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Hemoglobin hoe

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Red pigment molecule which gives RBCs (and blood) its color Contains 4 molecules of heme and 4 of globin (2 alpha chains and 2 beta chains) Each molecule of heme contains one iron ion

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Normal range of Hct pussy

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is the percent of a volume of whole blood occupied by intact red blood cells. Measured in percent. Normal range for women: 36 - 46% Normal range for men: 41 - 53%

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Normal range of HGB

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measures the concentration of hemoglobin expressed as grams of hemoglobin per deciliter (100 ml) of whole blood. Normal range for women: 12 - 16 g/dL Normal range for men: 13.5 - 17.5 g/dL

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Normal range of RBC

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count is the number of red blood cells per microliter of whole blood. Measured in millions of RBCs per microliter of whole blood. Normal range for women: 4.0 - 5.2 x106/mm3 Normal range for men: 4.5 - 5.9 x106/mm3

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Normal range of Mean Corpuscular Volume (MCV)

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is the average size of red blood cells. Normal range: 80-100 fL Low = "microcytic" ("too small") High = "macrocytic" ("too big") Normal = "normocytic" ("just right")

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Normal range of Red Cell Distribution Width (RDW)

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measures the variability in the size of red blood cells. Normal range: 11.5-14.5% On a peripheral blood smear, high RDW is described as "anisocytosis"

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Normal range of Mean Corpuscular Hemoglobin (MCH)

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is the amount of hemoglobin in an average red blood cell. Normal range: 26-34 pg/cell

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Normal range of Mean Corpuscular Hemoglobin Concentration (MCHC)

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is the average concentration of hemoglobin in an average RBC. Normal range: 31-37 g/dL "Hypochromic" = "too pale" "Normochromic" = "just right"

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Low MCV without anemia suggests

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thalassemia minor (trait)

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High MCV without anemia can be caused by

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certain medications (Dilantin, oral contraceptives, methotrexate) and is a "soft" marker of possible alcohol overuse

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If anemia is present, _____ is a useful tool to guide further testing

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MCV

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RDW is irrelevant in the absence of anemia

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BITCH

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Reticulocytes are

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"young" red blood cells that were recently released from the bone marrow. Normally, reticulocytes comprise 0.5 - 2.5% of all red blood cells.

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Normally, reticulocytes comprise

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0.5 - 2.5% of all red blood cells.

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Increased reticulocytes (reticulocytosis) is a

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normal response to blood loss or anemia. Since reticulocytes are larger, the MCV (and RDW) may be elevated.

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The combination of anemia with a low or normal reticulocyte count indicates

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that the bone marrow is unable to respond normally, either due to lack of essential ingredients (iron deficiency, vitamin B12 or folate deficiency), bone marrow disease, or chronic disease.

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WHAT IS FE??? AKA IRON!!!

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Iron: 60-170 mcg/dL (micrograms per deciliter) TIBC: 240-450 mcg/dL Transferrin saturation: 20-50% Serum Ferritin - major iron storage protein in the body Male: 12-300 ng/mL (nanograms per millilter) Female: 12-150 ng/mL

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serum folate known as....

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Folic acid and vitamin B9

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Serum folate is primarily used for

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is primarily used in the diagnosis of megaloblastic anemia.

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The reference range of the plasma folate level varies by age, as follows :

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2-20 ng/mL, or 4.5-45.3 nmol/L

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Serum cobalamin (vit B12) IS REQUIRED FOR

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normal red blood cell (RBC) formation, repair of tissues and cells, and synthesis of DNA, the genetic material in cells. B12 is essential for proper nerve function.

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Patients with serum B12 levels between ____ - ____ng/L are considered borderline and should be evaluated further by functional tests for vitamin B12 deficiency.

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150 and 400

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What is anemia

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Deficiency in the number of erythrocytes (RBCs), quantity of hemoglobin, and/or the volume of packed RBCs (Hct) Not a disease

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Main causes of anemia

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Decreased RBC production Blood Loss Increased RBC destruction

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Low MCV and Low RDW

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Thalassemia minor

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Low MCV and normal RDW

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"Thalassemia minor Anemia of chronic disease"

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Low MCV and high RDW

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iron insufficiency

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Normal RDW and normal MCV

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"Anemia of chronic disease Hereditary spherocytosis"

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Normal MCV and High RDW

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"Early deficiency of iron, B12, or folate Sickle cell anemia"

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High MCV and Normal RDW

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"Aplastic anemia Myelodysplastic syndrome"

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High MCV and high RDW

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"B12 or folate deficiency Hemolytic anemia"

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Because RBCs/Hgb transports oxygen, erythrocyte disorders can lead to

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HYPOXIA

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Mild anemia

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Mild (Hgb 10-12 g/dl)-heart palpitations, exertional dyspnea

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Moderate anemia

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Moderate (Hgb 6-10 g/dl)-increased palpitations, bounding pulse, dyspnea, fatigue

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Severe anemia

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Severe (Hgb <6 g/dl)-pallor or jaundiced skin/sclera, glossitis, tachycardia, angina, heart failure or MI, murmurs, dysrhythmias, dyspnea, headache, dizziness, irritable, impaired thought process, anorexia, weight loss, lethargy, chills

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GLOSSITIS

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Swollen tongue with a change in color

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dx of anemia

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CBC -Lower than normal RBC, Hgb, & Hct H&H - Hgb less than 10 - Hct less than 30 RBC Indices: -look at MCV (mean corpuscle volume): if low ( 96), then macrocytic -Then look at MCHC (mean corpuscle hemoglobin concentration) to determine color: if low (< 31), hypochromia exists (often with IDA Iron Deficiency Anemia)

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Lab studies for anemia

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Reticulocyte count Serum iron Serum ferritin Serum transferrin Total iron binding capacity Serum folate Serum cobalamin (vitamin B12) Serum bilirubin Coagulation studies Bone marrow aspiration Stool occult blood Stool occult blood

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Tx of anemia

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Treat underlying cause or disease state & relieve clinical manifestations Oxygen therapy Epogen/Procrit Iron replacement Vitamin replacement Blood transfusion - new guidelines for how low hemoglobin before transfusing - 6-8

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The oxygen-carrying protein heme contains iron, and gives blood its red color If iron levels are low, RBCs cannot be produced fast enough to match losses Iron-deficiency anemia is the most common form of anemia world-wide

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May be due to poor intake of iron or chronic loss of blood Blood is lost most commonly from the GI tract The most important factor to consider is - What is the cause? Possibilities include Stomach ulcers Colon cancer Vascular malformations in the GI tract Endometrial cancer Recent surgery or trauma Multiple blood donations Can be treated with iron supplements, blood transfusion and/or eradication of the cause

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Iron usage in the body

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tranferrin and ferritin

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transferrin

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A plasma protein that transports iron through the blood to the liver, spleen and bone marrow.

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ferritin

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a protein found inside cells that stores iron so your body can use it later. A ferritin test indirectly measures the amount of iron in your blood.

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S/S if iron deficiency anemia

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-Specific to IDA: ◊ Pallor ◊ Pica ◊ Glossitis (tongue) ◊ Paresthesias ◊ Cheilitis (lips) ◊ Brittle, spoon-shaped nails ◊ Headache ◊ Mental changes with IDA in elderly

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Dx IDA

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-Decreased: ◊ H & H, RBC, MCV, MCHC, MCH, iron, & ferritin -Increased: ◊ TIBC & RDW (>15%) Other tests: stool occult blood, EGD, colonoscopy

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IDA

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Correct underlying cause Supplemental oral iron + vitamin C Encourage diet in iron-rich foods Advise that iron supplements will cause changes in color of stools and can produce GI side effects Reevaluate Hgb in 3-4 wks after treatment; an increase in more than 1 g/dL indicates successful treatment. HOWEVER, should continue therapy for 4-6 more months Also evaluate ferritin level after treatment

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Nutritional therapy for IDA

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Cobalamin (Vit B12) Folic Acid (RBC maturation) Iron (Hemoglobin synthesis) Pyridoxine (Vit B6) Amino acids Ascorbic Acid (conversion of folic acid to its active forms, aids in iron absorption)

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Anemia if chronic disease

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Also known as anemia of chronic inflammation May occur in association with a wide variety of chronic diseases, especially inflammatory conditions, chronic infection, liver disease, congestive heart failure, diabetes, and cancer. Anemia is usually mild (Hgb 9-12, Hct 27-35), but can be lower in about 20% of cases. MCV is usually normal or low normal Platelets may be elevated, especially if inflammation is prominent

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Megaloblastic anemia

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A diverse group of anemias, all of which show elevated MCV on the blood count

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Megaloblastic anemia may be caused by

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May be caused by: Vitamin deficiency (usually B12 or folic acid) Alcohol intake (moderately high levels) Leukemia (WBCs would be abnormal, too) Certain medications

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Pernicious anemia

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vitamin B12 deficiency caused by an inability to absorb the vitamin from the GI tract. May cause neuropathy, weakness, or even psychiatric problems

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Pernicious anemia usually treated by

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Determining and eliminating the cause Correcting the vitamin deficiency (if any) May require injections of vitamin B12 if the cause is pernicious anemia Mortality concerns - determined by the underlying cause and severity of anemia

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Megaloblastic anemias

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Group of disorders caused by impaired DNA synthesis that produces impaired, large, premature, defective RBCs megaloblasts (due to lack of folate and B12) Macrocytic, normochromic

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Two most common forms of megaloblastic anemias

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Colbalamin (vit. B12) deficiency ◊ Folic acid deficiency

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Colbalamin (vit. B12) deficiency

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Normally intrinsic factor (IF) is secreted by the parietal cells of the gastric mucosa to aid in the absorption of vitamin B12 (which takes place in the ileum).

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When IF is not secreted, ___ is not absorbed.

answer

vit B12

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Colbalamin (vit. B12) deficiency

answer

-Pernicious anemia: autoimmune disease where gastric mucosa is not secreting IF -Gastrectomy/gastric bypass surgery -Gastritis -Nutritional deficiency -Chronic alcoholism -Intestinal malabsorption (Crohn's, celiac, or sprue diseases)

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Colbalamin (vit. B12) deficiency: Manifestations

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-Similar to those discussed earlier with general anemic manifestations -Specific to vitamin B12 deficiency: ◊ Glossitis ◊ Parasthesias ◊ Difficulty with balance/proprioception ◊ Yellow waxy pallor skin with premature greying of hair ◊ N/V/D, anorexia ◊ Headache, dizziness

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Dx of Colbalamin (vit. B12) deficiency

answer

Decreased: -H & H, RBCs, serum colbalamin, and reticulocytes may also be down Increased: -MCV Other tests: -Schilling test: Part 1: oral radiolabeled B12 + IM unlabeled vitamin B12 given to patient at same time. 24 hour urine collected. Normal result: >5% radiolabeled vit. B12 in urine. Abnormal result: <5% indicating either PA or malabsorption of Vit. B12 Part 2: Part 1 repeated + oral intrinsic factor given. If second urine collection normal → shows lack of IF and therefore PA. If still a low result of radiolabled vit B12, then malabsorption disease (celiac, sprue, crohn's, etc.)

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Schilling test for pernicious anemia

answer

Many false pos and neg results Not commonly used Not readily available in many places Less sensitive test checking HC and MMA to detect B-12 def. Only recommended when anti-IF antibodies are normal.

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Tx of pernicious anemia

answer

IM B-12 at 1000 mcg daily for one week, then 1000 mcg weekly for one month, then 1000 mcg every month for one year - indefinitely. No harm in "overtreatment." Inexpensive, non-toxic and excess is excreted in urine.

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