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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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day to day working definition of anaemia
Day to day “Working” definition of anaemia

Hb too low for age and gender at a given altitude

journey
Journey

DESTINATION

STARTING POINT

slide4

Effective treatment

Establishing the underlying cause

Presence of an anaemia

potential causes
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
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
Best Route ?

GPS Route Guidance

gps history and clinical findings
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
GPS: “Reticulocyte count”

Do not use the % count

RPI: RETICULOCYTE PRODUCTION INDEX

slide10

Blood loss

Response to hematinics

Bone marrow production defect

HEMOLYSIS

Red cell indices

hemolysis
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

slide12

Direct coombs

Red cell membrane studies

Micro-angiopathic hemolytic anaemia

DIC, TTP/HUS, PET/HELP

gps red cell parameters
GPS: “Red cell parameters”
  • MCV = mean corpuscular volume

(mean size of a red cell)

  • MCH = mean corpuscular hemoglobin

(mean Hb per red cell)

slide14

Iron studies

Renal functions

Iron studies

Vit B12 and RBC folate, TSH, LFT

slide17

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)

slide18

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
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
GPS: “Phone a friend: Local Pathologist”
  • Clues blood smear findings
  • Advice further investigations
gps bone marrow
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
BM not always the best route
  • Unexplained Iron Deficiency ?
  • Celiac disease
  • Antibodies
  • Small bowel biopsy
  • HLA-DQ2 and HLA-DQ8
  • PNH
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