RBC Flashcards
Where are RBC formed?
Bone Marrow, they mature in the bone marrow.
What is the term for the process of formation of RBC?
Erythropoesis
What is the lifespan of a mature RBC
120 days
What is the most common factor that triggers increased production of RBC?
Decrease in O2
Low tissue O2 levels trigger endothelial cells in the kidneys to secrete erythropoietin, with stimulates bone marrow and red cell production.
What is Anemia?
Decrease in number of RBC, Hgb, or Hct OR a decrease in the oxygen carrying capacity of the blood.
What is a normal RBC level?
4.1-5.1 m/mm3
What is a normal Hgb level?
12-16 g/dl
What is a normal Hct Level?
36-46%
What does MCV stand for?
Mean Corpuscular Volume- this allows us to further classify the type of anemia to further determine the eitology.
When discussing Mean Corpuscular Value MCV what are the Normocytic normal ranges?
80-100
When discussing Mean Corpuscular Value MCV what is the microcytic range?
<80 (defect in hgb synthesis)
When discussing Mean Corpuscular Value MCV what is the macrocytic range?
> 100
What are immature RBC called?
Reticulocytes
Mature RBC are smaller in size than immature RBC
What is the ratio of hgb to hct?
1:3, for every one hgb, three % of hct
What does the MCV tell us about?
It is telling us about the size of the RBC in circulation so we can narrow our differential diagnosis
What does MCHC stand for?
Mean Corpuscular Hemoglobin Concentration
What is MCHC?
Average concentration of hemoglobin in RBC. (Much more helpful than MCV) Provides us with information of color of the cell.
With MCHC what is Normochromic ranges?
32-37
With MCHC what is Hypochromic range?
<32
True/False Microcytic is always hypochromic?
True, MCV low- MCHC is always going to be low.
True/False Macrocytic is always normochromic?
True
What are the types of Macrocytic/Normochromic Anemias? Two main types
Increased MCV/Normal MCHC
- Vit B12 deficiency
- Folate deficiency
- Hypothyroidism
- Myelodysplastic process
What is another name for Vit B12 deficiency?
Pernicious Anemia- autoimmune destruction that allow for the production of B12, more common in women over the age of 50-60.
What are some causes of Normocytic/Normochromic anemias?
Normal MCV, Normal MCHC
Anemia of Chronic Disease (liver disease, kidney disease, lupus, RA, AK, inflmmatory autoimmune conditions, cancer, HIV
Acute Blood Loss
Early iron deficiency
What are some causes of Microcytic, Hypochromic Anemias?
Decreased MCV and decreased MCHC - Iron deficiency anemia - thalassemia -Lead poisoning - Sideroblastic anemia - Aluminum toxicity - G6PH Occasionally: Anemia of chronic disease
What does RDW stand for?
Red Cell Distribution Width
What is RDW?
Normally all red cells are equal in size, RDW is the degree of anisocytosis or the variability of the red cell size.
What does RDW help differentitate?
RDW helps to differentiate between various causes of MICROCYTIC, HYPOCHROMIC anemias
- IDA, Thalassemia, and AOCD
With Iron Deficient Anemia what is the RDW usually?
Increased
With Anemia of Chronic Disease, what is the RDW usually?
Normal
With Thalassemia what is the RDW?
Normal or slightly increased
What is the reticylocyte count?
The number of new, young, red blood cells found in 100 RBCs in circulation.
- It is an index of the bone marrows health and response to the anemia
What is a normal Retic count?
1-2%
What does an elevated Retic Count indicate?
Bone marrow is healthy and/or your treatment is working, BUT blood loss or destruction is likely occurring.
Anemia is not a diagnosis…..it is a….
Sign of an underlying health condition
What is the number 1 reason for IDA in indivdiuals >4?
Blood Loss
What is the most prevalent anemia worldwide?
IDA
What causes IDA?
Increased iron loss
Dietary inadequacy
Malabsorption
Increased iron needs
What are signs and symptoms of iron deficiency anemia determined by?
Degree of anemia
Acuteness of anemia
Presence of underlying disease
What labs are drawn to diagnose IDA?
Ferritin, Iron, TIBC, Peripheral Blood Smear
What does Ferritin measure?
Measurement of IRON STORES
What level of Ferritin is diagnostic of IDA?
<16
What is the normal reference range for Ferritin?
10-210
Can Ferritin be falsely elevated?
Yes, in febrile illness, malignancy, liver disease, inflammatory disease
What is the normal range for iron?
50-160
What does an iron level measure?
The amount of circulating iron
What is a low iron level with elevated TIBC suggestive of?
IDA
What is TIBC (Total Iron Binding Capacity)?
Number of cells NOT bound with iron
What is a normal TIBC?
250-350
Higher the Iron……_____ the TIBC
lower
Lower the iron…_____the TIBC
higher
Where is ferritin stored?
RBC’s, if we are losing RBC we are losing Ferritin
What does a pheripheral blood smear tell us?
pathologist report of what the cells look like
What is Poikoilocytosis?
abnormal pigmentation of blood cells
Waht is anisocytosis?
variation of size of cells in circulation
When do we see spherocytes?
hereditary condition, hemolytic anemia, cells are shaped like spheres, no bi concave discs
When do we see schistocyte?
prosthetic heart valve, mechanical heart valve alters the shape of the cell
When do we see elliptocyte or ovalcyte
IDA
When do we see tear drop cells?
IDA
When do we see target cells?
Thalassemia
When do we see basphilic stipping?
thalassemia, lead toxicity
When do we see bite cells?
G6PD deficiency
What are some treatments for IDA?
- Iron rich food increase (liver, beef, lamb, pork, veal, chicken, eggs, fish, beans, prunes, green leafy vegetables,
- Iron supplements Ferrous sulfate 325mg 1 PO TID, Ferrous Sequel 1 PO TID, Chromagen Forte capsules (1 cap daily, iron, plus folic acid)
If the bone marrow is healthy in IDA in 5 days we will see what?
Reticulocyte count increase
With adequate treatment the Hct should rise 1 point each week
Once Hct has normalized, how long does it take for iron stores to be replenished?
3-6 weeks
As long as dietary and bleeding issues have been corrected.
Need to continue to treat with Iron, dont stop too soon.
What type of treatment is necessary if an individual is unable to absorb the iron or when the rate of blood loss exceeds absorption?
IV Iron Dextran
What are the types of Macrocytic Normochromic anemias?
Vit B12 deficiency Folate deficiency Acute bleeding, hemolysis Hypothyroidism Myelonodysplastic syndrome
Vitamin B12 (cobalamin) is essential for he production of what?
DNA
What does deficiency of B12 result in?
Alteration in the production of DNA, decreased rate of production, enlarged red cell
What are the general causes of Vitamin B12 deficiency?
- Inadequate intake
- Decreased absorption
- Inadequate utilization
- Most common cause- inadequate absorption
What are some medical causes of inadequate absorption or utilization of B12?
- Crohn’s
- Celiac Disease
- S/p gastrectomy or bariatric sugery
Also medications: methotrexate, fluorouracil
Altered gastric acid production- PPI’s
What is the most common cause of Vit B12 deficiency?
Pernicious Anemia
What is a autoimmune disease characterized by presence of autoantibodies to teh parietal cells in the stomach and their secretory product called intrinsic factor?
Pernicious Anemia
What is intrinsic factor essential for?
absorption of Vit B12 in the terminal ileum of the bowel
Pernicious anemia is commonly seen in the setting of other autoimmune conditions such as:
Hashimotos thyroiditis and Vitiligo
When do we often see Pernicious Anemia begin?
Onset is insidious
5-6th decade of life
Women > men
What are important history questions to ask when discussing pernicious anemia?
- Dietary intake
- ETOH consumption
- Medication hx: chemo, PPI
- PMH- surgeries and conditions affecting the ileum/stomach
In pernicious anemia we see the inability of the body to maintain what?
myelin integrity
Therefore we have neurologic manifestations
What are Neurologic Manifestations of pernicious anemia?
-Parasthesias- pins and needles “stocking glove distribution”
- Weakness in extremities
- Delirium/psychosis
Decreased position and vibratory sense
Incoordination
Depression
Words of Warning: Patients with severe Vit B12 deficiency can develop what?
Severe hypokalemia
- Monitor K levels as B12 is administered
What is the standard med treatment for B12 deficiency?
Cyanocobalamin 1000 iu/day x 5 days, then…
weekly until hgb normal
1000 ug/month for life
Reticulocytosis within 1 week
Should see increase in Hgb and Hct with 1 week
Normalization of h/h within 2 months
Rapid improvement in symptoms, however may take 12-18 months for all neurlogic symptoms to improve.
Nascobal (cyanocobalamin) what is the treatment/dosage?
500mcg/0.1ml nasal gel
Used for maintenance of Vit B12 deficiency, after IM B12 has resolved anemia
I spray into each nostril each week
What are some causes of Folate Deficiency?
- most often inadequate intake of folic acid
- poor dietary intake, in elderly, chronically ill, ETOH users, and fad diets
- Occastionally increased need, impaired absorption, and inadequate utlization
What may a beefy red tongue, angular kelitis, diarrhea, anorexia, and fatigue possible symptoms of?
Vit B12 deficiency
How do we make a diagnosis of B12 deficiency?
- CBC- macrocytic
- Peripheral smear
Vit B12 level 200-800, like to have around 500 mark, around 200 they become symptomatic - Schilling Test
True/False B12 and Folate deficiencies are usually found together?
True
True/False? The body has very little folate in storage compared to B12?
True, very little folate stored, B12 3-5 years is held
What would cause impaired absorption of Folate?
- Celiac Disease
- Giardia Infection
- Phenytoin
What would cause increased need of Folate?
- Pregnancy
- Hyperthyroidism
- Malignancy
- Chronic Inflammatory DIseases- chrohns
What would cause impaired utilization of Folate?
- Methotrexate
- Metformin
- Trimethoprim
How do we diagnose Folate Deficiency?
Serum Folate level
Additional tests:
- MMA (methylmalonic acid)
- Homocysteine (Hcy)
- Both of these will be elevated in B12 deficiency
Only homocysteine will be elevated with Folate deficiency
What is the first line treatment for Folate Deficiency?
Folic Acid 1mg PO QD, may increase to 5mg/day
- Review cause with patient, dietary sources
- Reticulocytosis within 1 week
- Hct and Hgb should improve within 1 week
- Hct should normalize within 2 months
Chronic disorders are frequency accompanied by:
Normocytic Anemia - Acute and chronic infections - Malignancy - Inflammatory disorders - HIV disease Commonly confused with iron deficiency
What is it called when we see trapping or iron by macrophages?
Normocytic anemia
With Normocytic anemia we see:
- Iron unavailable for erythropoesis
- inflammatory processes also suppress erythropoesis leading to diminished production of RBC.
With what type of anemia will we see Normal MCV, normal MCHC, rarely a hct below 25%, low serum iron, TIBC low, normal or increased ferritin?
Anemia of Chronic Disease
- Low TIBC and also normal or increased Ferritin help differentiate from ACD from IDA.
Treatment of normocytic anemia in renal disease includes what?
Erythropoietin (Epoetin Alfa), Procrit, Aransep
Treatment of normocytic anemia with malignancies?
Chemotherapy
Treatment of normocytic anemai with hypothyroidism? Goal: TSH:
1.5
Hgb goal for individuals with normocytic anemia (ACD)?
10-12, increaseing hgb >12 could cause increased risk of MI
If anemia fails to resolve, remember ______ coexisits in 1/3 of all patients with these type of anemias.
IDA
