PCT V anemia exam 3

- Hb < 13 g/dL (men) or < 12 g/dL (women)
- blood produces lower than normal amount of healthy red blood cells
- loss of oxygen carrying capacity

anemia definition

- decreased red blood cell production
- increased red blood cell destruction
- increased red blood loss

what is happening to red blood cells in anemia

low \= < 80: micocytic
normal \= 80-100: normocytic
high \= \> 100: macrocytic

MCV value and descriptive term

low \= MCHC < 31: hypochromic
normal \= 31-37: normochromic
high \= \> 37: hyperchromic

MCHC values (color of RBC) and descriptive term

recitulocytes

immature red blood cells, number in the blood can indicate if the bone marrow is creating and releasing RBCs at an appropriate rate

0.5-2.5%

normal value of reticulocytes

- decreased RBC production:
\--- from low intake (dietary sources)
\--- lack of absorption: anatomic (surgical change stomach, small bowel), inflammatory condition, dietary
\--- increased demand: young children, pregnancy/lactation, illness
- increased RBC loss: bleeding (acute vs chronic)

causes of iron deficiency anemia (IDA)

- liver
- egg yolk
- beans
- fish
- red meat
- poultry
- nuts
- beans

dietary sources of heme

- koilonychia (spoon nails)
- glossitis (swollen tongue)
- pica/pagophagia (eating dirt)
- angular stomatitis (dryness in corners of mouth)
- restless legs
- infants/children: delayed growth or behavioral developmental problems

specific symptoms for iron deficiency anemia

serum iron (Fe)

concentration of iron bound to transferrin

transferrin

protein that transports iron to the bone marrow for hemoglobin synthesis, and to other sites for storage

TIBC (total iron binding capacity)

interpret serum iron (fe) concentration with what

ferritin

storage form of iron, reflects total body iron stores

falsely elevates in times of stress

ferritin in times of stress

TIBC (total iron binding capacity)

amount of transferrin binding sites available to bind iron (an indirect measure of transferrin)

low

TIBC (total iron binding capacity) is higher when body stores of iron are low/high

high

TIBC (total iron binding capacity) is lower when body stores of iron are low/high

TSAT (transferrin saturation)

measure amount of transferrin binding sites occupied by iron

serum iron divided by the TIBC

equation for TSAT (transferrin saturation)

low

TSAT is low/high in iron deficiency

- low MCV
- low MCH
- low MCHC
- low ferritin
- low Fe
- low TSAT
- high TIBC
- low retics

iron deficiency anemia lab indicators
- MCV
- MCH
- MCHC
- ferritin
- Fe
- TSAT
- TIBC
- retics

microcytic hypochromic anemia
(the RBCs are smaller than normal and have decreased red color)

iron deficiency anemia is what descriptive term anemia

without food, but tolerated better with food so ok to take with food if not tolerating otherwise

oral iron replacement is absorbed better with/without food

accidental overdose warning- child resistant packaging

safety of oral iron replacement

150-200mg/day of elemental iron

recommended oral iron replacement dose for adults

3-6mg/kg/day elemental iron

recommended oral iron replacement dose for pediatrics

- tea
- coffee
- fiber
- milk
- eggs
- infant formula

food interactions with oral iron replacement that DECREASE absorption

- aluminum, magnesium, calcium containing antacids
- tetracycline, doxycycline
- H2 antagonists
- PPIs
- cholestyramine

drugs that decrease iron absorption

- levodopa
- methyldopa
- levothyroxine
- fluoroquinolones
- tetracycline, doxycyclie
- mycophenolate

drug efficacy that is reduced by iron

oral iron formulations
parenteral iron

iron deficiency anemia treatment

- iron dextran
- iron sucrose
- ferumoxytol
- ferric carboxymaltose
- sodium ferric gluconate

parenteral iron examples

30mg/day orally; start in 1st trimester
- can get this through prenatal vitamins but be sure the vitamin has iron
- IV iron can be used in 2nd and 3rd trimester, but should be avoided in 1st trimester

standard CDC/UPSTF iron dose recommendation for all pregnant women

macrocytic

microcytic/macrocytic anemia can be megaloblastic or non-metaloblastic

- b12 deficiency
- folate deficiency
- drug induced

megaloblastic anemia

- dysphagia
- anorexia
- weight loss
- fatigue
- glossitis

symptoms of folate deficiency or b12 deficiency

- brusing
- early graying of hair

folate deficiency specific symptoms

- neuropathies (central and peripheral)
- ataxia
- paresthesia's of hands/feet
- forgetfulness
- personality changes
- dementia
- psychoses

B12 deficiency specific symptoms

- high MCV
- high MCH
- normal or elevated MCHC
- low retics
- normal or low B12 level
- low folate level

folic acid deficiency lab indicators
- MCV
- MCH
- MCHC
- retics
- B12 level
- folate level

- high MCV
- high MCH
- normal or elevated MCHC
- low retics
- low B12 level
- normal or low folate level

B12 deficiency lab indicators
- MCV
- MCH
- MCHC
- retics
- B12 level
- folate level

macrocytic, megaloblastic anemias
(RBCs are larger than normal)

B12 and folic acid deficiency are what type of anemias

both

B12 and folic acid deficiencies can occur together/separately

- meat
- liver
- fish
- eggs
- milk

foods with B12

vegetarians/vegans

population that is more prone to B12 deficiency

pernicious anemia

B12 deficiency specific to lack of intrinsic factor

lifelong parenteral replacement

treatment for pernicious anemia

- PPIs
- H2RA
- metformin
- colchicine
decrease absorption of B12

drug interactions with B12

- subcutaneous or intramuscular--Rx: cyancobalamin
- oral or sublingual--OTC: methylcobalaomin or cyancobalamin
- nasal--Rx: gel or spray

B12 treatment options

weekly for maintenance

frequency for nascobal B12 gel

daily
for maintenance only

frequency for B12 nasal spray

- leafy green vegetables
- fortified bred and cereal
- beef liver

dietary sources for folate

monoglutamated form (tablets)
(diet sources are a polyglutamated form)

which form of folate gets absorbed more

- phenytoin
- carbamazepine
- phenobarbital
- PPIs
- H2RAs
- oral contraceptives
- bile acid sequestrants

drugs that decrease absorption of utilization of folic acid/folate

- folic acid oral
- parenteral routes are available if absorption issues with oral

folate deficiency treatment

- history of baby with neural tube defects
- malabsorption
- pregnancy with other conditions like diabetes, higher BMI, anti-seizure medication use

special populations that may require a higher dose of folic acid in folate deficiency treatment

hepcidin (the regulator)

reduces ferroportin and transport of iron from stores (not a deficiency in stores)

ferritin
- low in IDA
- normal/elevated in ACD

what is a distinguishing factor between anemia of chronic disease/inflammation and iron deficiency anemia

decreased RBC production

sign of anemia of chronic disease/inflammation

- chronic infections
- inflammation
- malignancies

anemia of chronic disease/inflammation

typically normocytic (may be microcytic)

anemia of chronic disease is what type of anemia

false

T/F treatment for anemia of chronic disease/inflammation is iron replacement

true

T/F treatment for anemia of chronic disease/inflammation is not iron replacement

normal/low MCV
normal/low MCH
normal/low MCHC
normal/high ferritin
normal/low Fe
low TSAT
normal/low TIBC
low retics

anemia of chronic disease/inflammation lab indicators
- MCV
- MCH
- MCHC
- Ferritin
- Fe
- TSAT
- TIBC
- retics

treat the underlying condition

treatment of anemia of chronic disease/inflammation

hormone produced by kidneys to stimulate bone marrow to make RBCs

erythropoeitin

deficient

erythropoeitin is deficient/abundant in CKD

- iron therapy
- erythropoiesis-stimulating agents

treatment of CKD in anemia

- epoetin alfa
- darbepoetin

erythropoiesis stimulating agents

initiate when Hgb < 10
hold when Hgb \> 10 in nondialysis patients
hold when Hgb \> 11 in all patients

when to initiate and hold erythopoiesis-stimulating agents

uncontrolled hypertension

erythropoiesis stimulating agents contraindications in CKD

- increased risk of death
- serious CV events
- stroke
more at risk when hgb \> 11

risks with erythropoiesis stimulating agents in CKD

- erythropoiesis stimulating agents

- always correct for iron deficiency before starting!
- only use if minimum of chemotherapy is planned
- use to avoid blood transfusions

treatment of anemia in patients with cancer

- curative intent patients
- metastatic breast, head, neck cancer patients

do not use erythropoiesis stimulating agents in anemia patients with cancer in...

- increased risk of death
- serious CV events
- stroke
- VTE
more at risk when hgb \> 11

risks with erythropoiesis stimulating agents in cancer

- benzes
- chloramphenicol
- anti-seizure medications (carbamasepine, phenytoin)

drugs/chemicals that can cause aplastic anemia

bone marrow failure; cannot make enough RBCs, WBC, and platelets

aplastic anemia

normocytic or macrocytic

aplastic anemia is which type of anemia

- normal/high MCV
- normal/low MCH
- normal/low MCHC
- low retics
- low WBC
- low platelets

aplastic anemia lab indicators
- MCV
- MCH
- MCHC
- retics
- WBC
- platlets

- remove exposure to offending drug/chemical
- immune suppressant therapy, especially in young patients

- if still at risk for infections and bleeds after 3-6 months: allogeneic hematopoietic stem cell transplant

aplastic anemia treatment

- ATG (anti-thymocyte globulin)
- methylprednisolone
- cyclosporine
- blood and platelet transfusions as needed

immune suppressant therapy combination therapy

normocytic anemia

sick cell disease is what type of anemia

valine

in sick cell disease, the 6th AA of beta chain hgb is \_____ instead of glutamic acid

normal (possibly elevated) MCV
normal MCH
normal MCHC
high retics
normal or high WBC
normal or high platelets

lab indicators of sickle cell disease
- MCV
- MCH
- MCHC
- retics
- WBC
- platelets

hemolytic

what type of anemia is sickle cell anemia

increased RBC destruction --\> anemia

what happens to RBCs in sickle cell disease

- vaso-occlusive
- splenic sequestration crisis
- splenic infarct
- aplastic crisis
- hyper-hemolytic
- acute chest syndrome
- infection
- priapism
- stroke

acute complications of sickle cell disease

- dehydration
- avascular necrosis
- leg ulcers
- pain
- bilirubin gallstones (cholelithiasis)
- pulmonary hypertension
- renal impairment
- retinopathy
- pregnancy complications
- longer lifespan --\> more problems

chronic complications of sickle cell disease

- penicillin VK prophylaxis until at least 5 years old
- folate (deficiency possible cause of aplastic crisis)
- vaccinations
- hydrations: IV fluids
- pain control: APAP, NSAIDs, opiates
- blood transfusions
- 3rd generation cephalosporin in crisis (fever, positive cultures, positive chest x ray)
- splenectomy if 2 or more splenic sequestration crises
- iron chelation if overload
- hydroxyurea

sickle cell anemia treatment and supportive care

provides RBCs with HgbA

purpose of blood transfusions in sickle cell anemia

they are increased due to hemolyisis/tissue damage

what happens to AST, LDH, CPK, and bilirubin in sickle cell anemia and why

- folic acid
- birth control

what supplementation with hydroxyurea is needed

- myelosuppression: increased risk of infection
- increased risk of skin cancer, leukemia (use sun protection)

adverse effects of hydroxyurea

sulfate: 20% elemental iron
gluconate: 12% elemental iron
fumarate: 33% elemental iron

elemental iron in
- ferrous sulfate
- ferrous gluconate
- ferrous fumuarate

1000mg given over 1-5 visits

dose of parenteral iron

50-100 units/kg 3 times a week

epoetin alfa dosing for CKD patients

- hemodialysis: 0.45mcg/kg weekly or 0.75 mcg/kg every 2 weeks
- non-hemodialysis: 0.45mcg/kg every 4 weeks

darbepoetin dosing for CKD patients

150 units/kg 3 times per week or 40000 units weekly

epoetin alfa dosing for cancer patients

2.25mcg/kg weekly or 500 mcg every 3 weeks

darbepoetin dosing for cancer

80-100 fL

normal range for MCV

26-34 pg/cell

normal range for MCH

31-37 g/dL

normal range for MCHC