Term
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Definition
A decrease in the number of RBC's or Hgb below normal physiological levels
Results in decreased tissue oxygenation
Causes blood loss, increases RBC destruction, decreases RBC production |
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Term
| What effect does Anemia have on QOL? |
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Definition
- Decreased work/aerobic capacity
- Decreased sexual function
- Decreased cognition/mental alertness
- CV morbidity and mortality in the form of increased LVH and cardiac death. |
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Term
| What are the different signs and symptoms of anemia found throughout the body? |
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Definition
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Term
| What happens as tissue oxygen concentration goes down? |
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Definition
- Production/release of EPO goes up
- EPO stimulates production of RBC's
- EPO is produced by the kidneys |
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Term
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Definition
- Destroyed mostly by spleen
- Heme is converted to Bilirubin, which is conjugated by liver, which is excreted in feces
- Iron and Amino acids are reused |
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Term
| What would you look for in a physical exam for anemia? |
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Definition
- Pallor in nail beds, eyes, palm of hands and mucous membranes
- Postural hypotension, tachycardia
- Hemorrhaging
- Neurological findings in terms of B12
- Jaundice |
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Term
| What are normal RBC levels in a person? |
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Definition
- Normal levels: Males 4.6-6.2 million cells/mm3
Women 4.2-5.4 million cells/mm3
- Androgen causes higher levels in males
- RBC count is indirect estimate of HB content of blood |
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Term
| What are normal levels of Hemoglobin? |
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Definition
oNormal levels
nMales: 13.5 – 17.5 g/dL
nFemales: 12 – 16 g/dL
oHigher levels in males because...
nAndrogens effects on RBC production
nLess blood loss than females |
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Term
| What are normal levels of hematocrit? |
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Definition
oNormal levels
nMales: 36 – 46%
nFemales: 35 – 41%
oDescribes the volume of RBC – more prone to false readings
oApproximate ratio of Hb:Hct = 1:3 |
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Term
| What is the Mean Corpuscular Volume (MCV) and what should its value be? |
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Definition
oDescribes the average RBC relative to the volume
oHelps in the differential of anemia
oTerms
nNormocytic: 80 – 100 fL
nMicrocytic: < 80 fL
nMacrocytic: > 100 fL |
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Term
| What are the MCH and the MCHC and what should their values be? |
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Definition
oMean corpuscular hemoglobin (MCH)
nNormal: 27 – 33 pg/cell
oMean corpuscular hemoglobin concentration (MCHC)
nNormochromic: 31 – 35 g/dL
nHypochromic: < 31 g/dL |
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Term
| What are the RDW and the Reticulocyte Count and what should they be? |
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Definition
oRBC distribution width (RDW)
nIndicates variation in red cell volume
nNormal: 11 – 16%
oReticulocyte count
nIndirect assessment of new RBC formation
nNormal: 0.5 – 1.5%
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Term
| What are the different Iron indices? |
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Definition
oSr iron: ~50 – 165 mcg/dL
oTotal iron-binding capacity (TIBC): 250 – 440 mcg/dL
o% transferrin saturation (%TS): 33%
oSr ferritin: 10 – 200 ng/mL
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Term
| What are some other lab values in anemia that are important? |
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Definition
oErythropoietin: 0.01 – 0.03 U/mL
oVitamin B12: > 200 pg/mL
oFolate: > 4 ng/mL |
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Term
| What are the different kinds of anemia? |
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Definition
- Iron Deficiency Anemia
- Vitamin Deficiency Anemia (B12, Folic Acid)
- Hemolytic Anemia
- Sickle Cell Anemia
- Multifactorial
- Anemia of Chronic Disease |
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Term
| If you have Macrocytic Anemia (MCV > 100 fL), what are the possible causes and useful tests? |
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Definition
Possible Causes: Vitamin B12 or Folic Acid deficiency, drug induced bone marrow toxicity
Useful Labs: B12 and Folate
Schilling's Test |
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Term
| If you have Normocytic Anemia (80-100 fL), what are the possible causes and useful tests? |
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Definition
Possible Causes: Acute blood loss, hemolytic anemia, anemia of chronic disease
Useful Labs: Coomb's test (antiglobin test), Reticulocyte count |
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Term
| If you have Microcytic Anemia (MCV <80 100 fL), what are the possible causes and useful tests? |
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Definition
Possible causes: Iron Deficiency, Anemia of chronic disease
Useful labs: Iron indicies, RDW |
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Term
| What is IDA and what is its pathophysiology and etiology? |
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Definition
- Iron Deficiency Anemia
- Most common nutritional deficiency
- Increased risk in polar extremes of ages, adolescent girls and pregnancy
Patho: Conversion of Fe3 --> Fe2 to be absorbed in GI, binds to transferrin and moved to bone marrow. Daily loss of 1-2mg/day. Restored via dietary means and recycling. Once stores are depleted then Hg and heme decrease |
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Term
| What is the etiology of IDA? |
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Definition
oInadequate dietary intake
oBlood loss
oInadequate GI absorption
oIncrease iron demands
oUnderlying diseases |
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Term
| What are the signs and symptoms of IDA? |
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Definition
oLeg cramping
oGlossitis (tongue pain), smooth tongue
oKoilonychias (spooning of the nail)
oAngular stomatitis
oPica (compulsive eating of nonfood items – clay)
oPagophagia (compulsive eating of ice) |
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Term
| What do the lab values look like for IDA? |
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Definition
o↓ Hg, Hct, MCV, MCH, MCHC, reticulocyte count (or same)
o↑ RDW
o↓ Sr iron, Sr ferritin, %TS
o↑ TIBC |
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Term
| What is the treatment for IDA? |
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Definition
- Replace iron stores
- Identify cause and correct it
- Increase dietary intake (grains, veggies, dairy don't offer that much iron) of meat, fish, poultry
- Supplemental Iron |
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Term
| What are the oral product for iron supplementation? |
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Definition
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Salt form
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Dose (mg)
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Fe/tab (mg)
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% Fe
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tabs/day
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Ferrous gluconate
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325
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37
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12
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6
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Ferrous fumarate
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200
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66
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33
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3
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Ferrous sulfate
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325
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65
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20
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3
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Term
| What are some combination products to use for IDA? |
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Definition
- Vitamin C
- Stool softeners
- Folic Acid |
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Term
| What is the dosing for iron supplementation? |
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Definition
oDosing (based on elemental iron)
nAdults: ~200 mg/day
nChildren: ~3 – 6 mg/kg/day
o200 mg of elemental iron daily (adults)
nTypically in 3 divided doses
nTake 1 hour prior to meal (if tolerable)
oExample: Ferrous sulfate 325 mg po TID between meals
ADR's: N/V, constipation, dark colored stools.
Easier if you go from 1 dose a day each week to 2/day, then 3/day. Takes 3-6 months to reach full effect (monitor Hct, Hg, reticulocyte count, ADR |
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Term
| What are the counseling points for oral iron products in IDA? |
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Definition
oTake on empty stomach
oGI side effects are common
oSpace dosing of antacids, calcium products, TCA and FQ
oProtect bottle from children
nChild resistant does NOT mean child proof |
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Term
| Macrocytic Anemia includes Vitamin B12 deficiency as well as Folic Acid deficiency, what is the result of Vitamin B12 anemia? |
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Definition
- Rxns catalyzed by B12 and folic acid don't occur properly, making an immature erythrocyte, therby impairing DNA and RNA synthesis
- Nucleic acid synthesis is messed up, mitotic cell divisions are messed too, resulting in abnormall large cells (Megaloblastic) |
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Term
| What is the pathophysiology of Macrocytic Anemia? |
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Definition
- Normally, B12 is bound to IF in order to be absorbed in the gut. It is then stored in the liver
- As a result of deficiency, the synthesis of RBC's and axons of spinal cord nerves are impaired.
- Can lead to irreversible CNS lesions and degeneration (fatal) if left untreated |
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Term
| What is the etiology, as well as signs and symptoms, of B-12 deficiency anemia? |
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Definition
Etiology - IF deficiencies, malabsorption, others
Signs and Symptoms - Pallor, weakness, fatigue, loss of appetite, atrophic glossitis, parethesis in fingers/toes, tingling, difficulty walking, tremors, irritability, somnolence. |
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Term
| What is the Schilling test for Pernicious anemia? |
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Definition
- Used to determine if there is low or no IF
- Oral vitamin B12 (labeled), given and along with IM B12 (unlabeled)
- The person has pernicious anemia if less than 8% of the oral B12 was absorbed (normal 33%)
- Repeat in a few days, give IF with oral vitamin B12 |
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Term
| What are the lab findings for Pernicious anemia? What are the treatments? |
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Definition
o↓ Hg, Hct, Sr vitamin B12, reticulocyte count (or no change)
o↑ MCV, MCH, bilirubin, LDH
oNo change: MCHC
oIM cyanocobalamin
nInitial: 1 mg IM daily x 1 to 3 weeks
nMaintenance: 1 mg IM weekly to monthly
oIntranasal cyanocobalamin
nUsed after initial IM injections w/o CNS involvement
n1 hour before or after ingestion of hot foods/beverages
oOral cyanocobalamin
n1 – 2 mg PO daily
nAvoid oral cobalamin
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Term
| What are the ADR's of the treatments for Pernicious Anemia? |
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Definition
oRare and uncommon
oNa retention – exacerbation of CHF
oHypokalemia – monitor for symptoms
oHyperuricemia – gouty attack
- Should be rapid response to B12 therapy, and reversal of CNS issues if treated early enough |
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Term
| What are counseling points for patients who have a B12 deficiency? |
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Definition
oIncrease intake of foods with vitamin B12
oAssessment of Compliance:
nStress importance of taking/getting vitamin B12
nIM B12 is more expensive than PO B12
nIM B12 ensures better compliance than PO B12 |
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Term
| What is the etiology and signs and symptoms of a folate deficiency? |
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Definition
oInsufficient intake: alcoholism (automatically give), elderly, chronically ill
oInadequate absorption
oFolic acid antagonists
oIncreased requirements: pregnancy, malignancy
Signs
oLess CNS SE than vitamin B12 deficiency anemia but similar signs/symptoms
oMust r/o vitamin B12 deficiency with shillings test
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Term
| What are the laboratory findings of a folate deficiency? |
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Definition
o↓ Hg, Hct, Sr folic acid, reticulocyte count (or no change)
o↑ MCV, MCH
oNo change: MCHC
oNormal: schilling test, Sr vitamin B12 |
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Term
| What are the treatments and ADR's of a folate deficiency? |
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Definition
oFolic acid 1 mg PO daily
oConsider parenteral therapy in NPO patients, malabsorption status, or liver disease
oMust r/o vitamin B12 deficiency with shillings test
oFolate deficiency affects fetus development
nPremature labor, underweight, neural tube defects
oNeural tube defect (NTD): spina bifida
n800 – 1000 mcg/day ↓ incidence
n4 mg/day if h/o NTD
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Term
| What is hemolytic anemia and its subtypes? |
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Definition
oIncrease rate of blood cell destruction
oMain categories
nIntravascular: G6PD deficiency, Thalassemias, Sickle cell anemia
nExtravascular: Immune-mediated hemolytic anemia (coombs test) |
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Term
| What is the pathophysiology of Sickle Cell Anemia, and what are its treatments? |
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Definition
oPathophysiology
nHemoglobin has 2 alpha and 2 beta chains
nThe beta chains differ in patients with SCA
oHigher incidence in:
nAfrican heritage
nMediterranean regions
oPain treatment
nNarcotic analgesics
nScheduled!!! (not prn)
oPreventative
nHydroxyurea (not for acute attacks)
nUsed in patients with recurrent moderate to severe cases
nDosing:
pInitial: 500 mg PO daily (10 – 15 mg/kg/day)
pCommon doses: 1000 – 2000 mg PO daily (20 – 30 mg/kg/day)
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Term
| Alcoholics, pregnant patients, and post-gastretomy patients are at risk for what deficiencies? |
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Definition
Alcoholics – IDA and folate deficiency anemia
Pregnancy – IDA and folate deficiency anemia
Post-gastrectomy – IDA and vitamin B12 deficiency anemia |
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Term
| What are the main points of anemia? |
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Definition
Background/laboratory information:
General s/sx related to a decrease in tissue oxygenation and hypovolemia that
Normal Hg for males/females
MCV helps in the differential of anemia
All oral products are equally effective in equivalent doses (200 mg of elemental iron daily)
GI side effects are common
Vitamin B12
Can lead to irreversible CNS complications
Must perform Schilling test
IM, PO and intranasal dosage forms
Folic acid
Given during pregnancy to prevent neural tube defect
Must r/o B12 deficiency with Shillings test |
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