Anaemia

What is haemopoeisis? (1)

Process of producing cellular components of blood. In adults this occur in the bone marrow and lymphatic tissue. All blood cells are derived from a single pluripotent stem cell. In healthy adults there are ~ 10^11-10^12 new blood cells produced daily

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What is haemopoeisis? (2)

Maintains steady state levels in peripheral circulation (O2 transport, stress, infection/inflammation, response to injury)

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Describe features of the full blood count (1) - microscopy, RBCC, Hb

Microscopy (look at shape of cells under microscope). RBCC (number of rbc/L of blood. 4.5 - 6.5 x 10^12/L men, 3.8 x 10^12/L women, reduced in anaemia. Hb (weight of Hb/100 mL blood, 13-18 g/dL men, 11.5 - 16 g/dL women, reduced in anaemia)

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Describe features of the full blood count (2) - PCV and RBCC/Hb/PCV

PCV (volume of rbc//L blood, 0.4-0.5 L). RBCC/Hb/PCV are reduced in anaemia, increase in dehydration/polycythaemia/chronic hypoxia

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Describe features of the full blood count (3) - MCV

MCV (average volume of rbc, 80-96 fl, below range/microcytic, above range/macrocytic, conditions that affect MCV - thalassaemia, alcoholism, vit B deficiency, folic acid deficiency, chemotherapy)

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Describe features of the full blood count (4) - MCH

MCH (mean weight of Hb/rbc, 27-32 pg/cell, reduced in hypochromic anaemia)

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Describe features of the full blood count (5) - MCHC and reticulocytes

MCHC (mean weight of Hb/100 mL rbc, 30-35 g/100 mL cells). Reticulocytes (precursors of erythrocytes, 0.5-2%, 25-75 x 10^9/L)

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Describe features of the full blood count (6) - ESR

ESR (rate of settling of rbc, 0-0 mm/hr men, 0-20 mm/hr women, increased ESR indicated faster settling due to rbc clumping associated with inflammation, diagnostic)

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Describe features of the full blood count (7) - platelets

Platelets (number/L blood, 200-350 x 10^9/L, reduced/risk of bleeding, increased/risk of clotting, monitored if patients are on parenteral anti-coagulants)

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Describe features of the full blood count (8) - WCC

WCC (number of wbc/L blood, includes basophils, eosinophils, neutrophils, monocytes, lymphocytes, 4-11 x 10^9/L, increased in infection/tissue damage/leukaemia)

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What is anaemia?

Insufficient Hb. Blood can't carry sufficient oxygen from the lungs to the tissues to meet the tissue needs (decreased number of rbc)

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What are the signs and symptoms of anaemia?

SOB, muscle weakness, fainting, yellowing of eyes, chest pains (not specific symptoms to anaemia, could be for other disease states)

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What the investigations which need to be carried out?

Diagnose anaemia and assess severity (Hb, clinical symptoms). Determine cause - number of RBCs (RBCC), size of RBCs (MCV), normocytic, microcytic (Fe deficiency anaemia), macrocytic/megaloblastic (vit B12 deficiency anaemia/folate deficiency anaemia)

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What are the causes of anaemia? (1)

Reduced production of RBCs/Hb (due to lack of some factors required for rbc production - Fe/B12/folate deficiency, bone marrow failure). Increased Hb loss (excessive blood loss due to acute/chronic haemorrhage)

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What are the causes of anaemia? (2)

(increased destruction of RBCs, sickle cell anaemia, infections/malaria, some autoimmune diseases)

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Describe types of anaemia (1)

Normochromic (normal mean cell Hb concentration) and normocytic (normal number of rbc in blood). Characterised by normal MCHC/MCV. E.g. anaemia of chronic disease (CKD), haemolytic anaemias/characterised by accelerated destruction of rbcs

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Describe types of anaemia (2)

Aplastic anaemias (characterised by disappearance of rbc precursors from marrow)

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Describe types of anaemia (3)

Hypochromic (low mean cell Hb conc) and microcytic (low number of rbc in blood), low MCHC/MCV, e.g. Fe deficiency anaemias, thalassaemias, anaemia of chronic disease

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Describe types of anaemia (4)

Normochromic and macrocytic (large number of rbc in blood), normal MCHC, high MCV, vit B12 deficiency anaemia (pernicious anaemia), folate deficiency anaemia

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Describe the treatment of anaemia (1)

Depends on severity/case (if mild/no symptoms, patients have routine investigation, treatment based on type of anaemia diagnosed, if related to sudden blood loss, may required hospitalisation)

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Describe the treatment of anaemia (2)

Transfusion rarely necessary (problems - expensive, short supply/worsening, infection risk, transfusion reaction, HF). Management depends on type of anaemia (requires comprehensive assessment to identify cause of anaemia/determine management options

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Describe features of iron deficiency anaemia (1)

Most common cause of anaemia. Caused by blood loss (GI bleeding, menorrhagia), inadequate absorption, dietary deficiency, malabsorption, pregnancy, cancer (e.g. colon, gastric), coeliac disease (impaired absorption of nutrients e.g. Fe)

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Describe features of iron deficiency anaemia (2)

Microcytic (reduce MCV/MCHC), reduced serum iron, reduced serum ferritin

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What are the sign and symptoms of iron deficiency anaemia?

General fatigue, weakness, pale skin, SOB, dizziness, tingling/crawling feeling in legs, tongue swelling/soreness

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Describe the treatment for iron deficiency anaemia (1)

Iron supplementation only effective in treatment of Fe deficiency anaemia. Not effective in treatment of anaemia due to any other cause. Require 100-120 mg elemental iron/day. Different iron salts available

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Describe the treatment for iron deficiency anaemia (2)

(ferrous fumarate, ferrous gluconate, ferrous sulphate). Contain different quantities of elemental iron e.g ferrous sulphate 200 mg TDS (65 mg elemental iron TDS)

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Describe the treatment for iron deficiency anaemia (3)

MR preparations should not be used (Fe absorbed in duodenum, MR preps release iron after duodenum, fewer side effects as less Fe is absorbed). Iron absorbed better in acidic conditions (vitamin C/ascorbic acid can increase iron absorption)

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Describe the treatment for iron deficiency anaemia (4)

Combination preps not recommended as additional cost not worthwhile. Continue for 3 months after Hb normalised to replenish Fe stores (related to lifespan of RBC)

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What are the side effects from the treatment for iron deficiency anaemia? (1)

S/E - nausea, epigastric pain, constipation, black stools. Counselling (take on empty stomach/increase absorption), if GI side effects occur take after food. If GI side effects are problematic consider ferrous gluconate

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What are the side effects from the treatment for iron deficiency anaemia? (2)

or IV iron (risk of pain, anaphylaxis, under dosing as cannot give total amount in one infusion)

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What are the interactions with iron?

Iron absorption reduced by Mg, Ca, antacids, cholestyramine, tetracyclines. Iron reduces absorption of tetracyclines, quinolones, bisphosphonates, penicillamine, levodopa

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Describe features of macrocytic anaemias (1)

Vit B12/folic acid deficiency anaemia. General management - wait for serum B12/folate levels, start appropriate treatment, if treatment needs to be started urgently give both

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Describe features of macrocytic anaemias (2)

If patient is B12 deficient and you give folate - risk of precipitating peripheral neuropathy

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What are the causes of B12 deficiency anaemia? (1)

Dietary deficiency (liver, fish, dairy). Malabsorption (due to lack of intrinsic factor in stomach secretions). Surgery involving removal/bypassing of the end of SI where vit B12 is absorbed. Macrocytic (high MCV), low serum B12, megaloblastic

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What are the causes of B12 deficiency anaemia? (2)

Associated with peripheral neuropathy (tingling in fingers and toes)

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What are the signs and symptoms of B12 deficiency anaemia?

Weak muscles, numbness/tingling in hands and feet, difficulty walking, nausea, decreased appetite, weight loss, irritability, lack of energy/tiring easily (fatigue), diarrhoea, smooth/tender tongue, increased HR

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Describe the treatment for B12 deficiency anaemia

Usually caused by B12 malabsorption. Hydroxycobalamin injection 1 mg IM, 3x/week initially to restore body stores, then once every 3 months to maintain stores. PO cyanocobalamin can be given for cases caused by dietary deficiency, no ADRs

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What are the causes of folate deficiency anaemia

Dietary deficiency, malabsorption, increased requirement (pregnancy), antifolate drugs (e.g. anticonvulsants, methotrexate, azathioprine). Megaloblastic (high MCV), reduced serum folate, reduced red cell folate

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What are the signs and symptoms of folate deficiency anaemia?

A pale yellow tingue to skin, sore/red tongue (glossitis), mouth ulcers, paraesthesia (pins/needles), changes in the way they walk/move around, disturbed vision, irritability, changes in mood/depression

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Describe the treatment for folate deficiency anaemia

5 mg folic acid OD. 400 mcg tablets for prevention of neural tube defects during pregnancy. Treatment should be continued for 4 months after Hb normalised to replenish stores. No ADRs

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What are the causes of bone marrow failure?

Drugs (chemotherapy), radiation, chemicals. Reduce RBCs, platelets, WCC

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Describe features of an endocrine deficiency

Hypoxia, kidney detects that it's not receiving enough. EPO stimulates RBC production by bone marrow, increased RBC - more O2 carried by blood

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What causes endocrine deficiency?

Renal failure, anaemia of chronic disease. Normocytic, normochromic

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Describe features of haemolysis

Increased destruction of RBCs, caused by autoimmune disease, drugs, abnormal Hb (sickle cell anaemia). Normocytic, normochromic, increased bilirubin

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What is the management for autoimmune haemolytic anaemia?

Corticosteroids (1st line), other immunosuppressants e.g. rituximab, cyclophosphamide, azathoprine or cyclosporin

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Describe features of erythropoeitin deficiency (1)

Anaemia caused by chronic renal failure. Treatment mainly with recombinant human EPO (aranesp, eprex, neorecormon), IV/SC injection 1-3 times weekly, ineffective if insufficient iron available, expensive but increases exercise capacity, increases QOL

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Describe features of erythropoeitin deficiency (2)

Reduces mortality. S/E - hypertension, thrombosis

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Describe features of sickle cell anaemia

Abnormal Hb formation (HbS). When not carrying O2, can crystallise - shape of rbc distorted. Distorted rbc destroyed - reduced RBC lifespan (5-30 days vs 120 days). Distorted rbc stick together in clumps - occlusion in blood vessels

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What are the signs and symptoms of sickle cell anaemia?

Tissue ischaemia, organ damage, pain, increased risk of infection (reduce immune system response)

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What is the treatment for sickle cell anaemia?

Analgesia PRN (may have complex pain requirements). Vaccination and prophylactic antibiotics. Folic acid

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Summarise how patients are screened to diagnose anaemia type

Macrocytic anaemia (reduced B12/pernicious anaemia, reduced folate/folate deficiency anaemia). Normochromic/normocytic anaemia (haemorrhage, haemolytic anaemia, anaemia of chronic disease/renal failure). Hypochromic/microcytic anaemia (Fe deficiency)

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When do you refer to a haematologist?

To determine cause of anaemia, may be related to blood loss, pregnancy, symptoms associated with NS e.g. changes in vision, numbness, tingling hands/feet

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When do you refer to a gastroenterologist?

If suspicion of GI tract disorder associated with malabsorption e.g. if suspecting coeliac disease, Crohn's disease

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When do you refer to a dietician?

When malabsorption is caused by poor diet

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Anaemia

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