Anemia

1. Anemia
John R. Brill,
MD, MPH

2. Anemia
•Goals
–Review common causes of anemia
–Provide conceptual framework for evaluating
patients with anemia
–Show some interesting, gross and unusual
pictures
im ages

3. Anemia
•Definition: Age/gender-specific reduction
in the circulating red blood cell mass
•Commonly measured by the hemoglobin or
hematocrit

5. Anemia: Prevalence
•Approximately 4.7 million Americans
•6.6 % of men; 12.4 % of women
•Increases with age; 44.4 percent in men > 85
•“Although the elderly are more prone to
develop anemia, older age is not of itself a
cause of the condition.”
Brill JR, Baumgardner DJ.

Am Fam Physician 2000; 62:2255-63,2264

6. Primary Causes of Anemias
•Increased red blood cell loss or
destruction
•Decreased red blood cell production
•Overexpansion of plasma volume
•Maldistribution

7. RBCs
External losses
Maldistri-
bution
Precursors
Production
Plasma
Volume

8. Increased red blood cell
loss or destruction
•Blood loss
•Hypersplenism
•Hemolytic disorders
–Acquired conditions
–Congenital conditions

10. Case 1
•25 y/o woman, G2 P2002
•c/o fatigue
•TSH 1.3
•Hgb 10.3, Hct 31, Nl WBCs, Plts 538K, MCV 81,
RDW 18.5
•FeSO4 325 mg daily x 6 weeks
•Hgb 11.6, Hct 35

11. Congenital Hemolysis
•Hemoglobinopathies
•Disorders of red blood cell
membranes
•Red blood cell enzyme deficiencies

12. Hemoglobinopathies
•Homozygous sickle cell disease (hemoglobin SS
disease) Sickle cells, target cells.
•Heterozygous sickle hemoglobin C disease
(hemoglobin SC disease)
•Thalassemias (usually microcytic)

13. Disorders of red blood cell
membranes
Hereditary spherocytosisHereditary elliptocytosis

14. Red blood cell enzyme deficiencies
•Glucose-6-phosphate dehydrogenase deficiency
•Pyruvate kinase deficiency

15. Case 2
•22 y/o man
•Recently started doxycycline for acne
•Fatigued, tired, dizzy
•Hgb 10.6, Hct 31. CRI 3.7%
•Coombs (-). Stool heme neg. Urine dip +,
micro negative

17. Acquired Hemolysis
Mechanical hemolysis
•Macrovascular disorders
•Microangiopathic disorders

18. Macrovascular hemolysis
•Valves, atherosclerosis
•Schistocytes

19. Microvascular hemolysis
•Disseminated intravascular
coagulopathy
•Hemolytic-uremic syndrome
•Thrombotic thrombocytopenic
purpura

20. Case 3
•31 y/o woman
•3 day hx severe diarrhea; 2 other family
members also effected
•Now with bloody diarrhea, fever,
confusion
•Hgb 8.5, Hct 26, Plts 23K, WBC 23.6
•Creat 4.3

22. Autoimmune hemolytic
anemias
Warm-reactive anemias
Cold-reactive anemias
Drug-induced anemias
Paroxysmal nocturnal hemoglobinuria

23. Case 4
•72 year old woman, new pt
•DM, HTN. On glipizide,
lisinopril, HCTZ, ASA
•Fatigue, felt 2nd to care of
husband with CVA
•Rectal heme negative
•Hgb 6.7, Hct 20
•Nl WBC, Plts, CMP, TSH
•No prior CBC available

25. Case 4, cont
•Retic Count 4.9% (CRI 2.5%)
•Coombs +++
•Dx: Drug-Induced Hemolytic Anemia

27. Decreased RBC Production
Primary causes
Marrow hypoplasia or aplasia
Myelopathies
Myeloproliferative diseases
Pure red blood cell aplasia

29. Secondary causes
Anemia of chronic disease
Chronic renal failure
Endocrine deficiency states
Sideroblastic anemias

30. Iron Deficiency
•Most common cause of anemia world-wide
• Low Fe, Ferritin; elevated TIBC, platelets

31. Case 5
•63 y/o man
•Farmer, never came to doctor
•8 month hx weight loss, anorexia, fatigue
•Hgb 7.3, Hct 22 Plts464K, WBC 11.3
•MCV 82, RDW 18.5
•Ferritin 6
•Dark maroon heme +++ stool

35. Anemia of Chronic Disease
•Most common cause of anemia in US
•Increases with age
•30% hospitalized patients
•Malignancies, endocrinopathies, rheumatic
disease, hepatic disease
•Renal disease: not linked to degree of
impaired GFR

36. Case 6
•67 y/o man
•DM, HTN, Hyperlipidemia, CAD
•HgbA1c 9.4, microalbumin high, creat 1.6
•Hgb 9.5, Hct 29, nl WBC, Plts, MCV 84
RDW 14
•Ferritin 140
•Erythropoeitin x 6 weeks, Hgb 11.1

37. Summary
•Anemia is common
•Consider epidemiology, history to
formulate a differential, directed labs
•Use whole CBC

39. References
•Incidence of anemia
in older people: an epidemiologic study in a well defined population
. BJ Ania, VJ Suman, VF Fairbanks, DM
Rademacher, LJ … - J Am Geriatr Soc, 1997
•Advances in the anemia of chronic disease.
RT Means Jr - Int J Hematol, 1999
•Normocytic anemia. JR Brill, DJ
Baumgardner - Am Fam Physician, 2000 Nov
15;62(10):2255-64