Anemias Flashcards
Hgb and hematocrit in anemic men
Hgb < 13.5 g/dl
Hct <41%
Hgb and hematocrit in anemic women
Hgb <12
Hct<36%
Decreased RBC production causes of anemia
lack of nutrients, bone marrow disorders, and hypothyroidism
Increased rbc production causes of anemia
Inherited/ acquired hemolytic anemias
Blood loss causes of anemia
Obvious, occult and induced
Normal MCV
80 to 100 fl
Norm MCH
26-34 p/ cell
Normal Mean corpuscular hemoglobin concentration
32-36 g/dl
Symptoms of anemia
Sob, headache, tinnitus, syncope, dizziness, fatigue, sleep and mood disturbances, impaired concentration, neuro manifestations, chest pain, dementia, anorexia, skin pallor, tachycardia, increased pulse pressure, peripheral edema, flame like retinal hemorrhages, jaundice, arrhythmias
Anemia labs
Cbc with diff, reticulocyte (absolute), platelet count, Wright stained blood smear, serum ferritin, iron and total binding capacity
What does it mean if absolute retic count isn’t elevated?
Marrow failure (most common cause of anemia )
What does it mean if absolute retic count is elevated?
Blood loss or hemolysis
Microcytosis
MCV less than 80
Normocytosis
MCV 80 to 100
Macrocytosis
MCV greater than 100
Pernicious anemia: type
Megaloblastic, autoimmune
Pernicious anemia caused by?
Caused by lack of intrinsic factor produced by parietal cells of the gastric mucosa.
This prevents vitamin b12 absorption, resulting in vitamin b12 deficiency
Incidence/ predisposing factors for pernicious anemia
- most common in northern European
- rare in Asians and AAs
- may be caused by atrophic gastritis, antibodies to parietal cells, or autoimmune histamine fast achlorhydria
pernicious anemia S&S
pale, icteric, abnormal reflexes, babinski and romberg positive, vibratory sensation decreased in lower extremeties, paresthesia and numbness, ataxia, decreased sense of smell, smooth tongue with tenderness, depression, dementia, splenomegaly, tinnitus, hepatomegaly, tachy, CHF, weakness, asthenia, bleeding gums, nausea, weight loss, decreases appetite, sore tongue, yellowish tinge to eyes and skin, sob, headache, palpitations, chest pain
pernicious anemia MCV
macrocytic, 110-140 fl, but can be in normal range if concurrent with iron deficiency or thalassemia.
pernicious anemia RDW
increased
HCT in pernicious anemia
10-15 ml/dl or lower
blood smear in pernicious anemia
macro-ovalocytes, anisocytosis, poikilocytosis, hyper-segmented neutrophils (4 to six lobes)
retic count in pernicious anemia
reduced
serum folate in pernicious anemia
increased
chance of deficiency based on serum vitamin b12 in pernicious anemia
> 300- normal
200-300-borderline, deficiency possible
<200- deficiency likely
serum ferritin in pernicious anemia
increased
lactic dehydrogenase in pernicious anemia
elevated, mistaken for hemolytic anemia b/c of this
Major lab to affirm b12 deficiency
anti IF and anti-parietal cell antibodies. Presence affirms deficiency.
pernicious anemia tx
B12 sub q (1mg daily for 7 days then once a week then once a month) for rest of life
OR
or B12 with 2000 u load then 1000 u daily.
Giving folic acid in pernicious anemia
don’t give folic acid without B12 b/c of potential for neuro change
electrolyte changes during tx of pernicious anemia
HYPOkalemia
Are central nervous changes reversible in pernicous anemia?
Yes if tx is aggressive and symptoms lasted less than 6 months
Endoscopy for pernicious anemia
every 5 years, even if asymptomatic
What is vitamin b12 deficient anemia
Macrocytic, megaloblastic
results from deficiency of hydrochloric acid or pancreatic enzymes that cause inability to metabolize vitamin b12
who is more likely to have vitamin b12 deficient anemia
vegans, strict vegetarians, those with dz of ilieum and enteritis, blind loop syndrome, hemodialysis, gastric bypass, fish tapeworm,
drugs that make vitamin b12 deficient anemia more likely
alcohol, metformin, anesthetics, nitrous oxide, para-aminosalicyclic acid (anti TB med)
S&S of vitamin b12 deficient anemia
same as pernicious anemia; pale, icteric, abnormal reflexes, babinski and romberg positive, vibratory sensation decreased in lower extremeties, paresthesia and numbness, ataxia, decreased sense of smell, smooth tongue with tenderness, depression, dementia, splenomegaly, tinnitus, hepatomegaly, tachy, CHF, weakness, asthenia, bleeding gums, nausea, weight loss, decreases appetite, sore tongue, yellowish tinge to eyes and skin, sob, headache, palpitations, chest pain
labs for vitamin b12 deficient anemia
same as pernicious EXCEPT you won’t find anti IF and anti parietal cell antibodies
Serum b12 <100 when symptomatic
normal vitamin b12 deficient anemia tx
B12 IM or sub q (100 mcg daily for 7 days then once a week then once a month) for rest of life
OR
or B12 with 2000 u load then 1000 u daily.
vitamin b12 deficient anemia tx when patient has blind loop syndrome
also give antimicrobial coverage for 7-10 days
rifaximin, amoxicillin-clavulanate, flagyl, norfloxacin
vitamin b12 deficient anemia tx when patient has fish tapweorm
give IF and vitamin B12
common in scandanavian countries
iron deficient anemia type and definition
microcytic
iron stores in body inadequate to preserve homeostasis, less than 12 mcg/l
most common anemia worldwide
causes of iron deficient anemia
**most important is chronic blood loss: gi bleed, menstruation, repeated blood dontaions
blood loss, decreased iron absorption, celiac dz, certain meds, gastric/small bowel sx, blood donations, pregnancy, long term aspirin use, menstrual bleeding, chronic hemoglobinuria (traumatic hemolysis from abnormal cardiac valve function), repeated pregnancies with breastfeeding, diet deficient
S&S iron deficient anemia
pallor, red smooth tongue, spoon shape brittle nails (koilonychia), cracking corners of mouth (cheilosis), tachy, palpitations, peripheral parasthesia, apical systolic hemic murmur, fatigue, sob on exertion, dizzines, HA, exercise intolerance, pica
staging of iron deficient anemia using peripheral smear
stage 1: body stores depleted but labs normal
stage 2: hgb normal but iron stores depleted on labs
stage 3: iron depletion, slight anemia, normal MCV
stage 4: severe iron deficiency, hypochromic RBCs, low MCV with marked anemia
RDW in iron deficient anemia
elevated with absence of any other RBC abnormality
retic count in iron deficient anemia
decreased
ferritin level indicating low iron stores
less than 12
TIBC in iron deficient anemia
increased by > 300 mcg/dl
serum iron in iron deficient anemia
< 50
iron to TIBC ratio < 15%
platelet count in iron deficient anemia
elevated up to 1.5 million/mm
Gold standard for diagnosing iron deficient anemia when labs not conclusive
bone marrow iron stain, look for decreased or absent iron stores. Reported as “prussian blue negative”
iron deficient anemia tx
tx underlying cause- may need blood transfusion
oral ferrous sulfate (300-325 mg tid, 1 hr before meals for 6 months)
Uncomplicated cases can use polysaccharide iron complex for less adverse affects ( hytinic, niferex, nuiron
iron deficient anemia tx followup
repeat CBC in 3 weeks
hgb should be normal in 2 months
iron amount in PRBCs
1 ml of PRBCs has 1 mg iron
1 unit contains 200 mg iron
precautions for sodium ferric gluconate
can cause anaphylaxis,
rapid infusion can cause hypotension and flushing
keep epi and resuscitation equipment readily available
IV and IM iron, when to give and special precautions
only for noncompliance and intolernce with oral supplements
watch for anaphylaxis and keep benadryl and epi close by
painful- give in buttock
can cause plebitis when given IV
formula for IV/IM iron
{(normal hgb-patients hbg) x weight in kg} x 2.21 /1000
folic acid deficiency anemia type/definition
megaloblastic, macrocytic
decreased RBC and hemoglobin content caused by impaired production related to decreased serum folate
folic acid deficiency anemia causes
inadequate intake (alcoholism, anorexia special diet, older age), lack of absorption (celiac dz, tropical sprue,gluten sensitve enteropathy), inadequate conversion of folate to tetrahydrofolate, increased utiliztion during pregnancy, cancer and hemolysis
drug induced folic acid deficiency anemia caused by
methotrexate, pyrimethamine, phenytoin, alcohol, isoniazid, oral contraceptive
normal body store of folate
5000 to 20000
S&S of folic acid deficiency anemia
fatigue, pallor, mouth/tongue pain, signs of malnutrition, GI issues
serum folate in folic acid deficiency anemia
> 4- rule out folate deficiency
<2- diagnostic of folate deficiency in absence of anorexia or fasting
RBC folate in folic acid deficiency anemia
less than 150, indicative of folate deficiency
MCV in folic acid deficiency anemia
> 115 gl, macrocytic
homocysteine in folic acid deficiency anemia
elevated
folic acid deficiency anemia tx
make sure you have diagnosed correctly because giving folate to someone with b12 deficiency can make neuro symptoms worse
give oral folate 1-5 mg daily for 3-4 months
Total correction should be seen in 2 months
anemia of chronic dz definition
- gradual onset, 2nd most common anemia
- can be normochromic and normocytic, OR hypochromic and microcytic
- accompanies chronic dz (infection, inflammation,immune activation {rheumatoid}, CKD,malignancies, diabetes, MI, burns, liver dz, and hypo endocrine dzs) and is resolved when underlying dz fixed
subjective findings of anemia of chronic dz
usually no symptoms until severe, then fatigue, SOB, weight loss, light headedness, loss of appetite
Physical findings will be related to underlying dz
RBCs in anemia of chronic dz
can be normochromic and normocytic, OR hypochromic and microcytic
RDW normal
iron storage in anemia of chronic dz
normal or increased, sideroblasts absent in bone marrow
retic count in anemia of chronic dz
less than 1% or low absolute number
serum ferritin in anemia of chronic dz
normal or high. >100
TIBC in anemia of chronic dz
lowered, <250
anemia of chronic dz tx
tx underlying dz,
- may try oral iron in premenopausal women
- Recombinant human erythropoietin (epogen, procrit) to promote hematopoiesis
risk for fast HCT rise
hct should not be raised more than 4 points during any 2 week period b/c this could cause htn or seizures.
Thalassemia definition/type
group of inherited disorders that are the result of defective production of the globin portion of hemoglobin
-hypochromic and microcytic
Name for severe Thalassemia
Cooley’s anemia
Thalassemia incidence
most common in Mediterranean people (italian, greek)
alpha Thalassemia 4 types
1: silent carrier, asymptomatic, alpha Thalassemia-2 trait
2: mild microcytic , hypochromic, alpha Thalassemia 1 trait
3: moderately severe hemolytic anemia, usually don’t need transfusions, 3 genes affected
4: nonfunctional: all four genes affected, hydrops fetalis and bart’s hemoglobin
Who is most affected by beta Thalassemia in US
mediterranean, asian and african descent
Who is most affected by alpha Thalassemia in US
asian descent
S&S and physical findings of Thalassemia
Hepatosplenomegaly, cardiac failure/dilatation, jaundice, cooley’s anemia, growth retardation, delayed or absent adolescent growth (late menarche, oligomenorrhea or amenorrhea, delayed sexual characteristics, hypogonadism) pallor, fatigue, dark urine, poor growth
Cooley’s anemia findings
marked osteoporosis and cortical thining, erythroid overgrowth of the marow may distort bones of head, face, rib cage, and pelvis, predisposed to fxs
CBC for Thalassemia
Decreased Hgb, hct, MCV, and MCH, increased RBCs
Wright stain for homozygous beta Thalassemia and double heterozygous non alpha Thalassemia
extreme anisocytosis and poikilocytosis with bizarre shapes, target cells, and ovaloctyes and large number of nucleated RBCs
Wright stain for heterozygous beta Thalassemia
hypochromic and microcytic cells with mild to moderate anisocytosis and poikilocytosis.
Target cells with basophilic stippling
Indirect bilirubin level in Thalassemia
increased, 1-6 mg/dl, higher in Thalassemia intermedia
test to confirm diagnosis
Hgb electrophoresis
- If HbA2 is elevated= heterozygous beta Thalassemia
- if HbF and HbA2 levels are normal, microcytosis with minimal or no anemia= alpha Thalassemia
skull xray with Thalassemia
beta Thalassemia skull xray may show “hair on end” appearance
Severe beta Thalassemia tx
- blood transfusions- multiple transfusions pt patient at risk for hemochromatosis
- Iron chelation therapy: deferoxamine IM or sub q pump or hickman cath. Done to prevent organ damage from iron overload
- hgb goal 9-10
- concurrent admin of vitamin c to enhance iron excretion
Tx of choice for beta thalassemia major
allogeneic bone marrow transplant
this is the only cure
what to watch for to indicate spleen issues in Thalassemia
look for leukopenia and thrombocytopenia as indicator of splenic enlargement and possible need for spleenectomy
Which anemias are microcytic? (5)
Iron deficiency Thalassemia anemia of chronic dz lead toxicity zinc deficiency
Which anemias are macrocytic and megaloblastic (3)
Vitamin b12 deficiency
Folate Deficiency
DNA synthesis inhibitors
Which anemias are macrocytic and nonmegaloblastic (7)
Aplastic anemia myelodysplasia liver disease Reticulocytosis Hypothyroidism Bone marrow failure Copper Deficiency
Which anemias are normocytic
Kidney disease
Non thyroid endocrine gland failure
copper deficiency
the mild forms of most anemias start as normoctic
Ferritin levels indicating iron deficiency anemia
less than 30
What happens to transferrin levels when serum iron values drop
Transferrin (iron transport protein) increases to compensate leading to transferrin saturation of less than 15%
Medication for CKD patients with iron deficiency anemia
Ferric pyrophosphate citrate (triferic) is added to diasylate
Maintains hemoglobin without increasing iron stores
transferrin levels in iron anemia of chronic dz
normal or increased, Saturation may be low
Hematocrit in anemia of chronic dz
rarely falls <60% of baseline
Lab findings in alpha thalassemia trait
mild anemia hct: 28%-40% MCV is really low though (60-75) RBC normal or increased Blood smear: microcytes, hypochromia, some target cells, acanrhocytes Normal retic count and iron
Hemoglobin H disease labs
Hct: 22-32%
MCV: 60-70
Blood smear: hypochromia, microcytosis, target cells, poikilocytosis
Elevated retic count
RBC norm or elevated
-Fast migrating hemoglobin (hemoglobin H) which compromises 10-40% of hemoglobin
Blood smear will show hemoglobin H
Beta Thalassemia minor
HCT: 28-40%
MCV: 55-75
Retic counr norm or elevated
Blood smear: hypochromia, microcytosis, target cells
***Basophilic stippling present
-Elevation of HEmoglobin A2 to 4-8%, and hemoglobin F elevations to 1-5%
Beta thalassemia intermedia
Hct: 17-33%
MCV: 55-75
RBC norm or elevated
Elevated retic count
Blood smear: hypochromia, microcytosis, basophilic stippling, target cells
-30% Hemoglobin A1, increase in Hemoglobin A2 up to 10% and elevation of hemoglobin F from 6-10%
Beta thalssemia major
severe anemia, without transfusion, hct can drop to < 10%
blood smear bizarre: severe poikilocytosis, hypochromia, microcytosis, target cells, basophilic stippling, nucleated RBCs
Little or no hemoglobin A2, predominant hemoglobin seen is hemoglobin F
tx for hemoglobin H disease
folic acid supplement
AVOID medicinal iron and oxidative drugs such as sulfonamides
Normal serum b12
> 210
red blood cell folic acid level in folic acid deficiency
<150 ng/mL
Hemolytic anemias
RBC survival is reduced, and bone marrow will increase production to compensate until it is impaired
