Presentation on theme: "Classification of Anemia (Adults)"— Presentation transcript:
1 Classification of Anemia (Adults) Teoman SOYSAL Prof. MD
2 Definition of anemia Anemia: A reduction in red cell massO2-carrying capacityIt is expressed in terms of reduction in the concentration of Hb (or RBC or Hct%) compared to values obtained from a reference population.(2 SD below normal)
8 Definition of anemiaHb level of a patient which is below the normal ranges of that age and sex.For adults:WHO criteria define anemia as hemoglobin level lower than 12 g/dL in women and 13 g/dL in menBut: The reference values for red cells ,Hb or Hct may difer according tosex/ageRaceAltitudeSocioeconomical changesStudy/reference etc
9 BEUTLER andWAALEN BLOOD, 1 MARCH 2006 VOLUME 107, NUMBER 5
10 Age and blood count changes WBCNeutrophylsEos.BasoLenfoMonoHb12 mo6-17.50-0.204-10.54 y5.5-152-80-0.86 y5-14.51.5-80-0.651.5-710 y4.5-131.8-80-0.6021 y4.5-110-0.451-4.8E: 16K: 14WBC: x10E3/mm3 Hb:g/dL
11 !!!!!Plasma volume changes have to be considered before determining a diagnosis of anemia .Volume contraction:Underestimation of anemiaVolume overload: Underestimation of Hb level
13 !!!!!A normal Hb in a patient in whom an elevated Hb level is expected may represent anemia .(eg:COPD + Hb:N)
14 !!!!!! Eg: Low Hb, high RBC, low MCV Hb: 10 g/dL (anemia) Different red cell measures of the same patient may give discordant values in special conditions. (eg:Thalassemia trait)Eg: Low Hb, high RBC, low MCVHb: 10 g/dL (anemia)RBC: 6.5 million/mm3 (erythrocytosis)MVC : 70 fL
15 !!!! Anemia is rarely a disease by itself, It is mostly a manifestation or consequence of an underlying (genetic or acquired) disease.The finding of anemia has to start attempts to disclose an underlying disease .What is the cause of anemia ?
16 Anemia leads to two symptom complexes; Tissue hypoxiaFatigue,dyspnea on exertion etcCompensatory attemptsTachycardia,hyperventilation etc
17 O2 carrying capacity of normal blood:1.34 ml/g-Hb (200 ml/L-blood) The amount of O2 necessary to support life is : 250 ml/minO2 carrying capacity of normal blood:1.34 ml/g-Hb (200 ml/L-blood)Cardiac output: 5000 ml/minO2 delivery to tissues : 1000 ml/min
18 Reduced levels of Hb results with reduced oxygen delivery to tissues , leading to tissue hypoxia. The symptoms and findings of anemia concern many different systems/organs due to the widespread nature of hypoxia.
19 The most pronounced effects and symptoms derive from skeletal muscles, heart,and central nervous system(due to their greater oxygen demand and compensatory actions).What is the mechanism underlying compensatory mechanisms ?
20 Hypoxia-Inducible Transcription Factor 1 A DNA binding proteinRegulated by the O2 tensionRegulates genes that promote cell survival under hypoxic conditionsUp-reg. EPO geneUp-reg.Glycolytic enzyme genesUp-reg. AngiogenesisRespiratory controlEnergy metabolism
22 Compensating mechanisms in anemia: The release of oxygen to the tissues is increased (reduced oxygen affinity of Hb)
23 Compensating mechanisms in anemia The rate of blood circulation and cardiac output increases.An increase in plasma volume maintains total blood volume in normal or near normal ranges.Redistribution of blood flow.
24 The severity of the symptoms of anemia are related to; Different patients may have different severity of symptoms even for the same level of Hb.The severity of the symptoms of anemia are related to;The severity of anemiaThe age,CVS,pulmonary status etc of the patientThe rate of the development of anemiaGradual orRapid onset
25 Clinical symptoms and findings of anemia (1) The symptoms and findings are related to anemia itself or to the underlying disease that causes anemia .The symptoms and findings related to anemia itself will be mentioned during this course.
26 Clinical symptoms and findings of anemia (2) Fatigue, weaknessTiredness, lassitude, reduced exercise tolerenceGeneralized muscular weaknessPallor /skin or mucous membranesSkin color may change due to other reasons;eg :Blood flow of skin, subcutaneous fluid , pigment changes
27 Pallor (paleness): Look at Mucous membranes of mouth and pharynxConjunctivae,lips, nail beds,palmsCreases of the palms lose their pink colour when the Hb < 7g/dLIn pernicious anemia there is a lemon yellow pallor.Pallor + mild scleral icterus suggests hemolytic anemia.Pallor+ petechiae suggests severe bone marrow failure
28 Some other skin/mucosal changes Premature graying of hair:pern.anemiaHair loss and fragility + spooning of the nails:iron deficiencyChronic leg ulcers:Sickle cell or other hemolytic anemiaGlossitis/burning sense :Pern. anemia, iron deficiency(rare)Chelitis(angular stomatitis):iron def.Siideropenic dysphagia: iron def.Painful ulcerative mouth lesions: aplastic anemia/leukemia
29 Clinical symptoms and findings of anemia (3) Cardiovascular System(1) Palpitation and dyspnea (during activity)Angina pectorisClaudicatio intermittansMurmurs: Mid systolic (rarely diastolic) , mainly pulmonary valvular or apicalor over major peripheral arteriesor jugulary veins
30 High output state: Collapsing pulse, high pulse pressure Cardiomegaly Clinical symptoms and findings of anemia (3) Cardiovascular System(2)High output state: Collapsing pulse, high pulse pressureCardiomegalyCongestive failureIschemic ECG changes
31 Clinical symptoms and findings of anemia (4) Central nervous system HeadacheFaintnessGiddinessTinnitusDecreased concentration abilityDrowsiness,decreased muscle strengthClouding of consciousnessSymptoms are more prominent in older patientsParesthesias:Vitamin B12 deficiency (or other).
32 Clinical symptoms and findings of anemia (5) Reproductive systemMenstrual changes:Amenorrhea ,Menorrhagia(mostly a cause of anemia)Loss of libido
33 Clinical symptoms and findings of anemia (6) Gastrointestinal system(these symptoms may indicate underlying disorder that might indeed be a cause of anemia)AnorexiaFlatulenceNauseaConstipationWeight lossThese should remind GIS disease as a cause of anemia(eg:a bleeding lesion-ulcer/malignancy etc)
34 Clinical symptoms and findings of anemia (7) Ocular Fundi:Pale andsometimesHemorrhagesPapillaedema
35 Clinical symptoms and findings of anemia (8) Renal ChangesSlight proteinuriaConcentrating defectsFurther reduction of renal function in patients with previous renal impairment(Renal failure itself is a cause of anemia!!!!)Pyrexia: Due to a hypermetabolic state or other underlying disease (which may be a cause of anemia)
36 Some Other examples for history and physical examination The duration of symptoms (acute/insidious)Bleeding ? Nose/skin/urine/mens/stool etcFamily historyAnemia, gall stones and splenectomyBleeding disorderOccupation, hobbies,dietary history,alcohol or drug use,travel history etc (toxic/infectious contacts)Ask for skin and hair/nail changes
37 Some Other examples for history and physical examination Pain / mass / fever/systemic overview for an underlying diseaseRenal/endocrine/liver disease orChronic infection/malignancy/imflamatory conditionParasitisPregnanciesParesthesias ,walking difficultySternal or other bone tendernessSplenomegaly, hepatomegalyLymphadenomegaly
38 Diagnosis and investigation: Is the patient anemic?What is the type of anemia?What is the cause of anemia?
43 Megaloblastic Macrocytic Anemias Vit B12 deficiencyFolic acid deficiencyOther.
44 Non-megaloblastic Macrocytic Anemias Anemia of acute bleedingHemolytic anemiasLeukemias(esp: acute)Myelodysplastic syndromesLiver diseaseAplastic anemiaDiseases infiltrative to the bone marrowAlcoholismHypothyroidismScurvy
45 Pathogenic classification (Causes of anemia) Relative (increased plasma volume)Decreased RBC productionBlood lossAnemia due to acute bleedingIncreased RBC destruction
46 Pathogenic classification (Causes of anemia) Decreased RBC productionDecreased Hb productionDefective DNA synthesisStem cell defectsPluripotent stem cellErythroid stem cell(progenitors)Other less defined reasonsBlood lossAnemia due to acute bleedingIncreased RBC destructionRelative(increased plasma volume)
47 Decreased Hb production Iron deficiency anemiaThalassemiaSideroblastic anemiaLead poisoning
48 Defective DNA synthesis Vit B12 deficiencyFolic acid deficiencyOther.
49 Pluripotent stem cell defects Aplastic anemiaLeukemia or myelodysplastic syndromesDefective erythroid stem cellPure red cell aplasiaAnemia of chronic renal failureEndocrin disease anemiaCongenital dyserythropoetic anemias
50 Decreased RBC production due to multipl or undefined mechanisms Anemia of chronic diseasesBone marrow infiltrationAnemia due to nutritional defects
51 Anemias caused by increased RBC destruction (hemolytic anemias) Can be classified as;Hemolysis due to intracorpuscular defectsHemolysis due to extracorpuscular defectsOrHereditary hemolytic diseasesAcquired hem. diseasesIntravascular hemolysisExtravascular hemolysis etc.
53 Is the patient anemic ?RBC countHB levelHct levelVolume status
54 What is the type of anemia? History and physical exam.RBC,HB,Hct ,MCV, MCH,RDWRed cell morphology ( peripheral smear)Reticulocyte countIncresed ?Other Lab. investigations
55 Lab. investigation of anemia(1) WBC count and differentialPlatelet count and morphologyESRBiochemistry, special tests and othersBone marrow exam.(only when indicated)
56 Lab. investigation of anemia(2) Serum values ofIronTIBCFerritinBilirubinsProteins / electrophoresisLDHVit B12 and /or Folic acid(None of these tests are routine screening tests)
57 Lab. Investigation of Anemia(3) Red cell enzymesHb F,A2,Hb electrophoresisCoombs testsLiver, renal, endocrin functional testsUrinalysisHemosiderinOccult GIS bleeding / parasites etc(tests should be chosen individually-do not order routinly )
58 Investigation of a microcytic hypochromic anemia Blood FilmSerum IronSerum iron high Serum iron normal/high Serum iron lowMarrow for iron Hemoglobin studies Ferritin levelLow Normal / HighSideroblastic anemia Thalassemia İron deficiency Anemia of Abnormal Hb chronic disease
59 Bone marrow morphology hemolysis acute blood loss Investigation of a normocytic, normochromic anemiaReticulocyte countRetic. normal / low Retic. highBone marrow morphology hemolysis acute blood loss Normal AbnormalHypoplastic infiltration dysplasticSecondary anemia eg. Inflammation aplastic anemia leukemia myelodysplasialiver disease myelofibrosisRenal failure metastasesendocrine failureresponse to anemia treatment
60 Macrocytic anemia (MCV: high) Blood filmReticulocyte countRetic. High Retic. Normal/lowBone marrowNon-megaloblastic MegaloblasticAcute blood loss orHemolytic anemia normoblastic dysplastic(MDS) folate or B12 levels(Other macrocytic anemias)folate Vit B12deficiency deficiencyTreatment response