Anaemia

Anemia (anaemia)  is a decrease in the level of hemoglobin in the blood. We follow the set limits for the specified age and gender. For men, the hemoglobin standard is 136–176 g/l and for women this value is 120–168 g/l. Anemia is often associated with decreased erytrocyt and hematocrit levels. It can also be a symptom that occurs in some pathological conditions.

Causes of anemia

 * 1) Increased erythrocyte losses (hemolysis, bleeding).
 * 2) Decreased erythrocyte production (stem cell disorders; lack of erytropoietin, vitamn B12, folic acid).
 * 3) Increase in plasma volume –  so-called relative (dilution) anemia.

Anemic syndrome

 * Set of symptoms accompanying anemia:


 * pale skin and mucous membranes;
 * fatigue, decreased physical performance;
 * shortness of breath during exertion;
 * tachycardia, circulatory insufficiency (from myocardial hypoxia).


 * In addition, in hemolytic anemias, manifestations of hemolysis – hemoglobinemia, hemoglobinura (up to hemoglobinuric nephrosis), decrease in haptoglobin levels, hemosideróza, hemosiderosis, ikterus, formation of pigmented gallstones.

Morphological

 * Normocytic  (MCV 80–95 fl, or erythrocyte diameter 7–8 μm) – after acute bleeding, aplastic anemia, some hemolytic anemia;
 * Macrocytic (MCV over 95 fl, or erythrocyte diameter over 8 μm) – lack of vit. B12 or folic acid;;
 * Microcytic (MCV below 80 fl, or erythrocyte diameter below 7 μm) – Fe deficiency, spherocytosis, thalassemia, after chronic bleeding;


 * Normochromic  (MCHC 300–350 g/l) – after acute bleeding;
 * Hypochromic (MCHC below 300 g/l) – Fe deficiency, thalassemia;;
 * Hyperchromic (MCHC over 350 g/l) – lack of vit. B12.

Anemia from increased erythrocyte loss

 * Posthemoragic anemia;
 * Hemolytic anemia;


 * intracorpuscular:
 * Congenital:
 * erythrocyte structure disorders (hereditary spherocytosis);
 * enzymopathy (Glc-6-β-dehydrogenase, pyruvate kinase, hexokinase deficiency);
 * hemoglobinopathy (sickle cell disease, thalassemia);
 * Acquired ::
 * paroxysmal nocturnal hemoglobinuria.


 * extracorpuscular:
 * mechanical causes;
 * toxic hemolysis;
 * osmotic hemolysis;
 * production of antibodies or autoantibodies;
 * hypersplenism.

Anemia from decreased erythrocyte production

 * erytropoietin deficiency;
 * lack of factors necessary for erythropoiesis (proteins, iron – sideropenic anemia, vitamin B12, folic acid);
 * hematopoietic tissue disorder;
 * anemia of chronic diseases

Microcytic anemia investigation algorithm

 * serum ferritin level decreased →  iron deficiency anemia
 * serum ferritin level normal or elevated → LDH and haptoglobin
 * normal  → anamnesis, clinic, inflammatory indicators
 * positive → anemia of chronic diseases
 * negative  → bone marrow puncture
 * positive → myelodysplastic syndrome, subtype of refractory anemia with annular sideroblasts
 * negative  → anemia of chronic diseases
 * pathologica → hemoglobin electrophoresis, molecular genetic testing, blood smear → '''alpha-thalassemia, beta-thalassemia

Algorithm for distinguishins iron deficiency anemia from fronic disease anemia
biochemical and clinical signs of inflammation → transferrin saturation <20%
 * serum ferritin < 30 μg/l → iron deficiency anemia
 * serum feritin ferritin 30–100 μg/l → soluble transferrin receptor (sTfR)
 * sTfR / log ferritin > 2 → iron deficiency anemia with iron deficiency
 * sTfR / log ferritin 1–2 → ?
 * sTfR / log ferritin < 1 → anemia of chronic diseases
 * sérový ferritin > 100 μg/l → anemia of chronic diseases

Algorithm for investigating normocytic anemia

 * signs of bleeding → anemia from bleeding
 * no signs of bleeding → absolute reticulocyte count, reticulocyte index
 * increased → LDH and haptoglobin
 * normal → examination of the spleen
 * enlarged → hypersplenism
 * normal → bleeding anemia
 * LDH increased and haptoglobin decreased → hemolytic anemia
 * normal or decreased → differential blood count,  blood smear
 * pathological  → bone marrow puncture → leukemia, aplastic anemia, bone marrow infiltration by solid tumor or lymphoma, plasmacytoma, myelodysplastic syndrome, myeloproliferative syndrome
 * inconspicuous → creatinin
 * increased  → renal anemia
 * normal
 * anamnesis, clinic, inflammatory indicators → anemia of chronic diseases
 * occult bleeding → bleeding anemia
 * low or undetectable reticulocytes → serology parvovirus B19
 * positive→  parvovirus B19 infection
 * negative → pure red cell aplasia
 * bone marrow puncture → leukemia, aplastic anemia, bone marrow infiltration by solid tumor or lymphoma, plasmocytoma, myelodysplastic syndrome, myeloproliferative syndrome
 * TSH, calcium, phosphate, endocrinological examinations → hypothyroidism, hyperthyroidism , hypogonadism, hyperparathyroidism, panhypopituitarism

Macrocytic anemia investigation algorithm
anamnestic alcohol, drugs, radiation
 * yes → alcoholic-toxic anemiae, drug-induced macrocytic anemia, radiation-induced macrocytic anemia
 * no → absolute reticulocyte count, reticulocyte index
 * increased  → hemolytic anemia, AIHA from cold agglutinins or thermal antibodies, bleeding compensation or bleeding anemia, hypersplenism
 * reduced → vitamin B12 and folic acid
 * reduced  →  lack of vitamin B12 or folic acid
 * normal → blood smear
 * pathological → bone marrow puncture → myelodysplastic syndrome, myeloproliferative diseases, non-Hodgkin's lymphomas, plasmocytoma, leukemia, aplastic anemia
 * normal  → liver values, liver sonography
 * pathological → liver cirrhosis, chronic active hepatitis
 * normal → TSH, fT3, fT4
 * pathological  → hypothyroidism
 * normal → bone marrow puncture → myelodysplastic syndrome, myeloproliferative disease, non-Hodgkin's lymphomas, plasmocytoma, leukemia, aplastic anemia

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