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1
Q

Typical causes of anemia

A
  • Decreased RBC production
  • Hemolysis
  • Ineffective erythropoiesis
  • Acute blood loss
2
Q

Effects of decreased RBC production

A
  • Would have low retic count
  • Low indirect bilirubin
  • Low LDH levels
3
Q

Effects of hemolysis

A
  • High retic count
  • High bili
  • High LDH
4
Q

Effect of ineffective erythropoiesis

A
  • Low retic count
  • High bili
  • Very high LDH
5
Q

Effect of acute blood loss

A
  • High retic count
  • Low bili
  • Low LDH
6
Q

Anemias of decreased production

A
  • Fe deficiency (usually due to blood loss)
  • Anemias of chronic inflammations/disease
  • Lead poisoning and other sideroblastic anemias
  • RBC aplasia (i.e. acute or chronic leukemia)
7
Q

Anemias of chronic inflammation/disease (ACD)

A
  • Chronic infections: granulomatous disease (TB, coccidiomycosis, osteomyelitis, pulmonary abscess)
  • Non-infectious inflammation: RA, lupus, malignancy, burns, Hogkin’s lymphoma
8
Q

Proinflammatory anemia

A
  • Proinflammatory cytokine up-regulation increases macrophage erythrophagocytosis and heightened splenic function (due to RBC membrane changes and activation of macrophages by TNFa)
  • Shortens RBC survival by 10 to 20 days
  • Requires slight increase in erythropoiesis to maintain balance
  • Failure of increased erythropoiesis results in anemia
9
Q

Fe re-utilization anemia

A
  • Faulty Fe re-utilization leads to decreased erythropoiesis (microcytic anemia)
  • Lactoferrin, released from PMNs, binds to Fe w/ higher affinity than transferrin and delivers Fe to macrophages
  • Hepcidin is synthesized in liver and released in response to inflammation
10
Q

Functions of hepcidin 1

A
  • Causes Fe retention of macrophages by up-regulation of divalent metal transporter DMT1 on macrophage, leading to more influx of Fe into macrophage
  • Hepcidin also causes a reduction in DMT1 expression on the apical surface of duodenal cells, reducing their uptake of Fe
  • Further, it leads to the internalization and degradation of ferroportin from the basolateral surface of the duodenal cells (and macrophages)
  • Ferroportin allows efflux of Fe into the blood stream, thus decreasing it leads to lower Fe absorption
11
Q

Functions of hepcidin 2

A
  • There is a diversion of Fe from plasma to storage forms in macrophages (ferritin/hemosiderin)
  • Serum ferritin increases, but free serum Fe falls (causing a fall of transferrin saturation)
  • Low serum Fe and decreased transferrin delivery to erythroblasts in BM leads to Fe-restricted erythropoiesis
  • Decrease in erythropoiesis due to this inability to transport Fe leads to anemia
12
Q

Controlling factors of hepcidin

A
  • Malignancy, infection, chronic inflammation (inflammatory cytokines), and saturated transferrin all induce hepcidin release
  • IL6 injections decrease serum Fe by 30% in 2 hrs
  • Snadd is TF for hepcidin, and an increase in Snadd results in more hepcidin (and lower serum Fe)
  • Erythroferrone inhibits hepcidin production, thus increasing serum Fe
13
Q

Blunted EPO response and erythropoiesis

A
  • Lower EPO can result in decreased erythropoiesis and eventual anemia
  • EPO and hypoxia reduce hepcidin levels to allow for increased serum Fe for erythropoiesis
  • IL1 and TNFa directly inhibit EPO mRNA via ROS damage to EPO producing cells
  • IL1, IFNg and TNFa decrease erythropoiesis
  • IFNg does this directly
  • IL1 does this directly only in presence of T cells
  • TNFa is associated w/ decreased stem cell growth and anemia (Abs to TNFa improves anemia)
  • Normally there is a strong inverse relationship btwn EPO and Hct, but w/ blunted EPO response the relationship is much weaker
14
Q

Fe deficient anemia vs ACD 1

A
  • Direct measurement of Fe stores by BM biopsy (prussian blue stain) is gold standard for Dx
  • Also look at serum ferritin and transferrin levels, as they will differentiate Fe deficiency (low ferritin) from ACD (high ferritin)
  • Transferrin will be low in ACD, but high in Fe deficiency anemia
  • Transferrin is proportional to erythroid precursor mass in BM, so when erythropoiesis in inhibited in ACD (due to blunted EPO and cytokine inhibition), transferrin will decrease in serum
  • In contrast, erythropoiesis is increased in Fe deficiency (but not completed) which results in an increase in transferrin
15
Q

Fe deficient anemia vs ACD 2

A
  • Ferritin serum levels (an indication of excess Fe) will be high in ACD due to inhibition of erythropoiesis (could also be due to renal failure- not as reliable)
  • However in Fe deficiency ferritin serum levels will be low
  • Can also check free erythrocyte protoporphyrin (FEP) which will go up in Fe deficiency due to the inability to convert protoporphyrin to heme (requires Fe, last step of heme synthesis)
  • Measure serum/urine hepcidin (high in ACD, low in Fe deficiency)
16
Q

Anemia of chronic renal disease

A
  • Evident when renal function (creatinine clearance) is half of normal
  • Similar to chronic inflammation: altered Fe kinetics, decreased RBC survival, suppression of erythropoiesis
  • Important distinction: decreased production of EPO (in ACD the EPO is high but the response is low?)
  • Can also lead to Fe, folic acid, protein, and calorie deficiencies
  • Can acidify blood resulting in burr cells (difference from spur cells: burr cells’ thorny projections are smaller, evenly spaced, and more numerous)
  • Rx: recombinant EPO
17
Q

Anemia of chronic liver disease

A
  • Similar to chronic inflammation: altered Fe kinetics, decreased RBC survival, suppression of erythropoiesis
  • Specific features: increased plasma volume dilutes RBC mass
  • Altered lipid metabolism leads to mild macrocystosis (MCV 105) and target cells initially seen
  • Later spur cells are seen, with hemolysis
  • Also results in hypersplenism (splenomegaly) from portal hypertension
  • Bleeding from esophageal varices (acute or chronic w/ Fe deficiency)
18
Q

HIV infection

A
  • Similar to chronic inflammation: altered Fe kinetics, decreased RBC survival, suppression of erythropoiesis
  • Specific features: anemia corresponds to measure of disease severity (number of CD4 cells)
  • Pure RBC aplasia: due to parvovirus 19 (prevents erythropoiesis), drugs
  • Myelophthisis (infiltration of BM): from infection (mycobacterial, fungal), neoplasm (lymphoma)
19
Q

Malignancy

A
  • Similar to chronic inflammation: altered Fe kinetics, decreased RBC survival, suppression of erythropoiesis
  • Anemia corresponds to disease severity, can be associated w/ myelophthisis of the cancer
20
Q

Plumbism

A
  • Lead poisoning from paint, exhaust, or industrial sources
  • Shortens RBC lifespan, inhibits several steps in protoporphyrin metabolism: ALA dehydrate, ferrochelatase, coprophorphyrinogen oxidase
  • Results in increased ALA and coprophorphyrin in urine
  • Produces microcystic hypochromic anemia resembling thalassemia minor (B)
  • Basophilic stippling die to inhibition of pyrimidine nucleotidase
  • Ringed sideroblasts in BM due to inhibition of heme synthesis
  • Accumulates in tissue (brain, bone, gum line) leading to abdominal pain, gout, decreased mental function and growth, Pb line seen on Xray
21
Q

Pregnancy

A

-Causes a 20% increase in RBC mass, but a 45% increase in plasma volume (dilution)