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ANAEMIA

ANAEMIA. Dr. M Aamir Mirza MBBS, MCPS, MPhil, Ph.D C S Path (UAE), MABCP (USA). ANEMIA - DEFINITION . WHEN THE HEMOGLOBIN LEVEL IN THE BLOOD IS BELOW THE LOWER EXTREME OF THE NORMAL RANGE FOR THE AGE AND SEX OF THE INDIVIDUAL. Definition:.

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ANAEMIA

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  1. ANAEMIA Dr. M Aamir Mirza MBBS, MCPS, MPhil, Ph.D C S Path (UAE), MABCP (USA)

  2. ANEMIA - DEFINITION • WHEN THE HEMOGLOBIN LEVEL IN THE BLOOD IS BELOW THE LOWER EXTREME OF THE NORMAL RANGE FOR THE AGE AND SEX OF THE INDIVIDUAL

  3. Definition: Anemia is operationally defined as a reduction in one or more of the major RBC measurements: hemoglobin concentration, hematocrit, or RBC count Keep in mind these are all concentration measures

  4. The reticulocyte count(kinetic approach) • Increased reticulocytes (greater than 2-3% or 100,000/mm3 total) are seen in blood loss and hemolytic processes, although up to 25% of hemolytic anemias will present with a normal reticulocyte count due to immune destruction of red cell precursors. • Retic counts are most helpful if extremely low (<0.1%) or greater than 3% (100,000/mm3 total).

  5. Anemia? Production? Survival/Destruction? The key test is the …..

  6. IRON DEFICENCY - STAGES • Prelatent • reduction in iron stores without reduced serum iron levels • Hb (N), MCV (N), iron absorption (), transferin saturation (N), serum ferritin (), marrow iron () • Latent • iron stores are exhausted, but the blood hemoglobin level remains normal • Hb (N), MCV (N), TIBC (), serum ferritin (), transferrin saturation (), marrow iron (absent) • Iron deficiency anemia • blood hemoglobin concentration falls below the lower limit of normal • Hb (), MCV (), TIBC (), serum ferritin (), transferrin saturation (), marrow iron (absent)

  7. BLOOD PARAMETERS • Hemoglobin concentration (Hg) • F: 7,2 –10; M: 7,8-11,3 mmol Fe/l (12-18 g/dl) • Erythrocytes count (RBC) • F: 4-5,5; M: 4,5-6 x1012/l (4-6 x106 /l) • Hematocrit (Hct) • F: 37-47; M: 40-54; (37-54%) • Platelet count (Plt) • 150 – 450 x 103/l (150-450 x 109/l) • Leukocytes count (WBC) • 4-10 x 109/l (4-10 x 103/ l)

  8. Erythrocytes parameters • Mean corpuscular volume (MCV) • N: 80-100 fl • RDW(Red cell Distrubution Width) • Mean corpuscular hemoglobin (MCH) • N: 27-34 pg • Mean corpuscular hemoglobin concentration (MCHC) • N: 310 – 370 g/lRBC (31-37 g/dl)

  9. IRON DEFICIENCY ANEMIA • IRON METABOLISM • ABSORPTION IN DUODENUM • TRANSFERRIN TRANSPORTS IRON TO THE CELLS • FERRITIN AND HEMOSYDERIN STORE IRON • 10% of daily iron is absorbed

  10. Most body iron is present in hemoglobin in circulating red cells • The macrophages of the reticuloendotelial system store iron released from hemoglobin as ferritin and hemosiderin • Small loss of iron each day in urine, faeces, skin and nails and in menstruating females as blood (1-2 mg daily)

  11. IRON METABOLISM • Iron concentration (Fe) • N: 50-150 g/dl • Total Iron Binding Capacity • N: 250-450 g/dl • Transferrin saturation • Transferrin receptor concentration • Ferritin concentration • N: 50-300 g/l

  12. IRON DEFICIENCY ANEMIA • ETIOLOGY: • CHRONIC BLEEDING • MENORRHAGIA • PEPTIC ULCER • STOMACH CANCER • ULCERATIVE COLITIS • INTESTINAL CANCER • HAEMORRHOIDS • DECREASED IRON INTAKE • INCREASED IRON REQUIRMENT (JUVENILE AGE, PREGNANCY, LACTATION)

  13. IRON DEFICENCY - STAGES • Prelatent • reduction in iron stores without reduced serum iron levels • Hb (N), MCV (N), iron absorption (), transferin saturation (N), serum ferritin (), marrow iron () • Latent • iron stores are exhausted, but the blood hemoglobin level remains normal • Hb (N), MCV (N), TIBC (), serum ferritin (), transferrin saturation (), marrow iron (absent) • Iron deficiency anemia • blood hemoglobin concentration falls below the lower limit of normal • Hb (), MCV (), TIBC (), serum ferritin (), transferrin saturation (), marrow iron (absent)

  14. IRON DEFICIENCY ANEMIA • GENERAL ANEMIA’S SYMPTOMS: • FATIGABILITY • DIZZENES • HEADACHE • SCOTOMAS • IRRITABILITY • ROARING • PALPITATION • CHD, CHF

  15. CHARACTERISTICS SYMPTOMS • GLOSSITIS, STOMATITIS • DYSPHAGIA ( Plummer-Vinson syndrome) • ATROPHIC GASTRITIS • DRY, PALE SKIN • SPOON SHAPED NAILS, KOILONYCHIA, • BLUE SCLERAE • HAIR LOSS • PICA (APETITE FOR NON FOOD SUBSTANCES SUCH AS AN ICE, CLAY) • SPLENOMEGALY (10%) • INCREASED PLATELET COUNT

  16. Clinical Presentation • Asymptomatic • Pallor • Irritability, exercise intolerance, fatigue, and tachycardia • Blue sclera • Koilonychia • “Beeturia”

  17. IRON DEFICIENCY ANEMIA • MCV • MCH • MCHC N • Fe • TIBC • TRANSFERIN SATURATION • FERRITIN

  18. Anemia: Lab Evaluation • RBC Parameters • Hgb - Concentration of Hgb in whole blood • Hct - %Volume of blood occupied by RBCs • MCV - Mean Corpuscular Volume • MCHC - Mean Corpuscular Hgb Concentration • RDW - RBC Distribution Width • FEP - Free Erythrocyte Protoporphyrin • RBC - Number of RBCs per unit volume

  19. Normal Periperhal Smear Iron Deficiency Anemia Anemia: Lab Evaluation

  20. BLOOD AND BONE MARROW SMEAR • BLOOD: • microcytosis, hipochromia, anulocytes, anisocytosispoikilocytosis • BONE MARROW • high cellularity • mild to moderate erythroid hyperplasia (25-35%; N 16 – 18%) • polychromatic and pyknotic cytoplasm of erythroblasts is vacuolated and irregular in outline (micronormoblasticerythropoiesis) • absence of stainable iron

  21. Anemia: Lab Evaluation • Mentzer Index • Calculated ratio of MCV / RBC • > 13 - Fe deficiency anemia • < 13 - Hgb defect (ie thalassemia)

  22. Confusing Chart

  23. Management • History and physical examination is sufficient to exclude serious disease (e.g pregnant or lactating women, adolescents) - CURE ANEMIA • History and/or physical examination is insufficient (e.g old men, postmenopausal women) - FIND ETIOLOGY OF ANEMIA AND CURE (CAUSAL TREATMENT) • Benzidine test • Gastroscopy • Colonoscopy • Gynaecological examination

  24. IRON DEFICIENCY ANEMIACURE • ORAL • 200 mg of iron daily 1 hour before meal (e.g. 100 mg twice daily) • How long? • 14 days + (Hg required level – Hg current level) x 4 • half of the dose - 6 – 9 months to restore iron reserve • Absorption • is enhanced: vitC, meat, orange juice, fish • is inhibited: cereals, tea, milk

  25. Intervention • AAP Recommendations • Routine Hgb screening at 9 mos, 5 yrs, 14 yrs • Iron Intake • <4 years - 1 mg/kg/day • 4 to 10 years - 10 mg/day • 11 years and up - 18 mg/day

  26. Summary • Common Problem - especially among toddlers • Asymptomatic in the majority of patients • Leads to significant cognitive and motor deficits • Diagnosis and management fairly simple • Extensive work-up generally not needed • Rx failure needs further evaluation

  27. SIDEROBLASTIC ANEMIAS • HEREDITARY DISORDERS (rare) • SYNONIM FOR MDS (RA,RAES) • DISTURBANCES IN INTRACELLULAR IRON METABOLISM • HIGHER SIDEROBLASTS NUMBER IN BONE MARROW • CORRECT OR HIGHER IRON CONCENTRATION

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