anemia 439B Flashcards
regular Hgb levels
hbg <11 non prego females
MCV
mean corpuscular volume
mcv100
INTIAL lab approach
- is patient bld now or in the past? old cbc… anisocytosis or pokilocytosis or wbc ab
- is there evidence for increased RBC
- bone marrow suppressed?
- iorn deficient- yes? why?
- deficient in Folic acid or Vit b12- why?
reasons for microcytic anemia
MCV <80 iron def thalessemia anemia of chronic disease siderblastic anemia lead poisoning
reasons for normocytic anemia
mcv 80-99 sickle cell disease aplastic anemia anemia of chronic disease hemolytic anemias
reasons for macrocytic anemia
mcv >100
vit b12 def
folate def
IDA- s&s
asymptomatic usually
s&S- fatigue, decreased exercise tolerance, weakness, palpitations, irritability, HA
conjunctival pallor, angular cheilitis, decreased tongue papillae, pallor of palms and hands, koilonychia (lines in nails)
etiologies of IDA
abnormal uterine bld LT use of NSAIDS colon CA GI issue- PUD, h plyoria, gastrectomy etc. other- hematuria /epistaxis
Reticulocyte count
determine RBC underproduction from hemolysis
- high- bone marrow responding normally to bld loss, hemolysis or replacement of iron
norm 0.5-1.5%
with iron therapy 7-10 days increase and MCV normalize
IDA indicator
low ferritin level earliest indicator
Anemia of chronic disease
serum iron low (iron not released from storage) Transferrin TIBC low or normal Transferrin Sat low Ferritin high or normal inflammatory markers- very high!
IDA levels
serum iron- low TIBC- very high (iron stores depleted, empty binding sites) Transferrin sat- low Ferritin- low (depleted iron stores) Inflammatory markers- normal
both acute and IDA anemia
serum iron- low TIBC- low transferrin sat- low Ferritin- normal or slighly low Inflammatory markers- very high
ferritin
iron stores
low- depleted stores
TIBC
capacity is how many of those receptors available with binding
insuf iron- more space available
special characteristics of cells
spur cells, burr cells, schistocytes, spherocytes, target cells, teardrop cells, basophilic stippling
- more than iron def if these are reported in RBC
Iron Therapy considerations PO
NOT with food
2 hours before 4 hrs after ingestion of antacids
elemental iron 150-200mg daily
best absorbed with mildly acidic so add ascorbic acid tablet (250mg) or half glass or OJ to enhance
foods to avoid with iron supp
phosphates, phyates, and tannates in food
bind with iron and impair absorption
ca foods, tea, coffee, milk, eggs, fiber cereals
meds to avoid with iron supp
antacids, h2b, ppi, ca supp, abx (quinolones and tetracyclines)
iron fortified cereals, fiber, tea, coffee
ferrous fumarate
324 mg total
106mg element
bid daily
ferrous gluconate
300mg total
38 mg element
1-3 tabs TID daily
ferrous sulfate
325mg total
65mg element
1 tab TID
geri ferrous sulfate elixir
44mg elemental per 5cc
SE of iron supp
N/V/D, constipation epigastric distresss
- try smaller dose of elemental irion (sulfate to gluconate) or tab to liquid prep
only increase slowly
if must - take with food but decrease abp by 40%
Expected response to Iron suppl
- Immediate disappearance of PICA or RLS
- Improved feeling of well being within first few days of treatment
- For mod-severe anemia: modest reticulocytosis will be seen in 7-10 days (those w mild have no reticulocytosis).
- Hgb will rise slowly after approx. 1-2 weeks and will rise 2g/dL over approx. 3 weeks.
- Hgb deficit should be halved by approx. 1 month and hgb level should return to normal by 6-8 weeks.
Failure to respond to PO therapy
1) co-exisiting diseases
2) IDA incorrect dx- thalessemia, lead posiiong, etc)
3) non-adherence
4) not absorbed- malapsorbtion of iron
5) continued blood loss or need in excess iron dose being ingested (PUD) - tx underlying problem
H.Pylori causes IDA
- increased iron loss d/t active hemorrhage secondary gastrtitis, PUD, CA
- achlorhydria induced by chronic gastritis resulting ( reduced iron absorption)
- reduced secretion of ascorbic acid to gastric muscosa
- iron utilization by bacterium (using for their own work)
common causes of normocytic anemia
- increased RBC loss i.e. acute bleed, hemolysis
- decreased production of normal sized RBCs i.e. aplastic anemai, chronic disease anemai, endocrine DO
- overexpansion of plasma volume
i. e. prego or fld overload
Macrocytic anemias
slide
anemia of chronic disease/inflammation patho
infection, chronic inflam
macrophages stim and activate cytokine release i.e. IL-6, induces hepcidin which inhibits iron release- protective measurement
anemia of chronic disease tx
- tx underlying condition- infection/inflam
check ESR/c-reactive protien
sickle cell
normochromic but not normocytic- decreased rbc loss
vitamin b12 needed
DNA synthesis
formation of myelin sheaths- neuro deficits
synthesis of neurotransmitters - depression with vit b12 def.
erythropoiesis
PE of vit b12 def
- numbness/paresthesisas
- cognitive impairment and depression
- symmetrically decreased vibration and proprioception in feet.
- absent or decreased DTR in LE
cobalamin
vit b12
a water soluble vitamin req for proper RBC function, neuro function and DNA synthesis
late biomarker of vit b12
serum vit b12- low sen/spe when used alone
earliest bio marker of vit b12
holotranscobalamin aka active b12
elevated homocysteine >13 and elevated MMA (>0.4) are seen in vit b12
MMA
methylamolonic acid >0.4
most specific for vit b12
Vitamin B12 Deficiency lab Levels look..
MCV >100 macrocytosis with hypersegmented pernicious anemia - poss homocystine- elevated MMA- elevated
Folate Def lab levels….
>100 MCV macrocytosis with hypersegmented neutrophils per anemia- NO homocystine- elevated MMA- NORMAL**
risk factors Vit b12
decreased ileal absorption decreased intrinsic factor genetic inadq intake prolonged med use (h2b, metformin, PPI) food/vit b12 malabsorption
best dietary food for Vitamin B 12
fortified breakfast cereals
tx vit b12 def
1000ug daily x1 week then weekly x 1month then monthly for life- unless underlying cause tx
- 1000-2000 mcg of crystalline cobalamin PO daily
Folate normal level
> 4ng/ml
folate def dx level
<2ng/ml as long as anorexia or fasting
tx folate def by…
prevent neural tube deficits
1mg PO daily
r/o vit b12 before folic aacid begins- dont want to mask symptoms of vit b12 def
older adults vit b12 reason 1
low or normal b12 and elevated metabolites
due to age (decrease gastric acid) and atrophic gastritits (food bound malabsorption)
** inabiliyt to release b12 from food or binding protein
older adults vit b12 reason 2
small intestinal bacterial overgrowth from decreased gastric acid and reduced intestinal motility
h.plylori most common
vitamin b12 reason 3
- PPI
H2B
exacerbating impairment of b12 absorption from food
vitamin b12 reason 4
nitrous oxide induce def by oxidizing and sub inactivating b12
meds that inhibit vit b12 absorption
pPI H2B metformin colchine abx anti-convulsants
dietary intake of vit b12
2.4 ug per day
body store- 2-5mg in liver
