Anemia Flashcards by Jaren Woodard

What is anemia?

decrease in RBC or hemoglobin

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Signs/Symptoms of Anemia

exertional dyspnea
angina
tachycardia
fatigue
Pallor

may be asymptomatic if develops slowly

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Normal RBC

4.5-5.5 x 10^6 cells/uL –> male

4.1-4.9 x 10^6 cells/uL –> female

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Normal Hemoglobin

13.5-18 g/dL –> male

12-16 g/dL –> female

oxygen carrying capacity

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Diagnosis

Hb < 13.5 g/dL –> male

Hb < 12 g/dL –> female

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Normal Mean Corpuscular Volume (MCV)

80-100 mm^3

average volume of RBC (size)

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Normal RBC Distribution Width (RDW)

11.5-14.5%

variation in size of RBCs (range)

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Normal Ferritin

15-200 ng/mL

acute phase reactant –> elevated in acute inflammation or chronic disease

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Diagnostic Ferritin

< 45 ng/mL

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Normal TSAT

20-50%

amount of iron ready for erythropoiesis

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Diagnostic TSAT

< 20%

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Diagnostic B12

< 200 pg/mL

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Diagnostic Folate

< 5 ng/mL

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Causes of Anemia

Decreased RBC production
- Chronic diseases: CKD, cancer, CHF
- Nutritional deficiencies: iron, folic acid, vitamin B12

Increased RBC destruction
- drugs
- sickle cell anemia/thalassemia

Increase RBC loss
- acute blood loss
- NSAIDs, ASA

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Microcytic

MCV < 80

iron deficiency
sickle cell anemia
thalassemia

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Normocytic

MCV 80-100

anemia of chronic disease
blood loss
hemolysis

Macrocytic

MCV > 100

folic acid deficiency
B12 deficiency

Consequences of Anemia

impaired cognitive function
falls
heart failure
A-fib
CV events

Iron Deficiency Anemia

Bloodwork
- decreased Hb
- decreased MCV
- normal/increased RDW
- increased TIBC/transferrin
- normal/decreased serum iron
- decreased TSAT

Causes:
- blood loss: menstruation, blood donation
- decreased absorption of iron
** celiac disease
** malabsorptive state
- vegetarian diet
** heme (meat)
** non-heme (plants, diary) –> not absorbed well
- increased consumption –> pregnancy

Side effects:
- spoon-shaped nails (koilonychias)
- inflamed tongue (glossitis)
- pica
** pagophagia –> ice
** geophagia –> dirt, soil, clay

Treatment of Iron-Deficiency Anemia

ORAL IS PREFERRED

Oral Dose:
- 65 mg of elemental iron every other day

Exceptions favoring IV:
- cannot tolerate
- cannot absorb
- ESKD
- heart failure

Repletion:
- 3 to 6 months

Hepcidin

iron regulating peptide hormone produced in liver
decreases dietary iron absorption and iron transfer to the plasma
increased after a dose of oral iron for approx. 24 hours and normalizes within 48 hours

Elemental Iron

Ferrous fumarate
- tablet strength: 300 mg
- elemental: 100 mg

Ferrous sulfate
- tablet strength: 325 mg
- elemental: 65 mg

Ferrous gluconate
- tablet strength: 300 mg
- elemental: 30 mg

Counseling Points of Iron

increased absorption on empty stomach
causes stomach upset –> may take with food
absorption increased by ascorbic acid (vitamin C)
causes constipation
causes dark stools

Side Effects of IV Iron

hypotension during infusion

skin tattooing

Vitamin B12 Defiency Anemia

Bloodwork - decreased Hb - increased MCV - increased RDW - decreased serum B12 - increased homocysteine/methylmalonic acid - no iron studies Causes: - vegan/vegetarian diet - alcoholism - pernicious anemia (lack intrinsic factors) - decreased absorption (Crohn's) - Medications (PPI, Metformin) Side effects --> MUST ABSORB FROM DIET - weakness, numbness, cognitive dysfunction

Treatment of Vitamin B12 Deficiency Anemia

IM/SubQ - 100-1000 mcg daily, then weekly, then monthly Oral - 1000-2000 mcg/day ** may be less effective for pernicious anemia WATER SOLUBLE VITAMIN

Folic Acid Deficiency Anemia

Bloodwork - decreased Hb - increased MCV - increased RDW - decreased serum folate - increased homocysteine - no iron studies Causes: - malabsorption - malnutrition - alcoholism - Medications (methotrexate, phenytoin, sulfasalazine, Bactrim)

Treatment of Folic Acid Deficiency Anemia

Oral Folic Acid - 1 to 5 mg daily until Hb normalizes ** ALWAYS CHECK VITAMIN B12 ** WATER SOLUBLE VITAMIN Repletion: - 3 to 6 months

Anemia of Chronic Disease

Diseases: - CKD - CHF - Cancer - HIV/AIDs Occurs because: - decreased erythropoietin production - chronic inflammatory state - nutritional deficiencies (iron, folate, vitamin B12)

Treatment of Anemia of Chronic Kidney Disease

Avoid blood transfusions - risk of allosensitization Correct Nutritional Deficiencies - Folate - B12 - Iron ** CKD Stage 3-5: oral ** CKD HD: IV ** TSAT > 30% goal Erythropoiesis Stimulating Agents (ESA) - prevents blood transfusions - DO NOT TARGET NORMAL HB (maintain Hb > 10) - Side effects: CV events, stroke, death - only start after replenishing iron stores - do not titrate dose up for at least 4 weeks after initiating

Anemia of Chronic Heart Failure

May benefit: - NYHA Class II or III AND - iron deficiency (ferritin < 100 or 100-300 if TSAT > 30%)

Treatment of Anemia of Chronic Heart Failure

NO ORAL IRON NO ESA

Treatment of Blood Loss Anemia

STOP THE BLEEDING Transfuse packed RBC if Hb < 7 - each unit of RBC contains 250 mg of iron - 1000 mg of iron to replete stores

Hemolytic Anemia

RBC destroyed before 120 days Types: - sickle cell anemia - G6PD deficiency - drug induced

Sickle Cell Anemia

What? - RBC are irregular shaped and collects in the spleen and destroyed faster than production - homozygous recessive

Treatment of Sickle Cell Anemia

Folic Acid: 1 mg/day Blood Transfusions: symptomatic episodes of acute/chronic Hydroxyurea - fetal hemoglobin inducer leading to decreased sickling - 10-15 mg/kg/day Immunizations Pain Control - Tylenol - NSAIDs - opioids --> PCA