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J Haem > Anaemia > Flashcards

Anaemia Flashcards

1
Q

anaemia definition

A

red total RBC mass

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2
Q

what are the 2 possible pathophysiologies of anaemia

A

increased destruction of RBCs eg bleeding, haemolysis

decreased production of RBCs

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3
Q

what is the problem in microcytic anaemias

A

there is a problem with the haemoglobin production

either heme problem or globin problem

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4
Q

microcytic anaemia, potential causes of haem deficiency caused by iron deficiency (4)

A

low dietary intake
anaemia of chronic disease
malabsorption
blood loss

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5
Q

microcytic anaemia, cause of globin deficiency

A

thalassaemia

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6
Q

most common cause of microcytic anaemia

who gets it

A

low iron dietary intake

veggie/vegans

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7
Q

microcytic anaemia, potential causes of haem deficiency not caused by iron deficiency (2)

A

porphyrin synthesis problem - lead poisoning

genetic

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8
Q

pneumonic for remembering causes of microcytic anaemia

A

find the small cell

Fe deficiency - diet, malabsorption, blood loss, anaemia of chronic disease
Thalassaemia
Sideroblastic anaemia (don’t need to know)
anaemia of Chronic disease

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9
Q

relative iron deficiency anaemia

A

eat ‘enough’ iron but not enough for body eg pregnant, children

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10
Q

absolute iron deficiency anaemia

A

don’t eat enough iron

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11
Q

what is anaemia of chronic disease

A

when you have enough iron intake but cant use it

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12
Q

second most common cause of anaemia after iron deficiency

A

anaemia of chronic disease

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13
Q

causes of anaemia of chronic disease

A

malignancy
infection
inflammatory (eg rheumatoid arthritis)

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14
Q

in anaemia of chronic disease, the cause of the problem is due to increased inflammatory cytokines, what does this then lead to the production of

what does this do

A

hepcidin

inhibits release of iron from duodenum = decreased Hb production in bone marrow = anaemia

NOTE inflammatory cytokines also decrease EPO from kidneys and directly inhibit erythropoiesis in bone marrow, but above is the main mechanism

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15
Q

example of chronic condition with malabsorption of iron

A

coeliac

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16
Q

causes of blood loss that can cause anaemia (3)

A

GI bleed
haematuria
menorrhagia

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17
Q

cause of porphyrin synthesis problem = haem deficiency = anaemia

A

lead poisoning

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18
Q

globin deficiency

A

thalassaemia

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19
Q

why does haemoglobin deficiency cause MICROCYTIC anaemia

A

bone marrow still makes RBCs, they just contain less Hb than normal = smaller with less Hb (low MCV)

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20
Q

is haemogllobin deficiency hypo or hyperchromic anaemia

A

hypochromic - less Hb than normal RBCs

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21
Q

when do people present with symptoms in microcytic anaemia

A

late stage

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22
Q

once microcytic anaemia has been diagnosed, what do you want to measure to diagnose cause

A

serum ferritin

if low = iron deficiency cause
if high = globin problem (thalassaemia)

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23
Q

iron deficiency anaemia diagnosed (microcytic anaemia with low serum ferritin), what do you do

A

prescribe fe2+ supplements (ferrous fumarate)

AND investigate cause further for blood loss - FOB, endoscopy etc

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24
Q

what blood component will be increased in microcytic anaemia

why

A

platelets = thromobocytosis

bone marrow compensates for decreased RBCs = tries to make more, platelets come from same precursor

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25
Q

pencil/rod cells

A

iron deficiency anaemia

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26
Q

reticulocyte count in microcytic anaemia

A

low - bc not enough components to make RBCs in the first place

reticulocytes are only high in increased destruction where the bone marrow wants to get the RBCs out as soon as possible

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27
Q

side effect of ferrous fumarate

A

constipation

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28
Q

what is the expected response after starting iron supplements for microcytic anaemia

what may cause a lesser response

A

7-10g/L Hb rise per week

poor compliance (SEs) 
underlying problem eg bleed
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29
Q

cause of macrocytic anaemia (2 types)

A

megaloblastic - defects in DNA synthesis

non megaloblastic - liver disease, alcohol, hypothyroidism, bone marrow failure

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30
Q

cause of macrocytosis that doesn’t cause anaemia

A

alcohol

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31
Q

causes of megaloblastic macrocytic anaemia

A

B12 deficiency
folate deficiency
cytotoxic drugs eg methotrexate

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32
Q

pneumonic for megaloblastic anaemia causes

A

cant be fucked

cytotoxic drugs eg methotrexate
B12 deficiency
folate deficiency

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33
Q

causes of B12 deficiency causing megaloblastic microcytic anaemia (3)

A

vegan diet - B12 comes form animal products
eating disorder
pernicious anaemia
PPIs

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34
Q

definition of megaloblastic anaemia

A

DNA synthesis problem = cell maturation problems = megaloblasts formed (precursor cells)

failure of normal maturation

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35
Q

autoimmune cause of macrocytic anaemia

A

pernicious anaemia

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36
Q

PMH/Fx of autoimmune conditions or hypothyroid

develops anaemia

A

pernicious anaemia

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37
Q

how does pernicious anaemia cause B12 deficiency (and hence anaemia)

A

autoimmune destruction of gastric parietal cells = intrinsic factor deficiency = B12 malabsorption = B12 deficiency

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38
Q

folate deficiency causes

A

poor intake - alcoholics, eating disorder
malabsorption - coeliac, crohns
drugs

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39
Q

which drug causes folate deficiency

A

phenytoin (anticonvulsant)

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40
Q

which 2 substances are important in nuclear maturation

what does this cause

A

B12 and folate

abnormal cell division = premature stop = makes macrocytes

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41
Q

what DNA base is the folate cycle crucial in forming

A

thymidine (T)

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42
Q

where is B12 normally absorbed

A

ileum (distal bowel)

THINK: B12 = wants to get passed T12 = far away = distal bowel

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43
Q

what things bind to B12 when its broken down in the stomach to take it to the distal bowel (ileum)

A

protein R

intrinsic factor

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44
Q

where is folate normally absorbed

A

jejunum (proximal bowel)

THINK: not B12 so no need to get passed T12 = can be absorbed proximally

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45
Q

what is RNA, cytoplasm and haemoglobin synthesis like in macrocytic anaemia

A

all normal

the only problem is DNA synthesis = reduced maturation

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46
Q

how do megaloblasts look in comparison to normal RBCs

what RBC precursor are they similar to, whats the only difference

A

larger
has an immature nucleus

look similar to normoblasts/erythroblasts, just have an immature nucleus (erythroblasts = normal nucleus)

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47
Q

what happens to the majority of the megaloblasts produced in megaloblastic anaemia

A

apoptosis in the bone marrow (bc theyre faulty RBCs)
= intramedulary haemolysis (break down of RBCs)
= jaundice

48
Q

where does hameolysis happen in megaloblastic anaemia

A

intramedullary - in the bone marrow

due to apoptosis of megaloblasts (immature RBCs)

49
Q

what happens to a minority of the megaloblasts produced in megaloblastic anaemia

A

some survive = hence seen in blood count = anaemia

50
Q

what happens to normal RBCs as they mature

how is this differnet for megaloblasts

A

they get smaller

megaloblasts have faulty NDA = unable to undergo cell division = big cells = hence cause macrocytic anaemia

51
Q

beefy red tongue

A

megaloblastic macrocytic anaemia (B12/folate deficiency/cytotoxic drugs)

52
Q

what cells seen on blood film are characteristic of megaloblastic macrocytic anaemia

A

macroovalocytes
hypersegmented nucleus of neutrophils
tear drop RBCs

53
Q

hypersegmented nucleus of neutrophils

A

megaloblastic macrocytic anaemia

54
Q

macroovalocytes

A

megaloblastic macrocytic anaemia

55
Q

tear drop RBCs

A

megaloblastic macrocytic anaemia

56
Q

investigations after diagnosis of megaloblastic macrocytic anaemia

A

B12 levels
folate levels
anti-gastric-parietal cell AND anti-intrinsic factor autoantibodies - for pernicious anaemia
coeliac antibodies

57
Q

management of B12 deficiency causing megaloblastic macrocytic anaemia

what special consideration is needed if caused by pernicious anaemia

A

IM hydroxycobalamin

for life - if pernicious anemia
for 3 months and reassess - if dietary problem

58
Q

management of folate deficiency causing megaloblastic macrocytic anaemia

A

folic acid 5mg daily

59
Q

apart from megaloblastic causes of macrocytic anaemia, what are the other causes (4)

A

alcohol
liver disease
hypothyroidism
bone marrow failure

60
Q

how does hypothyroidism cause non-megaloblastic macrocytic anaemia

A

reduced EPO from kidney = anaemia

also link with pernicious anaemia, but don’t worry too much lol

61
Q

how does the blood film differ between megaloblastic macrocytic anaemia and non-megaloblastic macrocytic anaemia

A

megaloblastic macrocytic anaemia = macroovalocytes, hypersegmented nucleus of neutrophils, tear drop RBCs

62
Q

investigations once non-megaloblastic macrocytic anaemia diagnosed (find cause)

A

LFTs
TFTs
alcohol history
bone marrow biopsy

63
Q

false causes of macrocytosis (when MCV is high but mature red cells are actually the normal size)

A

reticulocytosis

autoimmune haemolytic anaemia - clumping of RBCs = get picked up as one not several

64
Q

what blood results do you look at for ?anaemia

what are each looking for

A

Hb - to confirm anaemia
MCV - to see if macrocytic or macrocytic
serum ferritin - if microcytic, to look at iron deficiency cause
blood film (MCH) - if macrocytic, for hypersegmented neutrophils and macroovalocytes = megaloblastic cause
B12/folate - if macrocytic for B12/folate deficiency
autoantibodies for pernicious anaemia - if macrocytic

65
Q

main presentation of anaemia

A

fatigue

66
Q

female anaemia Hb

A

<120 g/L

67
Q

male anaemia Hb

A

<130 g/L

68
Q

what does haematocrit measure (not used in UK)

problems with this

A

% of whole blood that is RBCs

blood loss causing anaemia = % will still be the same, even though low RBC (bc total blood volume is reduced)

69
Q

O2 sats in anaemia

pO2 sats in anaemia

A

probs 99% bc the heamoglobin that is going around is fully saturated, just isn’t much of the haemoglobin itself

pO2 also probs normal bc same amount of oxygen is entering the blood from the lungs (what pO2 measures) just isn’t much going round

70
Q

high platelets (thrombocytosis)

A

microcytic anaemia - bc bone marrow is trying to compensate for decreased RBC production, and platelets and RBCs have the same precursor cell

71
Q

is serum ferritin or transferrin preferred

why

A

serum ferritin - measure of iron stores, not just circulating iron

72
Q

when do you blood transfuse for anaemia

A

only if symptomatic and <70g/L

73
Q

which type of anaemia do you see reactive changes in

what are reactive changes

A

anaemia of chronic disease

neutrophilia (high neutrophils)
thrombocytosis (high platelets)

74
Q

haemolysis definition

A

premature destruction of RBCs <3 months

75
Q

most common cause of haemolysis

A

autoimmune haemolytic anaemia

76
Q

what are the 2 types of autoimmune haemolytic anaemia

what does this mean

A

cold and warm autoantibody

cold - happens in cold weather
warm - happens in warm weather

77
Q

which autoantibody is warm autoimmune haemolytic anaemia associated with

A

IgG

THINK: when you go to Ghana (warm) = IgG

78
Q

which autoantibody is cold autoimmune haemolytic anaemia associated with

A

IgM

THINK: when you go to Moscow (cold) = IgM

79
Q

is warm or cold autoimmune hemolytic anaemia more common

A

warm (IgG)

80
Q

what does positive coombs mean when testing for types of haemolysis

A

immune cause of haemolysis

81
Q

blood film of autoimmune hemolytic anaemia (2)

A

spherocytes

reticulocytes

82
Q

differentials of spherocytes (2)

how do you tell the difference (investigation)

A

autoimmune hameolytic anaemia
hereditary spherocytosis

do coombs test - positive in autoimmune haemolytic anaemia bc immune

83
Q

what does presence of reticulocytes mean

A

haemolysis (or haemorrhage) has occurred and bone marrow trying to compensate

84
Q

management of autoimmune haemolytic anaemia

A

steroids or immunosuppression bc autoimmune

85
Q

what antibody is associated with extravascular haemolysis as a result of ABO incompatibility

is it an immediate or a delayed reaction

A

IgG (THINK: igM = iMMediate, so igG must be delayed)

delayed - bc blood transfusion initially goes to blood vessels, then moves out of vessels (hence extravascular)

86
Q

what antibody is associated with intravascular haemolysis as a result of ABO incompatibility

is it an immediate or a delayed reaction

A

IgM (THINK: igM = iMMediate)

immediate - bc in the vessels (that’s where the blood transfusion goes)

87
Q

haemolysis associated with mechanical/leaking heart valves

A

microangiopathic haemolytic anaemia (MAHA)

88
Q

hereditary causes of haemolysis (2)

A

hereditary spherocytosis

G6PD deficiency

89
Q

blood film of hereditary spherocytosis

A

spherocytes - sphere shaped RBs instead of biconcave

90
Q

inheritance pattern of hereditary spherocytosis

A

autosomal dominant

91
Q

why are spherocytes susceptible to haemolysis

A

spherical shape means they get stuck in blood vessels = early deconstruction (haemolysis)

92
Q

are spherocytes hypo or hyperchromic

A

hyperchromic, loss of central pallor (the dip in the middle when RBCs are biconcave)

93
Q

what happens to bone marrow (hyper or hypo plasia) in haemolysis

A

bone marrow hyperplasia to compensate for haemolysis

tries to make more RBCs fast!!

94
Q

the presence of which cell is classic of haemolysis

A

reticulocytes - immature RBCs (still have RNA), bone marrow just fires out whatever it can make (whether theyre mature or not) to try and compensate for anaemia)

95
Q

spleen in hereditary spherocytosis

A

splenomegaly

96
Q

complication of bone marrow hyperplasia in spherocytosis

A

short stature

97
Q

skin in extravascular haemolysis

A

likely jaundice from excess bilirubin breakdown after haemolysis

intravascular = not jaundice bc break down of RBCs in circulation = Hb excreted in urine (not broken down)

98
Q

management of hereditary spherocytosis

A

folic acid - in encourage normal RBC production

splenectomy - sometimes in children

99
Q

which drug can alter RBC metabolism and cause hemolysis

A

dapsone

100
Q

which hereditary cause of abnormal haemoglobin can result in haemolysis

A

sickle cell anaemia

101
Q

difference between reticulocytes and RBCs

A

reticulocytes still have RNA = premature RBCs

reticulocytes are larger and more purple

102
Q

why does presence of reticulocytes cause macrocytosis

A

bc they are classed as the ‘same’ as RBCs but are larger = macrocytosis

103
Q

are most causes of haemolysis intravascular or extravascular

what does this mean

A

extravascular

haemolysis happens in the liver/spleen

104
Q

which causes of haemolysis are intravascular (3)

A

immediate ABO incompatibility (IgM mediated)
microangiopathic haemolytic anaemia (MAHA) - mechanical/leaking heart valves
G6PD deficiency

105
Q

when haemolysis happens inside the blood vessels (intravascular haemolysis) what breakdown product forms

how is it excreted
how can you tell if this has happened or not

A

schistocytes
free haemoglobin in circulation

excreted in urine (haemoglobinuria)
urine turns black on standing

106
Q

what blood film finding occurs in G6PD deficiency causing intravascular haemolysis

A

Heinz bodies

107
Q

investigations for hemolysis

A

Hb - anaemia
blood film - reticulocytes, spherocytes, Heinz bodies
direct coombs test - for immune cause

108
Q

what is the most common anaemia in children

A

iron deficiency anaemia

109
Q

the normal physiological response to which chronic condition can cause high RBCs

why

A

COPD

if hypoxia = EPO made from kidneys = increased RBC production

110
Q

causes for iron overload

A

hereditary haemochromatosis

repeated RBC transfusion

111
Q

what is the problem in hereditary haemochromatosis that results in increased iron

A

decreased hepcidin synthesis = increased iron absorption

occurs over years

112
Q

transferrin levels in hereditary haemochromatosis

A

> 50% (normal 20-30%)

113
Q

management of hereditary haemochromatosis

A

weekly venesection for life (take blood off them)

114
Q

complications of untreated hereditary haemochromatosis

A

end organ damage = BAD

115
Q

management of iron overload caused by repeated RBC transfusion

A

iron chelating durgs eg desferrioxamine

NOT venesection (like hereditary haemachromatosis) bc they need the Hb, just not the Iron

116
Q

microcytic anaemia with target cells

A

thalassaemia

117
Q

microcytic anaemia with rod cells

A

iron deficiency anaemia

J Haem (12 decks)

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