I. Definitions II. III. Red blood cell life cycle Iron metabolism IV. Causes of anemia A. Kinetic approach 1. decreased production 2. increased destruction 3. blood loss B. Morphologic approach 1. normocytic 2. microcytic 3. macrocytic V. Evaluation A. History B. Physical Exam C. Laboratory evaluation D. Bone marrow examination E. Specialty referrals VI. Treatment 1. Iron 2. Blood transfusion 3. Other therapies
6 Habits of Ineffective Anemia Evaluation & Treatment
Recognize ineffective habits in the evaluation & treatment of anemia. Replace with effective ones.
6 Habits of Ineffective Anemia Evaluation & Treatment 1. Giving iron to all anemics 2. Refilling iron to infinity 3. Transfusing to hemoglobin = 10 4. Referring all anemics to GI 5. Referring all anemics to Hematology 6. Ignoring high MCV
What defines anemia? Hemoglobin Hematocrit RBC count
Hemoglobin g/dl
Hematocrit %
RBC count millions 0f cells per microl whole blood Accurate Reliable
Mean Corpuscular Volume (MCV) average volume (size) of RBCs microcytic 80 100 fl normocytic macrocytic
Red Cell Distribution Width (RDW) variation in RBC size 11.6 to 14.6 homogenous anisocytosis
Who needs iron? poor intake malabsorption 1 high requirements
Who needs iron? Nosebleeds Vomiting blood Rectal bleeding Heavy menstrual periods Bleeding gums Hematuria Bleeding from trauma or surgery
History diet bleeding living conditions
fatigue dizziness headache chest pain dyspnea joint pain feeling cold TISSUE HYPOXIA
Glossy tongue (Atrophic glossitis) Spooning of nails (Koilonychia)
Low MCV (microcytosis) High RDW (anisocytosis) High platelet count
What test to order? FERRITIN
Ferritin reference range Men: 20 200 ng/ml Women: 15 150 ng/ml < 15 DEFINITE iron deficiency 16 to 50 likely iron deficiency 51 to 100 unlikely deficiency > 100 NO deficiency
Measures iron stores in SERUM Acute phase reactant Elevated in liver disease
FROM THE QUEST MENU Is ferritin included in an iron profile? Ferritin is a separate order. Iron profile has serum iron, unbound iron & total iron binding capacity (TIBC)
IRON PROFILES Unsaturated transferrin Iron bound to transferrin 385 425 200 160 270 100 35 90 50 NORMAL IRON DEFICIENCY LATE PREGNANCY INFLAMMATION IRON OVERLOAD
Other helpful tests in iron deficiency Iron Profile Low serum iron Low iron saturation High unbound iron High TIBC RBC morphology (peripheral blood smear) Hypochromic Microcytic Anisocytosis Poikilocytosis
Genius order Reticulocyte panel severe iron deficiency Reticulocyte count bleeding Reticulocyte hemoglobin Immature retic fraction
Empty stomach Vitamin C? Dairy products, cereals, fiber, tea, coffee, eggs Antacids, H2 blockers, PPIs, calcium supplements
Hemoglobin 8.5 GFR = 40 FEV1 = 35 % EF = 30%
Hemoglobin 9.5 HYPOADRENALIN
Anemia of chronic disease Chronic inflammation Chronic infection FERRITIN Iron Binding Capacity
IRON AVAILABILITY
Lab clues to anemia of chronic disease Normal MCV (normocytic) Low-normal RDW (homogenous) Reticulocyte count low to normal
Burr cells (echinocytes) Spur cells (acanthocytes) Target cells Target cells, Teardrop cells
Ferritin Rheumatoid arthritis COPD Chronic liver disease Anemia of chronic disease + NSAID gastritis + malnutrition + bleeding varices Iron deficiency anemia Reticulocyte henoglobin
Treatment goals: Build up iron stores Resolve blood loss 2 Ferritin = 50 100 Hb can lag behind, check in 2-3 mos Stop iron 3-6 mos. after normal hemoglobin
Transfusing when Hb < 10 = 3
BLOOD TRANSFUSION < 6 gm/dl : Definite 6 to 7 : Most likely, esp. in acute loss 7 to 8 : With symptoms, cardiovascular or pulmonary disease 8 to 10 : Selected cases severe smptoms, ongoing bleeding, coronary ischemia > 10 : Don t even think about it
IRON INFUSION GI Intolerance to oral iron Replete stores in few visits Ongoing blood loss exceeds capacity of oral iron Absorption issues Reduce need for transfusion
4 Dysphagia Reflux Vomiting blood Dark stools Belly pain Chest pain Aspirin NSAIDs Alcohol
Rectal bleed Hemorrhoids Belly pain Rectal pain Constipation Diarrhea Weight loss Family hx
CONFIRM Iron Deficiency FERRITIN Peripheral blood smear Reticulocyte panel HIGH retic count with bleeding LOW retic Hb
Important: Ferritin More important: Fecal Immunochemical Test (FIT)
Refer to Hematology 5 Anemia of decreased production Bone marrow disorders Anemia of increased destruction Hemolytic anemias
Bone marrow disorder: Aplastic anemia Low RBCs Low WBCs Low Platelets
Bone marrow function: Reticulocyte count Peripheral blood smear
Bone marrow disorder: Myelodysplasia Risk of leukemia Insidious onset, elderly Splenomegaly High MCV High vitamin B12
Myelodysplasia: Peripheral blood smear Hypochromic Tear drop cell Red cell fragments
Hemolytic anemia Splenomegaly Jaundice
Hemolytic anemia High LDH Low Haptoglobin High indirect bilirubin High reticulocyte count Smear: schistocytes, spherocytes
Macrocytosis 6 MCV > 100 Reticulocyte count > 2% Response to blood loss Response to hemolysis Normal or low reticulocyte count < 0.5% Abnomal DNA metabolism Bone marrow disorders Lipid abnormalities Unknown
MACROCYTOSIS, low-normal reticulocyte count Abnormal DNA metabolism Vitamin B12 deficiency Folate deficiency Drugs (MTX, 6MP, chemotx, anti-hiv) Bone marrow disorders Myelodysplastic syndromes Lipid abnormalities Liver disease Hypothyroid
MACROCYTOSIS, low-normal reticulocyte count Other or unknown mechanism Alcohol abuse Multiple myeloma Smoking, chronic lung disease Severe hyperglycemia Leukocytosis Post spelenectomy
Vitamin B12 deficiency
Vitamin B12 deficiency Autoimmune disease Type 1 diabetes Hypothyroid Grave s disease
Vitamin B12 deficiency on metformin on alcohol
Vitamin B12 deficiency
Vitamin B12 (cobalamin) deficiency Low or normal reticulocyte count Pancytopenia Low RBC Low WBC Low Platelets Macroovalocytes, Nuclear hypersegmentation of neutrophils
Vitamin B12 (cobalamin) levels pg/ml < 200 definitely deficient 200-300 probably deficient Methylmalonic acid HIGH in B12 deficiency > 300 not deficient
Folate ng/ml < 2 definitely deficient 2-4 probably deficient Homocysteine HIGH in folate deficiency > 4 not deficient
1. Before prescribing iron confirm iron deficiency by history, exam, FERRITIN 2. STOP refilling iron prescription when hemoglobin or ferritin goal is reached
3. Restrict transfusion to lower hemoglobin levels (6-7). Consider symptoms & clinical scenario. 4. Before referring to GI confirm iron-deficiency, obtain FIT test
5. Hematology gets anemias of decreased production & increased destruction 6. High MCV has many causes. Treat low vitamin B12 & folate.