1. Anaemia that isn’t due to iron deficiency
Dr Annette Nicolle
Consultant Haematologist
Queen Elizabeth Hospital/ Sunderland Royal Hospital

2. Objectives Look at the wide differential diagnosis of anaemia
Discuss some clinical cases
Look at laboratory pitfalls, and questions commonly asked

3. Thought for the day
“Many of us talk in our sleep. The distinctive achievement of lecturers is to talk in other people’s sleep”
Raymond Tallis
American Author

4. Laboratory results suggestive of anaemia
Hb<11.5 g/dl for females
Hb<13.0 g/dl for males
Hb<11.0 g/dl for F with rheumatoid arthritis
Hb<11.0 g/dl for M with rheumatoid arthritis
NB – take into account previous Hb level

5. Taught at med school – not terribly helpful in cases that aren’t straightforward
The Med School Version

6. How many causes of anaemia can you come up with?
Iron deficiency
EXERCISE
How many causes of anaemia can you come up with?
I’ve started you off
Bone Marrow
Blood vessels
Intravascular Haemolysis
Antibodies
I give this one to the SpRs I teach – you can probably do better
Liver and spleen
Causes of Anaemia
“Pooling”

7. Anaemia of chronic disease
Shortage of raw materials
External insults
Renal system
Reduced Erythropoeitin
Bone Marrow
“Abnormal Genes”
Blood Loss
Intrinsic Marrow Problems
Blood vessels
Rapid turnover
Intravascular Haemolysis
Antibodies
I use this to try to encourage the junior docs to think laterally….
Mechanical damage
Liver and spleen
Causes of Anaemia
Extravascular Haemolysis
“Pooling”

8. Case 1 See envelope set 1 Personnel:
Patient: Mike Tucker – 56 years old
GP:
BMS in the lab (Multitalented)
“Greek Chorus” – everybody else

9. The rules The consultation exercise is run by the GP and patient
The BMS in the lab can only answer questions – he/she cannot volunteer information
The GP can refer to the Greek chorus to seek opinions at any stage by calling a time-out

10. Case 1 Summary Polymyalgia Rheumatica Key features
History – limb girdle stiffness, extreme tiredness
Microcytic anaemia
High ESR
Inflammatory features – high platelets, raised immunoglobulins
Retics low – indicate reduced marrow output
Anaemia of Chronic disease

11. Microcytic anaemia MCV<80 Iron deficiency Reduced Iron availability
Anaemia of chronic disease
Small print:
Reduced Haem synthesis
Lead poisoning
Reduced globin production
Thalassaemia
Other haemoglobinopathies

12. Case 2
Helen Archer - first pregnancy antenatal screening bloods:
WBC 7.2
Hb 12.9
MCV (80-102)
MCH 19.2 (27-32)
Plt 251
Any thoughts?

13. Case 2 Ferritin 73 Next step? Haemoglobinopathy screen Significance?
HbA/A
HbA2 4.0%
Consistent with Beta thal trait
Significance?

14. Case 3 Envelope set 2 Personnel: Patient: Linda Snell 63 years old GP:
BMS in the lab (Multitalented)
“Greek Chorus” – everybody else
Same rules apply

15. Case 3 discussion
Macrocytic anaemia which had a wide differential diagnosis from history
Insidious onset
Family history
Pancytopenia
Note other clinical features of pernicious anaemia– not often present, but very useful when they are
However – need sense of perspective when investigating macrocytic anaemia

16. Macrocytic Anaemia Abnormal RBC maturation Abnormal DNA Synthesis
MCV>100
Abnormal RBC maturation
DRUGS
Alcohol abuse
Liver disease
MDS, Leukaemia
Hypothyroidism
Abnormal DNA Synthesis
B12 and Folate deficiency
Mild macrocytosis:
Reticulocytosis

17. Aetiology of macrocytosis in 300 patients with an MCV >99fl
Prevalence (%)
Drugs (cytotoxics, anticonvulsants, anti-retrovirals ) 37
Alcohol (+/- liver disease) 26
Reticulocytosis (haemolysis or bleeding) 8
Vit B12 or folate deficiency 6
Non-alcoholic liver disease
Primary bone marrow disorders (eg MDS, AML)
Hypothyroidism
0.6
BMJ 2009;338:1644

18. Normocytic Anaemia Early iron deficiency Acute blood loss
Anaemia of chronic disease (may be microcytic)
Renal Failure
Cancer
Haemolysis (or may be macrocytic)
Bone marrow suppression/ disorders
Combined haematinic deficiencies

19. Renal Anaemia GFR <60 = CKD possible cause of anaemia
GFR <30 (<45 in diabetics) = CKD is likely to be the cause
Should not be assessed until iron deficiency corrected
Can measure serum erythropoietin in clinic

20. Anaemia of Chronic Disease
Protective mechanism to reduce availability of iron where it may have a detrimental effect
Reduced availability of essential nutrient for bacteria and tumour cells
Anaemia limits oxygen transport which affects rapidly proliferating tissues/ organisms
Reduced serum iron also increases immune response

21. Anaemia of Chronic Disease
Reduced erythropoietin responsiveness and production
Reduced transferrin synthesis
Reduced Fe mobilisation from macrophages
Low serum iron despite adequate tissue stores
Reduced iron re-utilization in erythropoiesis
Raised serum ferritin
Reticulocytopenia

22. Lab pitfalls

23. Ferritin
SERUM FERRITIN is now a standard diagnostic test for Iron deficiency anaemia
only iron deficiency will give a low result.
A value <15 μg/L is diagnostic of IDA.

24. Ferritin
Iron deficiency anaemia can occur with a normal or high ferritin:
Liver dysfunction: ferritin is released when hepatocytes are damaged
Increased haem turnover: haemolysis and trauma (including surgery)
Inflammatory lesions: malignancy, infection and inflammation

25. SERUM IRON and TOTAL IRON BINDING CAPACITY (TIBC)
In iron deficiency the serum iron is low (<10 μmol/L) and the TIBC is usually raised (>70 μmol/L).
Erythropoiesis is iron-deficient when the transferrin saturation (SI  TIBC x 100%) falls below 15%.
TIBC can be affected by nutritional status

26. Soluble transferrin receptor ratio
Available in some hospitals in the region
Serum transferrin receptor-ferritin ratio
better for distinguishing between iron deficiency and anaemia of chronic disease
Ratio <1 suggests Anaemia of chronic disease and >2 iron deficiency
STR derived from bone marrow cells, inversely increased in iron deficiency 26

27. Type of anaemia
Blood film
Ferritin
Iron
TIBC
sTfR –ferritin ratio
Anaemia of chronic disease
Normocytic, normochromic
Normal or raised
Low
<1
Early Iron Deficiency
Hypochromic, mild anisocytosis
Normal or Low
Raised
>2

29. Problems with B12 levels
Serum B12 is not a good indicator of total body stores
Low serum levels without a true deficiency
OCP, pregnancy, iron deficiency, atrophic gastritis
False normal B12 levels
Myeloproliferative disease, hepatoma, acute liver disease, high titre IF Abs
Have to use the result in clinical context
Manufacturers warning that results should be interpreted in clinical context
High titre intrinsic factor abs can give false normal B12 levels

30. Problems setting the B12 range…
B12 assay curve
Setting lower end of range is difficult
Normal distribution curve
-applies to most lab tests

31. ALGORITHM FOR REPORTING B12 AND FOLATE RESULTS
B12 > 197 pg/ml. No need for comment
pg/ml. Borderline low B12 - probably not clinically significant
pg/ml - Low B12. Not macrocytic:
Check IFA: if positive, treat as PA
If negative, consider oral Rx (unless gastric or ileal resection) and check response

32. ALGORITHM FOR REPORTING B12 AND FOLATE RESULTS
pg/ml - Low B12.
If macrocytic: Advise trial of IM B12. If response, continue as for PA
< 100pg/ml - Low B12.
Advise IM B12 therapy, check response.
Diagnosis: ? PA (check IFA), ? Crohn’s,
? gastric or ileal resection

33. Problems with folate levels
(Labs do either serum or red cell folate)
False normal serum folate -folate deficient patient who has had a few folic acid tablets
False low serum folate – recent alcohol
False normal red cell folate – recent transfusion
False low red cell folate – primary B12 deficiency

34. ALGORITHM FOR REPORTING B12 AND FOLATE RESULTS
Folate > 4.0ng/ml - no need for comment
ng/ml - no need for treatment unless macrocytic and B12 normal, in which case advise trial of treatment and check response
< 2.2ng/ml – trial of treatment
? dietary deficiency.
Consider coeliac or other small bowel disorder or resection, anti-folate medication

35. Reticulocytes
The reticulocyte count (retics) reflects the bone marrow's response to anaemia.
A low retic count indicates bone marrow hypoplasia.
Reticulocytosis (high retic count) indicates the marrow is still responding

37. Case 4 – Kate Aldridge 1 week history of flu-like illness
Fainted a couple of times
Now dizzy every time she stands up
WBC 7.6
Hb 4.1
Plt 282
Further investigations?

38. Further investigations
MCV 80
Iron 9.0
Bilirubin 10
Retics 10
LDH 200
Normal renal function
Now what do you do?

39. Blood film
Normal film
Patient’s film

40. More results Spherocytes on film
No evidence of malignancy/ marrow infiltration
How does that fit with your differential diagnoses?
Other tests?

41. Other tests Parvovirus serology Confirm Hereditary spherocytosis
Family history?

42. “Aplastic” crisis Parvovirus B19 IgM positive Treatment 24/12/08
transfused as very symptomatic
Folic acid, iron (tests showed iron 9.0)
24/12/08
25/12/08
26/12/08
29/12/08 Hb
4.1
8.3
7.8
10.1
Retics
10.3
27.2
106
425

44. Lab evidence of haemolysis
Increased reticulocyte count
Increased bilirubin
DAT (Direct Antibody test) – Coombs test
low serum haptoglobin
Increased LDH
Film appearances
Haemoglobinemia/ Haemoglobinuria
Haemosiderinuria
NB – Red cell autoantibodies are common 3% over 70s have a positive DAT – it does not necessarily cause haemolysis
Fancy tests requested by haematology – osmotic fragility etc

45. Marrow Problems Anaemia may be secondary to Marrow infiltration
Cancer, Leukaemia, Lymphoma, inflammatory conditions, infections, fibrosis,
Ineffective/ reduced production
MDS, Aplastic anaemia, Inflammatory conditions, infections, DRUGS, anorexia
Call your friendly local Haematologist…….

46. Case 5: Adam Macy Blood film – What is causing his anaemia

47. Summary
Useful points
Remember anaemia of chronic disease – infection/ inflammation
Renal Impairment
Reticulocyte count – tells you marrow function
Combined haematinic deficiencies - can mask each other
Historical results are useful, and rate of change
Lab tests are not infallible

48. Any Questions?
Thankyou

49. Causes of Anaemia Bone Marrow Blood vessels Liver and spleen
Iron deficiency
Bone Marrow
Blood vessels
Intravascular Haemolysis
Antibodies
Slide for “brainstorm”
Liver and spleen
Causes of Anaemia
“Pooling”

50. Other abnormal Haematology results
When to refer and when to relax…

51. Haematology laboratory results
Haemoglobin (erythrocytosis)
Hb > 18.5, Hct >0.55 (M), Hb > 16.5, Hct > 0.50 (F)
If only Hb raised, consider hypoxia, smoking, alcohol, dehydration and correct if possible
If erythrocytosis persists, consider referral
If accompanied by raised neutrophils and/or platelets, check if itching, sweating, splenic discomfort, gout, etc.
Refer to haematology if PRV/MPD seems likely (JAK2, etc)

52. Haematology laboratory results
White cells
Neutrophils < 1.5
Consider whether secondary to medication, auto-immune disorder, hypersplenism, race or viral infection
If remains unexplained, refer to haematology (possible need for bone marrow biopsy)
Low lymphocyte or monocyte count - no specific referral criteria, but consider HIV if lymphocytes reduced, with appropriate clinical history

53. Haematology laboratory results
White cells
Neutrophils > 10.0, persisting for at least one month
Exclude latent infection or inflammation, medication (esp. steroids)
If accompanied by raised eosinophils and/or basophils, consider referral (? CML)
If accompanied by monocytosis, consider referral (? CMMoL)
If isolated neutrophilia but unexplained upward trend, consider referral

54. Haematology laboratory results
White cells
Lymphocytes > 10.0, persistent for at least one month
Consider infection, esp. IM or pertussis
Laboratory will arrange cell markers when appropriate, and may then advise referral
Monocytes >2.0, persistent for at least one month
Consider chronic infection, e.g. TB
If accompanied by anaemia and/or neutropenia, neutrophilia or thromoboctyopenia, refer to haematology

55. Haematology laboratory results
Platelets
Platelets >600, persistent for at least one month
Exclude blood loss, chronic infection or inflammation, prescribe low dose aspirin if no contra-indication
If no obvious cause, refer to haematology
Platelets do not refer, monitor to detect trend
Platelets consider medication, auto-immune disorder, hypersplenism. Do not refer to haematology unless symptomatic
Platelets <50 - consider referral to haematology unless cause is clear and/or more relevant to another speciality

56. Haematology laboratory results
Coagulation tests
Consider referral to haematology if patient symptomatic (bruising or bleeding) and abnormalities not secondary to anticoagulation, dietary deficiency or known liver disease:
PT > 18 secs
APTT > 40 secs - N.B. exclude lupus “anticoagulant”
Fibrinogen <1.0g/l
Any combination of abnormal coagulation results accompanied by relevant symptoms