Hemolytic anemia - Approach and Management

Hemolytic anemia - Approach and Management - PNH Autoimmune AICA Spherocytosis Elliptocytosis Donath Landsteiner Icterus Splenomegaly Megaloblastic

1. HEMOLYTIC ANEMIAS CHAIRPERSON – Dr.Sachin Hoskatti STUDENT – Dr. Manjunath

2. CLASSIFICATION OF ANEMIA Decreased production of red cells, Increased destruction of red cells, and Acute blood loss.

3. P atients who are anemic as a result of either increased destruction of red cells or acute blood loss Both have one important element in common: T he anemia results from overconsumption of red cells from the peripheral blood, whereas the supply of cells from the bone marrow is normal (indeed, it is usually increased). T hese two groups differ in physical loss of red cells from the bloodstream or from the body itself , as in acute hemorrhage , destruction of red cells within the body , as in hemolytic anemias .

4. Approach to Hemolytic Anemia Plan of Action: History and clinical examination Peripheral blood smear Confirm hemolysis Whether hemolysis is intra or extravascular Determine the etiology

5. Patient History Acute or chronic Medication/Drug precipitants G6PD AIHA Family history Concomitant medical illnesses Clinical presentation

6. FEATURES

7. Peripheral Blood Smear Determines the etiology of hemolysis . Intravascular hemolysis may reveal red cell fragmentation (i.e. schistocytes, helmet cells), whereas spherocytes indicate extravascular hemolysis . Polychromasia and nucleated RBCs are indicators of increased erythropoiesis .

8. Peripheral smear

9. STEP BY STEP APPROACH 1. Calculate for Corrected Reticulocyte Count Retic count: 10% Pt’s Hct 29 Control Hct 40 Corrected Retic Count = % Retic x Pt’s Hct Control Hct = 10% x 29/ 40 = 7.73 % > 2% if no blood loss Indicates hemolysis

10. 2 . Confirm (+) hemolysis: Corrected retic count > 2% Inc indirect bilirubins Inc LDH Low/absent haptoglobin Look for cause of hemolysis occult blood in urine, urine hemosiderin peripheral blood smear direct antiglobulin test, Hgb electrophoresis, RBC enzyme analysis

11. E VALUATION OF ANEMIA Low Hgb/Hct Corr. Retic Ct >2% Corr. Retic Ct <2% Acute Blood Loss MCV>100 MCV 80- 100 MCV<80 E VALUATE & TREAT APPRO - PRIATELY Evaluate for Hemolytic Anemias Evaluate for microcytic anemias Evaluate for macrocytic anemias Evaluate for normocytic anemias

12. CLASSIFICATION OF HEMOLYTIC ANEMIAS

13. HEREDITARY Causes correlate with intracorpuscular defects, because these defects are due to inherited mutations. ACQUIRED Causes correlate with extracorpuscular factors, because mostly these factors are exogenous.

14. Triad of hemolytic anemia Normomacrocytic anemia Reticulocytosis Hyperbilirubinemia

15. Compensated vs decompensated hemolysis Red cell destruction is a potent stimulus for erythropoiesis, which is mediated by erythropoietin (EPO) produced by the kidney. This mechanism is so effective that in many cases the increased output of red cells from the bone marrow can fully balance an increased destruction of red cells . In such cases, we say that hemolysis is compensated .

16. T here is no anemia . P atient with a hemolytic condition, even an inherited one, may present without anemia; and C ompensated hemolysis may become “decompensated,” i.e., anemia may suddenly appear, in certain circumstances, for instance in pregnancy, folate deficiency, or renal failure interfering with adequate EPO production. acute infection, depresses erythropoiesis E xample is infection by parvovirus B19 , W hich may cause a rather precipitous fall in hemoglobin A n occurrence sometimes referred to as aplastic crisis . C ompensated hemolysis

17. INHERITED HEMOLYTIC ANEMIAS There are three essential components in the red cell : Int racorpuscular hemoglobin, the membrane-cytoskeleton complex, and the metabolic machinery necessary to keep hemoglobin and the membrane-cytoskeleton complex in working order. Extracorpuscular : Familial (atypical) hemolytic uremic syndrome

18. A.Hemoglobinopathies

19. THALASSEMIAS/ THALASSEMIA SYNDROME Ep i d e miology : Most Common genetic disorder in Pediatric ward . 7% of the world population is carriers of hemoglobin disorder . 1.5% of world population is carriers of ß Thalassemia gene (20 millions in India alone ) . 8 to 10 thousand children born in India with homozygous state for the Thalassemia in every year. There are around 65 to 67 thousand Thalassemia patients in our country. In India, Prevalence of defective ß gene varies from 1 to 17 %.

20. α T HALASSEMIA S YNDROMES :

21. C LASSIFICATION , C LINICAL & H EMATOLOGICAL FEATURES OF ß THALASSEMIA

22. L eptocytes ( T arget cells) liver disease (obstructive jaundice) post splenectomy hemoglobinopathies (hypochromic anemias) thalassemia Hgb C disease Hgb H disease beta thalassemia relative increase of cell membrane --> ―target‖ formation

23. PRINCIPLES OF MANAGEMENT Confirmation of the Diagnosis By HPLC Diagnose of Complication Correction of Anemia –Packed Red Blood Cell (PRBC) transfusion Management of Complications –Iron Overload and Chelation Therapy –Anemia/ Hypoxia –Arrest of Growth –Infections –Hypersplenism Pharmacological Methods –Increase gamma chain Synthesis (HbF) Curative Treatment –Stem cell transplantation Future Treatment –Gene Replacement therapy Prevention of Disease

24. DIAGNOSIS OF COMPLICATION: It is not sufficient to diagnose the case as Thalassemia ONLY. For complete management of the case, it is necessary to think about its genetic classification, clinical and patho-physiological stage in which it now belongs to. THALASSEMIA S penom e galy Skeletal Deformity & Arrest of Growth Iron Overload & Chelation Therapy Anaemia Recurrent Blood BormeInfection DEATH

25. Why need a Transfusion? Correct Anemia &prevention of hypoxia Reduce Hepatosplenomegaly &Hypersplenism Reducing ineffective erythropoesis& GI absorption Reduce hemolytic facies& skeletal deformities. Improve growth BT is Mandatory For All children with Thalassemia Major Thalassemia Intermedia , Hb < 7 gm % Evidence of growth retardation Types of Transfusion Palliative(8.5g%) Hyper Transfusion(10g%) Super Transfusion(>12g%) Moderate Transfusion(9-10.5g%) TRANSFUSION THERAPY IN THALASSEMIA

26. Frequency of Transfusion Every 3-4 weeks Shorter interval of 2-3 weeks is more physiological avg. time taken 3-4 hrs(@5mi/kg/hr). Amount of Transfusion 180 ml / kg. / yr in non spenctomised, non-sensitised pt. 130 ml / kg /yr in spenctomised, sensitised pt. ( 30 % less) Efficacy of Transfusion Rate of fall of Hb should not exceed 1 gm / dl /week with spleen Rate of fall of Hb should not exceed 1.5 gm / dl /week without spleen Allo immunisation of RBC Hyperspenism Drag induced hemolysis Infection

27. Adequacy of Transfusion First decade : normal growth No. of Normoblast < 5 / 100 WBC Complication of Transfusion Non hemolytic febrile Transfusion reaction NHFTR Allo Immunisation Plasma Borne Infection Steps to prevent those infections Allergic reaction INDICATION OF SPLENECTOMY Annual PRBCc>200-250ml/kg >1.5times basal requirement Massive spleenomegaly hypersplenism

28. IRON OVERLOAD Causes of Iron Overload Treatment with multiple transfusion One bottle blood increases iron store by 200 – 250 mg iron. Ineffective erythropoesis Excessive dietary absorption of Iron Consequence of Iron overload Iron overload in Liver Hepatomegaly, Fibrosis & cirrhosis Iron overload in Spleen Splenomegaly, Hypersplenisim Cardiac complication Failure & Arrhythmia Endocrinal Dysfunction Thyroid, Para-Thyroid, Pituitary, Pancreas, Gonads Iron overload in Bones Osteoporosis, Osteopenia

29. IRON CHELATION THERAPY Iron Chelation Therapy Goal Reduce the Iron store & sub sequently maintain it at low level ( < 1000 µg/ml ) When to start Start after 15-20 transfusion or S.Ferritin > 1000 µg/ml (approx. 3 yrs of age) Needle Biopsy of Liver : 3.2Mg iron per gm of Liver tissue ( Drugs presently used Inj. Deferrioxamine (SC/IV) : DFO/Desferal Oral Deferiprone Oral Deferasirox Newer Iron Chelator Desferrithiocin ( DFT) Hydroxy Benzyl Ethilene Diamine Diacetic acid (HBED) Pyridoxal iso nicotinyl Hydrazone (PIH) GT 56-252 40 SD02 (CHF 1540)

30. CURATIVE TREATMENT Stem Cell Transplantation This is the only curative therapy available today. Though expensive, it is cost effective as compared to yearly cost of regular BT & chelation therapy Sources Bone Marrow Cord Blood Fetal Liver Peripheral Blood

31. FUTURE TREATMENT Gene Therapy Aim : Insertion of a normal copy of gene along with key regulatory sequences(LOCUS CONTROL REGION) in the stem cells of recipients. Two main approaches Somatic gene therapy in which non-germ line cells are involved. Transgenic approach in which transfuse gene can be expressed in subsequent generations Need high titre vectors for sustained expression Lentiviral vector from HIV is a hope.

32. SCREENING & PREVENTION Premarital screening programmes Alternative is to screen pregnant woman in early pregnancy. PRENATAL DIAGNOSIS: BY CVS AT 9-11WK Recently there has been attempt to isolate fetal cells from maternal blood. PARENTERAL COUNSELLING

33. SICKLE CELL ANEMIA Synthesis of an abnormal Hb, HbS (alpha 2, beta s 2) Substitution of valine for glutamic acid at position 6 on the beta chain Hb forms insoluble crystals at low oxygen tens. Red cells sickle and block the microcirculation causing infarcts in various organs Homozygous disease-severe haemolytic anaemia punctuated by crises

34. Clinical features *Painful crises- frequent, due to ischaemia. Precipitated by infections, acidosis, dehydration. Infarcts of bones, lungs, spleen(small spleen), brain *Haemolytic crises- fall in Hb, rise in retic count

35. Clinical features Aplastic crises- fall in Hb, fall in retic count (parvo virus or folate def) Visceral sequestration- severe chest syndrome, commonest cause of death L eg ulcers P igment gall stones

36. D repan o cytes (sickle cells) - sickle cell anemia

37. Treatment Avoid precipitating factors Hydration G ood nutrition & hygiene Blood transfusions D rugs to enhance HbF (hydroxyurea,Azactydine) Bone marrow transplant

38. SCREENING

39. B . Membrane defects The membrane-cytoskeleton complex is so integrat ed. A n abnormality of almost any of its components will be disturbing or disruptive, causing structural failure , which results ultimately in hemolysis . These abnormalities are almost invariably inherited mutations ; thus, diseases of the membrane- cytoskeleton complex belong to the category of inherited HAs .

40. H EREDITARY SPHEROCYTOSIS Incidence:1/5000 in North European population Autosomal dominant Defect in RBC cytoskeleton(spectrin,ankyrin) Pathophysiology:A deficiency in spectrin, ankyrin,protein 3, leads to weakening of the “vertical” interaction of the lipid bilayer & loss of membrane microvescicle . Loss of surface area,↑cation permeability, ATP use,& glycolysis leading to premature destruction in spleen.

41. -The main clinical findings are: Pigment gallstones Splenomegaly Jaun d ice

42. C LINICAL FEATURES Neonatal period: anemia+ jaundice, more severe. Infancy&childhood:variable severity. Mild: asymptomatic Moderate: intermittent jaundice,spleenomegaly,anemia. Severe:tranfusion dependeat,bone expansion,gall stone

43. LAB. DIAGNOSIS:Anemia (Hb:6-10g%), PBS : Spherocytes lacking central pallor , reticulocytes,MCV -N MCH↑, MCHC >35 ,RDW>14.5,DCT: Negative Osmatic fragility& Incubated osmotic fragility test. Differential diagnosis: autoimmune hemolytic anemia , G6PD def , Clostridial sepsis, wilsons disease.

44. - In most cases, the diagnosis can be made on the basis of red cell morphology and of a test for osmotic fragility , which is called the “pink test.” .

45. SPLENECTOMY

46. HS treatment D o not have a causal treatment for HS Bec ause of special role of the spleen: almost obligatory therapeutic measure was splenectomy. In mild cases, avoid splenectomy . Delay splenectomy until puberty in moderate cases or until 4–6 years of age in severe cases. Along with splenectomy, cholecystectomy should not be regarded as automatic; it should be carried out, usually by the laparoscopic approach, when clinically indicated.

47. 2. H EREDITARY ELLIPTOCYTOSIS Equatorial Africa, SE Asia AD / AR Functional abnormality in one or more anchor proteins in RBC membrane- Alpha & beta spectrin& defective spectrin heterodimer self association , Protein 4.1& glycophorinC. Usually asymptomatic Mx: Similar to H. spherocytosis Variant: SE-Asian ovalocytosis: Common in Malaysia , Indonesia… Asymptomatic-usually Cells oval , rigid ,resist invasion by malarial parasites SAO is associated with protein3 abnormality.

48. E lliptocytes heredirary elliptocytosis iron def. anemia myelofibrosis with myeloid metaplasia megaloblastic anemia sickle cell anemia normal (<10% of cells)

49. 3.ENZYMOPATHIES

50. 1. Glucose-6-Phosphate Dehydrogenase ( G6PD ) Deficiency  Pivotal enzyme in HMP Shunt & produces NADPH to protect RBC again oxidative stress Most common enzymopathy -10% world’s population 1% of indian males have G6PD deficiency Protection against Malaria X-linked recessive G6PD deficiency is a prime example of an HA due to interaction between an intracorpuscular cause and an extracorpuscular cause , because in the majority of cases hemolysis is triggered by an exogenous agent.

51. (Oxidised form) (Reduced form)

52. Clinical manifestations of G6PD deficiency  M ajority asymptomatic throughout their lifetime  A ll of them have an increased risk of D eveloping Neonatal jaundice a risk of developing acute HA ( AHA ) when challenged by a number of oxidative agents.

53. Neonatal jaundice in G6PD deficiency NNJ related to G6PD deficiency is very rarely present at birt h the peak incidence of clinical onset is between day 2 and day 3 , and in most cases, the anemia is not severe. very severe in association with prematurity , infection, and/or environmental factors (such as naphthalene-camphor balls, which are used in babies’ bedding and clothing ) Severity of NNJ is also increased by the coexistence of a monoallelic or biallelic mutation in the uridyl transferase gene ( UGT1A1 ; the same mutations are associated with Gilbert’s syndrome ). •

54. Acute hemolytic anemia in G6PD deficiency AHA can develop as a result of three types of triggers:  (1) fava beans (2) infections (3) drugs . Typically, a hemolytic attack starts with malaise, weakness, and abdominal or lumbar pain . After an interval of several hours to 2–3 days, the patient develops jaundice and often dark urine . The onset can be extremely abrupt , especially with favism in children . The anemia is moderate to extremely severe , usually normocytic and normochromic due partly to intravascular hemolysis;

55. Inv estigation : Chronic non-spherocytic intravascular hemolyis P. Smear: Bite cells, blister cells, irregular small cells, Heinz bodies , polychromasia G-6-PD level Treatment: Stop the precipitating drug or treat the infection Acute transfusions if required

56. B LISTER CELLS

57. H EINZ BODIES

58. 2. Pyruvate Kinase Deficiency AR Deficient ATP production, Chronic hemolytic anemia Inv : P. Smear: Prickle cells Decreased enzyme activity Treatment: Transfusion may be required

59. P RICKLE CELL

60. Intracorpuscular Acquired Hemolytic Anemia Paroxysmal Nocturnal Haemaglobinuria Acquired chronic HA characterized by persistent intravascular hemolysis subject to recurrent exacerbations. Same frequency in men and women. TRIAD Hemolysis Pancytopenia Tendency to venous thrombosis.

61. The natural history of PNH can extend over decades . Without treatment, the median survival is estimated to be about 8–10 years ; M ost common cause of death has been § venous thrombosis , § followed by infection secondary to severe neutropenia & hemorrhage becoz of severe thrombocytopenia . Rarely (estimated 1–2% of all cases), PNH may terminate in acute myeloid leukemia . On the other hand, full spontaneous recovery from PNH has been documented, albeit rarely.

62. Diagnosis of PNH Definitive diagnosis of PNH patient’s red cells have an increased susceptibility to complement (C), due to the deficiency on their surface of proteins (particularly CD59 and CD55) . The sucrose hemolysis test is unreliable. The acidified serum (Ham) test is highly reliable but is carried out only in a few labs. The gold standard today is flow cytometry , which can be carried out on granulocytes as well as on red cells. A bimodal distribution of cells, with a discrete population that is CD59 and CD55 negative, is diagnostic of PNH.

63. Management Most patients receive supportive treatment only. Transfusion Folic acid supplements Iron supplements Regular anticoagulant prophylaxis for those who had venous thrombosis Long-term glucocorticoids are not indicated. Humanized monoclonal antibody, eculizumab , which binds to the complement component C5 . Definitive cure for PNH is through allogeneic BMT.

64. EXTRACORPUSCULAR ACQUIRED

65. MECHANICAL DESTRUCTION ACUTE Self-inflicted Prolonged barefoot ritual dancing or intense playing of bongo drums. CHRONIC Iatrogenic Prosthetic heart valves, especially when paraprosthetic regurgitation is present. Usually microangiopathic hemolytic anemia.

66. Mal a ria Schistocytes

67. AUTOIMMUNE HEMOLYTIC ANEMIAS These can arise through at least two distinct mechanisms. There is a true autoantibody directed against a red cell antigen, i.e ., a molecule present on the surface of red cells. (2) When an antibody directed against a certain molecule (e.g., a drug) reacts with that molecule, red cells may get caught in the reaction, whereby they are damaged or destroyed.

68. Because the antibodies involved differ in optimum reactivity temperatures, They are classified in the time- honored categories of “cold” and “warm”. Autoantibody-mediated HAs may be seen in Isolation (when they are called idiopathic ) or As part of a systemic autoimmune disorder such as systemic lupus erythematosus .

69. MECHANISM OF HEMOLYSIS

70. AIHA is a serious condition ; without appropriate treatment, it may have a mortality of approximately. The onset is often abrupt and can be dramatic . The hemoglobin level can drop , within days, to as low as 4 g/ dL ; the massive red cell removal will produce jaundice; and sometimes the spleen is enlarged. When this triad is present , the suspicion of AIHA must be high.

71. PAROXYSMAL COLD HEMOGLOBINURIA PCH is a rather rare form of AIHA occurring M ostly in children, U sually triggered by a viral infection, S elf-limited , and C haracterized by the involvement of the so-called Donath-Landsteiner antibody . Clinically the differential diagnosis must include other causes of hemoglobinuria, B ut the presence of the Donath-Landsteiner antibody will prove PCH. Active supportive treatment, I ncluding blood transfusion, is needed to control the anemia subsequently , recovery is the rule.

72. CAD; Cold Agglutinin Disease A form of chronic AIHA that usually affects the elderly . First, the term cold refers to the fact that the autoantibody involved reacts strongly at lower temperatures The antibody is usually IgM Second, the antibody is produced by an expanded clone of B lymphocytes , and i s a monoclonal gammopathy. Third, because the antibody is IgM , CAD is related to Waldenström’s macroglobulinemia ( WM )

73. Treatment of CAD In mild forms of CAD , avoidance of exposure to cold . In more severe forms, the management of CAD is not easy. Blood transfusion is not very effective Immunosuppressive/ cytotoxic treatment with azathioprine or cyclophosphamide can reduce the antibody titer , but clinical efficacy is limited prednisone and splenectomy are ineffective . Plasma exchange will remove antibody but it is laborious and must be carried out at frequent intervals if it is to be beneficial. Up to 60% of patients respond, and remissions may be more durable with a rituximab-fludarabine combination.

74. INTRAVASCULAR HEMOLYSIS

75. R eferences Harrisons Principle O f I nternal M edicine 20 th Edition Williams Hematology 9 th edition Robbins Basic Pathology 10 th Edition

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