aE UkeReLC eee LO LPL sy si + Anemas area group of diseases characterined by 2 decreate in hemoglobin (HB) oF fed blood cell (REC, ressiting in decreased oxygen carping capacity of blood ‘The World Health Organiation defines anemia ar Hb lee than 13 g/L (e130 gts 807 mrs) sn men oles than 12 gla. (e120 gf <7 45 mmol sn women need ‘The fanctional dasifction of anemias i found im Fig. 33-1. The mat common amis ate included inthis apt, + Morphologie cauieaions are bused on cll alae. Macrcytc cells are lager tha normal and ae atociated wth defcencis of wtamin Bor fe aid. Mlcroeyie fells ae smaller than normal and ae associated wth oh deficiency whereas nor ‘moeyse anemia may be associated wih recent Blood loss of chrone disease + Ton deficiency anemia (IDA) canbe caused by inadequate dtary intake, adequate {strointentnal (GI) absorption. increased ron demand (e,pregaany), blood loss, nd chronic dzeses + Vitamin 8, and folic ackd-deficiency anemia can be cased by inadequate dctry lotake, detcased aioeption, and inadequate ullzation Deficiency of tens factor causes decreased absorption of wlamin B, (le, penicious anemia). Folie aid-defcency anemia canbe eatsed by hyperutiationdve to pregnancy hemo Iytc anemia, myelofibrosis, maligsancy chronic inlamsmatry disorders, ong tera dlls or growth spurt Drugs can cause anemia by seducing absorption of fla (ct. phenytoin) or through ft antagonism eg, methotreate) ‘Anemia of inflammation (AD) is2 newer term wed to deserve both anemia of ‘chronic disease and anemia of crcl nes. AT & bypopeliferative anemia thet teadiionlly has been avocited wih infecous or infammatory proceses, tase Injury. and conditions associated with release of proinflammatory cytokines. See “Table 33-1 for diate sroiated orth AI For information on anemia of chronic kidney disease, See Chap. 74 + Ageelated seductons in bone marrow reserve Can render eldely patents mote ovepble to snemia caused by multiple minor and often unrecognized disease le ‘tntional deficiencies) that negative affect erythropoiesis. + Pediatrie anemias are often due toa primary bematelogie abnormality. The ssk of IDA i incensed by rapid growth spurts and etary defienc eee se a em nd on dome cr aire Ae sca cet Seah re chen rs es ccc by en es hes Seen eee nn set ay tn a oA Ser yf a i a sy ou es Se ramen ee nth ama SOEEASS pitte aa ne cae ast soSECTION? | HemotalogicDsorers Anemia Hemorthagel hemolysis Cytoplasmic detects Blood loss non detctoney “Thalassemia | intravascular Ls ptnuaton ion seteaney | "hematysie “Renal disease | Sieroiaste “Iatemmaton' ‘Autoimmune sisease Metab ds Nuclear maturation Getect, Hemoslobinepathy Folate dteieney Ste ceteteney | Metabotcimembrane Ratrzctoy anemia defect FIGURE 33-1. Functional classification of anemia. Each ofthe major categories ‘of anema thysoprelferative maturation gorders ne hemorrmage/hemalyss con be ‘ter subclsied according tone functional defect in he sever components of normal enthronoess METS ois cognition ‘Common causer ane nections “berlore ‘the conc ung fection eg, ung abscess bronchiectasis) Human immanedefency vit Suosste tata endocarass atom Coron way act nectons crore afarmation heumatderint Sistem lupus eythematesus Infantry oe! sea Infirmary ones Goa (the eoagen asc) dass Gorone afar ier dees aignances ‘inom lymshama teri tole myeloma Less common causes ‘shale nerdsesse Congest ea fare Twombophiebis Crone obstructive slmonay disease Isher net ase 302Anemias | 33 ses inpaient ay alao occur with ite 8 deiceny. Anemia wih flat Aeficieney snot aetocnte with neurologic or peyhinie symptom Eres ‘Rapid diagnos i exvental because anemia often a ign of undeting pathology. ‘Initial easton of anemia volver a complete Mlood al count (CHC), reseuloeye index snd examination ofthe sol for acct Blood. Fiore 33-2 shows abrond, general algorithm forthe agnosis of anemia based on laboratory data. + Thecatis and most senate laboratory change for IDA is decreased serum esta (storage ron), which shouldbe interpreted i conjunction with decresed tanaerin saturation and inerested total ion-binding epacty (TIBC). Hb, hematocrit He), ‘nd RBC indices usually remain normal ust later sages of IDA, ‘sg macrocyte anemia, mean corpuscular volume usually devsted to greater than 100 1. Wamin Band flte concentrations can be mearured to diferent ie berween the two deficiency anemias. A vitamin B, vale les than 150 peal. (cit pelt, rogether with appropiate peripheral smear and cinial symptoms, Aisgovte of vitamin B, ~defcency anemia A decteared RBC folate concentration (250 agit. [340 aml) appears lo bea beter indicator of flse defcency seria than a decreased ser folate concenteation (3 ngimt. <7 nmol), Tae any tie) it . = seipitee]) (Ett) | as] Soe oy FIGURE:3-2. General algorithm for dagnoss of anemia. (decreased MOY mean | ‘corpuscular volume; 2c, oar bining capaci, WBC, white blond eas) 308SECTONT | Hematologic Disorders 1 he diagnose of Al ss unally one of excision, with consideration of coexisting iton and folate deficiencies. Serum ron is usually deceased, but unlike IDA, serum ferian is normal or inctesed. and TIBC is decreased. The bone marrow revels an sundance of on; the peripheral smear revs normocytc anemia 4 Hey patient th symptoms of anemia should undergo 2 CBC with peripheral smear and reiclocyte count and other Inborstory sii a needed to determine the tology of anemia. «The diagnts of anes in peditrle populations requires we of age- and gender djsted aorme for laboratory values, ioe + Goaleof Teatment The goals ate to alleviate signs and symptoms, conc the undesiang euology (eg, restore substzates neded for BBC production), replace body ores and prevent ecurence of anemia Uc ‘Oral iron sherapy with soluble ferrous iron sas, which are not enteric coted and ‘ot dlow- er sustulned-rlas,tstecommended a daly dosage of 200mg eletental ston in two or three divided doves Table 33-2) ‘on is pooti absorbed fom vegetables, grain products dairy product, and eggs, ad best absotbed rom mea fish and poultry Administer won atleast 1 hour bere ‘eas because ood interferes wit dbsorpion, but admiration wih food may be needed to improve tolerability + Consider parenteral iron fr patients with iron malabsorption intolerance of oral lon therapy or aoncompllance Parenteral administration, however doesnot hasten the onset of eteatelogi esponse,Thereplacernent dove depends onthe tlogy of anemia and Hb conceteaton (Table 33-3) ‘Iron destran, sodium ferric gluconate, erumoxyto, an iron sucrose are avaiable puresteral on preparation with sila efcacy bu diferent molecular se, phar facolinetiy, Mosralablty, and adverse effect roles (Table 33-4). PE + Oral vitamin B,, supplementation appears to be as efletive as parenteral. even in| pulents with peinicous anemia, because the aerate vitamin B,, absorption path tery is independent of ence factor Inte oral cobalamin at 102mg daly for | to? weeks flowed by 1 mg daly + Parenteral therapy acs more rpily than oral therapy and is recommended if nes rologie symptoms ae present A popular regimen is 1M eyanocobalamin 100 mcg Em OalrenProdcs ron Salt Percent Elemental ron Ferou uae 20 60-65 mg/324325 mg able Somgism syrup 44/5 el ISmg/i mL Ferous ste 0 165 mg/200g wl. (ewes) So mg/iso mg ale Feros leonate 2 38 ng325 mg taset 20-28 mg/240-245 mg tablet Ferousumsrte a (6 mg/200 mg ble osmgia24- 5g wet 308