0401 - Haematological Abnormalities in non-haematological conditions

Question 1

What is the typical anaemia of chronic disorders?

Answer 1

Normocytic and normochromic, or mildly hypochromic anaemia.

Question 2

What are some conditions associated with anaemia of chronic disorders?

Answer 2

Chronic infection - osteomyelitis, bacterial endocarditis, TB
Chronic inflammatory disorders - IBD, Rheumatoid Arthritis, Lupus
Malignancy - Carcinoma, myeloma, lymphoma
Others - AIDS, Congestive Heart Failure

Question 3

What is the cause of anaemia of chronic disease?

Answer 3

Disturbed erythropoiesis, whether due to dampened or reduced sensitivity to physiological stimuli, or reduced iron utilisation (NOT iron storage - ferritin is normal-high).

EPO is inappropriately low - The anaemia is a symptom of the systemic disease - you need to treat the disease to fix the anaemia.

Question 4

What are the haematological features of Anaemia of chronic disease (Hb, MCV, Serum Iron/total iron binding capacity, ferritin, transferrin sats, CRP)?

Answer 4

Hb - >90
MCV - Normal or mildly reduced
Serum Iron/Total iron binding - reduced
Serum Ferritin - Normal or increased
Transferrin Sats - Mildly reduced
CRP - Raised

Question 5

What is the association between chronic liver disease and anaemia, and why?

Answer 5

Liver disease causes greatest range of haematological change. 75% of chronic liver disease have anaemia.
All coag factors except vWF are liver synthesised, as well as AT-III, Proteins C/S, Heparin Cofactor II, and Plasminogen
Cholestasis causes malabsorption of vitamin K (for TV Coag Factors)
Reticuloendothelial cells in sinusoids clear the bloodstream of activated intermediates of coagulation and fibrinolysis.
As a result of all this, PT and APTT can reflect severity of liver failure.

Question 6

How can DIC manifest in liver disease?

Answer 6

Suspected with FVIII and fibrinogen levels fall. Remember, clotting factors and ATIII are formed in liver.
Damaged tissue triggers a burst of thrombin. Initially bound to ATIII, but this gets consumed, leading to extensive intravascular fibrin formation and end-organ vessel infarction.
As it progresses, coag factors, platelets, fibrinogen are used up, balance shifts to bleeding.
Fibrin depositing on endothelial cells stimulated tPA - fibrinolysis and subsequent reperfusion injuries.
Patient oozes blood from literally everywhere.

Question 7

What are two major haematological consequences of liver disease?

Answer 7

Anaemia

DIC

Question 8

What are three major haematological consequences of HIV disease?

Answer 8

Anaemia or Cytopaenia (marrow infection, imbalance of regulation, immune-mediated or iatrogenic)
Marrow failure and granulomas/serous atrophy.
HIV-associated lymphoma

Question 9

Briefly outline HIV-associated lymphoma

Answer 9

B-cell malignancy that occurs in 5-10% of HIV-antibody positive individuals. Associated with non-compliance or lack of therapy.
Major poor prognostic indicators - prior AIDS diagnosis, CD4

Question 10

What are some haematological consequences of malignancy?

Answer 10

Cells can all go up or down, or have functional changes depending on the cause
Anaemia/polycythaemia
White cells up or down and function
Platelets up or down and function
Coagulation disorders

Question 11

What are the two types of haemolytic anaemia associated with malignancy?

Answer 11

Autoimmune haemolytic anaemia (can be warm or cold)

Microangiopathic haemolytic anaemia (MAHA) - figure of disseminated carcinoma with marrow infiltration.