Anemia 411 Timothy Nguyen

How long does it take an erythrocyte to become a full RBC

4-6 weeks

What is a reticulocyte

pre mature red blood cell

What happens to erythropoietin if one has kidney failure

no erythropoietin

according to WHO what percent of world population have anemia

24%

What is the most common anemia

Iron Deficiency Anemia (IDA)

What level of Hg in MALES means you have anemia

less than 13

What level of Hg in FEMALES means you have anemia

less than 12

What is anemia

Decrease in either hemoglobin or RBC resulting in a reduction in the O2 carrying capacity of the blood

What are the functional classifications of anemia

- Hypoproliferative

- Maturation Disorders

- Hemorrhage/Hemolysis

Examples of Hypoproliferative anemia

- bone marrow damage

- iron Deficiency

- low stimulation seen in renal disease, inflammation or metabolic disease

Examples of Maturation Disorders

- Cytoplasmic Defects

- Nuclear Maturation Defect

What are examples of cytoplasmic defects

[Thalassemia- is a inherited blood disorder that causes your body to produce less Hb than normal], iron deficiency, [sideroblastic-poor ability to use iron.]

What are examples of nuclear maturation defects

folate deficiency , vitamin B12 (cyanocobalmin) , [Refractory anemia-Anemia that resists standard therapies]

What are examples of hemorrhage/hemolysis

Blood Loss surgery, IV Hemolysis, Autoimmune, Hemoglobinopathy, Metabolic/membrane defect

What are the causes of anemia

- geriatric patients

- IDA

- anemia of Chronic Disease (ACD,CKD)

- Acute bleeding

How is being a geriatric patient a cause of anemia

With age, their body can't metabolize nutrients

What nutrients get very low in anemic patients

- iron

- folate

- vitamin B12

- protein

What is the etiology of iron deficiency anemia

Malnutrition , malabsorption , pregnancy, chronic illness or blood loss

What medications cause iron deficiency anemia

ASA[aspirin], Corticosteroids, NSAIDS

What are the 3 types of anemias

- Macrocytic

- Microcytic

- Normocytic

What are ways people get macrocyitc anemia

Cyanocobalamin (B12) and Folic Acid Deficiencies

What are some ways people get microcytic anemia

IDA

what are some ways people get normocytic anemia

low production of normal sized RBC, ACD (acute chronic disease) , aplastic anemia

Metformin causes what to happen

low B12

How much iron is in a person’s body

3-4 grams per person

How much iron is in the form of Hb

2-3 gram

How much iron is stored as ferritin?

1 gram

how much iron is in the form of transferrin

3 mg

Iron expected to be in diet daily [intake and excretion match]

1mg/day

What form is iron stored in the body

ferritin

What happens if your stomach isn't acidic

body’s iron absorption decreases.

What percent of patients experience anemia w stage 5 CKD

90

What percent of patients experience anemia w stage 4 CKD

50

What percent of patients experience anemia w stage 3 CKD

5

In Anemia w CKD kidneys fail to produce what hormone

erythropoietin

What drugs do you give to patients with CKD and anemia

Iron AND EPO

What are cofactors required for efficient Erythopoiesis

Iron, Folic Acid and Vitamin B12

Does one target iron first or EPO w patients in CKD

iron

Acute symptoms of anemia

Angina (chest pain), tachycardia, palpitations, HoTN (hypotension), breathlessness, lightheadedness

Chronic symptoms of anemia

Pallor, vertigo, fatigue, dizziness, H/a (weakness), cold sensitivity, loss of skin tone

RBC count reference males

4.5-6 x 10^6

RBC count reference females

4.5-5.5 x 10^6

Hg Reference range females

12-16

Hg reference range males

13-18

RBC Distribution Width (RDW) shows

variation in RBC size

High RDW means

high RBC size variability

Mean Corpuscular Volume (MCV)

Avg volume of RBC , 80-100 microns

MCH

amount of Hb in an avg RBC (hb/RBC ration) , 26-32 pg

MCHC

ratio of Hb wt to Hct, 32-36%

high MCV

macrocytic anemia due to FA, Vit B12 deficiency

low MCV

microcytic anemia due to low Fe and thalassemia

Where is the main storage site of iron

liver

What are the 2 markers that assess iron

- ferritin

- TSAT

TSAT is

immediate iron on board for erythropoiesis

if you have low ferritin and low TSAT what condition do you have

IDA

ferritin high but TSAT be low points to

infection in a patient

TSAT reference range

20-50%, should be greater than 25

ferritin reference range

12-300, should be greater than 30

folic acid reference range

1.8-16 should know more than 2

vitamin B12 reference range

100-900, should be greater than 100

What happens if you have high MMA Methylmalmonic acid

Vitamin B12 deficiency

What happens if you have high Homocysteine

high is Vitamin B12 and FA deficiecny, CKD, hypothyroidism, meds (nictonic acid, theophylline,methotrexate)

what's the first line of treatment for iron

by mouth pills

what environment enhances absorption of iron

acidic and on an empty stomach

What's a common side effect for oral iron pills

GI, constipation

What are some Drug Interactions w iron

chelation, PPI, H2RA

-Ferrous-20% Fe- 60-65 mg/324-325 mg tablet

sulfate

-Ferrous-12% Fe- 38 mg/325 mg tablet

gluconate

-Ferrous-33% Fe- 29 mg/90 mg tablet

fumarate

-Ferric-100% Fe- 30 mg/30 mg

maltol

-Ferric-21% Fe- 210 mg/1,000 mg

citrate

-Polysacchar-N/A- 150 mg/326mg

ide-iron

complex

Examples of oral Fe Supplements

Elemental Fe[-mg]

Ferrous sulfate 324 mg: 65 mg

Ferrous gluconate 325 mg: 36 mg

Feostat chewable 100 mg: 33 mg

Feostat liquid 100 mg: 33 mg/5 mL

Slow Fe 160 mg: 50 mg

Fe 50 ER 160 mg: 50 mg

Ferro-Sequels timed release 50: 50 mg

Feosol caplets 50 mg: 50 mg

more oral irons

Ferrous fumarate

 Ferric citrate (Keryx)

 Polysaccharide iron complex (Niferex)

 Carbonyl iron

 Heme-iron polypeptide

What is important to know about Soluble Ferric Pyrophoshate

Formulated for slow, continuously delivery during dialysis, directly to the bone marrow and replaces the 5-7 mg Fe that is lost during each dialysis session

What are some important counseling points for someone taking iron

eat a lot of fiber and drink a lot of fluids

enhances the iron pill absorption

meat, fish, poultry, seafood and acid

Those that inhibit iron pills absorption

phosphate, Ca, tannic acid, coffee, colas, soy protein, high dose of minerals, bran/fiber

you can give someone IV if they reject PO iron in:

Chronic bleeding, intestinal malabsorption, intolerance to PO, nonadherence, Hb

What's special about Iron Dextan

Requires a test dose and causes anaphylaxis reaction

Side effects of IV iron

Anaphylaxis, Iron Overload, Hypotension, headache, myalgia, arthralgia (fatigue and aching), tissue staining

how to monitor iron therapy

Resolution of signs and symptoms, normalized Hg/hct. Normalized iron studies, Reticulocytosis 5-7 days after therapy, monitor for Fe overload

what to educate patient taking iron

Dark stools, take on empty stomach, avoid antacids, childproof containers

What are 3 ESA drugs

- Epoetin alfa

- Darbepoetin alfa (Aransep)

- Peginestade (Omontys)

How often is epoetin alfa given

2-3 times a week

How often is Aransep given

every 2 weeks or every 4 weeks

How often is Omontys is given

once a month

Functional Iron Deficiency

when you have high ferritin but low TSAT

hemodialysis patients have iron deficiency

- increase blood loss, ESA, poor dietary iron, functional iron deficiency

for kidney patients, level of Hg recommended

up to 11.5 but greater than 9 (NOT 12)

Examples of of IV iron

- Iron Dextan (InFed, Dexferrum)

- Sodium Ferric GLuconate (ferrlecit)

- Iron Sucrose (Venofer)

- Ferumoxytol (Feraheme)

- Ferric Carboxymaltose (Injectafer)