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What is Anamia
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A reduction the Hb concentration below normal ranges (M: <13g/dL / F: <12g/dL)
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Aetiology
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1. Decreased RCB production 2. Loss of RBCs 3. Increased RBC destruction
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Microcyctic / hypochomic
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Low MCV / Low MCH
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Normocyctic / normochomic
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Normal MCV / Normal MCH
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Macrocyctic / hyperchomic
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High MCV / High MCH
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fatigue
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dyspnoea
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chest pain
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dizziness
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palpitations
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headaches
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worsening of other conditions - intermittent claudication
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Normal MCV, indicating normal sized RBCs
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DDx: Anaemia of chronic disease/inflammation
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Haemolysis
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Bone marrow infiltration
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Acute blood loss
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Investigations
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FBC
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Low Hb, normal MCV
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Blood Film
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Normocytic, normochromic RBCs
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Iron Studies
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normal/low serum iron, low TIBC, normal/high serum ferritin
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+/- other Ix
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Serum erythropoietin (EPO) level is decreased in CKD
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Management
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Manage underlying cause
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consult haem/medical team
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EPO replacement
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RCC transfusion if severe or symptomatic
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Iron supplementation may or may not be needed
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Anaemia of Chronic Diseases
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Chronic renal disease, rheumatic disease, congestive heart failure
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Mechanism
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depends on underlying pathology
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decrease in release of stored iron
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shortened red cell survival
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impaired marrow response in red cell relacement
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Macrocytic Anaemia
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Large RBCs and increased MCV
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Aetiology
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Megaloblastic
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B12 or folate deficiency
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Normoblastic
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alcohol excess, reticulocytosis, liver disease
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Mechanism
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Megaloblastic
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Impaired DNA synthesis
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Normoblastic
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Unkown
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Signs and symptoms
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General symptoms of anaemia
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Pallor +/- glossitis, angular stomatitis
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B12 deficiency can lead to neurologic syndrome
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Vit B12
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Found in animal sources
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Causes of deficiency
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Pernicious anaemia (autoimmune disorder)
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Veganism
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Gastrectomy/gastric absorptive disease
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Chron's disease/coeliac
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Folate
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green veg,, organ meat, fortified cereals
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Causes of deficiency
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Poor dietary intake
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Alcohol
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Anti-epileptic drugs (phenytoin)
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Methotrexate
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Coeliac disease
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Treat underlying cause
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consult haem/medical team
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B12 deficiency
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IM hydroxocobalamin (B12): replenish levels with frequent administration then gradually reduce frequency
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Folat deficiency
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Oral folate replacement: folic acid 5mg OD
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Jaundice
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can occur in haemolysis
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Koilonychia
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spoon shaped nails in IDA
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conjunctive pallor
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ensure looking at palpebral conjunctiva
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sclera icterus
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jaundice (haemolysis)
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angular stomatitis
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B12/folate/iron deficiency
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systolic flow murmur
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mid-systolic ejection murmur due to increased semi-lunar blood flow
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Microcytic Anaemia
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Normocytic Anaemia
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Macrocytic Anaemia
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Iron deficiency anaemia (50% of cases)
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Anaemia of chronic disease
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Vitamin B12
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Thallasaemia
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Inflammation:
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Chronic diseases
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Chronic infection
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4 main causes
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Decreased intake (infant/vegan)
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Decreased absorption (gastrectomy, IBD, coeliac disease)
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Increased demand (childhood, pregnancy)
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Increased loss (chronic slow bleed)
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Potential Symptoms
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GI blood loss, heavy menstrual bleeding, Pica
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Investigations
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FBC
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decreased Hb and MCV. Check WCC & platelets (expect normal in IDA)
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Iron Studies
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decreased serum iron, serum ferritin, transferrin sat., increased TIBC
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Blood Film
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microcytic and hypochromic RBCs, Poikilocytosis / Anisocytosis
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+/- other Ix
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Faecal occult blood (FOB), OGD, colonoscopy
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Management
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Manage underlying cause
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consult haem/medical team
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Start supplemental iron
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Aim 1-2g raise in Hb every week
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1st line: oral iron replacement eg. Ferrous fumerate
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2nd line: IV iron replacement (Ferrinject)
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3rd line: RCC transfusion (if severe)
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Low Hb & MCV, indication RBCs
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Causes of microcytic anaemia; mnemonic TAILS
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Mechanism:
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Defect in synthesis of haem
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Thalassaemia - defect in synthesis of globin chain
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Investigations
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FBC
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Low Hb, MCV is elevated
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B12/Folate Deficiency
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check levels
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Anti-parietal cell anti-body & intrinsic factor antibody
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screening for pernicious anaemia
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Anti-tTG & IgA
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screening for coeliac disease
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LFTs
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GGT may be elevated in alcohol excess
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Peripheral blood smear
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anisocytosis, poikiloctyosis, hypersegmented neutrophils
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Serum iron levels
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LOW
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measures amount of iron in transit in blood
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Serrum ferritin
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LOW
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total iron stored in the body
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Total iron binding capacity
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HIGH
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TIBC increases in order to try and maximise use of the little iron available
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Transferrin saturation
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LOW
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level of saturation of transferring with iron: normal is 30%. Reduced in iron deficiency states
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Warm AIHA
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Antibody active at body temp
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Aetiologies include: rheumatic disease and lymphoproliferative disorders
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IgG antibodies +/- complement
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Cold AIHA
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Antibody active only at lower temps
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Aetiologies include: infections (eg. mono) and lymphoma
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IgM antibodies
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Investigations
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FBC
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Low Hb, normal MCV
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Reticulocytes
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elevated
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LDH
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elevated
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Haptoglonbin
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low
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LFT's
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unconjugated Bilirubin - elevated
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Direct Antioglobin (Coombs) Test
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if + then autoimmune haemolysis likely
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Blood Film
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look for specific abnormalities
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Management
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Treat underlying cause
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consult haem/medical team
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Stabilize pt
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consult haem re. need for transfusion
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Warm AIHA
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1st line: corticosteroids, 2nd line: Rituximab, Azathioprine, Cyclosporin, 3rd line: splectomy
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Cold AIHA
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Avoid cold temps & treat underlying cause +/- immunosuppressant (rituximab)
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Haenolytic Anaemia
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Haemolysis: destruction of red blood cells
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Aetiologies
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Autoimmune
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Warm, cold, transfusion reaction, drug induces
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Haemoglobinopathies
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sickle cell, hereditary spherocytosis, thalassaemia
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Infections
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malaria
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Enzyme defects
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G6PD
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Microangiopathic haemolytic anaemia (MAHA)
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haemolytic uremic syndrome, TTP, DIC, eclampsia/HELLP
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Mechanical haemolysis
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heart valve prosthesis
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Rare
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Paroxysmal noctural, haemoglobinuria (PNH)
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