Approach To Anemias I

Front 1

What is needed to make mature RBCs? (5)

Back 1

1. Hematopoeitic pregenitor cells
2. Normal bone marrow microenvironment/stroma
3. Signal for production (erythropoeitin)
4. Normal genetic machinery to make RBC cytoskeleton, hemoglobin and enzyme pathways
5. Building blocks: iron, vitamin B12, folic acid

Front 2

Anemia: Definition, Signs and Symptoms, Classification, Reticulocyte Response

Back 2

1. Definition: Hemoglobin below normal ranges (male 140-180, female 120-160)
2. Signs and Symptoms: Fatigue, exertional dyspnea, headache, palpitations, ischemic pain, heart failure, pallor, tachypnia, widened pulse pressure, systolic flow murmer
3. Classification: Size [microcytic <80 (TAILS), normocytic 80-95 (AI/ACD, BM problem, bleeding, hemolysis), macrocytic >95 (B12/folate deficit, MDS, bleeding, hemolysis, drugs/alcohol, hypothyroidism)], Underproduction vs Overproduction, Congenital vs Acquired, Location
4. Reticulocyte Response: decreased Hb->increased EPO->increased BM precursors->increased retics (>150x10^9/L)

Front 3

What is polychromasia?

Back 3

Characteristic colour of RBCs on blood film indicating they are immature/reticulocytes

Front 4

Underproduction Anemia: Reticulocyte Response, Etiology ( by Size)

Back 4

1. Reticulocyte response: inappropriately low (but may be in the normal range)
2. Etiology: MIcrocytic (Iron deficiency, thalassemia, sideroblastic anemia, anemia of chronic disease), Normocytic (AI/ACD, BM failure/infiltration), Macrocytic (B12/folate deficiency, myelodysplastic syndrome)

Front 5

Iron Deficiency Anemia: Iron Homeostasis, Response to Low Iron, Investigations, Treatment

Back 5

1. Iron Homeostasis: Enters blood through gut and reticuloendothelium via ferroportin, Hepcidin blocks ferroportin when stores high, once in blood transferrin binds/delivers iron to RBC, iron is stored as ferritin
2. Response to Low Iron: Increased GI iron absorption, decreased ferritin/transferrin saturation/serum iron, decreased TIBC, decreased hemoglobin/MCV/MCH
Investigations: Serum ferritin, serum iron and transferrin sat, soluble transferrin receptor, zinc protoporphyrin, bone marrow pearl's stain (gold standard), dietary history, gynecological referral, GI investigations
Treatment: Oral iron replacement (150-200mg/day for 3-6months), parenteral iron

Front 6

Anemia of inflammation/chronic disease: Examples, Pathophysiology of Anemia of Liver Disease/Anemia of Renal Disease/Inflammation, Treatment

Back 6

1. Examples: Chronic infections (TB, parasites), connective tissue disorders, IBD, malignancy, AIDS
2. Anemia of Liver Disease: RBC pooling in spleen->reduced RBC lifespan-> direct toxic effect of HBV/HCV on BM leading to poor response
3. Anemia of Renal Disease: Erythropoeitin deficiency
4. Inflammation: Reduced RBC life-span/sensitivity to EPO/iron utilization due to cytokines
5. Treatment: treat underlying disease, EPO (150-200 IU/kg 3x/wk)

Front 7

Aplastic Anemia: Pathophysiology, Effect on Blood Counts, Causes, Treatment, Complications of Treatment

Back 7

1. Pathophysiology: Autoimmune T cell-mediated BM suppression
2. Effect on Blood Counts: pancytopenia (2/3 low of reticulocytes, neutrophils, platelets AND BM<20% cellularity)
Causes: idiopathic (70-80%), inherited, drugs (radiation, chemo, benzene, chloramphenicol, NSAIDS), Hepatitis, SLE
4. Treatment: Immunosuppressive therapy, BM transplant
5. Complications of Treatment: Relapse, Transformation to MDS or Acute Leukemia

Front 8

What 5 cancers commonly metastasize to bone marrow?

Back 8

Breast
Kidney
Lung
Prostate
Thyroid

Front 9

What are causes of Macrocytic Anemia?

Back 9

B12/Folate deficiency
Myelodysplasia
Hypothyroidism
Alcoholic Liver Disease
Bleeding

Front 10

Megaloblastic Anemia: Causes, Pathophysiology, Clinical Features, Investigations

Back 10

1. Causes: B12/folate deficiency, cytotoxic drugs, rare genetic disorders
2. Pathophysiology: Defect in purine and pyrimidine synthesis
3. Clinical Features: Incidental finding on CBC, General features of anemia, pancytopenia, neropathy, fetal loss, neural tube defect, childhood ALL
Investigations: MCV (>100), Neutrophils (hypersegmented), cell counts (cytopenia), homocysteine (elevated)

Front 11

Cobalamin (B12) Deficiency: Source, Causes, Investigations, Schilling Test Procedure, Treatment

Back 11

1. Source of B12: animal food (liver, kidney, shellfish), body stores enough for 3-4days, absorbed in gut via Intrinsic Factor
2. Causes: Nutritional Deficiency, Malabsorption [terminal ileum disease, pernicious anemia (lack of IF), gastric surgery, tapeworm, bacterial overgrowth]
3. Investigations: Vitamin B assay, homcysteine or methylmalonic acid, IF antibody, parietal cell antibody, Schilling test, OGD+biopsy, autoimmune screen
5. Schilling Test: Fast then inject B12 orally, 24 hour urine collection, <10% excretion=malabsorption, confirm by injecting IF and repeating the test
6. Treatment: B12 injections (malabsorption), oral replacement (nutritional deficiency)

Front 12

Folate Deficiency: Body Stores, Investigation, Causes, Treatment

Back 12

1. Body Stores: last 4 months
2. Investigations: Serum Folate (cheap), Red Cell Folate (Chronic Folate Status, expensive)
3. Causes: nutritional deficiency or malabsorption, hemolysis, pregnancy
4. Treatment: oral folic acid

Front 13

Myelodysplasia: Pathophysiology, Causes, Categorization, Prognosis, Treatment

Back 13

1. Pathophysiology: Hyperactive BM but producing defective products -> peripheral blood cytopenias
2. Causes: idiopathic, radiation, solvents, benzene, pesticides
3. Categorization: # of defictive cell lines, # of immature cells/blasts, cytogenetic changes
4. Prognosis: based on categorization, 25% risk of acute leukemia, 20 month median survival
5. Treatment: Supportive Care, Transfusions, Treat Infections, EPO/G-CSF, Chemo, Targeted Drugs, BM Transplant