The anaemic patient basics and pitfalls
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The anaemic patient Basics and pitfalls. Bettie Oberholster 2013. Day to day “Working” definition of anaemia. Hb too low for age and gender at a given altitude . Journey. DESTINATION. STARTING POINT. Effective treatment. Establishing the underlying cause. Presence of an anaemia .

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The anaemic patient Basics and pitfalls

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The anaemic patientBasics and pitfalls

Bettie Oberholster

2013


Day to day “Working” definition of anaemia

Hb too low for age and gender at a given altitude


Journey

DESTINATION

STARTING POINT


Effective treatment

Establishing the underlying cause

Presence of an anaemia


Potential causes

1. PRODUCTION

2. PERIPHERAL LOSS

Bone marrow

Lack of nutritients (iron, vit B12, folate)

Bleeding

Primary BM disorders

↓ Thropic hormones

(EPO, thyroid, androgens)

Hemolysis

Bone marrow suppression by e.g. drugs, virus infections

BM Infiltration

↑Plasma volume


Which route ?

Cause & Effective treatment

DETOUR:

waste time and may be expensive

Fast and cost-effective

SHORT CUT:

may land up at wrong destination or get lost

Anaemic Patient


Best Route ?

GPS Route Guidance


GPS: “History and clinical findings”

  • Obvious blood loss

  • Drug history e.g chemotherapy, ARV’s

  • Chronic disease e.g. renal disease, SLE, malignancy

  • Organomegaly

  • Family history


GPS: “Reticulocyte count”

Do not use the % count

RPI: RETICULOCYTE PRODUCTION INDEX


Blood loss

Response to hematinics

Bone marrow production defect

HEMOLYSIS

Red cell indices


Hemolysis

SCREEN: confirm the presence of hemolysis

  • Raised unconjugatedbilirubin

  • Raised LDH

  • Decreased haptoglobin

  • Increased urinary urobilinogen

  • Haemosiderin in the urine (IV)

You still need to find out WHY the patient is hemolysing

Examination of blood smear is important for clues


Direct coombs

Red cell membrane studies

Micro-angiopathic hemolytic anaemia

DIC, TTP/HUS, PET/HELP


GPS: “Red cell parameters”

  • MCV = mean corpuscular volume

    (mean size of a red cell)

  • MCH = mean corpuscular hemoglobin

    (mean Hb per red cell)


Iron studies

Renal functions

Iron studies

Vit B12 and RBC folate, TSH, LFT


ImportantIron, vit B12 and red cell folate studiesBEFORE any blood transfusion


GPS: “Iron studies”


Normal ferritin does not exclude iron deficiency

Ferritin: 30-100 and % sat < 16%

May be iron deficiency in presence of an acute phase

Soluble serum transferrin receptor assay (sTfR)


Not all hypochromicmicrocyticanaemias are iron deficiencies or anaemia of chronic disease !!

Thalassaemia or hemoglobinopathy

(RBC count normal to high)

Hb electrophoresis/abnormal hemoglobin screen (HPLC)

Make sure that iron status is normal

DNA testing to exclude alfathalassaemia, lead levels and possible BM for sideroblasticanaemia


Macrocytic anaemia

Normal Vit B12/folate

Normal LFT

Normal TSH

No drug history

Do not miss underlying Myelodysplastic disorder


GPS: “Phone a friend: Local Pathologist”

  • Clues blood smear findings

  • Advice further investigations


GPS: “Bone marrow”

Unexplained anaemia with low RPI

FBC: pancytopenia, bicytopenia or abnormal WBC

Abnormal cells on blood smear e.g. blasts, dysplasia

Leuco-erythroblastic reaction


BM not always the best route

  • Unexplained Iron Deficiency ?

  • Celiac disease

  • Antibodies

  • Small bowel biopsy

  • HLA-DQ2 and HLA-DQ8

  • PNH


Right destination


Take home message


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