This document defines anemia and discusses its etiology, pathophysiology, classification, diagnostic tests, and treatment, specifically focusing on iron deficiency anemia. It states that anemia is a decrease in red blood cells or hemoglobin, and is the most common hematologic disorder. The main causes of anemia are blood loss, deficient red blood cell production, and increased red blood cell destruction. Iron deficiency anemia, one of the most prevalent nutritional deficiencies worldwide, occurs due to an imbalance between iron needs and supply.

1. ANEMIA
N.Sravanthi

2. Definition
 Decrease in either the hemoglobin (Hb) or the
volume of RBCs  oxygen-carrying capacity.
 Anemia is defined as decrease in the circulating red
blood cell mass
 <12 g/dL [hematocrit {Hct} <36%] in women
 <14 g/dL [Hct<41%] in men

3.  Most common hematologic disorder
 Rather sign than a disease itself

4. Etiology
 RBC Loss (without RBC destruction)
 Deficient RBC production
 Increased RBC destruction

5. RBC Loss (without RBC Destruction)
 Hemorrhage
 Trauma
 Disorders: e.g. cancer, ulcers, IBD
 Menstrual flow
 Gynecological disorders (e.g. endometriosis, fibroids)
 Pregnancy (especially at gestation)
 Parasitism
 Hookworms

6. Deficient RBC Production
 Neoplasia
 Leukemia
 Metastasis to bone
marrow
 Osteogenic sarcoma
 Myelofibrosis
 Pernicious anemia
Iron Deficiency
Aplastic anemia
Chloramphenicol
administration
Renal disease (lack of
erythropoietin production)
Increased RBC
destruction over
erythropoiesis

7. Increased RBC Destruction
Intrinsic Abnormalities
 Thalassemia
 G6PD
 Sickle Cell Anemia
Extrinsic Abnormalities
 Infections
 Malaria (Plasmodiumm species)
 Mycoplasma
 Lead poisoning

8. Normal RBC's
Zone of central pallor about 1/3 the size of the
RBC

9. Smaller RBCs
Increased zone of central pallor hypochromic microcytic
anemia.

10. Right Arrow RBC with a malarial parasite in the
shape of a ring. Three other RBC's in this
smear are also infected with a ring trophozoite.
Arrow at left is a gametocyte of P vivax.

11. Classification
- Based on Morphology
 Macrocytic Anemia – vit B12, folate deficiency
 Microcytic Hypochromic – IDA, sickle cell anemia
 Normocytic – recent blood loss, hemolysis, renal
failure
- Based on Etiology
- Based on Pathophysiology

12. Hematological Tests
 Complete blood count (CBC) or Complete Blood
Examination (CBE) is routinely ordered test
 Helps in diagnosis of multiple haematological
disorders

13. Routine Tests
 RBC count
 WBC count
 Hemoglobin (Hb)
 Hematocrit (Hct)
 RBC indices (specifically assess RBCs)
 Mean cell volume (MCV)
 Mean cell hemoglobin (MCH)
 Mean cell hemoglobin concentration (MCHC)

14. RBC count:
Male: 4.6 to 6.2 X106 cells /mm3
Female: 4.2 to 5.4 X106 cells /mm3
WBC count:
5000 to 10,000 cells /cu mm of blood
Hemoglobin (Hb):
Male: 14 to 18g/dl
Female: 12 to 16g/dl

15. Hematocrit (Hct) / Packed cell volume (PCV):
Volume of erythrocytes / L of whole blood indicating
the proportion of plasma and red cells.
Range:
Male: 42 to 52 %
Female: 37 to 47%

16. Mean cell volume (MCV):
Repesents average volume of RBCs
MCV = Hct / RBC count
Range:
Male: 80 to 96 fl (femtolitres – 10 -- 15)
Female: 82 to 98 fl

17. Mean cell hemoglobin (MCH):
It is the percent volume of Hb per RBC
Derived by dividing Hb by RBC count
Range: 27 to 33 pg /cell [picograms = 10 –12]
True increase in folate deficiency & decrease
in iron deficiency
A low MCH corresponds with hypochromic
RBCs - as seen in iron deficiency anaemia

18. Mean cell hemoglobin concentration (MCHC):
Is derived by dividing Hb by Hct
Range: 31 to 35 g/dl
Iron deficiency is the only anaemia in which
the MCHC is low

19. Reticulocytes:
Gives indirect measurement of RBC
production
Range: 0.5 to 2.5 % of RBCs

20. Peripheral Blood Smear
 Gives information on functional status of bone
marrow
 Information on anisocytosis, poikilocytosis

21. Serum Iron (50-100mcg/dL)
 Concentration of iron bound to transferrin
 Shows diurenal variation (20 – 30%)
 20 – 25 % day to day variation
 Decreases in infection and inflammation
 Best interpreted with TIBC
 in IDA, ACD
 in hemolytic anemias, iron overload

22. Ferrtin
 Cellular storage protein for iron
 Stores upto 4500 atoms of iron
 Accsessed for metabolic needs
 Plasma level reflects overall iron storage
 1 ng/mL  10 mg of total iron stores
 50 – 100 ng/ mL
 <10 -15 ng/mL  specific for IDA
 Inc Ferritin  iron overload state

23. TIBC (250 – 400 mcg%)
 Indirect measurment of iron binding capacity of
serum transferrin
 TIBC (Total Iron Binding Capacity) when
body iron stores are low
 Low serum iron and TIBC  IDA
 Actual measurement of protien, serum
transferrin

24. IRON DEFICIENCY ANEMIA
 Iron deficiency is the most common nutritional
deficiency in developing and developed
countries.
 More than 500 million people worldwide are
estimated to have IDA
 IDA is a leading cause of infant morbidity and
mortality
 children younger than 2 years, adolescent
girls, pregnant females, and elderly older than
65 years are at risk

25. BODY IRON DISTRIBUTION
Metabolically Active Iron
 Haemoglobin
 “Serum” iron bound to a protein transferrin
in blood
 Tissue Iron: in cytochromes and enzymes
 Myoglobin: oxygen reserve in muscles

26. Storage Iron
 Ferritin: found in blood, tissue fluids, and
cells
 Haemosiderin: found in macrophages
and assessed by staining bone marrow
with Prussian Blue stain

27. Food content of Iron &
absorption
6
mg/1000
Kcal
2000 -
2500 Kcal
12 – 15
mg of
elemental
iron
10%
1 mg of
elemental
iron

28. Etiology
 Results from imbalance between physiologic
iron need and supply
 Situations that increase the demand for iron
are frequent blood donations, participation in
endurance sports, menstruation, pregnancy
and lactation, infancy, and adolescence
 Occult blood loss from a single gastrointestinal
lesion has been shown to be a frequent cause
of “idiopathic” IDA

29.  Increased demand for iron and/or
hematopoiesis
 Rapid growth in infancy or adolescence
 Pregnancy
 Erythropoietin therapy
 Increased iron loss
 Chronic blood loss
 Menses
 Acute blood loss

30.  Blood donation
 Phlebotomy as treatment for polycythemia
vera
 Decreased iron intake or absorption
 Inadequate diet
 Malabsorption from disease (sprue, Crohn’s
disease)
 Malabsorption from surgery (post-gastrectomy)
 Acute or chronic inflammation

31. Pathophysiology
 Risk of iron deficiency is related to levels of iron
loss, iron intake, iron absorption, and physiologic
demands
 The margin between the amount of iron available
for absorption and the body’s iron requirement is
narrow for growing infants and female adults
 Manifestations of iron deficiency occur in three
stages:
 Prelatent
 Latent
 IDA

32. Laboratory Findings
 Low serum iron and ferritin levels and high
TIBC
 In early stages, RBC size is not changed. Low
ferritin concentration is the earliest and most
sensitive indicator
 Renal or hepatic disease, malignancies, infection,
or inflammatory processes may increase ferritin
values
 In the later stages of IDA, Hb and Hct 
microcytic hypochromic anemia develops
preceded with Microcytosis

33.  Low Transferrin saturation values likely
indicate IDA
 low serum transferrin saturation values also may
be present in inflammatory disorders
 TIBC usually helps to differentiate the
diagnosis TIBC >400 mcg/dL  IDA, values
<200 mcg/dL  inflammatory diseases
 With continued progression of IDA,
anisocytosis occurs and poikilocytosis
develops

34. Treatment
 The severity and cause of IDA determines the
approach to treatment
 Dietary supplementation and administration of
therapeutic iron preparations
 Iron is poorly absorbed from vegetables, grain
products, dairy products, and eggs
 Best absorbed from meat, fish, and poultry

35. Different formulations
General recommendation is administration of approx 200 mg
of elemental iron daily, in 2 or 3 divided doses to maximize

36. Parentral preparations
 Poor enteral absorption, continued blood loss,
intolerance to oral iron – prompts for parentral
therapy
 Dose (mL) = 0.0442 (Desired Hb - Observed
Hb) x LBW + (0.26 x LBW)
 For males: LBW = 50 kg + 2.3 kg for each inch
of patient’s height over 5 feet
For females: LBW = 45.5 kg + 2.3 kg for each
inch of patient’s height over 5 feet

37. Preparations
 Iron dextran
 Anaphylaxis noted in 1 out of 300 patients
 25mg of test dose in 50 mL normal saline
 Proceed if no reaction in 1 hour
 Pain and brown staining at injection site, flushing,
hypotension, fever, chills, myalgia, Anaphylaxis

38.  Ferric Gluconate
 Administered as 10 mL (125 mg of elemental iron)
in 100 mL normal saline intravenously over 1 hour
 cramps, nausea, vomiting, flushing, hypotension,
intense upper gastric pain, rash, and pruritus.

39. Monitoring Patient’s Response
 in reticulocyte begin in 3rd or 4th day of therapy
 in reticulocyte peak in 7th or 10th day of therapy
 By second week of therapy reticulocyte will back
to normal
 Hemoglobin increased by 2 gm/dL, Hematocrit
increased by 6% Within 3 weeks
 Anemia is resolved within 2 months
 Another 3-6 months of Iron therapy