Anemia

1. Anemia Clinical Pathology Kristin Canga, RVT

2. Reading Assignment • Page 68 – Lab Pro book • ‘Clinical Application’ box (Iron Deficiency Anemia) on pg. 12 of A&P book • Pages 55 – 57 Lab Pro book (about counting reticulocytes)

3. Anemia • Literally means “no blood” but clinically means an ______________ ____________________below normal in any of the following values: • ________________________________________ • ________________________________________ • ________________________________________ • In other words, anemia is a condition of reduced oxygen carrying capacity of RBCs • Rate of RBC ______________________ = decreased • Rate of RBC ______________________ = increased

4. Classification of Anemia • Classification is to aid in discovering the _______________ and to help guide __________________. • Remember: Anemia is not a __________________, but a sign of an underlying health concern. • Anemia may be considered _____________ or __________ and is generally classified in one of two different ways: • Classification by RBC ________ and ____ concentration a. RBC ____________________ (MCV, MCHC) • Classification according to bone marrow response • ________________________________ • ________________________________

5. Aiding in Classification of Anemia • A thorough ___________ must be obtained. • This helps the doctor know: what the patient has been ____________ /____________, where they have been, how long they have been suffering, and possibly _________ the anemia has occurred. • A physical exam should be completed. • Put your ____________ on the animal! • Look for _____________, _____________, _____________, active bleeding, elevated heart/respiratory rates, etc… • A complete _____________evaluation is a MUST.

6. PATIENT HISTORY 1. __________________________of clinical signs • ______________ onset suggests acute _________________ or ______________ • ______________ onset suggests chronic ______________ or bone marrow depression 2. Evidence of blood loss • ______________ • ______________ • ______________ • Blood in ______________

7. PATIENT HISTORY 3. ____________________________ 4. Existence of an underlying condition or prior illness • ____________________________ • ____________________________ • ____________________________ 5. Exposure to drugs - human ______________ , ______________ 6. Exposure to toxic ______________ in the ______________ - ______________ , poisonous _________, ______________

8. PHYSICAL EXAMINTION • ______________ • Suspect: infection, leukemia, hemorrhage, or hemolysis • Character of ___________________: • ______________ • ______________ – liver disease or hemolysis • ______________ + ______________ = hemolysis • ______________ - hypoxia • ______________ or ______________ = platelet or vascular defect

9. Petechia

10. Ecchymosis

11. PHYSICAL EXAMINATION 3. Palpation • ______________ • ______________ • ______________ • ______________ 4. ______________ signs of underlying disease 5. External wounds • ______________ • ______________ • ______________

12. LABORATORY EVALUATION Initial laboratory tests to evaluate the anemic patient include (but not limited to): • ______________ (and color of supernatent plasma) • Total ______________ protein • Examination of ______________ and ____________________________ • Total ______________ count • ______________ estimation • ______________ concentration • Total ______________ count • ______________ ** • ______________ evaluation **

13. PCV: Test yourself  • What is it measuring? • Normal ranges for dogs? • Normal ranges for cats • Plasma (supernatent) colors?

14. Plasma Protein • What is it measuring? • How is it measured? • What is normal range for dogs and cats?

15. How Many Cells should you have? • As a rule, the following values should be considered: • RBC total numbers should be in the ______________ . (106/μL) • Plt total numbers should be in the ______________ of ______________ . (200,000 – 500,000/μL) • WBC total numbers should be in the ______________ to ____________________________ . (6,000 – 17,000/μL) • Neutrophils: 60 – 77% • Lymphocytes: 12 – 30% • Monocytes: 3 – 10% • Eosinophils: 2 – 10% • Basophils: rare (<2%) In dogs and cats

16. Blood Film Evaluation and WBC Differential • What area are you evaluating? • How are cells arranged? • Are RBCs normal? • How many WBCs are counted? • How many fields are counted for plt. estimation? • What is calculation for plt. estimation?

17. Total WBC Count • Overall count should be in ______________ to ____________________________ . (6,000-17,000) • Total count calculated by machine • Manual hemacytometer is rare in clinic and diluent is no longer available. • Increased WBCs = ______________ • Decreased WBCs = ______________

18. Hemoglobin Calculation • Done by machine. • Aids us in calculating average ______________ of RBCs (_______) • Aids us in calculating average ______ concentration within RBCs (_______) • Can aid in calculating average ______________ of Hb within average RBC. (_______) *** MCH is LEAST accurate***

19. Classifying Anemia by RBC indices • MCV: ____________________________ • MCHC: ____________________________ • MCH: ____________________________

20. Rules of Thumb (ROTs): • Hb concentration is ~_______ of PCV (in g/dL) • Total RBCs are ~_______ of PCV (in millions)

21. Classification by RBC Indicies • Recall that MCV (mean corpuscular volume) describes the average volume of the individual RBC • Normal MCV = _____________________ • Increased MCV = _____________________ • Decreased MCV = _____________________ FORMULA: (PCV / Total RBC) X 10 = MCV (femtoliters) Normal MCV = canine: 60 – 77 fl. feline: 40 – 55 fl.

22. Let’s do the math: • The MCV of a patient with a PCV of 12% is: • Step 1: Recall the formula: • (_______/ ______________) X 10 = MCV (femtoliters) • Step 2: Remember the ROT • total RBC ≅ _______ PCV so: • ______________ = ______________ • Step 3: plug in the numbers • ___________________________________ • Is this normal for k9/fel? • How would you classify this RBC?

23. Possible Causes of Abnormal MCV • Possible causes of Increased MCV: • Increased _____________________activity = #1 • Reticulocytosis • Congenital (___________&_________________) • Cats with _______ (+/- anemia) • Possible causes of Decreased MCV: • ______________ deficiency = #1 • Congenital disorder (_______and ______________)

24. Classification by RBC Indicies • MCHC (mean corpuscular hemoglobin concentration): • Describes the ratio of the _______of hemoglobin to the ______________in which it is contained (concentration of hemoglobin in the avg. RBC) • Normal MCHC = ______________ • Decreased MCHC = ______________ • High MCHCs = artifact WHY???

25. Formula (______ / ______) X ______= MCHC (g/dL) Normal MCHC = canine: ______________g/dL feline: ______________g/dL • Remember the ROTs? • If you calculate MCHC by estimating Hb, the values will always come out the same. • Lets do the math!

26. Using the ROT • The MCHC of a patient with a PCV of 33% is: • Step 1: Recall the formula • (_______ / _______) X _______= MCHC (g/dL) • Step 2: Remember the ROT • Hb≅ _______ of PCV so: • _______= _______ • Step 3: Plug in the numbers • __________________________________________

27. Using actual numbers • The patient’s Hb is 9g/dL, and their PCV is 30% • Formula: (_______/_______) x _______ • SO: _______________________=_____g/dL • Is this normal for k9? Fel? • How would it classify the RBC?

28. Low MCHC usually results from: • Severe _______deficiency • Marked, regenerative anemia • ____________________________RBCs that do not yet have their full complement of Hb. MCHC increase: • Presence of ______________, ______________, and ___________ can interfere with tests and ______________increase MCHC • True _____________________anemia cannot exist; the erythrocyte cannot be oversaturated with ______.

29. Morphologic Classification of Anemia by RBC Indicies

30. Normocytic ; Normochromic MacrocyticMicrocytic HyperchromicHypochromic

31. Calculating MCH • You will need to know HOW to do this for VTNE, even though it is the _______accurate of the indices. • Calculates the average _______of Hb contained in average RBC. • (_______/_______) x _______= MCH in picograms (pg) • Normal ranges: • K9: _______pg • Fel: _______pg

32. Let’s do the Math • The MCH of a patient with a PCV of 54% is: • Step 1: Remember the formula • (_______/_______) x _______= MCH • Step 2: Remember the ROT • Hb≅ _______ PCV and RBCs≅_______ PCV • _______ = _______ and _______ = _______ • Step 3 • Plug in the numbers: • _____________________pg

33. Classification of Anemia According to Bone Marrow Response • Most pertinent of anemia classification • Distinguishes between _____________________and _____________________ anemia

34. Classification Based on Bone Marrow Response Regenerative anemia • Characterized by evidence of increased ______________ and delivery of new erythrocytes into ______________ (usually within 2-4 days). • Usually suggests bone marrow is responding appropriately to either: • _____________________ (acute or chronic; internal or external) or • _____________________ (intravascular or extravascular) • Involves determining whether absolute _____________________ numbers are increased in the blood.

35. Classification According to Bone Marrow Response Nonregenerative anemia • Lack of circulating ______________ RBCs in the face of _______ indicates a nonregenerative anemia and likely results from bone marrow ______________. • Either reduced erythropoiesis or defective erythropoiesis • No response evident in ______________blood. (usually ______________; ______________) • _____________________examination may be helpful with the diagnosis.

36. Regenerative Anemia • Blood Loss Anemia Acute _____________________– relatively large amount of blood lost in a brief period. (______________; ______________) • PCV initially = ______________ • Reticulocytes should appear ~_______ hrs (peak within ~ 1 week) • Causes: • ______________ • Internal or external • Accidental or surgical • ______________disorders • Bleeding ______________ or large ______________

37. Regenerative Anemia Chronic blood loss (_______Deficiency Anemia) – lost ______________and ______________for a period of time. a. Parasites • ______________, _______, blood-sucking _______, coccidia spp. b. GI ulcers and neoplasms c. Inflammatory bowel disease d. Overuse of ______________donors • Note: neonates can become iron deficient due to lack of adequate dietary _______ intake.

38. Iron Deficiency Anemia • Body compensates for anemia by lowering _______-_______ affinity, preferential shunting of blood to vital _______, increased ______________output (tachycardia), and increased levels of _____________________. • With decreasing _______ stores, erythropoiesis is limited and RBC’s become ______________and deficient in _______ (______________and _____________________). • Hallmark of iron deficiency anemia is decreased _______. • Keratocytes & schistocytes • Clinical signs include: lethargy, weakness, decrease exercise tolerance, anorexia, lack of grooming, mild systolic murmur.

39. Regenerative Anemia • 2. _____________________– Increased rate of erythrocyte ______________________within the body • a. Immune mediated • ______________________ • ______________________ • Incompatable ______________________ • b. Blood parasites • HemotrophicMycoplasmas • ______________________spp. • ______________________

40. Cytauxzoon felis inclusions

41. Regenerative Anemia c. Heinz body anemia • Plants • Onions*, garlic • ______________________ • Drugs or Chemicals • (______________________, Propylene glycol, Zinc, Copper, Methylene blue, Naphthalene, ______________________, phenothiazine, benzocaine • Diseases (in cats) • Diabetes mellitus • Hyperthyroidism • Lymphoma

42. Regenerative Anemia d. ______________________ induced hemolysis RBC glycolysis is inhibited by hypophosphatemia; no glycolysis = no ATP (energy) for RBC = cell lysis • Diabetic cats • Enteral alimentation

43. Regenerative Anemia e. Other Microorganisms • ______________________ • Clostridium spp. and Leptospirosis (cattle) • ______________________ • ______________________ f. ______________________intoxication (usually calves) • can also occur as a result of inappropriate administration of ______________________ therapy. g. ______________________ RBC defects • ______________________ (shortened RBC lifespan) • RBC membrane transport defects • Chronic intermittent hemolytic anemia (Abyssinian and Somali cats)

44. Regenerative Anemia h. Miscellaneous • Metabolic disorders (anything that interferes with synthesis of ______________________, RBC, etc. or anything that interferes with ______________________processes of RBC)

45. Nonregenerative Anemia • Most nonregenerativeanemias are ______________________ • Further subclassified based on whether ______________________ (neutrophil production) and ______________________ (platelet production) are also affected. • Animals with nonregenerative anemia in conjunction with ______________________ (neutropenia and thrombocytopenia) usually have ____________ cell injury. • Possible causes: drugs, toxins, viruses (FeLV), radiation, and immune-mediated stem cell injury.

46. Nonregenerative Anemia • Reduced ______________________ • Chronic ______________________ disease • Endocrine deficiencies • Inflammation and neoplasia • Cytotoxic damage to the ______________________ • Estrogen toxicity • Cytotoxic cancer drug therapy • Chlormphenicol (cats) • Radiation • Other drugs

47. Nonregenerative Anemia e. Infectious agents • FeLV • ______________________ spp. • ______________________ f. Immune-mediated • Continued treatment with recombinant erythropoietin • ______________________ aplastic anemia g. Congenital/inherited h. ______________________ and other ______________________ disorders

48. Nonregenerative Anemia 2. Defective ______________________ • Disorders of ___________ synthesis • Iron, copper, and pyridoxine deficiencies; lead toxicity; drugs • Folate and ____________ deficiencies • Abnormal ______________________ • can be inherited, drug-induced or idiopathic

49. Reticulocyte Count • Probably the most important diagnostic tool used in the evaluation of anemia. • Fewer _____________ erythrocytes are present in anemic animal; more ______________________are present. • Expressed as a _____ of the RBCs present. • The lifespan of a normal RBC is about 110 days (dogs) and 68 days (cats). • Bone marrow should replace ___ % of the RBCs daily so the reticulocyte count should be _____-______%.

50. Reticulocyte Count • Gently mix 4 drops of blood with 4 drops of new methylene blue in a test tube. • Let mixture stand for 15 minutes • Use 1 drop of mixture to prepare a diagnostic blood film and observe under high-power, oil-immersion field. • Count 1,000 RBCs while separately keeping track of the number of reticulocytes (only aggregate form) • Divide the reticulocyte number by 1,000 and convert to a percentage. (Multiply by 100)