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Highlights on Anemia

By
Dr Shaza Abdel wahab
Professor of hematology and
BMT
Ain Shams university
Cairo -Egypt

Objectives :
Approach to diagnosis (work-up ) of anemias
Diagnosis and management of iron deficiency
anemia
Highlighting anemia in special situations :
elderly people, critical care units and pregnancy
and lactation
Screening for hemoglobinopathies
Important notes on Sickle cell anemia

Definition of Anemia :
According to the WHO criteria as HB values
<12g/dl in women and <13g/dl in men.

* In African American the HB levels are


physiologically lower than Caucasians

Diagnosis of Anemia
MCV,MCH,MCHC,peripheral smear and
retics count
Low

NN
retics
1-iron def.anemia
1-Bm infiltration
2-hemoglobinopathies 2- anemia of CRF
3-Anemia of ch.illness 3-endocrinal
4-lead poisoning
4-hemolysis and
5-sideroblastic anemia hemorrahge

high(Macrocytic )
1-megaloblastic
2-non megalobl
-astic

MDS,CLD,alcohol
-ism

Clues to diagnosis of iron deficiency anemia :


Causes of iron deficiency :
in developing countries
hook worm infestation

in developed countries
GI bleeding is adult
males and post-meno
pausal females
Menstrual bleeding in
adult females

* Iron deficiency anemia is the late result of negative iron balance


with depletion of iron stores in BM,liver ,spleen
So
1-S.ferritin level is ( good reflection )
2- As iron stores become more
TIBC is ,TS is
So Anemia that is microcytic and hypochromic are present only
in the late stages of iron defiency .
3-s.iron is a poor reflection of the iron stores and may be
normal in IDA ,moreover subjected to diurnal variation ,
liable to fluctuation with dietary intake.

4-TS is low (< 10%)


5-Very low s.ferritin <15g/ l is diagnostic of IDA.
6-If as a result of inflammatory disease (being an acute
phase reactant ) so may be an normal However values >
100g/l is unusual in IDA.
Values > 1200g /l BM ex for exclusion of iron overload.
7-RDW is in iron deficiency anemia ( N in thalassemia ,N to
high in anemia of ch.inflammation )
8-Measurment of soluble s TfR is a good test for IDA where
the level of receptors is while N in anemia of ch.
inflammation. (investigational ).

Evaluation of the B.M. for stainable iron has


been considered the gold standard for
diagnosis of IDA. However is not part of the
routine work up .

Highlights on treatment :
1-typical replacement doses are 200mg elemental iron daily in
adults ,3-6mg/kg /d for infants and children in divided doses.
2-taken on empty stomach ,however better tolerated with food.
3- Vit C the absorption of inorganic (non hem iron )
4- failure of response either : non compliance or mal-absorption
syndrome.
5- Antacids ,tannis(tea),Ca supplementation ,bran and whole grains
iron absorption if taken concurrently.
6-duration of therapy: HB rises 1-2 wks with rise of reticulocytic
count and should continue 6-9mo(replete B.stores)
7- IMI should not be given (painful and associated with soft T.
sarcoma.)

Anemia of Chronic disorders (AOCD) :


Anemia is normocytic normochromic ,however
over time ,anemia may become severe with
hypochromia and microcytosis and reduced
reticulocytic counts .
Iron indices : s.iron level to N
TIBC
N
s.ferritin N or high

As result of inflammation

Cytokines released (IL-1,IL-6,TNF )


in erythroid precursors
proliferation
retics

in Epo production
Short RBCs survival

disturbed iron meta


-bolism by IL-6
Hepcidin overexpression
iron absorption

Concomittent iron deficiency may co-exist as


expressed by low N s.ferritin which necessates iron
replacement therapy .
ttt : is that of the underlying disorder , whevener
necessary Epo or darbepoetin .

Non Myelodysplastic sideroblastic anemia :


o The hallmark of sideroblastic anemia is the presence of
mitochondrial iron which surrounds or rings the nucleus .
o The presence of sideroblasts is due to ineffective
erythropoiesis .
o Sideroblastic anemia may be secondary to MDS or due to
inherited conditions ,while drugs ,toxins ,alcohol
,cycloserine, INH, and chloramphenicol are acquired
causes of sideroblastic anemia.

Anemia in Critically ill and ICU patients :


affects 50% of the hospitalized pts and 75% of the
elderly hospitalized.
60-65% are anemic at time of admission to the
ICU to 90% by the 3rd d. and 97% at day 8.
Causes of anemia are variable from : blood
loss/sampling ,drug induced marrow
suppression ,GI bleeding ,DIC.

Blood transfusion in the ICU :


Anemia in the ICU pts is associated with risk of morbidity and mortality.
Debate :
Benefits/risks of blood transfusion

1-faster mean
of HB level
2-avoid side effects
of ESA

1-costy
2-poor outcomes
with risk of
mortality and
morbidity
TRAIL,TRACO,TRI

Measures to minimize the need for transfusion :


avoid unnecessary blood sampling ,use of small volume
phlebotomy tubes, early detection of bleeding and pay
attention to drug effects.

However in a large cohort German study


anemia is associated with mortalities and
morbidities and transfusion was associated
with ICU and in hospital death .
(Sakr et al 2010).

Also correcting anemia by transfusion for patients


older than 65 y and severely ill was associated with
improved survival compared to non transfused.
(Athar et al 2012 )

Anemia of Pregnancy and lactation :


WHO defines anemia of pregnancy as HB level < 11g/dl
,hct <33% at any point of pregnancy .
The US centers for disease control and prevention (CDC)
define anemia of pregnancy as HB <11g /dl ,hct <33%
in the 1st and 3rd trimester and < 10.5 g% and 32% 2nd
Trimester .

Anemia of pregnancy primarily affects


women of low socioeconomic status.
The risk of anemia increases with
progression of pregnancy.

Causes :
1-Iron deficiency anemia
2-folate and B12 deficiency
3-other micronutrient deficiences
4-infectious diseases in pregnancy
5-Hemoglobinopathies
6-Aplastic anemia and pregnancy

o Pregnancy and lactation the demand for iron by


3 fold. Blood loss during delivery compromises
iron stores and contributes to iron deficiency .
o Additionally iron is secreted in breast milk .All
lactating women will become iron deficient if not
treated appropriately with iron supplementation.

Anemia in the elderly:


Anemia in older people who are >65y
The frequency of anemia increases and doubles
with age especially >85y old.
Associated with negative symptoms as falls and
frailty and cognitive impairment mortality
Causes : 1-IDA
D: iron studies

2-2ry to renal disease


3-ch.inflammatory disease
4-Unexplained anemia of the elderly (UAE)
UAE causes :hormonal :testosterone,MDS,
malignancy,IGF-1
Megaloblastic anemia constitute small percent in
anemia of the elderly ,so if resistant think of
MDS

Screening and diagnosis of hemoglobinopathies :


Presence of hypochromic microcytic anemia ,retics and
presence of target cells in PB and N RDW.
HB electrophoresis to diagnose the underlying disorder
indicated in pre-conceptional ,neonates ,pre-operative and
following transfusion of RBCs in SCD.
Severe iron deficiency may HB A so s.ferritin
measurement with iron replacement and repetition of the
test when the iron stores are replete.
Iron studies : s.iron , TIBC ,TS ,s.ferritin is N to
high