CLINICAL APPROACH TO ANEMIAdr. T.HARYANTO SURIJADI, SpPK

Anemia from the Greek (an-aîmia) meaning "without blood”

Difinition : Condition in which characterized Hb concentration decrease below the normal value. Usually is followed by a :decrease in hematocrit value or erythrocyte count.Hb concentration depends on sex, age, altitude and method used for Hb determination.CUT OFF POINT OF ANEMIA IN INDONESIA (Menkes 736 a/menkes 1989)Pre school age 11 g/dLSchool age 12 g/dLPregnant women : 11 g/dLAdult woman 12 g/dLAdult man 13 g/dL Hemoglobin normally carries oxygen from the lungs to the tissues, anemia leads to hypoxia (lack of oxygen) in organs. Varying degrees of anemia can have a wide range of clinical consequences.

ETIOLOGI OF ANEMIA 1. BLOOD LOSS - ACUTELY ----- HEMORRHAGE - CHRONICALLY ---- LOW-VOLUME LOSS 2.EXCESSIVE BLOOD CELL DESTRUCTION /HEMOLYSIS a.Hereditary abnormalities : erythrocyte membrane, enzyme defect, hemoglobinopathy b.Aquired abnormalities : immuologic defect, obstetric infection, chemistry, physic, mechanic abnormality

3.DEFICIENT RED BLOOD CELL PRODUCTION (ineffective hematopoiesis). a. Nutritrional anemia : protein, folic acid, Fe, vit B12 deff b. Bone marrow failure : aplastic anemia, anemia in malignancy

ANEMIA IS THE MOST COMMON DISORDER OF THE BLOOD.

C L I N I C A L E V A L U A T I O N :The causes anemia suggested from history and physical examination : H I S T O R Y - blood loss : obvious and dramatic clue to the causes anemia.- History of anemia reaches back to childhood is highly suggestive of a hereditary disorder ---especially congenital hemolytic anemia.- sudden onset pancytopenia in healthy individual may be explain with history of exposure to toxic chemicals or new medication.-TRANFUSION HISTORY- PAST BLOOD COUNT MEASUREMENTS-NUTRITIONAL HABIT-ACUTE OR CHRONIC ILLNES : WEIGHT LOSS, FEVER, NIGHT SWEATS . S Y M P T O M S : weakness or fatigue in general or during exercise, malaise and poor concentration , headache, dizziness .Severe anemia ------dyspnoe (shortness of breath) on exertion.

PHYSICAL EXAMINATION : PHYSICAL SIGN DEPEND ACUTE OR CHRONIC OF ONSET : ACUTE BLOOD LOSS SHOW SIGNS HYPOXIA AND HYPOVOLEMIA (FOR EXAMPLE TACHYCARDIA AND HYPOTENSI ORTHOSTATIC ) - --- LOSS 40 % BLOOD WILL EXHIBIT IN SIGN AND SYMTOMPS HYPOVOLEMIC SHOCK

ANEMIA DEVELOPS GRADUALLY BODY HAS TIME TO INCREASE PLASMA VOLUME : --- IN YOUNGER INDIVIDUAL SIGNS AND SYMTOMS NOT APPEAR UNTIL Hb 7 – 8 g/dL --- IN OLDER : Hb 10 g/dL CAN BE SYMTOMPMATIC (EXSPECIALLY PATIENT CVD OR ATHEROSCLEROTIC).GENERAL : SKIN AND MUCOUS MEMBRANE “PALLOR” ( LESS REALIBLE INHEAVILY PIGMENTED PATIENTS)

DIAGNOSISLABORATORY EVALUATION :Laboratory evaluation essential to definitive diagnosis and treatment Complete Blood Count : RBC number : Hb, Ht, RBC count, RBC indices : MCV , MCHC, MCH Platelet count WBC count , WBC diff Blood film morfology : cell size hemoglobinization, anisocytosis, poikilocytosis , polychromasia Reticulocyte count Marrow examination Marrow aspirate ( E/G RATIO, CELL MORF, IRON STAIN ) Marrow biopsy ( cellurality, morphology )

IRON STUDIESIRON TRANSFORT : si, tibcIRON STORES : Serum ferritin, Marrow iron stain, serum transferin receptor.

Hemoglobin/ Hb & hematocrit/ HtHemoglobin : The iron containing pigment of the red blood cells that functions to carry oxygen from the lung to the tissues Consists of approximately 6 % heme and 94 % globin Hematocrit : the proportion of red blood cells in whole blood expressed as a percentage.

Hb measurement more accurate than Ht because artifacts introduced by cell aglutination can increase mcv and false elevated the Ht

MCV ( mean corpuscular volume )basically measures the average volume of red blood cells in a blood sample.important in distinguishing the causes of anemia. Units of MCV are reported in : fl (femtoliters) , n : 80 -100 fl. a fraction of one millionth of a liter. MCV : Hematocrit ( %) x 10 Red blood cell count, million/ul

MCHC ( MEAN CORPUSCULAR HEMOGLOBIN CONCETRATION)A MEASURE OF CONCENTRATION OF HEMOGLOBIN IN THE AVERAGE RED CELL. REPPORTED IN g/dL, N : 31 - 36 MCHC : Hemoblobin in g/ 100 mL X 100 Hematocrit , percentMCH ( MEAN CORPUSCULAR HEMOGLOBIN )A MEASURE OF HEMOGLOBIN CONTENT OF RED CORPSCLES . REPPORTED IN : pg (PICOGRAM) . N : 26 - 34

MCH : Hemoglobin in g/ 100 mL X 10 Red blood cell count , millions / uL

RETICULOCYTE COUNTS. * A reticulocyte count is a quantitative measure of the bone marrow’s production of new red blood cells. * The reticulocyte production index is a calculation of the ratio between the level of anemia and the extent to which the reticulocyte count has risen in response. (If the degree of anemia is significant, even a "normal" reticulocyte count actually may reflect an inadequate response). If an automated count is not available, a reticulocyte count can be done manually following special staining of the blood film. Newly formed RBCs are usually slightly larger than older RBCs and show polychromasia. BONE MARROW EXAMINATION : TO KNOW ABOUT PRODUCTIVITY OF ERYTHROCYTE . TO KNOW CELLULARITY OF SOURCES.

RED BLOOD CELL SIZEMORPHOLOGICAL APPROACHANEMIA IS CLASSIFIED BY THE SIZE OF RED BLOOD

CELLS The size is reflected in the mean corpuscular

volume(MCV). N : 80 – 100 fL MICROCYTIC If the cells are smaller than normal

(under 80 fl),. NORMOCYTIC if they are normal size (80-100 fl).

MACROCYTIC if they are larger than normal (over 100 fl).

This scheme quickly exposes some of the most common causes of anemia; for example :

microcytic anemia is often the result of iron deficiency.

In clinical workup, the MCV will be one of the first pieces of information available.

MICROCYTIC ANEMIAMicrocytic anemia is primarily a result of hemoglobin synthesis failure/insufficiency, Etiologies:1.HEME SYNTHESIS DEFECT Iron deficiency anemia Anemia of chronic disease (more commonly presenting as normocytic anemia) 2.GLOBIN SYNTHESIS DEFECT alpha-, and beta-thalassemiaHbE syndrome HbC syndrome and various other unstable hemoglobin diseases 3.SIDEROBLASTIC DEFECT Hereditary sideroblastic anemia Acquired sideroblastic anemia, including lead toxicity Reversible sideroblastic anemia

MACROCYTIC ANEMIAETIOLOGI1.Megaloblastic anemia, the most common cause of macrocytic anemia(due to a deficiency of either vitamin B12, folic acid (or both). Deficiency in folate and/or vitamin B12 (inadequate intake or insufficient absorption). Folate deficiency normally does not produce neurological symptoms, while B12 deficiency does. 2.Pernicious anemia is an autoimmune condition-- decrease intrinsic factor produced by the parietal cells of the stomach. Intrinsic factor is required to absorb vitamin B12 from food-- destruction of intrinsic factor --- poor absorption of vitamin B12. 3. Removal of the functional portion of the stomach--- during gastric bypass surgery, leading to reduced vit B12/folate absorption. 4. Hypothyroidism 5. Alcoholism , liver Disease coomonly causes a macrocytosis, although not specifically anemia. 6 Methotrexate, zidovudine, and other drugs that inhibit DNA replication.

Macrocytic anemia divided to 1.megaloblastic anemia2.non-megaloblastic macrocytic anemia". The cause of megaloblastic anemia primarily a failure of DNA synthesis with preserved RNA synthesis, which result in restricted cell division of the progenitor cells. The megaloblastic anemias often present with neutrophil hypersegmentation (6-10 lobes).

The non-megaloblastic macrocytic anemias have different etiologies (i.e. there is unimpaired DNA globin synthesis,) which occur, for example in alcoholism.

Non-specific symptoms of anemia Specific features of vitamin B12 deficiency : 1.peripheral neuropathy and subacute combined degeneration of the cord with resulting balance difficulties from posterior column spinal cord pathology.2.smooth, red tongue and glossitis.

NORMOCYTIC ANEMIANormocytic anaemia occurs when the overall hemoglobin levels decreased, but the red blood cell size (MCV) remains normal. Causes :Acute blood loss Anemia of chronic disease Aplastic anemia (bone marrow failure) Hemolytic anemia DIMORPHIC ANEMIATwo causes of anemia act simultaneously, e.g., macrocytic hypochromic : - hookworm infestation leading to deficiency of both iron and vitamin B12 or folic acid - following a blood transfusion. Evidence for multiple causes appears with an elevated RBC distribution width (RDW), which suggests a wider-than-normal range of red cell sizes.HEINZ BODY ANEMIAHeinz bodies are an abnormality that form on the cells in this condition. This form of anemia may be brought on by taking certain medications; acetaminophen (Tylenol).

Treatment anemiaGoals of Treatment1.to increase the red blood cell count and/or hemoglobin level. 2.to treat the underlying condition or cause of the anemia.

depends on the type, cause, and severity of the conditioninclude 1.dietary changes or supplements 2.medicines 3. procedures. 1. Dietary Changes or SupplementsLow levels of vitamins or iron in the body can cause some types of anemia---low levels hb may be due to poor diet or certain diseases or conditions.

To Raise Vitamin Or Iron LevelsVitamin.Common vitamin supplements are vitamin B12 and folic acid/folate. Iron.Sources of iron to make hemoglobin1.iron supplement2. meat red meat, such as beef or liver—as well as chicken, pork, fish, and shellfish.3.Nonmeat foods sources of iron include: Spinach and other dark green leafy vegetables Peanuts, peanut butter, and almonds , Eggs ,Peas; lentils; and white, red, and baked beans .

Vitamin C is sometimes given to help the body absorb iron.

Medicinesgoal of medicines : increase the number of red blood cells and deleteunderlying cause of anemia. Some of these medicines include:*Antibiotics to treat infections. *Hormones to treat adult and teenaged women who have heavy menstrual bleeding. *erythropoietin to stimulate body to make more red blood cells. *Chelation therapy for lead poisoning.

Proceduressevere anemia medical procedure to treat it1.blood transfusions 2.blood and marrow stem cells transplants.

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