Approach to Anemia PG CME 2014 · RBC count/L 5 x 1012 MCH (pg) = Hb/L 150 = 30pg Normal range: 27...
Transcript of Approach to Anemia PG CME 2014 · RBC count/L 5 x 1012 MCH (pg) = Hb/L 150 = 30pg Normal range: 27...
Approach to Anemia
PG CME 2014
Vikram MathewsHaematology DepartmentChristian Medical CollegeVellore
2017
Definition of Anemia
Beutler et al. Blood 2006.
Definition of Anemia
WHO definition of anemia (40 years old)
– Adult male <13g%
– Adult female <12g%
– Adult pregnant female <11g%
Beutler et al. Blood 2006.
Definition of Anemia
Databases analyzed:
Third US National Health and Nutrition Examination Survey [ NHANES-III ]
Scripps-Kaiser database
Definition of Anemia
Beutler et al. Blood 2006.
At Birth
Day 3 1 month
2 months
3 – 6 months
1 yr 2 – 6 yrs
6 – 12 yrs
RBC x 106/dL
6 ± 1 5.3 ±1.3
4.2 ±1.2
3.7 ±0.6
4.7 ±0.6
4.5 ±0.6
4.6 ±0.6
4.6 ±0.6
Hb gm/dL
18 ± 4 18 ± 3 14 ±2.5
11.2 ±1.8
12.6 ±1.5
12.6 ±1.5
12.6 ±1.5
13.5 ±2
MCV fl
110 ±10
105 ±13
104 ±12
95 ±18
76 ± 8 78 ± 6 81 ± 6 86 ± 9
WBC 18,000
± 8000
15000
± 8000
12000
± 7000
10000
± 5000
12000
± 6000
11000
± 5000
10000
± 5000
9000
± 4000
ANC 4000 –14000
(9000)
3000 –5000
(4000)
3000 –9000
(6000)
1000 –5000
(3000)
1000 –6000
(3500)
1000 –7000
(4000)
1500 –8000
(4750)
2000 –8000
(5000)
ALC 3000 –8000
(5500)
2000 -8000
(5000)
3000 –16000
(9500)
4000 –10000
(7000)
4000 –12000
(8000)
3500 –11000
(7250)
6000-9000
(7500)
1000-5000
(3000)
Briefly address:
- Reticulocyte count
- Coulter principle
- Generation of red cell indices
Reticulocyte Count
The reticulocyte count is the key toanswer the question whether it is aproduction problem or a loss problem
Expressed frequently aspercentage of RBC’s
Normal 0.5 – 1.5%(RBC – 5,000,000/mcl)
Absolute 25,000 – 75,000/mcl
Corrected Retic count= Obs/Exp Hb x Retic count
Reticulocyte Count
Normal Hb 12g%RBC count 5,000,000/mclRetic % 1%Absolute Reticulocyte count 50,000/mcl
Severe anemiaHb 6g%RBC count 2,000,000/mclRetic % 2%Absolute Reticulocyte count 40,000/mclCorrected Retic count 6/12 x 2 = 1%
Reticulocyte Count
- Additional correction for prolonged survival in peripheral blood often twice the normal duration of 1 dayhence x 0.5 (Reticulocyte production index)
RPI=Retic% x (Obs / Exp Hb:HCT) x (1/RMT)
- Limitations of reticulocyte count- High CV - Poor inter-laboratory comparison
(reticluocyte maturation time)
The Coulter Principle
Sensing Zone
Red Blood Cell
A red cell passes through RBC aperture
OscilloscopeOhm’s law: Voltage = Current X resistance
HgbHgb MeasurementMeasurementIn Beckman Coulter InstrumentsIn Beckman Coulter Instruments
ADC Signal Processor
HGB Lamp
Hb Cuvette
SampleHGB Sensor &
PRE-AMP
Absorbance= log 10 ( VR / Vs )
Where VR = Reference voltageVs = Sample voltage
Derivation
RED CELL INDICES
MCV (fl)= PCV 0.45 = 90fl Normal range: 81 – 101 fl
RBC count/L 5 x 1012
MCH (pg) = Hb/L 150 = 30pg Normal range: 27 – 32 pg
RBC count/L 5 x 1012
MCHC (g/l) = Hb (g/l) 150 = 33.3g/l Normal range: 31.5 - 34.5 g/l
PCV (%) 45
Reference ranges from Dacie and Lewis Practical Haematology
RED CELL INDICES
MCV (fl)= PCV 0.45 = 90fl Normal range: 81 – 101 fl
RBC count/L 5 x 1012
MCH (pg) = Hb/L 150 = 30pg Normal range: 27 – 32 pg
RBC count/L 5 x 1012
MCHC (g/l) = Hb (g/l) 150 = 33.3g/l Normal range: 31.5 - 34.5 g/l
PCV (%) 45
Reference ranges from Dacie and Lewis Practical Haematology
RBC Distribution Width (RDW)
Normal ValuesAs CV 12.8±1.2%As SD 42.5±3.5fl
Anemia results in decrease in oxygen carrying capacity
Symptoms depend on:
Degree of anemiaRate of fall in hemoglobinCapacity to compensate
Increase cardiac outputTachycardiaIncreased stroke volumePeripheral resistance
Change in O2 dissociation curve – 2,3 DPGOther co-morbid conditions
Clinical Features
Clinical Features of Anemia
TIREDNESS / EXERTIONAL DYSPNOEA
PALPITATIONS
HEADACHE
PALLOR
TACHYCARDIA
HYPERPNOEA
HYPERDYNAMIC CIRCULATION
FEVER
FEATURES OF HYPOXIA
History: - DURATION OF SYMPTOMS- ONSET & PROGRESSION- BLOOD LOSS IF ANY
TRANSFUSIONS - FREQUENCY- DATE OF LAST TRANSFUSION
- OTHER TREATMENT RECEIVED- EXPOSURE TO DRUGS AND CHEMICALS- DEVELOPMENTAL HISTORY IN CHILDREN- FAMILY HISTORY- OTHER ASSOCIATED SYMPTOMS IF ANY
- INFECTIONS- BLEEDING- OTHER SYSTEMS REVIEW
1. Reticulocyte count in diagnosis of anemia
Decreased production
Increased peripheral destruction
Classification of Anemia based on red cell size
Microcytic Normocytic Macrocytic
2. Morphology approach – based on alteration of red cell size best indicated by the MCV along with the reticulocyte response
Microcytic Hypochromic Anemia
IRON STORES
LOW/ ABSENT
NORMAL / INCREASEDIRON DEFICIENCY- S.Iron /TIBC- S.Ferritin- BM Iron Stores
LOOK FOR CAUSE
1. THALASSEMIA α / β- Hb A2/F- HbH Stain- Globin Chain Analysis
2. HEMOGLOBINOPATHY(Few)- Hb Electrophoresis
3. SIDEROBLASTIC ANEMIA- Siderocytes- Sideroblasts4. ‘CHRONIC DISEASE’
- Diagnosis of Exclusion
Increased lossHemorrhage
GI tractKidneyUterusOther
Decreased intakeIncreased regq-mnt
NutritionalPregnancyLactationOther
Iron deficiency
Causes of GI Blood Loss
ESOPHAGEAL WEB
VARICES, REFLUXCARCINOMA ULCER, CARCINOMA
LEIOMYOMAGASTRITIS
DUODENALULCER
POLYPS, MECKEL’SAV MALFORMATION
HAEMORRHOIDS
CARCINOMAULCERATIVE COLITIS
AMOEBIASISCARCINOMATUBERCULOSISCHRON’S
Normal
Iron deficiency
Low MCVSerum FeS Ferritin
Thalassemia minor
Serum Iron : 32 115 +/- 50 mgm/dL
Iron Binding : 312 330 +/-30 mgm/dL
Capacity
% Saturation : 10.2% 35 +/- 15%
Serum Ferritin: 4 M - 30-300 ng/ml
F - 15-150 ng/ml
Thalassemia / haemoglobinapthy: - appropriate clinical setting- low MCV- low RDW- normal / increased ferritin
Peripheral smear
Hb electrophoresis
HPLC
Mutation analysis
Anemia of Chronic Disease:
Acute infections
Chronic infections
Tuberculosis
Infective endocarditis
Chronic urinary tract infection
Chronic fungal infection
Chronic inflammatory disorders Osteoarthritis Rheumatoid disease Collagen vascular disease Polymyalgia rheumatica Acute and chronic hepatitis Decubitus ulcer
Malignancy Metastatic carcinoma Hematologic malignancies Leukemia Lymphoma Myeloma
Proteinenergy malnutrition
Serum Iron and IBC
NORMAL IRON IRON ANAEMIA OFDEFICIENCY OVERLOAD CHRONIC DISEASE
SE
RU
M I
RO
N
Differentiating from iron deficiency anemia
- Important since ACD does not respond to iron supplements
- Peripheral smear- History
Bone marrow
Hereditary Spherocytosis Sickle cell anemia
MAHA
Aplastic Bone Marrow
Heinz Bodies- G6PD deficiency- Other enzymopathies- Thalassemia
AIHA - AUTOAGGLUTINATION
Leukemia Bone Marrow
Vitamin B12Total Body content –2-5 mgRDA-5-7 mcg/dayTakes 3-4 years to deplete stores
Folic AcidTotal Body content- 5-10 mgRDA- 50 mcgStores can be rapidly depleted.
Folate Deficiency
Decreased Intake
Pancreatic diseaseIncreased RequirementGrowthPregnancyLactationHaemolysis
Metabolic BlockPyrimethamineMethotrexate
Diseases of the smallintestineMal-absorptionBacterial overgrowth
B12 Deficiency
Decreased IntakePure vegetarians
GastrectomyPernicious anemia
Diseases of theterminal ileum
TC II deficiency
Metabolic Block
Megaloblastic Anaemia
Clinical Features
Anaemia with icterus
Macrocytosis, hypersegmented neutrophils, pancytopaenia
Raised indirect bilirubin, LDH
Hypercellular marrow with megaloblastic changes
Pathophysiology of megaloblastic anemia
1.B12 and folate deficiencies result in defective DNA synthesis .
2.This results in an abnormal cell maturation process
3.Megaloblastic cells die in the bone marrow. (apoptosis through p53)
Laboratory evaluation
Suspect when MCV raised
LDH raised
Raised Indirect Bilirubin
Peripheral smear Macrocytosis
Hypersegmented neutrophils
Pancytopenia
Bone Marrow examination
Serum B12 assay
Serum and red cell folate assays
Serum B12 and Folate
Reference ranges Serum B12: 100-700 pg/mL Serum Folate: 3-16 ng/mL
Lower limit for B12 deficiency not well defined
In untreated patients with folate deficiency levels are usually <1.0 ng/mL
Other tests may be needed in borderline cases Serum methyl malonic acid Serum homocysteine
MMA and tHcys are now considered GOLD STD for diagnosis of Vitamin B12 Deficiency.(98% and 96% sensitivity respectively- Savage- Am J Med 1994)
These tests are used in patients with-(1) Borderline Cobalamin and Folate Deficiency.
(2) In conditions which increase or decrease levels.
(3) Both Cbl and Folate are low( MMA= Cbl def)
(4) When there are low Serum levels.
Approach to a Patient with Hemolytic Anemia
Clinical Signs of hemolysis
Chronic long standing from childhood
– Skeletal Abnormalities» Frontal Bossing
» Maxillary prominence
» Harrison’s sulcus
» Genu valgum
Jaundice with acholuric urine
Hepatosplenomegaly
Chronic leg ulcers
Laboratory indices of hemolysis
Raised reticulocyte count, polychromasia
Raised serum bilirubin – indirect fraction
Increased urine urobilinogen
Raised LDH
Intravascular hemolysis– Urine hemoglobin
– Plasma hemoglobin
– Decreased serum haptoglobin
– Methhemalbumin
HEMOLYTIC ANEMIA
COOMBS TEST
IMMUNENON IMMUNE
+ -
WARM Antibody
COLD Antibody
CONGENITAL ACQUIRED
Primary idiopathicSecondary
LymphoproliferConnective tissueDrugsHaptenImmune complex
Primary idiopathicSecondary
LymphoproliferInfectionsMycoplasmaInf Mono
PCHSyphillisPost viral
HemoglobinopathyThal majorHb E disease
EnzymopathyG6PD def
MembranopathyHer spherocytosis
PNH
MAHA
Venoms
Infections
Drugs / Chemicals
Laboratory tests required to establish the cause of hemolysis
Congenital
– Blood Picture
– Sickle prep, Hb H prep, Electrophoresis/HPLC
– Osmotic fragility
– Unstable Hb, Heinz body
– G6PD, PK
Acquired
– Coomb’s test
– Tests for PNH
With a rational approach it is possible to determine the cause of anemia and then plan appropriate treatment