Anemia Syndromes

Approach to Anemia

• Pathologic state due to insufficient erythrocytes.
• Easiest way to classify:
  • 2ndary to loss
  • 2ndary to lack of production
  • 2ndary to destruction
• Symptoms:
  • Tachycardia, exertional dyspnea, pallor of nails/conjunctiva, fatigue, reduced exercise tolerance.
• Labs:
  • CBC
• Pathology:
  • To make RBC, require: Epo (Made in Kidney), Iron, Cobalamin, Vitamin B12, marrow microenvironment.
• Approach:
  • Look at MCV (micro/normo/macrocytic)
  • Peripheral blood smear (always look at smear).
  • Reticulocyte Count: (tells you if the marrow is working).
    • Typically a % of normal erythrocytes
    • Now done with flow cytometry.  
    • Patients with anemia have LOW total erythrocytes 
    • Often corrected as reticulocyte index as bone marrow stress causes increased Epo production --> doubles of half-life of circulating reticulocytes (multiply by 0.5).
      • Therefore, must correct to reticulocyte index = %retics * hematocrit (/45 *0.5)
      • (last part is the correction factor for the doubling of retics)
    • Absolute Retic Counts:
      (some labs do FLOW cytometry, which reports Absolute Number--> eaier to use, less available)

      • Retic Count	Retic Index	Interpretation
        23,000-90,000/uL	<2%	Normal (Inappropriate Response to Anemia)
        > 100,000/uL	>3%	Appropriate Anemia Response

        
        (Retic Index numbers: wikipedia, Retic count numbers: MKSAP 16)
      •  
  • 
• Mentzner index to distinguish thalassemia vs iron def anemia
  • MCV/RBC -->
    • <13 - talassemia (bone marrow still produces enough RBC)
    • >13 - Iron def anemia (bone marrow cannot produce as many, so there are few RBCs and microcytic)

Microcytic Anemia

DDx TAILS

• Thalassemia
• Anemia of Chronic Disease
• Iron Deficiency Anemia
• Lead Poisoning
• Sideroblastic Anemia

Standard Workup:

• Blood Film
• Ferritin
• Retics
• B12  (Folate low yield)

Can use RDW to help distinguish etiologies:

• Iron Deficiency: increased RDW (anisocytosis)
• Thalassemia minor: normal RDW (also expect high RBC count)

Normocytic Anemia

• Nutritional (Can be IDA, folate, B12, sick cell, methotrexate)
• Renal Failure (Often CKD stage 4)  EPO deficiency.  If giving Epo, ensure has iron too.
• Active Bleed

Macrocytic Anemia

• EtOH Use
• Myelodysplastic Syndrome
• Folate Deficiency
• B12 Deficiency (also glossitis, weight loss, macroovalocytes, hypersegmented PMNs, hemolysis, posteriour columns neuro deficits).
• etc...

Multiple Myeloma

• Pt may have history of fractures
• sPEP and uPEP (Serum Protein ElectroPhoresis, and urine Protein Electrophoresis)
• sPEP --> 80% sensitivity
  • adding uPEP --> raises sensitivity to 80-95% sensitivity
  • for uPEP they do spot urine for Bence Jones Proteins (even thought called uPEP)
• 5% of patients with MM will have normal sPEP and uPEP

Pancytopenia

Notes

• Bone Marrow Suppression causes 10 g/L/week loss of Hb.  NOT MORE!  
• High RDW associated with:
  • Iron deficiency anemia, hemolytic anemias, myelofibrosis, blood transfusion