Anemia Flashcards
1
Q
What is anemia?
A
- Decreased Hgb and RBCs =
2. Decrease in oxygen carrying capacity of blood
2
Q
What causes anemia?
A
- Decreased RBC productions
- Increased RBC loss
- Increased RBC destruction
3
Q
- Decreased RBC productions
- Increased RBC loss
- Increased RBC destruction
A
- Hgb < 13 g/dL for men
- Hgb < 12 g/dL for women
- “Sign of disease”
4
Q
What is the 2nd most prevalent and costly public health issue?
A
Anemia
5
Q
How can you monitor or screen for anemia?
A
With NO chronic conditions check CBC every 5 years, if Hgb 11-12 g/dL consider further workup
With chronic conditions check CBC yearly
6
Q
What is the clinical presentation of acute anemia?
A
- Tachycardia
- Angina
- Lightheadedness
- SOB
7
Q
What is the clinical presentation of chronic anemia?
A
- Fatigue
- Weakness
- Headache
- Dizziness
- Pallor
- Sensitivity to the cold
8
Q
What is the normal clarification of RBC size/Hgb content?
A
Normochronic and normocytic
9
Q
Define Macrocytic
A
an abnormally large red blood cell
10
Q
Define Microcytic
A
an abnormally small red blood cell
11
Q
Define Hyperchromic
A
the red blood cells have more hemoglobin than normal
12
Q
Define Hypochromic
A
the red blood cells have less hemoglobin than normal
13
Q
What is the initial evaluation of anemia?
A
- CBC-Complete blood count (RBC indices)
- Reticulocyte Index
- Supporting labs (iron, folate, B12, etc.)
- Fecal occult blood stool cards
14
Q
What is hemoglobin and what are the normal values?
A
- Estimates oxygen carrying capacity
- Men: < 13 g/dL
- Women: <12 g/dL
15
Q
Where is hemoglobin made?
A
in RBCs
16
Q
What happens with Hgb in anemia?
A
- Decreased Hgb per RBC
2. Decreased number of RBCs
17
Q
What is hematocrit?
A
The % of RBCs in unit volume of whole blood
usually 3x the Hgb value
18
Q
What happens to happens to hematocrit in anemia?
A
Decreased (increase in plasma volume)
19
Q
What is the red blood cell count?
A
- Number of RBCs per unit of blood (millions/mcg)
20
Q
What is the lifespan of a RBC?
A
120 days
21
Q
What happens to RBCs in anemia?
A
Decreases
22
Q
In what special populations do normal values vary?
A
- High altitude
- Smokers
- Elderly
23
Q
What are the three RBC indices?
A
- MCV
- MCH
- MCHC
24
Q
What are special facts about RBC indices?
A
- Describe size and Hgb content or RBCs
2. Do not express variation between cells
25
What is MCV?
Mean Cell Volume
26
What happens to MCV in macrocytic RBCs?
Increases
| ALSO, folic acid and B12 deficient
27
What happens to MCV in microcytic RBCs?
Decreases
| ALSO, Iron deficiency
28
What is Mean Cell Hemoglobin (MCH)?
The amount of Hgb in a RBC
29
What are false elevations of MCV referred to as?
Reticulocytosis
30
What happens to MCH in macrocytosis? microcytosis?
1. Increases
2. Decreases
* You actually can't distinguish between microcytosis and hypochromia*
31
What is the Mean Cell Hemoglobin Concentration (MCHC)?
Weight of Hgb per volume of cells (concentration)
| -Independent of cell size
32
What occurs when a patient has a low MCHC and MCH?
Hypochromia
33
What occurs when there is normal MCHC and a decreased MCH?
Microcytosis
34
What is a reticulocyte?
young red blood cell
| -indicates new RBC productions
35
What happens when total reticulocyte count is low? High?
1. problem with bone marrow production
| 2. increased erythropoietic response to hemolysis or blood loss
36
What is the RBC distribution width?
Variation in RBC size
-Increased % = greater variation in size
This is useful for Dx of mixed anemia
37
What is meant by 'serum iron'?
Concentration of iron bound to transferrin
| Transferrin = binds and transports iron (normally 1/3)
38
What is the total iron binding capacity (TIBC)?
Measures the iron binding capacity of transferrin
| DOES NOT FLUCTUATE
39
What does it mean when a patient has high TIBC and low serum iron?
Iron deficiency
40
What does it mean when a patient has low TIBC and low serum iron?
Anemia of chronic disease
41
What is transferrin saturation?
indicates the extent to which iron binding sites on transferrin are vacant
Serum Iron / TIBC X 100 = % ~33%
42
What is ferritin?
storage iron
| it is proportional to total iron stores in the body
43
What does it mean when a patient has low ferritin?
Virtually diagnostic for IDA--chronic disease
44
What do low levels of folic acid and vitamin B-12 mean?
Vitamin deficiencies
45
What is important about homocysteine?
Folic acid and b-12 are needed to convert homocysteine to menthinoine
If there are high levels of homocysteine there may be vitamin deficiencies
46
What is methylmalonic acid (MMA)?
Vitamin B-12 is needed to convert MMA to succinyl Co-A
| If there is an increase in urinary secretion of MMA usually before there is a decrease in serum b-12
47
What is erythropoietin?
it stimulates RBC production and maturation
| increases 100 to 1000 fold during hypoxia or anemia
48
What are the three reasons iron is important?
1. Transports O2 to tissue as part of Hgb
2. Cell's energy metabolism
3. Facilitates O2 use and storage in muscles
49
What causes IDA-the most common nutritional deficiency and type of anemia?
1. Inadequate dietary intake (3rd world)
2. Inadequate absorption (Gastrectomy)
3. Increased Iron needs (blood donations)
4. Blood loss (GI tract)
5. Other chronic illnesses (malabsorption)
50
What is the clinical presentation of IDA?
Don't appear until Hgb <8-9
1. Glossal pain
2. Decreased salivary flow
3. Pica/parophagia
4. Psychomotor/mental devalopment
5. "spoon" shaped nails
6. Guaiac stool
51
How does the lab dx a patient with depletion of storage iron?
* 1. Decreased serum ferritin*
| 2. Normal serum iron and Hbg/Hct
52
How does the lab dx a patient with a decrease in transport iron?
* 1. Decreased Serum iron*
* 2. Increased TIBC*
* 3. Decrease transferrin saturation*
4. Normal Hgb/Hct
53
How does the lab dx a patient with decreased Hgb production?
* 1. Decrease Hgb/Hct*
2. increased RDW
3. decreased MCV
4. decreased reticulocytes
54
What are the goals of treatment in IDA?
1. Replenish iron stores
2. Treat any underlying disease
3. Normalize Hgb/Hct
55
What are is the preferred treatment of IDA?
Oral iron therapy
56
What is the recommend iron dosage in a patient with IDA?
200 mg elemental iron in 2-3 daily doses
*Start with smaller doses and gradually increase*
Treat for 3-6 months *AFTER* anemia is resolved
OR
Every other day
Younger 325 bid-tid
Old 325 qd
57
What form of iron is better absorbed?
Ferrous (Fe++) is better absorbed than Ferric (Fe+++), Fe+++ needs ionized and reduced in the stomach first
58
Where is iron absorbed?
Duodenum
59
How can a patient increase the absorption of iron?
heme iron in meats, poultry, fish better than non-heme iron veggies and grains
60
What can decrease the absorption of iron?
1. Calcium
2. Slow release preparation/enteric coating
3. Tea
4. Food (1 hour before means 2 hours after)
61
What are disadvantages of oral iron preparation?
Poor absorption and low compliance
62
Where is oral iron preparations best absorbed?
In an acidic medium, needs to be non-enteric coated
63
What is the recommended dosages of oral iron preparation?
1. Younger: 325 mg ferrous sulfate BID-TID
| 2. Elders: 325 mg ferrous sulfate daily
64
What are notable side effects of oral iron preparations?
1. GI
diarrhea, nausea, constipation, dark stools
Need to titrate, and increase compliance
If you don't see SE's there may be noncompliance
65
How should you counsel a patient with GI intolerance when taking oral iron preparations?
1. Lower dose
2. Take with food
3. Use a different formulation
4. Attempt parenteral iron therapy
66
What is notable about toxicity in children?
1. Use child resistant containers
| 2. 10-15 tablets can be LETHAL AND AN EMERGENCY
67
What is the iron chelator?
Dexferoxamine
68
What drugs decrease iron absorption?
1. Al, Mg, Ca containing antacids
2. Tetracycline
3. Doxycycline
4. H2-antagonists
5. PPIs
6. Cholestyramine
69
What results in a treatment failure of anemia?
1. Noncompliance
2. Incorrect diagnosis
3. Continued bleeding
4. Inability to absorb iron
70
When should PN iron be used?
1. Sig. intolerance
2. Noncompliance
3. Malabsorption
4. Achlorhydria
5. Renal failure, TPN, Cancer, Dialysis
71
What is the preferred IV form of iron?
Iron dextran
| *Black Box Warning*: anaphylactic reactions
72
What are local reactions to iron dextran?
Pain, atrophy, brown skin staining, abscesses, necrosis
73
What are the immediate reactions to iron dextran?
* Mild:* malaise, nausea, headache, itching, sweating
| * Anaphylactic:* dyspnea, chest pain, flushing, urticaria, dizziness, hypotension
74
What are delayed reactions to iron dextran?
myalgia, arthralgia, phlebitis, fever, chills, dizziness, headache, n/v
75
Ferric Gluconate:
1. IV only
2. approved for hemodialysis patients
3. NO test dose required
4. less anaphylaxis
76
Iron Sucrose:
1. hemodialysis patients
2. NO test dose required *BBW*
3. Well tolerated: leg cramps, hypotension
77
Ferumoxytol (feraheme):
1. Initial dose followed by 2nd 3-8 days later (510)
2. Approved in CKD
3. No test dose required
4. Well tolerated
5. MRI procedures
78
Ferric Caboxymaltose (Injectafer)
1. Two doses of 750 mg
2. 15 min infusion
3. Hypophosphatemia
79
How do you differentiate between megaloblastic and non-megaloblastic anemias?
Peripheral blood smear
80
What is a megaloblast?
retarded DNA synthesis, unbalanced cell growth
81
What are the two types of megaloblastic anemias?
1. Vitamin B-12 Deficiency
| 2. Folic Acid Deficiency
82
What does vitamin B-12 do?
1. Essential for DNA synthesis
2. Maintains neurological system
3. Needed for metabolic rxns involving folic acid
83
What are the (3) causes of B-12 deficiency?
1. Inadequate intake (vegans)
2. Malabsorption syndromes (no intrinsic)
3. Inadequate utilization (overgrowth of bacteria)
84
What drugs can cause B-12 deficiency?
1. Metformin
2. H2-antagonists
3. PPIs
85
What are the clinical findings behind vitamin B-12 anemia?
1. Pale loss of appetite, glossitis, weakness
| 2. Neurological
86
What lab findings are associated with vitamin B-12 anemia?
Low: Hgb, HCT, RBCs
High: homocysteine, MMA, MCV, MCHC
Peripheral Blood Smear: macrocytosis
87
What are the goals of therapy in vitamin B-12 anemia?
1. Replace body stores of b-12
2. Reverse hematological manifestations
3. Prevent/reverse neurological problems
88
What is the early treatment for vitamin B-12 anemia?
1. VERY IMPORTANT
2. Neurological damage can be irreversible after 6-12 months
3. Range from numbness to psychosis/memory loss
89
What is the oral vitamin B-12 anemia therapy?
Cyanobalamin (1-2 mg daily)
| --> Can be used for pernicious anemia
90
What is the PN vitamin B-12 anemia therapy?
*Preferred with neurological symptoms*
| IM Cyanobalamin
91
How can you evaluate the treatment of vitamin B-12 anemia therapy?
1. Neurological Complications
| 2. Failure to respond (incorrect dx, other cause)
92
What is important about folic acid?
Necessary for DNA/RNA
93
What can occur in folic acid deficiency?
Increased risk for neural tube defects with pregnancy
94
What can cause folic acid deficiency?
1. Inadequate intake
2. Decreased absorption
3. Hyperutilization
4. Drug induced
95
What is the clinical presentation of folic acid anemia?
Similar to B-12 anemia without neurological symptoms, *must rule out B-12*
96
What are the lab presentation in folic acid anemia?
Same as B-12 with low serum folic acid
| Homocysteine elevates
97
What is the treatment of folic acid anemia?
Oral folic acid therapy
98
What is ACD?
anemia of chronic disease
99
How does ACD occur and what diseases can result in it?
1. > 1-2 months
2. HIV, RA, Malignancy, Heart failure
(Coexist with other anemias)
100
What happens during ACD?
1. Shortened RBC lifespan
2. Impaired bone marrow response (decreased EPO)
3. Change in iron metabolism
101
What are the lab manifestations in ACD?
1. No definitive test
2. Decreased serum iron
3. Ferritin normal or increased
4. normocytic and normochromic
102
How can you treat ACD?
1. Anemia = poorer prognosis
2. *Treat underlying disease!!*
3. Iron therapy alone = typically ineffective
4. Blood Transfusions
5. Epoetin, Darbepoetin
103
What are the erythropoietic agents?
Epoetin and Darbepoetin
1. Stimulates RBC production and maturation
2. IV/SQ
3. Supplement with iron therapy
104
What is the most common ADE of EPO?
Hypertension
105
What is the target Hgb level in ACD patients?
11-12 mg/dL
106
What are the contributing factors to anemia of critical illness?
sepsis, blood draws, surgical blood loss, immune mediated functional iron deficiency, GI bleeds
107
What are the lab findings in a patient with anemia of critical illness?
Low serum iron and TIBC
| Ferritin normal to high
108
What is the treatment plan in a patient with anemia of critical illness?
1. Supplemental iron
2. Mixed findings with epoetin/darb
3. Blood transfusions
109
What is the process of Anemia of chronic kidney disease
1. Diseased kidney cannot produce as much EPO
2. Bone marrow produces fewer
3. RBCs produced have shorter life span due to uremic environment
4. Less oxygen available to organs leading to complications
- -Onset and severity related to GFR--
110
When would you discontinue erythropoietic agent?
Hgb > 12
111
When should you discontinue erythropoietic agent?
failure to respond in 1st 8-12 weeks
112
Deleterious effects of anemia of critical illness
- cardiac morbidity and mortality
| - reduced oxygen carrying capacity to organs
113
Anemia in elderly
- 12% of those >60
| - more common in hospitalized or nursing home
114
Underlying cause of anemia in elderly can be identified in ____ % of cases. What is it generally?
80%
| chronic blood loss
115
Contributing factors of anemia in elderly
- progressive decrease in hematopoietic reserve
- declining renal function
- potentially lower Hgb in males
116
Anemia in elderly labs
- check nutritional status
| - lab same as other anemia
117
Two peak periods of children at risk of anemia
- late infancy/early childhood
| - adolescence
118
When is the 1st anemia screening for infants?
6-12 months
119
When do iron stores during gestation run out?
6 months
120
T/F anemia in pediatrics leads to significant morbidity and mortality worldwide
true
121
Anemia of prematurity treatment
RBC transfusions
122
When does anemia of prematurity occur?
3-12 weeks after birth in infants with <32 weeks gestation
123
What are the drug induced causes of folic acid deficiency?
```
Anticonvulsants* (phenytoin, primidone, phenobarb)
Oral contraceptives
Methotrexate*
TMP
Triamterene
```
124
Anticonvulsants cause folic acid deficiency how?
Interfere with folate abs
125
Methotrexate causes folic acid deficiency how?
Block dihydrofolate reductase
126
ADE of oral folic acid
Virtually none
