Anemia Flashcards
Anemia is a disorder characterized by a reduction in the amount of hemoglobin present in blood and a decrease in RBC count. The blood hemoglobin concentration is believed to be a better marker of the total cell mass than than which other test?
hematocrit
Diagnostic evaluation of anima starts with ______
Hemoglobin
Classification of Anemia Based on what 2 things?
RBC size and RDW
With a cell size of Microcytosis (MCV <80) which condition would show a normal RDW? An increased RDW?
Normal: Thalassemia minor
Increased: Iron deficiency anemia and G6PD deficiency
With a cell size of Nomocytosis which condition would show a normal RDW? An increased RDW?
Normal: Acute bleeding
Increased: Early or partially treated iron or vitamin deficiency and sickle cell disease
With a cell size of Macrocytosis (MCV >100) which condition would show a normal RDW? An increased RDW?
Normal: Aplastic anemia, myelodysplastic syndrome
Increased: Vitamin B12 or folate deficiency, alcohol, liver disease
Whenever anemia is suspected or discovered with a CBC, order a ______ __________ to check for cell abnormalities.
peripheral smear
Basophilic stippling representing aggregated ribosomes can be seen in which 3 conditions?
- thalassemia syndromes
- iron deficiency
- lead poisoning
Howell-Jolly bodies are nuclear remnants seen in which 3 conditions?
- asplenia
- pernicious anemia
- severe iron deficiency
Cabot’s ring bodies are nuclear remnants seen in which 3 conditions?
- lead toxicity
- pernicious anemia
- hemolytic anemias
Heinz’s bodies are from denatured aggregated hemoglobin and can be seen in which 3 conditions?
- thalassemia
- asplenia
- chronic liver disease
Which 2 tests detect Spherocytes? What do they indicate?
- Coombs DAT: indicates immune mediated hemolytic anemia (AIHA) 2. Osmotic fragility increased: indicates spherocytosis (HS)
When looking for Fragments, which test would be best, and what does it assess?
Disseminated Intravascular Coagulation (DIC) screen to assess: intravascular thrombus
With Sickle cells and target cells, which screen is used?
Hemoglobin electrophoresis
When screening for Nucleated RBC which exams would be used?
- Hemoglobin electrophoresis (HGBE)
2. Bone marrow examination
Microcytic hypochromic anemia is caused by which 3 main things and which 4 minor things:
Main:
- Iron deficiency anemia (IDA)
- Thalassemia
- Sideroblastic anemia
Minor:
- Anemia of chronic disease (some cases)
- Pyridoxine Responsive anemia
- Chronic blood loss
- Lead poisoning
Lack of iron or inability to use iron for heme production for Iron deficiency is a result of which 3 situations?
- Chronic Blood loss
- Dietary lack during high demand
- Poor absorption of food iron
Lack of iron or inability to use iron for heme production for poor iron mobilization from body stores results in what?
inflammatory states
Lack of iron or inability to use iron for heme production for Sideroblastic anemia is due to what?
Failure of iron incorporation into protoporphyrin ring leads to RBC iron precipitation called Basophilic stippling and causes polychromasia
Defective globin chain synthesis involves which 2 conditions?
- Alpha-thalassemia
2. Beta-thalassemia
What is the most common microcytic hypochromic anemia?
Iron deficiency anemia
In the GI tract, iron is chiefly absorbed from the _________
Duodenum
Dietary Iron absorption is facilitated by what?
gastric acid secretion
What has come to be recognized as the “gold” standard operation for treatment of morbid obesity? Exclusion of nearly all of the stomach & the entire duodenum predisposes these patients to develop vitamin/mineral deficiencies.
RYGB: Roux-en-Y Gastric Bypass
Average western diet includes what daily intake of iron? What is the % of absorption?
- 10-30 mg daily
- Absorption is 5-10% of intake
Total body iron is about ___ grams
4
Total iron absorption is approximately 1 or 2 mg a day, balanced by about the same daily loss, mostly through what 2 means?
- skin desquamation
- in the stool
Many common foods interfere with iron absorption, what are 3 examples?
- phytates in cereal & grains
- vegetables (very high in soy)
- casein in milk
___% of body total is incorporated into hemoglobin
___% of body total is stored as ferritin
70%
30%
What transports absorbed iron from intestine to bone marrow?
Transferrin
When assessing for IDA use iron indices, use which 4 laboratory parameters to make an accurate diagnosis?
- serum iron level
- total iron-binding capacity
- percentage transferrin saturation
- serum ferritin level
With IDA laboratory tests, which test is the measurment of the iron bound to transferrin?
Serum Iron
Severe stress decreases serum iron values by ___%
65
Which 6 conditions will increased serum iron values?
- Hemosiderosis or hemochromatosis
- Iron poisoning
- Hemolytic anemia
- Massive blood transfusions
- Liver dz
- Lead toxicity
Which 5 conditions will decreased serum iron values?
- Dietary deficiency
- Chronic blood loss
- Malabsorption
- Pregnancy – late
- Neoplasia
What are 4 interfering factors with iron measurements?
- Recent blood transfusions
- Recent ingestion of high iron meal or supplements
- Hemolytic diseases
- Drugs
What is the measurement of all proteins available for binding mobile iron?
Total iron binding capacity: TIBC
Which 4 conditions will have increased TIBC or transferrin?
- Estrogen therapy
- Pregnancy – late
- Polycythemia vera
- Iron def. Anemia
Which 6 conditions will have decreased TIBC or transferrin?
- Malnutrition
- Hypoproteinemia
- Inflammatory diseases
- Cirrhosis
- Hemolytic, pernicious
- Sickle cell anemias
Most iron in circulation is bound to what? TIBC is an indirect measurement of this.
transferrin
Ferritin not included in TIBC, why?
only binds stored iron
What is the major iron-storage protein? Where is it primarily found?
Ferritin; in the liver
T/F: Ferritin is a good indicator of available iron stores in the body.
True
Ferritin is normally present in serum in concentrations directly related to iron storage. 1 ng/ml serum ferritin corresponds to about ___ mg of stored iron. Levels below 11 in women and 24 in men mg/dl = diagnostic for which condition?
8; IDA
Ferritin levels rise persistently in which 2 populations?
males and post-menopausal females
T/F: Severe protein depletion can decrease ferritin levels.
True
T/F: Normal levels of ferritin will exclude iron deficiency
FALSE!!! Normal levels does NOT exclude iron deficiency
Ferritin is factitiously __________ in patients with chronic disease states
elevated
Ferritin acts as acute phase reactant protein. It ___________ 1-2 days after onset of acute illness, peaking at __-__ days
increases; 3-5
What are 5 interfering factors for lab testing ferritin?
- Recent blood transfusion, high iron intake
- Hemolytic dz
- Excess iron storage dz
- Menstruation
- Recent administration of radionuclide if test is performed via RIA
What are 6 causes for increased ferritin levels?
- Hemochromatosis, hemosiderosis
- Megaloblastic anemia
- Hemolytic anemia
- Alcoholism
- Inflammatory dz
- Advanced cancers
What are 3 causes of decreased ferritin levels?
- Iron deficiency anemia
2 Severe protein deficiency - Hemodialysis
What are the three stages of iron deficiency?
- iron depletion (reduced stores)
- early iron deficiency anemia (depleted stores, normal MCV, and red cell morphology)
- advanced iron deficiency anemia
In IDA, PLT count may be ________ secondary to BM stimulation. Reticulocyte count will be _________.
increased; decreased
In IDA, PB smear will show __________ __________ RBC
microcytic hypochromic
Free erythrocyte protoporphyrin (FEP) a precursor to HgB is _________ in IDA but _________ in thalassemia.
increased; normal
According to the Mentzer Index: Ratio of MCV/RBC:
Ratio 13 indicates ______
Thalassemia; IDA
What is an inherited disorder of globin chain synthesis and can affect either alpha or beta chain production? Homozygous is which form? Heterozygous?
Microcytic hypochromic anemias thalassemia
Homozygous: major
Heterozygous: minor
B-Thal Major smear exhibits which 4 types of cells?
- microcytic hypochromic cells
- basophillic stippling
- target cells
- NRBC’s
Which microcytic hypochromic anemia has the following conditions?
• Serum iron increased
• TIBC decreased or normal
• % saturation increased
• Ferritin increased or normal
• Reticulocyte count increased
• Serum LDH may be increased with active hemolysis
Thalassemia
What is a carrier for FREE plasma HGB- levels tend to be reduced due to hemolysis?
Haptoglobin
Hp levels ___________ with increased RETIC and decreased RBC/Hbg/Hct –> points to which condition?
DECREASED; hemolytic anemia
What is happening when Hp levels DECREASE without signs of hemolytic anemia?
Liver is not making enough Hp
What is happening when Hp levels are normal with increased RETIC?
RBC destruction in the spleen/liver with no free Hgb released and no Hp consumed.
What is happening when Hp levels are normal with NORMAL RETIC?
Anemia present is not due to RBC breakdown as no Hp is being consumed
Thalassemia related Anemia Lab Evaluation Summary:
- RBC size & Hgb content:
- Abnormal shape RBCs:
- Reticulocyte production response:
- Clinical indicators:
- microcytic
- “thalassemia picture” if severe, normal if mild
- increased
- Congenital hx of anemia
Tests to DDx from IDA:
- Thalassemia has ______ to ______ serum ferritin
- TIBC ______ to _____
- Serum iron ______ to _______
- Hemoglobin eletrophoresis in ____________
- normal to high
- normal to low
- normal to high
- Thalassemia
What is required for synthesis of δ-ALA for heme production?
B6
Which microcytic hypochromic anemia deficiency is an acquired form more common and associated most frequently with isoniazid therapy for TB, hereditary form very rare?
pyridoxine (vitamin B6) deficiency
Which condition has the following characteristics?
- Acquired or Hereditary (often due to B6 deficiency)
- Ineffective RBC formation (two RBC populations, one normochromic & one hypochromic)
- Diagnosed by BM biopsy, find “Rings” of Fe in RBC
Sideroblastic Anemia
Which condition has a defect in heme synthesis which leads to anemia when Pb levels are very high? Also, a significant lead intoxication will occur before micro-hypo anemia. Basophilic Stippling in RBCs & Retic Low
Lead Poisoning
The following are which types of -cytic/-chromic anemia?
- Acute blood loss
- Anemia of Chronic Disease (ACD)
- Hemolytic Anemia from any cause
- Hereditary spherocytosis
- Aplastic Anemia
- G6PD deficiency
Normocytic normochromic anemias
Which type of anemia has the following characteristics?
• Mild normo-normo (sometimes micro-hypo) anemia that persists more than 1-2 months.
• Characterized by low serum iron despite high iron stores (ferritin)
• Iron is being sequestered by the body so as to not damage the tissue during inflammatory processes.
• Mediated by cytokines and regulated by hepcidin
• Affects many aspects of RBC synthesis and lifespan
Anemia of chronic disease
What is the master regulator of iron homeostasis?
Hepsidin
Which type of anemia has the following characteristics?
• Cellular depletion with fatty replacement of marrow
• Pancytopenia - decreased production of all cell lines
• Increased serum iron - because there aren’t enough RBCs to store the iron
• Patients given marrow transplants, but have to match HLA (human leukocyte locus A), usually with a family member
Aplastic anemia
T/F: The etiology of aplastic anemia is almost always by environmental, or chemical factors, is idiopathic but linked to benzene, radiation, infections, and Chloramphenicol.
True
Lab features of aplastic anemia include which 3 things?
- normocytic normochromic anemia
- decreased platelets
- increased risk of infection
Lab tests for aplastic anemia include which 3 things?
- reticulocyte count of zero
- normocytic normochromic anemia
- elevated serum iron
Aplastic anemia patients need to be kept alive by what means? What is their prognosis?
transfusions of WBCs and platelets
die within 4-5 years of onset
In Hemolytic Anemia: due to G6PD deficiency, decreased ATP production leads to which 2 detriments of the RBC?
- decreased membrane flexibility
2. increased oxidative damage
Which anemic condition has the following characteristics?
• Sex-linked genetic disorder, X chromosome
• More common in Kurdish Jews & Af.-American
• Selective advantage to malaria
• Females can manifest if defect on both XX
Hemolytic Anemia: due to G6PD deficiency
What is the most definitive test method for hemolytic anemia due to G6PD deficiency?
Assay of G6PD enzyme
Susceptible persons with Hemolytic Anemia: due to G6PD deficiency exhibit hemolysis under which 3 conditions?
- oxidative stress – usually drugs: antimalarials, sulfa, nitrofurantoins, aspirin
- certain foods - fava beans
- high dose intravenous vitamin C
Spherocytosis has both hereditary and acquired forms. ___% or more RBC are affected if hereditary.
70%
Spherocytosis has an elevated retic (>9%) count in ____% of patients.
90%
The following are indicative of labs for which condition?
- Normal to decreased MCV
- Decreased Hgb
- Normal to increased MCH
- Increased MCHC
- Hemolytic anemia pattern
Spherocytosis
Osmotic fragility test indicates the ability of the RBC to do what, and depends upon surface/volume ratio or shape?
take up water without bursting
When conducting the Osmotic fragility test:
RBCs in hypertonic solutions, cells ______; in hypotonic solutions, cells ________
shrink; swell
Full/thick cells like spherocytes have a/an _________ fragility; thin cells like target cells have a/an _______ fragility
increased; decreased
