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ANEMIA

ANEMIA . BY: ASAL GHARIB. Objectives. Learn about iron deficiency anemia Learn about anemic of chronic disease Distinguish between iron deficiency anemia and anemia of chronic disease . What is Anemia?. Anemia is defined by reduction in Hg Concentration, Hct Concentration or RBC count

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ANEMIA

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  1. ANEMIA BY: ASAL GHARIB

  2. Objectives • Learn about iron deficiency anemia • Learn about anemic of chronic disease • Distinguish between iron deficiency anemia and anemia of chronic disease

  3. What is Anemia? • Anemia is defined by reduction in Hg Concentration, Hct Concentration or RBC count • Or defined as 2 standard deviations below the mean • WHO criteria is Hg < 13 in men and Hg < 12 in women • Revised WHO criteria for patient’s with malignancy Hg < 14 in men and Hg < 12

  4. Symptoms • Exertional dyspnea and Dyspnea at Exertion • Headaches • Fatigue • Bounding pulses and Roaring in the Ears • Palpitations • PICA

  5. Physical Manifestation : “Spoon Nails” in Iron Deficiency

  6. Kinetic Approach • Decreased RBC production • Lack of nutrients (B12, folate, iron) • Bone Marrow Disorder • Bone Marrow Suppression • Increased RBC destruction • Inherited and Acquired Hemolytic Anemias • Blood Loss

  7. Morphological Approach • Microcytic (MCV < 80) • Reduced iron availability • Reduced heme synthesis • Reduced globin production • Normocytic ( 80 < MCV < 100) • Macrocytic (MCV > 100) • Liver disease, B12, folate

  8. Labs • Information can be gleaned from good history taking and a physical exam (pallor, jaundice, etc) • CBC With Diff • Leukopenia with anemia may suggest aplastic anemia • Increased Neutrophils may suggest infection • Increased Monocytes may suggest Myelodysplasia • Thrombocytopenia may suggest hypersplenism, marrow involvement with malignancy, autoimmune destruction, folate deficiency • Reticulocyte Count • Peripheral Smear

  9. Iron Deficiency Anemia • Low Retic Count • High RDW • Low iron level • High TIBC • Low ferritin

  10. Degrees of Iron Deficiency

  11. Normal Peripheral Smear

  12. Iron Deficiency Anemia: Peripheral Smear Microcytosis &, Hypochromic RBCs

  13. Reticulocyte Count • Reticulocyte count is the percent of immature RBCs (released earlier in anemia from the marrow) • Normal levels 0.5-1.5% for non anemic stages • <1% means Inadequate Production • >/equal to 1 means increased production (hemolysis) • Corrected reticulocyte count compares anemic to non-anemic counterparts to assess response as reticulocyte count may overestimate response • Corrected Reticulocyte Count = % Retic X HCT/45

  14. Reticulocytes

  15. Reticulocyte Correction Factor • RPI = % reticulocytes X HCT/45 X 1/Correction Factor • Normal RPI =1 • RPI < 2 Hypoproliferative • RPI greater than/equal 2 Hyperproliferative Disorder

  16. So now that it’s iron deficiency…. • What Causes Iron Deficiency? • Blood Loss (occult or overt): PUD, Diverticulosis, Colon Cancer • Decreased Iron Absorption: achlorhydria, atrophic gastritis, celiac disease • Foods and Medications: phytate, calcium, soy protein, polyphenols decrease iron absorption • Uncommon causes: intravascular hemolysis, pulmonary hemosiderosis, EPO, gastric bypass • Decreased Intake (rare)

  17. Who needs a GI work-up? • All men, all women without menorrhagia, women greater than 50 with menorrhagia • If UGI symptoms, EGD • If asymptomatic, colonoscopy • Women less than 50 plus menorrhagia: consider GI workup based upon symptoms

  18. Gold Standard for Diagnosis • Bone Marrow Biopsy • Prussian Blue staining shows lack of iron in erythroid precursors and macrophages • However, it is invasive and costly

  19. Treatment Options

  20. Anemia of Chronic Disease • EPO production inadequate for the degree of anemia observed or erythroid marrow responds inadequately to stimulation • Causes: inflammation, infection, tissue injury, cancer • Low serum iron, increased red cell porphyrin, transferrin 15-20%, normal to increased ferritin

  21. Pathophysiology

  22. AICD vs. Iron Deficiency • Soluble Transferrin Receptor: elevated in cases of iron deficiency • Ferritin: elevated in anemia of chronic disease • If all else fails, Bone Marrow Biopsy • In anemia of chronic disease: macrophages contain normal/ increased iron & erythroid precursors show decreased/absent amounts of iron

  23. Anemia of Chronic Disease

  24. Treatment • Treat the underlying cause • Treat the underlying cause • And Treat the Underlying Cause! • Consider co-existent iron deficiency as well • If underlying disease state requires it, consider EPO injection

  25. Summary

  26. References • Harrison’s Principles of Internal Medicine • Adamson JW. Chapter 103. Iron Deficiency and Other Hypoproliferative Anemias. In: Longo DL, Fauci AS, Kasper DL, Hauser SL, Jameson JL, Loscalzo J, eds. Harrison's Principles of Internal Medicine. 18th ed. New York: McGraw-Hill; 2012. http://www.accessmedicine.com/content.aspx?aID=9117223. Accessed December 7, 2011 • Wians, F.H. and Urban JE. “Discriminating between Anemia of Chronic disease Using Traditional Indices of Iron Status v. Transferring Receptor Concentration”. 2001. American Journal of Clinical Pathology. Volume 115. • UptoDate • Schrier, SL. Approach to the adult patient with anemia. In: UpToDate, Landaw, SA(ED). UptoDate, Waltham, MA. 2012. • Schrier, SL. Causes and diagnosis of anemia due to iron deficiency. In: UpToDate. Landaw, SA.(ED). Uptodate, Waltham, MA. 2012.

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