What is Anemia?

Anemia is a decrease in the number of red blood cells (RBC) as measured 1. per cu mm on a slide or 2. by volume of packed RBC per 100 ml of blood. This is clinically obtained by doing a hematocrit (HCT)

There are several causes of anemia

1. RBC Loss without RBC destruction 2. Deficient RBC production 3. Increased RBC destruction over production

RBC loss without RBC Destruction

Hemorrhage Due to trauma Due to disorders: e.g.cancer, ulcers, tuberculosis, diverticular disease, and irritable bowel syndrome (including ulcerative colitis and Crohns disease) Menstrual flow Gynecological disorders (e.g. endometriosis, fibroids) Pregnancy, especially at gestation Parasitism Hookworms

Deficient RBC Production

Neoplasia Leukemia Metastasis to bone marrow Osteogenic sarcoma Myelofibrosis Pernicious anemia Iron Deficiency anemia Aplastic anemia Chloramphenicol administration Renal disease (lack of erythropoietin production) Increased RBC destruction over erythropoiesis

Increased RBC Destruction over Production (Hemolytic Anemias)

Intrinsic Abnormalities

Thalassemia G6PD Sickle Cell Anemia Hereditary Spherocytosis Infections Malaria (Plasmodiumm species) Mycoplasma Disseminated Intravascular Coagulation Lead poisoning

Extrinsic Abnormalities

Symtomatology.
Symptoms develop in proportion to the degree of anemia. Increasing fatigability, headache, tachycardia, exertional dyspnea, ankle edema, and pallor. Pica eating is a striking feature of anemia. Pagophagia, Amylophagia, and Geophagia.

Symtomatology
Abnormalities in epithelial tissue including sore or atrophic tongue, sore mouth, angular stomatitis, thinning or Spooning of nails (Koilonychia) and dysphagia may occur. Plummer-vinson syndrome (Sideropenic dysphagia) is characterized by the feeling of food sticking in the throat.

Symptomatology
Menstrual abnormalities are commonMenorrhagia, irregularity of flow, or even amenorrhea. When present, menorrhagia may aggravate the iron deficiency.

Symptomatology

In the fully developed state, the clinical picture is striking: A tired listless appearance, pallor, inelastic &often dry and wrinkled skin, dry & often scanty hair, pearly white sclera, and pale conjunctiva are found. Papillary atrophy of tongue, slight cardiac enlargement and functional systolic murmur.

Diagnosis.
The fall in blood Hemoglobin level is of a greater magnitude than the hematocrit. Peripheral blood smear shows anisocytosis and poikilocytosis. Mean copuscular volume and mean corpuscular Hemoglobin is reduced. Serum Iron is bellow 30/Mcrogram /dl.

Diagnosis
Total Iron binding capacity is increased. (600 micrograms/dl.) Prussian blue staining of bone marrow shows absence of hemosiderin. A significant reticulocytosis occurring after commencement of iron administration indicates a response.

In therapeutic trial period of 3-4 weeks , hemoglobin should increase on an average of 0.2gram/100 ml.

Selected Pharmacology of Anemias RBC Loss

Therapy: Packed RBC cells never whole blood Why? Ans: whole blood contains too much potassium from dead cells which lyse. Cardiac arrhythmias ensue.

Selected Pharmacology of Anemias Deficient RBC Production

Neoplasia: covered by another lecturer Myelofibrosis: Remove spleen; transfusion when necessary with packed cells. Pernicious anemia: B12 injections Microcytic (iron deficiency) anemia: iron: only ferrous iron (sulfate, fumarate, gluconate). Ferric iron is not absorbed liquid Geritol wont do. Aplastic anemia: stop medication; may have to do bone marrow transplant Renal disease: Correct if possible, otherwise renal transplant

Normal, RBC's. They have a zone of central pallor about 1/3 the size of the RBC.). A few small fuzzy blue platelets are seen. In the center of the field are a band neutrophil on the left and a segmented neutrophil on the right.

The RBC's here are smaller than normal and have an increased zone of central pallor. This is indicative of a hypochromic (less hemoglobin in each RBC) microcytic (smaller size of each RBC) anemia. There is also increased anisocytosis (variation in size) and poikilocytosis (variation in shape).

The most common cause for a hypochromic microcytic anemia is iron deficiency. The most common nutritional deficiency is lack of dietary iron. Thus, iron deficiency anemia is common. Persons most at risk are children and women in reproductive years (from menstrual blood loss and from pregnancy).

This peripheral blood smear comes from a patient with malaria caused by Plasmodium vivax. At the arrow on the right is a RBC with a malarial parasite in the shape of a ring. Three other RBC's in this smear are also infected with a ring trophozoite. Arrow at left is a gametocyte of this species.

Malaria

Erythropoiesis (Formation of RBCs)

Erythropoiesis begins with a pluripotent stem cell whose progeny are influenced by hormones to develop into several cell lines. One of these cells lines becomes committed to the erythroid line of development.

Erythropoiesis (Formation of RBCs)

1. The initial cell is a BFU-E (burst forming unit erythroid) 2. BFU-E in the presence of interleukin-3 and erythropoietin forms CFU-E (colony forming units erythroid). 3. CFU-E in the presence of a high concentration of erythropoietin forms a pronormoblast.

Erythropoiesis (Formation of RBCs)

4. The pronormoblast large nucleated cell but NO hemoglobin

Erythropoiesis (Formation of RBCs)

5. Normoblast characterized by increased hemoglobin synthesis. During this stage, cytoplasmic organelles are lost.
During the late normoblast stage, the nucleus is ejected. Once ejected, the cell is called a reticulocyte.

Erythropoiesis (Formation of RBCs)

6. The reticulocyte (arrow) Has no nucleus Has no organelles Is larger than the mature RBC Is not concave Has many polyribosomes In severe anemia, many of these are released into the blood prematurely. Normally, 25 billion cells, which is 1% of circulating blood, are reticulocytes

Ribosomal RNA stained with methylene blue

Notes on Terminology
Pronormoblast and normoblast are terms that relate to the normal development of the erythrocyte in contrast to the megaloblastic formation seen in megaloblastic anemia. The erythroid stages are depicted as Proerythroblast = pronormoblast Basophilic erythroblast Polychromatic erythroblast Orthochromatic erythroblast Reticulocyte (polychromatic erythrocyte)
normoblasts

Pronormoblast

Normoblasts

Factors necessary for erythropoiesis

1. Erythropoietin 2. Iron 3. Vitamin B12 (cyanocobalamin) 4. Folic Acid (folate) 5. Ascorbic acid (Vitamin C) 6. Pyridoxine (Vitamin B6) 7. Amino acids

Regulation of Erythropoiesis
Normal body requirements for oxygen is 250 ml/min Almost all of that is for use in oxidative phosphorylation by the mitochondria. The heart normally pumps out 1,000 ml oxygen per minute. Less than 250 ml/min causes tissue hypoxia

Regulation of Erythropoiesis
Kidneys receive 25% of cardiac output approximately 1,250 ml of blood/min yet it is only 0.5% of body weight. The 1,250 ml/min contains 250 ml/min of oxygen The amount of oxygen/min received by the kidneys is the same as that required by body tissues/min. Therefore, renal monitoring of oxygen is logical choice.

Regulation of Erythropoiesis
If renal tissue is hypoxic, erythropoietin is produced by renal peritubular interstitial cells. The gene for erythropoietin is located on chromosome 7. Erythropoietin is not the only factor required for red cell development. We will cover some of these later.

Regulation of Erythropoiesis

While the kidney produces most of the erythropoietin, the liver and other tissues also produce some. In fetal life, the liver produced all of the erythropoietin as the final kidney the metanephros - had not yet completed development.

Regulation of Erythropoiesis

Erythropoietin increases RBC production in 3 ways: Promotes pronormoblast production Shortens the transition time through the normoblast stage Promotes the early release of reticulocytes.

Regulation of Erythropoiesis

How many are produced: 25 billion /24 hours. The entering cells are reticulocytes which should be 1% of the total population of circulating erythrocytes. Erythrocytes last 120 days and are destroyed by the spleen. Red cell production should equal red cell destruction.

Determination of RBC size

MCV = mean corpuscular volume in femtoliters (10-15 liters) abbreviated fl. This is the most accurate method of measuring red blood cells and is the one done by automated Coulter counters. MCH = mean corpuscular hemoglobin does not add anything to the diagnosis except additional expense. It will not be considered further.

Differential Diagnosis using MCV

Macrocytic anemias (MCV = 150 fl) larger than normal cells Normocytic (MCV = 80-96 fl) cells are normal in volume. Microcytic anemias (MCV = 50 fl) cells are smaller than normal.

Our discussion of anemia is limited to:

We will only discuss those anemias that are due to a deficiency of: Iron Folic acid Vitamin B12 Vitamin Or those anemias that will be benefitted by the administration of erythropoietin. .

Erythropoietin
Recombinant human erythropoietin is produced using Chinese hamster ovarian cell line. There are differences in the carbohydrate portion of the molecule but it neither stimulates the immune system nor affects potency or efficacy.

Erythropoietin

Epoetin alpha (Eprex) is available in Saskatchewan in prefilled syringes and sterile solution for injection.

Erythropoietin is used to treat:

1. Anemia in chronic renal disease prior to dialysis (there is always destruction of RBC in dialysis as the blood goes through the dialysis pump) 2. Anemia in AIDS patients 3. Anemia in transplant patients

Erythropoietin is used to treat:

4. Anemia in cancer patients who have undergone chemotherapy that destroyed some of the bone marrow. 5. Anemia in surgical or extracorporeal procedures (e.g.: CABG and AVM) because the pumps may have destroyed many red blood cells.

6. Anemia in premature children.

7. Chronic inflammatory illnesses (e.g. systemic lupus erythematosus) in which RBCs are destroyed.

Erythropoietin is abused:
Athletes use erythropoietin to enhance their athletic prowess. Using erythropoietin in this way is called blood doping. Blood doping increases the concentration of RBCs and with it an increased chance for spontaneous coagulation. Several athletes have died as a result. It is not allowed by international sports associations, such as the International Olympic Committee.

Iron
Iron deficiency is the most common cause of anemia. Results in microcytic hypochromic anemia.

Iron is used in:

Hemoglobin. Heme enzymes, e.g., cytochromes, catalase, peroxidase Myoglobin Metalloflavoprotein enzymes such as xanthine oxidase The mitochondrial enzyme alphaglycerophosphate oxidase and other mitochondrial enzymes. Other enzymes and processes

Iron in hemoglobin

Iron in hemoglobin

Iron Deficiency Common Causes

Inadequate dietary intake of iron especially in: Infants in the postnatal period Young females after menarche Adolescents of both sexes During pregnancy

Iron Deficiency Common Causes (cont)

Partial gastrectomy due to ulcers Blood loss due to: Bleeding peptic ulcers Malignancy Trauma in which there is excessive bleeding (includes blood loss through extensive bruising) Malabsorption syndromes Cystic fibrosis Celiac Disease (nontropical sprue)

Iron Deficiency lead toxicity

Can lead to lead toxicity from pica Iron deficiency enhances uptake of heavy metals, including lead. Lead is still used in all outside house paint. Lead is highly concentrated in the first few inches of soil in cities from car exhaust of 20 years or more ago. Infants love to each pica their taste of the world.

Heme iron and nonheme iron

Heme iron very well absorbed. Present in muscle as part of myoglobin. But: Do not eat meat that is bloody. Bacteria love blood and it can be the source of severe food poisoning. Nonheme iron not absorbed well but forms the bulk of dietary iron.

Iron Absorption
Absorbed from the duodenum (where most drugs are absorbed) and upper jejunum. Vitamin C taken with the iron increases absorption by reducing dietary ferric to ferrous iron. Caffeine and other xanthines decrease absorption.

Iron Preparations available

Only absorbed well in the ferrous (us is for us) form. Ferrous sulphate, ferrous gluconate and ferrous fumarate are three that are available. Ferric form only 10% absorbed ick! Ferric ammonium citrate is in Geritol Tonic. However, patients feel good could it be because of the 12% alcohol content?

Iron Not from Geritol Tonic

Iron Therapy Side effects of oral preparations

Nausea Gastric discomfort Constipation Diarrhea

Good idea to start patients on small doses and increase gradually. Less side effects that way.

Iron Parenteral solution

Should be used cautiously because 0.2% to 3% of patients develop hypersensitivity including anaphylactic shock to parenteral iron. Parenteral iron does not appear to provide a faster response than oral preparations. Only one in Saskatchewan: iron dextran Reasons for use: Renal failure Short bowel Celiac disease (sprue)

Megaloblastic (macrocytic) anemia

Due to lack of folic acid or vitamin B12 Folate (folic acid) interacts with vitamin B12. Essential for normal blood and nerve function. Can

Vitamin B12
Also called the extrinsic factor Must combine with intrinsic factor produced by the parietal glands of the stomach. The combination enables binding to receptor and phagocytosis of the complex by the distal ileum cells.

Vitamin B12
Lack of vitamin B12 is called pernicious anemia. It is usually a result of an autoimmune disease that destroys the parietal cells of the stomach. The patients also have achlorohydria which also results in halitosis.

Vitamin B12

Vitamin B12 Must be ingested is not synthesized in body Sources: Meat Eggs Dairy products

Vitamin B12
Is also present in multivitamin preparations Can also be administered by injection in pernicious anemia as cyanocobalamin.

Vitamin B12 or Folic Acid

Lack of either prevents formation of DNA so RBC production does not occur or occurs abnormally. Macrocytic cells (large cells) which may have enough Hb, but are not concave and are fewer in number. Therefore, cannot take up or transport oxygen normally. The cells are more easily damaged also contributing to the anemia

Macrocytic anemia
Note the hypersegmented neurotrophil and also that the RBC are almost as large as the lymphocyte. Finally, note that there are fewer RBCs.

Macrocytic anemia - causes

Inadequate folate intake Alcoholics Teenagers Some infants Malabsorption may be due to barbiturates, phenytoin, and oral contraceptives. Impaired metabolism may be due to methotrexate or rare enzyme deficiencies.

Folic acid therapy

Recommended natural folate sources: Green vegebables Nuts Cereal Fruit Yeast Liver but only from certain farm sources

Folic acid therapy

Folate therapeutics: Usually in multivitamin preparations Also, as folic acid, 5mg tablets.