Exam 2 - Anemia

Serum MMA tests the body's vitamin B12 levels. What should the expected values of a normal person? What should be the expected values of someone with Vitamin B12 deficiency or Pernicious anemia?

A normal person would have low serum MMA because they have adequate Vitamin B12 In the case of pernicious anemia, they are Vitamin B12 deficient... Vitamin B12 metabolizes serum MMA, so.. if Vitamin B12 is low, serum MMA is high

If the patient has low H/H but normal MCV with no sign of hemolytic disorder, chronic disorder, nutritional imbalance, what should you suspect?

Active bleeding

A low H/H is indicative of __

Anemia

If a patient presents with: Low H/H Normal or Low MCV High Hepcidin High serum ferritin Low serum iron Or High serum creatinine Low Erythropoietin What might this indicate?

Anemia of chronic disease due to increased Hepcidin levels Consider CKD in the event that serum creatinine levels are high and low Epo

Normocytic anemia can occur if the __ is unable to compensate for the RBC loss

Bone marrow

If the kidneys do not secrete erythropoietin, what occurs?

Decreased RBC production

This type of test is more sensitive and specific than the Schilling's test. What is a negative consequence of the test?

More expensive

Another name for Vitamin B12 is __

Cyanocobalamin

Kidneys secrete __ which stimulate the production of RBCs in the bone marrow

Erythropoietin

If TSH is normal, what should be the next test?

Examine the bone marrow

T or F. Anemia of chronic disease is only normocytic

F - ACD is micro/normocytic

T or F. Anemia is its own diagnosis and is treated similar across the board.

F - Anemia is a non-specific manifestation of an underlying disorder

T or F. Anemia of chronic disease is only microcytic

F - Anemia of chronic disease is microcytic but can be normocytic

T or F. Intrinsic anemia is caused by the destruction of RBCs by the spleen or liver

F - Extrinsic hemolytic anemia

T or F. A decrease in hepcidin results in anemia because hepcidin blocks iron absorption in the small intestine and iron release in the bone marrow

F - Hepcidin blocks ABSORPTION of iron in small intestine and RELEASE of iron from bone marrow. A decrease in hepcidin wouldn't cause anemia as you'd have adequate iron

T or F. Serum MMA is an old test that is rarely used today but is more sensitive, specific and less expensive than the Schilling's test

F - Serum MMA is a new test and more expensive

T or F. Serum MMA (Methylmalonic acid) test is more sensitive, specific and costs the same as the Schilling's test.

F - Serum MMA is more expensive

T or F. Extrinsic anemia is caused by hereditary causes such as G6PD deficiency, Sickle cell and Thalessemia, which causes a problem with the RBC membrane

F - These are examples of intrinsic hemolytic anemia

T or F. Vitamin B12 deficiency or Folate deficiency anemia is only macrocytic

F - Vit B12 and Folate deficiency anemia can be macro or normocytic

Iron in the liver is stored as __ or __

Ferritin or Hemosiderin

__ is a carrier for hemoglobin in plasma and is synthesized by the LIVER

Haptoglobin

In regard to homocysteine levels, Vitamin B12 and Folate (Folic acid) are needed to metabolize Homocysteine. If someone is Vitamin B12 deficient or Folate deficient, what should the expected homocysteine level be?

High

Causes of Impaired Bone Marrow Function Anemia

IMCARPIT Infection Medication Chemo Aplastic anemia Radiation Pure red cell aphasia Infiltration marrow disease Toxins

If the TIBC is high, what can you say about the serum iron?

If TIBC is high, iron strongly binds to proteins, which decrease the chance of binding to transferrin, resulting in IDA

How is Iron deficiency anemia diagnosed with confidence?

Serum ferritin levels

__ is the blood's iron level

Serum iron

__ is a byproduct of normal hemoglobin metabolism

Indirect bilirubin

If a patient presents with: Low H/H Low MCV and MCHC High RDW Low serum ferritin Or Low serum iron Low transferrin saturation Normal TIBC What does this indicate? Reason with it

Iron deficiency anemia

Serum ferritin reflects the body's __

Iron stores

Adequate RBC production requires what types of vitamins/nutrients?

Iron, Vitamin B12 and Folic acid

__ is found in high amounts in the RBC and is released during tissue damage

Lactate dehydrogenase (LDH)

If the patient presents with active hemolytic anemia, what should you expect the values to be: Haptoglobin LDH Indirect bilirubin Reticulocyte count Creatinine level Ferritin level Homocysteine Coombs Test

Low Hp High LDH High IB High RC Normal creatinine (rules out kidney disease anemia) Normal ferritin and homocysteine (rules out nutritional anemia) Coombs test - normal or positive (if autoimmune)

If a patient has anemia, what can you say in regard to their oxygen content?

Low oxygen - Hypoxic - Can lead to tissue hypoxia

What are the types of microcytic, normocytic and macrocytic anemias?

Microcytic Iron deficiency anemia Thalessemia Sideroblastic anemia Anemia of chronic disease Sickle cell anemia Normocytic Anemia caused by active bleeding Anemia of chronic disease Hemolytic anemia Nutritional anemia Impaired bone marrow function Macrocytic Vitamin B12 deficiency anemia Folic acid deficiency anemia

A positive Coombs test determines that the blood is compatible/non-compatible. Why is this important?

Non-compatible A positive Coombs test (+ agglutination) signifies that the hemolytic anemia was caused by an immune reaction

If the patient has a suspected hemolytic anemia, what could be the potential results of the following tests: Peripheral blood smear Coombs Test Hgb electrophoresis Heinz body stain - what might it indicate?

PBS: Immature, uncleared RBCs Coombs: + if autoimmune Hgb electrophoresis: Thalessemia or Sickle cell (Hgb S) Heinz bodies (G6PD deficiency)

Anti-parietal cell or Anti-intrinsic factor antibodies can be found in patients who suffer from __

Pernicious anemia

This disease is an autoimmune disorder that has antibodies directed against parietal cells, which produce intrinsic factor

Pernicious anemia

__ is the most common cause of Vitamin B12 deficiency (90%)

Pernicious anemia

The common cause of Folic acid deficiency is __

Poor dietary intake

__ deliver oxygen to peripheral tissues

RBCs

RBCs are red and cellular, but what is their composition - why they are capable of carrying O2?

RBCs have hemoglobin capable of binding 1 oxygen to 1 heme

__ uses oral and injectable Vitamin B12 to measure the exception rate through urine. It determines if the stomach is producing IF required for Vitamin B12 absorption

Schilling's test

If a patient presents with: Low H/H High RBC Low Reticulocyte count Normal RDW Iron studies: normal What does this indicate?

Thalessemia

What anemic disorders are autosomal recessive?

Sickle cell and Thalessemia

If a patient presents with: Low H/H Low MCV Low MCHC Peripheral blood smear: Crescent-shaped cells Hgb electrophoresis: Hgb S What does this indicate?

Sickle cell anemia

If a patient presents with: Low H/H Low MCV Low MCHC Reports exposure to lead or lives in a building with lead paint PBS: basophillic stippling of RBC BME: Prussian blue stain reveals ringed sideroblasts What does this indicate?

Sideroblastic anemia

What type of anemia is associated with lead poisoning?

Sideroblastic anemia

Iron is absorbed in what organ and what region specifically?

Small intestine - duodenum and proximal jejunum

T or F. Extrinsic hemolytic anemia can be caused by trauma and immune mediated response

T

How do you confirm Thalessemia? How do you confirm Sideroblastic anemia?

T Hgb electrophoresis SB PBS: basophilic stippling of RBC BME: Prussian blue stain -> Ringed sideroblasts

T or F. Serum ferritin is the most specific and sensitive non-invasive iron study

T - Although, bone marrow biopsy will provide you a more specific and sensitive study, it is highly invasive

If a patient has signs of macrocytic anemia (MCV>100) but does not have signs of vitamin deficiency (Vitamin B12 or Folate), what test should be ordered?

TSH - It could be related to Hypothyroidism

What are causes of extrinsic hemolytic anemia? What are causes of intrinsic hemolytic anemia?

TTP HUS DIC Vasculitides Hypersplenism G6PD deficiency Sickle cell anemia Thalessemia

What does TIBC measure?

The amount of iron capable of binding to proteins

TIBC stands for?

Total iron binding capacity

Once iron enters the body, it binds to __ and is transferred to the __ to bind to __ and is stored in __

Transferrin Bone marrow Hemoglobin Liver - Bone marrow

__ is needed for RBC production __ is needed for RBC function

Vitamin B12 Folate

If the patient presents with: Low H/H High MCV What should you except for Vitamin B12 deficiency? Folate deficiency? Serum Vitamin B12 Serum Folate RBC Folate Methylmalonic acid (MMA) Homocysteine

Vitamin B12 Serum Vit B12: low Serum Folate: normal RBC Folate: normal MMA: High Homocysteine: High Folate Deficiency Serum Vit B12: normal Serum Folate: low RBC Folate: low MMA: normal Homocysteine: High

__ are the common causes for macrocytic anemia

Vitamin B12 and Folate deficiency

Percent transferrin saturation is defined by __

percentage of transferrin saturated (bound) with iron