Anemia

Question 1

Conditions that can suppress RBC production

Answer 1

-Renal insufficiency
-Cancer
-Myelodysplasia
-Chronic inflammatory disease

Question 2

WHO Definition of Anemia

Answer 2

• Hemoglobin level <13 g/dL (males)
• Hemoglobin level <12 g/dL (females

Question 3

Anemia can be a result of a number of conditions

Answer 3

-Nutritional deficiencies
-Systemic disease
-Bone marrow disease
-Underlying immunologic disorder
-Or when there is something intrinsically wrong with the RBC itself

Question 4

Normal Erythropoiesis

Answer 4

-Circulating erythrocyte has an average life span of 110-120 days
-More than 90% of the protein content is the oxygen-carrying molecule hemoglobin
-Hemoglobin is made up by four protein molecules or globulin chains that are connected together.
-The normal adult hemoglobin (Hbg) molecule contains two alpha-globulin chains and two beta-globulin chains.
-The globin chains are held together by HEME molecules
-Embedded in the HEME molecule is iron; which gives red blood cell it’s RED COLOR

Question 5

The most important role of the red blood cell is to

Answer 5

-TRANSPORT OXYGEN FROM THE LUNGS
-To the tissues throughout the body

Question 6

Erythrocyte maturation

Answer 6

-RBCs are derived from bone marrow where it undergoes 4 different maturation stages until is develops into a reticulocyte (process takes 2-3 days)
-Late maturation stage of the reticulocyte takes place in peripheral blood where it becomes an erythrocyte

Question 7

Increased Reticulocyte counts

Answer 7

An increased reticulocyte count (or reticulocytosis) is a reflection of the body’s attempt at trying to maintain homeostasis when there is decreased RBC production or shortened life span.

Question 8

Erythroid specific growth factor-erythropoietin
(EPO)

Answer 8

-Sensed by the juxtaglomerular apparatus of the kidney
-EPO is the primary regulatory hormone for erythropoiesis
-Under normal conditions, RBC mass is nearly constant because of the EPO feedback loop
-When the kidney senses hypoxia, it releases the hormone ERYTHROPOIETIN
-Erythropoietin is the chemical messenger that tells the BONE MAROW to produce more red cells BECAUSE THE BODY IS STARVING FOR OXYGEN

Question 9

Presenting Symptoms

Answer 9

-Fatigue, weakness, pallor, dizziness
-Dyspnea, tachypnea, O2 desaturation
-Tachycardia, palpitations, hypotension, arrhythmias, chest pain

Question 10

Physical Exam

Answer 10

-Pallor (usually occurs with hgb <8)
-Confusion, paresthesia
-Tachycardia/Tachypnea
-Systolic murmur
-splenomegaly (hemolysis)
-Orthostatic hypotension
-signs/symptoms of CHF
-Jaundice (hemolysis)

Question 11

Anemia-Probable etiology

Answer 11

-Poor production of RBC
-Increased RBC destruction
-Blood loss

Question 12

Poor RBC production

Answer 12

-Nutritional deficits-Folate, iron, B-12
-Bone marrow disorder
-Bone marrow suppression
-Low levels of hormones needed to
stimulate RBC production (EPO, thyroid hormone, androgens)
-Chronic disease/inflammation associated with malignant, infectious, inflammatory disorders

Question 13

Increased RBC destruction

Answer 13

-Hemolysis
-RBC lifespan is shortened <100 days.

Question 14

Blood loss-chronic

Answer 14

-Bleeding—loss of RBCs—depletion of iron stores—anemia
Usually occurs with blood loss of:
> 1200 ml for males
> 600 ml for females

Question 15

Anemia-The Cause

Answer 15

-Classified based upon erythrocyte morphology
-Size, shape, color, inclusions
-CBC, Peripheral blood smear-Morphology, Retic count-bone marrow integrity

Question 16

Retic Count

Answer 16

Retic count (0.5%-1.5%) shows to be elevated in hemolytic anemia hemorrhage, and Chronic renal failure; decreased in AA, marrow suppression,

Question 17

CBC

Answer 17

-Hgb-concentration
-HCT-Packed red cell volume-crucial for certain procedures
-RDW-RBC distribution width-measures the RBC size
-MCV (mean corpuscular volume)-average volume of an erythrocyte
-MCH (Mean corpuscular hemoglobin)-average weight (content) of hgb in an average erythrocyte
-MCHC (Mean corpuscular hemoglobin concentration)- (the average concentration of hemoglobin per unit volume of erythrocytes)

Question 18

Normal values of CBC

Answer 18

-Hgb: Males (12.7-17), Female (11.6-15.6)
-RBC (x 10^12/L): Males (4.0-5.6); Females (3.8-5.2)
-MCV (x 10^12/L): Males (81.2-101.4), Females (81.1-99.8)
-RBC distribution width %: Male (11.8-15.6), Females (11.9-15.5)
-Platelets (x10^9/L): Males (143-332), Female (169-358)
-WBC (x10^9/L); Males (3.6-9.2), Females (3.5-10.8)

Question 19

Decreased Retic Count

Answer 19

-Bone marrow disease
-B-12 deficiency
-Folate deficiency
-Iron deficiency

Question 20

Increased Retic Count

Answer 20

-Blood loss
-Hemolytic anemia
-Post-anemia Tx-response

Question 21

High MCV

Answer 21

-Macrocytic anemia

Question 22

MCV Normal

Answer 22

Normocytic Anemia

Question 23

MCV Low

Answer 23

-Microcytic anemia

Question 24

Microcytic Anemia

Answer 24

-Iron deficiency
-Thalassemia
-Anemia of chronic disease
-Siderblastic anemia

Question 25

Iron Deficiency Anemia

Answer 25

-Driven by lack of dietary intake, poor absorption by the jejunum, blood loss, blood loss-reproductive women -10-20 mg/ day of iron to maintain iron demand and iron absorption -Hgb (low), MCV (low), RDW (high). -Hypochromic, microcytic pattern on peripheral smear -Serum ferritin low -Total iron-binding capacity (TIBC)-high -Serum Iron-low -Chronic blood loss is one of the most common causes of IDA -always rule out GI bleeding

Question 26

Serum Ferritin

Answer 26

-Low ferritin is most helpful in distinguishing IDA-no need to check iron studies

Question 27

Clinical Features of IDA

Answer 27

-Angular cheilosis or stomatitis -Koilonychia-spoon shaped nails -Atrophic tongue-glottitis

Question 28

Treatment: Iron Supplementation

Answer 28

-Elemental iron 2-3 mg/kg daily (divided in 3 doses) -Slow-release tablets, 50-100 mg elemental iron per day -Ferrous fumarate-325 mg-elemental iron-108 mg -Ferrous sulfate-325 mg-elemental iron-65mg -Ferrous gluconate-325mg- elemental iron-35 mg ------First line therapy is oral iron tablets

Question 29

Iron patient education

Answer 29

-Best absorbed on an acidic environment (avoid PPIs, H2 blockers, antacids) -Best absorbed in the proximal and third of the duodenum -Vit C can increase acidity and improve iron absorption -Iron can reduce absorption of zinc and thyroid supplements

Question 30

IV Iron

Answer 30

-Iron Dextran: Given as single, large dose Some patients develop allergic reaction -Ferumoxytol: Large dose injected over shorter time 2 doses needed; 2nd dose given 3-8 days-510 mg Less likely to trigger allergic reaction -Ferric gluconate iron sucrose 10-14 days before you see a response w/ IV iron

Question 31

Microcytic Anemia Classifications

Answer 31

-IDA -Thalassemia -Anemia of chronic disease

Question 32

Anemia of Chronic Disease: Microcytic anemia

Answer 32

-Inflammatory: RA, SLE, acute hepatitis, chronic hepatitis, malignancies, AIDs, Temporal arteritis -Organ failure

Question 33

Anemia of Chronic Disease CBC values & peripheral smear

Answer 33

-CBC: Hgb (low), MCV (normal), MCV low (with severe anemia) -Peripheral Smear: Normocytic normochromic, microcytic hypochromic (with severe anemia)

Question 34

Tests for ACD

Answer 34

-Serum ferritin (high) -TIBC-low -Serum iron-low- -ACD is clinically similar to IDA Acute phase reactants may be elevated -Fibrinogen -Sedimentation rate -CRP

Question 35

Erythropoiesis Stimulating Agents

Answer 35

-Must demonstrate low erythropoietin level -Used to treat severely symptomatic anemia in danger of requiring a blood transfusions (hgb levels not >10) -Used in patients w/ chronic renal failure on dialysis -Tx cancer associated anemia -Black box warning-target hgb should be 12 or less. Higher hgb associated with CV and thrombolic events -Expensive

Question 36

Thalassemia: Microcytic anemia

Answer 36

-Inherited disorder of hemoglobin synthesis -Most common genetic diseases in humans -β-Thalassemia common in Greek and Italian descent - A-Thalassemia common in African American, American Indian, and Asian groups -Two main variants-major and minor

Question 37

Lab findings with Thalassemia

Answer 37

-Hgb (low), MCV (Low). -Peripheral Smear-Microcytic hypochromic -Iron studies-normal -Hgb electrophoresis-Hgb A (elevated B thalassemia), Hgb A2 (normal-alpha thalassemia) -Order a hgb electrophoresis cascade

Question 38

Macrocytic Anemia

Answer 38

-Produced by megaloblastic or nonmegaloblastic causes -Megaloblastic causes impair DNA synthesis in erythrocyte precursors ---anemia

Question 39

Megaloblastic Causes: Macrocytic Anemia

Answer 39

-Vitamin B12 deficiency (cobalamine) -Folate Deficiency -Bone Marrow disorders -Drug induced (anticonvulsant agents, oral contraceptives, chemo, bactrim)

Question 40

Nonmegaloblastic Anemia

Answer 40

Alcoholism Bone marrow disorders COPD Hypothyroidism

Question 41

Vitamin B12 Deficiency: Macrocytic Anemia

Answer 41

-Derived from food and animals -Deficiency with inadequate diet, vegetarianism, impaired absorption -Absorbed in the terminal ileum

Question 42

Causes of VB12 Deficiency causes

Answer 42

-Pernicious anemias: most common -Malabsorption states -Parasitic infection -Gastrectomy -Intestinal disease

Question 43

Folic Acid Deficiency: Macrocytic Anemia

Answer 43

-Inadequate dietary intake is a common cause of folic acid deficiency -Folate-Rich Foods-Fruits, green leafy vegetables, peanuts -High risk groups: Elderly, alcholics, impoverished, malabsorption syndrome (sprue, celiacs) -Folic acid antagonist-address certain meds that can cause macrocytic anemia

Question 44

Folic Acid Requirements Increase

Answer 44

-During childhood (growth and development) -Pregnancy -Recovery from serious Illness

Question 45

Tests for macrocytic anemia

Answer 45

-CBC: Hgb (low), MCV (high), RDW (high). -Peripheral smear: Normochromic Abnormal RBC morphology (anisocytosis, pokilocytosis)

Question 46

Anisocytosis

Answer 46

Means variation in cell sizes -Present on peripheral smear in macrocytic anemia

Question 47

Poikilocytosis

Answer 47

-Variation in the shape of the RBC -present on peripheral smear with macrocytic anemia

Question 48

B12 deficiency can cause was neuro defects

Answer 48

-Peripheral neuropathy & lesions in the posterior spinal cord can be seen with untreated B-12 deficiency Paresthesias & numbness Loss of vibration & position sense Sensory ataxia with positive Romberg’s Limb weakness Memory loss Psychosis

Question 49

B12 deficiency treatment

Answer 49

Injection regimen: 1000 mcg/day IM for five days, then 1000 mcg/week IM for one month, then 1000 mcg/month IM Oral regimen: 1000 mcg/day Lifetime treatment required

Question 50

Folic Acid Deficiency Treatment

Answer 50

Oral regimen: 1 mg - 5mg daily for the first 1-4 months OR until a complete hematologic recovery occurs

Question 51

Normocytic Anemia

Answer 51

-Acute blood loss -Iron def. or b12 def., folic acid def. -Hemolytic anemia -Endocrine disorder (hypothyroid, adrenal insufficiency) -Bone marrow disease (aplastic anemia, pure RBC aplasia, MDS) -Anemia of chronic disease

Question 52

Hemolytic anemias

Answer 52

-Extrinsic and intrinsic factors -Chemicals (Sulfonamides, penicillin, cephalosporins, EES, acetaminophen) -Infection (cdiff, e coli, typhoid, malaria, toxoplasmosis, cholera) -Immune mechanisms (autoimmune anemias) -Trauma (prosthetic heart valve, arterial grafts, DIC) -Underlying disease (NHL, CLL, connective tissue disease) -Structural defects -Enzyme defects -Globin synthesis defects (sickle cell anemia)

Question 53

Hemolysis Labs

Answer 53

-Haptoglobin (low) -Unconjugated bilirubin (high) -LDH (high) -Urine hemoglobin (present) -Coomb's test (positive) -Reticulocytes (high) -bone marrow is trying to compensate for RBC destruction -Peripheral smear (various inclusions)