Diabetes and hematology is there a link hematologic changes in diabetes mellitis

1. Dr/ Marwa Mahmoud Khalifa
Internal Medicine and Hematology Consultant

2. Anemia in DM
 Patients with T2DM are twice more likely to have
anemia than non diabetics
 Anemia is more common in poorly controlled DM
than well controlled
 7.2% of diabetics with normal renal function
 20% of diabetics with renal insufficiency
 Normochromic, normocytic anemia

4. Increased
renal blood
flow
Increased
renal oxygen
delivery
Suppress
EPO
production

5. Etiology
of
anemia
ACD
Nutritional
Concomitant
autoimmune
disorders
Medications
EPO
deficiency
and
resistance
Inflammatory
cytokines
Renal
impairment

6. Complications of Anemia in
Diabetes
 Anemia is a risk factor for cardiovascular and ESRD in
diabetic patients. It has direct mitogenic and
fibrogenic effects on the kidney and the heart
“The deadly triangle”
 Anemia is associated with expression of growth
factors, hormones and vasoactive agents implicated in
the diabetic microvascular disease
 Anemia is associated with rapid progression of renal
disease in diabetics

7. Complications of Anemia in
Diabetes
 Anemia is an independent risk factor for diabetic
retinopathy
 Anemic patients with T1DM were more than twice as
likely to have IHD
 Reduced Hb level identified diabetic patients at
increased risk for hospitalization and premature
death

9. Fallacies in HbA1c measurement in
Anemia
 HbA1c is altered in :
Hemolytic anemia
Pregnancy
Hemoglobinopathies
Vitamin B12 deficiency
 Caution must be taken when diagnosing diabetes and
pre diabetes among people with high erythrocyte
turnover

10. Fallacies in HbA1c measurement
in Anemia
 Iron deficiency may artificially increase HbA1c by
1- changing the shape of hemoglobin molecule,
promoting terminal valine glycation
2- lowering erythrocyte turnover, allowing more time
for hemoglobin glycation
 EPO therapy artificially lowers HbA1c while blood
glucose levels remained unchanged

11. Comparison between the two periods according to HbA1c in Iron deficiency
anemia before and after treatment

13. Leukocytic changes in Diabetes
 Total WBC count is higher in T2DM than non
diabetics
 Higher leukocyte count is correlated with macro and
micro vascular complications (nephropathy&
retinopathy) and can predict the severity of
complications
 Monocyte and neutrophil counts also increased in
parallel with the progression of complications.

14. Leukocytic changes in Diabetes
HOWEVER,
 The chemotactic, phagocytic and bactericidal
activities of neutrophils are impaired.
 Lysosomal enzymes release, myeloperoxidase activity
and ROS production by neutrophils are all decreased.
These changes increase the susceptibility to infection.

16. Platelets Changes in Diabetes
 Increased platelet aggregability and adhesiveness
(reduced membrane fluidity, increased intracellular calcium mobilization, decreased
intracellular magnesium, increased arachidonic acid metabolism, increased TXA2
synthesis, decreased prostacyclin and nitric oxide production, decreased antioxidant
levels and increased expression of GPIIb-IIIa and P-selectin )
 Impaired sensitivity to prostacyclin and NO that
normally blunt platelet activation
Inflammation mediated tissue damage in the
vasculature (Micro & Macro)

17. Platelets Changes in Diabetes
MPV is higher in
o diabetics >> non diabetic
o complicated (micro and macro vascular) >> non
complicated DM
o poor glycemic control >> good glycemic control.
MPV is a beneficial prognostic marker of DR in T2DM
patients

18. Effect of Hyperglycemia on
Coagulation and Fibrinolysis

20. Effect of hypoglycemia on blood
constituents
Hypoglycemia results in
1. Platelet hyperaggregability
2. Increase in fibrinogen and factor VIII.
3. Activated partial thromboplastin time is shortened,
4. Induces proinflammatory changes including an
increase in the IL-6, TNFα, IL-1β, and IL-8.
5. Inhibitory effect on fibrinolytic mechanisms.

21. OHDs and Blood Constituent
Changes
 Metformin, sulfonylureas, glitazones and acarbose
exert a favorable effect on platelet function.
 Among incretin therapies, only sitagliptin has been
demonstrated to have a beneficial effect on platelet
aggregation
 Thiazolidinediones and metformin lower FVII,
fibrinogen and PAI-1, enhance fibrinolysis

22. OHDs and Blood Constituent
Changes
 Metformin is associated with decrease absorption of
folic acid and vitamin B12 when used on a continuous
basis leading to megaloblastic anemia.
 Thiazolidinediones dilutional anemia

23. Iron overload and Diabetes
 Iron overload is a risk factor for diabetes.
 hereditary hemochromatosis and thalassemia
 mediated both by β-cell failure and insulin resistance
 Iron is also a factor in the regulation of metabolism in
most tissues involved in fuel homeostasis

24. Medications associated with
hyperglycemia

26.  Nilotinib use appears to be associated with
dysglycemia to a greater extent than other TKIs in
adult CML patients.
 Glycemic and metabolic outcomes in CML patients
should be closely monitored,