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ANAEMIA: Preventable,
Yet a Problem!!
RETICULOCYTES
Reticulocytes are premature red blood cells,
typically composing about 1% of the red cells in the
human body...
Remember that the bonemarrow has
the capacity to increase RBC
production 5-10 times the normal
production.
Thus, if all ne...
RBC “rule of 3’s”

For normal erythrocytes:
hemoglobin (g/dL)
hematocrit (%)

3 x RBC count (millions)

3 x hemoblobin (g/...
Normal range :
In male : 5 - 6 millions/cmm of blood

In female :4 – 5 millions/cmm of blood
Decrease in Hemoglobin concen...
Introduction
In its broadest sense, anemia is a functional
inability of the blood to supply the tissue with
adequate O2 fo...
ENTOMOLOGY
-from Ancient Greek ἀναιμία anaimia, meaning "lack of blood")
Magnitude of Problem
Globally, is about 30 %
In developing countries &
India, incidence is around
40 – 90%.

Responsible f...


Anemia is a common condition.



It occurs in all age groups and all racial and ethnic groups.



Both men and women ...
Definition
Anemia - insufficient Hb to carry out O2 requirement
by tissues.
WHO definition : Hb conc.

11 gm %

For develo...
CLASSIFICATION
WHO Classification of Anaemia
Degree

Hb%

Moderate

7-10.9

24-37%

Severe

4-6.9

13-23%

Very Severe

<4

Haematocrit (...
ANEMIA
Morphologic classification
macrocytic
normocytic
microcytic

MCV <80

MCV 80-100

MCV >100
ANEMIA
Classification by volume
I.

Microcytic Anemia (MCV <80)

II.

Normocytic Anemia (MCV 80-100)

III.

Macrocytic Ane...
NORMOCYTIC CELL
MICROCYTIC CELL
MACROCYTIC CELL
ANEMIA
Pathophysiologic classification
I RBC loss
1. blood loss
2. ↑ RBC destruction

a. intrinsic abnormality

b. extrins...
ANEMIA
Pathophysiologic classification
I RBC loss
1.

blood loss

a. acute : trauma, massive
hemorrhage

b. chronic : GI l...
ANEMIA
pathophysiologic
classification
2.↑ RBC destruction

a. intrinsic abnormality
b. extrinsic abnormality
ANEMIA
pathophysiologic
classification
2.↑ RBC destruction
a. intrinsic abnormality

i. membrane disorder
ii.enzyme disord...
Classification of Anemia
Based on cell size (MCV)

Macrocytic (large) MCV 100+ fl (femtoliters)
Normocytic (normal) MCV 8-...
NORMOCHROMIC CELL
HYPOCHROMIC CELL
HYPERCHROMIC CELL
COMMON CAUSES
The Three Causes of Anemia

Decreased red blood cell
production
Increased red blood cell
destruction
Red blood cell loss
Decreased RBC production

Lack of iron, B12, folate
Marrow is dysfunctional from myelodysplasia, tumor
infiltration, aplas...
Increased RBC destruction

RBCs live about 100 days
Acquired: autoimmune hemolytic anemia, TTP-HUS,
DIC, malaria
Inherited...
Symptoms

Irritability

Lack of
Concentration

Fatigue

Infection
Palpitation

Weakness
Dizziness
Clinical Features
Pallor of skin
And m/m

Soft ejection
systolic
murmur

Edema

Signs
Platynychia
Koilonychia

Tachycardia...
DIAGNOSIS
ASSESSMENT
– Patient history
– Patient physical exam

– Signs and symptoms exhibited by the patient
– Hematologic lab find...
Before making a diagnosis of anemia,
one must consider:
Age

Sex
Geographic location
Presence or absence of lung disease
DIAGNOSIS OF ANEMIA
How does one make a clinical diagnosis
of anemia?
Patient history
– Dietary habits
– Medication
– Poss...
DIAGNOSIS OF ANEMIA

• Tiredness
• Muscle fatigue and weakness
• Headache and vertigo (dizziness)
• Dyspnia (difficult or ...
Physical examination

–General findings might include

• Hepato or splenomegaly
• Heart abnormalities
• Skin pallor
–Speci...
Laboratory investigation
A complete blood count, CBC, will
include:
–An RBC count:

• At birth the normal range is 3.9-5.9...
DIAGNOSIS OF ANEMIA
–Hematocrit (Hct) or packed cell volume in
% or (L/L)

• At birth the normal range is 42-60% (.42.60)
...
DIAGNOSIS OF ANEMIA
–Hemoglobin concentration in
grams/deciliter - the RBCs are lysed and
the hemoglobin is measured
spect...
DIAGNOSIS OF ANEMIA

• Mean corpuscular volume (MCV) – is the

average volume/RBC in femtoliters (10-15 L)

• Hct (in %)/R...
DIAGNOSIS OF ANEMIA

•Mean corpuscular hemoglobin
concentration (MCHC) – is the
average concentration of
hemoglobin in g/d...
DIAGNOSIS OF ANEMIA

• Mean corpuscular hemoglobin (MCH) –
is the average weight of
hemoglobin/cell in picograms (pg= 1012...
DIAGNOSIS OF ANEMIA

• Red cell distribution width (RDW) – is
a measurement of the variation in RBC
cell size

• Standard ...
ANISOCYTOSIS
DIAGNOSIS OF ANEMIA
–Reticulocyte count gives an
indication of the level of the bone
marrow activity.

• Done by staining ...
DIAGNOSIS OF ANEMIA

• At birth the normal range is 1.8-8%
• The normal range in an adult (i.e. in
an individual with no a...
RETICULOCYTES
DIAGNOSIS OF ANEMIA
–Blood smear examination . The
smear should be evaluated for the
following:

• Poikilocytosis – descri...
POIKILOCYTOSIS
VARIATIONS IN RBC SHAPE
DIAGNOSIS OF ANEMIA

•Erythrocyte inclusions – the RBCs in the
peripheral smear should also be examined
for the presence o...
DIAGNOSIS OF ANEMIA

•A variation in size should be
noted (anisocytosis) and cells
should be classified as

•Normocytic
•M...
RBC MORPHOLOGY ON A PERIPHERAL SMEAR
DIAGNOSIS OF ANEMIA

•The peripheral smear should also
be examined for abnormalities in
leukocytes or platlets.

•Some nut...
•In a bone marrow sample, the
following things should be noted:
•
•
•
•
•
•

Maturation of RBC and WBC series

Ratio of my...
DIAGNOSIS OF ANEMIA
– Evaluation of RBC enzymes and metabolic pathways –
enzyme deficiencies in carbohydrate metabolic pat...
Management Options
Pre – pregnancy :

Treat the cause before conception
Pre-pregnancy balanced diet, education
and health ...
Modalities of Management

Oral Iron

Parenteral

Injectable Iron

Blood
transfusion

Human Recombinant
Erythropoietin
Oral Iron Therapy
Ideal dose – 100mg per day (prophylactic)
Ferrous gluconate, ferrous fumarate, ferrous
succinate, ferrou...
Absorption of Ferrous Salts
Uncontrolled Passive Absorption
Iron salts are dissociated into bivalent or trivalent iron sal...
Parenteral Therapy :
Traditional Indications
Intolerance to oral iron
Poor compliance to oral iron

Gastrointestinal disor...
Parenteral Therapy :
Traditional Indications
Inability to maintain iron balance
(haemodialysis)

Patient donating large am...
The

World Health Organisation
states…

‘transfusion should be
prescribed ONLY for conditions
for which there is NO OTHER
...
PREVENTION
Some common forms of anemia are most easily prevented by eating a healthy diet
and limiting alcohol use. All ty...
SUMMARY

Preventing anemia and having the correct number of red blood
cells requires cooperation among the kidneys, the bo...
Take Home Message
Anaemia although preventable is a global problem
Anaemia still is the commonest cause of maternal mortal...
Take Home Message
The youth need to be educated about diet,
sanitation and personal hygiene

Hookworm infestation should b...
Anaemia
Anaemia
Anaemia
Anaemia
Anaemia
Anaemia
Anaemia
Anaemia
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Anaemia

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Transcript of "Anaemia"

  1. 1. ANAEMIA: Preventable, Yet a Problem!!
  2. 2. RETICULOCYTES Reticulocytes are premature red blood cells, typically composing about 1% of the red cells in the human body. Reticulocytes develop and mature in the red bone marrow and then circulate for about a day in the blood stream before developing into mature red blood cells. Like mature red blood cells, reticulocytes do not have a cell nucleus. They are called reticulocytes because of a reticular (mesh-like) network of ribosomal RNA that becomes visible under a microscope with certain stains such as new methylene blue.
  3. 3. Remember that the bonemarrow has the capacity to increase RBC production 5-10 times the normal production. Thus, if all necessary raw products are available, the RBC life span can decrease to about 18 days before bone marrow compensation is inadequate and anemia develops.
  4. 4. RBC “rule of 3’s” For normal erythrocytes: hemoglobin (g/dL) hematocrit (%) 3 x RBC count (millions) 3 x hemoblobin (g/dL) 3% Failure to obey this “rule of 3’s” suggests an abnormality in erythrocytes (sickle cells, etc)
  5. 5. Normal range : In male : 5 - 6 millions/cmm of blood In female :4 – 5 millions/cmm of blood Decrease in Hemoglobin concentration Normal range : In male : 15 -18 gm/100ml of blood In female : 12 – 15 gm/100ml of blood
  6. 6. Introduction In its broadest sense, anemia is a functional inability of the blood to supply the tissue with adequate O2 for proper metabolic function. Anemia is not a disease, but rather the expression of an underlying disorder or disease.
  7. 7. ENTOMOLOGY -from Ancient Greek ἀναιμία anaimia, meaning "lack of blood")
  8. 8. Magnitude of Problem Globally, is about 30 % In developing countries & India, incidence is around 40 – 90%. Responsible for 40% of maternal deaths in third world countries. Important cause of direct and indirect maternal deaths - Vitere FE Adv Exp Med Biol 1994;352:127
  9. 9.  Anemia is a common condition.  It occurs in all age groups and all racial and ethnic groups.  Both men and women can have anemia, but women of childbearing age are at higher risk for the condition.  This is because women in this age range lose blood from menstruation.  Researchers continue to study how anemia affects older adults.  More than 10 percent of older adults have mild forms of anemia.  Many of these people have other medical conditions as well.
  10. 10. Definition Anemia - insufficient Hb to carry out O2 requirement by tissues. WHO definition : Hb conc. 11 gm % For developing countries : cut off level suggested is 10 gm % - WHO technical report Series no. 405, Geneva 1968 Centre for disease control, MMWR 1989;38:400-4
  11. 11. CLASSIFICATION
  12. 12. WHO Classification of Anaemia Degree Hb% Moderate 7-10.9 24-37% Severe 4-6.9 13-23% Very Severe <4 Haematocrit (%) <13%
  13. 13. ANEMIA Morphologic classification macrocytic normocytic microcytic MCV <80 MCV 80-100 MCV >100
  14. 14. ANEMIA Classification by volume I. Microcytic Anemia (MCV <80) II. Normocytic Anemia (MCV 80-100) III. Macrocytic Anemia (MCV >100)
  15. 15. NORMOCYTIC CELL
  16. 16. MICROCYTIC CELL
  17. 17. MACROCYTIC CELL
  18. 18. ANEMIA Pathophysiologic classification I RBC loss 1. blood loss 2. ↑ RBC destruction a. intrinsic abnormality b. extrinsic abnormality II ↓RBC production 1. stem cell abnormality 2. erythroblast abnormality 3. unknown/multiple mechanism
  19. 19. ANEMIA Pathophysiologic classification I RBC loss 1. blood loss a. acute : trauma, massive hemorrhage b. chronic : GI lesion, GYN lesion
  20. 20. ANEMIA pathophysiologic classification 2.↑ RBC destruction a. intrinsic abnormality b. extrinsic abnormality
  21. 21. ANEMIA pathophysiologic classification 2.↑ RBC destruction a. intrinsic abnormality i. membrane disorder ii.enzyme disorder iii.Hgb synthesis disorder iv.acquired memb. defect
  22. 22. Classification of Anemia Based on cell size (MCV) Macrocytic (large) MCV 100+ fl (femtoliters) Normocytic (normal) MCV 8-99 fl Microcytic (small) MCV<80 fl Based on hemoglobin content (MCH) Hypochromic (pale color) Normochromic (normal color) Hyperchromic cell
  23. 23. NORMOCHROMIC CELL
  24. 24. HYPOCHROMIC CELL
  25. 25. HYPERCHROMIC CELL
  26. 26. COMMON CAUSES
  27. 27. The Three Causes of Anemia Decreased red blood cell production Increased red blood cell destruction Red blood cell loss
  28. 28. Decreased RBC production Lack of iron, B12, folate Marrow is dysfunctional from myelodysplasia, tumor infiltration, aplastic anemia, etc. Bone marrow is suppressed by chemotherapy or radiation Low levels of erythropoeitin, thyroid hormone, or androgens
  29. 29. Increased RBC destruction RBCs live about 100 days Acquired: autoimmune hemolytic anemia, TTP-HUS, DIC, malaria Inherited: spherocytosis, sickle cell, thalassemia
  30. 30. Symptoms Irritability Lack of Concentration Fatigue Infection Palpitation Weakness Dizziness
  31. 31. Clinical Features Pallor of skin And m/m Soft ejection systolic murmur Edema Signs Platynychia Koilonychia Tachycardia Glossitis Stomatitis
  32. 32. DIAGNOSIS
  33. 33. ASSESSMENT – Patient history – Patient physical exam – Signs and symptoms exhibited by the patient – Hematologic lab findings Identification of the cause of anemia is important so that appropriate therapy is used to treat the anemia.
  34. 34. Before making a diagnosis of anemia, one must consider: Age Sex Geographic location Presence or absence of lung disease
  35. 35. DIAGNOSIS OF ANEMIA How does one make a clinical diagnosis of anemia? Patient history – Dietary habits – Medication – Possible exposure to chemicals and/or toxins – Description and duration of symptoms
  36. 36. DIAGNOSIS OF ANEMIA • Tiredness • Muscle fatigue and weakness • Headache and vertigo (dizziness) • Dyspnia (difficult or labored breathing) from exertion • G I problems • Overt signs of blood loss such as hematuria (blood in urine) or black stools
  37. 37. Physical examination –General findings might include • Hepato or splenomegaly • Heart abnormalities • Skin pallor –Specific findings may help to establish the underlying cause: • In vitamin B12 deficiency there may be signs of malnutrition and neurological changes • In iron deficiency there may be severe pallor, a smooth tongue, and esophageal webs • In hemolytic anemias there may be jaundice due to the increased levels of bilirubin from increased RBC destruction
  38. 38. Laboratory investigation A complete blood count, CBC, will include: –An RBC count: • At birth the normal range is 3.9-5.9 x 106/ul (1012/L) • The normal range for males is 4.5-5.9 x 106/ul • The normal range for females is 3.8-5.2 x 106/ul • Note that the normal ranges may vary slightly depending upon the patient population.
  39. 39. DIAGNOSIS OF ANEMIA –Hematocrit (Hct) or packed cell volume in % or (L/L) • At birth the normal range is 42-60% (.42.60) • The normal range for males is 41-53% (.41-.53) • The normal range for females is 38-46% (.38-.46) • Note that the normal ranges may vary slightly depending upon the patient population.
  40. 40. DIAGNOSIS OF ANEMIA –Hemoglobin concentration in grams/deciliter - the RBCs are lysed and the hemoglobin is measured spectrophotometrically • At birth the normal range is 13.5-20 g/dl • The normal range for males is 13.5-17.5 g/dl • The normal range for females is 12-16 g/dl • Note that the normal ranges may vary slightly depending upon the patient population. –RBC indices – these utilize results of the RBC count, hematocrit, and hemoglobin to calculate 4 parameters:
  41. 41. DIAGNOSIS OF ANEMIA • Mean corpuscular volume (MCV) – is the average volume/RBC in femtoliters (10-15 L) • Hct (in %)/RBC (x 1012/L) x 10 • At birth the normal range is 98-123 • In adults the normal range is 80-100 • The MCV is used to classify RBCs as: • Normocytic (80-100) • Microcytic (<80) • Macrocytic (>100)
  42. 42. DIAGNOSIS OF ANEMIA •Mean corpuscular hemoglobin concentration (MCHC) – is the average concentration of hemoglobin in g/dl (or %) • Hgb (in g/dl)/Hct (in %) x 100 • At birth the normal range is 30-36 • In adults the normal range is 31-37 • The MVHC is used to classify RBCs as: • Normochromic (31-37) • Hypochromic (<31) • Some RBCs are called hyperchromic
  43. 43. DIAGNOSIS OF ANEMIA • Mean corpuscular hemoglobin (MCH) – is the average weight of hemoglobin/cell in picograms (pg= 1012 g) • Hgb (in g/dl)/RBC(x 1012/L) x 10 • At birth the normal range is 31-37 • In adults the normal range is 26-34 • This is not used much anymore because it does not take into account the size of the cell.
  44. 44. DIAGNOSIS OF ANEMIA • Red cell distribution width (RDW) – is a measurement of the variation in RBC cell size • Standard deviation/mean MCV x 100 • The range for normal values is 11.5-14.5% • A value > 14.5 means that there is increased variation in cell size above the normal amount (anisocytosis) • A value < 11.5 means that the RBC population is more uniform in size than normal.
  45. 45. ANISOCYTOSIS
  46. 46. DIAGNOSIS OF ANEMIA –Reticulocyte count gives an indication of the level of the bone marrow activity. • Done by staining a peripheral blood smear with new methylene blue to help visualize remaining ribosomes and ER. The number of reticulocytes/1000 RBC is counted and reported as a %.
  47. 47. DIAGNOSIS OF ANEMIA • At birth the normal range is 1.8-8% • The normal range in an adult (i.e. in an individual with no anemia) is .51.5%. Note that this % is not normal for anemia where the bone marrow should be working harder and throwing out more reticulocytes per day. In anemia the reticulocyte count should be elevated above the normal values.
  48. 48. RETICULOCYTES
  49. 49. DIAGNOSIS OF ANEMIA –Blood smear examination . The smear should be evaluated for the following: • Poikilocytosis – describes a variation in the shape of the RBCs. It is normal to have some variation in shape, but some shapes are characteristic of a hematologic disorder or malignancy.
  50. 50. POIKILOCYTOSIS
  51. 51. VARIATIONS IN RBC SHAPE
  52. 52. DIAGNOSIS OF ANEMIA •Erythrocyte inclusions – the RBCs in the peripheral smear should also be examined for the presence of inclusions or a variation in erythrocyte distribution :
  53. 53. DIAGNOSIS OF ANEMIA •A variation in size should be noted (anisocytosis) and cells should be classified as •Normocytic •Microcytic •Macrocytic •A variation in hemoglobin concentration (color) should be noted and the cells should be
  54. 54. RBC MORPHOLOGY ON A PERIPHERAL SMEAR
  55. 55. DIAGNOSIS OF ANEMIA •The peripheral smear should also be examined for abnormalities in leukocytes or platlets. •Some nutritional deficiencies, stem cell disorders, and bone marrow abnormalities will also effect production, function, and/or morphology of platlets and/or granulocytes. •Finding abnormalities in the
  56. 56. •In a bone marrow sample, the following things should be noted: • • • • • • Maturation of RBC and WBC series Ratio of myeloid to erythroid series Abundance of iron stores (ringed sideroblasts) Presence or absence of granulomas or tumor cells Red to yellow ratio Presence of megakaryocytes – Hemoglobin electrophoresis – can be used to identify the presence of an abnormal hemoglobin (called hemoglobinopathies). Different hgbs will move to different regions of the gel and the type of hemoglobin may be identified by its position on the gel after electrophoresis.
  57. 57. DIAGNOSIS OF ANEMIA – Evaluation of RBC enzymes and metabolic pathways – enzyme deficiencies in carbohydrate metabolic pathways are usually associated with a hemolytic anemia. – Evaluation of erythropoietin levels – is used to determine if a proper bone marrow response is occurring. •Low levels of RBCs could be due to a bone marrow problem or to a lack of erythropoietin production. – Serum iron, iron binding capacity and % saturation – used to diagnose iron deficiency anemias (more on this later) – Bone marrow cultures – used to determine the viability of stem cells.
  58. 58. Management Options Pre – pregnancy : Treat the cause before conception Pre-pregnancy balanced diet, education and health support. Build up iron stores during adolescent phase
  59. 59. Modalities of Management Oral Iron Parenteral Injectable Iron Blood transfusion Human Recombinant Erythropoietin
  60. 60. Oral Iron Therapy Ideal dose – 100mg per day (prophylactic) Ferrous gluconate, ferrous fumarate, ferrous succinate, ferrous sulphate, ferrous ascorbate citrate Rise in Hb – 0.8 gm / dl / week Side effects -G I upset most common Pt. compliance not guaranteed Ineffective in pts with worm infestations Inconclusive evidence on benefit of controlled release Iron preparation
  61. 61. Absorption of Ferrous Salts Uncontrolled Passive Absorption Iron salts are dissociated into bivalent or trivalent iron salts Diffuses as free iron ions through the upper part of the gastrointestinal mucosa Taken up by transferrin and incorporated into ferritin. For binding to ferritin and transferrin ferrous iron has to be converted into ferric iron by oxidation Highly reactive free radicals are produced during this process All ionic iron including carbonyl iron are absorbed similarly • Borbolla JR. Cicero RE, Dibilox MM, Sotres RD et al.. Rev Mex Pediatr 2000; 67(2): 63-67 • Heubers KA, Brittenham GM, Csiba E, Finch CA. J Lab Clin Med 1986 ; 108 ; 473-8.
  62. 62. Parenteral Therapy : Traditional Indications Intolerance to oral iron Poor compliance to oral iron Gastrointestinal disorders Malabsorption syndromes Rapid blood loss
  63. 63. Parenteral Therapy : Traditional Indications Inability to maintain iron balance (haemodialysis) Patient donating large amount of blood for auto-transfusion programme ? Pregnant women with severe IDA, presenting late in pregnancy
  64. 64. The World Health Organisation states… ‘transfusion should be prescribed ONLY for conditions for which there is NO OTHER TREATMENT’
  65. 65. PREVENTION Some common forms of anemia are most easily prevented by eating a healthy diet and limiting alcohol use. All types of anemia are best avoided by seeing a doctor regularly and when problems arise. In the elderly, routine blood work ordered by the doctor, even if there are no symptoms, may detect anemia and prompt the doctor to look for the underlying causes.
  66. 66. SUMMARY Preventing anemia and having the correct number of red blood cells requires cooperation among the kidneys, the bone marrow, and nutrients within the body. If the kidneys or bone marrow are not functioning, or the body is poorly nourished, then normal red blood cell count and function may be difficult to maintain. Anemia is actually a sign of a disease process rather than a disease itself. It is usually classified as either chronic or acute. Chronic anemia occurs over a long period of time. Acute anemia occurs quickly. Determining whether anemia has been present for a long time or whether it is something new, assists doctors in finding the cause. This also helps predict how severe the symptoms of anemia may be.
  67. 67. Take Home Message Anaemia although preventable is a global problem Anaemia still is the commonest cause of maternal mortality and morbidity in spite of easy diagnosis and treatment Anaemia can be due to a number of causes, including certain diseases or a shortage of iron, folic acid or Vitamin B12. The most common cause of anemia in pregnancy is iron deficiency. Iron therapy is best given orally
  68. 68. Take Home Message The youth need to be educated about diet, sanitation and personal hygiene Hookworm infestation should be treated Pregnant women should be given Iron and folate supplements
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