Week 19 - Cases 1,2,3,4 and passmed Flashcards
what are the causes of microcytic anaemia
- there are four
- MCV <80
- iron deficiency anaemia
- thalassaemia
- sideroblastic anaemia
- anaemia of chronic disease
what are the causes of normocytic anaemia
- there are 7
- MCV 80-100
- acute blood loss
- early iron deficiency anaemia
- renal disease
- haemolytic anaemia
- malaria
- sickle cell disease
- aplastic anaemia
what are the causes of megaloblastic anaemia
- there are 2
- MCV >100
- B12 deficiency
- folate deficiency
what are the causes of non-megaloblastic macrocytic anaemia
- there are 2
- MCV >100
- alcoholism
- liver disease
what kind of cells are seen in iron deficiency anaemia
pencil cells
what may be seen on a blood film in B12/ folate deficiency
hyper segmented neutrophils
what are the causes of iron deficiency anaemia
- dietary in origin, due to lack of red meat, or green vegetables in the diet
- due to gastrointestinal blood loss and is a must not miss diagnosis
- in females, due to loss during menstraton
if a patient has an iron deficiency anaemia, what would constitute red flag symptoms and require a 2 week wait referral to exclude cancer
Urgently refer (appointment within two weeks) people:
- aged 40 and over with unexplained weight loss and abdominal pain
- aged 50 and over with unexplained rectal bleeding
- aged 60 and over with either:
– iron deficiency anaemia
– OR alteration in bowel habit - who have positively tested for occult blood in their faeces
what does ferroportin do
controls the release of iron from the intestinal enterocytes into the blood stream and the release of iron from the marrow macrophages for eryhtropoiesis
what does hepcidin do
in turn controls the levels of ferroportin in an inverse manner
what does an increase in hepcidin do
causes ferroportin to degrade, reducing ferroportin levels prevents iron release from GI tract enterocytes into the blood stream and also traps iron in the marrow macrophages, thus reducing total iron bio-availabiliy
therefore what happens when iron is plentiful and the transferrin saturation is high
less iron is absorbed and fewer red cells are produced in the bone marrow
what happens in inflammation when there are high levels of IL6
the same mechanism is activated, explaining the classical marrow iron findings of the normocytic, normochromic anaemia of chronic disease; with excess iron in the free and marrow particle marcophages but no iron in the eryhtroblasts
what does the lack of production in anaemia of chronic disease also explain
why sometimes this type of anaemia can be hypochromic and is not always normochromic and normocytic
what happens if there is a decrease in hepcidin
it promotes iron absorption from the gut and releasing iron rom the marrow macrophages to assist increased erythropoiesis
what happens does a low TFR situation inhibit in iron deficiency and what does this lead to
a low TFR situation inhibits hepcidin and ferroportin increases this promoting iron absorption and availabilityg
there are increased levels of what in haemolytic anaemia
increase in the levels of growth differentiation factor 15
how do high levels of GDF15 promote iron absorption
by inhibiting hepcidin and this explains why patients with chronic haemolysis can become iron overloaded without ingesting excess iron or by having blood transfusions
what treatment would you give to a patient with iron deficiency anaemia secondary to heavy mentruation
oral iron treatment
what are the four most common side effects of oral iron supplementation
diarrhoea
gastrointestinal discomfort
nausea
constipation
chronic kidney disease is a risk factor for what
osteoporosis
what are the side effects you should inform pregnant women about with paroxetine
Paroxetine use in pregnancy - can lead to increased risk of congenital malformations
in cases of pregnancy of unknown location, a serum bHCG of what points towards a diagnosis of an ectopic pregnancy
In the case of pregnancy of unknown location, serum bHCG levels >1,500 points toward a diagnosis of an ectopic pregnancy§
what is the pathway for oesophageal/gastric two week wait criteria
Urgent referral for endoscopy within two weeks. Urgently refer people:
of any age presenting with dysphagia (OG), or
aged 55 or over with weight loss, and
Upper abdominal pain, or
Reflux, or
Dyspepsia (OG)
what is the treatment for microcytic, hypochromic anaemia
ferrous sulphate and refer urgently to the GI team
what is glossitis
a red and inflamed tongue
what does hyper-segmented neutrophils look like
neutrophils usually have 2-5 lobes and therefore anything over this is classed as hypersegmented
how does megaloblastic anaemia cause macropcytic anaemia
from ineffective red blood cell production and intramedullary haemolysis
what are the most common causes
folate deficiency and cobalamin deficiency
a BMI of what is obese
a BMI of 30 or above is obese
what are the 3 reasons for why eGFR as a single value has several limitations
It is based on serum creatinine and so may overestimate actual GFR in patients with low muscle mass (e.g., those with cachexia and amputees) and underestimate actual GFR in individuals taking creatine supplements (as creatinine is a metabolite of creatine) or trimethoprim (which inhibits secretion of creatinine).
It tends to underestimate normal or near-normal function, so slightly low values should not be over-interpreted.
In the elderly, who constitute the majority of those with low eGFR, there is controversy about categorising people as having chronic kidney disease on the basis of eGFR alone, particularly at stage 3A, since there is little evidence of adverse outcomes when eGFR is >45 mL/min/1.73 m2 unless there is also proteinuria.
what is anaemia of chronic disease
microcytic hypochromic anaemia
what is hepcidin
an iron-regulating peptide hormone made in the liver
what is an accelerated progression of CKD defined as
A sustained decrease in GFR of 25% or more and a change in GFR category within 12 months or
A sustained decrease in GFR of 15 ml/min/1.73 m2 per year
Be aware that those patients are at increased risk of progression to end stage renal disease.
what is CKD defined as
CKD is defined as abnormalities of kidney function or structure present for more than 3 months, with implications for health. This includes all people with markers of kidney damage and those with a glomerular filtration rate (GFR) of less than 60 ml/min/1.73m2 on at least 2 occasions separated by a period of at least 90 days (with or without markers of kidney damage).
what is CKD classified based on
cause
GFR category
albuminruia category
How can ACEI/ARBs delay disease progression?
By dilating the efferent arteriole
what is HbH most often caused b¥
inherited deletion of three of the four alpha globin genes
how can beta thalasseaemia major be ‘cured’
using a stem cell transplant
A 65-year-old man known to have chronic kidney disease stage 3A secondary to diabetes was started on angiotensin converting enzyme inhibitor by his GP. Which percentage decline in eGFR from baseline would warrant stopping the treatment with ACE inhibitor?
We accept up to 25% decline in eGFR. This is due to the hemodynamic change at the level of the glomeruli because of efferent vasodilation and lowering of the intraglomerular pressure. More than 25% decline in eGFR from baseline should make you consider stopping the angiotensin converting enzyme inhibitor.
A 58-year-old man is known to have chronic kidney disease stage 4. His calcium levels are low, but phosphate and PTH (parathormone hormone) levels are elevated. Which is the most likely diagnosis?
Secondary hyperparathyroidism
Secondary hyperparathyroidism occurs in patients with chronic kidney disease. Due to the drop in the glomerular filtration rate, phosphate levels increase which then activates FGF-23 and increases PTH levels. At the same time, failure to activate vitamin D will result in low calcium levels. Hence answer B is correct. For primary hyperparathyroidism, calcium levels are elevated, phosphate levels are low and PTH levels are elevated. Hence answer A is not correct. In hypoparathyroidism, calcium levels are low due to low PTH levels, which is not the case here. Tertiary hyperparathyroidism occurs after many years of having a secondary hyperparathyroidism. Those patients have been under continuous stimulation of PTH, and so they will form an autonomous focus on the parathyroid gland that will produce high calcium levels regardless of the low vitamin D levels. The results are similar to secondary hyperparathyroidism except for elevated calcium levels, which is not the case here.
A 70-year-old man is known to have chronic kidney disease stage 3b. His haemoglobin level is 110g/l. T-sats 31% and ferritin of 250 ug/l. Which is the most appropriate management of his anaemia?
Regular monitoring
Based on the NICE guidelines, his haemoglobin levels, T-sats and ferritin levels are within acceptable range for a patient with chronic kidney disease. Regular monitoring is required to maintain those figures.
A 65-year-old man with heart failure, known CKD and is non-diabetic, recently heard about the benefits of SGLT2i in preventing CKD progression. Given that he is non-diabetic, would you still consider treatment with SGLT2i for him?
Yes
Recent evidence has shown that SGLT2i delayed CKD progression in non-diabetics with heart failure and lowered the cardiovascular disease events
