Anemia

A Finding, not yet a diagnosis

Herbert L. Muncie, Jr., MD

z Under

what clinical circumstances would you order a CBC for an outpatient?

When to order a CBC

z Order
z

if suspect patient could be anemic or infected based upon:

History z Symptoms z Signs or physical findings

When to order a CBC

z Do
z

not order CBC as a screening test

Baseline values are not necessary to diagnosis anemia z Variations in Hgb/Hct within the normal range have not been associated with increased morbidity or mortality

Case Finding - physical exam

z Absence

of pallor does not rule out

anemia z Pallor of conjunctivae, face & palms - if all 3 present helps confirm anemia z Pallor of nail beds/skin creases - of no value in assessing presence or absence of anemia

z What

laboratory values are used to define anemia?

What Defines Anemia

z Look

at hemoglobin & hematocrit z Anemia is diagnosed if Hgb & Hct are below normal z Normal Hgb and Hct ranges change:
throughout childhood z during pregnancy z higher for men than women
z

What Defines Anemia

z Normal
z

H & H should be adjusted for smoking, altitude

smokers have higher values due to carbon monoxide in smoke z > 3,000 feet - lower oxygen tensions, higher values

z On

the CBC results, what value on the report assists you in deciding the type of anemia?

1st Diagnostic Step

Look at MCV Microcytic - < 80fl Normocytic 80 100 fl Macrocytic - > 100 fl

Differential Diagnosis based on MCV

Microcytic Iron deficiency Thalassemia Lead poisoning Normocytic Chronic disease Macrocytic Folate defic. B12 defic. Liver disease Hypothyroid

Tests for Fe Deficiency

MCV - changes occur late
z z

< 70 probably iron deficiency MCH, MCHC - no useful info

RDW - reflects anisocytosis

z

helps to differentiate from thalassemia

z You

suspect iron deficiency anemia in your next patient. z What test(s) will you order to make that diagnosis?

Tests for Fe Deficiency

Serum iron - level alone of little value
z

low in anemia of chronic disease

Iron binding capacity - high in Fe deficiency

z

usually low in anemia of chronic disease

Tests - Ferritin
z Best
z

single test rule in or out Fe deficiency

levels < 15 uG/L - diagnostic z levels > 100 uG/L - Fe deficiency very unlikely

z Acute
z

phase reactant

may be elevated in inflammatory, malignant or liver disease

Iron Deficiency
Causes: children, teens - inadequate diet young women menorrhagia & inadequate diet older women

Neoplasm GI blood loss Angiodysplasia

Iron Deficiency - therapy

z Treat
z

with ferrous salts

Sulfate z Gluconate
z Start
z

qd, increase to t.i.d. with meals

Frequent GI distress

Microcytic Anemia Thalassemia

Definition: z hereditary microcytic anemia z carrier state: thalassemia minor
z Anemia

with low MCV & normal RDW

Thalassemia Minor - treatment

z No

disease specific treatment available z Adjunctive treatment not needed for most cases z Diagnosis has genetic ramifications
z

May suggest prenatal screening

z What

is anemia of chronic disease? z What causes anemia of chronic disease?

Normocytic -Anemia of Chronic disease

z z z

Misnomer - can see in acute illness

z

Another name anemia of chronic inflammation

Occurs in infection/ inflammation/ neoplasia and unknown other conditions Anemia can be first clue to disease
z

Without known disease pursue further evaluation

Anemia of Chronic disease

Pathogenesis:
z Impaired
z

release of Fe from RE cells

Increased Fe stores

z Results
z

in

Low serum iron z Low TIBC z Low transferrin saturation

Anemia of Chronic disease

Diagnosis: z Ferritin level helpful - increased z Transferrin receptor level
z z

raised in Fe deficiency, highly sensitive & specific normal in anemia of chronic disease Anemia of chronic disease Acute blood loss Fluid overload (eg. Pregnancy)

Normo/normo anemia then is either:

z z z

z What

are the most common etiologies of macrocytic anemia?

Macrocytic anemia
z Etiology

B12 (cobalamin Cbl) z Folate deficiency

z

z Typically
z

presents as MCV > 110 fL

MCV 100-110 common, often unexplained with no specific diagnosis found

Cbl Deficiency
z Level
z

< 100 pg/ml confirm deficiency z With levels > 100 & < 400 pg/ml
Measure MMA & homocysteine levels z Either will be elevated with deficiency
z Levels

> 400 pg/ml rule out deficiency

B12 Deficiency
z Etiologies
z
z

of B12 deficiency

Nutritional intake deficiency

Unless strict vegetarian, Cbl deficiency implies reduced absorption

Reduced absorption
Loss of intrinsic factor; achlorhydria Pernicious anemia z Drugs, blind loop, gastrectomy etc
z

Takes 2-5 years to develop deficiency even with severe malabsorption

Folate Deficiency
z Etiologyof
z

folate deficiency

Usually nutritional z Nutritional deficiency can occur quickly

z

In 2-3 weeks with very poor diet

z What z What

is the treatment of B12 deficiency?

is the treatment of folate deficiency?

Treatment of B12 Deficiency

z

Vitamin B12 IM or oral (preferred)

z

Oral 1000 - 2000 uG qd equally effective [Kuzminski 1998] four randomized trials
z

Minimum dosage 600 ug daily [Eussen 2005]

1000 uG IM q month

Treatment of Folate Deficiency

z Folate
z

oral supplements

1 mg qd z CAUTION - folate may correct anemia of B12 deficiency but not the neurologic sequelae
z

before initiating folate therapy verify normal B12 level

Key Points
z z z z

Only order a CBC when you need it to make a diagnosis When the MCV is low and the RDW is high probably iron deficiency When the MCV low and the RDW is normal probably thalassemia When the MCV is high order folate and B12 levels
z z

If initial values are non-diagnostic Order MMA or homocystein level

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