Gilmore - Anaemia

8/9/2019 Gilmore - Anaemia

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Anaemia

Bill Gilmore


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Normal red cell

Bill Gilmore


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Red Cell Development

• Stem Cells, Haemangioblast, mesenchymalstem cells, haemopoietic stem cell, CFU-GEMM, BFU-E, CFU-E

• Early Erythroblast

• Intermediate erythroblast

• Late erythroblast

• Reticulocyte• Mature red blood cell


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Red Cell Development

• Blasts

– Nuclear:cytoplasmic ratio

large

– Chromatin is fine andmeshy

– Nucleoli present

– Perinuclear halo present

(mitochondria)

– Membrane highly

refractile

– Cytoplasm blue

• Changes

– Nuclear:cytoplasmic ratio

lowers

– Chromatin condenses

– Nucleoli disappear

– Perinuclear halo

disappears

– Membrane become lessrefractile

– Cytoplasm become

haemoglobinised


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The red blood cell

• Biconcave disc

• 7 u in diameter

• Lifespan 120 days

• No nucleus, mitochrondria or other organelles

• Function is to carry O2 from the lungs to the

tissues and CO2 from the tissues to the lungs


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Haemoglobin

• Protein moiety - in normal adult

haemoglobin A; 2 chains and 2

chains• Haem - iron containing protoporphyrin

ring


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Haem SynthesisGlycine + succinyl CoA

- aminolaevulinic acidPorphobilinogen

Hydroxymethylbilane

Uroporphyrinogen III

Coproporphyri

nogen III

Protoporphyrinogen IX

Protoporpgyrin IX

Haem

Ala-synthase

FerrochelataseFe2+


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Globin SynthesisDNA

Hn RNA

AAAA5’ cap

5’ cap

5’ cap AAAA

AAAA

- globin

Splicing

Processing

Translation on cytoplasmic ri

Transcription


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Chromosome 16

Chromosome 11

2 1

G A


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Haemoglobin Function

• Carries gases around the body.

• Can bind O2, CO2, CO, Sulphur ,

Cyanide

• Methaemoglobin (Fe3+)

• Carboxy Hb


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Normal Red cell Metabolism

• Energy comes from Embden-Meyerhof

Glycolyic Pathway

• Produces 2,3 diphosphoglycerate fromLuebering-Rapoport shunt

• Produces reducing power from

glycolysis and from pentose phosphatepathway


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Red Cell Membrane

• Phospholipid Bilayer

• Contains important proteins eg spectrin


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Anaemia

• Normal range for Haemoglobin

– Men 150 (+ 20) g/l

– Women 135 (+ 15) g/l

• Clinically relevant anaemia =

Haemoglobin value below 105g/l


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Aetiology of Anaemia

• Decreased proliferation of new RBCs – Low EPO

– Damage to Bone Marrow

• Impairment of maturation of RBCs – Nutritional deficiency (iron, B12, folate)

– Abnormal haem synthesis

• Loss or destruction of RBCs – Haemorrhage

– Haemolysis


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Hypochromic anaemias

• Nutritional deficiency of iron

• Anaemia of chronic disorders

• Sideroblastic anaemia

• Iron overload


16/39Copyright ©2002 American Society of Hematology. Copyright restrictions may apply.

Schrier, S. ASH Image Bank 2002;2002:100325

Figure 1. Note the profound central pallor of the hypochromic and microcytic RBC


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The Haematology Laboratory

• General Haematology or Blood Science

• Coagulation

• Blood Bank

• Stem Cell Transplantation

•Specialist Haematology – Flow cytometry

– Molecular haematology


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General Haematology or Blood Science

• Automated Blood Cell Counts

• Reticulocyte Counts

• Platelet counts

• Eosinophil counts

•Blood Cell Morphology

• Blood Science includes automated

analysers for other blood parameters


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Blood Specimens

• Taken by venepuncture (branch of

Healthcare Science - Phlebotomy )

• Without anticoagulant = serum / buffycoat

• With anticoagulant = plasma / cells in

suspension

• Defibrinated blood – blood taken and

fibrin removed by agitation with glass

beads


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Anticoagulants

• Ethylene Diamine Tetra Acetic acid

(EDTA) – chelates Ca2+ ions, powerful,

very small amount required, can beheat treated and dried to a negible

volume.

• Sodium Citrate – Chelates Ca2+ ions,remains in liquid form – used for

coagulation studies

• Sodium Oxalate – as with citrate


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Initial Haematological tests

• Full Blood Picture

• Blood Cell Morphology – differential

white cell count plus microscopialobservations


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Normal Full Blood Picture


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Microcytic Anaemia

• Lowered Hb

• Microcytosis – MCV lowered

• Hypochromasia – MCH lowered

• Morphology

– Confirms microcytosis

– Confirms hypochromasia


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Full Blood Picture –

Micro,Hypo


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Macrocytic (Megaloblastic) Anaemia

• Lowered Hb

• Macrocytosis – MCV and MCH raised

• Lowered WCC and Platelet count

• Morphology

– Confirms macrocytosis

– Confirms low WCC and platelets

– Hypersegmented neutrophils present


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FBC- Megaloblastic


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Haemolytic Anaemia

• Lowered Hb

• May be Macrocytosis – MCV and MCH

raised• Morphology


– Macrocytes are polychromasic (reticulocytes) – May contain nucelated Red blood cells

– May be evidence of red cell damage


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FBC- Haemolytic Anaemia


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Microcytic Anaemia

• Lowered Hb

• Microcytosis – MCV lowered

• Hypochromasia – MCH lowered

• Morphology

– Confirms microcytosis

– Confirms hypochromasia


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Further Investigation of Microcytic,

Hyopchromic blood picture• Serum iron

• Total iron binding capacity

• Serum ferritin

• Transferrin receptor assays – soluble –

useful in the anaemia of chronic disease

• Hb electropheresis – useful for

thalassaemia

• Perls’ Prussian Blue – stain for iron

stores in BM – useful for identif in rin


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Macrocytic (Megaloblastic) Anaemia

• Lowered Hb

• Macrocytosis – MCV and MCH raised

• Lowered WCC and Platelet count

• Morphology


– Confirms low WCC and platelets

– Hypersegmented neutrophils present


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Further investigation of a

megaloblastic anaemia• Serum B12 – microbiological assay,

Euglena gracilis

• Serum and red cell folate – microbiological assay, Lactobacillus

casei

• Alternatively - A host of competitiveprotein binding assays for serum B12

and serum/red cell folate


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Investigation of absorption of

B12• Schilling test – excretion in urine after

feeding 27Co or 58Co labelled B12

following by a wash out of unlabeledvitamin. One isotope can be given alone

the other with Intrinsic Factor.

• Whole body counting – no flushing dose


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Investigation of a probable B12

deficiency• Estimation of intrinsic factor in gastric

juice

• Intrinsic factor antibidies

• Parietal cell antibodies


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Response to treatment (Therapeutic

Trial)• Observe the optimal haematological

response after administration of the

haematinic at day 0• Reticulocyte count rises on days 2 and

3 and reaches a peak between days 6

and 7• Red Cell count rises


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Haemolytic Anaemia

• Lowered Hb

• May be Macrocytosis – MCV and MCH

raised• Morphology


– Macrocytes are polychromasic (reticulocytes) – May contain nucelated Red blood cells

– May be evidence of red cell damage


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Diagnosis of a haemolytic

anaemia• Evidence of increased red cell break

down

– Serum bilirubin – Urobilogen

– Serum haptoglobin

– Haemosiderin – 51Cr red cell life span


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Type of Haemolysis

• Direct antiglobulin test (Direct Coombs)

• Osmotic fragility

• Haemosiderin and Hb in urine

• Plasma Hb


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If an hereditary disease is

suspected• Osmotic Fragility

• Autohaemolysis + glucose

• Red cell instability

• Screening test for G6PDH deficiency• Glycolytic enzyme assays – PK first

• Glutathione

• Electrophersis

• 5HbF

• Sickling• Unstale Hb

• Gel electropheresis for red cell membrane proteins

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Gilmore - Anaemia

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