Classification of AnaemiaClassification of Anaemia

Prof Roger PoolProf Roger PoolDepartment of HaematologyDepartment of Haematology

University of PretoriaUniversity of Pretoria

MEASUREMENT OF HAEMATOCRIT

The haematocrit ratio (Hct) is the proportion of blood made up of red blood cells.

bloodsample

centri-fuge

plasma

buffy coat

red cells

1.0

0.5

0

After centrifugation the heavier red cells settle to the bottom of the tube. The straw-coloured plasma remains at the top. The two layers are separated by a ‘buffy coat’ of white cells and platelets.

Normal values for Ht range between 0.42 - 0.47, generally higher in men than women.

Red Cell IndicesRed Cell Indices

MCVMCV haematocrit haematocrit <80, 80<80, 80--100, >100 fl100, >100 flRBC countRBC count

MCHCMCHC haemoglobinhaemoglobin <32, 32<32, 32--36, >36 g/dl36, >36 g/dlhaematocrithaematocrit

MCHMCH haemoglobinhaemoglobin 2727--31 pg31 pgRBC countRBC count

�� Macrocytic (MCV > 100)Macrocytic (MCV > 100)

�� MegaloblasticMegaloblastic�� Vit B12 or folate deficiencyVit B12 or folate deficiency

�� NonNon--megaloblasticmegaloblastic�� Alcohol, liver disease, hypothyroidism, aplastic anaemiaAlcohol, liver disease, hypothyroidism, aplastic anaemia

�� Normocytic (MCV 80Normocytic (MCV 80--100)100)

�� Haemolytic anaemiaHaemolytic anaemia�� Renal failureRenal failure�� Mixed deficiencies Mixed deficiencies �� Acute blood lossAcute blood loss�� Aplastic anaemia (bone marrow failure)Aplastic anaemia (bone marrow failure)

�� Microcytic (MCV < 80)Microcytic (MCV < 80)

�� Iron deficiencyIron deficiency�� ThalassaemiaThalassaemia�� Anaemia of chronic diseaseAnaemia of chronic disease�� Sideroblastic anaemiaSideroblastic anaemia

Low Hb=AnaemiaMCV

Low=microcytic Normal=normocytic High=macrocytic

Ferritin

Fe deficient Fe normal

Establishcause

Anaemia ofchronic diseaseorhaemoglobinopathy

Reticulocyte count

high low Anaemia of chronic diseaseRenal failureMarrow failure

Haemolysisor blood loss

Measure B12 + folate

Low -Establish cause

Normal

Obvious cause

Cause not obviousConsider bone marrow

Iron distribution in the bodyIron distribution in the body

Figure 9.1 Haematology at a Glance

Causes of iron deficiencyCauses of iron deficiency

Chronic blood lossChronic blood loss–– Menorrhagia, parasites, aspirin, haemorrhoids, Menorrhagia, parasites, aspirin, haemorrhoids,

carcinomacarcinoma

MalabsorptionMalabsorption–– PostPost--gastrectomygastrectomy, gluten , gluten enteropathyenteropathy

Inadequate diet Inadequate diet –– Unusual in developed countriesUnusual in developed countries

Increased demandsIncreased demands–– PrematurityPrematurity, adolescence, pregnancy, adolescence, pregnancy

Clinical featuresClinical features

General features of anaemiaGeneral features of anaemia–– Shortness of breathShortness of breath–– TirednessTiredness–– HeadacheHeadache–– PallorPallor

KoilonychiaKoilonychia (spoon shaped nails)(spoon shaped nails)

GlossitisGlossitisPica (abnormal appetite)Pica (abnormal appetite)Hair thinningHair thinningPharyngeal web Pharyngeal web (Paterson(Paterson--Kelly/PlummerKelly/Plummer--Vinson Vinson syndrome)syndrome)

KoilonychiaKoilonychia

GlossitisGlossitis

Plummer Vinson SyndromePlummer Vinson Syndrome

Laboratory findingsLaboratory findings

Hypochromic, microcytic anaemiaHypochromic, microcytic anaemiaElevated platelet count (Elevated platelet count (thrombocytosisthrombocytosis))Serum iron and ferritin reducedSerum iron and ferritin reducedBone marrowBone marrow–– Absent iron storesAbsent iron stores–– Erythroid hyperplasiaErythroid hyperplasia

Treatment of iron deficiencyTreatment of iron deficiency

Oral ferrous Oral ferrous sulphatesulphate (67mg Fe/tablet)(67mg Fe/tablet)3X/day before meals3X/day before mealsSide effects Side effects –– nausea, abdominal painnausea, abdominal painReticulocyte response within 7 daysReticulocyte response within 7 daysContinue treatment for 6 monthsContinue treatment for 6 monthsPoor responsePoor response–– NonNon--compliancecompliance–– MalabsorptionMalabsorption–– Ongoing blood lossOngoing blood loss–– Incorrect diagnosisIncorrect diagnosis

Intravenous ironIntravenous iron

Oral iron not toleratedOral iron not toleratedMalabsorptionMalabsorptionRapid filling of iron stores required e.g. Rapid filling of iron stores required e.g. late pregnancylate pregnancyAnaphylaxis may occur Anaphylaxis may occur –– always always administer a test doseadminister a test dose

Iron overload Iron overload -- causescauses

Primary haemochromatosis Primary haemochromatosis –– hereditary hereditary condition leading to condition leading to �� iron absorptioniron absorptionAfrican iron overload African iron overload –– use of iron utensilsuse of iron utensilsExcess dietary ironExcess dietary ironIneffective erythropoiesis with Ineffective erythropoiesis with �� iron iron absorptionabsorptionRepeated blood transfusionsRepeated blood transfusions

Iron overload Iron overload -- clinical featuresclinical features

Heart failureHeart failureRetarded growthRetarded growthExcessive skin pigmentationExcessive skin pigmentationRecurrent infectionsRecurrent infectionsSymptoms are caused by organ Symptoms are caused by organ dysfunction secondary to iron depositiondysfunction secondary to iron deposition

Iron overload Iron overload –– laboratory featureslaboratory features

Raised serum ferritinRaised serum ferritinIncreased iron in liver and bone marrowIncreased iron in liver and bone marrow

TreatmentTreatment

Iron chelation using subcutaneous Iron chelation using subcutaneous desferrioxamine by infusion pumpdesferrioxamine by infusion pump

Management of iron overloadManagement of iron overload

Sideroblastic anaemiaSideroblastic anaemia

Refractory anaemiaRefractory anaemiaMay present with hypochromic, microcytic May present with hypochromic, microcytic indicesindicesMay be congenital or due to:May be congenital or due to:–– Drugs (INH)Drugs (INH)–– Toxins (alcohol, lead)Toxins (alcohol, lead)–– MyelodysplasiaMyelodysplasia