General Approach to Anemia Dr Saleh

Approach to Anemia Approach to Anemia AGENDA • • • • • • Review of Physiology Normal Hematological Values Mechanisms of Anemia Classification Clinical Presentation and Physical Examination Laboratory Investigations Approach to Anemia AGENDA • • • • • • Review of Physiology Normal Hematological Values Mechanisms of Anemia Classification Clinical Presentation and Physical Examination Laboratory Investigations Approach to Anemia • Review of Physiology Cycle of Erythropoiesis - Regulatory feedback stimulus of erythropoietin (Epo). - RBC life span - Role of spleen - Erythropoietic feedback loop ensures the match of: - hemoglobin mass and the body’s needs - RBC destruction and production Approach to Anemia AGENDA • • • • • • Review of Physiology Normal Hematological Values Mechanisms of Anemia Classification Clinical Presentation and Physical Examination Laboratory Investigations Approach to Anemia • Normal Hematological Values - Sex differences - Age differences - Geographic differences - Clinically important RBC parameters: HGB, MCV, RDW - Reticulocyte count - HGB cut off value for anemia? Approach to Anemia AGENDA • • • • • • Review of Physiology Normal Hematological Values Mechanisms of Anemia Classification Clinical Presentation and Physical Examination Laboratory Investigations Approach to Anemia • Mechanisms of Anemia - Reduction in RBC mass. - Whenever an imbalance occurs. - Defective production (Hypo-regenerative). - Accelerated destruction (Hyper-regenerative). - Multifactorial - Sickness index (NOT A DIAGNOSIS). - The diagnostic challenge is in the workup. Approach to Anemia AGENDA • • • • • • Review of Physiology Normal Hematological Values Mechanisms of Anemia Classification Clinical Presentation and Physical Examination Laboratory Investigations Approach to Anemia • Classification - Several classification schemes. - The aim is clinically useful scheme. - Based on MCV (Micro-, Macro-, or Normocytic anemia). - Useful first step in approaching an etiologic diagnosis. - Microcytic Anemias - Deficient hemoglobin or defective heme synthesis (e.g.Iron deficiency, Thalassemias, sideroblastic anemias) - Macrocytic Anemias - Defective DNA metabolism (e.g. Vit B12/ folate deficiency, Myelodysplastic Syndrome) - Normocytic Anemias - e.g. Hemolytic anemias, anemia of chronic disease. Approach to Anemia • Classification Reticulocyte Count and Anemia (Kinetics)  Anemia with elevated reticulocyte count. - Hemolysis - Acute blood loss - Response to treatment.  Anemia with depressed reticulocyte count. - Bone marrow suppression due to: drugs, toxins, infectious agents.  Anemia with normal reticulocyte count. - Nutritional deficiencies. - lack of erythropoietin. - Anemia of chronic disease. Approach to Anemia AGENDA • • • • • • Review of Physiology Normal Hematological Values Mechanisms of Anemia Classification Clinical Presentation and Physical Examination Laboratory Investigations Approach to Anemia • Clinical Presentation and Physical Examination - History - Symptoms of anemia (Acute vs. Chronic) - The severity of cerebral and circulatory symptoms relative to the severity of anemia. - The possibility of chronic blood loss (GI, Gynecological). - The possibility of episodes of hemolysis. - The presence of neurological symptoms. - Prior therapy of anemia. - Use of other medications and exposure to toxins. - Dietary history. - Family history. - Social history - Underlying disease. - Effect of symptoms (Quality of Life) Approach to Anemia • Clinical Presentation and Physical Examination - Physical Examination - Vital signs esp. PR - Skin - Nails - Eyes - Lymph nodes - CVS - Abdomen - CNS - Leg ulcers - Endocrinological signs Approach to Anemia AGENDA • • • • • • Review of Physiology Normal Hematological Values Mechanisms of Anemia Classification Clinical Presentation and Physical Examination Laboratory Investigations Approach to Anemia • Laboratory Investigations - Initial Tests Aim - Classification - Search for morphological clues to the diagnosis. - Identify the kinetic basis. Tests - CBC: HGB, MCV, RDW, WBC, Platelets - reticulocyte count - Peripheral blood smear (PBS) Approach to Anemia • Laboratory Investigations (cont’d) - Specific Tests Aim - To reach specific diagnosis. Tests - Iron Studies (s-ferretin, iron profile). - Vitamin B12 and Folate levels. - Hemoglobin electrophoresis. - Work up for hemolysis. - Renal Function Test. - Liver Function Test. - Endocrine Evaluation. - Bone marrow examination. Approach to Anemia • Laboratory Investigations - Evaluation of microcytic anemia PBS, iron study, HGB electrophoresis - Evaluation of macrocytic anemia PBS, serum vitamin B12 level, serum & RBC folate levels, LFT, s-TSH level, bone marrow (BM) examination & cytogenetics - Evaluation of normocytic anemia PBS, s-bilirubin, s-LDH (if hemolysis suspected), iron studies, RFT, Epo level, BM examination Integration of Clinical Picture and Laboratory Data