Heme/ Anemia Flashcards by katie gazda

VOLUME of RBCs; tells you how big RBC is; allows for classification of anemia
Normal 80-100

Mean Corpuscular Volume (MCV)

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Concentration of hgb in RBCs; tells you how colorful RBCs are (pale, dark, norm)
Normal 32-36

Mean Corpuscular Hemoglobin Concentration (MCHC)

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baby RBCs
Marrow production of RBCs; differentiate if anemia is r/t decreased production or increased loss
Absolute retic: 25-70 x10/L
Normal: 0.5-2%

Reticulocyte count

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Shows percentage of subclass of hgb
Help to identify thalassemias

Hgb electrophoresis

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RBC distribution with - tells you variance in size of RBCs (let us know if there are a lot of reticulocytes or not)

RDW

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First level that becomes abnormal when iron stores are becoming depleted - total body iron stores

Serum ferritin

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amount of iron bound to transferrin (plasma carrier protein)

serum iron

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indirectly measures the amount of transferrin. indicates the availability of binding sites on the protein for iron transport

Total iron-binding capacity (TIBC)

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calculated with TIBS and serum iron (Serum iron/TIBC) x 100

Transferrin Saturation Percentage (20-50%)

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Normal Hgb Levels

Male 13.8-17.2; female 12.1-15.1

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Normal Hct Levels

Male 41-50%; female 36-44%

Rule of thumb: 1 hgb for every hct

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Normal RBCs

Male 4.7-6.1; female 4.2-5.4

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General Anemia

Men Hgb

Men Hgb <13.6g/dL

Women <12 r/t menstruation

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CM: gradual/vague until <6 typically; fatigue, malaise, HA, dyspnea, irritability, decrease in exercise tolerance

PE: resting tachycardia and dyspnea (severe); murmur, brittle nails (long term), glossitis, angular cheilitis, spoon-shaped nails. Pallor (nails, lips, mucous membranes, palmar creases), bruising
dx: with CBC

General Anemia

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Classification of anemia- MCV <80, decreased MCHC

Microcytic, hypochromic

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possible causes of Microcytic, hypochromic anemia

Iron deficiency anemia
Thalassemia
Lead poisoning
Sideroblastic anemia
Aluminum toxicity

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Classification of anemia- MCV >80, normal MCHC

Macrocytic, Normochromic

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possible causes of Macrocytic, Normochromic anemia

Vitamin B12 deficiency
Folate deficiency
G6PD

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Classification of anemia- MCV 80–100, normal MCHC

Normocytic, Normochromic

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possible causes of Normocytic, Normochromic anemia

Anemia of chronic disease
Acute blood loss
Early iron deficiency

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what kind of anemia is common in children and pregnant women.

IDA

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Kinds of anemia common in elderly

anemia of chronic disease (ACD), nutritional deficiencies (B12, folate)

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what kind of anemia is common in the Mediterranean, Middle East, Southeast Asia, India, and Pakistan

thalassemia

normal MCV, normal MCH/MCHC, hgb >9g/dL

Normocytic

reduced transport of iron to erythroid precursors; decreased RBC survival time, blunted erythropoietin response to anemia One of most common anemias Seen in: hospitalized pts, elderly, chronic disorders (acute/chronic infections, malignancy, inflammatory disorders, HIV), CAN coexist with IDA or be confused with it CM: mild and asymptomatic; cm usu r/t underlying disease process, Fatigue, tachycardia, pallor

Anemia of Chronic Disease

Lab findings for Anemia of Chronic Disease

low serum iron | Ferritin normal or elevated

How to tx Anemia of Chronic Disease

Treat the cause 1st line: recombinant human erythropoietin (rHuEPO) Used to stim the bone marrow to create more RBCs at a higher rate (HIV, cancer, CKD) Non-Pharm: Patient education: regular lab draws; call provider if increase in sx

normal MCV 80-100, normal MCHC Benign w/unknown cause, occurs in childhood in prev health children, first few years of life Frequently follows viral infection (viral suppression or IgG, IgM, or cell-mediated autoimmune response)

Transient Erythroblastopenia of Childhood (TEC)

6mon-3years of age, usually after 1 yr Develop over days or weeks & assoc with viral s/s (fever, malaise, lethargy, abdominal pain, upper respiratory symptoms) Gradually increasing pallor Decreased energy levels/fatigue PE: overall normal presentation Jaundice can appear (esp. If child has preexisting hemoglobinopathy)

Transient Erythroblastopenia of Childhood (TEC)

Dx and labs: Anemia ⬇Hgb (6-8g/dL, can be as low as 2.5g/dL) ⬇reticulocyte ✔MCV for age (this value will help differentiate it from other congenital hypoplastic anemias) ✔WBC (some neutropenia in 20%) ✔ or ⬆ platelet count ⬆ serum iron level (reflects decreased utilization) Erythroid hypoplasia in bone marrow aspiration

Transient Erythroblastopenia of Childhood (TEC)

How to tx Transient Erythroblastopenia of Childhood (TEC)

1st line: Ø specific treatment indicated | Severe: Transfusions may be required, possible REFERRAL to hematologist

Macrocytic, normochromic (MCV >80), normal MCHC) Folate r/t: malabsorption disorders, pregnancy (neural tube defects), cancer, hyperthyroid, ETOH abuse, sickle cell anemia, dietary folate deficiency, B12 r/t: malabsorption (pernicious anemia, crohn's dx, celiac dx, gastrectomy/bariatric sx), meds (GERD tx, long term H2 blocker use, PPI’s), strict vegetarians Normal B12 intake 3-5mcg/day Other causes: drug use, liver dx, hypothyroidism, myelodysplastic syndrome, chemo

Folate & Vitamin B-12 Deficiency

CM: few sx- GLOVE AND STOCKING (numbness and tingling) - classic. Can get nerve damage if you dont fix it, glossitis PE: B12: Sore mouth with loss of taste → smooth, red, shiny, large tongue (glossitis) if severe- neurologic findings (decreased vibratory sensation, loss of proprioception, peripheral neuropathy, ataxia, hyperactive reflexes, Romberg sign)

Vitamin B-12 Deficiency

diagnostic Methylmalonic acid...

elevated in vitb12 deficiency, normal in folate deficiency

foods high in folic acid and B12

Folic acid→ fruits and vegetables, liver, green leafy veggies, peas, beans, avocados, eggs, milk. Fortified foods: pasta, flour, cereal, bread, rice Vit. B12 → meat protein, dairy, egg

most prevalent cause of vitamin B12 deficiency...atrophy of parietal cells in stomach leads to loss of intrinsic factor (IF) → necessary to absorb b12

Pernicious Anemia

how to dx and tx Pernicious Anemia:

Dx: assay for anti-IF or anti-parietal cells antibodies Tx: 1st line: parental Vitamin B12 injections (IM or subQ): 6 week replacement schedule then monthly injections for life

Most common anemia in the world, most common nutrient deficiency. Mostly affects women of reproductive age and older adults

Iron Deficiency Anemia

CM include... Paresthesia, sore tongue, brittle nails, spoon-shaped nails, pica (starch, ice, or clay) Pica→ paper, dirt, clay; pagophagia→ ice

Iron Deficiency Anemia

Lab Findings for IDA

``` Hgb: ⬇ Serum ferritin: ⬇; RDW is the earliest marker for FE deficiency (p.748) Serum iron: ⬇ TIBC: ⬆ Transferrin saturation: ⬇ ```

IDA Patient education

take iron 30 mins before meals. Calcium inhibits iron absorption (no dairy or calcium 1-2 hrs after taking iron supplements) SE: constipation, nausea (add stool softener, take at bedtime) Stool may be dark tar color

Complex inheritance pattern as multiple genes involved Affected people: SE Asia, India, China, Philippines 4 genes (two from each parent) involved

Alpha (α) Thalassemia

four genes affected, leads to premature births that are either stillborn or die shortly after birth → incompatible with life

Alpha thalassemia major (hydrops fetalis)

Autosomal recessive Affected people: Mediterranean, Middle Eastern, African, Asian 2 genes (one from each parent) involved

Beta (β) thalassemia

Dx/Lab findings: Anemia ⬇ MCV ✔ iron studies Hemoglobin electrophoresis (⬆ levels of hemoglobin A2) >3.5%- p.751 (primary diagnostic) Alpha globin DNA mutation (REFER for this if thalassemia is suspected, test not readily available) Mentzer index <13

Beta (β) thalassemia

PE: only remarkable in beta intermedia and major (compatible with life + abnormal findings)

Short stature Abnormal facies Cranial marrow expansion - trying to make more RBCs Pallor, jaundice, enlarged spleen, liver, or heart

LIFE THREATENING, bone marrow stem cell failure. Secondary to infection or exposure to toxins or medications, or immune mediated. - REFER!

Aplastic Anemia

CM: abnormal bleeding, infection, anemia. Sudden onset. Hx may reveal recent viral infection, chronic disease, medication, toxin PE: petechiae, ecchymosis, purpura, pallor of skin and mucous membranes. Mild lymphadenopathy in late stage.

Aplastic Anemia

How to tx Aplastic Anemia

IMMEDIATE HEME REFERRAL >40 yo: immunosuppression therapy. HSCT (hematopoietic stem cell transplant) in younger pts Non-pharm Receive all vaccinations and maintain healthy diet and exercise Patient education: protection from infectious sources is essential

increased rate of RBC destruction (body making them fine, destroying them at very fast rate) Labs High retic (producing because its low) Low H/H, High LDH (direct cellular injury), Haptoglobin (low)- binds to free hbg as RBC rupture. Low indicates intravascular hemolysis High Bilirubin level (RBC destruction)

Hemolytic anemias

Meds or foods that can precipitate Hemolytic anemias

sickle cell, Hereditary Spherocytosis, G6PD (meds can precipitate/fava beans)- Normocytic Anemia

deoxygenated Hgb undergoes irreversible changes that give sickle shape. Sickle cells become trapped in microcirculation causing obstruction, ischemia, and infarct leading to severe pain and end-organ damage (sickle crisis). Most often occurs in joints, extremities, back, chest, ABD, lungs African Americans most affected CM: asymptomatic until in periods of crisis Vaso-occlusive crisis: severe pain, can lead to organ damage Acute chest syndrome! Or septicemia PE: jaundice, scleral icterus, murmur along left sternal border, cardiomegaly

Sickle Cell Anemia: REFER- Can affect every ROS

Treatment for sickle cell

Hydroxyurea: decreases percentage of hgb S (that become sickled) started at 10-20mg/kg/day Hematopoietic stem cell transplant is only cure for crisis: NSAIDs or oral narcotics, hydration, rest, heat, massage

Patho: mild chronic hemolytic anemia; RBC membrane has a smaller surface area with a spherical shape. CM: jaundice in newborn period. Splenomegaly by 2 years of age; chronic fatigue, malaise, and abdominal pain

Hereditary Spherocytosis

positive family hx and pathognomonic findings of peripheral blood smear. (many microspherocytes and elevated MCHC). Peripheral smear: RBC are uniformly spherical in shape, smaller than normal Severe forms may require splenectomy. Consider prophylactic cholecystectomy d/t high incidence of gallstones

Hereditary Spherocytosis

inherited erythrocyte enzyme deficiency; can result in acute hemolytic anemia. G6PD-induced hemolysis is precipitated by infection or ingestion of oxidant drug or food. Women are usually carriers and males affected, typically African american; tropical/subtropical regions (associated w/ malaria) Fava beans, ingestion of mothballs, or severe infections (viral or bacterial)

G6PD Deficiency

G6PD Deficiency... | Drugs a/w acute hemolysis:

ASA, phenacetin, sulfonamides, nitrofurantoin, and primaquine (malaria tx) → oxidant drugs→ ask “have you been on ABX recently?