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.

Classification of anemias

Symptoms of anemia

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.

Patogenetic

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

Links

Related articles

• ACD (signspot)
• Blackfan-Diamond anemia
• Antianemics
• hemotherapy

External links

• Anémia (TECHmED)

References

• SPANGENBERGER, Holger – MEUTHEN, Ingo. Anemie [online] . In Diferenciální diagnostika ve vnitřním lékařství. 1. české vydání. edition. Praha : Grada Publishing, 2010. 416 pp. pp. 62. Available from <http://books.google.cz/books?id=lhuy-2sCzdIC&lpg=PR3&dq=isbn%3A9788024727806&hl=cs&pg=PA68#v=onepage&q&f=false>. ISBN 978-80-247-2780-6

• SPANGENBERGER, Holger – MEUTHEN, Ingo. Anemie. In Diferenciální diagnostika ve vnitřním lékařství. 1. české vydání. edition. Praha : Grada Publishing, 2010. 416 pp. pp. 77. ISBN 978-80-247-2780-6

• SPANGENBERGER, Holger – MEUTHEN, Ingo. Anemie [online] . In Diferenciální diagnostika ve vnitřním lékařství. 1. české vydání. edition. Praha : Grada Publishing, 2010. 416 pp. pp. 68. Available from <http://books.google.cz/books?id=lhuy-2sCzdIC&lpg=PR3&dq=isbn%3A9788024727806&hl=cs&pg=PA68#v=onepage&q&f=false>. ISBN 978-80-247-2780-6

• ŠČUDLA, Vlastimil. Anémie chronických chorob [online]. Mladá fronta, ©2009. [cit. 2013-05-10]. <https://web.archive.org/web/20160331222721/http://zdravi.e15.cz/clanek/postgradualni-medicina-priloha/anémie-chronickych-chorob-447150>.

• PASTOR, Jan. Langenbeck’s medical web page [online]. [cit. 12.4.2010]. <https://langenbeck.webs.com/>.