1. Anaemia Oliver Rácz, 2015

2. Repetition of physiology and biochemistry Red cell properties and function –Number, synthesis, life span, degradation Haemoglobin structure and function –Structure, oxygen affinity and its regulation, variants, degradation Iron metabolism –See trace element lecture Vitamin B 12 and folic acid

3. Definition of anaemia  Deficiency in the oxygen-carrying capacity of the blood due to diminished erythrocyte mass (THEORY)  Low red cell count, Hb, HT (PRACTICAL MEDICINE)  May be due to:  Erythrocyte loss (bleeding, haemolysis)  Decreased erythrocyte production  Bone marrow dysfunction  Low erythropoietin/high hepcidin  Iron deficiency  Vitamin B 12, folic acid deficiency

4. Indicators of anaemia MEASURED ON AUTOMATIC ANALYZERS Haemoglobin, grams of Hb/liter of whole blood (or g/dL in USA) Hematocrit, ratio between cell and plasma volume RBC = millions/microliter (= mm 3 ) of whole blood (or 10 12 /liter) MCV = Mean corpuscular volume (of 1 RBC) > 100 femtoliter Macrocytes (1 fl = 10 -15 liter) 80 – 100 femtoliter Normocytes < 80 femtoliter Microcytes MCH = Mean corpuscular Hb (norm is 20 pg/cell; pico = 10 -12 ) RDW = Red blood cell distribution width –(Standard deviation of red cell volume/mean cell volume) × 100 –Normal value is 11-15% –If elevated, suggests large variability in sizes of RBCs

5. Normal and decreased values Hb (160) Women: <120 severe <100 Men: < 135 Ht (0,45) Women: < 0,36severe < 0,30 Men: < 0,41

6. Symptoms of Anaemia ? Decreased oxygenation –Pallor –Exertional dyspnea –Dyspnea at rest –Fatigue –Decreased mental function Decreased circulating volume –Fatigue –Muscle cramps –Postural dizziness –Syncope Disease/condition specific, e.g. –Jaundice –Other FOR LONG TIME MOSTLY NOTHING, HIDDEN BEHIND THE BASIC DISEASE OR COMPENSATED NO CYANOSIS

7. Special considerations Acute Bleeding Drop in Hb & Ht may not be shown until some time after acute blood loss (even though patient may be hypotensive) WHY??? Later reticulocytosis Pregnancy In third trimester, RBC and plasma volume are expanded but there is a bigger expansion of plasma volume than of red cell mass. Lab values show reductions in Hb, Ht, and RBC count, often to pathological levels, but according to RBC mass this is a haemodilution and not anaemia. BUT! Real anaemia is also frequent in gravidity Volume Depletion Patient’s who are severely volume depleted may have physiological Ht results and do not show anaemic values until rehydrated !!!

8. RBC Life Cycle In the bone marrow, erythropoietin enhances the growth of differentiation of burst forming units- erythroid (BFU-E) and colony forming units-erythroid (CFU-E) into reticulocytes. Reticulocytes spend ≈ 3 days maturing in the marrow, and ≈ 1 day maturing in the peripheral blood (reticulocyte count ≈ 0,5% of RBCs). After blood loss or haemolysis increased % of reticulocytes if bone marrow is OK Mature RBCs circulate in the peripheral blood for 120 days. Under steady state conditions, the rate of RBC production equals the rate of RBC loss. (Around 1/120 ≈ 0,8 % of cells/day. Iron recycling!)

9. Erythrocyte loss - bleeding Acute/Haemodynamically significant (not a haematological problem in general practice) Injury (shock!) Gastrointestinal (ulcus, oesophagus, polyps…) Retroperitoneal Hemophilia and other coagulation disorders Chronic kidney, abnormal menstrual cycle, ulcer disease in the past If not treated it can transform to iron deficiency anaemia

10. Haemolysis Osmotic – only in test tube (distilled water) Mechanical – artificial heart valves (past) Streptococcus haemolyticus ? ABO or Rh incompatibility Malaria, Babesiosis, and many others Autoimmune, toxic Inherited – Hb S and other Hbpathies, thalassemia, membranopathies, enzymopathies

11. Some forms of haemolytic anaemia Hereditary spherocytosis Glucose-6-phosphate dehydrogenase (G6PD) Deficiency Most common enzyme defect in erythrocytes X-linked Brisk haemolysis when patients exposed to oxidative stress from drugs, infections or toxins. Thrombotic Thrombocytopenic Purpura (TTP) Thrombocytopenia and microangiopathic haemolytic Anaemia, fever, renal insufficiency, neurologic symptoms Schistocytes on smear Haemolytic Uremic Syndrome Thrombocytopenia, Microangiopathic haemolytic Anaemia, renal insufficiency Autoimmune Haemolytic Anaemia –Warm-antibody mediated IgG antibody binds to erythrocyte surface most common Diagnosed by POSITIVE Coomb’s Test (detectgs IgG or complement on the cell surgace) Can be caused drugs Treated with corticosteroids or splenectomy if refractory –Cold agglutinin Disease IgM antibodies bind to erythrocyte surface Does not respond to corticosteroids, but usually mild. Infections –Malaria –Babesiosis –Sepsis Trauma –Includes some snake, insect bites

12. BABESIOSIS

13. Anaemia due to Low erythropoietin Kidney Disease (including diabetic nephropathy) –Normocytic –Low reticulocyte count –Target Hb for patients on dialysis: 110 -120 g/L Administer erythropoietin Good iron stores should be maintained –Peripheral smear in uraemic patients frequently show echinocytes

14. Aplastic anaemia (bone marrow dysfunction ) Radiation Toxic substances Drug side effects Leukaemias

15. Iron deficiency Iron Deficiency –Can result from: –Pregnancy/lactation –Normal growth –Blood loss –Intravascular haemolysis –Gastric bypass –Malabsorption »Iron is absorbed in proximal small bowel; decreased abosrption in celiac disease, inflammatory bowel disease –May manifest as „pica“ Tendency to eat ice, clay, starch, crunchy materials –May have pallor, koilonychia of the nails, beeturia –Peripheral smear shows microcytic, hypochromic red cells with marked anisopoikilocytosis.

16. Koilonychia

17. Laboratory findings Serum Iron LOW Total Iron Binding Capacity (TIBC) HIGH Soluble transferrin receptors HIGH Serum Ferritin LOW Can be “falsely”normal in inflammatory states

18. Cobalamin deficiency Macrocytic Anaemia (megaloblastic, in the past “pernicious” Lab Values –Cobalamin level < 200 pg/mL –Elevated serum methylmalonic acid –Elevated serum homocysteine Vit B12 binds to intrinsic factor in the small bowel in order to be absorbed – the pernicious form was an autoimmune condition blocking intrinsic factor Vit. B12 is needed for DNA synthesis –The anaemia is only the tip of an “iceberg” Deficiency can result in cardiac and neuropsychiatric symptoms –Spastic ataxia, psychosis, loss of vibratory sense, dementia –Dilated cardiomyiopathy Smear shows macrocytosis and hypersegmentation of polymorphonuclear cells, with possible basophilic stippling.

19. Folate deficiency –Macrocytic Anaemia and a lot of other consequences (spina bifida) –Lab Values –Low folate –Increased serum homocystine –NORMAL methylmalonic acid –Often occurs with decreased oral intake, increased utilization, or impaired absorption of folate –Folate is normally absorbed in duodenum and proximal jejunum – deficiency found in celiac disease, regional enteritis, amyloidosis –Deficiency frequently in alcoholics, because enzyme required for deglutamation of folate is inhibited by alcohol. –Deficiency often found in pregnant women, persons with desquamating skin disorders, patients with sickle cell Anaemia (and other conditions associated with rapid cell division and turnover) –Smear shows macrocytosis with hypersegmented neutrophils –BE CAREFUL WITH FOLATE OVERDOSE

20. Anaemia of „chronic disease“ Usually normocytic, normochromic (but can become hypochromic, microcytic over time) Occurs in people with inflammatory conditions such as collage vascular disease, malignancy or chronic infections Iron replacement is not necessary May benefit from erythropoietin supplementation. HEPCIDIN BLOCKS RESORBTION – IRON IS A GROWTH FACTOR OF BACTERIA

21. The anaemia of chronic disease the hepcidin story Hepcidin – a 25 aminoacid peptide from liver discovered in 2001 Ferroportin – a very specific transmembrane iron export system Hepcidin injection: Serum Fe decrease by blocking the Fe export from cells storing iron Hepcidin deficiency: High serum Fe – iron overload. Inflammation – hepcidin elevated to block iron for microbes

22. Normal peripheral „smear“

23. Echinocytes (“burr cells”)

24. Iron deficiency anaemia MICROCYTIC

25. Megaloblasts and hypersegmented neutrophil

26. Spherocytosis

27. TTP / HUS – microangiopathic haemolysis with schistocytes

28. Malaria

29. Babesiosis

30. Sickle Cell Anaemia

31. Lab Analysis in Haemolytic Anaemia Increased indirect bilirubin Increased LDH Increased reticulocyte count Normal reticulocyte count is 0.5 to 1.5% > 3% is sign of increased reticulocyte production, suggestive of haemolysis Reduced or absent haptoglobin < 25 mg /dL suggests haemolysis Haptoglobin binds to free haemoglobin released after haemolysis

32. Evaluating the patient with Anaemia Any history of medical problems that could cause Anaemia? –Sickle cell Disease? –Thalassemia? –Renal Disease? –Hereditary Spherocytosis?

33. Evaluating the Patient with Anaemia Are the other cell lines also low? –If WBC and platelets are both low, consider APLASTIC AnaemIA! –Check medication list »NSAIDS (phenylbutazone), Sulfonamides, Acyclovir, Gancyclovir, chloramphenicol, anti-epileptics (phenytoin, carbamazepine, valproic acid), nifedipine »Check parvovirus B19 IgG, IgM »Consider hepatitis viruses, HIV –If Platelets are low consider TTP or HUS! –Must check smear for schistocytes (for sign of microangiopathic haemolytic Anaemia) –If renal failure, E. Coli O157:H7 exposure → HUS –If renal failure, neurologic changes, fever → TTP

34. Evaluating the Patient with Anaemia Is the patient bleeding?! –Any bright red blood per rectum (hematochezia) or black tarry stools (melena)? Check stool guaiac, may consider sigmoidoscopy or colonoscopy –Any abdominal pain, or recent faemoral vein/artery manipulation? Consider retroperitoneal hematoma

35. Evaluating the Patient with Anaemia If other cell lines are okay, what is the MCV and RDW? –If MCV < 80, then it’s a microcytic Anaemia Check serum iron, ferritin, TIBC –If iron-deficiency Anaemia, look for sources of chronic bleeding – heavy menstrual bleeding, consider colonoscopy Consider lead poisoning, copper deficiency, thalassemias –If MCV 80-100, then it’s a normocytic Anaemia Any inflammatory conditions that could result in Anaemia of chronic disease? Consider checking indirect bili, LDH, haptoglobin, reticulocyte count –If MCV > 100, then it’s a macrocytic Anaemia Check Vit. B 12, folate Consider liver disease, alcoholism, myelodysplastic syndrome Check medications: hydoxyurea, AZT, methotrexate

36. Evaluating the Patient with Anaemia Any jaundice, elevated bilirubin, suspicious for haemolysis? –Check for increased indirect bilirubin, increased LDH, decreased haptoglobin, increased reticulocyte count –Any sign of infection? Malaria? Babesiosis? –Is Coombs test positive? –If yes, may be warm antibody haemolytic Anaemia; Consider drug as cause