approach to anemia abdul-kareem al-momen, md, frcpc ksu-med 341 17-04-2011 (13-05-1432)

Approach to anemia

• Abdul-Kareem Al-Momen, MD, FRCPC• KSU-MED 341

• 17-04-2011 (13-05-1432)

Anemia is defined as a reduction in one or more of the major RBC measurements:hemoglobin concentration, hematocrit, or RBC count to a degree lower than normal values for the tested population :newborn, childhood, adulthood (males & females), and sea level

Definition:

NewbornNewborn

ChldChld..

AdultAdult::

MaleMale

FemaleFemale

Sea LevelSea Level : :

JeddahJeddah

Hi.Alt.:AlbahaHi.Alt.:Albaha

Hb (gm/L)Hb (gm/L)

200200 -/+ -/+ 2020

110110 -/+ -/+ 1010

160160 -/+ -/+ 2020

1414 -/+ -/+ 2020

150150 g/Lg/L

190190 G/lG/l

PCV (Hct)PCV (Hct)%%

6060 -/+ -/+ 2020

3333 -/+ -/+ 33

4848 -/+ -/+ 55

4242 -/+ -/+ 55

4747% %

5858% %

Anemia?

Production? Destruction?

The key test is the reticulocytic count

The reticulocyte count

• Increased reticulocytes (greater than 2-3% or 100,000/mm3 total) are seen in blood loss and hemolytic processes.

The reticulocyte count• To be useful the reticulocyte count must be adjusted for

the patient's hematocrit, because when hematocrit is low, reticulocytes are released earlier (faster) from the marrow so one can adjust for this phenomenon as follows:

• Corrected retic. = Patients retic. x (Patients Hct/45)

Example: Hb 70 g/L, PCV (Hct) = 20, Retics.= 16 %Corrected Retics.= 16 X 20/45 = 7

The reticulocyte count • Reticulocyte Production index (RPI) = corrected retic.

count/Maturation time (Maturation time = 1 for Hct=45%, 1.5 for 35%, 2 for

25%, and 2.5 for 15%.)Example: PCV = 20 %, Retics.= 16, Corrected Retics=7RPI = 7/2 = 3.5

• Absolute reticulocyte count = retic x RBC number.

Causes of Anemia (kinetic approach)

Decreased erythrocyte production

Bone marrow suppression

Bone marrow infiltration

Nutritional deficiencies

Decreased erythropoietin production

Inadequate marrow response to erythropoietin

Causes of Anemia Blood loss

•Hemorrhage :

Bleeding tendencies,

Menorrhagea,

Anticoagulation

Liver disease

Hemolysis:

Autoimmune,

None-immune, (MAHA,

RBC defects, Hypersplenism)

Dilutional Anemia

• Dilutional- A patient's plasma volume increases with pregnancy,(Splenomegally), laying down possibly responsible for as much as a 3-6% drop in the hematocrit in the first two days of hospitalization.

First, measure the size of the RBCs:First, measure the size of the RBCs:

   MCV  (femtoliters) = 10 x HCT(percent) ÷ RBC (millions/µL)

Morphological Approach(big versus small)

High MCV

MCV>115• B12, Folate• Drugs that impair DNA synthesis (AZT,

chemo., azathioprine)• MDS

Normal MCV

Normocytic normocytic• Anemia of chronic disease• Mixed deficiencies• Renal failure• Endocrinopaties

Low MCV

Microcytic• Iron deficiency• Thalassemia trait• Anemia of chronic disease (30-40%)• Sideroblastic anemias• Lead poisoning

Iron deficiency anemia

• Iron deficiency is a common form of malnutrition that affects more than 2 billion people globally.

Iron Deficiency Anemia

– Smear:• hypochromic and microcytic (low MCV) RBCs,

usually not seen unless Hct 30%• platelet count is often elevated

– Ferritin: a measure of total body iron stores, but also an acute phase reactant

• <15g/l = Fe deficiency, 150 g/l = Not Fe deficiency 15-150 g/l = ?

Iron Deficiency Anemia

– Low Iron Saturation (Fe/TIBC ratio)• Fe (not reliable)• TIBC • Fe/TIBC (% saturation) 15%

– BM bx: absent Fe stores• Gold standard

– Therapeutic Trial of Oral Iron

Increased iron requirements

•Blood loss

•Gastrointestinal disorders (esophageal varices, hemorrhoids)

•Extensive and prolonged menstruation

•Pulmonary (hemoptysis, pulmonary hemosiderosis), urologic, or nasal disorders

•Dialysis

•Hookworm infestation

•Intravascular hemolysis with hemoglobinuria

•Paroxysmal nocturnal hemoglobinuria

•Cardiac valve prostheses

•Rapid growth in body size between 2 and 36 months of age

•Pregnancy and lactation

Inadequate iron supply

• Poor nutritional intake in children (not a common independent mechanism in adults but often a contributing factor)

• Malabsorption

• Gastric bypass surgery for ulcers or obesity

• Achlorhydria from gastritis or drug therapy

• Severe malabsorption (for example, celiac disease [nontropical sprue])

• Abnormal transferrin function

• Congenital atransferrinemia

• Autoantibodies to transferrin receptors

Oral iron failure?

• Incorrect diagnosis (eg, thalassemia)

• anemia of chronic disease?

• Patient is not taking the medication

• Not absorbed (enteric coated?)

• Rapid iron loss?

Intravenous Iron Therapy• Iron sacharate (Ferrosac), 200 mg in 100-250 cc normal saline IV over one hour daily to the total dose required•(Weight {kg} x Hb deficit {target Hb-current Hb] x 4).

• Ferric gluconate (Ferrlecit ) in patients on renal dialysis. The number of allergic reactions is lower than that from iron dextran

Utility of supraphysiologic doses of erythropoietinerythropoietin in the setting of inflammatory block.

B12/Folate Deficiency• Etiology:

– Anemia-- Vitamin B12 and folate are needed for DNA synthesis deoxyuridate to thymidylate , including RBC precursors

– Deficiency• B12 - Dietary intake, acid-pepsin in the

stomach, pancreatic proteases, gastric secretion of intrinsic factor, an ileum with Cbl-IF receptors (fish tapeworm)

• Folate-- Poor dietary intake EtOH, malabsorption, increased demand (pregnancy, hemolytic anemias), inhibitors of DHFR

B12/Folate Deficiency (2)

• Dx:– Smear: Macrocytic (High MCV) RBCs, +/- hypersegmented

neutrophils, +/- modest neutropenia, but…– the diagnosis of B12 def. was made in patients in whom only

29 percent had anemia, and only 36 percent had a MCV greater than 100 fL (Pruthi RK, Tefferi A, Mayo Clin Proc 1994 Feb;69(2):144-50)

– B12• Low serum B12, elevated serum methylmalonic acid

levels• Anti-IF Abs, Schilling test (?), PA accounts for 75%

– Folate• Serum folate level-- can normalize with a single good

meal

B12/Folate Deficiency (3)

• Tx:– B12 deficiency: B12 1 mg/month IM, or 1-2

mg/day po

– Folate deficiency: Improved diet, folate 1 mg/day

– Monitor for a response to therapy.

– Pernicious Anemia – monitor for gi cancers.

Cobalamin deficiency and neurological problems

• Subacute combined degeneration of the dorsal and lateral spinal columns.

• Well known study of B12 deficiency in the nursing home population (Carmel R Karnaze DS, JAMA 253:1284, 1985)

• Vitamin B-12 deficiency is present in up to 15% of the elderly population as documented by elevated methylmalonic acid in combination with low or low-normal vitamin B-12 concentrations.

• Is oral B12 good enough?

• Association between nitrous oxide anesthesia and development of neurological symptoms responsive to B12 in

patients with subclinical cobalamin deficiency (methionine?).

Diagnostic tests for Vit. B12 Deficiency

TestTest

Serum methylmalonic acid and Serum methylmalonic acid and serum homocysteineserum homocysteine

MCV>115, smear, CBCMCV>115, smear, CBC

Antibodies to IF and Parietal cellsAntibodies to IF and Parietal cells

Schilling testSchilling test

Spot urine for homocysteineSpot urine for homocysteine

Sideroblastic Anemias

• Heterogenous grouping of anemias defined by presence of ringed sideroblasts in the BM

• Etiologies:– Hereditary (rare), type of porphyria– Myelodysplasia– EtOH– Drugs (INH, Chloramphenicol)

• Tx:– Trial of pyridoxine for hereditary or INH induced

SA

Hemolytic AnemiasHemolytic Anemias

Hemolytic anemias are either acquired or congenital. The laboratory signs of hemolytic anemias include:

1. Increased LDH (LDH1) - sensitive but not specific. 2. Increased indirect bilirubin - sensitive but not specific*. 3. Increased reticulocyte count - specific but not sensitive 4. Decreased haptoglobin - specific but not sensitive. 5. Urine hemosiderin - specific but not sensitive.

*The indirect bilirubin is proportional to the hematocrit, so with a hematocrit of 45% the upper limit of normal is 1.00 mg/dl and with a hematocrit of 22.5% the upper limit of normal for the indirect bilirubin is 0.5mg/dl. Since tests for hemolysis suffer from a lack of sensitivity and specificity, one needs a high index of suspicion for this type of anemia.

Hereditary anemias• 1- RBC memberane defects :e.g.Heriditary

Spherocytosis• 2-Reduced Globin Chains:e.g. α

thalassemia ( reduced α chain ) ,& β thalassemia ( reduced β chain)

• 3-Abnormal amino-acid sequence e.g. Sickle Cell Anemia

• 3-Enzymopathies :e.g G6PD deficiency

Hemoglobinopathies

• Sickle cell disease/anemia• Thalassemias

Sickle Cell Anemia / Disease

• Hb SS due to replacement of glutamic acid by valine at position 6 on the β globin chain

• HbS molecule are less soluble ,tend to form crystals and fibers,which leads to RBC deformity ,sickling ,vaso-occlusion & hemolysis

Complications of Sickle Cell Disease

• 1- Vaso-occlusion ,with recurrent painful episodes (mild-moderate-severe )

• Acute chest syndrome• Recurrent infection (URT & chest )• Splenic sequestration• Priapism• Thrombo-embolic disease (CVA,PE,DVT)

SCD Complication: (cont.)

• Avascular necrosis (head of femur & humerus)• Tendency for Osteo-myelitis ( salmonella)• Leg ulcers• Gall stones

Presipitators of Vaso-Occlusive Episodes

• 1-Hypoxia : - low atmospheric oxygen , Lung diseases ,heart diseases

• 2-Increased blood viscosity: increased Hb/Hct ,dehydration, infection ,general anesthesia

• 3-Extreme hot/cold weather• 4-Unknown causes

Management of SCD

• Vaccination• Antibiotic prophylaxis• Avoidance of hypoxia and extreme weathers• Increase fluid intake• Treatment of acute episodes• Exchange transfusion /transfusion• Prevention: premarital screening & genetic

counseling

β Thalassemia

• 2 β genes on chromosome # 11 give 2 β globin chains.

• ββ = normal• -β = β thalassemia trait (hypochromic ,

microcytic anemia, asymptomatic , confused with iron deficiency anemia )

Thalassemia Major (Homozygous β Thalassemia )• No β chains• Severe intramedullary hemolysis• Severe hemolytic anemia• Jaundice + Pallor• Bone marrow expansion• Hepatosplenomegaly• Delayed puperty• Iron overload ( absorption + hemolysis )

H. Spherocytosis

• RBC = Spheres (not biconcave )_• Reduced survival (hemolytic anemia )• Jaundice,• Splenomegaly• Gall stones• Reticulocytosis• Increased direct billirubin

Treatment

• 1-Folic acid• 2-Splenectomy after vaccination against

S.Pneomoniae & H.Influenzaeز• Malaria avoidance / prophylaxis

Enzymopathies : G6PD Deficiency

• G6PD is essential for the production of the anti-oxidant Glutathione

• Acute hemolysis upon exposure to oxidative stress food (fava beans),drugs (e.g.sulfa derivatives ),chemicals or infection

• X- linked

Approach to anemia:

• History: Onset (acute versus chronic),Age at onset, character, associations (splenomegally, growth retardation, painful episodes, transfusions, dietary habits, family history, consanguinity, involvement of other systems, drug history : ASA, anticoagulantsetc )

• Symptoms (fatigue, exercise intolerance, headache, palpitation, lack of concentration, poor appetite,

• Adaptation

Approach to anemia:

• Signs (physical exam): Pallor, dry skin, smooth tongue, thin hair, hair loss, splenomegally, neuropathy,

• Signs of systemic diseases ( renal, hepatic, musculoskeletal, cancer, infection, etc )

Approach to anemia:

• Laboratory: RBC, Hb, Hct (PCV), MCV, MCH, MCHC, RDW, Reticulocytes, WBC, Platelets, blood filnm ( smear)

• Fe, Transferrin, ferritin, B12, folates (RBC)• ESR, ANA, RF, BUN, Cr, • Hb electrophoresis (Hb A, A2, S, F, )

•Good Luck