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CBL8 Anaemia Flashcards

1
Q

What’s the function of folic acid

A

Folic acid is converted to tetrahydrofolate (THF).

Functions

  • THF plays a key role in the transfer of 1-carbon units (e.g. methyl, methylene, and formyl groups) to the essential substrates involved in the synthesis of DNA & RNA
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2
Q

Total iron binding capacity

A

how much transferrin is available to bind to iron

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3
Q

What is B12 needed for in the body?

A

Vitamin B12 is mainly used in the body for red blood cell development and also maintenance of the nervous system

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4
Q

What ‘s sideroblastic anaemia? (simply what happens)

A

Sideroblastic anemia or sideroachrestic anemia is a form ofanemia in which the bone marrow produces ringed sideroblasts rather than healthy red blood cells (erythrocytes).

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5
Q

What is the pathophysiology of pernicious anaemia?

A
  • autoimmune disease caused by antibodies to gastric parietal cells or intrinsic factor
  • results in vitamin B12 deficiency
  • associated with thyroid disease, diabetes, Addison’s, rheumatoid and vitiligo
  • predisposes to gastric carcinoma
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6
Q

A classic picture of iron deficiency anaemia (values)

A

–Hb 95 g/L (male normal 130-180)

–MCV 72fL(normal 80- 100)

–MCH 26 pg MCH (normal 27 - 32)

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7
Q

How B12 is absorbed?

A
  • It is absorbed after binding to intrinsic factor (secreted from parietal cells in the stomach) and is actively absorbed in the terminal ileum
  • A small amount of vitamin B12 is passively absorbed without being bound to intrinsic factor
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8
Q

Consequences of folic acid deficiency (2)

A
  • macrocytic, megaloblastic anaemia
  • neural tube defects
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9
Q

Conditions that may lead to anaemia of chronic dissease

A
  • Chronic infection
  • Vasculitis
  • Rheumatoid
  • Malignancy
  • Renal failure
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10
Q

What are the plasma results for:

  1. iron 2. TIBC 3. ferritin
    in: chronic haemolysis
A
  1. Increased iron
  2. decrease tibc
  3. increased ferritin
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11
Q

just look on the picture (iron deficiency anamia)

buzzwords:

  • small and pale RBCs
  • ‘pencil’-shaped
A
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12
Q

When do we need to further investigate (other than blood) for the cause of iron deficiency anaemia?

A

If the MCV is low and there is a history of menorrhagia then iron can be started without any further tests. Otherwise, investigations of the GI system to exclude any GI bleeds such as -stool sample * endoscopy, colonoscopy and sigmoidoscopy

*stool sample as an investigation: this is not recommended as the sensitivity is very poor

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13
Q

How does iron def anaemia appear on a smear?

A

Less haemoglobin so blood cells appear lighter- HYPOCHROMIC

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14
Q
A
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15
Q

Causes of folate deficiency

A
  • Poor diet -poverty, alcoholic and elderly
  • Increased demand -pregnancy, increase cell turnover and this is seen in haemolysis, malignancy, inflammatory disease and renal dialysis.
  • Malabsorptions -coeliac disease and tropical sprue
  • Alcohol
  • Medication such as antiepileptics, methotrexate and trimethoprim
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16
Q

Causes of iron deficiency anaemia

A
  • Dietary: lack of red meat; beef and lamb are good sources and liver
  • Chronic blood loss (menorrhagia, chronic GI blood loss)
  • Decreased absorption (coeliac disease, atrophic gastritis, foods e.g. tea)
  • Pregnancy
  • Hookworm and schistosomiasis in the tropics that might cause GI loss -this is the leading cause worldwide
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17
Q

What result (on a blood test) would confirm IDA?

A

confirmed by reduced ferritin

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18
Q

Anaemia + increased erythropoiesis

What’s a possible explanation?

A

Haemolysis

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19
Q

Common causes of microcytic anaemia

A

Microcytic anaemia: TAILS

  • Iron deficiency
  • thalassaemic syndromes
  • sideroblastic anaemia
  • anaemia of chronic disease
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20
Q

Treatment of folate deficiency

A
  • Folic acid 5mg/day for 4 months
  • They are never given without the B12 unless the patient is known to have a normal B12
  • in pregnancy prophylactic doses of folate 400mcg/day are given from conception until the 12th week
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21
Q

What are the plasma results for:

  1. iron 2. TIBC 3. ferritin
    in: haemochromatosis
A
  1. Increased iron
  2. decreased TIBC/stays the same
  3. Increased ferritin
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22
Q

What’s MCV in macrocytic anaemia?

A

MCV > 96fL

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23
Q

Anaemia + normoblastic marrow (on a blood film)

What is the possible explanation?

A

Normoblastic marrow -liver disease and hypothyroidism

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24
Q

Management of pernicious anaemia

A
  • 3 monthly treatment of vitamin B12 injections
  • Folic acid supplementation may also be required
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25
Definition of **iron deficiency anaemia**
**Anaemia** in association with a low MCV and evidence of depleted iron stores such as: - low ferritin - increased TIBC (total iron binding capacity) \* \*as less iron bound = more space available = increased
26
Folate ## Footnote - dietary sources - where is it stored - absorption (where)
* Found in green vegetables, nuts, yeast and liver * It is synthesized by the gut bacteria * The body stores can last for 4 month * absorbed by the duodenum/proximal jejunum
27
Mechanisms (3) by which chronic disease may cause anaemia (anaemia of chronic disease)
_Develops due to any of 3 problems:_ * Poor use of iron in erythropoiesis * Cytokine induced shortening of RBC survival * Reduced production of and response to erythropoietin
28
Management of B12 deficiency (2 possible pathways)
* if no neurological involvement 1 mg of IM hydroxocobalamin 3 times each week for 2 weeks, then once every 3 months * if a patient is also deficient in folic acid then it is important to treat the B12 deficiency first to avoid precipitating subacute combined degeneration of the cor
29
What is seen on the blood film in iron deficiency anaemia?
microcytic, hypochromic, anisocytosis (RBCs unequal size) and poikilocytosis (different shape)
30
Transferrin in iron deficiency anaemia
INCREASED body wants more iron in the blood
31
Causes/ differentials of microcytic anaemia
Causes * iron-deficiency anaemia * thalassaemia\* * congenital sideroblastic anaemia * anaemia of chronic disease (more commonly a normocytic, normochromic picture) * lead poisoning
32
Management of anaemia of chronic disease
* Treat the underlying cause * Erythropoietin is effective in raising the Hb level however it has some SE (flu like symptoms) it is also effective in raising the Hb and QoL in those who have a malignant disease
33
What are the plasma results for: 1. iron 2. TIBC 3. ferritin in: **pregnancy**
34
What is MCH?
Mean corpuscular haemoglobin (MCH) = mean Hb quantity within the blood cells
35
Anaemia + abnormal erythropoiesis What's possible explanation?
Sideroblastic anaemia, leukaemia, aplasia
36
Symptoms of anaemia
* Fatigue * Dyspnoea * Faintness * Palpitations * Headache * tinnitus * Anorexia * Angina
37
Causes of macrocytic anaemia
_Macrocytic anaemia_ can be divided into causes associated with * **megaloblastic** bone marrow * **normoblastic** bone marrow
38
What dietary products is folic acid present in?
Folic acid is in green leafy veg. and fortified foods
39
What's megaloblast and why are they seen in macrocytic anaemias? (pathophysiology)
A megaloblast is a cell in which the nuclear **maturation** is **delayed** compared with the cytoplasm. B12 and folate deficiencies are both examples of megaloblastic anaemias because both are required for DNA synthesis
40
What's the most widely used method in identifying the cause of the anaemia?
The most widely used method utilises the **Mean Corpuscular Volume (MCV)** – the average volume of RBCs: –Too small: microcytic –Within normal limits: normocytic –Too big: macrocytic
41
What is a better marker for iron deficiency anaemia: serum transferrin or ferritin?
**Ferritin** is an acute phase protein and might increase with inflammation**.** **Serum transferrin** are also increased in the IDA but are less affected in inflammation.
42
What is MCV?
Mean cell volume (MCV) = mean volume of red blood cells (RBC)
43
Transferrin
the transport protein that the iron binds to in the blood
44
Possible investigations for pernicious anaemia
testing for **parietal cell antibodies** or **intrinsic factor antibodies**
45
What is Hb?
Haemoglobin (Hb) = concentration of Hb within the blood
46
47
Symptoms and signs of pernicious anaemia
* lethargy, weakness * dyspnoea * paraesthesia * also: mild jaundice, diarrhoea, sore tongue * possible signs: retinal haemorrhages, mild splenomegaly, retrobulbar neuritis
48
What type of anaemia iron deficiency anaemia is?
* IDA is a **microcytic hypochromic** anaemia
49
Is anaemia a late or an early sign of iron deficiency?
Anaemia is a late manifestation of iron deficiency and that symptomatic iron deficiency can manifest before anaemia manifests
50
What are the plasma results for: 1. iron 2. TIBC 3. ferritin in: **sideroblastic anaemia**
1. Increased iron due to iron overload 2. Increased ferritin - iron accumulates and we try to store it 3. TIBC decreases - want less iron around
51
Sideroblastic anaemia
- dysfunction of polyporphin component of haem - results in excess iron levels because of insufficient polyporphrin to combine to and create haem
52
What are the plasma results for: 1. iron 2. TIBC 3. ferritin in: **anaemia of chronic disease**
53
Considerations (3) for management of iron deficiency anaemia with ferrous sulphate ## Footnote - when to stop the treatment - response marker - SE
**Oral iron, ferrous sulphate 200mg.8h PO:** * Hb should rise by 1g/L per week with modest reticulocytosis * Continue until the Hb is normal and then for 3 months after * SE: nausea, abdominal discomfort, diarrhoea, constipation, black stool
54
Features of B12 deficiency
* macrocytic anaemia * sore tongue and mouth * neurological symptoms: e.g. ataxia * neuropsychiatric symptoms: e.g. mood disturbances
55
Investigations for anaemia of chronic disease
_Mild normocytic anaemia_ * Ferritin is normal or increased * Do a blood fil of B12 * Folate * TSH • Tests for haemolysis as anaemia is often multifactorial
56
Ferritin
Main storage complex in the liver, bone marrow and spleen
57
Hemolytic anaemia
abnormal breakdown of the rbc
58
Causes of macrocytic anaemia
​Macrocytic anaemia - FAT RBC * **B12 or folate deficiency** * **Alcohol excess/ Liver disease** * Reticulocytosis * Cytotoxics (e.g. hydroxycarbamide) * Myelodysplastic syndromes * Marrow infiltration * Hypothyroidism * **Antifolate drugs** (e.g.phenytoin) Macrocytic anaemia: differential FAT RBC: Fetus (pregnancy) Alcohol Thyroid disease(ie hypothyroidism) Reticulocytosis B12 and folate deficiency Cirrhosis and chronic liver disease
59
Causes of normocytic anaemia
Normocytic anaemia: * Acute blood loss * Anaemia of chronic disease * Bone marrow failure * Renal failure * Hypothyroidism * Haemolysis * Pregnancy *Anemia (normocytic): causes ABCD: Acute blood loss Bone marrow failure Chronic disease Destruction (hemolysis)*
60
What's the value of **Hb** to classify anaemia as **microcytic**?
This is when their mean cell Hb correlates with **less than 72**
61
What may be seen in thalassemia in terms of MCV and Hb
MCV is disproportionately low for Hb (e.g. Hb 105, MCV 65) Ranges: (just for reference) HaemoglobinMen: 135-180 g/l Women: 115-160 g/lMean cell volume82-100 fl
62
What is 'low Hb' in ranges for men and for women
Low Hb * Men: \<135 g/L * Women: \< 115 g/L
63
Is it reliable to rely only on MCV in identifying the cause of anaemia?
MCV is only a _mean_, and doesn’t tell you everything about the RBC characteristics
64
General management options for iron deficiency anaemia
* oral supplementation (ferrous sulphate) * IV iron supplementation - needed rarely (i.e. if oral cannot be tolerated/ in some chronic conditions e.g. anaemia that is a result of CKD
65
Ix for macrocytic anaemia
* blood film * LFTs * TFTs * serum B12 * serum folate * bone marrow biopsy \* \*only if the above test do not indicate the cause and pt is anaemic
66
What are the 'pitfalls' for these tests (in iron deficiency anaemia): - ferritin - serum iron - total iron binding capacity
–**ferritin** (_pitfall_: ferritin is an acute phase reactant) –**serum iron reduced** (_pitfall_: also reduced in chronic inflammation) – **total iron binding capacity** increased (_pitfall_: increased in pregnancy )
67
What are the plasma results for: 1. iron 2. TIBC 3. ferritin in: **iron deficiency anaemia**
68
What dietary products vitamin B12 is present in?
* vitamin B12 (hydroxocobalamin) present in liver and red meat -\> made by animal bacteria * it is stored in our liver \*not in fruit or veg. as made by bacteria in animals.
69
70
When is a blood transfusion needed?
The patient will not need blood transfusion unless: * they are **acutely bleeding** and therefore will need some until their blood is **up to 80g/L**
71
Side effects of iron supplementation
Side effects of iron supplementation include: * nausea * abdominal discomfort * constipation * black stools
72
Serum Iron
Measure the amount of iron circulating in the liquid part of the blood bound to transferrin
73
Definition of anaemia
* a reduction in one or more of the major RBC components obtained in a full blood count’: –RBC count –Haemoglobin –Haematocrit (ratio of RBCs to whole blood) \*may be due to either **low red cells** mass or **increased plasma volume** -for example in pregnancy
74
What can be seen on blood film in B12 and folate deficiency?
Hypersegmented neutrophils \*hypersegmented = nuclei of the cell have six or more lobes, happen due to slowed DNA synthesis
75
What is the type of anaemia and ferritin in anaemia of chronic disease ?
* Mild normocytic anaemia * Ferritin is normal or increased
76
Results for ferritin in iron deficiency anaemia
decreased, there is a drive to increase iron uptake to make blood cells less is stored
77
Causes of B12 deficiency
Causes of vitamin B12 deficiency * pernicious anaemia: most common cause (autoimmunity against parietal cells - intrinsic factor -\> so B12 cannot be absorbed) * post gastrectomy * poor diet * disorders of terminal ileum (site of absorption): Crohn's, blind-loop etc * metformin (rare)
78
What is ferritin?
Ferritin - blood cell protein that contains/ stores iron
79
Signs of anaemia
* pallor (including conjunctival pallor) * tachycardia * flow murmurs (ejection-systolic loudest over apex) * cardiac enlargement \*Heart failure may occur
80
Signs of Iron Deficiency Anaemia
* Koilonychia * Atrophic glossitis * Angular cheliosis * and rarely post-cricoid webs

Medicine Part 2 (12 decks)

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