Approach to the Patient with Nutritional and Hemolytic

ANEMIA

Laboratory Evaluation

Usual initial studies

– CBC – differential (includes RBC

indices,MCV,MCH,MCHC)– Reticulocyte count– Peripheral blood smear– TLC & DLC– Platelet count

Suspected iron deficiency

• Free eryhrocyte protoporphyrin• Serum ferritin levels• Stool for occult blood• Endoscopy upper and lower bowel

Suspected vit B12 & Folate deficiency

– Bone marrow– Serum B12 levels (180-914 pg/ml)– Serum folate level (3-17 ng/ml)– Red cell folate (400-800 ng/ml)– Vit B12 absorption test (schilling test)– Retic count newborn3.2+-1.4% and children

1.2+-0.7%

Suspected hemolytic anemia

1-Evidence of red cell breakdown– Blood smear– Serum bilirubin level– Urine urobilinogen excretion– Serum haptoglobin

2-Evidence of red cell regeneration– Reticulocyte count – Blood smear– Skeleton radiography

3-Evidence of type of hemolytic anemia Corpuscular

(a) Membrane

-Blood smear

-Osmotic Fragility test

-Autohemolysis test

(b)Hemoglobin

-Sickle test

-Hemoglobin electrophoresis

-Hemoglobin F Determination

-heat stability test

(c) Enzymes

-Heinz-body preparation

-Enzyme assay(G6PD def,pyruvate kiase def.)

3-Evidence of type of hemolytic anemia Extra Corpuscular

immune

- Antiglobulin test

- Acid serum lysis test

- sucrose lysis test- Donath landsteiner antibody- -ANA

PS(microcyte), retic count & iron studies

N or Reduced retic count

Low serum iron,low

ferritin,increase TIBC

Iron deficien

cy anemia

Low serum iron,

N or high ferritin,

N or low TIBC

ESR or CRP

Elevated

Inflammatory disease

Normal

Anemia of chronic disease

N or increase serum iron,

N or low TIBC & ferritin

Hb electophoresis(HPLC)abnormal

Hb pathies , Thallasemia

Normal

Sideroblastic anemia

Increase Retc count & abnormal red cell morphology

Hb electophoresis

Hb ss, Hb sc, S-B thallasemia

Retic count

N or reduced

Serum iron

lowAnemia of

chronic

early iron deficienc

y

N or high

Bone

marrow

biopsy

Infiltration(leukemia ), aplastic anemia ,MDS,

Screen for renal ,endocrine hepatic disease

negative

positiveAne

mia of

renal ,endocrin

e hepa

tic disease

Increase Retic count

+ve test for hemolysis

yes

Hemolytic anemia

No

Hemorrage or

recovery from

nutritional deficiency

PS (macrocyte),hyper segnented eutrophils

yes

Megaloblastic likely

B12 & folic acid level ,Bone marrowLow

level,megaloblast

ic changes in bone marrowMegaloblastic anemiaB12

& folat

e therapy

No megalobla

stic change in

bone marrowLook for

other cause

Hypothyroidism,Drug(phenytoin or sulphonamides)

,CHD,Down

syndrome,

Intrinsic faco

r deficienc

y

No

Non megaloblastic

Retic count

decreased

LFT, T3T4T

SHabnormal

Hypothyroid,Liver Ds

normalBMA

Aplastir A,Red cell aplasia,MDS

increased

Hemolysis ,hemorrha

ge

Red cell indices & iron studies in childrenRed cell indices

birth .5-2 yr 6-12 yr 12-18 yr(girls)

12-18yr(boys)

MCV 108 78 86 90 88

MCH 34 27 29 30 30

MCHC 33 33 34 34 34

RDW 12.8 + 1.2% SD of RBC Vol x 100 MCV

Serum Fe 60-170 ug/dl

Ferritin (median)

40(15-200)ng/ml

100(15-300)ng/ml

TIBC 250 - 400ug/dl

Transferrin saturation

20-50% Fe x 100 TIBC

Lab tests of iron deficiency of increased severity

NORMAL Fe deficiencyWithout anemia

Fe deficiency With mild anemia

Fe deficiency With severe anemia

Serum Iron 60-150 60-150 <60 <40

Iron Binding Capacity

300-360 300-390 350-400 >410

Saturation 20-50 30 <15 <10

Hemoglobin Normal Normal 9-12 6-7

Serum Ferritin 40-200 <20 <10 0-10

Laboratory assessment of microcytic anemia

Test Fe Defic Anemia ofinflammation

Thal

Ferritin Low* NL/high NL

Serum Fe Low Low NL

TIBC High NL/low* NL

% Sat Low Low NL

Retic index

NL/low NL/low NL/high

*best discriminators of Fe defic vs anemia of inflammation

KINETICS OF ERYTHROPOIESIS

Hyporegenerative (marrow not working well)

Hyperregenerative (marrow working)

Calculating the reticulocyte index will usually tell you which category your patient is in

Reticulocyte Response

Reticulocyte Index correlates best with RBC production– Correct for low RBC count (absolute retic count)– Correct for immature retics if present (factor of

2)

“Normal” RI = 1 but should go up in anemia if marrow function normal– Normal or low RI in anemia implies

hyporegenerative state– Very high RI (>4) suggests hemolysis

Corrected reticulocyte count

(Spuriously elevated when no. of RBC fall in anemia, hemolysis)

% = retic count x actual hematocrit

Normal hematocrit

Absolute reticulocyte count (50-100 x109/L)-

Retics/ L = Retics(%) X RBC count

(>1 lakh/dl indicate increase marrow activity)

Retic Index

Time Maturation

1

45

Hct % Retic RI

Retic Index Response

< 2 Inappropriate2 – 3 Not sure> 3 Appropriate

When Hct 25 or less, use 1/2 for maturation time term

Example – Labs:

Hct 25, WBC 12.0, Platelets 545, MCV 92,

Retic 5.8% (normal 0.5 to 2.2%)

days 2

1

45

25 5.8% RI RI = 1.6

too low

Calculation iron def. B-thal trait

(mentzer)

MCV >13 <13

RBC

(Srivastava)

MCH >3.8 <3.8

RBC

Hyporegenerative anemia

• Nutritional deficiency (iron, B-12, folate) • Marrow dyscrasia (leukemia,

myelodysplasia, aplastic anemia etc)• Thalassemia• Low EPO state (renal disease,

inflammation, endocrinopathy)

Retic index not appropriately increased

Hyperregenerative anemia

• Hemolysis • Blood loss

Retic count increase generally less striking than in hemolysis

Retic index increased

Normal Polychromasia

Normal rbcMicrocytosis, hypochromia

Normal Macrocytic/megaloblastic

Microangiopathic hemolytic anemia

                         

Spur cell anemia (liver disease)

Hereditary spherocytosis

Increased DestructionIMMUNE MEDIATED

Cold Agglutinin– Paroxysmal nocturnal hemoglobinuria– Post mycoplasmal hemolytic anemia

Warm Agglutinin– Drug induced– Autoimmune hemolytic anemia– Transfusion reaction

Increased DestructionNON-IMMUNE MEDIATED

Extra-corpuscular– Macro-circulatory

HypersplenismExtracorporeal circulation

– Micro-circulatoryDICTTPHUS

Intra-corpuscular– RBC Wall (membrane or enzyme defects)– Heme or globin abnormalities (HbS, C)

Functional Tests for Macrocytic Anemias

Homocysteine: high may mean

deficiencies of folate, B12 or B6Methylmalonic acid distinguish between B12 and folate deficiencies (↑ in B12 deficiency)Schilling test: radiolabeled cobalamin is used to test for B12 malabsorption

Methylfolate TrapMethylfolate TrapIn the absence of B12, folate in the body exists as 5-methyltetrahydro-folate (an inactive form)B12 allows the removal of the 5-methyl group to form THFA

Diagnosis of Folate Deficiency

Folate stores are depleted after 2-4 months on deficient dietMegaloblastic anemia, low leukocytes and plateletsTo differentiate from B12, measure serum folate, RBC folate (more reflective of body stores) serum B12High formiminoglutamic acid (FIGLU) in the urine also diagnostic

Iron deficiency anemia

Pathophysiology-

-dietry history

-Pica history –cause lead poisoning & helminthic infections.

C/F – irritability, anorexia weakness fatiguebleg cramps breathlessness & tachycardia.

CCF & spleenomegaly in severe anemia.

Angular stomatitis glossitis koilonychia &platynychia in severe cases.

Investigation-

PS – M/C H/C ,anisocyte, poikilocyte & RDW, MCV MCHC reducedtotal no. of RBCs reduce(unlike in thallasemia it is increase)

Serum Fe &Ferritin reduced but TIBC increased Transferrin saturation reduced to16%.

High free erythroprotoporphyrin precedes anemia

Megaloblastic anemia

Pathophysiology- impaired nuclear maturation due to lack of MTHF folic acid derivative need for DNA synthesis.

-premature death of cell before release from the bone marrow,termed as “ineffective erythropoisis”

-affect all cell line result in anemia, thrombocytopenia and leukopenia.

Dietry history malabsorbtion ,infestation pernicious anemia H/O autoimmune dissorder.

C/F – anemia anorexia, irritability.

Characterstically glossitis stomatitis hyperpigmentation of skin on knuckle & terminal phalanges hepatospleenomegaly (30 to 40%)

-neurologycal sign preced anemia.

-petechiae & hemorrhagic menifestation (25%)

- Signs of malabsorption- wt loss, diarrhoea abd distention & steatorrhea.

Neurological sign- loss of position & vibratory sensation.memory loss , confusion neuro psychiatric symptoms. Theses signs may persist despite correction of deficiency.

Lab investigationMacrocyte cell , cytopenias & hypersegmented neutrophil,serum B12 level & folic acid level.

-Shilling test

(Include intrinsic factor D/F between pernicious anemia & malabsorbtion (common in child))

- Bone marrow to rule out leukemia, MDS & aplastic anemia

- Bone marrow show- cellular Nuc/Cyt asynchrony in RBCs precursor

- -serum LDH & indirect bilirubin

Hemolytic anemiaC/F acute hemolysis- weakness, pallor & fatigue. Jaundice is prominent. Red urine suggest hemoglobinuria

- spleenomegaly in autoimmune & congenitaal hemolytic anemia.

-Gall stone (spherocytosis)

-hemolytic facies

-leg ulcer in(sickle cell anemia)

Lab investigation

Devide in 3 groups-

1- increase in RBCs destruction

2- comansatory increase in the rate of erythropoisis

3- features of etiology of hemolytic anemia

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