Anemia

Chapter 4

how to define anemia understand elements of a BS undetand and interpret RBC indices classify anemia by size, location of destruction, bone marrow respons makes easier to 'pull out' why pt anemia

Hematology for Medical Students RC 633 .S3651 2003

Atuomatic analyzeis sample divided one to directly asess hemoglobin by a colormetric assay one to focus on the WBC and the different subsets of WBC one to examine the RBC, associated features and platelets electircal current used to count numbers and change inr esistance correlates with size o f the cell laser is used to distinguish RBC from RBC by light scatter chrateristic scattter for each type of cell information compiled into a computer printout, reviewed, released

lots of flags built in to go back and do human inspection

hemotologists do often

Indices includeed in a CBC RBC count x10&12 per liter HgB in gm/dl or gm/100ml--colormetric hemtaocrit proportion of volume occupied by RBC mean corpuscular volume mean corpuscular volume FL(10-15 L) ratio of Hct x 100 / RB count 10&12/L) 80-100fL

mean corpuscular hemoglobin ratio of HgB/RBC count normal 27-31 pg mean corpusclar hb concentration ratio of HgB/Hct Red blood cell ditribution width co-efficient of variation of the MCV...SD of the MCV/MCV normal is 11.5-15.5%

lab values average Hb males/females

< > 'normal' considered w/i 2sd when going to fall below 2 sd... epo goes up

kidney senses pick definition

condition where any of these occur number of RBC/ml amt of Hgb/100ml volume of rbc/100ml if below 2sd of population standard

Clinical Manifestations person came to attention compensation of C system due to dimisnished blood volume blood loss change in whole blood volume reduciton in oxygen carrying capacity ratoe of formation of anemia is important in bringing to clincial attention cardiopulmonary reserve compromised manifestationo f underlying disease

something is going on that made pt anemic what caused it? complaint->anemia

wright-giemsa stain morphology compare in size olumphocytes need to know where to look for RBCs on smear look at central pallor

anisocytosis--uneven cells poikilocytosis--difference in shape lots of ragments no size reference not nice round cells quite a bit of size variation MV-mean corpuscualr volume 80-100 fl is normal <80 is microcytosis >100 is macrocytosis

MCH hgb/rbc count mchc-hgb/hct describes degree of hemoglobiniation i.e., characterizes degree of central pallor

How do you approach the classification of anemia? 2 schemes is there evidence of proliferation or erythropoietic reponse--is the marrow able to make RBCs?
 * presence of reticulocytes

What is the associated size of the cells with the anmia-are the RBCs 'normal'?
 * Mean corpuscualar volume
 * RDW (RBC distribution width)

polychromasia reticulocyte purple hue ?basophilic stiplling ribosomal activity no central pallor larger than normal RBC marked by flow cytometry or stained 'polychromasia'--variation in color in wright-giemsa stain

focus first on classifying anemia in terms of marrow response.... 2 sd from mean 15.4-1.8 g/l women 13.5-2 g/l

<2% of 74000/ul absolute count reticulaocyte count >2% or 100/0000/ul absolute count reciulocyte index is retic count*HCT/ideal Hct/*.5 if les than 2% or 750000/ul absolute implies hypoproliferative or maturation abnormality

if greater than 100,000 per ul or 100,00 absolute ierythropoeitic response blood loss hemolysis

sometimes, will have blood loss or hemolysis byt not have building blocks to build reticulocyte reponse i.e., no iron, no B12
 * LOOPHOLE!

etiology of anemia based on reiculocyte count decreased production: normal or decereased reticulcyte countin setting of anemia kidney disease: no erythropoietin nutriotional edeficiency: iorn, B12, folate BOne amrrow disorder: Primary: Secondary:
 * leukemia
 * lymphoma
 * myeloma
 * myeloproliferative/myelopdiysplastic
 * systemic illness
 * drugs

Elevated reticulocyte countin setting of anemia Bleeding: acute vs chronic Hemolysis: destruciton of RBC due to gcongentical or acquired efects

anemia in setting of high reticulocyte count high...>5% no hemoglobinopathy... ask self: evidence that cells being destroyed bilirubin, biliverdin

hemoglobin ldh-lactate dehydrogenase--goes up free hemoglobin bilirubin, hemosiderin in urine plasma bilirubin, haptoglobin, hemoglobin, LDH

if eveidnce found of hemolysis, consider...

immmune mdiated membrane idosrder hbopathy mehcanical..heart disease infection metabolic defects

What is the pts MCV? classifying anemia by size... microcytic, normocytic, macrocytic less than 80femtoliter, microcytic RDW (SD of the MCV)/MCV

Microcytic Anemia due to Decreased Hemoglobin Production
<80 globin chain production Heme synthesis inheritied: Thalassemia Acquired: iron deficiency anemia of chronic diseaes lead poisoning medications need: Hx, Hx, Hx

Megaloblastic
lobed cells bvery large cells Folate Deficiency Vitamin B12 Medication
 * imparied DNA syntheis:

Non-megaloblastic
bleeding-normal hemolysis-normal liver diseASE Alchoholims myelodystplastic syndrome

Adding in reticulocyte count Megaloblastic macrocytic anemia w/ low reiculocyte count...B12 defiicency, folate deficiency, medication

Non-megaloblastic anemia: High reticulocyte count: hemorrhage, hemolysis low retic count? REVIEW REVIEW REVIEW

Normocytic Anemias Problem Group Low Reticulocyte Count Normal behaving cells...anemic primary? * leukemia secondary >* may be assoc w/ reudced EPO
 * lymphoma
 * myeloma
 * myelodysplastic, myeloproliferative syndromes
 * cancer
 * chronic disease
 * medication
 * renal disease

need for bone marrow exam if systepc primary disease may be able to do work up with blood

sometimes hard to sort out hemolytic anemias review smear

acute hemorrhage smear normal bleeding initial focus GI tract most common source o f blood loss consider hemostatic defect as a cause of blood lososs menstrual blood loss

hemolytic anemias decrease in survival

hemolytic anemias Decreased RBC survival not explained by bleeding assoc w/ hemoglobin, biochemical, or membrane changes RBC morphology review is a must b/c often proveides clues ot underlying sdisease process

intravascular vs eravascular hemolysis lots of shape variation size variation...poikilocytosis suggests cells being destroyed in vasculature mechanical valve?

cells clumping together antibodies causing to stick...destroyed by complement spherocytes

hints on anemia from location of destruction intravascualr hemolysis mechanical destruction...heart valve immune-ediated damage sickle cells disease, PNH DIC< TTP, HUS vascular damage

extravascular hemolysis immine heolytic anemai IgG bound to RBC damaged RBC...heinz body abrnomral RBC membrane extravascular annromal RBC membrane...spherocytosis

evaluation of hemolytic anemias BLood smear, retic count, bone marrow

Plasma or serum bilirubin, haptoglobin, palsma hemoglobin, lactate dehydrogenase <>

to sumarize... anemia is reduced Hb Clincal hx exam CBC RBC indices retic count blood smear bone marrow exam

Nutritional Anemias