Professor Anwar Sheikha MD, FRCP, FRCPath ., FCAP, FRCPA, FRCPI, FACP

1. Professor Anwar Sheikha MD, FRCP, FRCPath., FCAP, FRCPA, FRCPI, FACP Senior Consultant Clinical & Lab. Hematologist Clinical Professor of Hematology University of Mississippi Medical Center, Jackson, Mississippi C.E.O., Raziana Company for Health Services, Hawler, IRAQ

2. Anemias

3. Anemias Reduction in the concentration of Hb below what is normal for age and sex ? ↓ RCC Is a Hb of 12 g/dL anemia? Hb (g/dL) Male Female Neonate 2-3 month 13-17 12-15 13.5-19.5 9.5-13.5

4. Anemias Anemia HYPOXIA REDISTRIBUTION 2,3 DPG COMPENSATORY MECHANISMS C.O. C.O. PLASMA PATHOPHYSIOLOGY OF ANEMAIS

5. Anemias TIREDNESS LASSITUDE EASY FATIGUABILITY MUSCLE WEAKNESS PALLOR GI CLINICAL FEATURES GUS CVS CNS

6. Anemias Classification Etiological Morphological

7. Anemias ETIOLOGIC Classification BLOOD LOSS I IMPAIRED RED CELL FORMATION INCREASED RED CELL DESTRUCTION II III

8. Anemias ETIOLOGIC Classification BLOOD LOSS I ACUTE CHRONIC IMPAIRED RED CELL FORMATION II HEMOLYTIC ANEMIAS III RBC ABNORMALITIES RBC ENVIRONMENT ABNORMALITIES DEFICIENCY NON DEFICIENCY

9. Anemias DEFICIENCY ANEMIAS ANEMIAS DUE TO DEFICIENCY OF SUBSTANCES ESSENTIAL FOR ERYTHROPOIESIS IRON DEFICIENCY ANEMAIS MEGALOBLASTIC ANEMAIS

10. Anemias NON DEFICIENCY ANEMIAS ANEMIAS NOT DUE TO DEFICIENCY OF SUBSTANCES ESSENTIAL FOR ERYTHROPOIESIS ANEMIA OF BONE MARROW INFILTRATION ACD ANEMIA OF CHRONIC DISORDERS APLASTIC ANEMIA

11. Anemias NON DEFICIENCY ANEMIAS ANEMIAS NOT DUE TO DEFICIENCY OF SUBSTANCES ESSENTIAL FOR ERYTHROPOIESIS ACD BM INFILTRATION AA INFECTION COLLAGEN DISEASES RENAL FAILURE LIVER FAILURE MALIGNANCY LEUKEMIAS LYMPHOMAS MYELOMA MYELOFIBROSIS

12. Anemias OTHER NON DEFICIENCY ANEMIAS CONGENITAL DYSERYTHROPOIETIC ANEMIAS SIDEROBLASTIC ANEMIAS

13. Anemias MORPHOLOGIC Classification I NORMOCYTIC NORMOCHROMIC II HYPOCHROMIC MICROCYTIC III MACROCYTIC ANEMIAS ACD Iron Deficiency Thalassemias Megaloblastic

14. Macrocytosis Megaloblastic Alcoholism Liver Diseases “Alcoholic” Reticulocytosis Hypothyroidism Chemotherapy Sideroblastic Anemia LEA Paraproteinemias Leukemias MDS 5q- Syndrome MPD Newborn Pregnancy Chronic Respiratory Failure

15. Iron Deficiency Anemias IRON 4% of Earth’s Crust 3 to 5 grams in Adult Human Hb 1.5 to 3.0 gm Hemosiderin Storage 1.2 to 2.0 gm Essential Plasma 0.3 gm 3 to 4 mg Ferritin

16. Iron Metabolism Circulating RBC 23 mg 23 mg RES BoneMarrow 7 mg 30 mg 30 mg Plasma Excretion Absorption 1 mg 1 mg

17. Anemias DAILY IRON LOSSES & REQUIREMTNS

18. Anemias FACTORS AFFECTING IRON ABSORPTION Favored By: • Organ meat & Hem iron • Ferrous form • Acid pH (e.g., Gastric HCL) • Vitamin C • Low M.Wt. Chelate (Sugar) • Iron Deficiency • Increased Erythropoiesis • Pregnancy Reduced By: Reduced Animal Food Ferric form Alkalies (Pancreatic secretion) Tea Iron overload Decreased Erythrpoiesis Acute or Chronic inflammation

19. Anemias PALLOR

20. NAIL CHANGES i

21. NAIL CHANGES ii

22. NAIL CHANGES iii

23. Anemias GLOSSITIS

24. Anemias DYSPHAGIA

25. Anemias MARROW IRON STORES

26. Anemias IRON DEFICIENT MARROW

27. Anemias IRON DEFICIENT ERYTHROPOIESIS

28. Anemias Ancylostoma

29. Anemias Ca Colon

30. BLOOD LOSS MALABSORPTION Causes of Iron deficiency Anemias DIETARY

31. Causes of Iron deficiency Anemias DIETARY MALABSORPTION BLOOD LOSS RENAL Hematuria Hb-uria GIT Esophageal varices Hiatus Hernia PU Aspirin Hookworm HHT Cancer (Stomach; Colon) Ulcerative Colitis Meckle’s Piles UTERINE Menorrhagia Pregnancy Post- Menopausal Bleeding LUNGS BLEEDING SELF-INDUCED

32. 20 mg of iron is lost with each menstrual period Iron loss per pregnancy ranges from 500 to 1000 mg During vaginal delivery about 500 ml of blood is lost In pregnancy, plasma volume is increased by 50%, while red cell mass is only increased by 10%-20% in women not receiving iron and by 30% in those taking iron This disproportionate expansion of plasma relative to red cell mass creates a state of dilutional anemia which is called physiological anemia of pregnancy. Women with a hemoglobin level of < 9 gm/dl or > 13 gm/dL have an increased risk of poor fetal outcome P R E G N A N C Y & I R O N

33. Anemias BLOOD LOSS MAL- ABSORPTION Celiac Gastrectomy Atrophic Gastritis Clay Eating DIETARY Causes of Iron deficiency Anemias

35. IRON ABSORPTION HEPCIDIN

36. SEQUENCE OF EVENTS IN IRON DEFICINCY

37. SEQUENCE OF EVENTS IN IRON DEFICINCY I Hb 15 g/dL RCC 5 million/ uL MCV 86 fL MCH 30 pg Hct. 0.45 MCHC 35 g/dL FERRITIN 150 ug/L TIBC= 300 ug/dL WBC 7,500/uL Serum Iron UIBC Platelet 200,000/uL 100 ug/dL 200 ug/dL Saturation 33%

38. SEQUENCE OF EVENTS IN IRON DEFICINCY II BLEEDING 40 ml/ Day Iron Absorption up to 5 mg/Day Net Daily Loss= 20-5 = 15 mg 1500 ------ = 100 Days 15 20 mg IRON No Clinical Features Normal Blood Values Increased Iron Absorption ↓Iron/ ↑TIBC/ ↓Ferritin Latent Iron Deficiency

39. SEQUENCE OF EVENTS IN IRON DEFICINCY III APK Hypochromia Microcytosis Thrombocytosis ↓Hb ↓ MCV IRON DEFICIENCY ANEMIA ↓ MCH ↑ RDW ↓ MCHC ↓ Ferritin ↓Iron ↑ TIBC NAIL Pale Dry Brittle Ridges Flat Koilonychia Pica Atrophic Gastritis Glossitis Angular Stomatitis DYSPHAGIA Kelly Paterson White Syndrome

43. MANAGEMENT OF IRON DEFICIECY ANEMIA

44. ORAL IRON THERAPY Avoid giving iron blindly to all hypochromic microcytic anemias Always evaluate iron status & look at blood smear Thalassemia minor patients or sideroblastic anemia patients do not need iron; they are already iron overloaded.

45. MANAGEMENT OF IRON DEFICIECY ANEMIA Treatment of the Underlying Cause (e.g., Colon Cancer) Correction of the Deficiency with Inorganic Iron Blood Loss is the usual cause of Iron Deficiency Whenever possible the site of blood loss must be identified and the lesion treated Always give iron since the deficiency cannot be corrected from normal diet for many years

47. Even in most severe iron deficiency anemia states, the amount of dietary iron absorbed cannot increase above 5 mg/day. Likewise, no matter how much is the extent of iron overload, obligatory iron loss cannot exceed 5 mg/day. In severe iron deficiency anemia, up to 30 mg of iron can be absorbed if 180 mg of elemental iron is prescribed.

48. ORAL IRON THERAPY Adult: 100 to 200 mg of Elemental Iron/day Children: 1 mg/kg tid as Liquid Iron (Teeth Staining) Space the doses as absorption is impaired for 4 hrs > dose

49. SIDE EFFECTS OF ORAL IRON THERAPY Reduce Iron Dose Change to Low Iron Tab Take Iron with Meal GIT Irritation Nausea Epigastric Pain Constipation Diarrhea

50. ORAL IRON THERAPY Avoid Enteric-Coated & Sustained Release tablets as iron is released past sites of optimal absorption Give Iron for 6 months to correct anemia & replenish stores Correction of Ferritin is a good guide for adequate treatment. Ferritin should be done a week after stopping iron Reticulocytosis starts > 3 days & lasts 3 weeks Ideally expect Hemoglobin rise of 1 gm/dL/week or at least 2 gm/3 weeks