Anemias - Rodak Chapter 16 PDF

What is? What meaning? What is? What is? What meaning? ANEMIAS MARIA DE LOS A. OLIVERAS, MHSA, MLS(ASCP) Profesor UAGM-Gurabo, Campus  Objectives  Describe the clinical signs of anemia  List the causes  Establish laboratory criteria for the diagnosis of anemia  Explain method of hemogl...

What is? What meaning? What is? What is? What meaning? ANEMIAS MARIA DE LOS A. OLIVERAS, MHSA, MLS(ASCP) Profesor UAGM-Gurabo, Campus  Objectives  Describe the clinical signs of anemia  List the causes  Establish laboratory criteria for the diagnosis of anemia  Explain method of hemoglobin determination in an automated instrument.  Explain how hematocrit is calculated on an automated instrument.  Calculate the importance of the RBC Indices related to anemia.  Describe the appearance of Blood Smear in anemias.  Explain diagnostic value of reticulocyte counting.  ANEMIAS It is the inability of the blood to adequately supply oxygen to the tissue for proper metabolic function. The diagnosis is based on: Patient History Physical exam Signs and symptoms Hematologic laboratory findings.  ANEMIAS Anemia is associated with decreased levels: Hemoglobin. RBC Volume- (Hematocrit). RBC Counting. Moderate Anemia- Hgb = 7 – 10 g / dl. It does not produce signs and symptoms. Severe Anemia - Hgb < de 7 g dl.  ANEMIAS Reference Values: Hemoglobin  “Newborns”: 14.0 – 22.0 g/dl --- HCT average: 55%.  6 months: 11.0 – 14.0 g/dl --- HCT average 43%.  Children 11.0 – 15.0 g/dl.  Men's 14.0 – 18.015.2 +- 0.9.  Women 12.0 – 16.013.3 +- 0.9. Influencing factors: Geriatric elderly population- slight decrease ------ male = female. Geographical elevation Elevations > de 8,000 pies - increased Hgb (compensation).  ANEMIAS Causes  Nutritional deficiencies.  Blood loss. Causes is simplified into  RBC Accelerated Destruction.  Conditions Increased RBC Destruction  Bone marrow replacement.  Decrease in RBC Production.  Infections.  Toxicity.  Combinations.  Arrest or Damage Stem Cells.  Hereditary or Acquired Diseases RBC Enzymes.  ANEMIAS Red Cell Production (RBC)  1% RBC Senescent - Loses Daily. Reticulocytes: 0.5 – 2.0% normal circulating. Bone marrow replacement(BM)– Stem Cell, Precursors. Hemoglobin Production (Hgb) and RBC. Iron (Fe). Vit B12. Folic acid. Decrease in Production– Hypoproliferative Anemia.  Symptoms of Anemia ANEMIAS With minimal exercise--- increased heart and breathing rate  Fatigue, weakness, nausea, diarrhea.  Neurological changes: Loss of proprioception---- Patient with Vit B12 Anemia  Loss of positional sensation, loss of vibration awareness  Severe pallor, smooth tongue, pale discoloration of mucous membranes: Iron deficiency  Somewhat fever, heart murmur  Low pressure and decreased intravascular volume  High heart rate - cardiac output  Dyspnea.  ANEMIAS Anemia Compensation Mechanism Increases 2,3 DPG (2,3-disphosphoglycerate) Erythropoietin increases(EPO) EPO levels help differential diagnosis. The production of new RBCs in response to appropriate nutrients, vitamins, and other factors can be assessed with Reticulocyte Counting.  The Classification of Anemias Hypo proliferative Anemia - Bone Marrow (BM) Dynamics Accelerated destruction– Hemolytic Anemia Ineffective hematopoiesis– Combined Associated with your cause: Blood loss, iron deficiency (Fe), Nutritional Deficiencies Hemolysis, Infection, Metastatic Replacement.  The Classification of Anemias Quantitative Laboratory Measurements: Hematocrit, Hemoglobin, RBC Index, Reticulocytes. RBC Size: Microcytic RBC, Normocytic RBC, Macrocytic RBC Hemoglobin Content: Hypochromic RBC, Normochromic RBC  ANEMIA Hemoglobin and Hematocrit. They determine anemia and hydration status, position of the population. Anemia such as moderate, severe, acute, chronic. Hemoglobin – Reference Method- Spectrophotometric Absorbance. Cyanmethemoglobin - Standard curve. Hematocrit = Packed RBC Volume (PCV).  Capillary centrifugation / calculated. Man 47% +/- 5%. Women 42% +/- 5%.  The Relationship (ration) Hgb: Hct 1:3  ANEMIA RBC Indices MCV – average corpuscular volume – average size RBC  Normocytic, Microcytic, Macrocytic MHC – average cellular hemoglobin – hemoglobin content in RBC MCHC- average cell hemoglobin concentration  Normochromic, Hypochromic, (There is no truly hyperchromic) RDW- RBC distribution, size variation index–Anisocytosis  ANEMIAS RBC Indices MCV  Average Size Red Blood Cells (RBC) 90 +- 10 fL (80 – 100 fL) Unreliable when there is marked variability in size(RDW) Formula: Hct x 10 / #rbc Instrument is measured by Voltage Change(Intensity Change) Normocytic, Microcytic, Macrocytic  ANEMIAS RBC Indices MCH Average hemoglobin content in cells Normal values: 29 +/- 2 pg (27 – 31 pg) Formula: Hgb x 10 / # RBC  ANEMIAS RBC Indices MCHC  Average Cell Concentration of Hemoglobin. Normochromic, Hypochromic, (there is no truly hyperchromic). An enlarged MCHC is only seen in Spherocytosis and is rarely greater than 38 g/dl. 34 +/- 2% (32 – 36 %) Hgb x 100 / Hct %  ANEMIAS RBC Indices RDW Red Blood Cell (RBC) Distribution Size Variation Index Anisocytosis 11.5 - 14.5 % Normal Values – Rodak 6th edition  RBC Indices Utility ANEMIAS Provides a general idea about the clinic. Normochromic Normocytic. Bone marrow failure, hemolytic anemia, kidney disease Differential diagnosis: Reticulocyte count. Macrocytic Normochromic. (MCV 100 – 150 fL) Associated deficiencies Vit B12, Folic Acid. Liver Diseases. Microcytic Hypochromic. (MCV 50 – 80 fL ) Iron deficiencies, lead poisoning, chronic infections/inflammation. B thalassemia, Sideroblastic anemias, Unstable hemoglobin.  ANEMIAS Treatment According to its cause  Obtaining diagnostic studies as soon as possible is the most responsible and cost-effective way to treat anemias.  Transfusions can confuse diagnostic test findings. Suppresses Erythropoiesis. Alters Vit B12 and Iron (Fe) levels. They can thwart the interpretation of diagnostic tests by looking for the specific cause.  It is extremely important to make every effort to establish a diagnosis before giving a transfusion.  ANEMIAS Anemia Diagnostic Tests Hemoglobin Cyanmethemoglobin – Reference Method(absorbance 540 nm) Recommended International Committee for Standardization in Hematology Errors: Collection and inappropriate handling of the sample. Turbidity: Lipemia, high WBC (> 30,000), Abnormal proteins.  ANEMIAS Anemia Diagnostic Tests Hemoglobin Cyanmethemoglobin Blood + potassium ferrocyanide solution (Drabkin’s Reagent)  Methemoglobin Methemoglobin + Potassium Cyanide ---- Cyanmethemoglobin  Spectrophotometer 540 nm Stable solution, CV< 2% Oxyhemoglobin- measures oxygen-carrying hemoglobin. Measuring Iron (Fe) content.  Hemoglobin Determination Reference Method Determinación de hemoglobina Oxyhemoglobin  ANEMIAS Anemia Diagnostic Tests Hematocrit (man: 42-52% woman 37- 47%) RBC volume / Whole Blood ratio Tube with anticoagulant: EDTA, Oxalate, Heparin Expressed as a percentage% SI International Units--- L/L Expressed as decimal fraction (0.42 L/L)  Anemia Diagnostic Tests ANEMIAS Hematocrit Centrifugation Errors: Incorrect centrifugation– Strength / Time-- Reading Anticoagulant: Blood Ratio– Falsely low HCT (RBC contraction) An increased concentration of anticoagulant (short draw in an evacuated tube) decreases the hematocrit reading because of RBC shrinkage Automated Instrument Calculated by MCV and RBC Counting. HCT= (MCV x #RBC) / 10 Errors: Agglutinins (#rbc)– False decreased HCT Hyponatremia (MCV)– increased HCT-- Capture Plasma within RBC  ANEMIAS Anemia Diagnostic Tests Blood Smear Study A lot of information can be obtained: Neutropenia, Thrombocytopenia and Anemia Bone marrow (BM) failure Anisocytosis – RBC size variation Poikilocytosis – RBC Shape Variation Chromatic content- Hemoglobin content  ANEMIAS Anemia Diagnostic Tests Blood Smear Study WBC Evaluates ex. Hyper segmentation --- Macrocytic Anemia RBC Evaluates Basophilic Stippling --- Lead Poisoning  Bone marrow (BM) production Polychromasia ---- Reticulocytes  ANEMIAS Anemia Diagnostic Tests Blood Smear Study Howell Jolly Bodies- DNA fragment  hyposplenism, pernicious anemia, hemoglobinopathies (thalassemia) Pappenheimers bodies – iron deposits Sideroblastic Anemia, Alcoholism, Thalassemia, Myelodysplastic Syndromes Iron-Nucleated RBCs– Sideroblasts – Ineffective erythropoiesis  ANEMIAS Anemia Diagnostic Tests Blood Smear Study Cabot Ring - nuclear membrane remnant.  Pernicious anemia, lead poisoning Heinz bodies- small round inclusions Hgb Denaturation–Supravital Tints (Violet Crystal) No Wright Stain 2.3 DPG deficiency, alpha thalassemia, hemoglobinopathies  Anemia Diagnostic Tests ANEMIAS Reticulocytes (0.5 – 2.0%) They are non-nucleated RBC that still contains RNA. Supravital tint includes violet crystal, shimmering cresyl blue. Precipitate RNA. Determines Bone Marrow Response and Potential. In anemia the Retics are increased– Corrects: Corrected Retics = % Retics x Hct% / 45 (Hct referencia) Manual - CV > 50% Automated using fluorescence improves reproducibility Children have a higher count.  Anemia Diagnostic Tests ANEMIAS Reticulocytes (0.5 – 2.0%) Automation  Increased the precision and accuracy of reticulocyte counting.  Has expanded the analysis of immature RBCs, providing new parameters that are useful in the diagnosis and treatment of anemias:. The IRF (Immature Reticulocyte Fraction) parameter  Represents the fraction of the most immature cells in the total reticulocyte population. The Reticulocyte Hemoglobin Content Parameter  A real-time assessment of the availability of iron for hemoglobin synthesis.  (CHr, Siemens; RET-He, Sysmex)  Anemia Diagnostic Tests ANEMIAS Reticulocytes (0.5 – 2.0%) Automation The IRF (Immature Reticulocyte Fraction) parameter Represents the fraction of the most immature cells in the total reticulocyte population. They are recognized by a higher staining intensity of their cellular RNA and greater optical scatter. The IRF, in conjunction with the absolute reticulocyte count, can be used to assess the level of erythropoiesis.  Anemia Diagnostic Tests ANEMIAS Reticulocytes (0.5 – 2.0%) Automation The Reticulocyte Hemoglobin Content Parameter (CHr/RET-He )  A decreased CHr/RET-He means that there is inadequate iron available for synthesis of hemoglobin in the patient’s developing erythroid cells (provided there are no underlying hematopoietic disorders).  Therefore, a decreased CHr/RET-He is an early indicator of iron deficient erythropoiesis and is useful for early diagnosis of absolute iron deficiency (decreased or absent iron stores) in both adults and children.  The CHr/RET-He is also decreased in functional iron deficiency (FID).  In FID, there is adequate iron in storage sites (macrophages and hepatocytes), but not enough iron is available for hemoglobin synthesis in developing erythroid cells.  FID occurs in ESA therapy, such as in chronic kidney disease, when iron is not released rapidly enough from storage sites to support the accelerated erythropoiesis.  It also occurs in anemia of inflammation, a condition in which inflammatory cytokines increase hepcidin production in the liver, causing degradation of ferroportin in the membranes of macrophages and hepatocytes.  Without ferroportin, macrophages and hepatocytes are unable to export their storage iron out of the cell for hemoglobin synthesis (iron sequestration syndrome)  Anemia Diagnostic Tests ANEMIAS Reticulocytes (0.5 – 2.0%)  Two successive corrections are made to the reticulocyte count to obtain a better representation of RBC production.  First, to obtain a corrected reticulocyte count, one corrects for the degree of anemia by multiplying the reticulocyte percentage by the patient’s hematocrit and dividing the result by 45 (the average normal hematocrit).  Corrected Retics = % Retics x Hct% / 45 (Hct referencia)  If the reticulocytes are released prematurely from the bone marrow and remain in the circulation 2 to 3 days (instead of 1 day), the corrected reticulocyte count must be divided by maturation time to determine the reticulocyte production index (RPI)  The RPI is a better indication of the rate of RBC production than the corrected reticulocyte count.  RPI = corrected reticulocyte count / maturation Time.  ANEMIAS Anemia Diagnostic Tests Bone Marrow Smear/ Biopsy Differential counting of Myeloid, Lymphoid, Erythroid series. Iron staining. Immunohistochemical tests.  Anemia Diagnostic Tests ANEMIAS Tests Diagnostic use Hemoglobin Electrophoresis Hemoglobinopathies / Thalassemia Syndromes Anti-Human Globulin Test(AHG) Hemolytic anemias Hereditary Spherocytosis (Primary Use) Osmotic Fragility Test Severe Iron Deficiency Sickle Cell/ Thalassemia B Paroxysmal Nocturnal Hemoglobinuria Sucrose Hemolysis Test (Sugar Water Test) Anemias Hypoplasia Syndromes Myelodysplastic Paroxysmal Nocturnal Hemoglobinuria Acidified Serum Test (Ham’s Test) Congenital Sideropoietic Anemia Hemolytic anemias Enzyme Testing on Red Blood Cells(rbc) G6PD Deficiency/ Pyruvate Kinase Total Iron, Iron Binding Capacity(IBC) Iron deficiencies Folate, Vit B12 Megaloblastic anemias Formulas ANEMIAS ANEMIAS