7Anaemia of chronic disease Impaired erythropoietin productionBlunted response of marrow to endogenous erythropoietinImpaired iron metabolism mediated by inflammatory cytokines and stimulates liver production of hepcidinHepcidin reduces iron absorption and decrease iron release from macrophagesNormocytic, hypochromic anaemia with low iron binding capacity, normal or high ferritin and increased marrow iron
8Myelodysplasia Most often in older age groups Anaemia could be only presenting featureDifficult to diagnose in early stagesBlood film may helpBone marrow assessment is required to confirm the diagnosisEpo<500 may respond to Epo injections
13Sideroblastic anaemia Inherited and acquired causesMutation of genes in haem biosynthesisMost common – ALA synthase gene mutationCharacterized by ring sideroblastsAccumulation in perinuclear mitochondria within erythroblasts due to impaired iron utilisationAcquired – MDS, alcohol, lead toxicity
16Congenital dyserythropoietic anaemias Rare congenital anaemias, 3 major subtypesMild to moderate anaemia due to ineffective erythropoiesisSecondary iron overload due to increased iron absorptionCharacteristic bone marrow changes and EM appearances of the erythroblasts
19Paroxysmal nocturnal Haemoglobinuria Rare diseaseAcquired mutation of PIG-A geneDefect in the production of GPI protein anchors which protects against complement destructionIncreased red cell destruction
27Retrospective cohort study of over 300000 patients 1997-2004 Age over 65 years undergoing non-cardiac surgery3 groups: Hct<39, , >5430 day mortality increase by 1.6% for every 1% change in Hct<39–Wu et al
32Erythropoietin MW 30400Da Discovered by Miyake et al in 1977 LC 4 alpha helical bundle class 1 cytokine
33ErythropoietinRenally secreted glycopeptide which stimulates erythropoiesisNormally rises with anaemiaBlunted response in chronic inflammatory conditions, cancer, RAHelps in reducing/avoid blood transfusions
34Biology Epo stimulates erythropoiesis Low oxygen supply increases the production of EpoProduced by the interstitial cells in kidney
3532 week randomised, double blinded crossover trial with placebo and Epoetin alpha in elderly -Agnihotri P et al62 patients with chronic anaemia
37Increase in Hb>2 g/dl Improvement in QOL studies
38Monitor blood pressure, risk of hypertension Avoid in patients with recent MI/CVAMaintain Hb g/l, aim lower Hb level in patients with thrombocytosis, ischaemic vascular disease.Responds better after iron/folate replacement in deficient patients.
39ICUSNew terminology coined for unexplained cytopenias, persists for at least 6 monthsHb<110 g/l, with no clear reasonAcknowledgement of diagnostic uncertaintyDoes not meet the diagnostic criteria for MDS or other conditionsRecommend long term monitoring as it may progress to MDSSuboptimal Epo production could be the cause
40SummaryConsider occult bleed, Anaemia of chronic disease or low grade haemolysis before UA.Polypharmacy, inadequate nutrition, alcohol abuse also have a negative impact on erythropoiesis.Associated neutropenia, low platelets are suggestive of bone marrow disorders.