Hemolytic Hemolytic anemiaanemia

Presented by Dr Samiul (PGT)

Moderator : Dr Sujit Nath Choudhury, Asso. Prof. Dept,of Pediatrics,SMCH

DEFINATIONDEFINATION

Hemolysis is defined as the premature Hemolysis is defined as the premature destruction of red blood cells (RBCs). destruction of red blood cells (RBCs).

Anemia results when the rate of Anemia results when the rate of destruction exceeds the capacity of the destruction exceeds the capacity of the marrow to produce RBCs. marrow to produce RBCs.

?? EFFECT?? EFFECT RBC survival and RBC count fallsRBC survival and RBC count falls

erythropoietin is increasederythropoietin is increased

stimulation of marrow activitystimulation of marrow activity

heightened RBC productionheightened RBC production

increased reticulocytesincreased reticulocytes

WHAT IS A RETICULOCYTE ?

WHAT IS A RETICULOCYTE ?WHAT IS A RETICULOCYTE ?

Young red cell containing RNA Young red cell containing RNA remnantsremnants

RNA stain with supravital stainRNA stain with supravital stain

Is reticulocyte count sufficient

CLASSIFICATION

SOME BASIC PHYSIOLOGY

RBC MEMBRANERBC MEMBRANE

GLOBINGLOBIN

? NEXT

PBS

Hereditary SpherocytosisHereditary Spherocytosis

prevalence 1/5,000 prevalence 1/5,000 autosomal dominant autosomal dominant less frequently autosomal recessiveless frequently autosomal recessive

A recessive defect has been described A recessive defect has been described in α-spectrin; dominant defects, in β-in α-spectrin; dominant defects, in β-spectrin and protein 3;spectrin and protein 3;

and dominant and recessive defects, and dominant and recessive defects, in ankyrinin ankyrin

C/FC/F

HDN and may present as anemia and HDN and may present as anemia and hyperbilirubinemia sufficiently severe hyperbilirubinemia sufficiently severe to require phototherapy or exchange to require phototherapy or exchange transfusions.transfusions.

Some children remain asymptomatic Some children remain asymptomatic into adulthood, but others may have into adulthood, but others may have severe anemia, with pallor, jaundice, severe anemia, with pallor, jaundice, fatigue, and exercise intolerancefatigue, and exercise intolerance

LABLAB

indicesindices

MCHC increasedMCHC increasedMCH normalMCH normalMCV slightly lowMCV slightly low

OFTOFT

otherother

Autohaemolysis testAutohaemolysis testAcidified Glycerol Lysis timeAcidified Glycerol Lysis timeEosin 5 maleimide binding testEosin 5 maleimide binding test

TREATMENTTREATMENT

splenectomy splenectomy not recommend (hemoglobin values exceed 10 g/dL not recommend (hemoglobin values exceed 10 g/dL

and whose reticulocyte percentage is <10%.)and whose reticulocyte percentage is <10%.)

Folic acid, 1 mg daily Folic acid, 1 mg daily

Vaccines FOR pneumococcus, meningococcus, and Vaccines FOR pneumococcus, meningococcus, and Haemophilus influenzaeHaemophilus influenzae type b, should be type b, should be administered before splenectomy, and prophylactic administered before splenectomy, and prophylactic oral penicillin V (age <5 yr, 125 mg twice daily; age 5 oral penicillin V (age <5 yr, 125 mg twice daily; age 5 yr through adulthood, 250 mg twice daily) yr through adulthood, 250 mg twice daily) administered thereafter. administered thereafter.

OTHER MEMBRANE OTHER MEMBRANE DEFECTSDEFECTS

Hereditary elliptocytosis(interactions of Hereditary elliptocytosis(interactions of spectrin, protein 4.1and glycophorin c)spectrin, protein 4.1and glycophorin c)

Hereditary stomatocytosis( associated Hereditary stomatocytosis( associated with diminution of protein 7.2, or with diminution of protein 7.2, or “stomatin”; the gene is located on “stomatin”; the gene is located on chromosome 9)chromosome 9)

Paroxysmal nocturnal hemoglobinuriaParoxysmal nocturnal hemoglobinuria

PNHPNH

Is a clonal disorder characterised by Is a clonal disorder characterised by expansion of defective haemopoietic stem expansion of defective haemopoietic stem cell.cell.

Deficient DAF and MIRL Deficient DAF and MIRL DAF inhibit c3 convertaseDAF inhibit c3 convertaseMIRL inhibit MACMIRL inhibit MAC

LABLAB

PancytopeniaPancytopeniaURINEURINE

SEROLOGICAL TESTSEROLOGICAL TEST

a)a) Sucrose haemolysis test:Sucrose haemolysis test:

b)b) Acidified Serum test(Ham Test)Acidified Serum test(Ham Test)

c)c) Fow cytometryFow cytometry

treatmenttreatment

Folic acid, 1 mg qd Folic acid, 1 mg qd Hemolysis and other cytopenias—Hemolysis and other cytopenias—

prednisone, 60 mg qd initially, then prednisone, 60 mg qd initially, then taper if possible; maintenance therapy taper if possible; maintenance therapy 15–40 mg qod 15–40 mg qod

Androgen:fluoxymesterone Androgen:fluoxymesterone Anticoagulation Anticoagulation Marrow transplant Marrow transplant ECLIZUMABECLIZUMAB

HEREDITARY DISORDER OF HEREDITARY DISORDER OF HAEMOGLOBINHAEMOGLOBIN

Inherited disorder of haemoglobin are the Inherited disorder of haemoglobin are the commonest genitic disorder in the world.commonest genitic disorder in the world.

In many countries they constitute a major In many countries they constitute a major public health problem.public health problem.

CLASSIFICATIONCLASSIFICATION

HaemoglobinopathiesHaemoglobinopathies

ThalassaemiasThalassaemias

Hereditary persistence of foetal Hereditary persistence of foetal haemoglobinhaemoglobin

APPROACH TO DIAGNOSIS OF APPROACH TO DIAGNOSIS OF DISORDER OF HAEMOGLOBINDISORDER OF HAEMOGLOBIN

Hb/ Haematocrit/ Red cell countHb/ Haematocrit/ Red cell countRed cell indicesRed cell indicesPBSPBSElectrophoresis : Electrophoresis :

a) Cellulose acetate electrophoresis at a) Cellulose acetate electrophoresis at alkaline mediumalkaline medium

b) Citrate Agar electrophoresis at acid pHb) Citrate Agar electrophoresis at acid pH

HPLCHPLC

Test for HbSTest for HbS

a)slide test using reducing agenta)slide test using reducing agent

b)solubility testb)solubility test Quantification of HbA2/ HbFQuantification of HbA2/ HbF

BETA- THALASSEMIA MAJORBETA- THALASSEMIA MAJOR

Single beta globin locus in chromosome Single beta globin locus in chromosome 1111

ββo thalassaemia: Complete absence of beta o thalassaemia: Complete absence of beta chain synthesischain synthesis

β+ thalassaemia: synthesis is reducedβ+ thalassaemia: synthesis is reduced

PATHOGENESISPATHOGENESIS

C/FC/F

If not treated, children with β-If not treated, children with β-thalassemia usually become thalassemia usually become symptomatic as a result of progressive symptomatic as a result of progressive hemolytic anemia, with profound hemolytic anemia, with profound weakness and cardiac decompensation weakness and cardiac decompensation during the 2nd 6 mo of lifeduring the 2nd 6 mo of life

INVESTIGATIONINVESTIGATION

Prognosis(De Gruchy)Prognosis(De Gruchy)

-life epectancy in major averages from 15--life epectancy in major averages from 15-25 yrs25 yrs

-if regularly transfused-pts die in 2-if regularly transfused-pts die in 2 ndnd or 3 or 3rdrd decade due to CCF, cirrhosis or diabetesdecade due to CCF, cirrhosis or diabetes

-if untreated pt die before 5 years due to -if untreated pt die before 5 years due to severe anaemia or infectionsevere anaemia or infection

GENE THERAPYHbF MODULATION

BETA- THALASSEMIA MINORBETA- THALASSEMIA MINOR

Heterozygous stateHeterozygous stateWhen a person inherit normal When a person inherit normal β gene β gene

from one parent and either β0 or β+ from one parent and either β0 or β+ thalassaemia allele from the otherthalassaemia allele from the other

Hb not less than 9 gm/dlHb not less than 9 gm/dlMCV < 70 flMCV < 70 flMCH <25 pgMCH <25 pgOF decreaseOF decrease

αα- THALASSAEMIA- THALASSAEMIA4 4 αα globin genes / two in each chromosome 16 globin genes / two in each chromosome 16

Defect may occur in one, two, three or all four Defect may occur in one, two, three or all four globin genesglobin genes

Three main clinical form: Heamoglobin Bart’s Three main clinical form: Heamoglobin Bart’s hydrops foetalis syndrome, Haemoglobin H hydrops foetalis syndrome, Haemoglobin H disease and disease and αα thalassaemia carrier state thalassaemia carrier state

HbE HAEMOGLOBINOPATHY HbE HAEMOGLOBINOPATHY

HbE alone or in combination with HbE alone or in combination with thalassemia(E-thalassemia) is the most thalassemia(E-thalassemia) is the most common heriditary Hb disorder in eastern common heriditary Hb disorder in eastern part of the countrypart of the country

In this disease red cells contain In this disease red cells contain HbE(substitution of lysine for glutamic acid HbE(substitution of lysine for glutamic acid in the 26in the 26 thth position of beta chain) position of beta chain)

Types- HbE trait, HbE disease and E-Types- HbE trait, HbE disease and E-thalassemiathalassemia

1.HbE trait-asymptomatic and Hb level 1.HbE trait-asymptomatic and Hb level normalnormal

2.HbE disease-may also be asymptomatic 2.HbE disease-may also be asymptomatic or may present with mild anaemiaor may present with mild anaemia

-no organomegaly-no organomegaly

-may have low Hb during -may have low Hb during periods of rapid growthperiods of rapid growth

. 3.HbE – Beta thalassemia- more severe . 3.HbE – Beta thalassemia- more severe condition -clinical and haematological condition -clinical and haematological features resmble beta-thal major or features resmble beta-thal major or intermediaintermedia

Sickle Cell AnemiaSickle Cell AnemiaSickle Cell anemia is an inherited red blood cell Sickle Cell anemia is an inherited red blood cell disorder. Normal red blood cells are round like disorder. Normal red blood cells are round like doughnuts, and they move through small blood tubes doughnuts, and they move through small blood tubes in the body to deliver oxygen. in the body to deliver oxygen.

Sickle red blood cells become hard, sticky and shaped Sickle red blood cells become hard, sticky and shaped like sickles used to cut wheat. When these hard and like sickles used to cut wheat. When these hard and pointed red cells go through the small blood tube, they pointed red cells go through the small blood tube, they clog the flow and break apart. This can cause pain, clog the flow and break apart. This can cause pain, damage and a low blood count, or anemia.damage and a low blood count, or anemia.

The origin of the disease is a small The origin of the disease is a small change in the protein hemoglobinchange in the protein hemoglobin

The change in cell structure arises from a change inThe change in cell structure arises from a change inthe structure of hemoglobin. the structure of hemoglobin.

A single change in an amino acid causes hemoglobinA single change in an amino acid causes hemoglobinto aggregate.to aggregate.

Sickle Cell Trait

Sickle haemoglobin (S) + Normal haemoglobin (A) in RBC Adequate amount of normal Hb (A) in red blood cells

RBC remain flexible Carrier Do Not have the symptoms of the sickle cell

disorders, with 2 exceptions

1. Pain when Less Oxygen than usual (scuba diving, activities at high altitude (12,000ft), under general anaesthesia)

2. Minute kidney problems

Early Symptoms and Complications

Typically appear during infant's first year 1st symptom: dactylitis and fever (6 mo-2 yrs) Pain in the chest, abdomen, limbs and joints Enlargement of the heart, liver and spleen

nosebleeds Frequent upper respiratory infections Chronic anemia as children grow older

Over time Sickle Cell sufferers can experience damage to organs such as liver, kidney, lungs, heart and spleen

Can result in death

Medical Complications

1. pain episodes

2. strokes

3. increased infections

4. leg ulcers

5. bone damage

6. yellow eyes or jaundice

7. early gallstones

8. lung blockage

9. kidney damage and loss of body water in urine

10. painful erections in men (priapism)

11. blood blockage in the spleen or liver (sequestration)

12. eye damage

13. low red blood cell counts (anemia)

14. delayed growth

Infectious complications Prominent early in life Leading cause of morbidity and mortality Great improvement in the prognosis related to newborn

screening for sickle cell disease, vaccination for childhood illnesses, the use of prophylactic antibiotics, and aggressive diagnosis and treatment of febrile events

Acute splenic sequestration Episodes of rapid increase in splenic size and

decrease in hemoglobin Potential source of morbidity and mortality early in life

for children with sickle cell anemia and at any age for those with Hb SC disease and sickle thalassemia

Serious Complications

Strokes Up to 15% of children may have overt or silent strokes during

childhood Chronic transfusion therapy reduces the recurrence rate of

overt stroke which may approach 75% without intervention

Bone disease Early risk is primarily from osteomyelitis

Infectious usually painful inflammatory disease of bone often of bacterial origin and may result in bone tissue death

Avascular necrosis of the femur and humerus Death of bone tissue due to disrupted blood supply Marked by severe pain in the affected region and by

weakened bone that may flatten and collapse

Serious Complications

Serious ComplicationsSerious Complications

Leg ulcersLeg ulcers Seen in patients older than 10 years of ageSeen in patients older than 10 years of age Resistant to therapy and cause significant morbidityResistant to therapy and cause significant morbidity

OphthalmicOphthalmic complications complications Proliferative retinopathy, vitreous hemorrhage, & retinal Proliferative retinopathy, vitreous hemorrhage, & retinal

detachmentdetachment

PriapismPriapism Distressing complication that occurs at all agesDistressing complication that occurs at all ages Difficult to treatDifficult to treat Causes a high incidence of impotenceCauses a high incidence of impotence

Chronic Anemia Chronic Anemia Associated with fatigue, irritability, jaundice, pain, delayed Associated with fatigue, irritability, jaundice, pain, delayed

puberty, leg sores, eye problems, gum disease puberty, leg sores, eye problems, gum disease

LABLAB

What is G6PDWhat is G6PD?? It is an X-linked recessive inheritance. (males It is an X-linked recessive inheritance. (males

usually affected and females are carriers)usually affected and females are carriers)

Risk factors:Risk factors: being black, being male, or having a being black, being male, or having a family history of G6PD deficiency.family history of G6PD deficiency.

G6PD enzyme functions in the Pentose-G6PD enzyme functions in the Pentose-Monophosphate shunt and in the process, Monophosphate shunt and in the process, catalyzes the reduction of NADP+ to NADPH catalyzes the reduction of NADP+ to NADPH required in triggering a cascade of events that can required in triggering a cascade of events that can detoxify the harmful oxidant Hdetoxify the harmful oxidant H22OO22..

Role of G6PDRole of G6PD

Responsible for maintaining adequate levels Responsible for maintaining adequate levels of NADPH inside cell. of NADPH inside cell.

The oxidation of NADPH back to NADP+ is The oxidation of NADPH back to NADP+ is coupled with the reduction of oxidized coupled with the reduction of oxidized glutathione (GSSG) to reduced glutathione glutathione (GSSG) to reduced glutathione (GSH).(GSH).

Thus, NADPH keeps glutathione, a tri-peptide, Thus, NADPH keeps glutathione, a tri-peptide, in its reduced formin its reduced form..

Role of G6PD Cont’d...Role of G6PD Cont’d...

Reduced glutathione Reduced glutathione (GSH) acts as a (GSH) acts as a scavengerscavenger for dangerous oxidative for dangerous oxidative metabolites in the cell.metabolites in the cell.

GSH converts harmful hydrogen peroxide to GSH converts harmful hydrogen peroxide to waterwater catalyzed by the enzyme, glutathione catalyzed by the enzyme, glutathione peroxidase (catalase enzyme also detoxifies peroxidase (catalase enzyme also detoxifies HH22OO22).).

If HIf H22OO22 cannot be detoxified by GSH or cannot be detoxified by GSH or

catalase, hydroxyl radical formed from Hcatalase, hydroxyl radical formed from H22OO22

can be scavenged by Vit C/E.can be scavenged by Vit C/E.

G6PD DeficiencyG6PD Deficiency

Red cells deficient in G6PD are unable to Red cells deficient in G6PD are unable to neutralize hydrogen peroxide - Hneutralize hydrogen peroxide - H22OO22 converts to converts to

hydroxyl radicals and this can lead to oxidative hydroxyl radicals and this can lead to oxidative damage/toxic injury.damage/toxic injury.

Impaired response to oxidizing drugsImpaired response to oxidizing drugs can also can also induce hemolytic anemia (Individuals with G6PD induce hemolytic anemia (Individuals with G6PD deficiency are particularly susceptible)deficiency are particularly susceptible)

Drugs that affect itDrugs that affect it Drugs that can precipitate this reaction Drugs that can precipitate this reaction

include:include: •• anti-malarial agents anti-malarial agents •• sulfonamides (antibiotic) sulfonamides (antibiotic) •• aspirin aspirin •• non-steroidal anti-inflammatory drugs non-steroidal anti-inflammatory drugs (NSAIDs) (NSAIDs) •• nitrofurantoin nitrofurantoin •• quinidine quinidine •• quinine quinine •• othersothers

Also: Also: exposure to certain chemicals such as those in exposure to certain chemicals such as those in mothballs and flava beans.mothballs and flava beans.

How Drugs Affect G6PD Deficient How Drugs Affect G6PD Deficient Individuals?Individuals?

Glucose

Glucose-6-phosphate

6-Phosphogluconate

Ribose-5-phosphate

Fructose-6-phosphate

Glyceraldehyde-3-phosphate+

Pentose S

hunt

G6PDehydrogenase

NADPH

NADP+

GSSG

GSHGSH reductase

NADPH

NADP+

H2O

↑H2O2 O2

Catalase

NAD+

NADH

Fe2+ (oxyHb)

Fe3+

(metHb)

Drugs

Glyceraldehyde-3-phosphate

2 OH

Hemolysis

SuperoxideDesmutase(SOD)

(Fe2+)GSH Peroxidase

NADPH

(O2 )

What are the symptoms?What are the symptoms? The most common symptoms include:The most common symptoms include:

abnormal paleness or lack of color of the skinabnormal paleness or lack of color of the skin jaundice, or yellowing of the skin, eyes, and mouthjaundice, or yellowing of the skin, eyes, and mouth dark color to urinedark color to urine feverfever weaknessweakness dizzinessdizziness confusionconfusion intolerance to physical activityintolerance to physical activity

Required TestsRequired Tests

Blood tests are taken to measure levels of:Blood tests are taken to measure levels of: red cells, assess size and shape of red cellsred cells, assess size and shape of red cells measure the Hb levelmeasure the Hb level determine the number of reticulocytes.determine the number of reticulocytes.

Other blood tests may include:Other blood tests may include:

Coombs' testCoombs' test (direct and indirect) — checks for (direct and indirect) — checks for hemolytic anemia caused by an abnormal immune hemolytic anemia caused by an abnormal immune reaction. reaction.

Heinz body presentationHeinz body presentation — looks for a deficiency in — looks for a deficiency in amount of G6PD enzyme, which results in hemolysis amount of G6PD enzyme, which results in hemolysis

if if certain medications or foods are ingested.certain medications or foods are ingested.

Treatments may includeTreatments may include Stopping use of offending drug.Stopping use of offending drug. For more severe cases, treat with: For more severe cases, treat with:

corticosteroids (e.g. prednisone)corticosteroids (e.g. prednisone) intravenous immunoglobulin infusions intravenous immunoglobulin infusions immunosuppressive (e.g. azathioprine (Imuran) and immunosuppressive (e.g. azathioprine (Imuran) and

cyclophosphamide (Cytoxan) cyclophosphamide (Cytoxan) Vitamin and mineral supplements (e.g. folic acid).Vitamin and mineral supplements (e.g. folic acid). Change in diet.Change in diet. If Hb levels If Hb levels ↓↓, treatment may include blood transfusion or , treatment may include blood transfusion or

splenectomy (surgical removal of the spleen).splenectomy (surgical removal of the spleen). If physical damage to RBC, then treat w/ blood transfusions or If physical damage to RBC, then treat w/ blood transfusions or

simple iron supplements. simple iron supplements. Iron - Taken during pregnancy and when iron levels are low.Iron - Taken during pregnancy and when iron levels are low. Erythropoietin (Procrit) - To increase RBC production in people Erythropoietin (Procrit) - To increase RBC production in people

w/ kidney problems.w/ kidney problems.

IMMUNE HAEMOLYTIC ANAEMIA

CLSSIFICATIONCLSSIFICATION

TREATMENTTREATMENT

Prednisolone 1mg /kg for 4 week Prednisolone 1mg /kg for 4 week Tappered over 4 to 6 monthTappered over 4 to 6 month IVIG 1 gm/kg / day for 2 daysIVIG 1 gm/kg / day for 2 days Immunosuppressive agentImmunosuppressive agentDanazolDanazolRituximab (monoclonal antibody to CD20)Rituximab (monoclonal antibody to CD20)Hematopoetic stem cell transplantationHematopoetic stem cell transplantation

MICROANGIOPATHIC MICROANGIOPATHIC HAEMOLYTIC ANAEMIAHAEMOLYTIC ANAEMIA

mechanical injury as the cells traverse mechanical injury as the cells traverse a damaged vascular bed. a damaged vascular bed.

Damage may be microvascular, when Damage may be microvascular, when RBCs are sheared by fibrin in the RBCs are sheared by fibrin in the capillaries during intravascular capillaries during intravascular coagulation coagulation

renovascular disease accompanies renovascular disease accompanies hemolytic-uremic syndrome or hemolytic-uremic syndrome or thrombotic thrombocytopenic purpura.thrombotic thrombocytopenic purpura.

“schistocytes”