Comprehensive Review of Clinical Laboratory Tests for Investigating the Etiology of Anemia in the Elderly.

Comprehensive Review of Clinical Laboratory Tests for Investigating the Etiology of Anemia in the Elderly. December 15, 2017 Dennis J Chapron MS, RPh Medication Safety Pharmacist Saint Francis Hospital and Medical Center Hartford, CT 06105 Dennis J Chapron reports no real or potential conflicts of interest relevant to this lecture. 1

At the conclusion of this knowledge based activity, the participant will be able to: Compare the kinetic vs the morphological approach for identifying the cause of anemia. Discuss the laboratories tests used to investigate and differentiate anemia due to nutrient deficiency, blood loss, hemolysis, chronic inflammation, renal failure and marrow failure. Describe the physiological mechanisms that maintain adequate nutrients for red cell production and how diseases and medications adversely affect these mechanisms. WHO Definition of Anemia In woman: hemoglobin concentration below 12 gm/dl. In men: hemoglobin concentration below 13 gm/dl 2

Hematocrit Approx 3 x Hgb Plasma Packed RBCs Anemia Severity Scale Mild anemia Hgb >10<12 Moderate anemia Hgb >8 10 Severe anemia 8 3

Estimated Anemia Prevalence in the Elderly Based on WHO definition 12% in those living in the community 40% in those admitted to the hospital 47% in nursing home residents Hematologica 2014;99:1127 Some Disorders Associated with a High Prevalence of Anemia in the Elderly Chronic upper and lower GI bleeding Chronic inflammatory disorders Heart failure Cancer Debility Chronic renal failure Unintentional weight loss 4

Anemia is Often an Important Sign of an Underlying Pathological Process Anemia is common in the elderly. Anemia impacts morbidity Anemia impacts mortality Am Fam Phys Sept 2010 5

Anemia Morbidity/Mortality and QOL Anemia Disease M/M and QOL 6

Anemia and the Elderly Anemia in the elderly is due to a primary underlying disease and is not related to aging. Look for the problem behind the problem. Anemia: Problems in Diagnosis and Treatment Not recognized (not in problem list) Recognized but not investigated Recognized, investigated (at least partially), but failure to treat or considered not worth treating. Recognized, investigated and treated suboptimally 7

Types and Prevalence of Anemia Observed in Geriatric Populations Anemia of chronic inflammation 20% Iron deficiency anemia 17% Vitamin B 12 or folate deficiency 15% Chronic kidney disease 9% Kidney disease with inflammation 5% Unexplained anemia 34% NHANES III Blood 2004;104:2263 2 Conceptual Views of Anemia Etiology 8

Kinetic Approach Steady-state [hemoglobin] PRODUCTION RATE [Hgb] = -------------------------------- CLEARANCE DJ Chapron Kinetic Approach Bone marrow Nutritional PRODUCTION RATE [Hgb] = -------------------------------- CLEARANCE Bleeding Hemolysis DJ Chapron 9

Hematology Basic Principles and Practices 2013 Chronic inflammation Hemolysis MDS/Ca EP Bone marrow RBCs Kidney Bleeding Iron, B-12, folate DJ Chapron 10

Reticulocyte Count (RC) Immature red cell released from bone marrow into the circulating blood and contains residual ribosomal RNA that can be stained with special dyes. Normal RC is about 1% (range 0.6-2.0%). Helps to define mechanism of anemia by defining the appropriateness of the bone marrow response to a low hemoglobin level. They are almost twice as large a mature erythrocytes and when present in increased numbers raise the MCV. Increased peripheral blood reticulocytes indicate increased marrow erythroid activity and a normal erythropoietin response. Increased reticulocyte counts indicate a high RBC turnover caused by either hemolysis or blood loss. RC is adjusted to the Hct yielding a value known as the reticulocyte index (RI). In anemic patients with chronic bleeding (with normal iron stores) or hemolytic disorders, the RI is 3% or greater. Anemias due to compromised red cell production, the RI is less than 3%, often in the range of 1.5% or less. RI = RC x Patient Hct /45% Kinetic Classification of Anemia Decreased production (Retics decreased) Stem cell and progenitor cell-based Aplastic anemia Pure red cell aplasia Leukemia Myelodysplastic syndrome Marrow infiltration Anemia of chronic inflammation Anemia of chronic renal failure Nutritional deficiency Vitamin B-12 Folate Iron 11

Kinetic Classification of Anemia Increased destruction (Retics increased) Intracorpuscular Membrane (hereditary) Enzyme deficicency (G6PD) Hemoglobinopathy (sickle cell) Extracorpuscular-immunological Autoimmune Alloimmune Extracorpuscular Acute / chronic blood loss Chemicals (oxidative stress) Hypersplenism Infectious Mechanical (heart valve) Chronic inflammation Hemolysis MDS/Ca EP Bone marrow RBCs Kidney Bleeding Iron, B-12, folate DJ Chapron 12

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Morphological Approach Anemias According to Cell Size (MCV) Microcytic - MCV< 80 fl Normocytic MCV 80-100 fl Macrocytic MCV > 100 fl MCV = mean corpuscular volume 14

Microcytosis Normocytic and Macrocytosis hypochromia normochromic Hillman and Finch 1985 UpToDate 2017 15

Morphological Classification of Anemia Microcytic (MCV <80 fl) Iron deficiency (chronic blood loss) Anemia of chronic inflammation Thalassemias Sideroblastic anemias Aluminum toxicity Normocytic (MCV 80 100 fl) Anemia of chronic inflammation Anemia of renal disease Acute blood loss Morphological Classification of Anemia Macrocytic (MCV >100 fl): Megaloblastic Folate deficiency Vitamin B-12 deficiency Medications Nonmegaloblastic Ethanol abuse Hypothyroidism Liver disease Primary bone marrow disease Reticulocytosis 16

Multiple Choice Question : A key component of the kinetic approach to anemia classification is: a. Mean corpuscular volume (MCV) b. Mean corpuscular hemoglobin concentration (MCHC) c. The reticulocyte response d. Nutritional indices including serum folate, vitamin B 12 and iron. 17

ECCO Anemia Statement JCDC 2015 18

The Diagnosis of Anemia is Dependent on Laboratory Measurements Initial Testing Hemoglobin Hematocrit Complete blood count Red Cell Indices mean corpuscular volume (MCV), MCH mean hemoglobin (MCH), mean hemoglobin concentration (MCHC) Reticulocyte count Red Blood Cell distribution width (RDW) Examination of peripheral blood smear Complete Blood Count (CBC) CBC includes red cells, white cells and platelets. CBC helps to distinguish isolated anemia from pancytopenia or bicytopenia. 19

Red Cell Indices MCV mean cell volume, normal being 80 100 fl. Accurately detects any general increase or decrease in red blood cell volume. MCH mean cell hemoglobin an excellent measure of the amount of hemoglobin in each individual red blood cell. Patients with IDA show significant reductions in the MCH. Normal value is 26 34 pg MCHC mean corpuscular hemoglobin concentration. Not sensitive to disorders where Hgb production is defective, since such disorders are paralleled by reductions in cells size. Normal value is 31 37 g/dl. Red Blood Cell Distribution Width (RDW) Normal RDW is 11 14.5% An index of the distribution of red cell volumes and is a mathematical representation of anisocytosis (variation in red cell size). Increases in RDW suggest the presence of a mixed population of cells (ex., microcytes with normal cells, or macrocytes with normal cells). 20

Iron Deficiency Anemia (IDA) The Diagnosis of Anemia is Dependent on Laboratory Measurements Initial Testing Hemoglobin Hematocrit Red Cell Indices mean corpuscular volume (MCV), MCH mean hemoglobin (MCH), mean hemoglobin concentration (MCHC) Reticulocyte count Red Blood Cell distribution width (RDW) Examination of peripheral blood smear 21

COMPREHENISVE LABORATORY EVALUATION OF ANEMIA Complete blood count (CBC) Hemoglobin/ hematocrit Red cell indices: MCV, MCH, MCHC Red blood cell distribution width (RDW) Peripheral smear Total reticulocyte count: absolute number or as a percentage: Serum [iron] Total iron binding capacity (TIBC) Percent transferrin saturation: (serum iron / TIBC) Serum [ferritin] Serum [folate] Serum [vitamin B-12], methylmalonic acid, homocysteine Serum [haptoglobin], [bilirubin (indirect)], [LDH] Serum [erythropoietin] Serum [transferrin receptors] Stool for occult blood Seminars in Nephrology 2016 22

Seminars in Nephrology 2016 GI Fe absorption Serum Fe + Transferrin (TIBC) Serum Fe --- Transferrin complex Bone marrow Fe/TIBC = % saturation 23

Serum [Iron] (50 150 ug/dl) as circulating transferrin bound iron. Serum iron levels are higher in the morning and levels should be determined on fasting AM samples. Total Iron Binding Capacity (TIBC) Transferrin is a circulating transport protein for iron. TIBC is a measure of the amount of iron that can be bound by transferrin and is equivalent to measuring the serum concentration of transferrin protein. Normal TIBC is 250 350 ug/dl Transferrin saturation (T sat) is the ratio expressed as: serum iron/tibc x 100. Normal values are 25 45%. A transferrin level (mg/dl) can be converted to a TIBC (mcg/dl) by multiplying by 1.389. TIBC levels are increased in IDA and normal or reduced in anemia of chronic disease (ACD). In IDA, serum iron is reduced while TIBC is increased yielding a low T sat. A T sat < 10 16% is often used as a cutoff for IDA. In iron overload (ex., hereditary hemochromatosis) T sat often approaches 90 100%. 24

T-SAT = Transferrin saturation Iron deficiency anemia [Fe] TSAT = -------------- IBC Serum Ferritin Normal levels in adult men and postmenopausal women are 50 200 ug/l. A circulating iron storage protein that is proportional to body iron stores and primarily reflects hepatic iron stores. A very low ferritin is very specific for absolute iron deficiency (<15/20/30 ug/l). Serum ferritin may increase due to underlying inflammation. In the presence of inflammation serum ferritin can be high despite very low iron stores. In the presence of inflammation, a serum ferritin 100 ug/l may still be consistent with absolute iron deficiency. Massive increases in serum [ferritin] (>1000) are seen in patients with iron overload (hemochromatosis), hepatocellular disease, and malignancies. 25

Iron Deficiency Anemia Bone marrow Nutritional PRODUCTION RATE [Hgb] = -------------------------------- CLEARANCE Bleeding Hemolysis Kinetic Classification of Anemia Decreased production (Retics decreased) Stem cell and progenitor cell-based Aplastic anemia Pure red cell aplasia Leukemia Myelodysplastic syndrome Marrow infiltration Anemia of chronic inflammation Anemia of chronic renal failure Nutritional deficiency Vitamin B-12 Folate Iron 26

Morphological Classification of Anemia Macrocytic (MCV >100 fl): Megaloblastic Folate deficiency Vitamin B-12 deficiency Medications Nonmegaloblastic Ethanol abuse Hypothyroidism Liver disease Primary bone marrow disease (MDS) Reticulocytosis Morphological Classification of Anemia Microcytic (MCV <80 fl) Iron deficiency Anemia of chronic inflammation Thalassemias Sideroblastic anemias Aluminum toxicity Normocytic (MCV 80 100 fl) Anemia of chronic inflammation Anemia of renal disease Acute blood loss 27

COMMON CAUSES OF IRON DEFICIENCY ANEMIA Deficient diet (vegetarian, malnutrition) Decreased absorption (celiac disease, partial gastrectomy,) Increased requirements pregnancy lactation Blood loss gastrointestinal menstrual blood donation Hemoglobinuria (traumatic hemolysis from cardiac valve) ENDOSCOPIC LESIONS ASSOCIATED WITH OCCULT BLOOD LOSS ESOPHAGOGASTRODUODENOSCOPY (EGD) Esophagitis Gastric ulcer Gastritis Duodenal ulcer Duodenitis Carcinoma Vascular ectasia Adenomatous polyp COLONOSCOPY Adenoma Carcinoma Colitis Vascular ectasia (angiodysplasia) Ulceration NEJM 12/2/93 28

NEJM 1993;329:1691 29

Microcytosis Normocytic and Macrocytosis hypochromia normochromic Hillman and Finch 1985 30

Normal RBCs, a single granulocyte and many platelets. Hillman and Ault 2002 Microcytosis with hypochromia, anisocytosis and poikilocytosis 31

12/1/2017 Normal erythrocytes Schmaier 2003 Iron deficiency anemia RBCs - micocytic and hypochromic (central pallor >1/3 diameter of cell) Schmaier 2003 32

Severe microcytosis and hypochromia due to IDA Severe iron deficiency anemia Hillman and Ault 2002 33

Iron Deficiency Anemia Case -1 Anemia Case-1 An 84 year old woman complains of not feeling well. She says she is having dizzy spells, problems with walking and cannot concentrate on certain tasks. These symptoms seem to have developed gradually over the last several months. 34

Anemia Case-1 This 84 year old woman has formidable problem and medication lists, which includes the following: 84 year old woman; her problem list: CAD (MI CABG) HTN Hyperlipidemia COPD GERD with hx PUD OA Hypothyroidism Depression OP 35

Medication List L-thyroxine 125 mcg qd Aspirin 81 mg qd Clopidogrel 75 mg qd Simvastatin 20 mg qd Escitalopram 10 mg qd Lansoprazole 30 mg bid Calcium carbonate 500 bid Metoprolol 50 mg bid Multivitamin 1 qd DOSS 100 mg bid Ipratropium/albuterol nebs tid Anemia Case -1 A complete blood count is obtained and reveals the following: Hemoglobin = 8.8 gm/dl Hematocrit = 27 % MCV = 70 fl (80 100 fl) MCH = 22 pg/cell (26-34) MCHC 31 gm/dl (31-37) White blood cell and platelet cts - normal 36

Anemia Case 1 Classification Microcytic, hypochromic anemia Anemia case -1 A complete blood count is obtained and reveals the following: Hemoglobin = 8.8 gm/dl Hematocrit = 27 % MCV = 70 fl (80 100 fl) Reticulocyte count = 0.5% (0.6 2.0%) Corrected as RI = 27/45 x 0.5% = 0.3% 37

Anemia Case 1 Classification Microcytic, hypochromic anemia Hypoproliferative Same 84 Year old woman Serum iron (500-150 ug/dl) 14 TIBC (250-350 ug/dl) 460 % saturation (25 45%) 3 Ferritin (50-200 ug/l) 15 38

Anemia Case 1 Classification Microcytic, hypochromic anemia Hypoproliferative Iron indices indicate iron deficiency anemia Anemia Case -1 Stools are positive for occult blood 39

Anemia Case -1 Stools are positive for occult blood Is blood loss upper or lower GI tract? Anemia Case 1 Classification Microcytic, hypochromic anemia Hypoproliferative Iron indices indicate iron deficiency anemia Dx GI bleeding blood loss anemia, with PPI use lower GI bleeding may be more likely. Consider combined effects of aspirin, clopidogrel and escitalopram. 40

Temporal relationship between laboratory tests results and the evolution/stages of iron deficiency anemia 41

Hillman and Finch 1985 42

Stages of Iron Deficiency Anemia Storage iron - Serum ferritin Serum iron - TIBC - Percent saturation Hemoglobin / Hematocrit Microcytosis / Hypochromia Anemia of Chronic Disease Anemia of Chronic Inflammation 43

Chronic inflammation Bone marrow Nutritional PRODUCTION RATE [Hgb] = -------------------------------- CLEARANCE Bleeding Hemolysis DJ Chapron Chronic inflammation Hemolysis MDS/Ca EP Bone marrow RBCs Kidney Bleeding Iron, B-12, folate DJ Chapron 44

Anemia of Chronic Disease Occurs in patients with acute or chronic immune activation. Elevated pro inflammatory cytokines (esp IL 6) mediate the induction of hepcidin synthesis. Hepcidin inhibits intestinal iron absorption and the release of recycled iron from macrophages, resulting in iron restrictive anemia. Serum iron and transferrin levels are depressed as well transferrin saturation. This is referred to as a functional iron deficiency where iron stores are normal, but with a restricted iron availability in the bone marrow and a resulting reduced erythropoiesis. Elevated cytokines reduce erythropoietin production and inhibit bone marrow erythropoiesis. There is enhanced apoptosis of erythroid progenitor cells in the marrow Hematologica 2014;99:1127 45

Iron Restricted Anemia Any anemia where the bone marrow erythropoietic activity is reduced due to a restricted availability of iron in the bone marrow, either by true/absolute iron deficiency or functional iron deficiency. Absolute iron deficiency Iron deficiency anemia Hypoferremia [Fe] Anemia of Chronic Disease Decreased GI iron absorption and Increased iron sequestration by RES 46

J Clin Epi 1994; 47:23 47

J Clin Epi 1994; 47:23 Anemia of Chronic Inflammation Biochemical and/or clinical evidence of inflammation Decreased serum iron Decreased iron binding capacity Normal iron stores (stainable iron in the bone marrow or elevated serum ferritin (> 100 ug/l) and a TSAT < 20% 48

T-SAT = Transferrin saturation Anemia of chronic disease [Fe] TSAT = -------------------- IBC Iron deficiency anemia [Fe] TSAT = -------------- IBC Anemia of Chronic Disease (ACD) When anemia occurs in the presence of biochemical or clinical evidence of inflammation, the diagnostic criteria for ACD are a serum ferritin > 100 ug/l and a TSAT < 20%. If the serum ferritin concentration is between 30 100 ug/l, a combination of absolute iron deficiency and ACD is likely. JCDC 2015 ECCO Consensus Paper 49

Tests used to detect Systemic Inflammation ESR (10 30 mm/hr) C-Reactive Protein (5-10 mg/l) Anemia of Chronic Disease Case 2 50

Anemia Case-2 76 year old man has complains of fatigue and a 10 lb weight loss. He is a smoker. His problem and medication lists, includes the following: Problem List Anemia Case 2 Chronic prostatitis Chronic urinary tract infections COPD Hypertension Peripheral vascular disease 51

Medication List Anemia Case 2 Lisinopril 20 mg qd Ipratropium inhaler 2 puffs qid Nitrofurantoin 50 mg at night Anemia Case -2 A complete blood count is obtained and reveals the following: Hemoglobin = 10.0 gm/dl Hematocrit = 30.0 % MCV = 82 fl (80 100 fl) MCH = 27 pg/cell (26-34) MCHC = 31 gm/dl (31-37) White blood cell and platelet cts - normal 52

Anemia Case 2 Classification Normocytic, normochromic, anemia Anemia case -2 A complete blood count is obtained and reveals the following: Hemoglobin = 10.0 gm/dl Hematocrit = 30 % MCV = 82 fl (80 100 fl) Reticulocyte count = 0.5% (0.6 2.0%) Corrected as RI = 30/45 x 0.5 = 0.33 53

Anemia Case 2 Classification Normocytic, normochromic, anemia Hypoproliferative Anemia Case 2 Additional Lab Tests Serum iron = 35 ug/dl (50 150 ug/dl) TIBC = 220 ug/dl (250 350 ug/dl) Tsat = 35/220 = 15.9% (25 45%) Serum ferritin = 200 ug/dl (50 200 ug/dl) Serum creatinine 1.0 mg/dl (0.6 1.0 mg/dl) Thyroid function tests = normal 54

Anemia Case -2 Tests used to detect Systemic Inflammation ESR (10 30 mm/hr) C-Reactive Protein (5-10 mg/l) Anemia Case 2 Additional Lab Tests Serum iron = 35 ug/dl (40 170 ug/dl) TIBC = 220 ug/dl (260 460 ug/dl) Tsat = 35/220 = 15.9% (20 45%) Serum ferritin = 200 ug/dl (60 200 ug/dl) Serum creatinine 1.0 mg/dl (.6 1.0 mg/dl) Thyroid function tests = normal ERS = 80 mm/hr (10 30mm/hr) C reactive protein = 90 mg/l (5 10 mg/l) 55

Anemia Case 2 Classification Normocytic, normochromic, anemia Hypoproliferative Anemia of chronic inflammation Multiple Choice Question : Which laboratory test is NOT consistent with a diagnosis of anemia of chronic disease? a. Serum ferritin level of 15 ug/l (normal 50 200). b. Total iron binding capacity of 220 ug/dl (normal 250 350). c. Serum iron of 38 ug/dl (normal 50 100) d. Suppressed reticulocyte count. 56

Combined IDA with ACD Patient with IBD and GI bleeding Case 3 Anemia of Chronic Disease (ACD) When anemia occurs in the presence of biochemical or clinical evidence of inflammation, the diagnostic criteria for ACD are a serum ferritin > 100 ug/l and a Tsat < 20%. If the serum ferritin concentration is between 30 100 ug/l, a combination of absolute iron deficiency and ACD is likely. JCDC 2015 ECCO Consensus Paper 57

Differential Biochemical Diagnosis for IDA ACD Combined IDA/ACD IDA ACD Combined IDA / ACD Serum Ferritin (ug/l) <30 >100 30 100 C reactive protein Normal Elevated Elevated DJChapron 58

Anemia case-3 ACD with IDA A CBC reveals the following: Hemoglobin = 9.4 gm/dl Hematocrit = 28.2 % MCV = 78 fl (80 100 fl) MCH 25 pg (26-34) MCHC 32 g/dl (31-37) Reticulocyte count = 1.5 (0.6 2.0%) Corrected as RI = 9.4/45 x 1.5 = 0.31% Peripheral smear normocytes with microcytes. Normal leukocytes WBC = 7,900/uL (4,500-11,000) Platelet Ct 300,000/uL (150,000-450,000) Anemia Case 3 Classification Mild microcytic, hypochromic, anemia Hypoproliferative Because of a dx of IBD, check for active inflammation and iron indices and stools for occult blood. 59

Case-3 - Combined IDA with ACD Serum iron (40-170 ug/dl) 36 TIBC (250-450 ug/dl) 270 % saturation (25 45%) 13 Ferritin (50-200 ug/l) 65 ESR (10-30mm) 100 C-reactive protein (5-10 mg/l) 58 Stool positive for blood Anemia Case 3 Classification Mild microcytic, hypochromic, anemia Hypoproliferative Iron deficiency anemia with concurrent active inflammation and intestinal blood loss. 60

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Hemolytic Anemia Bone marrow Nutritional PRODUCTION RATE [Hgb] = -------------------------------- CLEARANCE Bleeding Hemolysis DJ Chapron 63

Chronic inflammation Hemolysis MDS/Ca EP Bone marrow RBCs Kidney Bleeding Iron, B-12, folate DJ Chapron Kinetic Classification of Anemia Increased destruction (Retics increased) Intracorpuscular Membrane (hereditary) Enzyme deficicency (G6PD) Hemoglobinopathy (sickle cell) Extracorpuscular-immunological Autoimmune Alloimmune Extracorpuscular Acute / chronic blood loss Chemicals (oxidative stress) Hypersplenism Infectious Mechanical (heart valve) 64

Common Causes of Hemolytic Anemias Intrinsic: (almost always inherited) Membrane defects Spherocytosis/elliptocytosis Hemoglobin defects: Sickle cell Thalassemia Metabolic defect: G6PD deficiency Extrinsic: membrane defects Autoimmune Oxidative drugs/chemicals SELECTED DRUGS THAT MAY CAUSE HEMOLYTIC ANEMIA PROMOTING RED CELL DESTRUCTION (HEMOLYSIS) IMMUNE MEDIATED ALPHAMETHYLDOPA PENICILLINS/CEPHALOSPORINS QUINIDINE OXIDATIVE ANTIMALARIALS NITROFURANTOIN PHENAZOPYRIDINE SULFONAMIDES 65

Peripheral blood smear characteristic of intravascular hemolysis, with fragmented (schistocytes) and crescent-shaped (helmet) cells Schmaier 2003 66

Degmacyte = bite cell 67

Heinz bodies Microscopically visible refractile intraerythrocyte hemoglobin precipitates (oxidized and denatured) that attach to the internal surface of the red cell membrane. Red blood cells containing Heinz bodies have a shortened survival, mostly due to splenic sequestration. They are found in patients with unstable hemoglobin's, thalassemias and G6PD deficiencies and drug induced oxidative stress. Heinz bodies 68

UpToDate 2017 Anemia Case-X A 78 year old man has just received intravesical therapy with mitomycin C for bladder cancer. Soon after he develops a very painful chemical cystitis that is substantially relieved by phenazopyridine 100 mg bid, which he is placed on chronically. Over the course of several weeks he complains of fatigue and shortness of breath. A routine CBC and electrolytes are ordered. 69

Anemia Case -X A complete blood count is obtained and reveals the following: Hemoglobin = 8.0 gm/dl Hematocrit = 24 % MCV = 110 fl (80 100 fl) MCH = 32 pg/cell (26-34) MCHC = 33 gm/dl (31-37) White blood cell and platelet cts normal Electrolytes normal Anemia Case X Classification Macrocytic, normochromic anemia 70

Anemia case -X A complete blood count is obtained and reveals the following: Hemoglobin = 8.0 gm/dl Hematocrit = 24 % MCV = 110 fl (80 100 fl) Reticulocyte count = 21% (0.6 2.0%) Corrected as RI = 8/45 x 21 = 3.7% Anemia Case X Classification Macrocytic (due to increased RC), with normochromic anemia Proliferative bone marrow response elevated reticulocyte index 71

Laboratory Tests That Assist in the Diagnosis of Hemolytic Anemia Serum Indirect Bilirubin concentration Serum Haptoglobin Level Serum LDH level Reticulocyte count Anemia case X Additional tests Bilirubin total = 4.0 mg/dl; 3.5 mg/dl indirect (normal total = 0.3 1.0 mg/dl; approx 70% is indirect or unconjugated). Serum haptoglobin = 5 mg/dl (26 185 mg/dl). Serum lactate dehydrogenase (LDH) = 1100 U/L (90 176 U/L). Peripheral smear reveals bite cells and a special stain shows Heinz bodies. 72

Anemia Case X Classification Macrocytic, normochromic anemia Proliferative elevated reticulocyte index Peripheral smear with bite cells, special stain showing Heinz bodies, elevated serum LDH and indirect serum bilirubin and reduced serum haptoglobin are consistent with a hemolytic process. Prolonged phenazopyridine use is the source of the hemolytic process. 73

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Multiple Choice Question Which set of laboratory tests is NOT consistent with a hemolytic anemia: a. Elevated reticulocyte index, presence of bite cells and an elevated serum total bilirubin b. Discovery of Heinz bodies, elevated serum lactate dehydrogenase and bite cells c. Elevated serum haptoglobin, reduced serum bilirubin and normal reticulocyte index d. Reticulocytosis, elevated MCV and an elevated serum indirect bilirubin Macrocytic Anemias B 12 and Folate 75

Microcytosis Normocytic and Macrocytosis hypochromia normochromic Hillman and Finch 1985 76

UpToDate 2017 Normal neutrophil 77

Hypersegmented neutrophils (contains five or more nuclear lobes) Hypersegmented Neutrophils 5 or 6 or more lobes or nuclear segmentation. Hypersegmentation of neutrophils is the first morphological change in patients with megaloblastic anemia. It is the last morphological change to disappear after appropriate treatment. Signal to investigate the cause of underlying megaloblastosis. 78

Macrocytic Anemias 2 types Megaloblastic: morphologic characteristics on peripheral smear include macroovalocytes (oval as opposed to spherical) and hypersegmented neutrophils (5 or more nuclear segments or lobes). Nonmegaloblastic: spherical macrocytes, absence of hypersegmented neutrophils. Hematological Features of Megaloblastic Anemia Due to Folate and Cobalamin Deficiency In severe cases MCV > 115 fl. White blood cell and platelet counts are often decreased. Marked changes in RBC size and shape (increased RDW) and on peripheral smear macro ovalocytes are common. Hypersegmentation of neutrophils; platelet morphology is normal. Nucleated RBCs can be observed on smear. Reticulocyte count is low. Serum LDH and indirect bilirubin levels may be elevated because of hemolysis of abnormally formed cells within the marrow. 79

Megaloblastic Anemia Result of a defect in DNA synthesis and repair due to a perturbation in thymidine synthesis. In the marrow, normal RBC nuclear development is disrupted with a lagging of nuclear behind cytoplasmic maturation. There is cell loss in the marrow because of ineffective hematopoiesis resulting in increased serum levels of lactic dehydrogenase and bilirubin. AFP 2009 80

Morphological Classification of Anemia Macrocytic (MCV >100 fl): Megaloblastic Folate deficiency Vitamin B-12 deficiency Medications Nonmegaloblastic Ethanol abuse Hypothyroidism Liver disease Primary bone marrow disease Reticulocytosis 81

Laboratory Testing for Vitamin B 12 Deficiency A vitamin B 12 level < 200 pg/ml is strongly suggestive of B 12 deficiency. A vitamin B 12 level > 400 pg/ml generally rules out B 12 deficiency. Vitamin B 12 levels between 200 400 pg/ml are considered borderline/high risk and require the addition of measuring MMA serum levels. Elevated MMA levels are considered the most sensitive and specific test for identifying B 12 deficiency. A low MMA serum level is strongly indicative of normal B 12 status. 82

Laboratory Testing for Vitamin B 12 Deficiency continued Vitamin B 12 deficiency due to pernicious anemia (an autoimmune disease) is diagnosed by the detection of circulating anti intrinsic factor antibodies (high specificity, but moderate sensitivity). 83

Biochemical Detection of Cobalamin Deficiency Serum cobalamin concentration ( nl-200 900 pg/ml) < 400 pg/ml Elevated serum homocysteine concentration (5.8-11.9 umol/l) >13 umol/l Elevated serum methylmalonic acid (MMA) concentration (70-270 nmol/l) >350 nmol/l 84

CAUSES OF VITAMIN B-12 DEFICIENCY Dietary deficiency (vegetarians) Decreased liberation from foodstuffs (achlorhydria atrophic gastritis)) Decreased production of intrinsic factor pernicious anemia (anti-if antibodies) gastrectomy Competition for vitamin B-12 gut absorption (bacterial, medications) Pancreatic insufficiency (malabsorption) Decreased ileal absorption of vitamin B-12 surgical resection Crohn's disease AIDS Transcobalamin II deficiency 85

Neurological Effects of Cobalamin Deficiency Nerve injury due to demyelination. Usually starts with painful paresthesias, in fingers and feet and is associated with problems in vibratory sense and proprioception. Weakness, gait ataxia and spasticity Somnolence, changes in affect and mentation, frank psychosis (megaloblastic madness) Neurological effects of cobalamin deficiency can occur in the absence of anemia or elevated MCV 86

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[Total vitamin B-12] = [Holotranscobalamin] + [Holohaptocorrin] Enters cells via specific receptors Inert Enters cells via specific receptors Active B 12 Deficiency results in elevated methylmalonic acid (MMA) and Homocysteine (HC) serum levels. MMA >350 nmol/l HC > 13umol/L Inactive B 12 Total Vitamin B 12 Concentration 88

Vitamin B 12 deficiency Case Z Case -Z SJ is a 84 year old woman who is concerned about progressive memory loss and decreased sensations in her right foot. Her medical history includes osteoporosis, hypertension, and hypothyroidism, which are well managed calcium carbonate 500 mg bid, alendronate 35 mg qwk, hydrochlorothiazide 12.5 qd and L-thyroxine 100 mcg qd. Neurologic examination reveals a MMSE of 23/30, decreased vibratory sensations in both legs, and an ataxic gait. 89

Anemia Case -Z A complete blood count is obtained and reveals the following: Hemoglobin = 11.5 gm/dl Hematocrit = 34.5 % MCV = 109 fl (80 100) MCH = 33 pg/cell (26-34) MCHC = 32 gm/dl (31-37) White blood cell ct = 4400/uL (4500-11,000) Platelet ct - 89,000/uL (150,000-400,000) Anemia Case Z Classification Macrocytic, normochromic anemia Low WBC and platelets counts 90

Anemia case -Z A complete blood count is obtained and reveals the following: Hemoglobin = 11.5 gm/dl Hematocrit = 34.5 % MCV = 109 fl (80 100 fl) Reticulocyte count = 1.5% (0.5 1.5%) Corrected as RI = 11.5/45 x 1.5 = 0.38% Anemia Case Z Classification Macrocytic, normochromic anemia Low WBC and platelets Hypoproliferative anemia 91

Anemia case -Z A complete blood count is obtained and reveals the following: Hemoglobin = 11.5 gm/dl Hematocrit = 34.5 % MCV = 109 fl (80 100 fl) Reticulocyte count = 1.5% (0.5 1.5%) Corrected as RI = 11.5/45 x 1.5 = 0.38% Peripheral smear mixed population of macroovalocytes and normocytes, with notable hypersegmented neutrophils. Anemia Case Z Classification Macrocytic, normochromic anemia Low WBC and platelets Hypoproliferative anemia Megaloblastic macrocytic anemia consider nutritional deficiencies. 92

Anemia Z Additional lab tests Serum vitamin B 12 and folate. Results Vitamin B 12 = 150 pg/ml (200 900 pg/ml) Folate = 8 ug/l (>4 ug/l) Anemia Case Z Classification Macrocytic, normochromic anemia Low WBC and platelets Hypoproliferative anemia Megaloblastic macrocytic anemia consider nutritional deficiencies. Vitamin B 12 is abnormally low Dx vitamin B 12 deficiency. Determine etiology of Vitamin B 12 deficiency. 93

Anemia Z additional laboratory tests Anti intrinsic factor antibodies Patient is found to be positive for circulating anti intrinsic factor antibodies. Anemia Case Z Classification Macrocytic, normochromic anemia Low WBC and platelets Hypoproliferative anemia Megaloblastic macrocytic anemia consider nutritional deficiencies. Vitamin B 12 abnormally low Dx pernicious anemia 94

Vitamin B 12 deficiency Case ZZ Case ZZ SJ is a 84 year old woman who is concerned about progressive memory loss and decreased sensations in her right foot. Her medical history includes osteoporosis, hypertension, and hypothyroidism, which are well managed calcium carbonate 500 mg bid, alendronate 35 mg qwk, hydrochlorothiazide 12.5 qd and L-thyroxine 100 mcg qd. Neurologic examination reveals a MMSE of 23/30, decreased vibratory sensations in both legs, and an ataxic gait. 95

Anemia Case -ZZ A complete blood count is obtained and reveals the following: Hemoglobin = 12.5 gm/dl Hematocrit = 37.5 % MCV = 96 fl (80 100) MCH = 33 pg/cell (26-34) MCHC = 32 gm/dl (31-37) White blood cell ct = 6400/uL (4500-11,000) Platelet ct - 200,000/uL (150,000-400,000) Anemia Case ZZ Classification Neurological findings on physical exam suggestive of a possible vitamin B 12. Patient is not anemic and has a normal MCV. 96

Anemia case -ZZ A complete blood count is obtained and reveals the following: Hemoglobin = 12.5 gm/dl Hematocrit = 37.5 % MCV = 96 fl (80 100 fl) Order serum vitamin B-12 level. Anemia ZZ Additional lab tests Order a serum vitamin B 12 Results Vitamin B 12 = 250 pg/ml (200 900 pg/ml) 97

Anemia Case ZZ Classification Neurological findings on physical exam suggestive of a possible vitamin B 12. Patient is not anemic and a normal MCV. Serum vitamin B 12 levels are in the borderline/high risk range. Order a serum methylmalonic (MMA) acid level. Anemia ZZ Additional lab tests Results Vitamin B 12 = 250 pg/ml (200 900 pg/ml). Methylmalonic acid = 800 nmol/l (70 270 nmol/l). 98

Anemia Case ZZ Classification Neurological findings on physical exam suggestive of a possible vitamin B 12. Patient is not anemic. Serum vitamin B 12 levels are in the borderline/high risk range. Serum methylmalonic acid level (MMA) is elevated indicating a functional vitamin B 12 deficiency state. Multiple Choice Question : All of the following are common features of a significant vitamin B 12 deficiency except: a. Elevated serum homocysteine b. Hypersegmented neutrophils seen on a peripheral smear c. Macrocytosis d. A suppressed serum methylmalonic acid level. 99

Medications and Vitamin B 12 Deficiency 100

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DM + Metformin DM No DM 102

Diabetes Mellitus Metformin Vitamin B-12 deficiency Peripheral Neuropathy 103

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Diabetes Mellitus Metformin Vitamin B-12 deficiency Peripheral Neuropathy Proton Pump Inhibitors Diabetes Mellitus Metformin Vitamin B-12 deficiency Peripheral Neuropathy Proton Pump Inhibitors 105

Medications and Macrocytosis 106

Folate Deficiency 107

Laboratory Testing for Folate Deficiency A serum level less than 4 ug/l us indicative of folate deficiency. Borderline serum levels have been described as 4 8 ug/ml. A borderline level with an elevated plasma homocycteine level is indicative of a functional folate deficiency. Of note, plasma homocysteine levels are increased in B 12, folate and vitamin B 6 deficiencies. MMA serum levels are not effected by folate deficiency. RBC folate levels provide a time integrated folate level, whereas serum folate levels may be acutely influenced by recent dietary or multivitamin intake. Symptoms of folate deficiency are primarily due to anemia, but long term exposure to hyperhomocysteinemia may have adverse neurological and cardiovascular effects. Folate Deficiency Folate stores in the body are limited and last only a few months when intake/absorption is negligible. With the introduction of mandatory folic acid fortification in the diet in North America, folate deficiency is rare in this region. 108

Hillman and Finch 1985 109

CAUSES OF FOLATE DEFICIENCY Dietary deficiency Decreased absorption Jejunal pathology Medications phenytoin sulfasalazine ethanol Increased requirements Chronic hemolytic anemia Pregnancy Exfoliative skin disease Compromised utilization: MTX,TMP Loss: dialysis 110

Nutr Rev 1988;46:320 111

Nutr Rev 1988;46:320 Multiple Choice Question All of the medications with chronic use may be associated with hypersegmented neutrophils on a peripheral smear except: a. Metformin b. Omeprazole c. Phenazopyridine d. Sulfasalazine 112

Unexplained Anemia Patients with UA, by definition, do not have a well characterized anemia resulting from a single cause, such as iron or B12 deficiency. Unexplained anemia accounts for approximately one third of all anemia in individuals >65 years of age. Several theories have been put forward to explain the high rate of unexplained anemia in elderly individuals, including reduced pluripotent hematopoietic stem cell reserve, decreased production of hematopoietic growth factors, reduced sensitivity of stem cells and progenitors to growth factors, marrow microenvironment abnormalities, androgen deficiency, unrecognized CKD, undiagnosed myelodysplasia, or early stage ACD. 113

Unexplained Anemia (UA) in the Elderly Routine investigation yields no apparent cause. Anemia is generally mild with Hgb of 10 12 g/dl. Anemia is normocytic and hypoproliferative (low reticulocyte count/index). EPO level is usually within normal limits but is low relative to the [Hgb]. Serious causes have been excluded (malignancy). Bone marrow examination may be needed for transfusion dependent UA. Consider bone marrow examination for UA with macrocytosis, thrombocytopenia and neutropenia. Also consider (BME) if splenomegaly, bone pain, weight loss and fever and chills are present. Brocklehurst 2017 Chpt 17 114

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2 Other Disorders to Consider in the Elderly Patient with Unexplained Anemia both bone marrow disorders Myelodysplasia Multiple Myeloma Myelodysplasic Syndrome MDS 116

Myelodysplastic Syndrome with anemia MDS include a heterogenous group of disorders characterized by dysplastic (abnormal) changes within the bone marrow and impaired proliferation of one or more cell lines (erythroid, myeloid and megakaryocytic). It occurs primarily in older men, with a median age of occurrence of 76 yrs. 117

FAB Classification of MDS Refractory anemia Refractory anemia with ringed sideroblasts Refractory anemia with excess blasts Refractory anemia excess blasts in transformation Chronic myelomonocytic leukemia (CMML) FAB = French, American, British classification Anemia Case MDS Classification Macrocytic, normochromic anemia. Hypoproliferative/ineffective erythropoiesis. Leukopenia and thrombocytopenia. Bilobed leukocyte (Pelger Huet abnormality) on smear suggests myelodysplastic process. Consider bone marrow biopsy. Serum B 12, folate and iron studies are normal. 118

UpToDate 2017 Anemia case -MDS A CBC reveals the following: Hemoglobin = 10.5 gm/dl Hematocrit = 32 % MCV = 104 fl (80 100 fl) MCH 32 pg MCHC 33 g/dl Reticulocyte count = 1.0% (0.5 1.5%) Corrected as RI = 10.5/45 x 1.5 = 0.35% Peripheral smear mixed population of macrocytes and normocytes, with occasional bilobed cells (ie., Pelger-Huet anomaly). WBC = 3,900/uL (4,500-11,000) Platelet Ct 99,000/uL (150,000-450,000) 119

Multiple Myeloma Multiple Myeloma (MM) Multiple myeloma (MM) is a neoplastic disease deriving from an abnormal proliferation of monoclonal plasma cells in the bone marrow and immunoglobulin or light chain overproduction that can cause end organ damage. MM is a disease of the elderly reflected by a median age at diagnosis of approximately 70 years, with 35 40% of patients being older than 75 years, and with the highest rates of diagnosis reported in the 80 to 89 year age group. MM accounts for approximately 13% for all hematologic malignancies and 20% of hematologic malignancy related deaths. The major hematological manifestation of MM is anemia due to decreased erythropoiesis as a result of marrow damage and a relative failure of the erythropoietin response to anemia. Rouleaux formation may be seen on the peripheral smear. 120

UpToDate 2017 UpToDate 2017 121

Any Questions? 122