1. Clinical Pathology Kristin Canga, RVT
Anemia
Clinical Pathology
Kristin Canga, RVT

2. Reading Assignment Page 68 – Lab Pro book
‘Clinical Application’ box (Iron Deficiency Anemia) on pg. 12 of A&P book
Pages 55 – 57 Lab Pro book (about counting reticulocytes)

3. Anemia
Literally means “no blood” but clinically means an ______________ ____________________below normal in any of the following values:
________________________________________
In other words, anemia is a condition of reduced oxygen carrying capacity of RBCs
Rate of RBC ______________________ = decreased
Rate of RBC ______________________ = increased

4. Classification of Anemia
Classification is to aid in discovering the _______________ and to help guide __________________.
Remember: Anemia is not a __________________, but a sign of an underlying health concern.
Anemia may be considered _____________ or __________ and is generally classified in one of two different ways:
Classification by RBC ________ and ____ concentration
a. RBC ____________________ (MCV, MCHC)
Classification according to bone marrow response
________________________________

5. Aiding in Classification of Anemia
A thorough ___________ must be obtained.
This helps the doctor know: what the patient has been ____________ /____________, where they have been, how long they have been suffering, and possibly _________ the anemia has occurred.
A physical exam should be completed.
Put your ____________ on the animal!
Look for _____________, _____________, _____________, active bleeding, elevated heart/respiratory rates, etc…
A complete _____________evaluation is a MUST.
HBC, toxins, iron deficiency, post-operative, parasites, etc….
Lab tests:

6. PATIENT HISTORY 1. __________________________of clinical signs
______________ onset suggests acute _________________ or ______________
______________ onset suggests chronic ______________ or bone marrow depression
2. Evidence of blood loss
______________
Blood in ______________
Melena = blood in stool
Hemoptysis = blood originating in lungs being expelled through nose, or coughing it up.

7. PATIENT HISTORY 3. ____________________________
4. Existence of an underlying condition or prior illness
____________________________
5. Exposure to drugs
- human ______________ , ______________
6. Exposure to toxic ______________ in the ______________
- ______________ , poisonous _________, ______________

8. PHYSICAL EXAMINTION ______________ Character of ___________________:
Suspect: infection, leukemia, hemorrhage, or hemolysis
Character of ___________________:
______________ – liver disease or hemolysis
______________ + ______________ = hemolysis
______________ - hypoxia
______________ or ______________ = platelet or vascular defect
Ecchymoses = larger than petechia.

9. Petechia

10. Ecchymosis

11. PHYSICAL EXAMINATION 3. Palpation
______________
4. ______________ signs of underlying disease
5. External wounds

12. LABORATORY EVALUATION
Initial laboratory tests to evaluate the anemic patient include (but not limited to):
______________ (and color of supernatent plasma)
Total ______________ protein
Examination of ______________ and ____________________________
Total ______________ count
______________ estimation
______________ concentration
Total ______________ count
______________ **
______________ evaluation **
** are the two ways to classify anemia.

13. PCV: Test yourself  What is it measuring? Normal ranges for dogs?
Normal ranges for cats
Plasma (supernatent) colors?

14. Plasma Protein What is it measuring? How is it measured?
What is normal range for dogs and cats?

15. How Many Cells should you have?
As a rule, the following values should be considered:
RBC total numbers should be in the ______________ .
(106/μL)
Plt total numbers should be in the ______________ of ______________ . (200,000 – 500,000/μL)
WBC total numbers should be in the ______________ to ____________________________ . (6,000 – 17,000/μL)
Neutrophils: 60 – 77%
Lymphocytes: 12 – 30%
Monocytes: 3 – 10%
Eosinophils: 2 – 10%
Basophils: rare (<2%)
In dogs and cats

16. Blood Film Evaluation and WBC Differential
What area are you evaluating?
How are cells arranged?
Are RBCs normal?
How many WBCs are counted?
How many fields are counted for plt. estimation?
What is calculation for plt. estimation?
CAN look at entire slide on 10x and 40x to see how cells are appear. Following that, move to 100x and monolayer

17. Total WBC Count
Overall count should be in ______________ to ____________________________ . (6,000-17,000)
Total count calculated by machine
Manual hemacytometer is rare in clinic and diluent is no longer available.
Increased WBCs = ______________
Decreased WBCs = ______________
Diluent would lyse the RBCs and allow only WBCs to remain.

18. Hemoglobin Calculation
Done by machine.
Aids us in calculating average ______________ of RBCs (_______)
Aids us in calculating average ______ concentration within RBCs (_______)
Can aid in calculating average ______________ of Hb within average RBC. (_______)
*** MCH is LEAST accurate***
MCH is least accurate because it uses Hb and RBC count instead of PCV.

19. Classifying Anemia by RBC indices
MCV: ____________________________
MCHC: ____________________________
MCH: ____________________________

20. Rules of Thumb (ROTs): Hb concentration is ~_______ of PCV (in g/dL)
Total RBCs are ~_______ of PCV (in millions)

21. Classification by RBC Indicies
Recall that MCV (mean corpuscular volume) describes the average volume of the individual RBC
Normal MCV = _____________________
Increased MCV = _____________________
Decreased MCV = _____________________
FORMULA: (PCV / Total RBC) X 10 = MCV (femtoliters)
Normal MCV = canine: 60 – 77 fl.
feline: 40 – 55 fl.

22. Let’s do the math: The MCV of a patient with a PCV of 12% is:
Step 1: Recall the formula:
(_______/ ______________) X 10 = MCV (femtoliters)
Step 2: Remember the ROT
total RBC ≅ _______ PCV so:
______________ = ______________
Step 3: plug in the numbers
___________________________________
Is this normal for k9/fel?
How would you classify this RBC?
Normal for k9, not for feline. Canine = normocytic, Feline = Macrocytic

23. Possible Causes of Abnormal MCV
Possible causes of Increased MCV:
Increased _____________________activity = #1
Reticulocytosis
Congenital (___________&_________________)
Cats with _______ (+/- anemia)
Possible causes of Decreased MCV:
______________ deficiency = #1
Congenital disorder (_______and ______________)
Polycythemia can also cause

24. Classification by RBC Indicies
MCHC (mean corpuscular hemoglobin concentration):
Describes the ratio of the _______of hemoglobin to the ______________in which it is contained (concentration of hemoglobin in the avg. RBC)
Normal MCHC = ______________
Decreased MCHC = ______________
High MCHCs = artifact WHY???

25. Formula (______ / ______) X ______= MCHC (g/dL)
Normal MCHC = canine: ______________g/dL
feline: ______________g/dL
Remember the ROTs?
If you calculate MCHC by estimating Hb, the values will always come out the same.
Lets do the math!

26. Using the ROT The MCHC of a patient with a PCV of 33% is:
Step 1: Recall the formula
(_______ / _______) X _______= MCHC (g/dL)
Step 2: Remember the ROT
Hb ≅ _______ of PCV so:
_______= _______
Step 3: Plug in the numbers
__________________________________________

27. Using actual numbers The patient’s Hb is 9g/dL, and their PCV is 30%
Formula: (_______/_______) x _______
SO: _______________________=_____g/dL
Is this normal for k9? Fel?
How would it classify the RBC?
Not normal for either, both would be Hypochromic

28. Low MCHC usually results from:
Severe _______deficiency
Marked, regenerative anemia
____________________________RBCs that do not yet have their full complement of Hb.
MCHC increase:
Presence of ______________, ______________, and ___________ can interfere with tests and ______________increase MCHC
True _____________________anemia cannot exist; the erythrocyte cannot be oversaturated with ______.

29. Morphologic Classification of Anemia by RBC Indicies
MCHC normal
MCHC decreased
MCV normal
Normocytic
Normochromic
Hypochromic
MCV increased
Macrocytic
MCV decreased
Microcytic
Hyprochromic

30. Normocytic ; Normochromic
Macrocytic Microcytic
Hyperchromic Hypochromic

31. Calculating MCH
You will need to know HOW to do this for VTNE, even though it is the _______accurate of the indices.
Calculates the average _______of Hb contained in average RBC.
(_______/_______) x _______= MCH in picograms (pg)
Normal ranges:
K9: _______pg
Fel: _______pg

32. Let’s do the Math The MCH of a patient with a PCV of 54% is:
Step 1: Remember the formula
(_______/_______) x _______= MCH
Step 2: Remember the ROT
Hb ≅ _______ PCV and RBCs ≅_______ PCV
_______ = _______ and _______ = _______
Step 3
Plug in the numbers:
_____________________pg

33. Classification of Anemia According to Bone Marrow Response
Most pertinent of anemia classification
Distinguishes between _____________________and _____________________ anemia

34. Classification Based on Bone Marrow Response
Regenerative anemia
Characterized by evidence of increased ______________ and delivery of new erythrocytes into ______________ (usually within 2-4 days).
Usually suggests bone marrow is responding appropriately to either:
_____________________ (acute or chronic; internal or external) or
_____________________ (intravascular or extravascular)
Involves determining whether absolute _____________________ numbers are increased in the blood.

35. Classification According to Bone Marrow Response
Nonregenerative anemia
Lack of circulating ______________ RBCs in the face of _______ indicates a nonregenerative anemia and likely results from bone marrow ______________.
Either reduced erythropoiesis or defective erythropoiesis
No response evident in ______________blood. (usually ______________; ______________)
_____________________examination may be helpful with the diagnosis.

36. Regenerative Anemia Blood Loss Anemia
Acute _____________________– relatively large amount of blood lost in a brief period. (______________; ______________)
PCV initially = ______________
Reticulocytes should appear ~_______ hrs (peak within ~ 1 week)
Causes:
______________
Internal or external
Accidental or surgical
______________disorders
Bleeding ______________ or large ______________
Normal PCV initially because fluid and cells lost in proportion. Takes time for spleen to release immature cells.

37. Regenerative Anemia
Chronic blood loss (_______Deficiency Anemia) – lost ______________and ______________for a period of time.
a. Parasites
______________, _______, blood-sucking _______, coccidia spp.
b. GI ulcers and neoplasms
c. Inflammatory bowel disease
d. Overuse of ______________donors
Note: neonates can become iron deficient due to lack of adequate dietary _______ intake.

38. Iron Deficiency Anemia
Body compensates for anemia by lowering _______-_______ affinity, preferential shunting of blood to vital _______, increased ______________output (tachycardia), and increased levels of _____________________.
With decreasing _______ stores, erythropoiesis is limited and RBC’s become ______________and deficient in _______ (______________and _____________________).
Hallmark of iron deficiency anemia is decreased _______.
Keratocytes & schistocytes
Clinical signs include: lethargy, weakness, decrease exercise tolerance, anorexia, lack of grooming, mild systolic murmur.

39. Regenerative Anemia a. Immune mediated ______________________
2. _____________________– Increased rate of erythrocyte ______________________within the body
a. Immune mediated
______________________
Incompatable ______________________
b. Blood parasites
Hemotrophic Mycoplasmas
______________________spp.

40. Cytauxzoon felis inclusions
Look like a ring inside the cell.

41. Regenerative Anemia c. Heinz body anemia Plants Drugs or Chemicals
Onions*, garlic
______________________
Drugs or Chemicals
(______________________, Propylene glycol, Zinc, Copper, Methylene blue, Naphthalene, ______________________, phenothiazine, benzocaine
Diseases (in cats)
Diabetes mellitus
Hyperthyroidism
Lymphoma
Propylene glycol and Ethelene glycol are both ingredients in antifreeze. Propylene = green, Ethelene = blue

42. Regenerative Anemia d. ______________________ induced hemolysis
RBC glycolysis is inhibited by hypophosphatemia; no glycolysis = no ATP (energy) for RBC = cell lysis
Diabetic cats
Enteral alimentation
Phosphate = required for bone density. Also binds with ATP to create energy for the cell.

43. Regenerative Anemia e. Other Microorganisms
______________________
Clostridium spp. and Leptospirosis (cattle)
f. ______________________intoxication (usually calves)
can also occur as a result of inappropriate administration of ______________________ therapy.
g. ______________________ RBC defects
______________________ (shortened RBC lifespan)
RBC membrane transport defects
Chronic intermittent hemolytic anemia (Abyssinian and Somali cats)
H2O intoxication may occur in claves given ad lib access to H20 for the first time. Excessive intake without appropriate renal response causes intravascular hemolysis due to dilution of the blood. C/s on set within 1 hour and can include: neuro, resp distress, bloat, hemoglobinuria, and death.

44. Regenerative Anemia h. Miscellaneous
Metabolic disorders (anything that interferes with synthesis of ______________________, RBC, etc. or anything that interferes with ______________________processes of RBC)

45. Nonregenerative Anemia
Most nonregenerative anemias are ______________________
Further subclassified based on whether ______________________ (neutrophil production) and ______________________ (platelet production) are also affected.
Animals with nonregenerative anemia in conjunction with ______________________ (neutropenia and thrombocytopenia) usually have ____________ cell injury.
Possible causes: drugs, toxins, viruses (FeLV), radiation, and immune-mediated stem cell injury.

46. Nonregenerative Anemia
Reduced ______________________
Chronic ______________________ disease
Endocrine deficiencies
Inflammation and neoplasia
Cytotoxic damage to the ______________________
Estrogen toxicity
Cytotoxic cancer drug therapy
Chlormphenicol (cats)
Radiation
Other drugs

47. Nonregenerative Anemia
e. Infectious agents
FeLV
______________________ spp.
______________________
f. Immune-mediated
Continued treatment with recombinant erythropoietin
______________________ aplastic anemia
g. Congenital/inherited
h. ______________________ and other ______________________ disorders

48. Nonregenerative Anemia
2. Defective ______________________
Disorders of ___________ synthesis
Iron, copper, and pyridoxine deficiencies; lead toxicity; drugs
Folate and ____________ deficiencies
Abnormal ______________________
can be inherited, drug-induced or idiopathic
Pyridoxine = Vit B6
Cobalimin = Vit B12

49. Reticulocyte Count
Probably the most important diagnostic tool used in the evaluation of anemia.
Fewer _____________ erythrocytes are present in anemic animal; more ______________________are present.
Expressed as a _____ of the RBCs present.
The lifespan of a normal RBC is about 110 days (dogs) and 68 days (cats).
Bone marrow should replace ___ % of the RBCs daily so the reticulocyte count should be _____-______%.

50. Reticulocyte Count
Gently mix 4 drops of blood with 4 drops of new methylene blue in a test tube.
Let mixture stand for 15 minutes
Use 1 drop of mixture to prepare a diagnostic blood film and observe under high-power, oil-immersion field.
Count 1,000 RBCs while separately keeping track of the number of reticulocytes (only aggregate form)
Divide the reticulocyte number by 1,000 and convert to a percentage. (Multiply by 100)
We will be using two blood smears and counting 500 cells on each slide to tally the 1000 cells.

51. Example Reticulocyte count
If you see 10 retics on slide 1 and 15 on slide 2, your total is 25 reticulocytes.
25/1000 = x 100 = 2.5%

52. Corrected Reticulocyte Count
Performed to take in account the reduced number of circulating RBC’s in the anemic animal.
Called CRC or Corrected Reticulocyte Count
FORMULA:
Observed retics % x PCV / normal PCV
(Normal PCV: use 45% for dogs and 35% for cats)
Ex: 2.5% X 30% / 45% = 1.67%
Note: This calculation is necessary because the reticulocyte count is misleading in anemic patients. The problem occurs because the reticulocyte count is not really a count but rather a percentage: it reports the number of reticulocytes as a percentage of the number of red blood cells. In anemia, the patient's red blood cells are reduced, creating an elevated reticulocyte count.