Anemia Flashcards
What is anemia?
decrease in RBC or hemoglobin
Signs/Symptoms of Anemia
- exertional dyspnea
- angina
- tachycardia
- fatigue
- Pallor
may be asymptomatic if develops slowly
Normal RBC
4.5-5.5 x 10^6 cells/uL –> male
4.1-4.9 x 10^6 cells/uL –> female
Normal Hemoglobin
13.5-18 g/dL –> male
12-16 g/dL –> female
oxygen carrying capacity
Diagnosis
Hb < 13.5 g/dL –> male
Hb < 12 g/dL –> female
Normal Mean Corpuscular Volume (MCV)
80-100 mm^3
average volume of RBC (size)
Normal RBC Distribution Width (RDW)
11.5-14.5%
variation in size of RBCs (range)
Normal Ferritin
15-200 ng/mL
acute phase reactant –> elevated in acute inflammation or chronic disease
Diagnostic Ferritin
< 45 ng/mL
Normal TSAT
20-50%
amount of iron ready for erythropoiesis
Diagnostic TSAT
< 20%
Diagnostic B12
< 200 pg/mL
Diagnostic Folate
< 5 ng/mL
Causes of Anemia
Decreased RBC production
- Chronic diseases: CKD, cancer, CHF
- Nutritional deficiencies: iron, folic acid, vitamin B12
Increased RBC destruction
- drugs
- sickle cell anemia/thalassemia
Increase RBC loss
- acute blood loss
- NSAIDs, ASA
Microcytic
MCV < 80
iron deficiency
sickle cell anemia
thalassemia
Normocytic
MCV 80-100
anemia of chronic disease
blood loss
hemolysis
Macrocytic
MCV > 100
folic acid deficiency
B12 deficiency
Consequences of Anemia
- impaired cognitive function
- falls
- heart failure
- A-fib
- CV events
Iron Deficiency Anemia
Bloodwork
- decreased Hb
- decreased MCV
- normal/increased RDW
- increased TIBC/transferrin
- normal/decreased serum iron
- decreased TSAT
Causes:
- blood loss: menstruation, blood donation
- decreased absorption of iron
** celiac disease
** malabsorptive state
- vegetarian diet
** heme (meat)
** non-heme (plants, diary) –> not absorbed well
- increased consumption –> pregnancy
Side effects:
- spoon-shaped nails (koilonychias)
- inflamed tongue (glossitis)
- pica
** pagophagia –> ice
** geophagia –> dirt, soil, clay
Treatment of Iron-Deficiency Anemia
ORAL IS PREFERRED
Oral Dose:
- 65 mg of elemental iron every other day
Exceptions favoring IV:
- cannot tolerate
- cannot absorb
- ESKD
- heart failure
Repletion:
- 3 to 6 months
Hepcidin
- iron regulating peptide hormone produced in liver
- decreases dietary iron absorption and iron transfer to the plasma
- increased after a dose of oral iron for approx. 24 hours and normalizes within 48 hours
Elemental Iron
Ferrous fumarate
- tablet strength: 300 mg
- elemental: 100 mg
Ferrous sulfate
- tablet strength: 325 mg
- elemental: 65 mg
Ferrous gluconate
- tablet strength: 300 mg
- elemental: 30 mg
Counseling Points of Iron
- increased absorption on empty stomach
- causes stomach upset –> may take with food
- absorption increased by ascorbic acid (vitamin C)
- causes constipation
- causes dark stools
Side Effects of IV Iron
hypotension during infusion
skin tattooing
Vitamin B12 Defiency Anemia
Bloodwork
- decreased Hb
- increased MCV
- increased RDW
- decreased serum B12
- increased homocysteine/methylmalonic acid
- no iron studies
Causes:
- vegan/vegetarian diet
- alcoholism
- pernicious anemia (lack intrinsic factors)
- decreased absorption (Crohn’s)
- Medications (PPI, Metformin)
Side effects –> MUST ABSORB FROM DIET
- weakness, numbness, cognitive dysfunction
Treatment of Vitamin B12 Deficiency Anemia
IM/SubQ
- 100-1000 mcg daily, then weekly, then monthly
Oral
- 1000-2000 mcg/day
** may be less effective for pernicious anemia
WATER SOLUBLE VITAMIN
Folic Acid Deficiency Anemia
Bloodwork
- decreased Hb
- increased MCV
- increased RDW
- decreased serum folate
- increased homocysteine
- no iron studies
Causes:
- malabsorption
- malnutrition
- alcoholism
- Medications (methotrexate, phenytoin, sulfasalazine, Bactrim)
Treatment of Folic Acid Deficiency Anemia
Oral Folic Acid
- 1 to 5 mg daily until Hb normalizes
** ALWAYS CHECK VITAMIN B12 **
WATER SOLUBLE VITAMIN
Repletion:
- 3 to 6 months
Anemia of Chronic Disease
Diseases:
- CKD
- CHF
- Cancer
- HIV/AIDs
Occurs because:
- decreased erythropoietin production
- chronic inflammatory state
- nutritional deficiencies (iron, folate, vitamin B12)
Treatment of Anemia of Chronic Kidney Disease
Avoid blood transfusions
- risk of allosensitization
Correct Nutritional Deficiencies
- Folate
- B12
- Iron
** CKD Stage 3-5: oral
** CKD HD: IV
** TSAT > 30% goal
Erythropoiesis Stimulating Agents (ESA)
- prevents blood transfusions
- DO NOT TARGET NORMAL HB (maintain Hb > 10)
- Side effects: CV events, stroke, death
- only start after replenishing iron stores
- do not titrate dose up for at least 4 weeks after initiating
Anemia of Chronic Heart Failure
May benefit:
- NYHA Class II or III
AND
- iron deficiency (ferritin < 100 or 100-300 if TSAT > 30%)
Treatment of Anemia of Chronic Heart Failure
NO ORAL IRON
NO ESA
Treatment of Blood Loss Anemia
STOP THE BLEEDING
Transfuse packed RBC if Hb < 7
- each unit of RBC contains 250 mg of iron
- 1000 mg of iron to replete stores
Hemolytic Anemia
RBC destroyed before 120 days
Types:
- sickle cell anemia
- G6PD deficiency
- drug induced
Sickle Cell Anemia
What?
- RBC are irregular shaped and collects in the spleen and destroyed faster than production
- homozygous recessive
Treatment of Sickle Cell Anemia
Folic Acid: 1 mg/day
Blood Transfusions: symptomatic episodes of acute/chronic
Hydroxyurea
- fetal hemoglobin inducer leading to decreased sickling
- 10-15 mg/kg/day
Immunizations
Pain Control
- Tylenol
- NSAIDs
- opioids –> PCA
