Please enable JavaScript.
Coggle requires JavaScript to display documents.
Anemia - Coggle Diagram
Anemia
1. Intro
prevalence and impact
usually, anemia is a sign of an underlying disease
signs and symptoms
fatigue, weakness, lightheadedness, SOB, low exercise, white eyes, white nails, pale face, white creases in palms
pathophysiology
Hgb is a protein in RBC that carries oxygen
transferrin delivers iron to the bone marrow so that it gets incorporated into Hgb
in anemia, ⬇️ RBC production, ⬆️ RBC destruction, ⬆️ RBC loss
goals of therapy
alleviate signs and sx of anemia
normalize or ensure normal Hgb level
improve QofL
prolong survival
definition
decrease in number of RBC OR [Hgb]
important to correct the underlying cause of iron deficiency where possible
2. RBC production and labs
CBC components
RBC, WBC, Hgb, hematocrit, MCV, MCH, MCHC, RBC distribution width, platelets
RBC indices
MCH
average
amount
of Hgb in one RBC
MCHC
average
concentration
of Hgb in total RBCs
MCV
size of average RBC
RDW
measure of variation in RBC
volume
hematocrit
packed cell volume, actual volume of RBCs in a unit of volume
reticulocyte count
immature RBCs (big in size)
increased number of reticulocytes in circulation leads to a larger MCV
iron studies
TIBC
indirect measurement of serum transferrin
transferrin saturation (TSAT)
30% of circulating transferrin is saturated with iron, normally
serum iron
conc of iron bound to transferrin
ferritin
total body iron storage
3. Classification of Anemia
B. normocytic anemia (MCV 80-100)
causes
aplastic anemia
hemolysis
CKD
, liver disease, endocrine issues
anemia of chronic disease
acute blood loss
focus
anemia of chronic disease
labs (vs IDA)
low-normal MCV, normal RDW, low TIBC,
normal ferritin
treatment
recovery from inflammatory process
supplements won't do anything unless Fe, folate, B12 are actually low and in that case you need them
erythropoietin or transfusions ✅
pathophysiology
caused by infectious, inflammatory diseases lasting 2+ months like TB, HIV, RA, leukemia
RBC life span is short, bone marrow capacity is inadequate
anemia of chronic renal failure
erythropoietin therapy
+iron and folic acid if necessary and they are low too
epoetin alfa, or darbepoetin. dose depends on Hgb and if pt is on dialysis or not. as Hgb reaches 120, lower dose
monitoring parameters
Hgb, BP, ferritin, TSAT
causes
low erythropoietin production, low RBC lifespan, low folic acid stores, blood and iron loss from hemodialysis
helpful labs: reticulocyte, CRP, liver function, eGFR, SCr, TSH
C. macrocytic anemia (MCV >100)
signs and sx
neurologic signs in B12 deficiency and beefy red tongue
anorexia, constipation/diarrhea switching, ab pain
vitamin B12
labs
⬇️RBC, ⬇️ Hgb/hematocrit, MCV > 100, ⬇️B12
treatment (oral vs parenteral)
parenteral
cyanocobalamin 1000 mcg/mL daily for 7 days, then 1000 msg monthly as maintenance
oral
cyanocobalamin tabs, need 500-2000mcg/d for dietary defiency, or 1000-2000 a day for pernicious anemia
causes of deficiency
diet,
low intrinsic facto
r due to pernicious anemia or gastric bypass surgery
intestinal malabs
food-cobalamin malabs
monitoring
reversal of neurological sx (neuropathy, altered mental status) may take several weeks
Hgb should go up in 1-2 months, so do CBC and B12 1-2 months after tx and every 3-6 months after that
monitor for K, for pts with severe anemia
absorption
water soluble, found in eggs, meat, dairy
takes 3-5 years to become deficient
important in DNA synthesis and neurologic system
causes
folate deficiency
drugs
folate
MTX, phenytoin, sulfasalazine, trimethoprim
B12
anticonvulsants, H2RAs, Metformin, PPIs
B12 deficiency
liver disease, alcoholism, hypothyroidism
folate
causes of deficiency
diet, defective conversion form, increased requirement (pregnancy), intestinal malabs
treatment and monitoring
1-5mg daily for 1-4 months or indefinitely
monitor for reticulocytosis within 2-3 days, Hct rise in 2 weeks but normalizes in 1-2 months, repeat CBC in 1 month
labs will show: high MCV, low reticulocytes
folate might reverse any blood abnormalities, but it will not correct the neurologic damage caused by B12
helpful labs: vitamin B12/folate, reticulocyte, TSH, protein electrophoresis
A. microcytic anemia (MCV < 80)
iron deficiency anemia
signs/sx
fatigue, decreased exercise tolerance, pale eyes, white nails (koilonychia), pica (eating nonfood items like paper), craving ice, sore or smooth tongue 👅 🧊 📄 💅
diagnostic labs
low serum ferritin; IF ferritin is normal, check for ⬇️ serum iron, ⬇️ TSAT, ⬆️ TIBC
etiology
happens when there is not enough iron to support RBC production
caused by inadequate diet, inadequate absorption (celiac, gastritis), increased demands (pregnancy), increased loss of iron (periods)
daily intake or iron from diet is 10-20mg; we absorb 1-2mg/d, hepcidin regulates intestinal iron absorption and movement from liver
dietary considerations
iron from meat is better than fruits, veggies, dairy, grains bc meat iron is heme
ascorbic acid (Vitamin C) helps with non-heme iron absorption
8mg for men and postmenopausal women; 18mg for women
oral iron therapy
dosing strategies
100mg elemental iron per day, better on empty stomach but can take with food (❌ cereals, dairy, coffee) to minimize GI upset
can do alternate day dosing or twice weekly dosing as well to reduce a/e but will just have lesser iron yield; can also start at a low dose, then increase gradually
formulations
all the different salts absorb the same, but they differ in amount of elemental iron; max absorption occurs in duodenum
polysaccharide-iron: 150mg elemental (💰), fumarate: 100mg elemental, sulfate: 60mg, gluconate: 35mg,
heme-iron polypeptide: 11mg heme iron. (💰)
heme iron & sulphate --> same efficacy for CKD
sulfate and polysaccharide iron --> sulfate better for young children
a/e
GI upset, dark stools, constipation/diarrhea
d/i
decreases iron abs
Al, Mg, Ca, antacids, tetracyclines, PPIs, H2RAs
iron decreases them:
levodopa, synthroid, fluoroquinolones, tetracycline, mycophenolate, bisphosphonates, HIV integrase inhibitors
monitoring
check CBC after 3-4 weeks, should be normal in 6-10 weeks continue until ferritin is repleted (3-6 months), but check ferritin before d/c
switch to low maintenance dose when ferritin is normal
monitor for a/e --> most common cause of nonadherence
parenteral iron (IV or IM)
formulations
iron sucrose, Dextran, gluconate complex
dosing
dosing is based on calculating the iron deficit of the pt
indications
iron malabsorption, intolerance of oral, non adherence to oral
anemia of chronic disease
thalassemias
helpful labs: ferritin, CRP