Anemia

John R. Brill, MD, MPH

Anemia

• Goals– Review common causes of anemia– Provide conceptual framework for evaluating

patients with anemia– Show some interesting, gross and unusual

pictures

Anemia

• Definition: Age/gender-specific reduction in the circulating red blood cell mass

• Commonly measured by the hemoglobin or hematocrit

Anemia: Prevalence

• Approximately 4.7 million Americans • 6.6 % of men; 12.4 % of women• Increases with age; 44.4 percent in men > 85 • “Although the elderly are more prone to

develop anemia, older age is not of itself a cause of the condition.”

Brill JR, Baumgardner DJ. Am Fam Physician 2000; 62:2255-63,2264

Primary Causes of Anemias

• Increased red blood cell loss or destruction

• Decreased red blood cell production

• Overexpansion of plasma volume

• Maldistribution

RBCs

External losses

Maldistri-bution

Precursors

Production

Plasma Volume

Increased red blood cell loss or destruction

• Blood loss

• Hypersplenism

• Hemolytic disorders– Acquired conditions– Congenital conditions

Case 1

• 25 y/o woman, G2 P2002• c/o fatigue• TSH 1.3• Hgb 10.3, Hct 31, Nl WBCs, Plts 538K, MCV 81, RDW 18.5• FeSO4 325 mg daily x 6 weeks• Hgb 11.6, Hct 35

Congenital Hemolysis

• Hemoglobinopathies

• Disorders of red blood cell membranes

• Red blood cell enzyme deficiencies

Hemoglobinopathies• Homozygous sickle cell disease (hemoglobin SS

disease) Sickle cells, target cells.• Heterozygous sickle hemoglobin C disease

(hemoglobin SC disease)• Thalassemias (usually microcytic)

Disorders of red blood cell membranes

Hereditary spherocytosis Hereditary elliptocytosis

Red blood cell enzyme deficiencies

• Glucose-6-phosphate dehydrogenase deficiency

• Pyruvate kinase deficiency

Case 2

• 22 y/o man• Recently started doxycycline for acne• Fatigued, tired, dizzy• Hgb 10.6, Hct 31. CRI 3.7%• Coombs (-). Stool heme neg. Urine dip +,

micro negative

Acquired Hemolysis

Mechanical hemolysis

• Macrovascular disorders• Microangiopathic disorders

Macrovascular hemolysis

• Valves, atherosclerosis

•Schistocytes

Microvascular hemolysis

• Disseminated intravascular coagulopathy

• Hemolytic-uremic syndrome• Thrombotic thrombocytopenic

purpura

Case 3

• 31 y/o woman

• 3 day hx severe diarrhea; 2 other family members also effected

• Now with bloody diarrhea, fever, confusion

• Hgb 8.5, Hct 26, Plts 23K, WBC 23.6

• Creat 4.3

Autoimmune hemolytic anemias

Warm-reactive anemias Cold-reactive anemias Drug-induced anemias Paroxysmal nocturnal hemoglobinuria

Case 4• 72 year old woman, new pt• DM, HTN. On glipizide,

lisinopril, HCTZ, ASA• Fatigue, felt 2nd to care of

husband with CVA• Rectal heme negative• Hgb 6.7, Hct 20• Nl WBC, Plts, CMP, TSH• No prior CBC available

Case 4, cont

• Retic Count 4.9% (CRI 2.5%)• Coombs +++• Dx: Drug-Induced Hemolytic Anemia

Decreased RBC ProductionPrimary causes

Marrow hypoplasia or aplasia Myelopathies Myeloproliferative diseases Pure red blood cell aplasia

Secondary causes

Anemia of chronic disease

Chronic renal failure Endocrine deficiency states Sideroblastic anemias

Iron Deficiency

• Most common cause of anemia world-wide

• Low Fe, Ferritin; elevated TIBC, platelets

Case 5

• 63 y/o man

• Farmer, never came to doctor

• 8 month hx weight loss, anorexia, fatigue

• Hgb 7.3, Hct 22 Plts464K, WBC 11.3

• MCV 82, RDW 18.5

• Ferritin 6

• Dark maroon heme +++ stool

Anemia of Chronic Disease

• Most common cause of anemia in US

• Increases with age

• 30% hospitalized patients

• Malignancies, endocrinopathies, rheumatic disease, hepatic disease

• Renal disease: not linked to degree of impaired GFR

Case 6

• 67 y/o man

• DM, HTN, Hyperlipidemia, CAD

• HgbA1c 9.4, microalbumin high, creat 1.6

• Hgb 9.5, Hct 29, nl WBC, Plts, MCV 84 RDW 14

• Ferritin 140

• Erythropoeitin x 6 weeks, Hgb 11.1

Summary

• Anemia is common

• Consider epidemiology, history to formulate a differential, directed labs

• Use whole CBC

References

• Incidence of anemia in older people: an epidemiologic study in a well defined population. BJ Ania, VJ Suman, VF Fairbanks, DM Rademacher, LJ … - J Am Geriatr Soc, 1997

• Advances in the anemia of chronic disease. RT Means Jr - Int J Hematol, 1999

• Normocytic anemia. JR Brill, DJ Baumgardner - Am Fam Physician, 2000 Nov 15;62(10):2255-64