Anaemia: Concept and

Classification
DR LAWAL OB
 Outlines
• Introduction
• definition
• Epidemiology
• Pathophysiology
• Etiology
• Clinical presentation
• Diagnosis
• Investigation
• Classification
• Treatment
• Prognosis
 Introduction
• Anaemia is defined as a decrease in red blood cell mass
with a consequent reduction in oxygen carrying capacity
of blood
• In practice, anaemia is defined as a reduction in RBCs, the
hemoglobin concentration, or packed cell volume
(haematocrit) below the lower limit of normal range for
age and sex
• Most common haematological disorder
• Almost always a secondary disorder
• As such, critical for all practitioners to know how to
evaluate / determine its cause / treat
 Definiton
• Anaemia is present when there is a decrease in
the level of Hb in the blood below the reference
level for the age and sex of the individual in that
environment.
• Also there is anemia when there are values of
hemoglobin, hematocrit or RBC counts which are
more than 2 standard deviations below the mean
• – HGB<13.5 g/dL (men) <12 g/dL (women)
• – HCT<41% (men) <36% (women)
 Epidemiology
• In the developed countries, the prevalence of
anaemia among healthy non-pregnant adult is about
4% in men and 8% in women.
• In developing countries, the prevalence of anaemia
among healthy subjects is 2-5 times greater than that
in the developed countries.
• Anaemia is twice as prevalent in females as in males.
• Certain races and ethnic groups have an increased
prevalence of genetic factors associated with certain
anaemias.
 Pathophysiology
• The mature red cell remains in circulation for about 120 days.
• Abnormalities of the membrane, the chemical composition
of the Hb, or certain glycolytic enzymes can reduce the
lifespan of RBCs sufficiently enough to cause anemia.
• At times anaemia is due decrease production rather than
shorten lifespan of red cell
• In some situation there is no problem with either lifespan or
production of red cell as in blood loss
• Frequently, two or mechanism can work tandem to cause
anaemia or one mechanism may be complicated by another
during the course of anaemia
 Etiology
• Blood loss:
– Acute: RTA, Obstetric/Gynaecological bleeding,
surgical bleeding
– Chronic: G.I & genitourinary bleeding
• Increased red cell destruction:
– Haemoglobinopathies, Enzymopathies,
Membranopathies
• Decreased red cell production:
– Nutritional anaemias, bone marrow suppression or
infiltration
 Clinical presentation
• Carefully obtain a history and perform a physical examination
on every patient with anaemia
• The anaemia may be asymptomatic
• Symptoms that may be present are non-specific or related to
heart failure.
• The clinical features of anaemia depend on a number of
factors.
– Speed of onset
– Severity
– Age
– Hb-O2 dissociation curve
• The signs may be general or specific .
• Symptoms Signs
• Fatique Pallor/ jaundice
• Headache Tachycardia
• Faintness Systolic flow mummur
• Breathlessness Cardiac failure
• Angina Retinal haemorrhage
• Int claudication Papilloedema
• Palpitation Lymphadenopathy
• Tinnitus Hepatosplenomegaly
• Pica Glossitis/mouth ulcers
 Clinical presentation
Other signs and symptoms specific to the
cause of the anaemia may be present :-
• Weakness in the lower limbs
• Leg ulceration
• Koilonychia
• Jaundice
• Lymphadenopathy
• Splenomegaly
• Body swelling
 DIAGNOSIS
• Clinical assessment
• History
• Biodata- area of res, occup, socio economic status
• Family hx of anaemia, Anaemia since childhood
• Parity and Obs hx
• Hx of bleeding
• Drugs, alcohol
• Past medical hx
• Physical examination- look for
• Signs of anaemia and clinical decompensation
• Signs of the underlying cause
• CBC:
– CBC is a series of tests used to evaluate the composition and concentration
of the various cellular components of blood
– Components: WBC, RBC, HGB, HCT, MCV, MCH, MCHC, RDW, PLT, MPV and
Differential
– Nowadays, RBC indices are computer calculated & form the basis for
classifying anaemias
• Blood film:
– The peripheral smear picture should reflect the morphological classification
generated by automated results
• Reticulocyte count:
– Used in assessing red cell generation or response to anaemia
• Specific investigations to identify the cause of anaemia are most
important
 Blood pictures
• Microcytes Basophilic stippling
• Macrocytes Rouleaux
• Dimorphic RBC Reticulocytosis
• Polychromasia Heinz bodies
• Spherocytes Howell –Jolly bodies
• Pencil/ rod RBC H bodies
• Elliptocytes Fragmented
• Teardrop Sickle cells
• Target cells Crenated cells
• Burr cells Acanthocytes
• Bite cells Leucoerythroblastic picture
• Hyposplenic blood picture Blasts
• Platelet size Activated lymphocytes
 Classification
• Generally, anaemias are classified either morphologically or according to
pathophysiological cause
• The pathophysiological approach refers to the cause of anaemias; whether
the anemia is caused by blood loss, increased RBC destruction, or decreased
production of RBCs
• However, morphological classification is the most important classification
because it gives guide to etiology and management
• Normocytic, normochromic anaemia: (MCV of 80 – 95 fl)
The causes include:
Haemolytic anaemias
Anaemia of chronic disorders (most cases)
After acute blood loss
Renal disease
Mixed deficiencies
Bone marrow failure.
• Microcytic, hypochromic anaemia: (Mcv of <
80 fl)
– Iron deficiency
– Thalassaemia
– Anaemia of chronic disorder (some cases)
– Lead poisoning
– Sideroblastic anaemia
• Macrocytic anaemia: (Mcv of >95 fl)
– Megaloblastic:
• folate or
• Vitamin B12 deficiency
– Non-megaloblastic:
• Alcohol
• liver disease
• Myelodysplasia
• aplastic anaemia
• Myxoedema
• smoking, etc
 Treatment
• Anaemia is not a diagnosis:
• It is an abnormal finding requiring an
explanation for its cause which is primary
target in the management
• Supportive not encourage and should avoided
if possible
• Definitive base on the cause
 Principle of treatment
• The management of anaemia will vary according
to the cause, time course and degree of
compensation to the anaemia
• The general principles of treatment are:-
1- Treat underlying cause
2- Optimize all the components of the O2 delivery
system to improve the O2 supply to the tissue
• Hb concentration
• Degree of saturation of Hb by O2 Cardiac output
 Treatment
- Decompensated and life threatening anaemia
need urgent intervention in the form of blood
transfusion (packed cells)
- Replacement of deficient nutrients eg Fe, vitB12,
folate
- Treatment of underlying cause in cases of ACD
and those due to infection and inflammation
- Chemotherapy in neoplasms
- Epo in CKD and SCA
 Prognosis
• Usually, the prognosis depends on the
underlying cause of the anemia
• However, the severity of the anemia and the
rapidity with which it developed can play a
significant role
• Similarly, the age of the patient and the
existence of other comorbid conditions
influence outcome
 Follow-up
• Inform patients of the etiology of their
anaemia
• Educate patients requiring periodic
transfusions about the symptoms that herald
the need for transfusion
• Likewise, they should be aware of the
potential complications of transfusion
– Haemolytic transfusion reactions
– Transmission of infectious disease