Download - The anaemic patient Basics and pitfalls
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The anaemic patient
Basics and pitfalls
Bettie Oberholster2013
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Day to day “Working” definition of anaemia
Hb too low for age and gender at a given altitude
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Journey
STARTING POINT
DESTINATION
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Presence of an anaemia
Effective treatment
Establishing the underlying cause
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Potential causes
Bone marrowLack of nutritients (iron, vit B12, folate)
Bone marrow suppression by e.g. drugs, virus infections
Bleeding
Hemolysis
↑Plasma volume
Primary BM disorders
BM Infiltration
1. PRODUCTION 2. PERIPHERAL LOSS
↓ Thropic hormones(EPO, thyroid, androgens)
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Anaemic Patient
Cause & Effective treatment
Fast and cost-effective
DETOUR: waste time and may be expensive
SHORT CUT: may land up at wrong destination or get lost
Which route ?
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Best Route ?
GPS Route Guidance
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GPS: “History and clinical findings”
• Obvious blood loss
• Drug history e.g chemotherapy, ARV’s
• Chronic disease e.g. renal disease, SLE, malignancy
• Organomegaly
• Family history
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GPS: “Reticulocyte count”
Do not use the % count
RPI: RETICULOCYTE PRODUCTION INDEX
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RPI <2.0
RPI ≥2.5
Blood lossResponse to hematinics
Bone marrow production
defectHEMOLYSIS
Red cell indices
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Hemolysis
SCREEN: confirm the presence of hemolysis• Raised unconjugated bilirubin• Raised LDH • Decreased haptoglobin • Increased urinary urobilinogen• Haemosiderin in the urine (IV)
You still need to find out WHY the patient is hemolysing
Examination of blood smear is important for clues
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Direct coombs
Red cell membrane studies
Micro-angiopathic hemolytic anaemia
DIC, TTP/HUS, PET/HELP
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GPS: “Red cell parameters”
• MCV = mean corpuscular volume (mean size of a red cell)
• MCH = mean corpuscular hemoglobin (mean Hb per red cell)
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Normochromic NormocyticMCV and MCH normal
Hypochromic Microcytic
MCV and MCH low
Macrocytic
MCV high
Blood lossChemotherapyHaemolysis (RPI ≥2.5)
Anaemia chronic diseaseBone marrow failureMixed nutrient deficiencies (RDW high)Early iron deficiency
Iron deficiencyAnaemia of Chronic disease
ThalassaemiaHemoglobinopathySideroblastic anaemiaLead poisoning
MegaloblasticVit B12/folate defDrugs e.g MTX, AZT
Non-megaloblastic Liver diseaseAlcoholARV’sHypothyroidismMyelodysplasiaReticulocytosis
Iron studiesRenal functions
Iron studies Vit B12 and RBC folate, TSH, LFT
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Important
Iron, vit B12 and red cell folate studies
BEFORE any blood transfusion
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GPS: “Iron studies”
Serum Iron
Transferrin % Transferrin saturation
S-Ferritin
Typical Iron Deficiency
↓ ↑ ↓ ↓
Typical anaemia of Chronic disease
↓ ↓ ↓ Normal to raised
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Normal ferritin does not exclude iron deficiency
Ferritin: 30-100 and % sat < 16%
May be iron deficiency in presence of an acute phase
Soluble serum transferrin receptor assay (sTfR)
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Not all hypochromic microcytic anaemias are iron deficiencies or anaemia of chronic disease !!
Thalassaemia or hemoglobinopathy(RBC count normal to high)
Hb electrophoresis/abnormal hemoglobin screen (HPLC)Make sure that iron status is normal
DNA testing to exclude alfa thalassaemia, lead levels and possible BM for sideroblastic anaemia
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Do not miss underlying Myelodysplastic disorder
Macrocytic anaemia
Normal Vit B12/folateNormal LFTNormal TSHNo drug history
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GPS: “Phone a friend: Local Pathologist”
• Clues blood smear findings
• Advice further investigations
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GPS: “Bone marrow”
Unexplained anaemia with low RPI
FBC: pancytopenia, bicytopenia or abnormal WBC
Abnormal cells on blood smear e.g. blasts, dysplasia Leuco-erythroblastic reaction
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BM not always the best route
Unexplained Iron Deficiency ?
Celiac disease
• Antibodies•Small bowel biopsy•HLA-DQ2 and HLA-DQ8
•PNH
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Right destination
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Take home message