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Santosha Vardhana, MD PHD
New anemia: H&P
History
• Fatigue
• Exertional dyspnea,
palpitations, angina,
claudication
• Dizziness/Syncope
• Remember ...
New Anemia: Labs (Basic)
What lab What’s normal Who cares
Hgb >12 (F), >13 (M) You do – it’s the topic of this lecture
WBC...
My approach to anemia
Reticulocyte
Index
RI>2
(normal)
RBC loss
RBC
destruction
RI<2 (low)
Check MCV
Step 1: the reticulocyte index
• How do I calculate the RI?
– RI = retic count x [Pt Hct/45] x correction factor
– Correct...
My approach to anemia
Reticulocyte
Index
RI>2
(normal)
RBC loss
RBC
destruction
RI<2 (low)
Check MCV
Step 1b (normal RI): look for blood loss
Other areas: menorrhagia, post-surgical, traumatic, iatrogenic
Step 1b (normal RI): workup RBC
destruction
Test Interpretation
LDH Elevated in any hemolysis
Haptoglobin Decreased with i...
Destruction: immune vs. non-immune mediated
Immune (agglutinin+)
Cold PNH
Post-mycoplasma
Warm Drug-induced
AIHA
Transfusi...
Obligatory slide of peripheral smears
MAHA AIHA
My approach to anemia
Reticulocyte
Index
RI>2
(normal)
RBC loss
RBC
destruction
RI<2 (low)
Inadequate Materials
Heme IDA, ACD, Copper deficiency
Globin Thalassemia
Nucleotides B12, Folate, nucleoside analogs, lead...
My approach to anemia
Reticulocyte
Index
RI>2
(normal)
RBC loss
RBC
destruction
RI<2 (low)
Check MCV
Step 2b (decreased RI): check the MCV
• Microcytosis (<80)
– IDA, ACD, thalassemia
• Macrocytosis (>100)
– B12/Folate
– Me...
Step 2c (decreased RI): order the
appropriate “anemia labs”
Normal IDA ACD Mixed
Fe 60-170 mcg/dl   
TIBC 240-450
mcg/d...
Anemia of chronic disease: hepcidin
Homocysteine and MMA metabolism
Prochain SlideShare
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Anemia 101

Anemia 101

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Anemia 101

  1. 1. Santosha Vardhana, MD PHD
  2. 2. New anemia: H&P History • Fatigue • Exertional dyspnea, palpitations, angina, claudication • Dizziness/Syncope • Remember to ask about: – Ethnicity – Medications (NSAIDs) – EtOH use Physical • VS/General – Orthostasis, hypotension, – Lethargy, dizziness – Back or leg pain • Skin: – Conjunctival rim pallor – Delayed capillary refill – Petechiae or purpura • CV: – Bounding pulses – Ejection murmur – Clinical heart failure
  3. 3. New Anemia: Labs (Basic) What lab What’s normal Who cares Hgb >12 (F), >13 (M) You do – it’s the topic of this lecture WBC 3.5-10.5 Increase may indicate MPD Decrease may indicate bone marrow failure Platelets 150-450 Decrease may indicate bone marrow failure or platelet consumption (TTP) Red Cell Indices MCV 80-96 fL Identifies microcytic/macrocytic anemia MCHC 27.5-33.2 pg Decreased when there is less Hgb/cell (IDA, thalassemia), increased when there is more Hgb/cell (hemolytic anemia, spherocytosis) RDW 11.5-14.5 Microcytic/normal RDW: suspect thalassemia Microcytic/high RDW: suspect IDA Macrocytic/high RDW: suspect B12/Folate def.
  4. 4. My approach to anemia Reticulocyte Index RI>2 (normal) RBC loss RBC destruction RI<2 (low) Check MCV
  5. 5. Step 1: the reticulocyte index • How do I calculate the RI? – RI = retic count x [Pt Hct/45] x correction factor – Correction factor is determined by pt Hct • RI normal (>2): normal production – Evaluate for occult blood loss – Evaluate for hemolysis • RI decreased (<2): impaired production – Evaluate RBC morphology
  6. 6. My approach to anemia Reticulocyte Index RI>2 (normal) RBC loss RBC destruction RI<2 (low) Check MCV
  7. 7. Step 1b (normal RI): look for blood loss Other areas: menorrhagia, post-surgical, traumatic, iatrogenic
  8. 8. Step 1b (normal RI): workup RBC destruction Test Interpretation LDH Elevated in any hemolysis Haptoglobin Decreased with intravascular hemolysis Coombs Positive in any immune-mediated hemolysis (includes drugs that induce immune-mediated hemolysis) Smear Review Can reveal microspherocytes (hemolytic anemia), schistocytes (MAHA)
  9. 9. Destruction: immune vs. non-immune mediated Immune (agglutinin+) Cold PNH Post-mycoplasma Warm Drug-induced AIHA Transfusion rxn Non-Immune Macro- circulatory Hypersplenism Mechanical valve Micro- circulatory DIC TTP HUS Intra-RBC G6PD Strutural defects (spherocytosis, elliptocytosis, HbS, HbC)
  10. 10. Obligatory slide of peripheral smears MAHA AIHA
  11. 11. My approach to anemia Reticulocyte Index RI>2 (normal) RBC loss RBC destruction RI<2 (low)
  12. 12. Inadequate Materials Heme IDA, ACD, Copper deficiency Globin Thalassemia Nucleotides B12, Folate, nucleoside analogs, lead poisoning Inadequate precursors Maturation arrest MDS, Leukemia, aplastic anemia, PRCA, viral infections, drugs, toxins Destruction of precursors Sideroblastic anemia, PNH Inadequate stimulus EPO Anemia of CKD T4 Hypothyroidism Step 2 (decreased RI): what is causing the failure?
  13. 13. My approach to anemia Reticulocyte Index RI>2 (normal) RBC loss RBC destruction RI<2 (low) Check MCV
  14. 14. Step 2b (decreased RI): check the MCV • Microcytosis (<80) – IDA, ACD, thalassemia • Macrocytosis (>100) – B12/Folate – Medication review – Liver, EtOH disease • Normocytosis (80-100) – Bone marrow disorders – Toxins, drugs – Chronic inflammation – Renal failure – Thyroid disease
  15. 15. Step 2c (decreased RI): order the appropriate “anemia labs” Normal IDA ACD Mixed Fe 60-170 mcg/dl    TIBC 240-450 mcg/dl  Normal/ Variable Ferritin 12-300 ng/mL   Normal sTfR 1.8-4.6 mg/L  Normal  Normal B12 deficiency Folate deficiency Serum B12 180-914 ng/L <200-300 Normal Serum Folate >4 mcg/L Normal <4 Serum MMA 70-270 nmol/L  Normal Serum homocysteine 5-15 umol/L  
  16. 16. Anemia of chronic disease: hepcidin
  17. 17. Homocysteine and MMA metabolism

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