Anemia

sites.google.com/view/fmres/page/anemia

1. Assess the risk of decompensation of anemic patients (e.g., volume status, the
presence of congestive heart failure [CHF], angina, or other disease states) to decide
if prompt transfusion or volume replacement is necessary.
2. In a patient with anemia, classify the anemia as microcytic, normocytic, or macrocytic
by using the MCV (mean corpuscular value) or smear test result, to direct further
assessment and treatment.
3. In all patients with anemia, determine the iron status before initiating treatment.
4. In a patient with iron deficiency , investigate further to find the cause.
5. Consider and look for anemia in appropriate patients (e.g., those at risk for blood loss
[those receiving anticoagulation, elderly patients taking a nonsteroidal anti-
inflammatory drug]) or in patients with hemolysis (mechanical valves), whether they
are symptomatic or not, and in those with new or worsening symptoms of angina or
CHF.
6. In patients with macrocytic anemia:
1. Consider the possibility of vitamin B12 deficiency.
2. Look for other manifestations of the deficiency (e.g., neurologic symptoms) in
order to make the diagnosis of pernicious anemia when it is present.
7. As part of well-baby care, consider anemia in high-risk populations (e.g., those
living in poverty) or in high-risk patients (e.g., those who are pale or have a low-iron
diet or poor weight gain).
8. When a patient is discovered to have a slightly low hemoglobin level, look carefully
for a cause (e.g., hemoglobinopathies, menorrhagia, occult bleeding, previously
undiagnosed chronic disease), as one cannot assume that this is normal for them.
9. In anemic patients with menorrhagia, determine the need to look for other causes of
the anemia.

See iron deficiency, vitamin B12 deficiency.

General Overview
Usually defined as low hemoglobin or hematocrit (Approximately Hb <135 for men
<120 for women)

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 Restrict transfusions if stable, consider maintain Hb>70-80 (if underlying
cardiovascular disease, planned surgery)
Consider transfusions in symptomatic, unstable, ongoing losses
If transfused, may repeat post-transfusion hemoglobin levels even after 15
minutes (1pRBC usually raises Hb by 10g/L)

Microcytic (MCV <80: TAILS)

Thalassemia (alpha, beta)
Africa, Mediterranean, Southeast Asia
Mild Splenomegaly
Anemia of chronic disease
Iron deficiency
Nutrition
Chronic blood loss (GI, celiac, menstruation)
Rare
Lead poisoning
B6 deficiency
Copper or Zinc deficiency
Sideroblastic (iron metabolism defect)

Normocytic (MCV 80-100: ABCD)

Acute blood loss
Bone marrow failure
Chronic disease
ESR, CRP, creatinine
Destruction (Hemolysis)
Inherited:
Hemoglobinopathy: Sickle cell, Thalassemia, Unstable Hb
Membrane: Spherocytic
Metabolic: HMP shunt, glycolytic
Acquired
Immune
Infection
MAHA
Oxidative

Macrocytic (MCV>100: FATRBC)

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 Folate / Fetus (pregnancy)
Alcoholism / Liver disease
Thyroid (hypo) / Endocrine
Reticulocytosis
B12 deficiency
Cytotoxic Drugs / Dysplasia

Kinetic Approach
Decreased RBC production
Nutrients (B12, iron)
Bone marrow disorder/suppression
Low trophic hormones (EPO, thyroid hormone, androgens)
Note: Inflammation reduces available iron, EPO, and RBC lifespan
Increased RBC destruction
Extravascular (spleen/liver)
Inherited (spherocytosis, sickle, thalassemia)
Acquired (autoimmune, thrombotic thrombocytopenic purpura, malaria,
paroxysmal nocturnal hemoglobinuria)
Hypersplenism
Intravascular
MAHA
Paroxysmal nocturnal hemoglobinuria
Cold agglutinin
Blood loss

Investigations
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 CBC
Serial hemoglobin and hematocrit
RBC indices
MCV as above, MCH (similar to MCV)
Increased MCH concentration (mean corpuscular hemoglobin
concentration) occur almost exclusively in congenital/acquired
spherocytosis or other congenital hemolytic anemias (sickle cell, Hb C,
xerocytosis)
WBC (monocytosis may suggest myelodysplasia)
Platelets
Rule out pancytopenia (bone marrow infiltration, aplasia or
destruction/sequestration)
Reticulocyte
Blood smear
Red cell fragmentation ("helmet cells," schistocytes) in microangiopathic
hemolysis
Microspherocytes in autoimmune hemolytic anemia
Teardrop RBC in myelofibrosis
Leukoerythroblastic pattern in bone marrow infiltration or replacement
RBC parasites in malaria or babesiosis
Iron profile (consider if blood loss or low MCV, low MCH, high RDW)
Ferritin
TIBC (transferrin)
Hb electrophoresis
Hemolysis work-up
LDH
Bilirubin (indirect)
Haptoglobin (reduced in hemolysis)
Consider Coombs' test
Consider urinary hemoglobin and hemosiderin for intravascular hemolysis in
paroxysmal nocturnal hemoglobinuria
Bone marrow biopsy
Usually indicated in pancytopenia or blast cells (rule out malignancy)
TSH/B12/Folate
INR
DIC panel (fibrinogen, D-dimer)

Anemia in Children

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History
Lethargy, tachycardia, pallor
Signs of hemolysis (urine color, scleral icterus, jaundice)
Failure to thrive
Bleeding history
PMH (birth, jaundice, anemia, medical conditions)
Family History
Bleeding disorder, hemoglobinopathy, IBD
Poverty
Non-iron-fortified formula
Ethnicity
Hb S and C in black/Hispanic
Thalassemia in Mediterranean/Southeast Asian
G6PD in Sephardic Jews/Filipinos/Greeks/Sardinians/Kurds/black
Whole cow's milk diet
Exclusive breastfeed after 6 months of age
Poorly controlled maternal diabetes

By Age
0-3 months:
Newborns: Blood loss, hemolysis (Rh or ABO incompatibility), congenital
infection, twin-twin transfusion, congenital hemolytic anemia (spherocytosis,
G6PD deficiency)
Physiologic anemia (nadir of 110 at 6-9w of age due to decrease in EPO)
3-6 months:
Hemoglobinopathy (thalassemia, sickle cell)
9-12 months:
Acquired (iron deficiency anemia)
WHO recommends screening in all children 9-12 months
Consider targeted screening if risk factors (poverty, poor weight gain,
excessive milk intake + low iron-rich foods [malnutrition], malabsorption,
GI blood loss, obesity)

References:

UpToDate
Cochrane 2016. Transfusion.
http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD002042.pub4/full
AAFP 2016. Anemia in Children. https://www.aafp.org/afp/2016/0215/p270.html
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 CFP 2015. Elderly. http://www.cfp.ca/content/61/2/159
AAFP 2013. Iron Deficiency. http://www.aafp.org/afp/2013/0115/p98.html
BC Guidelines 2010. Iron Deficiency.
http://www2.gov.bc.ca/gov/content/health/practitioner-professional-resources/bc-
guidelines/iron-deficiency
Transfusion 1997. https://www-ncbi-nlm-nih-gov.proxy3.library.mcgill.ca/pubmed?
term=9191816

Iron-Rich Foods: Patient Handout

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