RBC measurements: -RBC mass (MCV), RBC count (MCH), H/H (MCHC), Morphology (RDW).

Polycythemia: increased RBC mass.

Anemia:decreased RBC mass; not a disease but a symptom. -Most common symptom: Fatigue due to lack of oxygen for cell metabolism. -Other symptoms: -Pale skin, koilonychia (spooning of nails). -Lab tests: -CBC, RBC morphology, reticulocyte index (retic count), bilirubin. -Relative hemoglobin: -Measured in lab in g/dL; mass of Hb relative to plasma volume. -Increased plasma volume (excessive hydration) can result in falsely low Hb. -Loss of blood and plasma during acute hemorrhage may result in normal Hb; but Hb will be decreased later and plasma increased. -Absolute hemoglobin: -Total mass of Hb independent of plasma volume.

Serum iron: -Iron metabolism: -Fe is present in Hb and involved in oxygen transport. -The rest are stored in bone marrow, spleen, liver, and myoglobin. -Iron requirement increased during pregnancy, growth, and menstruation. -Test: Enzyme immunoassay (EIA).

-Specimen:Draw in the morning due to diurnal variation; decreased iron in the afternoon. -Reference range: varies with age, gender, and methodology.

Serum ferritin: -Fe bound to apoferritin, forming ferritin (main storage form in body). -Ferritin stores or releases iron for hematopoiesis (RBC production). -Water soluble; Fe is readily available. -Not stained by iron stain. Can be stained by Prussian blue stain. -1st test value to decrease during iron deficiency anemia. Used to confirm iron deficiency. -Acute phase protein; increased serum ferritin does not exclude iron deficiency anemia. -Test: EIA -Reference range: Varies with age, gender, and methodology.

Hemosiderin: Storage form of iron that is not readily available. -Water-insoluble; contains 50% Fe. -Can be stained by Prussian blue stain. -Degradation product of ferritin.

Transferrin: -Fe transport protein; carries iron to bone marrow for heme production. -Free iron is toxic.

Total iron-binding capacity (TIBC): Rarely used. -Total amount of iron that can bind to transferrin (fully saturated).

-Decreased when excess Fe is present. -TIBC = unsaturated iron-binding capacity (UIBC) + Fe -Same as measuring percent transferrin saturation.

Percent transferrin saturation: -Percent Transferrin Saturation = (Serum Fe/TIBC) x 100 -Normal % saturation: 33%

-As ferritin increases, serum Fe increases, transferrin saturation increases, TIBC decreases. -As ferritin decreases, serum Fe decreases, TIBC increases, transferrin saturation decreases.

Free erythrocyte protoporphyrin (FEP): -Protoporphyrin IX + Fe2+ = Heme -During Fe deficiency, zinc protoporphyrin (ZPP) is produced to increase protoporphyrin level. -Zinc binds to protoporphyrin instead of Fe. -FEP is used to differentiate thalassemia from Fe deficiency anemia and ACD. -FEP is increased in Fe deficiency, ACD, lead poisoning. -Normal in thalassemia (genetic disorder; abnormal Hb is produced; RBCs are destroyed, causing anemia).

Microcytic anemia: -Anemias due to abnormal heme synthesis: -Fe deficiency anemia, anemia of chronic disease, sideroblastic anemia, lead poisoning.

-Due to abnormal globin synthesis: -Beta thalassemia. -Fe deficiency anemia: Most common nutritional deficiency. -Cause: -Blood loss (mainly males), menstrual period. -G.I. bleeding due to ulcer, hernia, or cancer. -Growth spurts, pregnancy, dietary deficiency, malabsorption. -Symptoms: Fatigue, skin pallor, koilonychia, pica (craving for dirt and ice). -Differential: Microcytic hypochromic anemia; target cells and ovalocytes present. -Reticulocyte production index (RPI) < 2 -Possible thrombocytosis (overproduction of platelets). -Test: Iron studies. -Serum Fe decreased, ferritin decreased, TIBC increased, transferrin saturation decreased, FEP increased, bone marrow Fe storage absent. -Treatment: Administer Fe (ferrous sulfate). -Reticulocytes increase on day 8-10; anemia resolves in 6-10 wks. -Continue therapy for 6 months after Hb level has returned normal.

-Anemia of chronic disease (ACD): -2nd most common anemia; most common anemia in hospitalized patients. -Occurs in patients with chronic infections, inflammations, or neoplasms. -Apoferritin and macrophages withhold Fe; Fe is present but not available. -Resolves after underlying chronic disease is treated. -Differential: Microcytic normochromic anemia. -RPI < 2 hypochromic anemia; possible normocytic

-Test: Iron studies. -Iron decreased; ferritin increased; TIBC decreased; transferrin saturation decreased; FEP increased; bone marrow storage present. -TIBC decreased due to inflammation and presence of Fe storage in bone marrow. -Sideroblastic anemia: -Cause: Abnormal heme synthesis. -Presence of ringed sideroblasts in bone marrow. -Due to increase in free iron in mitochondria surrounding RBC nucleus. -Presence of dimorphic anemia (2 different cell populations). -Presence of hypochromic and normochromic cells. -Or microcytic and macrocytic cells. -Types: Hereditary or acquired (more common) -Differential: Dimorphic; increased RDW; pappenheimer bodies and basophilic stippling. -RPI < 2 -Test: Iron studies -Fe increased; ferritin increased; TIBC normal-decreased; transferrin saturation increased; FEP variable; bone marrow storage present. -Lead poisoning: -Cause: Ingestion of lead-based compounds. -Associated with hyperactivity, mental retardation, hearing loss, and stunted growth. -Differential: Microcytic hypochromic anemia, course basophilic stippling. -Serum iron normal. -Treatment: Administer lead chelators.

Megaloblastic anemia: -Cause: -Folate deficiency (most common), B12 deficiency. -Coenzyme folate required to form thymine; thymine used to form DNA. -Folate deficiency results in impaired DNA synthesis. -Asynchrony: Cytoplasm matures but nucleus does not. -Symptoms: Enlarged RBCs, WBCs, platelets, hair, nails, mucosal lining. -Megaloblasts: Oval RBCs. -Large, premature, nucleated RBC; nucleus resembles salami; chromatin not clumped. -Destroyed by bone marrow; causing anemia. -Differential: -Macrocytic, normochromic anemia; MCV > 99 fL. -Macroovalocytes, Howell-Jolly bodies, hypersegmented PMNs present. -Giant bands, decreased retics. -Increased LDH, bilirubin, iron. -Bone marrow study: -Hypercellular marrow (excess cells), erythroid hyperplasia (excess immature RBCs). -Decreased myeloid to erythroid ratio (M:E ratio of 1:1; normal is 3:1 or 4:1).

Non-megaloblastic anemia: -Cause: -Alcoholism (most commoon), liver disease, hypothyroidism.

Vitamin B12: Cyancobalomin

-Only synthesized by microbes in soil and intestines. -Food source is meat, liver, fish, milk, eggs; daily requirement: 2-5 ? g. ? -Body stores 2-5 mg; stored in liver. -Absorbed in small intestine: -B12 binds to intrinsic factor secreted by gastric parietal cells (epithelium). -The resulting complex binds to microvilli; B12 is absorbed; intrinsic factor remains. -Transcobalamin carries B12 to liver and bone marrow. B12 deficiency: -Cause: -Nutritional deficiency: Lack of animal proteins. -Malabsorption: Lack of intrinsic factor (pernicious anemia) caused by gastric atrophy (weakening and shrinking of stomach muscles). -Autoimmune: Ab formed against gastric parietal cells and intrinsic factor. -Symptoms: abdominal pain, glossitis (swollen tongue, changed color), megaloblastic madness (CNS degeneration) -Treatment: Inject B12. -Increased utilization: Hyperthyroidism. -Consumed by microbes and D. latum.

Schilling test: Only performed if B12 is decreased. -B12 measurement: EIA. -3 phases: -Phase 1: -Oral dose of B12; administer 57Co-B12; measure 57Co-B12 excreted in urine. -If tested normal then the lowered B12 is caused by dietary deficiency.

-If abnormal, perform phase 2. -Phase 2: -Administer hog IF + 57Co-B12. -If normal then the lowered B12 is caused by lack of intrinsic factor (pernicious anemia). -If abnormal, perform phase 3. -Phase 3: -Treat patient with antibiotics for 10 days to remove all normal flora. -Administer 57Co-B12. -If tested normal, then lowered B12 is caused by parasitic infection. -If abnormal, then it is due to malabsorption.

Methylmalonic acid (MMA): -Marker for early B12 deficiency; produced as byproduct during protein metabolism. -B12 acts as cofactor when converting methylmalonyl CoA to succinyl CoA. -Methylmalonyl CoA is converted to MMA when B12 is low and MMA increases.

Test battery for diagnosing pernicious anemia: -Serum B12; MMA, IFBAb (intrinsic factor blocking antibody), parietal cell Ab, gastrin.

Folic acid (or folate) deficiency: -Body stores last for months; stored in liver. -Food source: Eggs, milk, leafy vegetables, yeast; overcooking destroys folate. -Cause: -Dietary deficiency (most common), alcoholism.

-Malabsorption, increased requirements, drug inhibition, hereditary enzyme deficiencies. -Tests: Measure both serum and RBC folate. -Serum folate: reflective of dietary intake. -RBC folate: reflective of folate stores. -Methodology: EIA.

Megaloblastoid maturation: Has multiple nuclei less clumped than megaloblast nucleus. -Present in preleukemia, leukemia, DiGuglielmo's, arsenic poisoning. -Cannot be treated with B12 or folate; can develop into leukemia.

Macrocytic anemia: Round RBCs. -Cause: (ALAH) -Alcoholism (most common) -Liver disease (associated with target, acanthocytes, and schistocytes) -AZT (drug used to treat AIDS; associated with decreased lymphs) -Hypothryoidism -RPI < 2

Normocytic anemia: -Symptoms: -Hypoproliferative anemia; associated with bone marrow hypocellularity (decreased cells). -Bone marrow cells replaced by fat. -Aplastic, aplasia, and hypoplastic all refer to bone marrow with decreased hematopoietic cells (RBC-producing cells).

-Cause: Due to inhibition or damage of stem cells: -If pluripotent stem cell is affected: -Pancytopenia of WBC, RBC, platelets; causes aplastic anemia. -If erythroid stem cell is affected: -Causes pure red cell aplasia. -Aplastic anemia: -Types: Acquired or congenital (Fanconi's anemia). -Cause: Pluripotent stem cell disorder; -Symptoms: -Hypocellular bone marrow (< 25%; normal is 70%), pancytopenia. -Normocytic, normochromic anemia. - RPI < 2; poor prognosis -Treatment: Bone marrow transplant. -Fanconi's anemia: -Cause: Autosomal recessive disorder. -Associated with acute leukemia and tumors. -Leads to aplastic anemia in patients between 5-10 yr. -Myelophthisic anemia: -Pluripotent stem cell disorder. -Differential: Dacrocytes are present. -Associated with prostate, breast, and stomach cancer. Pure red cell aplasia: -Types: Acquired or congenital (TEC). -Cause: Erythroid stem cell disorder. -Symptoms: Decrease of erythroid precursors in bone marrow; anemia.

-Diamond-Blackfan Syndrome (erythroblastic hypoplasia): -Develops in newborn-1 yr old. -Symptoms: -Severe normocytic anemia; WBCs and platelets normal. -Treatment: Transfusion. -Must differentiate from TEC. -Transient erythroblastemia of childhood (TEC): Congenital -Affects newborns and children 1-4 yrs. -Symptoms: -Microcytic anemia. -Associated with infections. -Treatment: Supportive therapy. -Anemia of chronic renal disease: -Normocytic, normochromic anemia; RPI < 2 -Diff: Anisocytosis, Burr cells (echinocytes) present.