The anaemic patient Basics and pitfalls

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

The anaemic patient Basics and pitfalls