Anemia

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  • Anemia

    1. 1. Anemia John R. Brill, MD, MPH
    2. 2. Anemia <ul><li>Goals </li></ul><ul><ul><li>Review common causes of anemia </li></ul></ul><ul><ul><li>Provide conceptual framework for evaluating patients with anemia </li></ul></ul><ul><ul><li>Show some interesting, gross and unusual pictures </li></ul></ul>
    3. 3. Anemia <ul><li>Definition: Age/gender-specific reduction in the circulating red blood cell mass </li></ul><ul><li>Commonly measured by the hemoglobin or hematocrit </li></ul>
    4. 5. Anemia: Prevalence <ul><li>Approximately 4.7 million Americans </li></ul><ul><li>6.6 % of men; 12.4 % of women </li></ul><ul><li>Increases with age; 44.4 percent in men > 85 </li></ul><ul><li>“ Although the elderly are more prone to develop anemia, older age is not of itself a cause of the condition.” </li></ul><ul><li>Brill JR, Baumgardner DJ. Am Fam Physician 2000; 62:2255-63,2264 </li></ul>
    5. 6. Primary Causes of Anemias <ul><li>Increased red blood cell loss or destruction </li></ul><ul><li>Decreased red blood cell production </li></ul><ul><li>Overexpansion of plasma volume </li></ul><ul><li>Maldistribution </li></ul>
    6. 7. RBCs External losses Maldistri-bution Precursors Production Plasma Volume
    7. 8. In creased red blood cell loss or destruction <ul><li>Blood loss </li></ul><ul><li>Hypersplenism </li></ul><ul><li>Hemolytic disorders </li></ul><ul><ul><li>Acquired conditions </li></ul></ul><ul><ul><li>Congenital conditions </li></ul></ul>
    8. 10. Case 1 <ul><li>25 y/o woman, G2 P2002 </li></ul><ul><li>c/o fatigue </li></ul><ul><li>TSH 1.3 </li></ul><ul><li>Hgb 10.3, Hct 31, Nl WBCs, Plts 538K, MCV 81, RDW 18.5 </li></ul><ul><li>FeSO4 325 mg daily x 6 weeks </li></ul><ul><li>Hgb 11.6, Hct 35 </li></ul>
    9. 11. Congenital Hemolysis <ul><li>Hemoglobinopathies </li></ul><ul><li>D isorders of red blood cell membranes </li></ul><ul><li>Red blood cell enzyme deficiencies </li></ul>
    10. 12. Hemoglobinopathies <ul><li>Homozygous sickle cell disease (hemoglobin SS disease) Sickle cells, target cells. </li></ul><ul><li>H eterozygous sickle hemoglobin C disease (hemoglobin SC disease) </li></ul><ul><li>Thalassemias (usually microcytic) </li></ul>
    11. 13. Disorders of red blood cell membranes <ul><li>Hereditary spherocytosis </li></ul><ul><li>Hereditary elliptocytosis </li></ul>
    12. 14. Red blood cell enzyme deficiencies <ul><li>Glucose-6-phosphate dehydrogenase deficiency </li></ul><ul><li>Pyruvate kinase deficiency </li></ul>
    13. 15. Case 2 <ul><li>22 y/o man </li></ul><ul><li>Recently started doxycycline for acne </li></ul><ul><li>Fatigued, tired, dizzy </li></ul><ul><li>Hgb 10.6, Hct 31. CRI 3.7% </li></ul><ul><li>Coombs (-). Stool heme neg. Urine dip +, micro negative </li></ul>
    14. 17. Acquired Hemo lysis <ul><li>Mechanical hemolysis </li></ul><ul><li>Macrovascular disorders </li></ul><ul><li>Microangiopathic disorders </li></ul>
    15. 18. Macrovascular hemolysis <ul><li>Valves, atherosclerosis </li></ul><ul><li>Schistocytes </li></ul>
    16. 19. Microvascular hemolysis <ul><li>Disseminated intravascular coagulopathy </li></ul><ul><li>Hemolytic-uremic syndrome </li></ul><ul><li>Thrombotic thrombocytopenic purpura </li></ul>
    17. 20. Case 3 <ul><li>31 y/o woman </li></ul><ul><li>3 day hx severe diarrhea; 2 other family members also effected </li></ul><ul><li>Now with bloody diarrhea, fever, confusion </li></ul><ul><li>Hgb 8.5, Hct 26, Plts 23K, WBC 23.6 </li></ul><ul><li>Creat 4.3 </li></ul>
    18. 22. Autoimmune hemolytic anemias <ul><li>Warm-reactive anemias Cold-reactive anemias Drug-induced anemias Paroxysmal nocturnal hemoglobinuria </li></ul>
    19. 23. Case 4 <ul><li>72 year old woman, new pt </li></ul><ul><li>DM, HTN. On glipizide, lisinopril, HCTZ, ASA </li></ul><ul><li>Fatigue, felt 2nd to care of husband with CVA </li></ul><ul><li>Rectal heme negative </li></ul><ul><li>Hgb 6.7, Hct 20 </li></ul><ul><li>Nl WBC, Plts, CMP, TSH </li></ul><ul><li>No prior CBC available </li></ul>
    20. 25. Case 4, cont <ul><li>Retic Count 4.9% (CRI 2.5%) </li></ul><ul><li>Coombs +++ </li></ul><ul><li>Dx: Drug-Induced Hemolytic Anemia </li></ul>
    21. 27. Decreased RBC Production <ul><li>Primary causes </li></ul><ul><li>Marrow hypoplasia or aplasia Myelopathies Myeloproliferative diseases Pure red blood cell aplasia </li></ul>
    22. 29. Secondary causes <ul><li>Anemia of chronic disease </li></ul><ul><li>Chronic renal failure Endocrine deficiency states Si deroblastic anemias </li></ul>
    23. 30. Iron Deficiency <ul><li>Most common cause of anemia world-wide </li></ul><ul><li>Low Fe, Ferritin; elevated TIBC, platelets </li></ul>
    24. 31. Case 5 <ul><li>63 y/o man </li></ul><ul><li>Farmer, never came to doctor </li></ul><ul><li>8 month hx weight loss, anorexia, fatigue </li></ul><ul><li>Hgb 7.3, Hct 22 Plts464K, WBC 11.3 </li></ul><ul><li>MCV 82, RDW 18.5 </li></ul><ul><li>Ferritin 6 </li></ul><ul><li>Dark maroon heme +++ stool </li></ul>
    25. 35. Anemia of Chronic Disease <ul><li>Most common cause of anemia in US </li></ul><ul><li>Increases with age </li></ul><ul><li>30% hospitalized patients </li></ul><ul><li>Malignancies, endocrinopathies, rheumatic disease, hepatic disease </li></ul><ul><li>Renal disease: not linked to degree of impaired GFR </li></ul>
    26. 36. Case 6 <ul><li>67 y/o man </li></ul><ul><li>DM, HTN, Hyperlipidemia, CAD </li></ul><ul><li>HgbA1c 9.4, microalbumin high, creat 1.6 </li></ul><ul><li>Hgb 9.5, Hct 29, nl WBC, Plts, MCV 84 RDW 14 </li></ul><ul><li>Ferritin 140 </li></ul><ul><li>Erythropoeitin x 6 weeks, Hgb 11.1 </li></ul>
    27. 37. Summary <ul><li>Anemia is common </li></ul><ul><li>Consider epidemiology, history to formulate a differential, directed labs </li></ul><ul><li>Use whole CBC </li></ul>
    28. 39. References <ul><li>Incidence of anemia in older people: an epidemiologic study in a well defined population . BJ Ania, VJ Suman, VF Fairbanks, DM Rademacher, LJ … - J Am Geriatr Soc, 1997 </li></ul><ul><li>Advances in the anemia of chronic disease. RT Means Jr - Int J Hematol, 1999 </li></ul><ul><li>Normocytic anemia. JR Brill, DJ Baumgardner - Am Fam Physician, 2000 Nov 15;62(10):2255-64 </li></ul>

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