anemia approach
DESCRIPTION
approach to anemiaTRANSCRIPT
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Anemia: Classification,general features and approach
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Definition of anemia
Anemia is functionally defined as an insufficient RBC mass to adequately deliver oxygen to peripheral tissues.
Indicators: Hemoglobin level, hematocrit, RBC number
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Adult Reference Ranges for Red Cells
Measurement (units) Men Women Hemoglobin (gm/dL) 13.617.2 12.015.0 Hematocrit (%) 3949 3343
Red cell count ( 106/L) 4.35.9 3.55.0 Reticulocyte count (%) 0.51.5
Mean cell volume (fL) 8296
MCH(pg) 2733
MCHC(gm/dL) 3337
RDW 11.514.5
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Limitations in this concept
Hb and HCT may reflect altered plasma volume not a change in RBC mass
Hb and HCT changes may reflect underlying physiological conditions with different oxygen needs
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Classification
Etiological
Blood loss
Increased red cell destruction
Decreased red cell production (Hypo-proliferative or maturation disorder)
Morphological
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Clinical features
Symptoms depend on duration of the disease
Weakness
Fatigue
Palpitation
Shortness of breath
Tachycardia
Headache,vertigo,tinitus,parasthesias
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Patient History
Dietary habits
Bowel habits
Medications
Exposure to chemicals and toxins
History of fever
Menstrual bleeding
Bruises,ecchymoses
Family history
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Physical examination
Skin pallor/Pale conjunctiva
Jaundice
Smooth tongue
Sternal tenderness
Spleno/Hepatomegaly/lymphadenopathy
Purpura
Neurological dysfunction
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Koilonychia Glossitis Angular Stomatitis
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Laboratory Examination
First Line Studies - CBC:Hb, Hcrit, Rbc indices, Cell count,
Reti count - PB morphology examination
- Chemistry
-Urine examination
Second Line Studies - Iron/TIBC/Ferritin
- BM study
-HPLC
- others
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Useful RBC indices
Mean cell volume: the average volume of a red cell expressed in femtoliters (fL)
Mean cell hemoglobin: the average content (mass) of hemoglobin per red cell, expressed in picograms
Mean cell hemoglobin concentration: the average concentration of hemoglobin in a given volume of packed red cells, expressed in grams per deciliter
Red cell distribution width: the coefficient of variation of red cell volume
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Reticulocyte count
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Corrected Reti(%) (Reticulocyte Index, RI)
Correction of dilutional factor
= Reti(%) x Patients Hcrit / 45
Normal
Anemia
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Red Cell Production Index(RPI)
Correction of shift factor
= Corrected Reti / Shift factor
Hcrit 45
35
25
15
BM normoblasts & reticulocytes(days)
PB reticulocytes(days)
3.5
3.0
2.5
1.5
1.0
1.5
2.5
2.0
Shift correction factor
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Normal marrow response to anemia
Hematocrit Production index Marrow M/E ratio
45 1 3:1
35 2-3 2:1-1:1
25 3-5 1:1-1:2
15 3-5 1:1-1:2
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Anemia alone or Not ?
Anemia alone
Bicytopenia or Pancytopenia - Aplastic anemia/PNH
- MDS
- Acute leukemia
- Hypersplenism/Autoimmune disorders
- Megaloblastic anemia(not always)
- Myelophthisic anemia
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Is there an appropriate reticulocyte response to anemia
If reticulocytosis is present look for evidence of hemolysis.
Hyperbilirubinemia
Increased LDH
Increased excretion hemoglobin (low haptoglobin,hemoglobinemia,hemoglobinuria,hemosiderinuria)
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Anemia associated with low reticulocyte count
Reflects impairment of normal hematopoeisis
Impaired erythropoeisis may be because of
Reduction in red cell precursors (hypogenerative)
Ineffective erythropoeisis
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Macro-, Normo-, or Microcytic ?
Microcytic (MCV < 80 fL) - IDA, Thalassemia, ACD
Macrocytic (MCV > 100 fL)
- Megaloblastic anemia, Reticulocytosis Liver disease, Aplastic anemia
Normocytic Anemia of renal failure, MDS, Leukemia, Aplastic
anemia, ACD, Others
- R.INDEX
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R INDEX>2.5
HEMOLYSIS/HAEMORRHAGE
BLOOD LOSS
INTRAVASCULAR HEMOLYSIS
MEMBRANE ABNORMALITY
HEMOGLOBINOPATHY
AUTOIMMUNE DEFECT
FRAGMENTATION HEMOLYSIS
METABOLIC DEFECT
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Is anemia associated with red cell populations of different sizes?
Is the anemia associated with abnormalities on peripheral smear?
Is a bone-marrow examination required for clarifying the cause of anemia?
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Peripheral Blood Smear
Size
Central pallour
Shape
Distribution
Inclusions
Abnormal cells
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PBS Shape (cont)
Spherocyte,Sickle cell,schistocytes
Target cell increased ratio RBC surface/volume CLD, thalassemia
Teardrop myelofibrosis
Acanthocyte (spur cells) severe liver disease
Burr cell uremia, artifact
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Microcytic hypochromic picture
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Macrocytic picture
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Megaloblasts in bone-marrow
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Leuco-erythroblastic reaction
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Normocytic picture with rouleaux
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Spherocyte
http://www.wadsworth.org/chemheme/heme/microscope/spherocyte.htm
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Sickle Cell
http://www.wadsworth.org/chemheme/heme/microscope/sicklecell.htm
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Schistocyte
http://www.wadsworth.org/chemheme/heme/microscope/schistocyte.htm
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Target Cell
http://www.wadsworth.org/chemheme/heme/microscope/targetcells.htm
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Burr cell
http://www.wadsworth.org/chemheme/heme/microscope/echinocytes.htm
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Tear drop cell (dacrocyte)
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Rouleaux formation
http://www.wadsworth.org/chemheme/heme/microscope/rouleaux.htm
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PBS - Inclusions
Nucleated RBC immature RBCs Extramedullary hematopoiesis, hypoxia, hemolysis
Heinz bodies denatured and precipitated hemoglobin G6PD deficiency
Howell-Jolly bodies small nuclear remnant with the colour of a pyknotic nucleus s/p splenectomy, hyposplenism
Basophilic stippling deep blue granulations, pathologic aggregation of ribosomes Lead intoxication, thalassemia
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Howell Jolly Bodies
http://www.wadsworth.org/chemheme/heme/microscope/howelljolly.htm
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Basophilic stippling
http://www.wadsworth.org/chemheme/heme/microscope/basostip.htm
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Bite cells and Heinz Bodies
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When is bone-marrow required?
Refractory anemias
Parasites
Presence of abnormal cells on peripheral smear
Rule out infiltration of marrow
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Hypocellular bone marrow in aplastic anemia
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Contrast with erythroid hyperplasia
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LD bodies in bone-marrow
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Bone-marrow granuloma
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Thank You..