anaemia intermediate cycle ii hltm
TRANSCRIPT
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Anaemia
This material is intended to supportThis material is intended to support
the didactic lecture series provided bythe didactic lecture series provided by
The Department of Medicine forThe Department of Medicine forIntermediate Cycle IIIntermediate Cycle II
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Learning Objectives
At the end of this lecture you should be able to describe:At the end of this lecture you should be able to describe:
Physiology of erythropoiesisPhysiology of erythropoiesis
AnaemiaAnaemia
DefinitionDefinition
Clinical featuresClinical features
InvestigationsInvestigations
ClassificationClassification
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Erythropoiesis
25billion erythrocytes /24 hours25billion erythrocytes /24 hours
The entering cells areThe entering cells are
reticulocytes which should be 1%reticulocytes which should be 1%
of the total population ofof the total population of
circulating erythrocytes.circulating erythrocytes.
Erythrocytes last 120days and areErythrocytes last 120days and are
destroyed by the spleen.destroyed by the spleen.
Red cell production should equalRed cell production should equal
red cell destruction.red cell destruction.
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Factors necessary for
erythropoiesis
1.1. ErythropoietinErythropoietin
2.2. IronIron
3.3. Amino acidsAmino acids
4.4. Vitamin BVitamin B1212 (cyanocobalamin)(cyanocobalamin)
5.5. Folic Acid(folate)Folic Acid(folate)
6.6. Ascorbic acid(Vitamin C)Ascorbic acid(Vitamin C)
7.7. Pyridoxine (Vitamin BPyridoxine (Vitamin B66))
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Regulation of erythropoiesis
Equal number of RBCEqual number of RBCproduced to thoseproduced to those
lost throughlost throughsenescencesenescence
Decreased delivery ofDecreased delivery ofoxygen to the kidneyoxygen to the kidneydrives Epodrives Epo
production, whichproduction, whichstimulates RCCstimulates RCC
production in theproduction in themarrowmarrow
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Anaemia definition
NB. Definition: reduction in one or more of the majorNB. Definition: reduction in one or more of the majorRBC measurementsRBC measurements
Haemoglobin concentrationHaemoglobin concentration (HGB) =(HGB) = thetheconcentration of the major oxygenconcentration of the major oxygen--carryingcarryingpigment in whole blood.pigment in whole blood.
HaematocritHaematocrit(HCT) =(HCT) = the percent of a sample ofthe percent of a sample ofwhole blood occupied by intact red blood cellswhole blood occupied by intact red blood cells
RBC countRBC count== the number of red blood cellsthe number of red blood cellscontained in a specified volume of whole bloodcontained in a specified volume of whole blood
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Anaemia WHO criteria
BloodHGB below normalBloodHGB below normalrange for age and sexrange for age and sex
MaleMale 13.013.0--------17.5g/dl17.5g/dl
FemaleFemale 12.012.0--------16.0g/dl16.0g/dl
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Anaemia- Clinical Features
Signs and symptoms are dependent upon:Signs and symptoms are dependent upon:
1.1. the degree of anaemiathe degree of anaemia
2.2. the rate at which it has evolvedthe rate at which it has evolved
3.3. the oxygen demands of thethe oxygen demands of the
patientpatient decreased oxygen delivery,
hypovolemia
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Symptoms - Anaemia
1.1. Lassitude /Lassitude /FatigueFatigue
2.2. BreathlessnessBreathlessnesson exertionon exertion
3.3. PalpitationsPalpitations4.4. Throbbing inThrobbing in
head and earshead and ears5.5. DizzinessDizziness
6.6. TinnitusTinnitus7.7. HeadacheHeadache8.8. Dimness ofDimness of
visionvision9.9. InsomniaInsomnia10.10. ParaesthesiaParaesthesia
e in fingerse in fingersand toesand toes
11.11.AnginaAngina
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Signs - Anaemia
1.1. Pallor of Skin,Pallor of Skin,
1. mucous membranes,
2. Palmor creases
3. conjuctivae
2.2. TachycardiaTachycardia
3.3. Cardiac dilatationCardiac dilatation-- displaced apex beatdisplaced apex beat
4.4. Systolic Flow murmursSystolic Flow murmurs(due to dilatation of ventricle,(due to dilatation of ventricle,
leading to mitral and tricuspid regurgitation)leading to mitral and tricuspid regurgitation)
5.5. Angular stomatits/atrophic glossititsAngular stomatits/atrophic glossitits in iron deficiencyin iron deficiency
or B12deficiencyor B12deficiency--related anaemiasrelated anaemias
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Clinical features of anaemia due to acute
haemorrhage=features of
hypovolemia!!!
1.1. easy fatigabilityeasy fatigability2.2. muscle crampsmuscle cramps
3.3. postural dizzinesspostural dizziness
4.4. lethargylethargy5.5. syncopesyncope
6.6. persistent hypotensionpersistent hypotension
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Anaemia classifications
A kinetic approachA kinetic approach
A morphologic approachA morphologic approach
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Anaemia - a kinetic
approach
1.1. Decreased RBC productionDecreased RBC production1. Lack of nutrients2. Bone marrow disorders
3. Bone marrow suppression
4. The anaemia of chronic disease/inflammation
2.2. Increased RBC destructionIncreased RBC destruction1. Inherited haemolytic anemias
2. Acquired haemolytic anemias3.3. Blood lossBlood loss
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Anemia - morphologic
approach
Size of red cells
MCV
Uniform size or differing
RDW
Isolated anaemia or
abnormal wcc/plts also
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Anaemia- MCV
1.1. MACROCYTIC > 100 fl (Large red cells)MACROCYTIC > 100 fl (Large red cells)
2.2. NORMOCYTIC 80
NORMOCYTIC 80--100
fl (Normal size red100
fl (Normal size redcells)cells)
3.3. MICROCYTIC
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Low MCV small RBC
CommonCommon
Iron DeficiencyIron DeficiencyNonNon--essential informationessential information
1.1. FF -- ThalassaemiaThalassaemia
2.2. Anaemia of Chronic DisorderAnaemia of Chronic Disorder3.3. Sideroblastic AnaemiaSideroblastic Anaemia
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High MCV - macrocytic
Core Causes
B12 & Folate deficiency Alcohol
Liver Disease
Non-essential info
Hypothyroidism
Chemotherapy
Haemolytic anaemia
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Normal MCV - normocytic
1. Anaemia of Chronic Disorders
2. Early Iron Deficiency
3. Anaemia due to acute haemorrhage
Additional Info
1. Combined Anaemia e.g. B12 deficency+ Fe deficiency
2. Sideroblastic Anemia
3. Aplastic Anemia
4. Bone Marrow Infiltration
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Systematic Approach to the
evaluation of anemia
History and Physical examinationHistory and Physical examination Fatigue, palpitations, SOB, headache Past medical history
Medications
Occupational history
Social history
Dietary history
Family history
History of blood loss (GI, Gynaecological)
Pallor, jaundice, angular chelitis, koilonychia,
s lenome al ,
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Case 1
BD, female, 75BD, female, 75
Tiredness for more than 6/12Tiredness for more than 6/12
Otherwise asymptomaticOtherwise asymptomatic
PMHx: HE 34 years agoPMHx: HE 34 years ago
(myomas; menorrhagia)(myomas; menorrhagia)
HTN, well corrected on txHTN, well corrected on tx
OsteoporosisOsteoporosis
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Patient ResultsPatient Results Normal Range (Female)Normal Range (Female)
HbHb 7.9 g/dl7.9 g/dl 11.711.7 -- 16.0g/dl16.0g/dl
MCVMCV 62fl62fl 7979 -- 96 fl96 fl
MCHMCH 19.0pg19.0pg 27.027.0 32.0pg32.0pg
MCHCMCHC 30g/dl30g/dl 32.032.0 36.5g/dl36.5g/dl
RDWRDW 19.219.2
WBCWBC 5.3 x 105.3 x 1099/l/l 4.04.0-- 11.0x 1011.0x 1099/l/l
PlateletsPlatelets 550x10550x1099/l/l 140140--450x 10450x 1099/l/l
Case 1
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Case 1
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How to prove a lack ofiron???
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Iron deficiency anaemia Iron
studies
Ferritin lowFerritin low
Fe lowFe low Transferin saturation lowTransferin saturation low
TBIC highTBIC high
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Causes of Iron Deficiency
Diet(vegetarians)Diet(vegetarians)
MenorrhagiaMenorrhagia
PregnancyPregnancy
G.I.T. BleedG.I.T. BleedGrowth SpurtGrowth Spurt
MalabsorptionMalabsorption
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Treatment of Iron deficiency
anaemia
Iron replacement therapyIron replacement therapy
(p.o., eventually i.v. if refractory)(p.o., eventually i.v. if refractory)
Treatment of underlyingTreatment of underlying
conditioncondition this is crucial,this is crucial,
otherwise it will recur!!otherwise it will recur!!
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Case 2
DD, female, 48DD, female, 48
Newly diagnosed with seroNewly diagnosed with sero--positive RApositive RA
Medication: NSAIDMedication: NSAID
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Patient ResultsPatient Results Normal Range (Male)Normal Range (Male)
HbHb 9.8 g/dl9.8 g/dl 13.013.0-- 17.5g/dl17.5g/dl
MCVMCV 78fl78fl 7979 -- 96 fl96 fl
MCHMCH 26.026.0pgpg 27.027.0 32.0pg32.0pg
MCHCMCHC 33 g/dl 33 g/dl 32.032.0 36.5g/dl36.5g/dl
WBCWBC 9.2x 109.2x 1099/l/l 4.04.0-- 11.0x 1011.0x 1099/l/l
lympholympho 0.7x0.7x101099/l/l 1.001.00--4.00x4.00x 101099/l/l
PlateletPlatelet
ss
550x10550x1099/l/l 140140--450x 10450x 1099/l/l
Case 2
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Case 2
Ferritin 344 ng/dL highFerritin 344 ng/dL high
Fe 8 microg/mL lowFe 8 microg/mL low Transferin saturation 15% NTransferin saturation 15% N
TBIC 150microg/dL lowTBIC 150microg/dL low
ESR 68 mm/hESR 68 mm/h highhigh
CRP 130mg/LCRP 130mg/L highhigh
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Anaemia of chronic disorders
Can be NormocyticCan be Normocytic--normochromic or microcyticnormochromic or microcytic--hypochromic,hypochromic,
PathogenesisPathogenesis
1.1. Low iron absorptionLow iron absorption
2.2. inappropriate distribution of iron in bodyinappropriate distribution of iron in body
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Anaemia of inflammation -
pathophysiology
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ACD - therapy
Treat the underlying disorderTreat the underlying disorder
Also can give erythropoietinAlso can give erythropoietinsupplementation to stimulatesupplementation to stimulate
RCC productionRCC production
EPO30EPO30--60.000units / week60.000units / week
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Conclusion:
anaemia is not a final diagnosis
Characterize the anaemiaCharacterize the anaemia Confirm type of anaemiaConfirm type of anaemia
Treat the anaemiaTreat the anaemia
Find the underlying causeFind the underlying cause Treat the causeTreat the cause