![Page 1: MED 341 Anemia Abdul kareem Al Momen, MD, FRCPC Professor of Medicine- Hematology King Saud University (Jan 26, 2014)](https://reader036.vdocuments.us/reader036/viewer/2022062407/56649e255503460f94b13a84/html5/thumbnails/1.jpg)
MED 341Anemia
Abdul kareem Al Momen, MD, FRCPCProfessor of Medicine- Hematology
King Saud University(Jan 26, 2014)
![Page 2: MED 341 Anemia Abdul kareem Al Momen, MD, FRCPC Professor of Medicine- Hematology King Saud University (Jan 26, 2014)](https://reader036.vdocuments.us/reader036/viewer/2022062407/56649e255503460f94b13a84/html5/thumbnails/2.jpg)
Definition
• Anemia is defined as reduction in the level of Hb/Hct (PCV) in relation to the normal level of tested healthy population at there own normal circumstances (Age, type of Hb, Oxygen tension).
![Page 3: MED 341 Anemia Abdul kareem Al Momen, MD, FRCPC Professor of Medicine- Hematology King Saud University (Jan 26, 2014)](https://reader036.vdocuments.us/reader036/viewer/2022062407/56649e255503460f94b13a84/html5/thumbnails/3.jpg)
Average normal Hb/Hct (PCV) level in various populations
Population Average Hb level g/l (Hct=(PCV %)
Comment
Fetus 200 (0.60)Newborn 180 (0.54)Child 110 (0.33)Adult: Male Female
160 (0.48)140 (0.42)
High altitude: ↑High affinity Hb ↑Low Affinity Hb ↓
![Page 4: MED 341 Anemia Abdul kareem Al Momen, MD, FRCPC Professor of Medicine- Hematology King Saud University (Jan 26, 2014)](https://reader036.vdocuments.us/reader036/viewer/2022062407/56649e255503460f94b13a84/html5/thumbnails/4.jpg)
Symptoms
![Page 5: MED 341 Anemia Abdul kareem Al Momen, MD, FRCPC Professor of Medicine- Hematology King Saud University (Jan 26, 2014)](https://reader036.vdocuments.us/reader036/viewer/2022062407/56649e255503460f94b13a84/html5/thumbnails/5.jpg)
Symptoms & signs• Symptoms: (non-specific) fatigue, weakness, ↓ exercise
tolerance, impaired memory, comprehension, appetite, Pica ( craving for non-food substances such as mud, sand, ice).
• Signs: Depend on severity: pallor (↓ circulation to skin), • Symptoms and signs vary greatly and correlate with
severity (severe ˃ mild) and onset/chronicity ( acute ˃ chronic)
• Adaptation to anemia: • ↑ Heart rate, • ↑ stroke volume, • ↑ 2,3 DPG (→↓ affinity)
![Page 6: MED 341 Anemia Abdul kareem Al Momen, MD, FRCPC Professor of Medicine- Hematology King Saud University (Jan 26, 2014)](https://reader036.vdocuments.us/reader036/viewer/2022062407/56649e255503460f94b13a84/html5/thumbnails/6.jpg)
Lack of energy
![Page 7: MED 341 Anemia Abdul kareem Al Momen, MD, FRCPC Professor of Medicine- Hematology King Saud University (Jan 26, 2014)](https://reader036.vdocuments.us/reader036/viewer/2022062407/56649e255503460f94b13a84/html5/thumbnails/7.jpg)
Pallor
![Page 8: MED 341 Anemia Abdul kareem Al Momen, MD, FRCPC Professor of Medicine- Hematology King Saud University (Jan 26, 2014)](https://reader036.vdocuments.us/reader036/viewer/2022062407/56649e255503460f94b13a84/html5/thumbnails/8.jpg)
Koilonychia, Papillary atrophy, erythema and angular stomatitis
![Page 9: MED 341 Anemia Abdul kareem Al Momen, MD, FRCPC Professor of Medicine- Hematology King Saud University (Jan 26, 2014)](https://reader036.vdocuments.us/reader036/viewer/2022062407/56649e255503460f94b13a84/html5/thumbnails/9.jpg)
Classification
• Congenital/ hereditary Or Acquired
• Morphological : MCV (Microcytic, normocytic, macrocytic) , RDW (↑)
• Etiological: Blood loss, Nutritional deficiencies, Hemolysis (RBC Destruction), Erythropoietin deficiency, Chronic inflammation, ( Infection, Malignancy, Connective tissue disease).
![Page 10: MED 341 Anemia Abdul kareem Al Momen, MD, FRCPC Professor of Medicine- Hematology King Saud University (Jan 26, 2014)](https://reader036.vdocuments.us/reader036/viewer/2022062407/56649e255503460f94b13a84/html5/thumbnails/10.jpg)
Morphological Classification of Anemia
• Low MCV (< 84 fl): IDA, Thalassemia traits, some cases of chronic illnesses, lead poisoning
• High MCV (> 96 fl): Megaloblastic (Folate & B12 defeciency), Aplastic anemia, Myelodysplastic syndrome, Cytotoxic drugs ( e.g. hydroxyurea)
• Normal MCV (84-94 fl): Acute blood loss, Erythropoietin deficiency, some cases of chronic illnesses
![Page 11: MED 341 Anemia Abdul kareem Al Momen, MD, FRCPC Professor of Medicine- Hematology King Saud University (Jan 26, 2014)](https://reader036.vdocuments.us/reader036/viewer/2022062407/56649e255503460f94b13a84/html5/thumbnails/11.jpg)
Normocytic anemia
![Page 12: MED 341 Anemia Abdul kareem Al Momen, MD, FRCPC Professor of Medicine- Hematology King Saud University (Jan 26, 2014)](https://reader036.vdocuments.us/reader036/viewer/2022062407/56649e255503460f94b13a84/html5/thumbnails/12.jpg)
Normal red cell morphology
![Page 13: MED 341 Anemia Abdul kareem Al Momen, MD, FRCPC Professor of Medicine- Hematology King Saud University (Jan 26, 2014)](https://reader036.vdocuments.us/reader036/viewer/2022062407/56649e255503460f94b13a84/html5/thumbnails/13.jpg)
Microcytic anemia
![Page 14: MED 341 Anemia Abdul kareem Al Momen, MD, FRCPC Professor of Medicine- Hematology King Saud University (Jan 26, 2014)](https://reader036.vdocuments.us/reader036/viewer/2022062407/56649e255503460f94b13a84/html5/thumbnails/14.jpg)
Macrocytic anemia
![Page 15: MED 341 Anemia Abdul kareem Al Momen, MD, FRCPC Professor of Medicine- Hematology King Saud University (Jan 26, 2014)](https://reader036.vdocuments.us/reader036/viewer/2022062407/56649e255503460f94b13a84/html5/thumbnails/15.jpg)
Hereditary Anemia
• 1- Hemoglobinopathies: a- Sickle cell anemia (homozygous) due to replacement of glutamic acid at position 6 in the beta chain → change of Hb character when Oxygen tension is low →↓ solubility, crystallization, fiber formation, cell rigidity, Obstruction of microcirculation, hemolysis, painful crises, thrombosis.
![Page 16: MED 341 Anemia Abdul kareem Al Momen, MD, FRCPC Professor of Medicine- Hematology King Saud University (Jan 26, 2014)](https://reader036.vdocuments.us/reader036/viewer/2022062407/56649e255503460f94b13a84/html5/thumbnails/16.jpg)
a-sickle cell anemia
• Painful episodes are precipitated by ↓ Oxygen tension in circulation ( high altitude, basements, use of charcoal in heating, pulmonary diseases, cardiac diseases)
• ↑ viscosity (↑ Hb, WBC, Platelets, dehydration, infection, )
• Unknown causes
![Page 17: MED 341 Anemia Abdul kareem Al Momen, MD, FRCPC Professor of Medicine- Hematology King Saud University (Jan 26, 2014)](https://reader036.vdocuments.us/reader036/viewer/2022062407/56649e255503460f94b13a84/html5/thumbnails/17.jpg)
a-sickle cell anemia
![Page 18: MED 341 Anemia Abdul kareem Al Momen, MD, FRCPC Professor of Medicine- Hematology King Saud University (Jan 26, 2014)](https://reader036.vdocuments.us/reader036/viewer/2022062407/56649e255503460f94b13a84/html5/thumbnails/18.jpg)
a-sickle cell anemia
![Page 19: MED 341 Anemia Abdul kareem Al Momen, MD, FRCPC Professor of Medicine- Hematology King Saud University (Jan 26, 2014)](https://reader036.vdocuments.us/reader036/viewer/2022062407/56649e255503460f94b13a84/html5/thumbnails/19.jpg)
a-sickle cell anemia
• Prevention of disease: premarital testing, contraception, fetal selection (IVF)
• Prevention of painful episodes: daily hydroxyurea, avoidance of hypoxia, dehydration, infection.
• Management of painful crises; Hydration, pain killers, (Rarely transfusion)
![Page 20: MED 341 Anemia Abdul kareem Al Momen, MD, FRCPC Professor of Medicine- Hematology King Saud University (Jan 26, 2014)](https://reader036.vdocuments.us/reader036/viewer/2022062407/56649e255503460f94b13a84/html5/thumbnails/20.jpg)
a-sickle cell anemia
• Other complications of Sickle cell anemia; Hemolytic crises ( severe episodes), Splenic sequestration ( medical emergency), aplastic crisis (parvovirus B19 infection), Priapism (continuous, painful erection), stroke (cerebral infarction)
• Treat accordingly
![Page 21: MED 341 Anemia Abdul kareem Al Momen, MD, FRCPC Professor of Medicine- Hematology King Saud University (Jan 26, 2014)](https://reader036.vdocuments.us/reader036/viewer/2022062407/56649e255503460f94b13a84/html5/thumbnails/21.jpg)
b-Thalassemia
• Alpha thalassemia• - aaa = alpha thalassemia trait type 2 (silent),• --aa = alpha thalassemia trait type 1(↓ MCV),• ---A = Hb H disease• ---- = Hydropes fetalis (incompatible with life)
![Page 22: MED 341 Anemia Abdul kareem Al Momen, MD, FRCPC Professor of Medicine- Hematology King Saud University (Jan 26, 2014)](https://reader036.vdocuments.us/reader036/viewer/2022062407/56649e255503460f94b13a84/html5/thumbnails/22.jpg)
b-Thalassemia
![Page 23: MED 341 Anemia Abdul kareem Al Momen, MD, FRCPC Professor of Medicine- Hematology King Saud University (Jan 26, 2014)](https://reader036.vdocuments.us/reader036/viewer/2022062407/56649e255503460f94b13a84/html5/thumbnails/23.jpg)
b-Thalassemia
• Beta thallassemia:• -b = thalassemia trait (↓ MCV),• -- = (Homozygous) thalassemia major: severe
anemia with severe intramedullary hemolysis, bone marrow expansion, hepato-splenomegally, growth and sexual retardation,
![Page 24: MED 341 Anemia Abdul kareem Al Momen, MD, FRCPC Professor of Medicine- Hematology King Saud University (Jan 26, 2014)](https://reader036.vdocuments.us/reader036/viewer/2022062407/56649e255503460f94b13a84/html5/thumbnails/24.jpg)
b-Thalassemia
• Prevention: premarital screening, early abortion (in some countries).
• Treatment: regular blood transfusion ( Q 2-4 weeks),
• Splenectomy ( after vaccination) at 6 years of age ( to reduce transfusion requirements),
• Iron chelation.• Stem cell transplantation ( in some cases)
![Page 25: MED 341 Anemia Abdul kareem Al Momen, MD, FRCPC Professor of Medicine- Hematology King Saud University (Jan 26, 2014)](https://reader036.vdocuments.us/reader036/viewer/2022062407/56649e255503460f94b13a84/html5/thumbnails/25.jpg)
c-enzymopathies
• G6PD deficiency (x-linked)→↓ production of the antioxidant glutathione, → Hemolysis due oxygen free radicals that can be produced by certain foods and drugs e.g. fava beans.
• Prevention: avoidance of oxidative foods & drugs
![Page 26: MED 341 Anemia Abdul kareem Al Momen, MD, FRCPC Professor of Medicine- Hematology King Saud University (Jan 26, 2014)](https://reader036.vdocuments.us/reader036/viewer/2022062407/56649e255503460f94b13a84/html5/thumbnails/26.jpg)
d-membrane defects
• Hereditary spherocytosis: → ↓ RBC survival, hemolysis, reticulocytosis, splenomegaly, jaundice, gall stones.
• Treatment: Splenectomy
![Page 27: MED 341 Anemia Abdul kareem Al Momen, MD, FRCPC Professor of Medicine- Hematology King Saud University (Jan 26, 2014)](https://reader036.vdocuments.us/reader036/viewer/2022062407/56649e255503460f94b13a84/html5/thumbnails/27.jpg)
Nutritional Anemia
• a- Iron deficiency anemia (IDA; the commonest acquired anemia)
• Causes: Blood loss, impaired iron absorption (↓ pH ), Increased requirement (growth, pregnancy, EPO therapy).
• Functional IDA (Suppression of erythropoiesis due to inflammation), Erythropoietin deficiency
![Page 28: MED 341 Anemia Abdul kareem Al Momen, MD, FRCPC Professor of Medicine- Hematology King Saud University (Jan 26, 2014)](https://reader036.vdocuments.us/reader036/viewer/2022062407/56649e255503460f94b13a84/html5/thumbnails/28.jpg)
a- Iron deficiency anemia
• Treatment: Ferrous sulphate/ gluconate/ fumerate, or iron polymaltose orally,
• Intravenous iron succharate or iron dextran (only when oral iron is intolerable, unabsorpable, or ineffective)
• Liver ( good for iron & B12 deficiency)
![Page 29: MED 341 Anemia Abdul kareem Al Momen, MD, FRCPC Professor of Medicine- Hematology King Saud University (Jan 26, 2014)](https://reader036.vdocuments.us/reader036/viewer/2022062407/56649e255503460f94b13a84/html5/thumbnails/29.jpg)
b-megaloblastic anemia
• i-Folate deficiency: MTHFR mutation→ hyperhomocysteinemia due to defective folate metabolism, Eating only cooked food, lack of vegetables and fruits, Hemolytic anemia anti-folate drugs (e.g. methotrexate),
• Treatment: folate supplement
![Page 30: MED 341 Anemia Abdul kareem Al Momen, MD, FRCPC Professor of Medicine- Hematology King Saud University (Jan 26, 2014)](https://reader036.vdocuments.us/reader036/viewer/2022062407/56649e255503460f94b13a84/html5/thumbnails/30.jpg)
b-megaloblastic anemia• Ii-Vitamin B12/Cobalamin deficiency:
vegetarian diet, Gastric, pancreatic or terminal elium resection, lack of gastric acidity, lack of intrinsic factor, intestinal bacterial overgrowth, fish worm (Diphyllobothrium latum), Crohn’s diseases, metformin
![Page 31: MED 341 Anemia Abdul kareem Al Momen, MD, FRCPC Professor of Medicine- Hematology King Saud University (Jan 26, 2014)](https://reader036.vdocuments.us/reader036/viewer/2022062407/56649e255503460f94b13a84/html5/thumbnails/31.jpg)
Role of MTHFR
![Page 32: MED 341 Anemia Abdul kareem Al Momen, MD, FRCPC Professor of Medicine- Hematology King Saud University (Jan 26, 2014)](https://reader036.vdocuments.us/reader036/viewer/2022062407/56649e255503460f94b13a84/html5/thumbnails/32.jpg)
MTHFR mutation
![Page 33: MED 341 Anemia Abdul kareem Al Momen, MD, FRCPC Professor of Medicine- Hematology King Saud University (Jan 26, 2014)](https://reader036.vdocuments.us/reader036/viewer/2022062407/56649e255503460f94b13a84/html5/thumbnails/33.jpg)
Cobalamin/B12 absorption
![Page 34: MED 341 Anemia Abdul kareem Al Momen, MD, FRCPC Professor of Medicine- Hematology King Saud University (Jan 26, 2014)](https://reader036.vdocuments.us/reader036/viewer/2022062407/56649e255503460f94b13a84/html5/thumbnails/34.jpg)
Hemolytic anemia
• i-Autoimmune: IgG (Warm): -1ry, -2ry: autoimmune diseases, lymphoid malignancies, drug-induced
• ii-Autoimmune: IgM (cold),• Iii-Non-immune: RBC abnormalities (Sickle,
thalassema, spherocytosis, enzyme deficiency,• MAHA
![Page 35: MED 341 Anemia Abdul kareem Al Momen, MD, FRCPC Professor of Medicine- Hematology King Saud University (Jan 26, 2014)](https://reader036.vdocuments.us/reader036/viewer/2022062407/56649e255503460f94b13a84/html5/thumbnails/35.jpg)
Hemolytic anemia
• Treatment of 1ry warm, autoimmune hemolytic anemia ; steroids, IgG, Rituximab (anti-CD 20), splenectomy
• 2ry: treatment of underlying disease
![Page 36: MED 341 Anemia Abdul kareem Al Momen, MD, FRCPC Professor of Medicine- Hematology King Saud University (Jan 26, 2014)](https://reader036.vdocuments.us/reader036/viewer/2022062407/56649e255503460f94b13a84/html5/thumbnails/36.jpg)
Anemia of Chronic Illnesses
• Functional iron deficiency+ Erythropoietic inhibitors
• Infection,• Connective tissue/autoimmune diseases• Malignancies • Treatment: Transfusion,
Treat underlying illnesses, mega doses of erythropoietic stimulants
![Page 37: MED 341 Anemia Abdul kareem Al Momen, MD, FRCPC Professor of Medicine- Hematology King Saud University (Jan 26, 2014)](https://reader036.vdocuments.us/reader036/viewer/2022062407/56649e255503460f94b13a84/html5/thumbnails/37.jpg)
Summery
![Page 38: MED 341 Anemia Abdul kareem Al Momen, MD, FRCPC Professor of Medicine- Hematology King Saud University (Jan 26, 2014)](https://reader036.vdocuments.us/reader036/viewer/2022062407/56649e255503460f94b13a84/html5/thumbnails/38.jpg)
Diagnosis
• Gender, Age, Nutrition (meats, vegetables), blood loss, illnesses, drugs (ASA, Anticoagulants, Anti-inflammatory)
• Physical examination,• Laboratory investigations, CBC, ESR,
Reticulocytes, Blood film, Serum Fe , TIBC (transferrin), Ferritin, Creatinine, Folate level (serum + RBC), B12, Hb electrophoresis,
• Diagnosis of underlying illnesses ; Autoimmune, infection, cancer, etc.
![Page 39: MED 341 Anemia Abdul kareem Al Momen, MD, FRCPC Professor of Medicine- Hematology King Saud University (Jan 26, 2014)](https://reader036.vdocuments.us/reader036/viewer/2022062407/56649e255503460f94b13a84/html5/thumbnails/39.jpg)
Treatment of Anemia
• Improve nutrition,
• Prevent blood loss,
• Treat underlying illnesses,
• Specific therapy:
( Iron, folic acid, vitamin B12, Erythropoietin)
![Page 40: MED 341 Anemia Abdul kareem Al Momen, MD, FRCPC Professor of Medicine- Hematology King Saud University (Jan 26, 2014)](https://reader036.vdocuments.us/reader036/viewer/2022062407/56649e255503460f94b13a84/html5/thumbnails/40.jpg)
Iron therapy
• Hem iron• Non-hem iron• Oral iron (Ferrous sulphate, gluconate, fumerate ), Iron
polymaltose,• Absorption enhancers & inhibitors,• Parenteral iron therapy (indications, iron saccharate, iron
dextran)• Response/ Complications
![Page 41: MED 341 Anemia Abdul kareem Al Momen, MD, FRCPC Professor of Medicine- Hematology King Saud University (Jan 26, 2014)](https://reader036.vdocuments.us/reader036/viewer/2022062407/56649e255503460f94b13a84/html5/thumbnails/41.jpg)
Folate , B12 & Epo
• Folate treatment,• Folate supplement,• Polyglutamate/monoglutamate• B12 (IM)• Erythropoietin (Epo): • a-Chronic renal failure (hemodialysis), b-Anemia
of cancer, AIDS, chronic illnesses
![Page 42: MED 341 Anemia Abdul kareem Al Momen, MD, FRCPC Professor of Medicine- Hematology King Saud University (Jan 26, 2014)](https://reader036.vdocuments.us/reader036/viewer/2022062407/56649e255503460f94b13a84/html5/thumbnails/42.jpg)
Treatment failures
• Occult continuous blood loss• Occult deficiencies,• Erythropoietic inhibitors
![Page 43: MED 341 Anemia Abdul kareem Al Momen, MD, FRCPC Professor of Medicine- Hematology King Saud University (Jan 26, 2014)](https://reader036.vdocuments.us/reader036/viewer/2022062407/56649e255503460f94b13a84/html5/thumbnails/43.jpg)