Anemia Flashcards
What is anemia?
Decrease in # of RBC’s or less than normal quantity of Hgb in the blood
What does anemia primarily result in?
Decrease in oxygen carrying capacity in the blood
What is erythropoiesis?
formation of RBC’s
What are the components of RBC’s?
2 alpha, 2 beta chains
heme group (porphyrin ring +iron)
What is the difference of RBC’s between infants and adults?
Infants have gama chains instead of beta chains which are much more affinitive for oxygen?
How does erythropoiesis work?
Feedback loop, decrease in tissue oxygen results in stimulation of EPO production and release
Where is EPO released from?
90% kidneys
What does EPO do?
stimulates stem cells to differentiate, increases release of reticulocytes from bone marrow, induces Hb formation
What are the 3 classifications of anemia (pathophysiology)
Blood Loss
Inadequate RBC production
Excessive RBC destruction
What are the classifications of anemia based on RBC morphology?
Size:
Microcytic
Normocytic
Macrocytic
- megaloblastic
- non-megaloblastic
Colour:
hypochromic
normochromic
hyperchromic
Describe Microcytic
Primarily result in Hb synthesis failure or Hb insuffeciency, can be caused by issue of heme or globin portion
<80 fL (small)
Describe Normocytic
Normal size but low number of RBC’s
Decrease production or increase in desctruction/ loss
80-100 fL (normal)
Describe Megaloblastic
Impaired DNA synthesis
- B12 deficiency
- folate deficiency
Describe non-megaloblastic
Not cuased by DNA synthesis
- liver disease, etc.
What is the general Presentation of Anemia?
acute/ devlop slowly (sometimes)
End result of decreased oxygen carrying capacity
perfusion of non-vital organs compromised to sustain vital organs –> itially pts asymptomatic
What are common symptoms of anemia?
Fatigue, dizziness, weakness, SOB, tachycardia, decreased mental acuity, pallor(whiteness especialy in eye lids or nail bed), cold extremities, postural hypotension, jaundice(hemolysis), bleeding gums, blood in stool/urine
What medical history do you need to consider for diagnosis?
Past and current hgb and blood work
Comorbitites
Transfusion
Family history
Medications
Social history
What is a CBC and what do you use from it?
Complete Blood Count
- Hb (amount of hemoglobin in blood)
- Hematocrit (packed cell volume)
- RBC count
- RBC indicies (MCV, MCH, MCHC)
What is MCV?
mean corpuscular volume (size, average cell volume)
What is MCH?
mean corpuscular hemoglobin (hemoglobin/cell)
What is MCHC?
mean corpuscular hemoglobin concentration (colour marker)
What is RDW?
red blood cell distribution width (variation in size/width)
What is a peripheral blood smear used for?
follow-up of CBC
What is the stool for occult blood used for?
Marker of blood loss
What level of hemoglobin is a diagnosis for anemia (male and female numbers)?
Men: <130g/L
Women: <120g/L
What factors can affect the number of hemoglobin?
Higher altitudes (increases number)
Smoking (increases)
Pregnancy (expansion of plasma volume can be lower)
What are the specific types of anemias?
Deficiency related anemia
- Iron
- Folate
- B12
Hemolytic
Sickle cell
Aplastic
Anemia related to otehr diseases/conditions
- chronic disease, CKD, critical illness/blood loss
What is the most common nutritional deficiency world wide?
Iron
What symptoms are associated with iron defecient anemia?
pallor
cardiovascular symptoms
respiratory
cognitive complications
decrease quality of life
What us the definition of iron deficient anemia?
negative state of iron balance where daily iron intake are unable to meet RBC and other body tissue needs
What can cause iron deficient anemia?
Low Dietary intake
Blood Loss
Decreased absorption
Increased requirement (infancy, pregnancy)
Impaired utilization
What is NIMBLE?
Need
Intake is low
Malabsorption
Blood
Loss
Excessive donation
What is the mortality w/ iron defecient anemia
Rarely direct cause of death
Moderate/severe anemia can cause hypoxia, exacerbate pulmonary/CV disorders
Morbitity with iron defecient anemia?
Disruptive symptoms
impair to daily functioning
slwoed growth rate in children
decreased ability to learn
lower IQ
Splenomegaly in severe untreated
Effect of Iron defecient anemia in elderly?
increased risk of mortality and morbitity
Decreased quality of life
Decrease physical functioning
Effect of iron deficient anemia in pregnancy?
low birth wts
preterm delivery
perinatal mortality
Iron Characteristics in the body?
3-5g in body, 2g in hemoglobin
significant stores in ferritin or aggregated ferritin in liver, spleen, bone marrow
despite turnaround of RBCs iron stores are usually well preserved
iron metabolism is regulated by hepcidin
What is TIBC?
total iron binding capacity
What is Tsat?
percent of transferrin saturation
serum iron/TIBC x100
What labs correlate with Iron deficient anemia?
decreases in ferritin, serum iron, trasferrin saturation, and Hb and HCT (decline later on in progression)
Increase in TIBC
RBCs: microlytic, hypochromic
What is the diagnosis of iron defecient anemia based on?
Symptoms, medical histpry, CBC, labs, morphology
What are some other symptoms of iron defecient anemia (not including the typical anemia symptoms)
brittle nails
Pica
Pagophagia
Smooth tongue
Treatment for iron defecient anemia?
Iron supplement;
Oral first line
Parental iron therapy only used if needed
Adult dosing for iron in iron defecient anemia?
105-200mg elemental iron daily
Formulation of trablet?
basic, enteric coated or altered formulations not great, as iron absorption occurs early in gut
Iron supplements and % of elemental iron
fumerate: 33%
sulfate: 20%
gluconate: 11%
polysaccharide: 100%
polypeptide: 100%
SE’s of rion supplements?
NV, constipation (sometimes diarrhea)
dark stool
Length of therapy for iron supplement (iron defeceint anemia)
3-6 months after normalization
What is the dosing for pediatrics with iron?
wt based, 3-6mg/kg/d divided TID
What are some considerations with liquid iron?
iron overdose in children very toxic so counsel appropriately
Store properly so children cannot access iron supplements
Mix with water/juice to prevent teeth staining
Iron poisoning decription/treatment?
SE’s seen within 6hrs –> severe vomitting, diarrhea, abdominal pain, dehyfration, lethargic, blood in vomit/stool
Treatment: Deferoxamine to bind excess iron
How can you make iron supplements more tolerable to take for pts?
lower dose
titrated up
alternate day dosing
take w/ food (decreases absorption though)
take before bed (sleep off bothersome SEs)
At what time frame is iron defecient anemia usually corrected w/ treatment?
~6 weeks but need to continue to prevent relapse and replenish stores
What is B12 used for?
required for proper RBC formation, neurological function, and DNA synthesis
Where is B12 stored?
in liver
Is B12 defeciency quick?
NO, develops over many years
How is B12 absorbed?
Free B12 binds to intrinsic factor, then IF is discared and bound to transcobalmin II for secretion into the blood
What are common causes of B12 defecient anemia?
inadequate intake
Malabsorption:
- age
- pernicious anemia
- gastrectomy, bariatric surgery, achlorhydria, small bowel disorders, drugs
Inadequate utilization
What is pernicious Anemia?
autoimmune disorder affecting gastric mucousa, results in gastric atrpohy; failure of IF production
B12 malabsorption from lacking IF, associated with increased risk of gastric cancer
Symptoms of B12 anemia?
typical anemia symptoms
Often neurological
- numbness/tingling in extemities
- off balance
- depression, confusion, dementia, poor memory
Soreness of mouth/tongue
Can neurological issues occur w/out anemia forB12 deficiency?
Yes, are usually progressive and can become irreversible
What meds can B12 defeciency be a concern?
PPI’s, H2, colchicine, metformin
What do you see occur in labs w/ B12 deficiency anemia?
decrease n serum/plasma B12 levels
increase in homocysteine levels (early), methylmalonic acid levels
RBC: macrolytic, mormochromic
What tests can be done to check for pernicious anemia?
Schilling test, antibodies to IF/ parietal cells
Treatment for B12 deficient anemia (non-pernicious)
100ug/d po to normalize B12 levels within a month
When is IM B12 used for treatment?
Pernicious anemia
severe malabsorption issues
non-adherent w/ oral
Neurological symptoms
What are disadvantages of B12 IM?
Expensive, inconvenient, injection related SE’s
Were is folate stored? how big of a reseve?
Liver, 4-6 months of stores but, can be depleted in ~6 weeks if diet severly laking
Lay out treatment regime for B12 deficient anemia and pernicious anemia/other chronic malabsorption
Non: Initial: 30g/ug daily SC/IM x 5-10d or 500-2000 ug daily PO.
Maintenance: 100-200ug monthly SC/IM or 250ug daily PO
Pernicious: 100ug daily SC/IM x 1 week; 200ug weekly SC/IM until Hb normalizes
Maintenance: 100ug monthly SC/IM or 1000-2000ug daily po
What can cause folate deficiency?
inadequate intake
Increased requirements (pregnancy)
Malabsorption
Some drugs
What drugs can cause folate deficiency?
metformin
methotrexate
sulfasalazine
triamterene
trimethoprim
What is a major difference between folate and B12 anemia deficiency symptoms?
No neurological SE’s
What do you see with labs in folate defecient anemia?
decrease in serum folate
increase in homocystiene levels
RBCs: macrocytic, normochromic (same as B12)
What is the treatment for folate deficiency?
1mg/day or 5mg/d (Rx) if absorption compromised
Duration: ~4months for folate-deficient RBCs to be cleared from circulation
May be on long-term or dietary corrections made.
What are the response rates for Reticulocytes, Hb, resolution of anemia, and Neurologic(B12 only) for Folate/B12 defiency
Reticulocytes: response within 3-4 days
Hb improving by ~day 10 of treatment
Full resolution of anemia ~2 months
neurological deficiets w/ B12 may take 6 months or longer
What is something to watch for with rapid production of hematopoietic cells?
Can cause a dramatic shift in K; hypokalemia is possible so monitor for SE’s/ lab work especially in elderly and HF pts
Describe hemolytic anemia
decreased survival time of RBCs secondary to destruction in the spleen or circulation
RBCs: usually normocytic and normochromic. Increased levels of reticulocytes
what causes hemolytic anemia?
usually idopathic
Can be caused by immune reactions,
malignancy,
drugs (ACE-I, NSAIDs/ASA, antibiotics),
G6PD enzyme deficiency (inherited defect, normally protects RBCs againt oxidative stress)
What is the most common enzyme deficiency?
G6PD
What is the treatment for hemolytic anemia?
correcting underlying cuase (or contorlling)
steroids and other immunosuppressant agents for management of autoimmune
splenectomy sometimes indicated in attempt to reduce RBC destruction
What is the cause of sickle cell anemia?
autosomal recessive Hgb disorder characterized by a DNA substitution at the beta-globulin gene
What happens to hemoglobin/ RBCs in sickle cell anemia?
abnormal Hb called hemoglobin S formed
distorts shape of RBC especially when exposed to low O2 levels
What is the issue with sickled RBCs?
Rigid, do not pass through microvasculature, prone to rupture
- Ischemia, pain
- chronic organ damage
What are symptoms of Sickle cell anemia?
impaired growth/development
enlarged spleen
chronic damage to many organs
Vaso-occlusive crises
- sludging
- pain in bones of the back, long bones, chest
What labs are done to determine sickle cell anemia?
Hb electrophoresis, HbS presence
RBCs: mormochromic, normocytic, sickled cells present
How do you treat Sickle-cell anemia?
Acute: pain meds, hydration
Vaccinations and penicillin prophylaxis for children up to 6
Hydroxyurea
partial blood transfusion
bone marrow transplant (curative but has risks)
Describe anemia of inflammation
Used to describe both anemia of chronic disease and critical illness
reflects inflammatory process resulting in disturbances in iron homeostasis underlying both types of anemia
How is anemia of inflammation diagnosed?
Exclusion diagnosis
What are symptoms of anemia of chronic disease?
mild, non-specific
What do labs look like for anemia of chronic disease?
decreased hematocrit, serum iron, normal or increased ferritin, normal or decreased TIBC
RBCs: usually normocytic and normochromic (can be microcytic)
Compare/ Contrast Anemia of chronic disease vs deficient anemia (serrum ferritin, serum iron, Tsat, TIBC, Hb)
Chronic: Decreased or normal, decreased, normal or decreased, normal or decreased, decreased
Deficient: Decreased, decreased, decreased, increased, decreased
What is seen in anemia b/c of CKD
ERythropoiesis decreased, uremic metabolites decrease life span of RBCs
Symptoms of CKD anemia?
general anemia sx, angina, ischemia on ECG, CHF
How do you treat CKD anemia?
Iron
eryhtropoetin stimulating agents
transfusions
Which pts are responsive to erythropoisis pharmacological stimulation?
chronic renal failure
HIV pts
chronic hep C recieving ribavirin
chemotherapy nonhematologic cancers
surgery pts
low risk myelodysplastic syndrome
Describe aplastic anemia
failure of pluripotent stem cells in bone marrow; hematopoiesis interupted resulting in anemia neutropenia, thrombocytopenia
Which anemias arwe microcytic?
Iron deficiency, thalassemia, chronic disease anemia
Which anemias are normocytic?
SIckle cell, hemolytic, aplastic, chronic disease, CKD, mixed deficiency anemias
WHich anemias are macrocytic?
B12/folic acid deficiency, liver disease
