SAM Final - M

What is anemia?

• Decrease in red blood cell mass

What is HCT?

• Hematocrit

• Calculated value (MCV x RBC) / 10

What is PCV?

• packed cell volume

• percentage of whole blood composed of erythrocytes

Who do you mainly see pica in with anemia?

• cats

Hematocrit below __% can lead to heart murmurs

• 25%

MCVs?

• How big are the RBCs

What tells you how much hemoglobin is in the RBCs

• MCHC

What is the only cause of a high MCHC?

• Cell lysis or hemolysis

Classic sign of iron deficiency anemia?

• Microcytic, hypochromic

Most patients with hemolytic anemia will have a high ___

• bilirubin

Are rads and ultrasound useful for chronic non-regenerative anemia?

• No not likely think bone marrow

Diangostics IMHA

• slide agglutination

• Direct Coombs test

• RBC surface antibody test

Diagnostics for infectious diseases causing anemia?

• FeLV/FIV in cats

• vector-borne disease testing

• fecal floatation

What do you test for non-regenerative anemia?

• Bone marrow aspiration

Causes for regenerative anemia?

• Hemolysis

• Blood loss

Causes of non-regenerative anemia?

• Pre-regenerative

• secondary bone marrow

• primary bone marrow

• there may be a combination of mechnisms!!

How long does it take for bone marrow to start making RBCs?

• 2-5 days

• pre-regenerative RBCs should start going up in a few days

Primary bone marrow non-regenerative anemia categories?

• Erythroid

• hypoplasia/aplasia

• Myelopthisis

• Myelofibrosis

• Myelodysplasia

What is Erythroid hypoplasia/aplasia?

• pure red cell aplasia

• Immune mediated destruction of RBC precursors

What is myelopthisis?

• Condition where bone marrow gets “crowded” out maybe lymphoid neoplasia or infectious diseases

Secondary bone marrow non-regenerative anemia categories?

Things that just cause anemia (extrinsic)

• Anemia of inflammatory disease (AID)

• Renal disease (reduces erythropoeitin production)

• Endocrine disease

• Iron deficiency anemia

What is anemia of inflammatory disease used to be called?

• Anemia of chronic disease

Can iron deficient anemia become non-regenerative?

• YES

• if it becomes severe and chronic enough

Dogs should never be less than __% with AID and cats never less than __%

• 30 and 20

Most common cause of primary bone marrow non-regenerative anemia?

• Precursor-targeted immune mediated anemia

• PIMA

Diagnostic of choice for primary bone marrow disorder?

• Bone marrow aspirate

• Parvo and chemo are examples of acute hits to the bone marrow

General therapies?

• Blood transfusion

• red blood cell production help

• Iron injection every 3-4 weeks

Do you have hemolysis with icterus?

• Yes, common

Do you have hemolysis with hemoglobinemia?

• Yes, common

Do you have hemolysis with hemosiderinuria?

• YES

Do you have hemolysis with agglutination?

• occasionally

Is hemoglobinemia/hemoglobinuria intravascular or extravascular hemolysis?

• INTRAVASCULAR hemolysis only

Six categories of hemolytic anemia?

• IMHA

• Erythorycte

• toxins

• microangiopathic or fragmentation anemia

• increased erythrocyte fragility

• hemophagocytic syndrome

What erythrocyte organisms may you see in dogs?

• Babesia

• Mycoplasma hemocanis

What erythrocyte organisms may you see in cats?

• Mycoplasma hemofelis and M. haemominutum

• Cytauxzoon felis (very geographical)

What do heinz bodies indicate?

• Oxidative injury to red blood cell leading to fragility and hemolysis

What are a result of mechanical trauma to RBC secondary to fibrin strands or other?

• Schistocytes or keratocytes

T or F?

Phosphorus is very important for RBC integrity

• True

What immunoglobulin is responsible for the activation of the complement leading to MAC and intravascular hemolysis?

• IgM

When antibodies bind to RBC they mark them and macrophages _______

This is extravascular hemolysis

• Eat them or Nibble them

• A nibble is what makes spheroxytes

Do the antibodies destroy the RBCs?

• No

• But they mark them for destruction

With intravascular hemolysis, marked RBCs are punched and have holes created by what?

• The membrane attack complex

• MAC

What big features are specific for intravascular hemolysis

• Hemoglobinemia

• Hemoglobinuria

• Ghost cells

Most common cause of IMHA in dogs?

• Idiopathic

• less common in cats, idiopathic is rare

Examples of secondary IMHA neoplasia causes?

• LSA, leukemia, histiocytic sarcoma

What drugs could cause secondary IMHA

• Antiobiotics (sulfas, B lactams) ANY

What is pure definition of hematuria

• Discolouration of urine

What is the first and only FDA drug approved for the treatment of non-regenerative anemia in cats with chronic kidney disease?

• Varenzin (Molidustat)

MOA: induces the genetic transcription of EPO, increasing both EPO and red blood cell production in a cats body

• Basically increases RBC count

What is disadvantage of Varenzin?

• Have to continue it as soon as you stop the RBC lower

• GI upset

Pigmentation of hemoglobinuria

• Port wine

Pigmentation of bilirubinuria?

• Darker/orange

What does a serum look like in an IMHA patient?

• Icteric serum

If there is saline agglutination is that positive or negative for IMHA?

• BIG indication of IMHA

If there is no saline agglutination does that mean there is no IMHA

• NO

• there could still be IMHA just hasnt clustered yet

Do not confuse cluster of grapes with rouleaux what is rouleax?

• Artifactual sign

What makes up the saline agglutination test?

• 1-5 drops of saline + 1 drop of blood

What will you see in a patient with IMHA on a CBC?

• Macroscopic, hypochromic anemia

• regenerative

• spherocytes, ghost cells

• often thrombocytopenic

• may have profound neutrophilia and bands without it being a bacterial infection

With IMHA, is there hyperbilirubinemia on chemistry panel?

• Yes

Big two things that confirm the IMHA diagnosis?

• Spherocytosis

• Autoagglutination

• usually one or both of these is present

What are the things that require acute management for IMHA

• *Immunosuppression

• Thromboprophylaxis*

• adjunctive immunomodulatory therapy

• supportive care

Which immunosuppression works best?

• Glucocorticoids:

  • Prednisone

  • Dexamethasone (7-10x more potent than pred)

What is the immunosuppressive dose of prednisone a day?

• 2mg/kg

• Max dose of 60mg/dog/day

Common second line immunosuppressive drugs?

• Cyclosporine

• Azathioprine

Why add second line immunosuppressive?

• Large breed dogs

• Even add to patients with diabetes

What is the leading NATURAL cause of death involving IMHA?

• Thromboprophylaxis

• specifically thromboembolism

What is DOC for platelet inhibition?

• Clopidogrel (Plavix)

• Irreversible platelet inhibition

What is given for immunomodulatory therapy?

• Human intravenous immunoglobulin (IVIg)

How many times can you give IVIg?

• ONCE

• repeat of infusion is a risk for hypersensivity reaction

What is the MOA of IVIg?

• Blocks Fc receptors in splenic macrophages - macrohoahe has antibody sitting in it so RBC can pass by

• prevents extravascular hemolysis

When do you start to taper immunosuppressive drugs?

• Do not start until PCV is normal

Typically reduce the drugs by __ - __ % every 2 to 4 weeks

• 20-25%

  • can take 4-6 months to taper completely off

Prognosis for IMHA?

• guarded to fair

• most say mortality rate of 30-50%

Most causes of IMHA in cats are ____

• secondary!!!!

• often caused by infections

Can cats have primary IMHA?

• Yes but rare

• They are typically young and male

Diagnose Feline IMHA?

• Autoagglutination

• Rule-out secondary IMHA before dx primary

Treatment for Feline IMHA?

• primary: Prednisolone, ± cyclosporin

• secondary: treat infection ± prednisolone

Does hyperbilirubinemia help differentiate between extravascular and intravascular hemolysis?

• NO it does not

What are the two main components of treating both acute and chronic IMHA?

• Immunosuppression

• Thromboprophylaxis

What is a very important tool for determining if its blood loss vs hemolytic?

• Total protein

Dogs that are bleeding and you cant figure out why need a ?

• Abdominal cavity search

_____ Blood loss might have normal TP

• Chronic

What is discovered during a rectal exam to indicate internal bleeding?

• Melena

What is an important diagnostic for blood loss?

• platelet count

• may have mild thrombocytopenia > 100k

• if severe <20-30k, consider as CAUSE of bleeding

Are most blood loss regenerative or non-regenerative?

• Regenerative

What may you see on a chemistry panel with blood loss?

• Decreased total protein

• increased BUN (with normal creatinine)

What may be helpful for determining secondary coagulopathy

• Coagulation panel

• Can identify anti-coagulant rodenticide

Why is a complete history important?

• identify NSAID use

What is also an important test for infectious disease?

• Fecal float

• Can identify intestinal parasites (hookworms)

Treatment for blood loss?

• Blood transfusion

• STOP the bleeding

• treat undelryig cause

What types of dogs have slightly higher PCV?

• sighthounds

• Dachshunds

What are the two categories of absolute erythrocytosis ?

• appropirate

• Inappropriate

Examples of appropriate erythrocytosis?

• Pulmonary disease

• Right to left cardiac shunts

• High altitude

Examples of inappropriate erythrocytosis

• Renal mass

• Neoplasia

• Cushings

• Hyperthyroid

Excessive EPO production in absence of hypoxia

What type of diagnostics may you run to investigate underlying cause of absolute erythrocytosis?

• Thoracic rads

• abodminal ultrasound

• echocardiogram

• arterial blood gas

Therapeutic phlebotomy is a treatment method for erythrocytosis.

What is this?

• Replace 5-10ml/kg of blood with fluids

• can be done sub q or IV

What is treatment of choice for chronic therapy of erythrocytosis?

• Hydroxyurea

What is hydroxyurea?

• Bone marrow suppressive agent targeting red blood cell production

Big increase of nucleated RBC is indicative of what?

• Strongly regenerative anemia

• Bone marrow injury allowing escape into circulation (heat stroke and bone marrow neoplasia)

Nucleated RBC can often be miscounted as what?

• WBC

Is it normal to have nucleated RBCs without anemia?

• no

• This is potentially indicative of something else investigate