Tutorial #25: Anemia

Question 1

What is the most common etiology of anemia

Answer 1

iron deficiency anemia

It is also by far the most common cause of microcytic anemia.

Question 2

What are the risk factors for iron deficiency anemia? (x2)

Answer 2

1. bleeding of any kind
2. Low iron diet (ex. vegan)

Question 3

In iron deficiency anemia, what would the:
1. MCV
2. Ferritin
3. TIBC
4. Tsat

Answer 3

1. MCV < 80 (microcytic)
2. Low ferritin
3. High TIBC
4. Low Tsat

Note: iron deficiency anemia is normocytic early, and microcytic later, so you should reference the RDW to see the spread of size.

Question 4

What is the intial confirmatory testing for iron deficiency anemia

NOT the gold standard of marrow iron on biopsy.

Answer 4

Ferritin.

Note: low ferritin is confirmatory, but normal or high ferritin can be present if there is also an inflammatory disorder.

Question 5

What is the treatment of iron deficiency anemia?

Answer 5

Iron supplements

Can use diet or tablets (Ferrous sulfate). Uncommonly needs IV iron

Question 6

In anemia of chronic disease, what would the:
1. MCV
2. Retic count
2. Ferritin
3. TIBC
4. ESR/CRP

Answer 6

1. MCV < 80
2. Retic count = low
3. Normal or high ferritin
4. Low TIBC
5. High ESR/CRP

Question 7

What is the treatment of anemia of chronic disease?

Answer 7

Treat underlying disease.

Question 8

What is the myelodysplasia, and what is it’s most common risk factor?

.

Answer 8

These are hematopoietic stem cell neoplasms that is characterized by impaired proliferation and differentation of myeloid stem cells within the bone marrow.

Most common risk factor: older age (>65)

Question 9

What are two findings in the CBC that raise your concern for myelodysplasia?

Answer 9

1. unexplained cytopenias (i.e. anemia with associated thrombocytopenia or leucopenia)
2. Abnormal blood smear (i.e. dysplasias on smear)

Bone marroq biopsy and cytogenic analysis are gold standard for diagnosis.

Question 10

In anemia caused by hemolysis, what would the:
1. MCV
2. retic count
3. bilirubin
4. LDH

Answer 10

1. MCV = 80-100 (normocytic)
2. High retic count*
3. High bilirubin
4. High LDH

*Need to rule out acute bleeding (which also has high retic count)

Question 11

In anemia caused by B12 deficiency, what would seen on:
1. MCV
2. blood smear?
3. history/physical exam?

Answer 11

1. MCV > 100 (macrocytic)
2. Hypersegmented PMNs.
3. neurologic or neurophsyiatric symptoms

Question 12

What is the confirmatory testing for anemia caused by B12 deficiency? (x2)

Answer 12

1. B12 LEVEL (>300 umol/L rules out deficiency)
2. High methlmalonate and high homocysteine*

*Rarely measured. Usually after CBC and B12 levels, you can trial B12 supplementation and see improvement of symptoms.

Question 13

The differential diagnosis for microcytic anemia can be rememered by the mnemonic “TAILS”

Answer 13

Thalassemia
Anemia of chronic disease
Iron deficiency anemia
Lead poisoning
Sideroblastic anemia

Question 14

The differential diagnosis for macrocytic anemia can be remembered by the mnemonic FAT RBC

Answer 14

F: fetus (ie. pregnancy)
A: alcohol
T: thyroid disease (ie. hypo)

R: retiulocytosis
B: B12 and Folate deficiency
C: cirhosis OR chronic liver disease

Question 15

The general causes of Normocytic anemia can be remembered by the mnemonic “A B C D”

Answer 15

A: Acute blood loss
B: Bone marrow failure
C: Chronic Disease
D: Destruction (hemolysis)

1. Acute blood loss -> self explanatory
2. Bone marrow failure -> Marrow ilfiltration, stem cell defect, myeloma, Marrow toxin (look at drug history for this one)
3. Chronic disease -> Inflammatory disorder, Liver disease, Renal failure (lack of EPO), combined anemia (ex. Iron deficiency anemia and B12 deficiency
4. Hemolysis -> self explanatory

Question 16

In terms of normocytic anemia, how can you differentiate between a hypoproliferative or hyperproliferative cause

Answer 16

Reticulocyte count.

For our purposes,
- hypoproliferative = < 0.5%
- Normal value = 0.5-2.0%
- Hyperproliferative = > 2.0%

In most cases, hyperproliferative will be due to hemolysis.

Question 17

What is primary literature?

Answer 17

Original research available as journal pubs, presentations, and discovery

Question 18

What is the general benefit of primary literature vs other types of literature?

Answer 18

Results are most transparent and you can evaluate bias and validity.

Question 19

What is the general problem of primary literature compared to other types? (x2)

Answer 19

Results are generally less valid due to a variety of reasons*

There is also way too many primary literature publications to try to parse through to answer your specific question.

*Can be due to low sample numbers, issues with methodology, or statistics.

Question 20

What is secondary literature?

Answer 20

Synthesis of primary literature, and usually published as systematic reviews, meta-analyses, or practice guidelines

Question 21

What is the MAIN benefit of secondary literature compared to others?

Answer 21

The results are more valid because you are analzying multiple sets of data.

Question 22

What are the general problems of secondary literature compared to others?

Answer 22

“Garbage in = garbage out” If the primary literature being analzyed is bad, then you have a synthesized literature that is just as bad.

Question 23

What is Tertiary Literature?

Answer 23

Summary or condensed version of material found in textbooks or online databases (like uptodate.com)

Question 24

Whats are the benefits of tertiary literature compared to others

Answer 24

Most accessible and readable: summarizes all the stats in the primary and secondary research into key points (like uptodate)

Question 25

What are the problems of tertiary literature compared to others?

Answer 25

LEAST transparent because you are unable to review issues around bias. You have to assume that the results are valid (i.e. do you ever check the conflicts of interest for UTD authors, or question thier publication biases?)