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SA Anemia 1-4 (Wilkinson) Flashcards

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1
Q

Define Anemia

A

reduction in RBC mass –> reduced O2 delivery to tissue

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2
Q

O2 delivery to tissue depends on what 3 factors

A
  1. Blood flow and is distrubution to different organs
  2. O2 carrying capacity of the blood (Hgb concentration or # RBCs in circulation)
  3. Oxygen’s ability to extract the RBC into tissues
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3
Q

Body’s physiologic responses (4) to chronic anemia

A

1. Increases CO

2. Redistributes blood flow to caridac and cerebral circulation (via vasodilation) and decreases to splanchnic vascular bed (GIT, spleen, etc.) & periphery (e.g., pale gums) (via vasocinstriction)

3. Increased erythropoietin production (hormone that signals bone marrow to produce more RBCs)

4. Improved O2 extraction (via compensatory mechanism)

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4
Q

Why do animals with acute onest of anemia tend to have more severe clinical signs/exam changes than those with chronic anemia?

A

In chronicly anemic animals, the body has gotten used to its anemic state via compensatory mechanisms

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5
Q

3 main causes of anemia

A

1. Hemorrhage (hypovolemia)
2. Hemolysis (RBC destruction)
3. Hypoplasia (decreased RBC production- bone marrow dz, kidney failure)

Erythropoietin (hormone that stimulates RBC production) is produced in kidneys

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6
Q

First step in assessing anemia is determining whether it’s regenerative or non-regenerative. Define the two and what they each indicate.

A
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7
Q

Pre-regenerative anemia time period: the time period b/w anemia onset & bone marrow release of reticulocytes

A

~2-5 days

IMHA or hemorrhage: may initially present as non-regen., but b/c not enough time has lapsed, and not b/c bone marrow isn’t working properly

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8
Q

How to assess RBC regeneration

A
  • Reticulocyte count (expressed as a % of the CURRENT RBC count, so must be corrected for anemia)
  • Blood smear (polychromasia and anisocytosis; nRBCs)
  • RBC indices (MCV and MCHC)

  • Polychromasia and anisocytosis indicate presence of reticulocytes; nRBCs indicate appropriate metarubricytosis if reticulocytosis is present)
  • MCV = size of RBCs, MCHC = hemoglobin content of RBCs –> Macrocytosis and hypochromasia (not always abnormal)
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9
Q

Absolute reticulocyte count calculation

A

ARC = Reticulocyte % x RBC count

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10
Q

Values for regenerative response in dogs vs cats

A

Dogs: > 95,000/uL reticulocytes
Cats: > 60,000/uL reticulocytes

cats do not have as robust response to anemia as dogs

non-regen = less than these values

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11
Q

What is seen on blood smear of non-regen case

A

lack of polychromasia and anisocytosis; nRBCs ( = inappropriate metarubricytosis)

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12
Q

Metarubricytosis w/out reticulocytosis is associated with what?

A

Bone marrow disease or injury, splenic disease, lead poisoning

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13
Q

2 differentials for non-regen anemia:

A

Either pre-regenerative period or true hypoplasia (in bone marrow)

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14
Q

Hemorrhagic Anemia (Regenerative)

Signs of GIT blood loss

A
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15
Q

Hemorrhagic Anemia (Regenerative)

Signs of urinary or reproductive tract blood loss

A

Hematuria (gross or microscopic)

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16
Q

Hemorrhagic Anemia (Regenerative)

Signs of respiratory tract blood loss

A
  • Epistaxis
  • Hemopysis (coughing blood)
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17
Q

Hemorrhagic Anemia (Regenerative)

Where are sources of internal blood loss contributing to anemia?

A
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18
Q

Hemorrhagic Anemia (Regenerative)

3 common causes of acute blood loss

A
  1. Trauma
  2. Coagulopathy
  3. Neoplasia

Coagulopathy: 1º hemostasis defects (PLTs) or 2º hemostasis defects (clotting factors)

Neoplasia: hemangiosarcoma (liver, spleen, lung)

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19
Q

Hemorrhagic Anemia (Regenerative)

Common causes of chronic blood loss

A
  • GI tract (hookworms, ulcers, neoplasia)
  • Fleas
  • Urinary tract
  • Respiratory tract (chronic epistaxis)
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20
Q

Hemorrhagic Anemia (Regenerative)

Animals with acute hypovolemia usually have what strength of pulses and why?

A

Weak and thready pulses: they are losing large volumes of blood very quickly

loss of plasma/fluid/plasma proteins

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21
Q

Hemorrhagic Anemia (Regenerative)

Animals with hemolysis-caused anemia typically have what strength of pulse and why?

A

Hemolysis is NOT a loss of blood volume (pulses can still be strong/bounding)

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22
Q

Hemorrhagic Anemia (Regenerative)

Chronic external hemorrhage vs chronic internal hemorrhage reticulocytes

A

External chronic: present (regen) or absent (non-regen) –> NON-REGEN b/c they are losing iron in the blood –> microcytic and hypochromic anemia

Internal chronic: present (regen)

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23
Q

Hemorrhagic Anemia (Regenerative)

Relationship b/w iron & RBCs

A

Iron = essential for hemoglobin production

Iron deficiency (microcytic and hypochromic)
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24
Q

Hemorrhagic Anemia (Regenerative)

Signs of poor tissue oxygenation (5)

A

weakness, depression; tachycardia; tachypnea; bounding femoral pulses (or weak w/ acute blood loss)

Indicate start of blood transfusion

PCV < 15%: consider blood transfusion or low PCV + these clinical signs

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25
# **Hemorrhagic Anemia (Regenerative)** What type of blood product for **blood-loss anemia & cogaulopathy**?
**Fresh whole blood (prior to refrigeration)**: - RBC + PLTs + all clotting factors + plasma proteins - not usually used b/c requires another animal who can immediately donate their blood
26
# **Hemorrhagic Anemia (Regenerative)** Refrigerated vs non-refrigerated (stored vs fresh) whole blood products?
- **Refrigerated (stored)**: RBC + some clotting factors (no V or VIII or vWF) + plasma proteins - **Non-refrigerated (fresh)**: RBC + PLTs + all clotting factors + plasma proteins ## Footnote vWF clotting factor: attaches to small blood cells called platelets. This helps the platelets stick together, like glue, to form a clot at the site of injury and stop the bleeding.
27
What type of blood product for **hemolytic or hypoplastic anemia**?
**Packed Red Blood Cells**: - RBC only
28
Desired PCV after blood transfusion?
~25%
29
Equation for blood transfusion volume
(BWkg x BVml/kg) x [(PCVdes - PCVpat) / (PCVdon)]
30
DEA 1.1
Dog Erythrocyte Antigen 1.1 | a surface protein on RBC
31
When will dogs have naturally occurring antibodies against DEA 1.1?
If they are DEA 1.1 (-) and receive a blood transfusion
32
What blood types are most common in cats?
Types A, B, AB | in U.S.: 99% are type A
33
Type A cats have _ anti-B antibodies Type B cats have _ anti-A antibodies
Type A cats have **WEAK** anti-B antibodies --> these cats will have a negative rxn if given type B blood Type B cats have **VERY STRONG** anti-A antibodies --> these cats will DIE if given type blood A
34
What is a **crossmatch**
*To assess compatibility b/w patient serum (antibody) and donor red blood cells (antigen):* take patient's serum with donor's RBCs and see if they react (does pt have antibodies against donor's antigens)
35
When should a crossmatch be performed?
- Previous blood transfusion hx or hx is unknown - If given back-to-back (e.g., IMHA pt in ICU getting q12h) after ≥ 3 days following a known RBC transfusion (time it takes Abs to form)
36
Blood transfusion rates: 1. first 15 mins 2. second 15 mins (if going well) 3. remainder of 4-hour window
1. 1 ml/kg/hr 2. 2 ml/kg/hr 3. increase to rate that allows for remainder of blood to be administered within the 4-hour window | faster rates can be used if the anemia is life-threatening ## Footnote TPR q15 mins first hour TPR q30mins for remaining time
37
Transfusion Reactions (2) / which is most common and which is life-threatening
1. **Transfusion-associated circulatory overload (non-immunologic)** = pt gets fluid-overloaded 2. **Non-hemolytic febrile reaction (immunologic)** = immune response to the transfused blood, **very common** but *not life-threatening*. 3. **Hemolytic transfusion reaction (immunologic)** = anaphylaxic reaction which can lead to shock: febrile + tachypnea + tachycardia + vomiting + hypotension
38
Hemolytic transfusion reaction
IV hemolysis which is completely destroying the transfused blood --> stop immediately and treat supportively (IVF, O2, corticosteroids, vasopressors). Can check PCV to see if blood is hemolyzed.
39
# **Hemolytic Anemia (Regenerative)** EV vs IV hemolysis (mechanism + color of blood/urine)
## Footnote CS: icterus, splenomegaly (EV), fever (IMHA, infectious anemia), bounding femoral pulses)
40
# **Hemolytic Anemia (Regenerative)** Blood smear findings for EV vs IV hemolysis
EV: spherocytes IV: ghost cells
41
# **Hemolytic Anemia (Regenerative)** Differentials for EV hemolysis
**1. IMHA** (**1º = idiopathic//most common**; 2º = infection, neoplasia, drugs or vaccines) **2. Oxidant injury** **3. Infectious Anemia** **4. Abnormal mø activation and/or proliferation** (UNCOMMON, but due to erythophagocytic histiocytic sarcoma or hemophagocytic syndrome) ## Footnote EHS: møs have malignant characteristics, versus HS = too many møs present
42
# **Hemolytic Anemia (Regenerative)** What drug classes (3) can secondarily cause IMHA?
Sulfonamides, penicillins, cephalosporins
43
# **Hemolytic Anemia (Regenerative)** Most common **infectious causes of IMHA** in dogs (1) versus cats (3)
Dogs: *Babesia* spp. Cats: *Mycoplasma haemofelis*, FeLV, FIP
44
# **Hemolytic Anemia (Regenerative)** Autoagglutination, Spherocytosis, and positive Coombs test are **strong evidence** of what?
***IMHA*** - BOTH dogs & cats will have **autogluttination** - ~75% of IMHA DOGS will have **spherocytes** on path review - Consider Coombs if ^^ are unidentified
45
# **Hemolytic Anemia (Regenerative)** First line of treatment for IMHA
Corticosteroids - Prednisone/prednisolone (rapid onset of 5-7 days for full effect)
46
# **Hemolytic Anemia (Regenerative)** 3 side effects of corticosteroids that are dose-dependent.
**Iatrogenic hyperadrenocorticism** --> adrenal gland suppression - PU/PD, polyphagia, weight gain, panting, haircoat changes **Cats: insulin resistance** --> 2º diabetes millitus **Mild-moderate elevated ALKP and GGT**
47
# **Hemolytic Anemia (Regenerative)** **Azathioprine** side effects (3) | an immunosuppr. that can be used in combo w/ corticosteroid
**Bone marrow suppression** - monitor serial CBCs **Hepatotoxicity** - monitor liver enzymes **Pancreatitis**
48
# **Hemolytic Anemia (Regenerative)** **Mycophenolate** side effects (2) | an immunosuppr. that can be used in combo w/ corticosteroid
**Potentially severe GI upset** - may be delaye dup to weeks after starting medication **Bone marrow suppression** - less likely than Azothioprine
49
# **Hemolytic Anemia (Regenerative)** **Cyclosporine** side effects (3) | an immunosuppr. that can be used in combo w/ corticosteroid
- GI upset - Gingival hyperplasia - Increased risk for opportunistic fungal infections
50
# **Hemolytic Anemia (Regenerative)** Complications associated with IMHA?
- ***Systemic thromboembolism*** - Acute kidney injury (AKI) - Disseminated intravascular coagulation (DIC) - Opportunistic infections (integument, UT, RT; bacterial andor fungal pathogens ## Footnote *Low-dose Aspirin* (0.5-1.0 mg/kg SID) or *Clopidogrel* (1-4 mg/kg SID) should be started right when you diagnose IMHA as a *preventative measure*
51
# **Hemolytic Anemia (Regenerative)** Infectious Anemia: pathogenesis and potential 2º IMHA
Agents directly damage RBCs --> causes hemolysis. Can activate the immune system into thinking hte RBCs are pathogens and can trigger 2º IMHA (from induced Ab formation against RBCs
52
# **Hemolytic Anemia (Regenerative)** Hemotropic Mycoplasma and effects
*Mycoplasma haemofelis* = important organism that causes severe hemolytic anemia in cats - Epicellular parasite of RBCs --> direct damage + triggers erythrophagocytosis (EV hemolysis)
53
# **Hemolytic Anemia (Regenerative)** Risk factors for hemotropic myoplasma in cats
- male - outdoor access (other cats, flea/arthropods) - FeLV or VIF (+)
54
# **Hemolytic Anemia (Regenerative)** **Babesiosis** Babesia canis vogeli - pathogenesis - transmission
- large, piriform-shaped **protozoan** exisiting within erythrocytes (singly or paired) that **causes 2º IMHA** - brown dog tick (Rhipicephalus sanguineus) - subclinically infected animals can be carriers (e.g., greyhounds) ## Footnote greyhouds almost always subclinically infected --> if greyhound dx with IMHA, always look for B. canis as well
55
# **Hemolytic Anemia (Regenerative)** **Babesiosis** Babesia gibsoni - pathogenesis - transmission
- Small **protozoan** existing within erythrocytes with ring-like configuration - **Bite wounds** likely play a role in transmission - Sub-clinically infected dogs can be carriers (e.g., **American pitt bulls**)
56
# **Hemolytic Anemia (Regenerative)** How is Babesiosis best diagnosed?
**PCR** (is species-specific/most sensitive)
57
# **Hemolytic Anemia (Regenerative)** **Cytauxzoonosis** Cytauxzoon felis - transmisison - two forms
- Tick-transmitted protozoan infection of cats (Lone Star = Amblyomma americanum) - Forms: 1. Tissue phase (schizont) - infects mononuclear phagocytes 2. Erythrocyte phase (piroplasm) ## Footnote Dx = blood smear or PCR
58
# **Hemolytic Anemia (Regenerative)** Oxidant-Induced Hemolytic Anemia - etiology
- Hbg is constantly being oxidized, and is reversed by a reducing mechanism. - **Certain toxins can cause massive/rapid oxidation** --> *reducing mechanism becomes overwhelmed* --> Hgb damage (Heinz body formation or methemoglobinemia)
59
# **Hemolytic Anemia (Regenerative)** Heinz bodies
denatured, oxidized hemoglobin --> hemolysis
60
# **Hemolytic Anemia (Regenerative)** Culprits of Heinz Body Oxidant-Induced Hemolytic Anemia
61
# **Hemolytic Anemia (Regenerative)** What toxicity that causes Heinz Body Oxidant-Induced Hemolytic Anemia can **mimic IMHA**? How is it diagnosed?
**Zinc toxicity** (pennies minted post 1982). **Dx via abd rads!** | All pts with hemolysis shoild have abd rads performed (FB)
62
# **Hemolytic Anemia (Regenerative)** Methemoglobinemia - etiology - causes
- Methemoglobin = oxidized heme iron - Is a "physiologic anemia" = normal RBC but has reduced O2 carrying capacity - Causes = **Acetominophen**
63
# **Hemolytic Anemia (Regenerative)** Tx for Oxidant-Induced Hemolytic Anemia (3)
1. Remove offending drug or toxin 2. **N-acetylcysteine** (antioxidant that helps increse the reducing mechanism = increase intracellular gluthaione levels) 3. Supportive care (Heinz body anemia = blood transfusion if indicated; Methemoglobinemia = supplemental O2)
64
# **Hemolytic Anemia (Regenerative)** **Fragmentation Hemolytic Anemia** (also known as microangiopathic hemolytic anemia) - etiology - causes
- RBC fragmentation due to *contact w/ abnormal vasculature* - HW disease, DIC, splenic torsion, hemangiosarcoma, vasculitis | Is NOT an immune response against RBCs
65
# **Hemolytic Anemia (Regenerative)** Blood smear findings of fragmentation hemolytic anemia
- Schistocytes - Acanthocytes
66
# **Hypoplasia Anemia (Non-Regenerative)** **Primary** Hypoplasia Anemia - definition - causes (3)
Decreased production INSIDE the bone marrow - 1º failure of erythropoiesis (RBC only) - Aplastic anemia/pancytopenia (multiple cell lines --> e.g., PLTs or WBCs affected plus the RBCs) - Infiltration of bone marrow w/ disease, directly affecting erythropoiesis
67
# **Hypoplasia Anemia (Non-Regenerative)** **Secondary** Hypoplasia Anemia - definition - causes (2)
Disease is OUTSIDE of the bone marrow - Hgb synthesis defect = iron deficiency (RBC only) - 2º failure of erythropoiesis (RBC only)
68
# **1º Hypoplasia Anemia (Non-Regenerative)** Primary failure of erythropoiesis pathogenesis
IMHA, but at the bone marrow level - The precursor RBCs in the bone marrow are getting attacked - severe anemia often present (is a chronic condition) - other cell lines are normal (leukocytes, platelets) - is a.k.a. pure red cell aplasia and non-regen. immune-mediated anemia
69
# **1º Hypoplasia Anemia (Non-Regenerative)** Key difference b/w *Pure Red Cell Aplasia and Non-Regenerative Immune-Mediated Anemia* and traditional IMHA?
Pure Red Cell Aplasia and Non-Regenerative Immune-Mediated Anemia have **much slower remission times than IMHA** (as long as 3-4 months)
70
# **1º Hypoplasia Anemia (Non-Regenerative)** Aplastic Anemia (Pancytopenia)
Peripheral blood cytopenias due to **hypocellular/acellular** bone marrow
71
# **1º Hypoplasia Anemia (Non-Regenerative)** Bone Marrow Infiltration (Myelophthisis)
Dispalcement of bone marrow tissue by... - neoplastic cells - collagen (myelofibrosis) --> idiopathic, potentiallly immune-mediated; dr - adipose tissue
72
# **2º Hypoplasia Anemia (Non-Regenerative)** Hemoglobin synthesis defect's **CBC progression in iron deficiency**
73
# **2º Hypoplasia Anemia (Non-Regenerative)** What is the most common cause of non-regenerative anemia in dogs and cats? How severe is the anemia typically? Characteristics of the RBCs?
**Anemia of chronic disease // of inflammatory disease** - mild-moderate anemia (Dogs: PCV = 20-37%, Cats: 15-26%) - Always normocytic and normochromic anemia, all other cell lines normal ## Footnote anemia resolves once underlying disease (underlying inflamm. disease) is addressed
74
# **2º Hypoplasia Anemia (Non-Regenerative)** How does **Chronic Kidney Disease** lead to 2º hypoplastic anemia?
- **lack of erythropoietin production**; GI blood loss, decreased RBC life span
75
# **2º Hypoplasia Anemia (Non-Regenerative)** When would you expect **total solids** to be low?
Hemorrhage
76
# **2º Hypoplasia Anemia (Non-Regenerative)** When would you expect **plasma color** to appear yellow or red/pink?
Hemolysis
77
# **2º Hypoplasia Anemia (Non-Regenerative)** When would you expect to see **Spherocytes, +/- ghost cells**, on blood smear?
Hemolysis
78
When would you *not* expect to see **agglutination** on blood smear?
Hemorrhage and hypoplasia; may or may not with hemolysis

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