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Haematology > Anaemia > Flashcards

Anaemia Flashcards

1
Q

What does anaemia mean and how is it measured?

A

Reduced total red cell mass (not easy to measure)

Hb concentration + haematocrit (Hct) are surrogate markers

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2
Q

What is Hct?

A

Ratio/% of the whole blood that is red cells if the sample was left to settle

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3
Q

In which situations might Hb and Hct not be a good marker of anaemia?

A

Rapid bleeding –> massively reduced blood volume –> plasma expansion
Haemodilution

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4
Q

How does the body respond to anaemia?

A

Increase in RBC production –> reticulocytosis

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5
Q

What are reticulocytes and what do they look like?

A

Red cells that have just left the bone marrow

  • larger than mature red cells
  • still have remnants of RNA so stain purple/deeper red
  • -> blood film appears ‘polychomatic’
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6
Q

How can anaemias be calculated by pathophysiology and how can they be differentiated?

A

Reduced production of RBCs –> low reticulocyte count
vs
Increased loss or destruction of RBCs –> high reticulocyte count

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7
Q

How can ‘reduced production of RBCs’ be further classified?

A 
Hypoproliferation (reduced amount of erythropoeisis)
Maturation abnormality (ineffective erythropoeisis)
- cytoplasmic defects (impaired Hb)
- nuclear defects (impaired cell division)
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8
Q

What are the causes of increased loss or destruction of RBCs –> increased reticulocytes?

A

Bleeding

Haemolysis

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9
Q

How is anaemia classified by MCV and which problems should be considered?

A

If MCV low –> microcytic –> problem with haemoglobinisation
If MCV high –> macrocytic –> problem with maturation

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10
Q

What is the pathophysiology behind microcytic anaemias?

A

Hb synthesised in cytoplasm with:
- globins
- haem = porphyrin ring + Fe2+
Shortage of any of these results in small red cells with low Hb content

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11
Q

How would the cells be described in microcytic anaemia?

A

Microcytic (small) and hypochromic (lacking in colour)

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12
Q

What is the differential for a hypochromic microcytic anaemia?

A

Haem deficiency:

  • lack of iron (iron deficiency or sometimes anaemia of chronic disease)
  • problems with porphyrin synthesis (lead poisioning, pyridoxine responsive anaemias)
  • congenital sideroblastic anaemia (very rare)

Globin deficiency:
- thalassaemia

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13
Q

How is iron deficiency anaemia confirmed?

A

Anaemia - low Hb (reduced functional iron)

Low serum ferritin (reduced storage iron)

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14
Q

What are the causes of iron deficiency?

A 
Insufficient intake 
Blood loss
- menorrhagia (>60ml)
- occult GI blood loss
- haematuria
Malabsorption (uncommon)
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15
Q

If reticulocytosis is seen, how would you determine whether it is caused by bleeding or haemolysis?

A

Look for red cell breakdown products

  • raised in haemolysis
  • not in bleeding
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16
Q

What is the differential for macrocytic anaemia?

A

Nuclear maturation defects (failure of cell division):
- B12/folate deficiency (megaloblastic anaemia)
- myelodysplasia
- drugs e.g. chemotherapy
Apparent:
- agglutination
- reticulocytosis

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17
Q

Which conditions may cause macrocytosis without significant anaemia?

A

Hypothyroidism
Alcohol
Liver disease

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18
Q

What are the causes of normochromic normocytic anaemia?

A
  • -> hypoproliferative
  • marrow failure: drug induced, aplastic anaemia
  • hypometabolic
  • marrow infiltration: metastatic malignancy, fibrosis
  • renal impairment –> reduced Epo production
  • chronic disease: infective, inflammatory, malignant
19
Q

What is the pathophysiology behind anaemia of chronic disease?

A

Multifactorial:

  • blunted Epo response by kidney
  • impaired iron availability to erythroid precursors
  • inhibition of proliferation
  • reduced red cell survival
20
Q

How to the following parameters differ in iron deficiency anaemia and anaemia of chronic disease?

  • serum iron
  • transferrin
  • % transferrin saturation
  • ferritin
  • MCV
A

Iron deficiency:

  • serum iron LOW
  • transferrin NORMAL or HIGH
  • % transferrin saturation LOW
  • ferritin LOW
  • MCV LOW

Anaemia of chronic disease:

  • serum iron LOW
  • transferrin NORMAL or LOW
  • % transferrin saturation LOW
  • ferritin NORMAL or HIGH
  • MCV NORMAL (can be low)
21
Q

How is macrocytosis classified?

A

Genuine (true):
- megaloblastic
- non-megaloblastic
Spurious (false)

22
Q

What is a megaloblast?

A

An abnormally large nucleated red cell precursor with an IMMATURE nucleus

23
Q

What is the pathophysiology of megaloblastic anaemia?

A

Lack of red cells due to defects in DNA synthesis and nuclear maturation
RNA + Hb synthesis are preserved –> bigger cell (macrocyte)

–> larger cell size due to failure to become smaller

24
Q

What are the causes of megaloblastic anaemia?

A

B12 deficiency
Folate deficiency
Others: drugs, rare inherited abnormalities

25
Q

What are the causes of B12 deficiency, classified by site of problem?

A 
Mouth: vegan diet
Stomach: (intrinsic factor produced)
- pernicious anaemia
- atrophic gastritis
- PPIs/H2 receptor antagonists
- gastrectomy/bypass
Chronic pancreatitis
Jejunum: bacterial overgrowth, Coeliac
Duodenum: resection, Crohn's
Ilium (B12 absorbed): inherited defect of Cubulin receptors
26
Q

What is pernicious anaemia?

A

Autoimmune destruction of gastric parietal cells

27
Q

What are the causes of folate deficiency?

A 
Inadequate intake 
Malabsorption: Coeliac, Crohn's
Excess utilisation:
- haemolysis
- exfoliating dermatitis
- pregnancy
- malignancy
Drugs e.g. phenytoin (anticonvulsants)
28
Q

How long would body stores of B12 and folate last?

A

B12 –> 2-4 years

Folate –> 4 months

29
Q

What are the clinical features of B12/folate deficiency?

A 
Tiredness, fatigue
Sore red tongue
Weight loss
Diarrhoea
Infertility
Jaundice (intramedullary haemolysis)
Neurological and psychiatric symptoms --> B12
- paraesthesia
- depression, confusion
- memory problems
30
Q

How should a suspected B12/folate deficiency be investigated?

A

FBC: macrocytic anaemia
Blood film: macrovalocytes + hypersegmented neutrophils
Serum B12 and folate (not always reliable)
Check anti-IF and anti-gastric parietal cell (GPC) antibodies

31
Q

What are the causes of non-megaloblastic macrocytosis?

A 
Alcohol 
Liver disease
Hypothyroidism
Marrow failure (likely associated anaemia);
- myelodysplasia
- myeloma
- aplastic anaemia
32
Q

What does spurious macrocytosis mean?

A

The volume of mature RBCs is normal but MCV is measured as high

33
Q

What are the causes of spurious macrocytosis?

A 
Reticulocytosis (increased number of reticulocytes makes the MCV appear larger)
Cold agglutinins (clumps of agglutinated red cells are registered as 1 giant cell)
34
Q

What are the signs/symptoms of anaemia?

A 
SOB
fatigue
pallor (skin + conjunctiva)
angina
tachycardia
35
Q

What are the signs/symptoms of iron deficiency?

A

Same as for anaemia +

  • angular chelitis
  • glossitis
  • brittle nails
  • koilonychia (spoon-shaped nails)
  • pica: appetite for non food items e.g. clay, paper
  • restless leg syndrome
36
Q

How should suspected iron deficiency anaemia be investigated?

A

Low ferritin + low Hb
Low iron, raised TIBC, low transferrin saturation
Blood film: poikilocytes (abnormal shaped RBCs)
Investigate cause e.g. endoscopy

37
Q

What are the cancer referral guidelines for iron deficiency anaemia?

A

2 week urgent referral if:

  • > 60 years old or
  • > 55 with post-menopausal bleeding or
  • > 50 with PR bleeding
38
Q

How is iron deficiency anaemia managed?

A

Oral ferrous sulphate/fumarate
200mg 2-3 times daily
Take on an empty stomach

Or IV iron

39
Q

How long does oral iron take to have an effect and when should bloods be checked?

A

Takes 3-6 months to normalise ferritin

Check Hb after 2-4 weeks

40
Q

What are the side effects of oral iron?

A

Nausea and vomiting
Constipation
Black stools

41
Q

What are the indications for IV iron?

A

Failure of oral therapy
Impaired absorption e.g. IBD, gastrectomy
Taking Epo stimulating agents for CKD
Alternative to red cell transfusion e.g. if rejected for religious reasons

42
Q

How is B12 deficiency treated?

A

Hydroxycobalamin 1mg IM

  • initially 3x a week for 2 weeks (more in neurological symptoms)
  • then once every 3 months for life
43
Q

How is folate deficiency treated?

A

Oral folic acid 5mg daily for 4 months

  • may be required for life if cause is persistent
  • dietary advice

Haematology (15 decks)

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