can%t be cured.
Treatment focuses on reducing your amount of blood cells. In many
cases. treatment can prevent complications from polycythemia vera
and decrease or eliminate the disease;s signs and symptoms.
Treatment may include2
Taking blood out of your veins. 'rawing a certain amount of
blood out of your veins in a procedure called phlebotomy is
usually the 8rst treatment option for people with polycythemia
vera. This reduces the number of blood cells and decreases your
blood volume. making it easier for your blood to function
properly. -ow often you need phlebotomy depends on the
severity of your condition.
&o$'dose aspirin. 4our doctor may recommend that you take a
low dose of aspirin to reduce your risk of blood clots. Cow9dose
aspirin may also help reduce burning pain in your feet or hands.
(edication to decrease blood cells. &or people with
polycythemia vera who aren;t helped by phlebotomy alone.
medications. such as hydro*yurea +'ro*ia. -ydrea,. to suppress
your bone marrow;s ability to produce blood cells may be used.
Interferon alpha may be used to stimulate your immune system
to 8ght the overproduction of red blood cells.
Therapy to reduce itching. If you have bothersome itching.
your doctor may prescribe medication. such as antihistamines. or
recommend ultraviolet light treatment to relieve your discomfort.
Aedications that are normally used to treat depression. called
selective serotonin reuptake inhibitors +00/Is,. may be helpful in
relieving itching. )*amples of 00/Is include paro*etine +Pa*il, or
@uo*etine +Pro(ac,.
Lifestyle and home remedies
E)ercise. Aoderate e*ercise. such as walking. can improve your
blood @ow. which decreases your risk of blood clots. Ceg and
ankle stretches and e*ercises also can improve your blood
circulation.
!void tobacco. Dsing tobacco can cause your blood vessels to
narrow. increasing the risk of heart attack or stroke due to blood
clots.
Be good to your skin. To reduce itching. bathe in cool water
and pat your skin dry. Avoid hot tubs. heated whirlpools. and hot
showers or baths. Try not to scratch. as it can damage your skin
and increase the risk of infection. Dse lotion to keep your skin
moist.
!void e)treme temperatures. Poor blood @ow increases your
risk of in=ury from hot and cold temperatures. In cold weather.
always wear warm clothing. particularly on your hands and feet.
In hot weather. protect yourself from the sun and drink plenty of
liBuids.
Watch for sores. Poor circulation can make it di>cult for sores
to heal. particularly on your hands and feet. Inspect your feet
regularly and tell your doctor about any sores.
Polycythemia vera +P", is a stem cell disorder characteri(ed as a
panhyperplastic. malignant. and neoplastic marrow disorder. Its most
prominent feature is an elevated absolute red blood cell mass because
of uncontrolled red blood cell production. This is accompanied by
increased white blood cell +myeloid, and platelet +megakaryocytic,
production. which is due to an abnormal clone of the hematopoietic
stem cells with increased sensitivity to the di6erent growth factors for
maturation.
The word polycythemia indicates increased red blood cells. white blood
cells. and platelets. Aost of the time. it is used in place of
erythrocythemia. or pure red blood cell increase. such as in secondary
polycythemia.
The term polycythemia is reserved for the myeloproliferative disorder
called polycythemia vera. in which all E peripheral blood cell lines can
be increased.
)rythrocytosis or erythrocythemia is a more speci8c term that is used
to denote increased red blood cells.
Pathophysiology
Increased hemoglobin and hematocrit values re@ect the ratio of red
blood cell mass to plasma volume. Any change in either the
hemoglobin or the hematocrit can alter test results.
/elative polycythemia. or erythrocythemia. results from decreased
plasma volume +7 a isb ck syndrome,. A true polycythemia or
erythrocythemia results from increased red blood cell mass. Therefore.
hemoglobin and hematocrit levels cannot accurately help make this
distinction. 'irect measurement of red blood cell mass is necessary to
di6erentiate these conditions.
In primary polycythemia. the disorder results from a mutation
e*pressed within the hematopoietic stem cell or progenitor cells. which
drives the eventual accumulation of red blood cells. The secondary
polycythemic disorders may be acBuired or congenitalF however. they
are driven by circulating factors that are independent of the function of
hematopoietic stem cells.
Polycythemia vera +P", is a disorder of the multipotent hematopoietic
stem cell that manifests as e*cess production of normal erythrocytes
and variable overproduction of leukocytes and platelets. It is grouped
with the Philadelphia chromosomeGnegative myeloproliferative
disorders and can usually be di6erentiated from them by the
predominance of erythrocyte production. 0ee the image below.
In polycythemia vera. the blood becomes thickened with too many red
blood cells. The number of white blood cells and platelets may also
increase. These e*tra blood cells may collect in the spleen and cause it
to swell. The increased number of red blood cells. white blood cells. or
platelets in the blood can cause bleeding problems and make clots
form in blood vessels. This can increase the risk of stroke or heart
attack. In patients who are older than #H years or who have a history of
blood clots. the risk of stroke or heart attack is higher. Patients also
have an increased risk of acute myeloid leukemia or primary
myelo8brosis.
In addition to a complete blood count. bone marrow aspiration and
biopsy. and cytogenetic analysis. a serum erythropoietin test is used to
diagnose polycythemia vera. In this test. a sample of blood is checked
for the level of erythropoietin +a hormone that stimulates new red
blood cells to be made,.
Polycythemia Primary *auses
In primary polycythemia. inherent or acBuired problems with red blood
cell production lead to polycythemia. Two main conditions that belong
to this category are polycythemia vera +P" or polycythemia rubra vera
IP/"J, and primary familial and congenital polycythemia +P&5P,.
Polycythemia vera (P#) is related to a genetic mutation in the
JA! gene. which is thought to increase the sensitivity of bone
marrow cells to )po. resulting in increased red blood cell
production. Cevels of other types of blood cells +white blood cells
and platelets, are also often increased in this condition.
Primary familial and congenital polycythemia (P+*P) is a
condition related to a mutation in the )P1/ gene and causes
increased production of red blood cells in response to )po.
Polycythemia Secondary *auses
5ontrary to primary polycythemia in which overproduction of red blood
cell results from increased sensitivity or responsiveness to )po +often
with lower than normal levels of )po,. in secondary polycythemia.
more red cells are produced because of high levels of circulating )po.
There also are more benign conditions that may cause increase )po
secretion. such as kidney cysts and kidney obstruction.
5hronic carbon mono*ide e*posure can also lead to polycythemia.
-emoglobin naturally has a higher a>nity for carbon mono*ide than
for o*ygen. Therefore. when carbon mono*ide molecules attach to
hemoglobin. polycythemia +increased red cell and hemoglobin
production, may occur in order to compensate for the poor o*ygen
delivery by the e*isting hemoglobin molecules. A similar scenario can
also occur with carbon dio*ide in long9termcigarette smoking.
Polycythemia in newborns +neonatal polycythemia, is often caused by
transfer of maternal blood from the placenta or blood transfusions.
Prolonged poor o*ygen delivery to the fetus +intrauterine hypo*ia, due
to insu>ciency of the placenta can also lead to neonatal polycythemia.
,elative Polycythemia
/elative polycythemia describes conditions in which red cell volume is
high due to increased blood concentration of red cells as a result of
dehydration. In these situations +vomiting. diarrhea. e*cessive
sweating, the number of red blood cells is normal. but because of the
@uid loss a6ecting the blood +plasma,. red blood cell counts may seem
elevated.
Stress Polycythemia
0tress erythrocytosis +also known as pseudopolycythemia or
7aisbock;s syndrome, is seen in obese middle aged men who are being
treated with a diuretic medication for hypertension. It is not unusual
that such men are also cigarette smokers.
Polycythemia ,isk +actors
0ome of the risk factors for polycythemia include2
chronic hypo*iaF
long9term cigarette smokingF
familial and genetic predispositionF
living in high altitudesF
long9term e*posure to carbon mono*ide +tunnel workers. car
garage attendants. residents of highly polluted cities,F and
Ashkena(i Jewish ancestry +may have increased freBuency of
polycythemia vera due to genetic susceptibility,.
Polycythemia Symptoms
0ymptoms of polycythemia can vary widely. In some people with
polycythemia. there may be no symptoms at all.
In secondary polycythemia. most of the symptoms are related to the
underlying condition responsible for polycythemia.
Self'*are at -ome
In individuals with primary polycythemia. some simple measures can
be taken at home to control potential symptoms and avoid possible
complications.
It is important to stay well hydrated in order to avoid
concentrating the blood even further by dehydration. In general.
there are no restrictions in physical activity.
If a person has an enlarged spleen. contact sports may be
avoided to prevent splenic in=ury and rupture.
It is best to avoid iron supplementation as this can promote more
red blood cell production.
The Facts on Polycythemia
The $ord polycythemia simply means .many cells in the
blood.. There are two forms of this disease2 polycythemia vera and
secondary polycythemia.
Polycythemia vera +also called primary polycythemia, is a rare
growth disorder of the bone marrow. occurring when the marrow is
overactive and produces more blood cells than the body needs.
Secondary polycythemia a6ects some people as a result of limited
o*ygen due to smoking or living at high altitudes.
Polycythemia vera usually produces a high concentration of red blood
cells or hemoglobin in the circulating blood. but it;s important to note
that white blood cell and platelet counts may also be increased.
Causes of Polycythemia
Polycythemia vera stems from problems $ith the bone marro$.
3one marrow is found in the centre of most bones and normally
produces all red blood cells and platelets and most white blood cells.
<hen this process breaks down. production of cells is no longer orderly
and conditions such as polycythemia can result. Although the e*act
cause of polycythemia vera is unknown. researchers have found that a
speci8c gene mutation is associated with almost all people with this
condition.
Polycythemia vera is a rare condition usually a/ecting men in
their 01s. It is more common in men than in women. The condition is
rarely seen in people under age 40. but can also a6ect babies.
!lthough the cause of polycythemia vera is unkno$n" a
number of factors are involved that appear to lead to
secondary polycythemia. A high content of red blood cells builds up
in response to low o*ygen concentration in the air. 3ecause there;s less
o*ygen in the blood. the body attempts to overcome the lack by
making more red blood cells. It doesn;t stop. however. and keeps
producing them until there are too many. The bone marrow can also be
overstimulated by testosterone replacement therapy.
Civing for long periods at high altitudes where there;s less o*ygen may
lead to polycythemia. It also may occur in people with chronic lung
conditions and certain kidney tumours and cysts. -eavy smoking is
associated with an increase in carbon mono*ide in the blood and may
also lead to higher red cell and hemoglobin levels. Cow blood o*ygen
levels +hypoxia, due to congenital heart disease also appear to be a
factor in the development of polycythemia.
Polycythemia facts
Polycythemia means increased red blood cell volume.
Polycythemia is divided into two main categoriesF primary and
secondary.
Polycythemia can be linked to secondary causes. such as. chronic
hypo*ia or tumors releasing erythropoietin.
Polycythemia vera due to abnormally increased red cell
production in the bone marrow.
Treatment of secondary polycythemia is dependent on the
underlying condition.
Polycythemia is treated by phlebotomy +controlled blood letting,
and hydro*yurea.
What is polycythemia2
Polycythemia is a condition that results in an increased level of
circulating red blood cells in the bloodstream. People with
polycythemia have an increase in hematocrit. hemoglobin. or red blood
cell count above the normal limits.
Polycythemia is normally reported in terms of increased hematocrit or
hemoglobin.
-ematocrit (-*T)3 Polycythemia is considered when the
hematocrit is greater than 4KL in women and H!L in men.
-emoglobin (-4B)3 Polycythemia is considered when a
hemoglobin level of greater than $#.HgMdC in women or
hemoglobin level greater than$K.H gMdC in men.
Polycythemia can be divided into two categoriesF primary and
secondary.
Primary polycythemia3 In primary polycythemia the increase
in red blood cells is due to inherent problems in the process of
red blood cell production.
Secondary polycythemia3 0econdary polycythemia generally
occurs as a response to other factors or underlying conditions
that promote red blood cell production.
/ed cell production +erythropoiesis, takes place in the bone marrow
through a comple* seBuence of tightly regulated steps. The main
regulator of the red cell production is the hormone erythropoietin
+)P1,. This hormone is largely secreted by the kidneys. although.
about $0L may be produced and secreted by the liver.
Erythropoietin secretion is up9regulated in response to low o*ygen
levels +hypo*ia, in the blood. Aore o*ygen can be carried to tissues
when erythropoietin stimulates red blood cell production in the bone
marrow to compensate for the hypo*ia.
What are normal ranges of hematocrit" red cell counts" and
hemoglobin2
-ematocrit is the ratio of the volume of red cells to the volume of
whole blood. The normal range for hematocrit varies between se*es
and is appro*imately 4HL to H!L for men and E%L to 4KL for women.
,ed cell count signi8es the number of red blood cells in a volume of
blood. The normal range in men is appro*imately 4.% to #.$ million
cellsMul +microliter,. The normal range in women range from 4.! to H.4
million cellsMul. according to ?I- +?ational Institutes of -ealth, data.
-emoglobin is a protein in the red blood cells that carries o*ygen and
gives blood its red color. The normal range for hemoglobin may di6er
between the se*es and is appro*imately $E to $K grams per deciliter
for men and $! to $# grams per deciliter for women.
What are the causes of primary polycythemia2
Primary polycythemias are due to acBuired or inherited genetic
mutations causing abnormally high levels of red blood cell precursors.
Primary familial and congenital polycythemia +P&5P, and polycythemia
vera +P", are in this category.
*an other sources of Erythropoietin (EP) cause polycythemia2
)rythropoietin +)P1, has been made synthetically for clinical treatment
of certain types of anemia. 0ome professional athletes have used this
type of in=ectable )P1 +blood doping, to improve their performance in
competitions by producing more hemoglobin and. therefore. improving
the delivery of o*ygen to their tissues. mainly muscles. This type of
doping practice is banned by many professional sport committees.
What is relative polycythemia2
In some forms of secondary polycythemia. the hemoglobin or red blood
cell count is perceived to be abnormally high due to an increased
concentration of blood. This can happen as a result of plasma volume
loss from dehydration. severe vomiting or diarrhea. or e*cessive
sweating. Polycythemia in these situations may be called relative
polycythemia. because the actual numbers of red blood cells are not
abnormal.
What is stress polycythemia2
Stress polycythemia is a term applied to a chronic +long standing,
state of low plasma volume which is seen commonly in active. hard
working. an*ious. middle9aged men. In these people. the red blood cell
volume is normal. but the plasma volume is low. This condition is also
known as 7aisbock;s disease. stress erythrocytosis. or
pseudopolycythemia.
0moker;s polycythemia is a similar condition in which increased levels
of deo*ygenated hemoglobin +hemoglobin that does not carry o*ygen.
instead carrying carbon dio*ide, causes an increase in red blood cell
counts.
What are the risk factors for polycythemia2
-ypo*ia from long standing +chronic, lung disease and smoking
are common causes of polycythemia. Therefore. smoking can be
signi8cant risk factor for polycythemia.
5hronic carbon mono*ide +51, e*posure can also be risk factor
for polycythemia. -emoglobin has a higher a>nity for 51 than
for o*ygenF therefore. as it replaces o*ygen in favor of 51.
polycythemia may ensue to compensate for the low o*ygen
carried by hemoglobin.
5hronic carbon mono*ide e*posure is a risk factor for people
working in underground tunnels or parking garages. cab drivers
in highly polluted and congested cities. or workers in factories
with e*posure to engine e*haust.
People living at high altitudes may also be at risk of developing
polycythemia due to low environmental o*ygen levels.
People with genetic mutations and familial types of polycythemia
and certain hemoglobin abnormalities also carry risk factors for
this condition as mentioned in earlier sections.
-o$ is polycythemia diagnosed2
Polycythemia may be diagnosed incidentally on routine blood work.
-emoglobin. hematocrit. and red blood cell concentration are typically
found on a complete blood count +535,. /epeating the laboratory tests
+blood work, to con8rm the diagnosis is usually advised to rule out
possible laboratory or drawing errors.
A complete physical e*amination including the assessment of body
habitus +stature,. vital signs. o*ygen saturation. heart and lung e*ams.
and evaluating for an enlarged spleen +splenomegaly, are essential in
the evaluation of people with polycythemia.
A chest N9ray. electrocardiogram +)7,. and echocardiogram may be
performed to screen for lung disease or heart disease. -emoglobin
analysis may be necessary if conditions with high a>nity for o*ygen or
!. E93P7 de8ciency are suspected. If carbon mono*ide poisoning is in
Buestion. its level can be detected by a blood test.
)rythropoietin +)P1, blood levels may also be helpful. although the
results need to be interpreted carefully as the level may be high in
response to chronic hypo*ia. In polycythemia vera. the )P1 levels are
low as a response to an increased production of red blood cells. In
tumors secreting erythropoietin. the )P1 levels may be abnormally
high.
What is the treatment for polycythemia2
The treatment for polycythemia is generally dependent on the cause.
In polycythemia vera or other primary polycythemia syndromes. the
treatment options are more speci8c. Phlebotomy +drawing blood or
blood letting, is the most essential part of the treatment. The
recommended hematocrit of less than 4H in men and less than 4! in
women is the goal of phlebotomy.
0everal medications have been considered in con=unction with
phlebotomy to suppress the abnormal production of red blood cells.
Aost of these chemotherapeutic drugs have been linked with side
e6ects and their use has been controversial and limited.
The medication hydro*yurea +-ydrea, has been recommended for
some patients with primary polycythemia and higher risk of blood clot
formation due to high blood viscosity. The factors favoring treatment
with hydro*yurea are age greater than %0. platelet count greater than
$.H million. and general cardiovascular risk factors.
Aspirin and other anti9platelet agents +dipyridamole, may also be
bene8cial in patients with polycythemia by reducing clotting
complications. unless the patient has a history of bleeding problems.
In patients with secondary polycythemia. the goal is to treat the
underlying condition. &or e*ample. in patients with lung or heart
disease with hypo*ia. appropriate management of these conditions
along with o*ygen supplementation is generally advised.