Anemia Part I Flashcards
Fundamentally, anemias are generally due to either (1) of red cells and these two major types can be distinguished by (2)
- decreased production or increased destruction
2. the reticulocyte count
Reticulocyte count in anemias of decreased production
low reticulocyte count
(1) are newly produced red cells and can be identified by their larger size or by stains that identify their (2)
- Reticulocytes
2. ribosomes.
The normal range for reticulocyte count changes based on age since newborns have (1)% reticulocytes in their blood whereas adults have (2)% reticulocytes in their blood.
- 2-6%
2. 1-2%
Laboratories often provide a reticulocyte index which is a derived value based on the (1) and the (2). It is based on the idea that there are fewer red blood cells in anemia so the percentage of reticulocytes (3) the number of reticulocytes.
- RBC count
- reticulocyte count
- underestimates
Reticulocyte count in anemias of increased destruction
elevated reticulocyte count
Red cell indices are measurements and derivations which describe the (1) of red blood cells (RBCs).
- size and color
The (1) is the measured number of particles of a specific size (bigger than (2) but smaller than (3) present in a microliter of blood measured by light scatter.
- RBC count
- platelets
- white cells
The (1) is the volume in femtoliters of blood per RBC and is directly determined by measuring the mean volume of cells based on light scatter.
mean corpuscular volume (MCV)
How is hematocrit determined?
Measure the MCV and the RBC count by light scatter
MCV = hematocrit/RBC count
hematocrit = MCV x RBC count
MCH =
mean corpuscular hemoglobin
MCH = Hb/RBC count
MCHC =
mean corpuscular hemoglobin concentration
MCHC = Hb/Hct
Microchromic
low MCH or MCHC
Normochromic
normal MCH or MCHC
Microcytic
low MCV due to low volume per cell
Macrocytic
high MCV due to high volume per cell
macrocytic anemias tend to be due to?
impaired bone marrow maturation
microcytic, microchromic anemias tend to be due to ?
problems with red cell production or synthesis
Patients with severe anemia due to any cause often have what s/s?
weakness
tire easily
DOE
pale skin and oral mucosa
Hypoxia as a consequence of anemia can also cause CNS problems including:
headache, blurry vision, and confusion or lethargy.
If the anemia is due to acute blood loss and is leading to hypovolemic shock (shock is a decrease in BP) than (1) can result as a consequence of ?
- oliguria or anuria
2. pre-renal azotemia.
Acute blood loss can rapidly lead to?
decreased intravascular volume, cardiovascular collapse and death
The initial evaluation of a bleeding patient requires an assessment of ?
vascular volume (BP predominantly)
How might an acute blood loss anemia lead to an iron deficiency anemia?
If the patient bleeds into tissues then the hemoglobin is recaptured. If the bleed is into the GI tract or outside the body then there will be iron loss.
The resulting reduction in oxygenation due to decreased blood delivery of oxygen induces the kidneys to produce erythropoietin which stimulates the proliferation of (1) within the bone marrow.
- CFUe (colonies of later erythroid progenitors)
Blood loss can also lead to (1) production along with increased secretion of (2) which will increase the number of (3).
- increased platelet
- adrenergic hormones
- white blood cells
measurements of Hb, Hct, or RBC count in initial acute blood loss
will be normal (there is less blood but it has the same concentration)
measurements of Hb, Hct, or RBC count in acute blood loss a few hours later
decreased hematocrit
due to hemodilution as blood volume is restored caused by shifting of water from interstitial fluid to plasma
Five to seven days after the bleed, the progency from the CFUe mature and appear as (1)
- reticulocytes.
Chronic blood loss outside of the body (including into the GI tract, respiratory tract, urinary tract, female reproductive tract) leads to (1) which must be viewed as a medical finding and not a specific diagnosis.
- iron deficiency anemia
Why is it important to be concerned about iron deficiency anemia in the elderly?
Many older patients with iron deficiency anemia have early cancers
(1) is a very common cause of GI bleeding and iron deficiency anemia in people over 50.
- Colon cancer
Iron deficiency anemia is ____cytic and ____chromic. Levels of MCV, MCH/MCHC, Hb, Hct, and RBC?
micro and micro
reduced MCV, MCH/MCHC, Hb, Hct, and RBC count
Iron levels and TIBC levels in iron deficiency anemia?
iron is reduced and TIBC (total iron binding capacity) is increased
Reticulocyte count in iron deficiency anemia?
low
Healthy people have about 80% of their iron in (1) and about 20% in storage forms including (2)
- hemoglobin
2. ferritin and hemosiderin.
(1) is the major regulator of iron metabolism and is (2) when the body has excess iron stores.
- Hepcidin
2. increased
Hepcidin inhibits iron transfer from the enterocyte to plasma by binding to (1) and causing it to be endocytosed and degraded.
- ferriportin
What happens to hepcidin levels in iron deficiency?
decrease
What happens to hepcidin levels during increased hematopoiesis?
decrease
What happens to hepcidin levels when the body has excess iron stores?
increase
Anemia of chronic disease (ACD) is seen in many patients with chronic illness particularly those with (1) disorders.
- inflammatory
Anemia of chronic disease MCV, MCH, and MCHC levels
normocytic normochromic anemia with normal MCV, MCH, and MCHC.
Inflammation increases acute phase reactants such as (2) and (3), leading to anemia due to reduced iron uptake, and
- ferritin
3. hepcidin
Iron and TIBC levels in ACD
Iron levels are usually low in ACD but TIBC can be normal or decreased.
Reticulocyte count in ACD
low since this is a production problem
Macrocytic anemias are most commonly seen in patients with ?
vitamin B12 or folate acid deficiencies or correct liver disease
Macrocytic anemias are also called megaloblastic anemias because (1) cells are enlarged in the bone marrow due to the bone marrow maturation defect responsible for this condition.
- erythroid (megaloblasts) and myeloid precursor
The cellular maturation defect in macrocytic anemia is poorly understood but it is clear that (1) maturation occur independently of (2) maturation.
- DNA synthesis and nuclear maturation
2. cytoplasmic
neutrophils can have multiple lobes (>5 is considered abnormal) since the nucleus is continuing to grow and differentiate before the cell divides
megaloblastic anemia/macrocytic anemia
(1) is a disorder in which all three formed elements are decreased in the blood: red cells, white cells, and platelets.
- Aplastic anemia
Reticulocyte count in megaloblastic anemia
low
Aplastic anemia leads to multiple hematologic problems presenting with what signs and symptoms?
fatigue and pallor (from decreased red cells)
frequent infections (from decreased white cells)
bruises and bleeding (from decreased platelets)
The causes of aplastic anemia are poorly understood but are thought to involve (1).
- the immune system
Patients with the autoimmune disorder (1) have an increased risk of aplastic anemia, suggesting an autoimmune connection.
- paroxysmal nocturnal hemoglobinuria
Bone marrow aspirates from patients with aplastic anemia have (1) and biopsies are (2)
- very few hematopoietic cells
2. predominantly fat due to the absence of myeloid or erythroid precursors
RDW
red cell distribution width; indicator of variation in size of RBCs
platelets lack ___ but have ____
nuclei; mitochondria for energy demands
Luminal nonheme iron is mostly in the Fe3+ (ferric) state and must first be reduced to Fe2+ (ferrous) iron by (1)
- ferrireductases, such as cytochromes
Fe2+ iron transported by (1) which is regulated by (2)
- divalent metal transporter 1 (DMT1)
2. hepcidin
Fe2+ iron destined for the circulation, is transported by (1). This process is coupled to the (3) of Fe2+ iron to Fe3+ iron, which is carried out by the iron
oxidases (2)
- ferriportin
- oxidation
- hephaestin and ceruloplasmin
Newly absorbed Fe3+ iron binds rapidly to the plasma protein (1), which delivers iron to 2) in the marrow
- transferrin
2) red cell progenitors
When lots of Fe: plasma (1) levels are high. This leads to down-regulation of (2) so Fe lost when duodenal epithelial cells are shed
- hepcidin
2. ferriportin
When body iron stores decrease or when erythropoiesis is stimulated, (1) levels fall and (2) activity increases, so more absorbed iron transferred to plasma (3)
- hepcidin
- ferriportin
- transferrin
Ferritin levels in ACD
normal or increased
Ferritin levels in iron deficiency anemia
decreased
A 25 year old man is in a severe car accident
and witnesses on the scene say he lost a lot of blood
BP and assessment of fluids as a way to figure out how much blood is lost.
A 65 year old woman is tired and pale
rule out cancer
A 28 year old man with sausage like fingers,
subluxations, and antibodies against Fc is tired and pale
Pt. has RA which is autoimmune; Anemia of chronic disease
INC. hepcidin and Ferritin;
DEC Iron and TIBC;
INC. WBC due to inflammation
A 75 year old woman with long-standing diabetes has recently been diagnosed with colon cancer.
Type of anemia and lab values
Diabetes is inflammatory so anemia of chronic disease;
Colon cancer leads to blood loss so Iron def anemia; pt has COMBINED anemia;
RC low (underproduction)
INC. hepcidin;
ferritin and TIBC may be high or low depending on whether it is more Iron deficient or Inflammation;
A 24 year old women with heartburn and
achlorhydria now is tired and pale
Pernicious anemia so MACROCYTIC;
Low RC;
Low B12;
INC. methylmalonic acid
A 22 year old woman has nosebleeds, bruises,
frequent infections, and is tired and pale
aplastic anemia;
Bleeding and bruises–> low platelet
Infections–>low WBC
Tired and pale–> Low RBC;
normal RBCs have 1)
Too much central pallor seen in 2)
NO central palor seen in 3)
1) central palor
2) iron def. anemia
3) hereditary spherocytosis
1) Percentage of blood represented by red cells
2) Number of red cells per cubic microliter
1) Hct
2) Red cell count
hct/RBC
CMV
1) Hg/RBC: the average content (mass) of hemoglobin per red
cell
2) (Hb/Hct): the average concentration of
hemoglobin in a given volume of packed red cells, expressed in grams per deciliter
1) MCH
2) MCHC
Blood loss produces a compensatory release of adrenergic hormones mobilizes
granulocytes and results in 1)
1) leukocytosis
Initially after acute blood loss, red cells 1)
1) normocytic and normochromic
Early recovery from blood loss is also often accompanied by 1), which
results from an increase in platelet production
1) thrombocytosis
acute blood loss vs. chronic; differentiate anemia
acute blood loss–> NORMOCYTIC and NORMOCHROMIC;
Chronic blood loss–> Microcytic and HYPOchromic
how do you identify HYPOCHROMIC on histo
Normal RBCs have central palor and should be 1/3rd;
Hypochromic has more than 1/3rd central palor
total body iron content is normally about 1) in women and 2) in men
1) 2 gm
2) 6 gm
Iron that enters the duodenal cells can follow one of two pathways
1) transport to the blood via transferrin;
2) storage as mucosal iron
A small circulating peptide that is synthesized and released from the liver in response to increases in intrahepatic iron
levels
Hepcidin
mechanism of ACD
Inflammation increases Hepcidin (phase reactant) which leads to
inappropriate iron loss
Nuclear maturation doesn’t match cytoplasmic;
Macrocytic anemia;
FYI lack of DNA precursors means that cells are stuck in G2 phase and cannot progress to mitosis; cell was able to grow during G1 and S which is why you see DEC. nuclear/cytoplasmic ratio;
Nuclear material/cytoplasm ratio in Macrocytic anemia
DECREASES;
Nuclear maturation doesn’t match cytoplasmic;
