Anemia part 3 and 4 Flashcards
if MCV > 100 and and they have a vitamin B 12 and folic acid deficiency then
they have megaloblastic anemia
if MCV > 100 and vitamin B 12 and folic acid levels are normal then
it is non megaloblastic anemia
- hepatic dx
- drug induced anemia
- hypothyroidism
Vitamin B12 & Folate Deficiency
• General anemia symptoms
• Sore tongue
• Glossitis- burning of the mouth
• Beefy smooth, shiny, red tongue
• GI symptoms: diarrhea, gas, nausea
• Neurologic symptoms
• Psychiatric manifestations
-Impaired mentation
-Irritability
- Depression↓ Folate level
(< 4 ng/mL)
Normal B12 level
then they have folic acid deficiency –> megaloblastic anemia
↓ B12 level ( < 200 pg/mL)
Normal folate level
vitamin b12 deficiency –> megaloblastic anemia
When both vitamin B 12 and folic acid levels are low it’s hard to differentiate between them. in this case,
methylmelonic acid (MMA) and homocysteine can be done. if vitamin b 12 deficiency is present, then MMA conversion to succinyl CoA is inhibited, so elevated levels of MMA. homocysteine conversion to methionine is also inhibited, leading to elevated levels of homocysteine.
folic acid is not involved in the MMA metabolism. so when folic acid deficiency is present, conversion of homocysteine to methionine is prevented, so there will be elevated levels of homocysteine without elevated MMA levels.
Vitamin B12 Deficiency cause
• Pernicious anemia • Malabsorption -Gastric bypass surgery -Pernicious anemia • Vegan diet • PPI or H2 blocker use • Helicobacter pylori infection
Vitamin B12 Deficiency treatment
• Neurologic damage may be
irreversible if not treat early on
• Treat underlying cause- (i.e h.pylori)
• Oral: 1000-2000 mcg oral daily
• Neurologic symptoms:
- IM/SubQ: 1000 mcg daily x 1 week,
1000 mcg weekly x 2 weeks, then 1000
mcg monthly
• Pernicious anemia: treat for life
• Gastric bypass surgery: prevention
for lifefolate Deficiency cause
alcoholism
rapid cell turnover
Folate Deficiency Treatment
• PO: 1 -5 mg qday
• IV/IM/SubQ: 1-5 mg qday if absorption issues
• Continue for 4 months or until underlying causes are
corrected
• Essential during pregnancy to prevent neural tube
defects such as anencephaly and spinal bifida
Anemia of Chronic Kidney Disease
Primarily caused by a decrease in erythropoietin production • Morphology: normocytic, normochromic Risk factors: • Shorter life span of red blood cells • Blood loss during dialysis • Iron deficiency Initiate of work-up when: • Crcl < 60 ml/min/1.73m2 • Hb < 13 g/dL in men, < 12 g/dL in women
CKD stage 3
annually
CKD stage 4 and 5 who are not on dialysis
at least twice a year
CKD stage 5 on hemodialysis
at least every 3 months
KDOQI
TSAT
Ferritin
> 20%
100 ng/mL ( CKD no HD)
200 ng/mL (CKD on HD)
KDIGO
TSAT
Ferritin
> 30%
> 500 ng/mL
ESA Agents
Epoetin α (Epogen, Procrit)
CKD on HD: -IV route preferred -IV/SubQ: 50-100 units/kg 3 x week CKD not on HD: • IV/SubQ: 50-100 units/kg q week
ESA Agents
Darbepoetin α (Aranesp)
CKD on HD • IV route preferred • IV/SubQ: 0.45 mcg/kg qweek or 0.75 mcg/kg q 2weeks CKD not on HD • IV/SubQ: 0.45 mcg/kg
esa monitoring
• Maximal increase:1 g/dL q2-4 weeks
• Dosage titration: no more than q4 weeks
• Dosage adjustments: 25 % increments (keep goal hemoglobin between 10 and 11)
• Hypertension
inadequate response:
iron deficiency
esa therapy should be started when labs are
normal but hemoglobin is less than 10 or when anemia is not corrected by iron therapy alone
Requires 25 mg test dose and > 1 hour of monitoring after dose
iron dextran
Hb values at which anemia is diagnosed for men
What is Hb < 13 g/dL
Following labs can be seen in this type of anemia:
Hb 11 g/dL, Crcl 45 ml/min/1.73^2, Tsat 15%
Anemia workup in CKD patients should be initiated when CrCl < ml/min/1.73^2 and Hb < 13 g/mL in men, < 12g/mL in women
Iron treatment should be initiated to keep Tsat >20%, ferritin >100 ng/mL
Following labs are seen in this type of anemia.
↑TIBC, ↓Tsat, ↓Ferritin
ida
Adequate Hb response to ESA therapy
What is Hb increase by 1 g/dL in 2-4 weeks?
if Hb change is < 1 g/dL in 4 weeks- increase dose by 25%
If Hb change is > 1 g/dL in 2 weeks-decrease dose by 25%
total body iron storage?
ferritin
Following labs can be seen in this anemia:
↓Vitamin B12,↓Folate, ↔MMA, ↑Homocysteine
What is Folic Acid Deficiency Anemia?
When Vitamin B12 and folate levels are both low or borderline low, MMA must be checked. Normal MMA and increased homocysteine indicate folic acid deficiency.
Elevated MMA and homocysteine indicate vitamin B 12 deficiency
What is the most likely cause of PK’s anemia?
What is GI bleed potentially from high doses of ibuprofen. + Occult blood
PPI therapy could have contributed but likely is gi bleed.
Folic acid therapy partially reverses hematologic effects of Vitamin B12 deficiency but not these symptoms
What are neurological symptoms caused by Vitamin B12 deficiency?
Lab value(s) below that is NOT specific to PK's diagnosis. ↓ TSAT ↓MCV ↓Hb ↑ TIBC
What is Hb?
Hb is low in all types of anemia.
This is the most likely cause of anemia in AS.
What is malabsorption from gastric bypass surgery?
type of anemia as is experiencing
What is Vitamin B 12 deficiency?
↑ MCV, ↓ Vitamin B 12, Folate is normal
______ is used to keep Hb > 10g/dL to prevent transfusions in ________ patients
ESA, CKD non dialysis
This iron salt has the highest amount of elemental iron
What is ferrous fumarate?
Why is the target goal for ferritin level higher in patients with CKD?
Anemia of CKD.
Functional iron deficiency is where TSAT is low but ferritin levels are normal.
TSAT and ferritin levels have poor prediction of bone marrow iron stores and erythropoietic response to iron supplementation in CKD patients.
