anemia

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