NEW HEMATOLOGY PARAMETERS

Transcription

1 NEW HEMATOLOGY PARAMETERS CASE STUDIES and IMPLEMENTATION WHAT WE WILL COVER new parameters Ret-He, IPF (and some not so new parameters) - anemias - hemoglobinopathies - problem platelets - uncommon things - really annoying stuff - implementing new parameters OBJECTIVES Learn how to pronounce and spell the new parameters Explain what they are and where they come from Interpret what they mean Know when they are helpful Discuss implementation strategies 1

2 RBCs and PLATELETS..zzzzzzz THE ARCHEOLOGY OF HEMATOLOGY OLD HGB HCT MCV RETICS MCHC, MCH SORT of NEW RDW IRF MPV NEW IPF RET-He huh? 2

3 NEW and NOT SO NEW PARAMETERS What they are RDW.red cell distribution width IRF.immature retic fraction Ret-He reticulocyte hemoglobin content MPV.mean platelet volume IPF.immature platelet fraction Notes on the RDWs RDW-CV RDW-SD They are not the same all the time RDW-SD and RDW-CV ANEMIA CLASSIFICATION IRON DEFICIENCY THALASSEMIA MINOR RDW CV ELEVATED (reference range 11 15) RDW CV NORMAL RDW SD ELEVATED (reference range 39 49) RDW SD DECREASED 3

4 THE RDW IT S SUPPOSED TO HELP DIFFERENTIATE THE MICROCYTIC ANEMIAS IRON DEFICIENCY ANEMIA OF CHRONIC DISEASE THALASSEMIA MINOR RDW SD 55.7 RDW SD 57.9 RDW SD 33.8 RDW CV 22.1 RDW CV 20.4 RDW CV 14.8 They are not the same THE RDW-CV IS LESS RELIABLE WHEN THE MCV IS ABNORMAL OOPS! 4

5 IRF Immature Retic Fraction (SORT OF THE LEFT SHIFT OF THE RETICS) LFR = LOW FLUORESCENT RATIO MFR = MEDIUM FLUORESCENT RATIO HFR = HIGH FLUORESCENT RATIO MFR + HFR = IRF ( Ratio) IRF WHAT IT TELLS YOU RED BLOOD CELLS ARE BEING PUSHED OUT OF THE MARROW EARLY OR THEY RE NOT RET-He Sort of the MCH of the Retics Do the retics have enough hemoglobin Sensitive monitor of iron availability ( pg) 5

6 RET-He Sensitive monitor of iron availability Why is this better than the MCV, MCH, MCHC, RDW????? THE RBC INDICES ARE AVERAGES THE RBC INDICES ARE AVERAGES 6

7 THE RBC INDICES ARE AVERAGES WITHOUT THE RET-He.WHAT WOULD YOU KNOW. 7

8 STAGES OF IRON DEFICIENCY IRON DEPLETION CBC NORMAL IRON DEFICIENCY HGB NORMAL, NEWLY PRODUCED RBCs AFFECTED RDW STARTS TO RISE, MCV STARTS TO DROP IRON DEFICIENCY ANEMIA HGB LOW IPF IMMATURE PLATELET FRACTION SORT OF THE RETICS OF THE PLATELETS In fact very young platelets are called reticulated platelets. IPF Immature platelet fraction Measures platelets newly released from the bone marrow Indicates thrombopoiesis (or not) (reference range 1 7 %) Forward Scatter Fluorescence mature platelets IPF 8

9 Differential Diagnosis of Thrombocytopenia Decreased Production LOW IPF Aplastic anemia Leukemia Marrow suppression Drugs Increased Destruction HIGH IPF Immune Thrombocytopenia (ITP), ThromboticThrombocytopenic Purpura TTP Disseminated intravascular coagulation (DIC) Drugs WHAT ABOUT THE MPV?? Helpful in a general way It s an AVERAGE Not stable over time platelets swell AND YOU DON T ALWAYS GET ONE 9

10 FINALLY. CASE STUDIES M/90 ANEMIA 10

11 F/74 ANEMIA and THROMBOCYTOPENIA and 11

12 F/74 ITP (IDIOPATHIC THROMBOCYTOPENIC PURPURA) AND WHY WAS THE OPTICAL PLATELET COUNT NOT CHOSEN? MORE TYPICAL ITP F/37 Thrombocytopenia 12

13 TTP (THROMBOTIC THROMBOCYTOPENIC PURPURA) M/59 oncology DECREASED PLATELET PRODUCTION 13

14 F/37 SURPRISE QUIZ! 14

15 F/37 HEREDITARY ELLIPTOCYTOSIS with HEMOLYSIS F/11 SICKLE CELL CRISIS 15

16 WHAT S IMPORTANT IN SICKLE CRISIS? DO THEY HAVE RETICS OR NOT F / 11 SICKLE CELL DISEASE RETIC 355,100 /ul (9.9%) IMMATURE RETIC FRACTION.34 M/ 23 SICKLE CELL CRISIS RETIC 22,800 /ul (1.2%) IMMATURE RETIC FRACTION

17 DAY 1 DAY 2 RETIC 22,800 /ul RETIC 9,200 /ul IRF 9.6% IRF 30.4% AND JUST FOR FUN. F/17 17

18 BERNARD SOULIER SYNDROME BERNARD SOULIER SYNDROME a rare autosomal recessive bleeding disorder incidence is estimated to be less than 1 in 1 million It is a giant platelet syndrome that is characterized by abnormally large platelets, prolonged bleeding time, thrombocytopenia, increased megakaryocytes, and decreased platelet survival. 18

19 IMPLEMENTING NEW PARAMETERS IPF & RET He LESSONS LEARNED OUR JOURNEY START Obama elected (the 1 st time) Obama inaugurated for the 2 nd time TA DA!.PLAN AHEAD YOU WILL NEED TEST CODES 19

20 IT PLEASE LEAVE A MESSAGE RET He DECISIONS TO MAKE Part of retic orders Separate test order IPF Separate test order Included with all PLT only orders. Reflex based on platelet count and history DECISIONS TO MAKE RET He Part of retic orders if you want to know about the retics, wouldn t you want to know everything about them? Separate test order 20

21 PATIENT WITH GREAT RETIC RESPONSE PATIENT WITH GREAT RETIC RESPONSE.. OR MAYBE NOT IPF DECISIONS TO MAKE Separate test order Included with all PLT only orders Reflex based on platelet count and history ( i.e. PLT < 50,000 and no history) 21

22 A CASE STUDY 44 year old male Presented to ER early evening Critical PLT count Other critical finding not reported until the next day (on the 3 rd CBC ordered) Bone Marrow done on day 3 M / 44 THROMBOCYTOPENIA 22

23 What if we had reflexed an IPF the 1 st day? SOMETHING TO THINK ABOUT WE ARE THE LABORATORY WE GIVE NUMBERS MAYBE WE SHOULD EXPLAIN OURSELVES 23

24 PHARMACY CRESTOR is contraindicated in patients with a known hypersensitivity to any component of this product, in patients with active liver disease, which may include unexplained persistent elevations of hepatic transaminase levels, in women who are pregnant or may become pregnant, and in nursing mothers Cases of myopathy and rhabdomyolysis with acute renal failure secondary to myoglobinuria have been reported with statins, including CRESTOR. These risks can occur at any dose level, but are increased at the highest dose (40 mg) CRESTOR should be prescribed with caution in patients with predisposing factors for myopathy (eg, age 65 years, inadequately treated hypothyroidism, renal impairment). The risk of myopathy during treatment with CRESTOR may be increased with concurrent administration of some other lipid lowering therapies (fibrates or niacin), gemfibrozil, cyclosporine, lopinavir/ritonavir, or atazanavir/ritonavir Therapy with CRESTOR should be discontinued if markedly elevated CK levels occur or myopathy is diagnosed or suspected. There have been rare reports of immune mediated necrotizing myopathy associated with statin use. All patients should be advised to promptly report unexplained muscle pain, tenderness, or weakness, particularly if accompanied by malaise or fever, and if muscle signs and symptoms persist after discontinuing CRESTOR It is recommended that liver enzyme tests be performed before the initiation of CRESTOR and if signs or symptoms of liver injury occur. All patients treated with CRESTOR should be advised to promptly report any symptoms that may indicate liver injury, including fatigue, anorexia, right upper abdominal discomfort, dark urine, or jaundice. There have been rare postmarketing reports of fatal and non fatal hepatic failure in patients taking statins, including CRESTOR. If serious liver injury with clinical symptoms and/or hyperbilirubinemia or jaundice occurs during treatment with CRESTOR, promptly interrupt therapy. If an alternate etiology is not found, do not restart CRESTOR CRESTOR should be used with caution in patients who consume substantial quantities of alcohol and/or have a history of chronic liver disease CRESTOR significantly increased INR in patients receiving coumarin anticoagulants. In patients taking coumarin anticoagulants and CRESTOR concomitantly, INR should be determined before starting CRESTOR and frequently enough during early therapy to ensure that no significant alteration of INR occurs Dipstick positive proteinuria and microscopic hematuria were observed among patients treated with CRESTOR. These findings were more frequent in patients taking CRESTOR 40 mg, though it was generally transient and was not associated with worsening renal function. Although the clinical significance of this finding is unknown, dose reduction should be considered for patients on CRESTOR therapy with unexplained persistent proteinuria and/or hematuria during routine urinalysis testing Increases in HbA1c and fasting serum glucose levels have been reported with statins, including CRESTOR In the controlled clinical trials database, the most common adverse reactions were headache (3.7%), myalgia (3.1%), abdominal pain (2.6%), asthenia (2.5%), and nausea (2.2%) # Rare postmarketing reports of cognitive impairment (eg, memory loss, forgetfulness, amnesia, memory impairment, confusion) have been associated with statin use, including CRESTOR. These reports are generally nonserious and reversible upon statin discontinuation The dose range for CRESTOR is 5 mg to 40 mg orally once daily. The usual starting dose is 10 mg to 20 mg. Patients initiating CRESTOR therapy or switching from another statin should begin treatment with CRESTOR at the appropriate starting dose. After initiation or upon titration of CRESTOR, lipid levels should be analyzed within 2 to 4 weeks and the dosage adjusted accordingly. CRESTOR 40 mg should be used only for those patients not achieving their LDL C goal with 20 mg Indications CRESTOR is indicated as an adjunct to diet to reduce elevated Total C, LDL C, ApoB, non HDL C, and triglycerides, and to increase HDL C in adult patients with primary hyperlipidemia or mixed dyslipidemia and to slow the progression of atherosclerosis in adult patients as part of a treatment strategy to lower Total C and LDL C to target levels CRESTOR is indicated to reduce the risk of myocardial infarction, stroke, and arterial revascularization procedures in patients without clinically IF YOU ORDER AN X RAY. IS THIS ALL YOU GET BACK? IF YOU ORDER AN IPF THIS IS WHAT YOU GET BACK IPF 17.5 % H 24

25 INFORMATION NOT JUST NUMBERS IPF 17.5 % H Thrombocytopenia with high IPF indicates platelet destruction or consumption Ret He 22.4 pg L Low Ret He indicates decreased iron stores or ineffective erythropoeisis IRF 0.34 ratio H High IRF indicates increased bone marrow erythropoeisis Thank You QUESTIONS?? 25