1. Anemia John R. Brill, MD, MPH

2. Anemia Goals –Review common causes of anemia –Provide conceptual framework for evaluating patients with anemia –Show some interesting, gross and unusual pictures

3. Anemia Definition: Age/gender-specific reduction in the circulating red blood cell mass Commonly measured by the hemoglobin or hematocrit

5. Anemia: Prevalence Approximately 4.7 million Americans 6.6 % of men; 12.4 % of women Increases with age; 44.4 percent in men > 85 “Although the elderly are more prone to develop anemia, older age is not of itself a cause of the condition.” Brill JR, Baumgardner DJ. Am Fam Physician 2000; 62:2255-63,2264

6. Primary Causes of Anemias Increased red blood cell loss or destruction Decreased red blood cell production Overexpansion of plasma volume Maldistribution

7. RBCs External losses Maldistri- bution Precursors Production Plasma Volume

8. Increased red blood cell loss or destruction Blood loss Hypersplenism Hemolytic disorders –Acquired conditions –Congenital conditions

10. Case 1 25 y/o woman, G2 P2002 c/o fatigue TSH 1.3 Hgb 10.3, Hct 31, Nl WBCs, Plts 538K, MCV 81, RDW 18.5 FeSO4 325 mg daily x 6 weeks Hgb 11.6, Hct 35

11. Congenital Hemolysis Hemoglobinopathies Disorders of red blood cell membranes Red blood cell enzyme deficiencies

12. Hemoglobinopathies Homozygous sickle cell disease (hemoglobin SS disease) Sickle cells, target cells. Heterozygous sickle hemoglobin C disease (hemoglobin SC disease) Thalassemias (usually microcytic)

13. Disorders of red blood cell membranes Hereditary spherocytosisHereditary elliptocytosis

14. Red blood cell enzyme deficiencies Glucose-6-phosphate dehydrogenase deficiency Pyruvate kinase deficiency

15. Case 2 22 y/o man Recently started doxycycline for acne Fatigued, tired, dizzy Hgb 10.6, Hct 31. CRI 3.7% Coombs (-). Stool heme neg. Urine dip +, micro negative

17. Acquired Hemolysis Mechanical hemolysis Macrovascular disorders Microangiopathic disorders

18. Macrovascular hemolysis Valves, atherosclerosis Schistocytes

19. Microvascular hemolysis Disseminated intravascular coagulopathy Hemolytic-uremic syndrome Thrombotic thrombocytopenic purpura

20. Case 3 31 y/o woman 3 day hx severe diarrhea; 2 other family members also effected Now with bloody diarrhea, fever, confusion Hgb 8.5, Hct 26, Plts 23K, WBC 23.6 Creat 4.3

22. Autoimmune hemolytic anemias Warm-reactive anemias Cold-reactive anemias Drug-induced anemias Paroxysmal nocturnal hemoglobinuria

23. Case 4 72 year old woman, new pt DM, HTN. On glipizide, lisinopril, HCTZ, ASA Fatigue, felt 2nd to care of husband with CVA Rectal heme negative Hgb 6.7, Hct 20 Nl WBC, Plts, CMP, TSH No prior CBC available

25. Case 4, cont Retic Count 4.9% (CRI 2.5%) Coombs +++ Dx: Drug-Induced Hemolytic Anemia

27. Decreased RBC Production Primary causes Marrow hypoplasia or aplasia Myelopathies Myeloproliferative diseases Pure red blood cell aplasia

29. Secondary causes Anemia of chronic disease Chronic renal failure Endocrine deficiency states Sideroblastic anemias

30. Iron Deficiency Most common cause of anemia world-wide Low Fe, Ferritin; elevated TIBC, platelets

31. Case 5 63 y/o man Farmer, never came to doctor 8 month hx weight loss, anorexia, fatigue Hgb 7.3, Hct 22 Plts464K, WBC 11.3 MCV 82, RDW 18.5 Ferritin 6 Dark maroon heme +++ stool

35. Anemia of Chronic Disease Most common cause of anemia in US Increases with age 30% hospitalized patients Malignancies, endocrinopathies, rheumatic disease, hepatic disease Renal disease: not linked to degree of impaired GFR

36. Case 6 67 y/o man DM, HTN, Hyperlipidemia, CAD HgbA1c 9.4, microalbumin high, creat 1.6 Hgb 9.5, Hct 29, nl WBC, Plts, MCV 84 RDW 14 Ferritin 140 Erythropoeitin x 6 weeks, Hgb 11.1

37. Summary Anemia is common Consider epidemiology, history to formulate a differential, directed labs Use whole CBC

39. References Incidence of anemia in older people: an epidemiologic study in a well defined population. BJ Ania, VJ Suman, VF Fairbanks, DM Rademacher, LJ … - J Am Geriatr Soc, 1997Incidence of anemia in older people: an epidemiologic study in a well defined population Advances in the anemia of chronic disease. RT Means Jr - Int J Hematol, 1999Advances in the anemia of chronic disease. Normocytic anemia. JR Brill, DJ Baumgardner - Am Fam Physician, 2000 Nov 15;62(10):2255-64Normocytic anemia.