Anaemia Intermediate Cycle II HLTM

8/3/2019 Anaemia Intermediate Cycle II HLTM

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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

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Anaemia Intermediate Cycle II HLTM