Clinical laboratory Clinical laboratory diagnostics of diagnostics of

anemiasanemias

•

AnemiaAnemia - -is the decreasing of hemoglobin and red blood is the decreasing of hemoglobin and red blood

cells level in the unit of blood volume cells level in the unit of blood volume Reduction in one or more of the major red blood Reduction in one or more of the major red blood

cell (RBC) measurements:cell (RBC) measurements: Hemoglobin concentration Hemoglobin concentration

Hematocrit Hematocrit RBC count RBC count

From data of WHO:From data of WHO:a hematocrit less than 40 in men and 37 in a hematocrit less than 40 in men and 37 in

women, or hemoglobin women, or hemoglobin less thanless than 130 g/l in men 130 g/l in men and and less thanless than 120 g/l in women. 120 g/l in women.

Anemia SymptomsAnemia Symptoms Because a low red blood cell count Because a low red blood cell count

decreases oxygen delivery to every tissue decreases oxygen delivery to every tissue in the body, anemia may cause a variety in the body, anemia may cause a variety of signs and symptoms. It can also make of signs and symptoms. It can also make almost any other underlying medical almost any other underlying medical condition worse. If anemia is mild, it may condition worse. If anemia is mild, it may not cause any symptoms. If anemia is not cause any symptoms. If anemia is slowly ongoing (chronic), the body may slowly ongoing (chronic), the body may adapt and compensate for the change; in adapt and compensate for the change; in this case there may not be any symptoms this case there may not be any symptoms until the anemia becomes more severe.until the anemia becomes more severe.

Symptoms of anemia may include the Symptoms of anemia may include the following:following:• FatigueFatigue• Chest painChest pain• Abdominal painAbdominal pain• Weight lossWeight loss• WeaknessWeakness• Dizziness and passing out, especially Dizziness and passing out, especially

upon standingupon standing

Signs and symptomsSigns and symptoms

Anemia SymptomsAnemia Symptoms FatigueFatigue decreased energydecreased energy weakness weakness lightheadedness lightheadedness palpitations (feeling of the heart (feeling of the heart

racing or beating irregularly) racing or beating irregularly) looking palelooking pale

Symptoms of severe anemia may Symptoms of severe anemia may include:include:

chest pain, , angina, or heart attack , or heart attack dizziness dizziness fainting or passing out fainting or passing out rapid heart rate rapid heart rate

Depending on the level of hemoglobin in the blood anemia is divided on:

- mild degree (Hb 110-90 g/l),- moderate degree (Hb 89-70 g/l), - severe degree (Hb less than 69 g/l).Depending on the size of RBC and their

saturation by hemoglobin (from data of colour index - CI) anemia is divided on:

- Normocytic anemia (can be normochromic anemia: colour of RBC is normal and CI is 0,86-1,1);

- Microcytic anemia (can be hypo- or normochromic): microcytosis , anizopoykilocytosis, hypochromia, CI < 0,7;

- Macrocytic anemia: macrocytosis, megalocytosis, CI > 1,1.

Approaches to AnemiaApproaches to Anemia

Kinetic approachKinetic approach Decreased RBC Decreased RBC

productionproduction Increased RBC Increased RBC

destructiondestruction Blood lossBlood loss

Morphologic Morphologic approachapproach

MacrocyticMacrocytic NormocyticNormocytic MicrocyticMicrocytic

Decreased RBC ProductionDecreased RBC Production

Nutrient deficiencyNutrient deficiency

Dietary, malabsorptionDietary, malabsorption Bone marrow disorders/suppressionBone marrow disorders/suppression

Anemia of chronic diseasesAnemia of chronic diseases

Low levels of trophic hormones Low levels of trophic hormones

Epo, thyroid hormone, androgensEpo, thyroid hormone, androgens

Blood LossBlood Loss

Most common cause of anemiaMost common cause of anemia Fe deficiency almost always due to Fe deficiency almost always due to

blood lossblood loss Obvious bleedingObvious bleeding Occult bleedingOccult bleeding Induced bleedingInduced bleeding Operative blood lossOperative blood loss

Normocytic anemia (MCV - 80-100)•A loss or destruction of RBC is increased-Acute bleeding-Early iron deficiency- Hemolytic anemia- Hypersplenism•Decreasing of RBC synthesis-Anemia of chronic diseases (most commonly)-Endocrine dysfunctions-Renal insufficiency•Pathology of bone marrow (for example, action of medications, infection, aplastic anemia, myelodysplastic syndrome, multiple myeloma and other infiltrative diseases).

Anemia of Chronic DiseaseAnemia of Chronic Disease

••CommonCommon • • Develops over 1 to 2 monthsDevelops over 1 to 2 months • • Non-progressive Non-progressive • • Usually mild to moderateUsually mild to moderate – – but hematocrit < 0.20 occasionallybut hematocrit < 0.20 occasionally • • 30% mildly microcytic30% mildly microcytic • • WBC, platelets normal or increasedWBC, platelets normal or increased

Hemolytic AnemiaHemolytic Anemia

• • Anemia of increased destructionAnemia of increased destruction normochromic anemianormochromic anemia – – Shortened RBC survivalShortened RBC survival – – Reticulocytosis - Response to increased Reticulocytosis - Response to increased

RBC RBC DestructionDestruction

Hemolytic AnemiaHemolytic Anemia

Coombs’ (DAT)

Positive Negative

Immune HemolysisDrug related HemolysisTransfusion, Infection, Cancer

Hemoglobinopathy, G6PD, PK, Spherocytosis, Eliptocytosis, PNH, TTP, DIC

Equired hemolytic anemia Reticulocytosis

Equired hemolytic anemia Reticulocytosis

Hereditary disordersHereditary disorders

include erythrocyte membrane and enzymatic defects and hemoglobin abnormalities. Some hereditary disorders include the following:G6PD deficiencyHerediditary spherocytosisSickle cell anemiaThalassemia

Acquired hemolytic Acquired hemolytic conditionsconditions

can be due to immune disorders, toxic chemicals and drugs, antiviral agents (eg, ribavirin) physical damage, and infections

Autoimmune hemolytic anemia (AIHA) may result from warm or cold autoantibody types; rarely, mixed types occur. Most warm autoantibodies are immunoglobulin (Ig) G and can be detected with the direct Coombs test, which is also known as the direct antiglobulin test (DAT)

Acquired hemolytic Acquired hemolytic conditionsconditions

•Autoimmune hemolytic anemia and hereditary spherocytosis are classified as examples of extravascular hemolysis because the red blood cells are destroyed in the spleen and other reticuloendothelial organs.•Intravascular hemolysis occurs in hemolytic anemia due to prosthetic cardiac valves, G6PD deficiency, thrombotic thrombocytopenic purpura, disseminated intravascular coagulation, and paroxysmal nocturnal hemoglobinuria (PNH).

Peripheral blood smear with sickled cells

Spherocytes. One arrow points to a Spherocytes. One arrow points to a spherocyte; the other, to a normal RBC spherocyte; the other, to a normal RBC

with a central pallor.with a central pallor.

Hemolytic anemia due to pyruvate kinase insefficiency.

Reticulocytosis

Membranopathy Hereditary microspherocytosis -

blood

Membranopathy Hereditary eliptocytosis – blood

- Usually hypochromic as wellIron-deficiency anemia Anemia of chronic diseases(rare) Sideroblastosis Hereditary anemia (thalassemia) Lead poisoning Deficit of copper, poisoning by zinc

Microcytic anemia Microcytic anemia (MCV less than 80) (MCV less than 80)

Iron AbsorptionIron Absorption

• • Stomach acid converts ferric (insoluble) to Stomach acid converts ferric (insoluble) to ferrous (absorbable) stateferrous (absorbable) state Decreased absorption w/ acid blockersDecreased absorption w/ acid blockers Increased w/ citrate & ascorbateIncreased w/ citrate & ascorbate(chelators)(chelators) Increased absorption w/ orange juiceIncreased absorption w/ orange juice Decreased w/ plant phytates, tannins, soil Decreased w/ plant phytates, tannins, soil clay, & laundry starchclay, & laundry starch – – Pica may exacerbate Fe deficiencyPica may exacerbate Fe deficiency

Iron DeficiencyIron DeficiencyCausesCauses

– – Blood lossBlood loss • • GI tractGI tract • • Renal (rare)Renal (rare) • • Pulmonary (rare)Pulmonary (rare) – – Insufficient dietary ironInsufficient dietary iron Decreased absorptionDecreased absorption

Consequences of Iron Consequences of Iron DeficiencyDeficiency

HematologicHematologic • • Microcytic, hypochromic anemicMicrocytic, hypochromic anemic • • Low grade hemolysis d/t stiff RBC Low grade hemolysis d/t stiff RBC

membranemembrane • • Thrombocytosis w/ plts 500-700kThrombocytosis w/ plts 500-700k – – Erythropoietin may cross react w/ Erythropoietin may cross react w/

pltplt PrecursorsPrecursors

Makrocytic anemia (MCV more than 100 fl)

- Megaloblastic anemia (vitamin В12 or folic acid deficiency )- Toxic effect of chemotherapeutic agents (methotrexate) or other medications (zidovudine (AZT), phenytoin)- Pathology of bone marrow- Chronic abuse by alcohol (toxic effect)- Liver disease

Macrocytosis (MCV > 100 fl)Macrocytosis (MCV > 100 fl) ••CommonCommon – – Drugs (cytotoxics, immunosuppressants, AZT, Drugs (cytotoxics, immunosuppressants, AZT,

anticonvulsants)anticonvulsants) – – AlcoholAlcohol – – Liver diseaseLiver disease – – ReticulocytosisReticulocytosis ––B12/folate deficiencyB12/folate deficiency – – Myelodysplastic syndromeMyelodysplastic syndrome – – Marrow infiltration (malignancy, fibrosis)Marrow infiltration (malignancy, fibrosis) • • Less commonLess common ––AplasiaAplasia – – Cold agglutininsCold agglutinins – – HyperglycemiaHyperglycemia – – HyperleukocytosisHyperleukocytosis

Megaloblastic HematopoiesisMegaloblastic Hematopoiesis

• • Marrow failure due to: disrupted DNA synthesis Marrow failure due to: disrupted DNA synthesis

& ineffective hematopoiesis& ineffective hematopoiesis • • Giant precursors and nuclear:cytoplasmic Giant precursors and nuclear:cytoplasmic

dyssynchrony in marrow dyssynchrony in marrow • • Neutrophil hypersegmentation & macroovalocytesNeutrophil hypersegmentation & macroovalocytes

in bloodin blood • • Anemia (and often leukopenia & Anemia (and often leukopenia &

thrombocytopenia)thrombocytopenia) • • Almost always due to Cbl or folate deficiencyAlmost always due to Cbl or folate deficiency

Megaloblastic AnemiaMegaloblastic Anemia

SmearSmear Macro-ovalocyticMacro-ovalocytic PolychromasiaPolychromasia Hypersegmented Hypersegmented

neutrophilneutrophil

The only way to diagnose anemia is with a The only way to diagnose anemia is with a blood blood testtest. Generally, a . Generally, a full blood countfull blood count is done. Apart is done. Apart from reporting the amount of from reporting the amount of red blood cellsred blood cells and the and the hemoglobinhemoglobin level, the automatic counters also level, the automatic counters also measure the size of the red blood cells, which is an measure the size of the red blood cells, which is an important tool in distinguishing between the causes.important tool in distinguishing between the causes.

Occasionally, other tests are required to further Occasionally, other tests are required to further distinguish the cause for anemia. These are discussed distinguish the cause for anemia. These are discussed with the differential diagnosis. The doctor may also with the differential diagnosis. The doctor may also decide to take some other screening blood tests that decide to take some other screening blood tests that might identify the cause of fatigue; might identify the cause of fatigue; glucose glucose levelslevels, , ESR, ferritin, renal function ESR, ferritin, renal function tests andtests and electrolytes electrolytes may be part of such a workup.may be part of such a workup.

DiagnosisDiagnosis

Lab tests for anemia may include the following:

1. Complete blood count - Determines the severity of the anemia and is almost always the first test ordered

2. Stool guaiac - Tests for blood in stool3. Peripheral blood smear - Looks at the red blood cells

under a microscope4. Iron level - Low iron is one of the most common causes

of anemia5. Transferrin level - Looks at a protein that carries iron

around the body6. Ferritin - Looks at the total iron available in the body7. Folate - A vitamin needed to produce red blood cells,

which is low in people with poor eating habits

Thank for your Thank for your attention!attention!