Anaemia

This material is intended to support the didactic lecture series provided by The Department of Medicine for Intermediate Cycle II

Learning Objectives
 At the end of this lecture you should be able to describe:  Physiology of erythropoiesis  Anaemia  Definition  Clinical features  Investigations  Classification

Erythropoiesis

 25 billion erythrocytes /24 hours  The entering cells are reticulocytes which should be 1% of the total population of circulating erythrocytes.  Erythrocytes last 120 days and are destroyed by the spleen.  Red cell production should equal red cell destruction.

Factors necessary for erythropoiesis

1. 2. 3. 4. 5. 6. 7. Erythropoietin Iron Amino acids Vitamin B12 (cyanocobalamin) Folic Acid (folate) Ascorbic acid (Vitamin C) Pyridoxine (Vitamin B6)

Regulation of erythropoiesis
 Equal number of RBC produced to those lost through senescence  Decreased delivery of oxygen to the kidney drives Epo production, which stimulates RCC production in the marrow

Anaemia definition
NB. Definition: reduction in one or more of the major RBC measurements  Haemoglobin concentration (HGB) = the concentration of the major oxygen-carrying oxygenpigment in whole blood.  Haematocrit (HCT) = the percent of a sample of whole blood occupied by intact red blood cells  RBC count = the number of red blood cells contained in a specified volume of whole blood

Anaemia WHO criteria

 Blood HGB below normal range for age and sex

 Male  Female 13.0 ----17.5 g/dl ----17.5 12.0 ----16.0 g/dl ----16.0

Anaemia- Clinical Features

Signs and symptoms are dependent upon:

1. the degree of anaemia 2. the rate at which it has evolved 3. the oxygen demands of the patient
  decreased oxygen delivery, hypovolemia

Symptoms - Anaemia
6. Tinnitus 7. Headache 8. Dimness of

1. 2. 3. 4. 5.

Lassitude / Fatigue Breathlessness on exertion Palpitations Throbbing in head and ears Dizziness

vision 9. Insomnia 10. Paraesthesia e in fingers and toes 11. Angina

Signs - Anaemia
1.

2. 3. 4. 5.

Pallor of Skin, 1. mucous membranes, 2. Palmor creases 3. conjuctivae Tachycardia Cardiac dilatation- displaced apex beat dilatationSystolic Flow murmurs(due to dilatation of ventricle, murmurs(due leading to mitral and tricuspid regurgitation) Angular stomatits/atrophic glossitits in iron deficiency or B12 deficiency-related anaemias deficiency-

Clinical features of anaemia due to acute haemorrhage=features of hypovolemia!!!

1. 2. 3. 4. 5. 6.

easy fatigability muscle cramps postural dizziness lethargy syncope persistent hypotension

Anaemia classifications

 A kinetic approach  A morphologic approach

Anaemia - a kinetic approach

1.
1. 2. 3. 4.

Decreased RBC production

Lack of nutrients Bone marrow disorders Bone marrow suppression The anaemia of chronic disease/inflammation

2.
1. 2.

Increased RBC destruction

Inherited haemolytic anemias Acquired haemolytic anemias

3.

Blood loss

Anemia - morphologic approach

Size of red cells MCV Uniform size or differing RDW Isolated anaemia or abnormal wcc/plts also

Anaemia- MCV
1. 2. 3.

MACROCYTIC > 100 fl (Large red cells) NORMOCYTIC 80-100 fl (Normal size red 80cells) MICROCYTIC <80 fl (Small red cells)

Low MCV small RBC

Common Iron Deficiency NonNon-essential information 1. F - Thalassaemia 2. Anaemia of Chronic Disorder 3. Sideroblastic Anaemia

High MCV - macrocytic

Core Causes

B12 & Folate deficiency Alcohol Liver Disease Non-essential info Hypothyroidism Chemotherapy Haemolytic anaemia

Normal MCV - normocytic

1. 2. 3. 1. 2. 3. 4. Anaemia of Chronic Disorders Early Iron Deficiency Anaemia due to acute haemorrhage Combined Anaemia e.g. B12 deficency+ Fe deficiency Sideroblastic Anemia Aplastic Anemia Bone Marrow Infiltration

Additional Info

Systematic Approach to the evaluation of anemia

History 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, splenomegaly,

Case 1
 BD, female, 75  Tiredness for more than 6/12  Otherwise asymptomatic  PMHx: HE 34 years ago (myomas; menorrhagia) HTN, well corrected on tx Osteoporosis

Case 1
Patient Results Hb MCV MCH MCHC RDW WBC Platelets 7.9 g/dl 62fl 19.0 pg 30g/dl 19.2 5.3 x 109/l 550 x109/l 4.0 - 11.0 x 109/l 140 - 450 x 109/l Normal Range (Female) 11.7 - 16.0 g/dl 79 - 96 fl 27.0 32.0 pg 32.0 36.5 g/dl

Case 1

How to prove a lack of iron???

Iron deficiency anaemia Iron studies

    Ferritin Fe Transferin saturation TBIC low low low high

Causes of Iron Deficiency

Diet (vegetarians) Menorrhagia Pregnancy G.I.T. Bleed Growth Spurt Malabsorption

Treatment of Iron deficiency anaemia

 Iron replacement therapy  (p.o., eventually i.v. if refractory)  Treatment of underlying condition this is crucial, otherwise it will recur!!

Case 2
DD, female, 48 Newly diagnosed with seroseropositive RA Medication: NSAID

Case 2
Patient Results Hb MCV MCH MCHC WBC lympho Platelet s 9.8 g/dl 78fl 26.0pg 26.0pg 33 g/dl 9.2 x 109/l 0.7x 109/l 550 x109/l Normal Range (Male) 13.0 - 17.5 g/dl 79 - 96 fl 27.0 32.0 pg 32.0 36.5 g/dl 4.0 - 11.0 x 109/l 1.001.00-4.00 x 109/l 140 - 450 x 109/l

Case 2
      Ferritin 344 ng/dL high Fe 8 microg/mL low Transferin saturation 15% N TBIC 150microg/dL low ESR 68 mm/h high CRP 130 mg/L high

Anaemia of chronic disorders

Can be Normocytic-normochromic or microcyticNormocyticmicrocytichypochromic, Pathogenesis 1. Low iron absorption 2. inappropriate distribution of iron in body 

Anaemia of inflammation pathophysiology

ACD - therapy
 Treat the underlying disorder  Also can give erythropoietin supplementation to stimulate RCC production  EPO 30-60.000 units / week 30-

Conclusion: anaemia is not a final diagnosis

 Characterize the anaemia  Confirm type of anaemia  Treat the anaemia  Find the underlying cause  Treat the cause