Paediatrics , Hemolytic Anemia , From Nelson Textbook of Pediatrics, Lanzkowsky's Manual of Pediatric Hematology and Oncology.

1. Hemolytic Anemia
Moderator: Dr. PavanKumar J
Presenter : Dr. Sunil Mulgund

2. TOPICS
•Definition
•Pathophysiology
•General approach to haemolytic anemia
•Classification
•Discussion on each type
•Summary

3. Hemolysis is defined as the premature destruction of red blood cells (RBCs) (a
shortened RBC life span).
Anemia results when the rate of destruction exceeds the capacity of the marrow to
produce RBCs. Normal RBC survival time is 110-120 days .
During hemolysis, RBC survival is shortened, the RBC count falls, erythropoietin is
increased, and the stimulation of marrow activity results in heightened RBC
production, reflected in an increased percentage of reticulocytes in the blood.
Thus, hemolysis should be suspected as a cause of anemia if an elevated
reticulocyte count is present. The reticulocyte count may also be elevated as a
response to acute blood loss or for a short period after replacement therapy for
iron, vitamin B12, or folate deficiency.

4. The reticulocyte percentage can be corrected to measure the magnitude of marrow
production in response to hemolysis as follows.
• where µ is a maturation factor of 1-3 related to the severity of the
anemia
• The normal reticulocyte index is 1.0
• The index measures the fold increase in erythropoiesis (e.g., 2-fold, 3-
fold).
• Reticulocyte index is essentially a measure of RBC production per day

5. • Hemolysis -> Erythropoietin increases -> Erythroid hyperplasia -> medullary spaces expand at the expense of the
cortical bone.
• These changes may beevident onphysical examinationor onradiographs of theskull and long bones .
• A propensity to fracture long bones can also occur.

6. Average life span is 110- 120 days

8. The exaggerated degradation rate
of hemoglobin
Increases biliary excretion of heme
pigment derivatives and increased
urinary and fecal urobilinogen.
Gallstones composed of calcium
bilirubinate may be formed
Elevations of serum unconjugated
bilirubin and lactate dehydrogenase
also can accompany hemolysis.

9. Haemolytic Anaemia
Cellular
Defects
Membrane
Defects
Enzyme
Deficiencies
Haemoglobin
Abnormalities
Extracellular
defects
Autoimmune
Fragmentation
Hemolysis
Plasma Factors

11. Membrane defects
• Hereditary spherocytosis
• Hereditary elliptocytosis
• Hereditary
pyropoikilocytosis
• Hereditary
stomatocytosis
• Paroxysmal nocturnal
hemoglobinuria
Enzyme Deficiencies
• Pyruvate kinase
deficiency
• G6PD deficiency
Hemoglobin Abnormalities
• Structural
• Thalassemia
• Thalassaemic variant
• Hereditary persistence
of fetal Hb
• Acquired
Cellular Defects

12. Autoimmune
• Warm antibody
• Cold antibody
Fragmentation Hemolysis
• Hypersplenism
• Burns, thermal injury
• Prosthetic heart valve
• Extracorporeal
membrane oxygenation
• DIC, TTP, HUS, aHUS,
• pneumococcal-induced
HUS
Plasma Factors
• Liver disease
• Abetalipoproteinemia
• Infection
• Wilson disease
Extracellular Defects

13. Clinical features of hemolytic process in a child
with anemia:
1. History of anemia, jaundice, or gallstones in family
2. persistent or recurrent anemia associated with reticulocytosis
3. anemia unresponsive to hematinics
4. intermittent bouts or persistent indirect hyperbilirubinemia/jaundice
5. splenomegaly
6. hemoglobinuria
7. presence of multiple gallstones
8. development of anemia or hemoglobinuria after exposure to certain drugs
9. cyanosis without cardiorespiratory distress
10. polycythemia (2,3-diphosphoglycerate mutase deficiency)
11. dark urine due to dipyroluria (unstable hemoglobins, thalassemia, and ineffective erythropoiesis)

14. Laboratory findings
•Evidence of accelerated hemoglobin catabolism
•extravascular hemoglobin
•intravascular hemoglobin
•Evidence of increased erythropoiesis.

15. MARKERS OF EXTRAVASCULAR HEMOLYSIS MARKERS OF INTRAVASCULAR HEMOLYSIS
1. Increased unconjugated bilirubin
2. Increased lactic acid dehydrogenase in
serum
3. Decreased plasma haptoglobin
(normal level, 36-195 mg/dL)
4. Increased fecal and urinary
urobilinogen
5. Increased rate of carbon monoxide
production.
1. Increased unconjugated bilirubin
2. Increased lactic acid dehydrogenase
in serum
3. Hemoglobinuria
4. Low or absent plasma haptoglobin
5. Hemosiderinuria (due to sloughing of
iron-laden tubular cells into urine)
6. Raised plasma hemoglobin level
7. Raised plasma methemalbumin
(albumin bound to heme; unlike
haptoglobin, albumin does not bind
intact hemoglobin)
8. Raised plasma methemoglobin

16. Markers of increased erythropoiesis
1. Reticulocytosis frequently up to 10-20%; rarely, as high as 80%
2. Increased MCV
3. Increased RDW red cell distribution width (RDW-range of variation of
RBC size)
4. Normoblasts in the peripheral blood
5. Specific morphologic abnormalities: sickle cells, target cells, basophilic
stippling, irregularly contracted cells or fragments (schistocytes),
elliptocytes, acanthocytes, and spherocytes
6. Expansion of marrow space in resulting in:
a. Prominence of the frontal bones and broadened cheekbones
b. Widened intratrabecular spaces , hair-on-end appearance of skull
c. Biconcave vertebrae with fish-mouth intervertebral spaces

17. HEREDITARY SPHEROCYTOSIS
• Hereditary spherocytosis (HS) is a common cause of
hemolysis and hemolytic anemia, 1 in 5,000 persons.
• Affected patients may be:
• asymptomatic, without anemia
• minimal hemolysis with mild symptoms
• severe hemolytic anemia requiring regular blood transfusions and a
splenectomy.
• MC- Autosomal dominant , but Autosomal recessive variants
are also seen.

19. deficiency
• Beta spectrin
• Alpha spectrin
• band 3
• Ankyrin 1
• protein 4.2
Results in
uncoupling in the
“vertical”
interactions of the
lipid bilayer
skeleton
subsequent
release of
membrane
microvesicles. loss
of membrane
surface area
without a
proportional loss
of cell volume
causes sphering of
the RBCs, and an
associated
increase in cation
permeability,
cation transport,
adenosine
triphosphate use,
and glycolysis.
spherocytic RBCs
impairs cell
passage from the
splenic cords to
the splenic
sinuses, and the
spherocytic RBCs
are destroyed
prematurely in the
spleen

21. Table 458-2 Hereditary Spherocytosis Disease Classification
TRAIT MILD MODERATE SEVERE
Hemoglobin (g/dL) Normal 11-15 8-12 <6-8
Reticulocytes (%) Normal (<3) 3-6 >6 >10
Bilirubin <17 17-34 >34 >51
Transfusions 0 0 0-2 Regular
Typical heredity AD AD AD or de novo mutation AR
Splenectomy Not indicated Not indicated May be indicated* Indicated

22. CLINICAL MANIFESTATIONS OF HS
• Anaemia – might require transfusion in first 8 weeks of life
• Jaundice
• Splenomegaly

23. INVESTIGATIONS:
Hb- Low
MCV- Low
MCHC and RDW – Raised
Retic -3-15% raised
PS-spherocytes, microspherocytes
Increased red cell osmotic fragility (spherocytes lyse in higher concentrations of saline than normal red cells)
Eosin-5-maleimide dye staining of red cells and analysis by flow cytometry is the test of choice to diagnose
Genetic analysis for the α- and β-spectrin, ankyrin, and band 3 mutations
Indirect hyperbilirubinemia
Gallstones

24. TREATMENT
1. Folic acid supplement (1 mg/day).
2. Ultrasound should be carried out before
splenectomy to exclude the presence of
gallstones. If present,n cholecystectomy is
also indicated.

25. 3. Splenectomy
• Splenectomy is recommended for patients with severe HS.
It should be considered for patients with moderate HS and
frequent hypoplastic or aplastic crises, poor growth, or
cardiomegaly , should be performed after the age of 6 yr,
• Postsplenectomy thrombocytosis is commonly observed,
but requires no treatment and usually resolves
spontaneously.
• Vaccines for encapsulated organisms, such as pneumo
coccus, meningococcus, and H. influenzae type b, should
be administered at least 14 days before splenectomy

28. HEREDITARY ELLIPTOCYTOSIS
• Defects in horizontal protein interactions result in gross
membrane fragmentation,
• The RBCs show various degrees of elongation
• If hereditary elliptocytosis represents a morphologic abnormality
on the blood film without evident hemolysis, no treatment is
necessary usually.
• Patients with chronic hemolysis should receive folic acid, 1 mg
daily, to prevent secondary folic acid deficiency.
• Splenectomy decreases the hemolysis and should be considered if
the hemoglobin is <10 g/dL and the reticulocyte count is >10%.

29. HEREDITARY STOMATOCYTOSIS
• Morphologic changes in the red blood cells (RBCs) and increased
red cell cation permeability.
• The RBCs are cup-shaped, creating a mouth-shaped area (stoma)
of central pallor instead of the usual circular area of central pallor.
Hereditary stomatocytosis is classified by the RBC hydration
status.
• The 2 major varieties are either overhydrated (hydrocytosis - have
excess intracellular sodium and water content ) or dehydrated
(xerocytosis - net loss of RBC potassium that is not accompanied
by an increase in sodium.).

30. PAROXYSMAL NOCTURNAL HEMOGLOBINURIA
• PNH is a acquired somatic mutation (X linked PIGA gene) that
affect proteins of the cell membrane
• The absence of the surface complement regulatory proteins
CD55 and CD59 -> deposition of complement factors and C3
convertase complexes. This leads to chronic complement-
mediated intravascular hemolysis, resulting in hemoglobinuria.
• Increased hemolysis at night may be due to changes in the
balance of the inhibitor-hemolysin system in addition to the
effect on pH that may be produced by retention of CO2 during
sleep.

32. CLINICAL MANIFESTATIONS
• Intravascular hemolysis.
• Nocturnal and morning hemoglobinuria is a classic finding
• In addition to chronic hemolysis, thrombocytopenia and leukopenia
are often characteristic.
• Hemoglobinuria is rarely seen in children compared to adults with
PNH.
• Thrombosis and thromboembolic phenomena are serious
complications
• Abdominal venous thrombosis presents as recurrent episodes of
abdominal pain, Budd-Chiari syndrome (hepatic veins), or
splenomegaly (splenic vein).

33. INVESTIGATIONS
• Markedly reduced levels of RBC acetylcholinesterase
activity and decay- accelerating factor
• Flow cytometry is the diagnostic test of choice for
PNH. (Better than the classis HAM test , where blood
is added in a acidic medium and hemolysis is seen.)
• Fluorescent-labeled aerolysin testing can heighten the
sensitivity of detection by binding selectively to
glycosylphosphatidylinositol anchors.

34. Treatment
• Glucocorticoids such as prednisone (2 mg/kg/24 hr)
• Prolonged anticoagulation (heparin or low- molecular-weight
heparin) therapy may be of benefit when thromboses occur.
• iron therapy may be necessary.
• Bone marrow transplantation
• Eculizumab has also resulted in sustained survival in the majority of
patients.
• Eculizumab is an approved and effective treatment
• It is a monoclonal antibody against complement component C5

35. HEMOGLOBINOPATHIES:
• Hemoglobin is a tetramer consisting of 2 pairs of globin
chains. Abnormalities in these proteins are referred to as
hemoglobinopathies
• Two hemoglobin gene clusters are involved in the production
of hemoglobin and are located at the end of the short arms of
chromosomes 16 and 11.
• Chromosome 16 – α gene cluster -> zeta , alpha 1 , alpha 2
• Chromosome 11 – β gene cluster -> epsilon , 2 gamma genes
, delta ,beta

37. Hb A is first appears at 4 weeks
of fetal life.
At 8 week of fetal life – Gower 1
and Gower 2 ,Portland are
formed.
At 9 week of fetal life HbF is
major Hemoglobin.
At around 6 months of age final
adult Hb A is achieved.
The normal hemoglobin pattern
is ≥ 95% HbA, ≤3.5 HbA2, and
<2.5% HbF.

38. SICKLE CELL DISEASE(Defect in quality)
• The HbS allele results from a single nucleic acid substitution from GAG to GTG in the beta
globin gene, 6th position (point mutation)
• This causes glutamic acid to be substituted with valine. Individuals with one HbS allele
(HbAS) are carriers while those who are homozygous for the HbS allele (HbSS) have sickle
cell disease. (Autosomal dominant trait)
• HbS is more positively charged than HbA and hence has a different electrophoretic
mobility. Deoxygenated HbS polymerizes, leading to cellular alterations that distort the red
cell into a rigid, sickled form.
• Sickle cell anemia occurs when both β-globin alleles have the sickle cell mutation.
• Sickle cell disease is , one Beta chain having sickle cell mutation and second beta chain has
some other mutation,
• In sickle cell anemia, HbS is commonly as high as 90% of the total hemoglobin; whereas as in
sickle cell disease, HbS is >50% of all hemoglobin.

45. CLINICAL MANIFESTATIONS
Fever and Bacteremia
• Children with sickle cell anemia are at an increased risk of
bacterial infection , especially from encapsulated
organisms like Streptococcus pneumoniae, Haemophilus
influenzae type b, and Neisseria meningitidis.
• Infants with sickle cell anemia develop abnormal immune
function due to splenic infarction, and by 5 years of age,
most children have complete functional asplenia.
• Children with SCA and presenting with fever must be
admitted for minimum 24 hrs and blood culture to be sent
and IV 3rd generation cephalosporins to be started

46. Clinical Factors Associated with Increased Risk of Bacteremia
Requiring Admission in Febrile Children with Sickle Cell
Disease
Seriously ill appearance
Hypotension
Poor perfusion: capillary-refill time >4 sec
Temperature >40.0°C (104°F)
white-cell count >30,000/mm3 or <5000/mm3
Platelet count <100,000/mm3
History of pneumococcal sepsis
Severe pain
Dehydration: poor skin turgor, dry mucous membranes,
history of poor fluid intake, or decreased output of urine
Infiltration of a segment or a larger portion of the lung
Hemoglobin level <5.0 g/dL

47. Aplastic crisis
• Human parvovirus B19 - causes temporary red cell aplasia, which
can lead to significant anemia. (due to cytotoxicity due to viral
protiens.)
• Children with sickle cell disease who present with fever and
reticulocytopenia - should be suspected of having parvovirus B19
infection.
• Treatment for acute anaemia of an aplastic crisis typically involves
blood transfusions and close monitoring of the patient's condition
• Patients with parvovirus-associated aplastic crisis are contagious
and infection precautions should be taken to avoid nosocomial
spread of the infection.

48. Splenic Sequestration
• Acute splenic sequestration is a life-threatening complication
• Most commonly affects children between 6 months and 2
years.
• Symptoms of splenic sequestration include rapid spleen
enlargement, left-sided abdominal pain, and a decline in
hemoglobin of at least 2 g/dL from the patient's baseline.
• Sequestration may cause signs of hypovolemia due to
trapped blood in the spleen and may result in profound
anemia, with total hemoglobin falling below 3 g/dL.
• Sequestration may be triggered by fever, bacteremia, or viral
infections.

49. • Treatment includes early intervention to maintain
hemodynamic stability using isotonic fluid or blood
transfusions.
• Only 5 mL/kg of red blood cells is recommended to prevent
hypovolemia.
• Prophylactic splenectomy performed after an acute episode
has resolved is the only effective strategy for preventing
future life-threatening episodes.
• Furthermore, prophylactic blood transfusion therapy may
put the patient at risk for autotransfusion (the phenomenon
when the blood sequestered in the spleen is released and
dramatically increases the hemoglobin concentration,
putting the patient at risk for hyperviscosity syndrome.

50. Liver and Gallbladder
• Hepatic sickle cell crisis or "sickle hepatopathy" occurs in ~10% of
patients
• Symptoms include intense RUQ pain and tenderness, fever,
leukocytosis, and jaundice.
• Bilirubin levels may be markedly elevated, while serum ALP levels may
be only moderately elevated.
• Symptoms of sickle hepatopathy generally resolve within 1-3 weeks
and are self-limited.
• Sickle cell intrahepatic cholestasis is a more severe form of sickle cell
liver disease that can progress to acute liver failure, requiring
transplantation as the only therapeutic option.

51. Sickle Cell Pain
• Dactylitis, or hand-foot syndrome, is a common first manifestation of pain
• Dactylitis can cause symmetric or unilateral swelling of the hands/ feet
• Acute vasoocclusive pain is the hallmark feature of sickle cell anemia,
Painful episodes can occur in the chest, abdomen, or extremities
• Rx- Paracetomol, IV morphine
• The majority of painful episodes in patients with sickle cell anemia can be
managed at home with comfort measures such as heating blankets,
relaxation techniques, massage, and oral pain medication.
• Should be differnentiated from Ostemyelitis -patients with osteomyelitis
often have a longer duration of fever and pain, swelling of the affected
area, fewer or only 1 location of pain and tenderness, higher white blood
cell counts, and an elevated C-reactive protein.

53. Avascular necrosis
• AVN most commonly affects the femoral head, but can also occur in
the humeral head and mandible.
• Risk factors for AVN in patients with sickle cell anemia include HbSS
disease with α-thalassemia trait, frequent vasoocclusive episodes,
and elevated hematocrit.

54. Priapism
• Priapism is an unwanted painful erection of the penis.
• The mean age of the first episode is 15 years
• Priapism occurs in two patterns: prolonged, lasting more
than 4 hours, or stuttering, with brief episodes that resolve
spontaneously but may occur in clusters
• Acute priapism - supportive therapy, such as a hot shower,
short aerobic exercise, or pain medication, is commonly used
by patients at home.
• A prolonged episode lasting more than 4 hours should be
treated by aspiration of blood from the corpora cavernosa
followed by irrigation with dilute epinephrine.

55. Pulmonary Complications
• ACS is defined as a new radiodensity on chest radiography
plus any two of the following: fever, respiratory distress,
hypoxia, cough, or chest pain
• All patients with fever should receive a chest radiograph to
identify evolving ACS because clinical examination alone is
insufficient
• The radiographic findings in ACS may include single or
multiple lobe involvement and pleural effusions.
• ACS can progress rapidly, and continued pulse oximetry and
frequent clinical exams are necessary.

56. CNS
•Silent cerebral infarction
•Management of children with silent infarcts includes
neuropsychological testing and monitoring of academic
performance.
•Symptoms of stroke include:
i. focal motor deficits (e.g., hemiparesis and gait dysfunction),
ii. speech defects,
iii. altered mental status,
iv. seizures, and
v. headache

57. THERAPEUTIC CONSIDERATIONS
• Hydroxyurea has been shown to be an effective treatment
option for reducing the frequency of painful episodes (It
raises the level of HbF and the haemoglobin level , )
• For patients who are unable to tolerate other treatments
or cannot continue blood transfusion therapy to prevent
recurrent stroke, hydroxyurea may be a reasonable
alternative.
• The typical starting dose of hydroxyurea is 15-20 mg/ kg
given once daily, with an incremental dosage increase
every 8 wk of 5 mg/kg, and if no toxicities occur, up to a
maximum of 35 mg/kg per dose.

58. Hematopoietic Stem Cell Transplantation
• The only cure for sickle cell anemia is transplantation
with human leukocyte antigen (HLA)–matched
hematopoietic stem cells from a sibling or unrelated
donor.

59. Red Blood Cell Transfusions
• Red blood cell transfusions are frequently used in the
management of children with sickle cell anemia, both in the
treatment of acute complications such as ACS, aplastic crisis,
splenic sequestration, and acute stroke, and to prevent
surgery-related ACS and first stroke

60. SICKLE CELL TRAIT (HEMOGLOBIN AS)
• People who inherit one sickle cell gene and one normal gene have
sickle cell trait.
• By definition among individuals with sickle cell trait, the HbS level is
<50%.
• The life span of people with sickle cell trait is normal, and serious
complications are extremely rare. The CBC is within the normal range
• Hemoglobin analysis is diagnostic, revealing a predominance of HbA,
typically >50%, and HbS <50%.
• Rare complications - sudden death during rigorous exercise, splenic
infarction at high altitude, hematuria, hyposthenuria, deep vein
thrombosis, and susceptibility to eye injury with formation of a
hyphema

62. THALASSEMIA SYNDROMES(Defect in quantity)
•Thalassemia is a group of genetic disorders that affect globin
chain production .
•β-Thalassemia - is decrease in β-globin chains, resulting in an
excess of α-globin chains.
•β0-Thalassemia is a complete absence of β-globin production
•β+-Thalassemia produces decreased amounts of normal β-
globin.

64. •Homozygous β-thalassemia patients cannot produce any
normal β chains, while β+-thalassemia patients still produce
some.
•β-Thalassemia major refers to the severe form that often
requires early transfusion therapy and is usually
homozygous for β0 mutations.
•β-Thalassemia intermedia is a less severe form that often
doesn't require transfusion therapy in childhood and is
usually associated with at least one β+-thalassemia
mutation.

66. HOMOZYGOUS β-THALASSEMIA (THALASSEMIA MAJOR, COOLEY ANEMIA)
• Children with homozygous β0-thalassemia become symptomatic with
progressive hemolytic anemia, profound weakness, and cardiac
decompensation during the second 6 months of life.
• The decision to transfuse is multifactorial and not determined solely by the
degree of anemia.
• The developing signs of ineffective erythropoiesis such as growth failure, bone
deformities secondary to marrow expansion, hepato- splenomegaly are
important variables in determining transfusion initiation.
• The classic presentation of children with severe disease includes thalassemic
facies (maxilla hyperplasia, flat nasal bridge, frontal bossing), pathologic bone
fractures, marked hepatosplenomegaly, and cachexia.

67. Clinical features
Thalassemia minor/trait/carrier.
• These children are usually asymptomatic or may have mild anemia .
Thalassemia intermedia.
• Presents as mild anemia in absence of other causes of anemia
• Can also present with growth retardation , jaundice ,hemolytic facies
and hepatosplenomegaly .

68. Thalassemia major
• Most children manifest in first year of life .
• Present with varying degree of pallor ,failure to thrive and weight
gain,irritability,intercurrent infections,hepatospleenomegaly.

73. Cause of death
1. Congestive heart failure.
2. Arrhythmia.
3. Infection.
4. Multiple organ failure due to iron overload.

74. SCREENING TESTS
1. Red blood cell indices
2. NESTROFT(Naked Eye Single Tube Red Cell Osmotic Fragility
Test)
3. Various Discriminant functions derived from Red Cell Indices

75. How to Interpret
• Low MCV, MCH coupled with a normal RDW and a high RBC
count with a Mentzer index of < 13 (MCV/RBC) are a good
indicator of thalassemia trait or carrier state.
• However, confirmation by Hb Electrophorosis or HPLC is
mandatory.

77. NESTROFT TEST

78. CONFIRMATORY TESTS
• Hemoglobin electrophoresis.

79. High performance liquid chromatography

81. TREATMENT
• Blood transfusion is the main stay of treatment .

84. • The decision to start transfusions is based on severity of
symptoms and inability to compensate for the low hemoglobin
• Less commonly, on increasing symptoms of ineffective
erythropoiesis (bone changes, massive splenomegaly)

85. WHEN TO START TRANSFUSION
• The decision to start regular transfusions is clear when the
initial hemoglobin level is well below 6 g/ dL.

86. • Patients with a hemoglobin level less than
7 g/ dL may sometimes require regular
transfusions in the presence of growth
impairment, marked skeletal changes, or
extramedullary hematopoiesis.

87. • Assessment may be accomplished by withholding
transfusions and monitoring weekly hemoglobin level.
• If the hemoglobin drops under 7 g/dL on two
occasions two weeks apart, then regular transfusions
should be commenced.

88. HOW FREQUENTLY WE HAVE TO TRANSFUSE ?
• Transfusions should generally be given at an interval of three to
four weeks.
• Transfusions should be scheduled in advance and maintained
at a fixed schedule. This enables patients and families to
establish routines and will improve quality of life

89. HOW MUCH TO TRANSFUSE?
• The amount of blood received on transfusion day is
determined by pre-transfusion hemoglobin levels.
• 10-15ml/kg of blood is transfused per transfusion.
• The target is to maintain the pre-transfusion hemoglobin level
between 9 and 10 g/dL.

90. • Blood should be transfused at 5 mL/kg/hour, and the post-
transfusion hemoglobin should not exceed 14 g/dL.
• In patients with severe anemia (hemoglobin less than 5 g/dL)
or cardiac compromise, the rate of transfusion should be
reduced to 2 mL/kg/hour to avoid fluid overload.

91. • If cardiac insufficiency is present, higher pretransfusion
hemoglobin levels (10 to 12 g/dL) should be maintained with
smaller volume transfusions given every one to two weeks .
• Diuretics may be used (1-2mg/kg) for some patients.

92. • The patient’s weight and pre-transfusion hemoglobin and the
volume of transfusion should be recorded at each visit.
• These values should be periodically reviewed to assess the
volume of blood required to maintain the desired pre-
transfusion hemoglobin level.
• Annual blood transfusion requirement in patients without
hypersplenism is usually below 200 mL packed red blood
cells/kg per year.

94. • Iron is a highly reactive compound and generates significant
free radicals while transitioning between the ferric and ferrous
states.
• The reactive oxygen species and hydroxyl radicals generated
are responsible for activating cytokines and inflammatory
markers, including TGF-B1 and caspase.

95. • The resultant lipid peroxidation leads to organelle and DNA
damage and subsequent apoptosis and cell death.
• Free radicals also form a bed for increased risk of infections.

96. • Iron accumulation causes cardiomyopathy, cirrhosis, and
endocrinopathies.
• The most commonly seen endocrine disorders are
panhypopituitarism, hypogonadism, short stature,
hypothyroidism, diabetes mellitus, osteopenia, osteoporosis,
and infertility.

99. • Liver iron concentration (LIC) is the most reliable
indicator of iron overload.
• Average values are up to 1.8 mg/g dry weight of the
liver.
• Methods to detect LIC include biopsy, SQUID
(superconducting quantum interface device), and MRI

100. • Echocardiography to assess left ventricular ejection
fraction (LVEF) has been used to evaluate cardiac
function.
• MRI T2 is a more reliable tool to assess cardiac iron
and, inferentially, cardiac function.
• MRI T2 values of >20 milliseconds (ms) are expected,
and 10 to 20 ms and <10 ms suggest moderate and
severe cardiac iron overload

101. • Ferritin is an acute-phase reactant, and we often
observe a falsely high value during periods of
inflammation and infections.
• Serum ferritin may be low despite high tissue iron.
Therefore, monitoring the trend in serum ferritin
values is more reliable than a single estimate.

102. Management of iron overload in thalassemia major
can be of three types:
1. Preventive therapy when we commence iron chelation
before endorgan damage.
2. Rescue therapy where there has been a significant iron
overload in tissues with changes in end organs.
3. Emergency therapy, mainly when the patient presents
with cardiac failure secondary to unchecked cardiac iron
overload.

103. WHEN TO START CHELATION THERAPY
• Thalassemia International Federation has recommended
guidelines for optimal chelation.
• We need to initiate chelation when the serum ferritin is above
1000 µg/L, after > 10 - 20 blood transfusions, or once the child is
above two years of age.

105. MECHANISM OF CHELATION
• The purpose of the iron chelator is to increase the
solubility of the iron, thus ensuring excretion in the
urine.
• Iron chelators bind specifically to the labile iron,
which is in a constant state of production.

106. • Mainly there are 3 iron chelators
1. Desferroxamine.
2. Deferiprone.
3. Deferasirox.

107. DESFERROXAMINE
Rs. 2000 approx. per vial

108. DEFERIPRONE
Rs. 10 per tablet

109. DEFERASIROX
Rs. 135 per tablet

111. Splenectomy
• Splenectomy reduces the transfusion requirements in patients
with hypersplenism.
• Indications include
1. Presence of leukopenia or thrombocytopenia
2. Annual packed cell transfusion exceeds 200ml/kg/year
3. Massive spleen with abdominal discomfort
4. Difficult to maintain pretransfusion Hb of 10g/dl

112. - More recently, splenectomy is utilized less frequently due to the
increased risk of pulmonary hypertension,thromboembolism,
and infection after splenectomy

113. • At least 2 weeks prior to splenectomy, a polyvalent
pneumococcal and meningococcal vaccine should be given.
• If the patient has not received a H. influenzae vaccine, this
should also be given.
• Following splenectomy, prophylactic penicillin 250 mg bid is
given to reduce the risk of overwhelming postsplenectomy
infection.

114. HYDROXYUREA
• Fetal hemoglobin inducer
• Decreases imbalance between alpha globin versus non alpha
globin chains.
• levels of HbF ameliorate the symptoms of β-thalassemia by
increasing the hemoglobin concentration of the thalassemic
red cells and decreasing the accumulation of unmatched α-
chains, which cause ineffective erythropoiesis.

115. • HU has been demonstrated to increase HbF production and
mean hemoglobin levels in patients with NTDT, including
hemoglobin E β-thalassemia.
• Typically, a starting dose of 10 mg/kg per day is utilized and
dose escalation beyond 20 mg/kg per day is usually not
tolerated.

116. Hematopoietic stem cell transplant
• Allogeneic HSCT is the only curative method currently
available in clinical practice.
• Outcomes and cure rates are better with matched sibling
donor transplant compared to other alternative donor
transplant.

117. • Risk factors which decide the outcome includes
1.Hepatomegaly>2cms.
2.Liver fibrosis.
3.Increased ferritin levels.

118. • The biggest drawback of this novel therapy in India is high cost
and lack of enough centres capable of providing this
treatment.
• Post-transplant regular follow-up, prevention and
management of complications will further improve outcomes.

119. Centres in Bangalore which perform bonemarrow
transplant
• Manipal Hospital (Old Airport Road)
• Fortis Hospital, Bangalore (Bannerghatta Road)
• Apollo Hospital (Bannerghatta Road)
• Apollo Spectra Hospital.
• Sparsh Hospital (Yeshwanthpur)
• Sakra World Hospital.
• Aster cmi hospital.
• BGS global hospital .

120. Average cost of transplant
• 1500000- 1700000 lakhs

121. Enzymatic Defects
• Enzyme deficiencies
• affects the generation of adenosine triphosphate
(ATP) within RBCs, leading to low levels of ATP,
pyruvate, and the oxidized form of nicotinamide
adenine dinucleotide (NAD+).
• As a result of the decreased ATP,
• RBCs cannot maintain their potassium and water
content, which causes the cells to become rigid and
• their lifespan to be considerably reduced.

123. LABORATORY FINDINGS
•Diagnosis relies on demonstration of a marked
reduction of RBC PK activity or an increase in the
Michaelis-Menten dissociation constant (Km) for
its substrate, phosphoenolpyruvate (high Km
variant).
•Other RBC enzyme activity is normal or elevated,
reflecting the reticulocytosis.
•No abnormalities of hemoglobin are noted.

124. TREATMENT
• Phototherapy and exchange transfusions may be indicated for hyper-
bilirubinemia in newborns.
• Transfusions of packed RBCs are necessary for severe anemia or for
aplastic crises.

125. DEFICIENCIES OF ENZYMES OF THE HEXOSE
MONOPHOSPHATE PATHWAY
•function of the hexose monophosphate pathway
is to maintain glutathione (GSH) in its reduced
state as protection against the oxidation of RBCs
.
•If glutathione, is decreased, the SH groups of the
RBC membrane are oxidized and the hemoglobin
becomes denatured -> precipitate into RBC
inclusions called Heinz bodies.

126. Glucose-6-Phosphate Dehydrogenase Deficiency
• Glucose-6-phosphate dehydrogenase (G6PD)
deficiency,
• episodic hemolytic anemia
• chronic nonspherocytic hemolytic anemia.
• The most common manifestations of this disorder are
neonatal jaundice and episodic acute hemolytic
anemia, which is induced by infections, certain drugs,
and, rarely, fava beans.

127. Agents Precipitating Hemolysis in Glucose-6-Phosphate Dehydrogenase
Deficiency
MEDICATIONS Others
Acetanilide
Vitamin K analogs
Methylene blue
Toluidine blue
Probenecid
Dimercaprol
Acetylsalicylic acid
Phenazopyridine
Rasburicase
Antibacterials
Sulfonamides
Dapsone
Trimethoprim-sulfamethoxazole
Nalidixic acid
Chloramphenicol
Nitrofurantoin
Antimalarials
Primaquine
Pamaquine Chloroquine
Quinacrine Antihelminths
β-Naphthol Stibophen
Niridazole
CHEMICALS
Phenylhydrazine Benzene
Naphthalene (moth balls)
2,4,6-Trinitrotoluene
ILLNESS
Diabetic acidosis
Hepatitis

129. •Most individuals with G6PD deficiency are asymptomatic,
with no clinical manifestations of illness unless triggered by
infection, drugs, or ingestion of fava beans.
•Hemolysis typically ensues within 24-48 hours after
ingestion of a substance with oxidant properties
•G6PD deficiency can produce hemolysis in the neonatal
period, with spontaneous hemolysis and hyperbilirubinemia
observed in preterm infants

130. Laboratory findings
• Onset of acute hemolysis leads to a sudden drop in hemoglobin and
hematocrit levels.
• Heinz bodies, which are precipitated hemoglobin, can be seen in
unstained or supravital preparations of RBCs, but not visible on the
Wright-stained blood film.
• Cells containing Heinz bodies are only visible within the first 3-4 days
of illness due to rapid clearance from the blood.
• The blood film may also show red cells with a bite taken from their
periphery and polychromasia, indicating reticulocytosis, which is
evidence of bluish, larger RBCs.

131. Heinz bodies

132. Diagnosis
•The diagnosis of G6PD deficiency relies on demonstrating
reduced G6PD activity in RBCs.
•Screening tests - methylene blue decoloration,
methemoglobin reduction, or NADPH fluorescence.
•G6PD variants can be detected through electrophoretic and
molecular analysis.
•G6PD deficiency should be considered in neonates with
hyperbilirubinemia and borderline low G6PD activity.

133. Prevention and treatment
• The usual doses of aspirin and trimethoprim-sulfamethoxazole do not
typically cause hemolysis
• However, administering aspirin in doses used for acute rheumatic fever
(60-100 mg/kg/24 hr) may lead to severe hemolysis in individuals with
G6PD deficiency.
• If severe hemolysis has occurred, supportive therapy may require blood
transfusions, but recovery is usually observed when the oxidant agent is
discontinued.

134. HEMOLYTIC ANEMIAS RESULTING FROM EXTRACELLULAR
FACTORS— IMMUNE HEMOLYTIC ANEMIAS
•The direct Coombs test detects antibodies
that are already attached to red blood cells
•Indirect Coombs test detects antibodies
that are present in the blood but not yet
attached to red blood cells.

136. Diseases Characterized by Immune- Mediated Red Blood Cell
Destruction
AUTOIMMUNE HEMOLYTIC ANEMIA CAUSED BY WARM REACTIVE AUTOANTIBODIES
Primary (idiopathic) Secondary
Lymphoproliferative disorders
Connective tissue disorders (especially systemic lupus erythematosus)
Nonlymphoid neoplasms (e.g., ovarian tumors) Chronic inflammatory diseases
(e.g., ulcerative colitis) Immunodeficiency disorders
AUTOIMMUNE HEMOLYTIC ANEMIA CAUSED BY COLD REACTIVE AUTOANTIBODIES
(CRYOPATHIC HEMOLYTIC SYNDROMES)
Primary (idiopathic) cold agglutinin disease Secondary cold agglutinin disease
Lymphoproliferative disorders
Infections (Mycoplasma pneumoniae, Epstein-Barr virus) Paroxysmal cold
hemoglobinuria
Primary (idiopathic)
Viral syndromes (most common) Congenital or tertiary syphilis
DRUG-INDUCED IMMUNE HEMOLYTIC ANEMIA
Hapten/drug adsorption (e.g., penicillin)
Ternary (immune) complex (e.g., quinine or quinidine) True autoantibody
induction (e.g., methyldopa)

137. Etiology
•In the autoimmune hemolytic anemias,
autoantibodies are directed against RBC
membrane antigens.
• The autoantibody may be produced as an
inappropriate immune response to an RBC
antigen or to another antigenic epitope similar to
an RBC antigen, known as molecular mimicry.

138. Autoimmune hemolytic anemias may occur in
either of 2 general clinical patterns.
• acute transient type lasting 3-6 months and occurring
predominantly in children ages 2-12 yr, accounts for 70-80%
of patients. It is frequently preceded by an infection, usually
respiratory. Good response to glucorticoid therapy.
• prolonged and chronic course, which is more frequent in
infants and in children >12 yr old. Hemolysis may continue
for many months or years. Abnormalities involving other
blood elements are common, and the response to
glucocorticoids is variable and inconsistent.

139. Laboratory Findings
• Anemia is profound, with hemoglobin levels <6 g/dL.
• Results of the direct antiglobulin test are strongly
positive, and free antibody can sometimes be
demonstrated in the serum (indirect Coombs test).
• These antibodies are active at 35-40°C (95-104°F)
(“warm” antibodies) and most often belong to the IgG
class.

140. AUTOIMMUNE HEMOLYTIC ANEMIAS
ASSOCIATED WITH “COLD” ANTIBODIES
• “Cold” antibodies agglutinate RBCs at temperatures <37°C (98.6°F).
They are primarily of the IgM class and require complement for
hemolytic activity.

141. Other causes of hemolytic anemia:
• Liver disease – Wilson
• Burns
• Thermal injury
• Fragmentation – prosthetic valves

146. REFERENCES
•Nelson Textbook of Pediatrics , 21st edition
•Lanzkowsky's Manual of Pediatric Hematology
and Oncology , 7th edition

147. Thank you