Anemia part 3 and 4

Question 1

if MCV > 100 and and they have a vitamin B 12 and folic acid deficiency then

Answer 1

they have megaloblastic anemia

Question 2

if MCV > 100 and vitamin B 12 and folic acid levels are normal then

Answer 2

it is non megaloblastic anemia

• hepatic dx
• drug induced anemia
• hypothyroidism

Question 3

Vitamin B12 & Folate Deficiency

Answer 3

• 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

Question 4

↓ Folate level
(< 4 ng/mL)
Normal B12 level

Answer 4

then they have folic acid deficiency –> megaloblastic anemia

Question 5

↓ B12 level ( < 200 pg/mL)

Normal folate level

Answer 5

vitamin b12 deficiency –> megaloblastic anemia

Question 6

When both vitamin B 12 and folic acid levels are low it’s hard to differentiate between them. in this case,

Answer 6

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.

Question 7

Vitamin B12 Deficiency cause

Answer 7

• Pernicious anemia
• Malabsorption
-Gastric bypass surgery
-Pernicious anemia
• Vegan diet
• PPI or H2 blocker use
• Helicobacter pylori infection

Question 8

Vitamin B12 Deficiency treatment

Answer 8

• 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 life

Question 9

folate Deficiency cause

Answer 9

alcoholism

rapid cell turnover

Question 10

Folate Deficiency Treatment

Answer 10

• 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

Question 11

Anemia of Chronic Kidney Disease

Answer 11

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

Question 12

CKD stage 3

Answer 12

annually

Question 13

CKD stage 4 and 5 who are not on dialysis

Answer 13

at least twice a year

Question 14

CKD stage 5 on hemodialysis

Answer 14

at least every 3 months

Question 15

KDOQI
TSAT
Ferritin

Answer 15

> 20%
100 ng/mL ( CKD no HD)
200 ng/mL (CKD on HD)

Question 16

KDIGO
TSAT
Ferritin

Answer 16

> 30%

> 500 ng/mL

Question 17

ESA Agents

Epoetin α (Epogen, Procrit)

Answer 17

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

Question 18

ESA Agents

Darbepoetin α (Aranesp)

Answer 18

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

Question 19

esa monitoring

Answer 19

• 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

Question 20

esa therapy should be started when labs are

Answer 20

normal but hemoglobin is less than 10 or when anemia is not corrected by iron therapy alone

Question 21

Requires 25 mg test dose and > 1 hour of monitoring after dose

Answer 21

iron dextran

Question 22

Hb values at which anemia is diagnosed for men

Answer 22

What is Hb < 13 g/dL

Question 23

Following labs can be seen in this type of anemia:

Hb 11 g/dL, Crcl 45 ml/min/1.73^2, Tsat 15%

Answer 23

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

Question 24

Following labs are seen in this type of anemia.

↑TIBC, ↓Tsat, ↓Ferritin

Answer 24

ida

Question 25

Adequate Hb response to ESA therapy

Answer 25

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%

Question 26

total body iron storage?

Answer 26

ferritin

Question 27

Following labs can be seen in this anemia:

↓Vitamin B12,↓Folate, ↔MMA, ↑Homocysteine

Answer 27

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

Question 28

What is the most likely cause of PK’s anemia?

Answer 28

What is GI bleed potentially from high doses of ibuprofen. + Occult blood

PPI therapy could have contributed but likely is gi bleed.

Question 29

Folic acid therapy partially reverses hematologic effects of Vitamin B12 deficiency but not these symptoms

Answer 29

What are neurological symptoms caused by Vitamin B12 deficiency?

Question 30

Lab value(s) below that is NOT specific to PK's diagnosis.
↓ TSAT
↓MCV
↓Hb
↑ TIBC

Answer 30

What is Hb?

Hb is low in all types of anemia.

Question 31

This is the most likely cause of anemia in AS.

Answer 31

What is malabsorption from gastric bypass surgery?

Question 32

type of anemia as is experiencing

Answer 32

What is Vitamin B 12 deficiency?

↑ MCV, ↓ Vitamin B 12, Folate is normal

Question 33

______ is used to keep Hb > 10g/dL to prevent transfusions in ________ patients

Answer 33

ESA, CKD non dialysis

Question 34

This iron salt has the highest amount of elemental iron

Answer 34

What is ferrous fumarate?

Question 35

Why is the target goal for ferritin level higher in patients with CKD?

Answer 35

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.