Week 19 - Cases 1,2,3,4 and passmed

Question 1

what are the causes of microcytic anaemia
- there are four
- MCV <80

Answer 1

• iron deficiency anaemia
• thalassaemia
• sideroblastic anaemia
• anaemia of chronic disease

Question 2

what are the causes of normocytic anaemia
- there are 7
- MCV 80-100

Answer 2

• acute blood loss
• early iron deficiency anaemia
• renal disease
• haemolytic anaemia
• malaria
• sickle cell disease
• aplastic anaemia

Question 3

what are the causes of megaloblastic anaemia
- there are 2
- MCV >100

Answer 3

• B12 deficiency
• folate deficiency

Question 4

what are the causes of non-megaloblastic macrocytic anaemia
- there are 2
- MCV >100

Answer 4

• alcoholism
• liver disease

Question 5

what kind of cells are seen in iron deficiency anaemia

Answer 5

pencil cells

Question 6

what may be seen on a blood film in B12/ folate deficiency

Answer 6

hyper segmented neutrophils

Question 7

what are the causes of iron deficiency anaemia

Answer 7

• dietary in origin, due to lack of red meat, or green vegetables in the diet
• due to gastrointestinal blood loss and is a must not miss diagnosis
• in females, due to loss during menstraton

Question 8

if a patient has an iron deficiency anaemia, what would constitute red flag symptoms and require a 2 week wait referral to exclude cancer

Answer 8

Urgently refer (appointment within two weeks) people:

• aged 40 and over with unexplained weight loss and abdominal pain
• aged 50 and over with unexplained rectal bleeding
• aged 60 and over with either:
  – iron deficiency anaemia
  – OR alteration in bowel habit
• who have positively tested for occult blood in their faeces

Question 9

what does ferroportin do

Answer 9

controls the release of iron from the intestinal enterocytes into the blood stream and the release of iron from the marrow macrophages for eryhtropoiesis

Question 10

what does hepcidin do

Answer 10

in turn controls the levels of ferroportin in an inverse manner

Question 11

what does an increase in hepcidin do

Answer 11

causes ferroportin to degrade, reducing ferroportin levels prevents iron release from GI tract enterocytes into the blood stream and also traps iron in the marrow macrophages, thus reducing total iron bio-availabiliy

Question 12

therefore what happens when iron is plentiful and the transferrin saturation is high

Answer 12

less iron is absorbed and fewer red cells are produced in the bone marrow

Question 13

what happens in inflammation when there are high levels of IL6

Answer 13

the same mechanism is activated, explaining the classical marrow iron findings of the normocytic, normochromic anaemia of chronic disease; with excess iron in the free and marrow particle marcophages but no iron in the eryhtroblasts

Question 14

what does the lack of production in anaemia of chronic disease also explain

Answer 14

why sometimes this type of anaemia can be hypochromic and is not always normochromic and normocytic

Question 15

what happens if there is a decrease in hepcidin

Answer 15

it promotes iron absorption from the gut and releasing iron rom the marrow macrophages to assist increased erythropoiesis

Question 16

what happens does a low TFR situation inhibit in iron deficiency and what does this lead to

Answer 16

a low TFR situation inhibits hepcidin and ferroportin increases this promoting iron absorption and availabilityg

Question 17

there are increased levels of what in haemolytic anaemia

Answer 17

increase in the levels of growth differentiation factor 15

Question 18

how do high levels of GDF15 promote iron absorption

Answer 18

by inhibiting hepcidin and this explains why patients with chronic haemolysis can become iron overloaded without ingesting excess iron or by having blood transfusions

Question 19

what treatment would you give to a patient with iron deficiency anaemia secondary to heavy mentruation

Answer 19

oral iron treatment

Question 20

what are the four most common side effects of oral iron supplementation

Answer 20

diarrhoea
gastrointestinal discomfort
nausea
constipation

Question 21

chronic kidney disease is a risk factor for what

Answer 21

osteoporosis

Question 22

what are the side effects you should inform pregnant women about with paroxetine

Answer 22

Paroxetine use in pregnancy - can lead to increased risk of congenital malformations

Question 23

in cases of pregnancy of unknown location, a serum bHCG of what points towards a diagnosis of an ectopic pregnancy

Answer 23

In the case of pregnancy of unknown location, serum bHCG levels >1,500 points toward a diagnosis of an ectopic pregnancy§

Question 24

what is the pathway for oesophageal/gastric two week wait criteria

Answer 24

Urgent referral for endoscopy within two weeks. Urgently refer people:

of any age presenting with dysphagia (OG), or
aged 55 or over with weight loss, and
Upper abdominal pain, or
Reflux, or
Dyspepsia (OG)

Question 25

what is the treatment for microcytic, hypochromic anaemia

Answer 25

ferrous sulphate and refer urgently to the GI team

Question 26

what is glossitis

Answer 26

a red and inflamed tongue

Question 27

what does hyper-segmented neutrophils look like

Answer 27

neutrophils usually have 2-5 lobes and therefore anything over this is classed as hypersegmented

Question 28

how does megaloblastic anaemia cause macropcytic anaemia

Answer 28

from ineffective red blood cell production and intramedullary haemolysis

Question 29

what are the most common causes

Answer 29

folate deficiency and cobalamin deficiency

Question 30

a BMI of what is obese

Answer 30

a BMI of 30 or above is obese

Question 31

what are the 3 reasons for why eGFR as a single value has several limitations

Answer 31

It is based on serum creatinine and so may overestimate actual GFR in patients with low muscle mass (e.g., those with cachexia and amputees) and underestimate actual GFR in individuals taking creatine supplements (as creatinine is a metabolite of creatine) or trimethoprim (which inhibits secretion of creatinine).

It tends to underestimate normal or near-normal function, so slightly low values should not be over-interpreted.

In the elderly, who constitute the majority of those with low eGFR, there is controversy about categorising people as having chronic kidney disease on the basis of eGFR alone, particularly at stage 3A, since there is little evidence of adverse outcomes when eGFR is >45 mL/min/1.73 m2 unless there is also proteinuria.

Question 32

what is anaemia of chronic disease

Answer 32

microcytic hypochromic anaemia

Question 33

what is hepcidin

Answer 33

an iron-regulating peptide hormone made in the liver

Question 34

what is an accelerated progression of CKD defined as

Answer 34

A sustained decrease in GFR of 25% or more and a change in GFR category within 12 months or
A sustained decrease in GFR of 15 ml/min/1.73 m2 per year
Be aware that those patients are at increased risk of progression to end stage renal disease.

Question 35

what is CKD defined as

Answer 35

CKD is defined as abnormalities of kidney function or structure present for more than 3 months, with implications for health. This includes all people with markers of kidney damage and those with a glomerular filtration rate (GFR) of less than 60 ml/min/1.73m2 on at least 2 occasions separated by a period of at least 90 days (with or without markers of kidney damage).

Question 36

what is CKD classified based on

Answer 36

cause
GFR category
albuminruia category

Question 37

How can ACEI/ARBs delay disease progression?

Answer 37

By dilating the efferent arteriole

Question 38

what is HbH most often caused b¥

Answer 38

inherited deletion of three of the four alpha globin genes

Question 39

how can beta thalasseaemia major be ‘cured’

Answer 39

using a stem cell transplant

Question 40

A 65-year-old man known to have chronic kidney disease stage 3A secondary to diabetes was started on angiotensin converting enzyme inhibitor by his GP. Which percentage decline in eGFR from baseline would warrant stopping the treatment with ACE inhibitor?

Answer 40

We accept up to 25% decline in eGFR. This is due to the hemodynamic change at the level of the glomeruli because of efferent vasodilation and lowering of the intraglomerular pressure. More than 25% decline in eGFR from baseline should make you consider stopping the angiotensin converting enzyme inhibitor.

Question 41

A 58-year-old man is known to have chronic kidney disease stage 4. His calcium levels are low, but phosphate and PTH (parathormone hormone) levels are elevated. Which is the most likely diagnosis?

Answer 41

Secondary hyperparathyroidism

Secondary hyperparathyroidism occurs in patients with chronic kidney disease. Due to the drop in the glomerular filtration rate, phosphate levels increase which then activates FGF-23 and increases PTH levels. At the same time, failure to activate vitamin D will result in low calcium levels. Hence answer B is correct. For primary hyperparathyroidism, calcium levels are elevated, phosphate levels are low and PTH levels are elevated. Hence answer A is not correct. In hypoparathyroidism, calcium levels are low due to low PTH levels, which is not the case here. Tertiary hyperparathyroidism occurs after many years of having a secondary hyperparathyroidism. Those patients have been under continuous stimulation of PTH, and so they will form an autonomous focus on the parathyroid gland that will produce high calcium levels regardless of the low vitamin D levels. The results are similar to secondary hyperparathyroidism except for elevated calcium levels, which is not the case here.

Question 42

A 70-year-old man is known to have chronic kidney disease stage 3b. His haemoglobin level is 110g/l. T-sats 31% and ferritin of 250 ug/l. Which is the most appropriate management of his anaemia?

Answer 42

Regular monitoring
Based on the NICE guidelines, his haemoglobin levels, T-sats and ferritin levels are within acceptable range for a patient with chronic kidney disease. Regular monitoring is required to maintain those figures.

Question 43

A 65-year-old man with heart failure, known CKD and is non-diabetic, recently heard about the benefits of SGLT2i in preventing CKD progression. Given that he is non-diabetic, would you still consider treatment with SGLT2i for him?

Answer 43

Yes
Recent evidence has shown that SGLT2i delayed CKD progression in non-diabetics with heart failure and lowered the cardiovascular disease events