Gao Qingping

1
Anemia
Gao Qingping Department of Hematology
Renmin Hospital of Wuhan University
2
Renmin Hospital of Wuhan University
3

• ??Overview

4

• 1?Definition

5
Anemia is defined as a reduction in one or
more of the major RBC measurements Hb
(hemoglobin concentration) Hct
(hematocrit) or RBC (red blood cells count)
6
anemia is a symptom of underlying
disorders and is characterized by a lower than
normal hemoglobin value or a low red cell count
or low hematocrit
7
Hemoglobin (Hb) ,hematocrit
(Hct) or red blood cells count (RBC) is below the
normal range for age and sex
8

• ??????????????,??????????????????(?)
• ???????????????????,??????(?)???????????,?????????
  ?
• ??????

9
Normal Blood
10

• 2?Criteria of Diagnosis

11

• Adults
• Hblt120g/L in males
• Hblt110g/L in females
• Hblt100g/L in maternals

12

• Children
• Hblt145g/L in babies 9d
• Hblt100g/L in babies 5m
• Hblt110g/L in babies infants 5y
• Hblt120g/L in children 14y

13

• 3?Factors of Affecting Anemia

14

• (1)increased plasma volume

• increased plasma volume (relative anemia)
• seen in pregnancy, hypoproteinemia,
  congestive heart failure, splenomegaly,
  macroglobulinemia
• increasing plasma volume make blood
  dilution,the concentration of hemoglobin is
  decreased

15

• (2)decreased plasma volume

• (2)decreased plasma volume (Dehydration and The
  blood loss )bring about hemoconcentration,the
  concentration of hemoglobin is decreased

16

• ? ?Classification of Anemia

17

• Classified according to
• progress
• erythrocyte morphological features
• the hemoglobin concentration
• degree of erythropoietic proliferation
• Etiology and pathogenesis

18

• (?)Classified According to Progress

19

• acute
• Sever aplastic anemia, acute hemolysis, Acute
  Hemorrhage
• chronic
• Iron deficient anemia, Not-severe aplastic
  anemia, chronic hemolysis, and chronic blood loss

20

• (?)Classified According to
• Erythrocyte Morphology

21

• In the morphological approach, anemia is
  classified by the size of red blood cells this
  is either done automatically or on microscopic
  examination of a peripheral blood smear

22

• The size is reflected in the mean
  corpuscular volume (MCV). If the cells are
  smaller than normal (under 80 fl), the anemia is
  said to be microcytic if they are normal size
  (80-100 fl), normocytic and if they are larger
  than normal (over 100 fl), the anemia is
  classified as macrocytic

23

• This scheme quickly exposes some of the
  most common causes of anemia for instance, a
  microcytic anemia is often the result of iron
  deficiency

24

• In clinical workup, the MCV will be one
  of the first pieces of information available so
  even among clinicians who consider the "kinetic"
  approach more useful philosophically, morphology
  will remain an important element of
  classification and diagnosis

25
Types MCV (fl) MCH (pg) MCHC (g/L) example
Macrocytic gt100 gt32 310-350 Megaloblastic, HA,MDS,Liver
Normocytic 80-100 26-32 310-350 AA,PRCA,HA
Microcytic lt80 lt26 310-350 Anemia of chronic disease
hypochromic microcytic lt80 lt26 lt310 IDA,MDS-RS, thalassemia
MCV mean corpuscular volume MCH mean
corpuscular hemoglobin MCHC mean corpuscular
hemoglobin concentration
26

• The Criterion of Classified According to
  Erythrocyte Morphology(2007)

Criterion MCV (fl) MCH (pg) MCHC (g/L) example
Macrocytic gt100 gt34 320-360 Megaloblastic, HA,MDS,Liver
Normocytic 80-100 27-34 320-360 AA,PRCA,HA
Microcytic lt80 lt27 320-360 Anemia of chronic disease
hypochromic microcytic lt80 lt27 lt320 IDA,MDS-RS, thalassemia
27
Normocytic
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
28
Hypochromic Microcytic
The RBCs 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)
29
Microcytic
the average size of erythrocytes is smaller than
normal
30
Macrocytic
Note the hypersegmented neurotrophil and also
that the RBC are almost as large as the
lymphocyte. Finally, note that there are fewer
RBCs.
31

• (?)Classified According to
• the Hemoglobin Concentration

32
mild 90g/L moderate
60-89g/L sever
30-59g/L extremely severe lt30g/L
33

• (?)Classified According to
• Degree of Erythropoietic Proliferation

34
hyperplastic anemia other anemia except
AA
and MA hypoplastic anemia
AA megaloblastic anemia
MA
35

• (?)Classified According to
• Etiology and Pathogenesis

36

• The "kinetic" approach to anemia yields
  what many argue is the most clinically relevant
  classification of anemia

37

• This classification depends on evaluation
  of several hematological parameters, particularly
  the blood reticulocyte (precursor of mature RBCs)
  count

38

• This then yields the classification of
  defects by decreased RBC production versus
  increased RBC destruction and/or loss

39

• Clinical signs of loss or destruction
  include abnormal peripheral blood smear with
  signs of hemolysis elevated LDH suggesting cell
  destruction or clinical signs of bleeding, such
  as guiaic-positive stool, radiographic findings,
  or frank bleeding

40

• 1?Decreased Production of RBCs

41
Erythropoiesis depended on
three kinds of factors 1.hematopoietic cells
HSC HPC BFU-E CFU-E RBC 2.hematopoietic
regulatory SSC Lym HGF(SCF IL
G(M)- CSF Epo Tpo TNF
IFN) 3.hematopoietic elements Protein, Lipid,
Vitamin, Mineral
42
Natural Killer cell(NK)
Hematopoiesis
T-cells
Eosinophil
Basophil
Lymphoid progenitor
B-cells
Neutrophil
femur
M-Mf
Hematopoietic Stem Cell(HSC)
Myeloid progenitor
Multipotential Stem cell
Platelets
RBC
Hematopoietic Support cell
Osteoblast
Pre-osteoblast
adipocyte
Osteocyte
Stromal Stem Cell
43
The life cycle of a RBC a) Kidneys respond to a
lower than normal oxygen concentration in the
blood by releasing erythropoietin(Epo) b) Epo
travels to the red bone marrow(RBM) and
stimulates an increase in the production of red
blood cells (RBCs) c) RBM manufactures RBCs from
stem cells that live inside the marrow d) RBCs
squeeze through blood vessel membranes to enter
the circulation e) The heart and lungs work to
supply continuous movement and oxygenation of
RBCs f) The old RBCs are destroyed primarily by
the spleen
f
a
e
b
d
c
The RBC lifetime is about 120 days
44
The pictures shown the cells of
BFU-E (day 3), CFU-E (day 7), immature
erythroblast (day 11) and mature erythroblast
(day 15) in culture in vitro. Cells were stained
by the Romanowski water-based adaptation of
Wright-Giemsa
45

• Erythropoiesis is the development of
  mature red blood cells (erythrocytes)
• Like all blood cells, erythroid cells
  begin as pluripotential stem cells

46

• The earliest erythroid progenitor, the
  BFU-E (burst forming unit-erythroid), is small
  and without distinguishing histologic
  characteristics
• The stage after the BFU-E is the CFU-E
  (colony forming unit-erythroid) which is larger
  and is the stage right before hemoglobin
  production begins

47

• The first cell that is recognizable as
  specifically leading down the red cell pathway is
  the proerythroblast

48

• As development progresses, the
  nucleus becomes smaller and the cytoplasm becomes
  more basophilic, due to the presence of
  ribosomes. In this stage the cell is called a
  basophilic erythroblast

49

• The cell will continue to become smaller
  throughout development
• As the cell begins to produce
  hemoglobin, the cytoplasm attracts both basic and
  eosin stains, and is called a polychromatophilic
  erythroblast

50

• The cytoplasm eventually becomes more
  eosinophilic, and the cell is called an
  orthochromatic erythroblast

51

• This orthochromatic erythroblast will
  then extrude its nucleus and enter the
  circulation as a reticulocyte
• Reticulocytes are so named because
  these cells contain reticular networks of
  polyribosomes

52

• They become mature red blood cells as
  reticulocytes loose their polyribosomes

53

• (1)Stem-Cell Failure

54

• A. Multipotential stem cells failure
• a. Aplastic anemia
• b. Anemia of leukemia
• c. Anemia of myelodysplastic syndrome

55

• B. Unipotential stem cells failure
• a. Pure red cell aplasia
• b. Anemia of renal failure
• c. Anemia of chronic disorders
• d. Anemia of endocrine disorders

56

• (2)Abnormal Regulation of Hematopoiesis

• Damaged bone marrow stromal cells
• bone marrow necrosis and
  myelofibrosis
• Abnormal function of lymphocytes
  
• T(apoptosis)
• B(immune damage)
• Abnormal hematopoietic regulatory factor
• Epo? TNF? IFN?
• Increased hematopoietic cell apoptosis PNH

57

• (3)Hematopoietic Elements Deficiency

• Folate and Vit B12 deficiency
• Iron deficiency and utilization obstacle
• IDA
• MDS-RAS RCMD-RAS

58

• 2?Excessive Destruction of RBCs

59
Hereditary Acquired
Membrane defects immunological(AIHA, blood group incompatibility)
Hemoglobin defects Angiopathic (Valvular Disease of Heart ,TTP,DIC, March hemoglobinuria)
Enzyne defects Biological (Venom, malaria)
physical and chemical factors (burns, The Change of plasma osmotic pressure , nitrite poisoning)
60

• 3?Blood Loss

61

• Hemorrhagic disorders
• (ITP, Hemophillia,
• Live disease)
• Non-hemorrhagic disorders
• (injury, tumor,
• bronchiectasis,
• cankerulcer)

62
                    Anemia Anemia Anemia Anemia Anemia Anemia Anemia Anemia Anemia Anemia Anemia Anemia Anemia Anemia Anemia Anemia            
                                                       
                                                   
          Ret(?) shows inadequate production response to anemia         Ret(?) shows inadequate production response to anemia         Ret(?) shows inadequate production response to anemia         Ret(?) shows inadequate production response to anemia         Ret(?) shows inadequate production response to anemia         Ret(?) shows inadequate production response to anemia         Ret(?) shows inadequate production response to anemia         Ret(?) shows inadequate production response to anemia         Ret(?) shows inadequate production response to anemia         Ret(?) shows inadequate production response to anemia         Ret(?) shows inadequate production response to anemia         Ret(?) shows inadequate production response to anemia         Ret(?) shows inadequate production response to anemia         Ret(?) shows inadequate production response to anemia         Ret(?) shows inadequate production response to anemia       Ret(?)shows appropriate response to anemiaongoing hemolysis or blood loss without RBC production problem     Ret(?)shows appropriate response to anemiaongoing hemolysis or blood loss without RBC production problem     Ret(?)shows appropriate response to anemiaongoing hemolysis or blood loss without RBC production problem     Ret(?)shows appropriate response to anemiaongoing hemolysis or blood loss without RBC production problem     Ret(?)shows appropriate response to anemiaongoing hemolysis or blood loss without RBC production problem     Ret(?)shows appropriate response to anemiaongoing hemolysis or blood loss without RBC production problem     Ret(?)shows appropriate response to anemiaongoing hemolysis or blood loss without RBC production problem     Ret(?)shows appropriate response to anemiaongoing hemolysis or blood loss without RBC production problem     Ret(?)shows appropriate response to anemiaongoing hemolysis or blood loss without RBC production problem     Ret(?)shows appropriate response to anemiaongoing hemolysis or blood loss without RBC production problem     Ret(?)shows appropriate response to anemiaongoing hemolysis or blood loss without RBC production problem     Ret(?)shows appropriate response to anemiaongoing hemolysis or blood loss without RBC production problem     Ret(?)shows appropriate response to anemiaongoing hemolysis or blood loss without RBC production problem     Ret(?)shows appropriate response to anemiaongoing hemolysis or blood loss without RBC production problem     Ret(?)shows appropriate response to anemiaongoing hemolysis or blood loss without RBC production problem     Ret(?)shows appropriate response to anemiaongoing hemolysis or blood loss without RBC production problem
                                                       
                                                         
  No clinical findings consistent with hemolysis or blood loss pure disorder of production No clinical findings consistent with hemolysis or blood loss pure disorder of production No clinical findings consistent with hemolysis or blood loss pure disorder of production No clinical findings consistent with hemolysis or blood loss pure disorder of production No clinical findings consistent with hemolysis or blood loss pure disorder of production No clinical findings consistent with hemolysis or blood loss pure disorder of production No clinical findings consistent with hemolysis or blood loss pure disorder of production Clinical findings and abnormal MCV hemolysis or loss and chronic disorder of production   Clinical findings and abnormal MCV hemolysis or loss and chronic disorder of production   Clinical findings and abnormal MCV hemolysis or loss and chronic disorder of production   Clinical findings and abnormal MCV hemolysis or loss and chronic disorder of production   Clinical findings and abnormal MCV hemolysis or loss and chronic disorder of production   Clinical findings and abnormal MCV hemolysis or loss and chronic disorder of production   Clinical findings and abnormal MCV hemolysis or loss and chronic disorder of production   Clinical findings and abnormal MCV hemolysis or loss and chronic disorder of production   Clinical findings and abnormal MCV hemolysis or loss and chronic disorder of production   Clinical findings and abnormal MCV hemolysis or loss and chronic disorder of production   Clinical findings and abnormal MCV hemolysis or loss and chronic disorder of production   Clinical findings and abnormal MCV hemolysis or loss and chronic disorder of production   Clinical findings and abnormal MCV hemolysis or loss and chronic disorder of production   Clinical findings and abnormal MCV hemolysis or loss and chronic disorder of production   Clinical findings and abnormal MCV hemolysis or loss and chronic disorder of production   Clinical findings and normal MCV acute hemolysis or loss without adequate time for bone marrow production to compensate Clinical findings and normal MCV acute hemolysis or loss without adequate time for bone marrow production to compensate Clinical findings and normal MCV acute hemolysis or loss without adequate time for bone marrow production to compensate Clinical findings and normal MCV acute hemolysis or loss without adequate time for bone marrow production to compensate Clinical findings and normal MCV acute hemolysis or loss without adequate time for bone marrow production to compensate Clinical findings and normal MCV acute hemolysis or loss without adequate time for bone marrow production to compensate Clinical findings and normal MCV acute hemolysis or loss without adequate time for bone marrow production to compensate Clinical findings and normal MCV acute hemolysis or loss without adequate time for bone marrow production to compensate
  No clinical findings consistent with hemolysis or blood loss pure disorder of production No clinical findings consistent with hemolysis or blood loss pure disorder of production No clinical findings consistent with hemolysis or blood loss pure disorder of production No clinical findings consistent with hemolysis or blood loss pure disorder of production No clinical findings consistent with hemolysis or blood loss pure disorder of production No clinical findings consistent with hemolysis or blood loss pure disorder of production No clinical findings consistent with hemolysis or blood loss pure disorder of production Clinical findings and abnormal MCV hemolysis or loss and chronic disorder of production   Clinical findings and abnormal MCV hemolysis or loss and chronic disorder of production   Clinical findings and abnormal MCV hemolysis or loss and chronic disorder of production   Clinical findings and abnormal MCV hemolysis or loss and chronic disorder of production   Clinical findings and abnormal MCV hemolysis or loss and chronic disorder of production   Clinical findings and abnormal MCV hemolysis or loss and chronic disorder of production   Clinical findings and abnormal MCV hemolysis or loss and chronic disorder of production   Clinical findings and abnormal MCV hemolysis or loss and chronic disorder of production   Clinical findings and abnormal MCV hemolysis or loss and chronic disorder of production   Clinical findings and abnormal MCV hemolysis or loss and chronic disorder of production   Clinical findings and abnormal MCV hemolysis or loss and chronic disorder of production   Clinical findings and abnormal MCV hemolysis or loss and chronic disorder of production   Clinical findings and abnormal MCV hemolysis or loss and chronic disorder of production   Clinical findings and abnormal MCV hemolysis or loss and chronic disorder of production   Clinical findings and abnormal MCV hemolysis or loss and chronic disorder of production   Clinical findings and normal MCV acute hemolysis or loss without adequate time for bone marrow production to compensate Clinical findings and normal MCV acute hemolysis or loss without adequate time for bone marrow production to compensate Clinical findings and normal MCV acute hemolysis or loss without adequate time for bone marrow production to compensate Clinical findings and normal MCV acute hemolysis or loss without adequate time for bone marrow production to compensate Clinical findings and normal MCV acute hemolysis or loss without adequate time for bone marrow production to compensate Clinical findings and normal MCV acute hemolysis or loss without adequate time for bone marrow production to compensate Clinical findings and normal MCV acute hemolysis or loss without adequate time for bone marrow production to compensate Clinical findings and normal MCV acute hemolysis or loss without adequate time for bone marrow production to compensate
                                                 
                                         
Macrocytic anemia (MCVgt100)  Macrocytic anemia (MCVgt100)  Macrocytic anemia (MCVgt100)  Macrocytic anemia (MCVgt100)  Macrocytic anemia (MCVgt100)  Macrocytic anemia (MCVgt100)  Macrocytic anemia (MCVgt100)  Normocytic anemia (80ltMCVlt100) Normocytic anemia (80ltMCVlt100) Normocytic anemia (80ltMCVlt100) Normocytic anemia (80ltMCVlt100) Normocytic anemia (80ltMCVlt100) Normocytic anemia (80ltMCVlt100) Normocytic anemia (80ltMCVlt100) Normocytic anemia (80ltMCVlt100) Normocytic anemia (80ltMCVlt100) Normocytic anemia (80ltMCVlt100) Normocytic anemia (80ltMCVlt100) Normocytic anemia (80ltMCVlt100) Normocytic anemia (80ltMCVlt100) Normocytic anemia (80ltMCVlt100) Normocytic anemia (80ltMCVlt100) Normocytic anemia (80ltMCVlt100) Normocytic anemia (80ltMCVlt100) Normocytic anemia (80ltMCVlt100) Microcytic Anemia (MCVlt80)  Microcytic Anemia (MCVlt80)  Microcytic Anemia (MCVlt80)  Microcytic Anemia (MCVlt80)  Microcytic Anemia (MCVlt80)   
63

• ??Pathphysiology

64

• (?)Decreased Oxygen Consumption

The activation of genes coding for
glycolytic enzynes wiil save oxygen but at the
expense of using less-efficient metabolic pathways
65

• (?) Decreased Oxygen Affinity

The earliest and least costly adjustment
of oxygen delivery This permits
increased oxygen extraction without jeopardizing
oxygen pressure The red cells generate
increased amounts of 2,3-bisphosphoglycerate
66

• (?)Increased Tissue Perfusion

Performed selectively with blood shunted
from presumably nonvital donor areas to
oxygen-sensitive recipient organ
67

• (?)Increased Cardiac Output

To decrease the fraction of oxygen that
needs to be extracted during each circulation and
thereby keep the oxygen pressure high To
bring out tachycardia, increased arterial and
capillary pulsation, and many hemodynamic murmurs
68

• (?)Increased Pulmonary Function

Exertional dyspnea and orthopnea are
characteristic clinical manifestations of severe
anemia
69

• (?)Increased Red Cell Production

The most appropriate response to anemia
is a compensatory increase in the rate of red
cell production In anemia this may reach
6 to 10 times normal and is powered by an
increased synthesis of renal erythropoietin
70

• (?)Uncorrected Tissue Hypoxia

Some of this contributes the necessary
driving force to sustain cardiovascular and
erythropoietic adjustments But tissue hypoxia
per se (itself) cause disturbing and even
disabling symptoms
71

• ??Clinical Manifestation

72

• Clinical manifestation depends on
• Etiology of anemia
• The degree of delining of oxygen carrying
  capacity in blood which caused by anemia
• The degree of the decrease of blood volume in
  patients with anemia
• The rate of resulting in anemia
• The capacity of compensation and resistance of
  hematology, circulation and respiratory system to
  anemia

73

• Nervous System

• Presentation
• dizzy ,headache, vertigo, syncope,
  tinnitus, sleepiness, insomnia, dreaminess,
  hypomnesia, inattention, dysphoria(???????????????
  ??????????? ????????????)
• Causes
• brain anoxia
• hypovolemia or blood pressure drop
• hyperbilirubinemia or increasing of free
  hemoglobin
• complication for patients with anemia
  neuritis

74

• Mucocutaneous

• Presentation
• pallor, roughness, jaundice, ulcer
• Causes
• blood redistribution
• Folacin, VitB12,and iron deficiency
• Autoimmunity
• hemolysis

75

• Respiratory System

• Presentation
• dyspnoea and orthopnea
• ???????
• Causes
• hypoxia

76

• Circulatory System

• Presentation
• palpitation and tachycardia
• ???????
• Causes
• anemia
• hemochromatosis

77

• Digestive System

• Presentation
• anorexia, nausea, vomiring, abdominal
  distension , cholelithiasis,
• sense of eyewinker in swallowing, glossitis,
  mirror-like tongue
• ?????????????????? ????????????
• Causes
• reduction of digestive fluid
• hemolysis
• iron deficiency
• Folacin, or VitB12 deficiency

78

• Urinary System

• Presentation
• oliguria or anuria?????
• bilirubinuria, high uro-bilinogen,
  hematuria and proteinuria
• Causes
• hemolysis
• TTP and HUS
• AA
• MM
• hypovolemia that hemorrhage cauces

79

• Endocrine System

• Presentation
• endocrine dyscrasia???????
• Causes
• Sheehanssyndrome
• hypothyroidism
• hypogonadism
• hypoadrenalism
• decrudescence of pancreatic function

80

• Reproductive System

• Presentation
• weakened male characteristics
• increasing or decreased amount of
  menstruation??????????????
• hypaphrodisia????
• don juanism??????
• masculinization?????
• Causes
• anemia
• treatment of androgen

81

• Immune System

• Presentation
• immunologic decline
• Causes
• effect of anemia on immune function
• immune resulting in anemia
• inhibition of drug on immune function

82

• Hematopoietic System

• Presentation
• Change of blood cell number
• Morphologic Changes of Blood Cells
• Changes of blood cells biochemistry
  
• Abnormal plasma component (M protain,
  Free hemoglobin, hyperbilirubinemia , electrolyte
  disturbance, Abnormal Coagulation and
  Fibrinolysis System )
• Causes
• Etiopathogenisis of anemia
• Complication(hypersplenia?DIC?drugs)

83

• ??Diagnosis

84

• To understand the degree, type and
  etiology of anemia
• 1 ask disease history in detail
• 2 careful medical examination
• 3 correlated laboratory tests

85

• (?)Inquiring History

86

• 1 History of Present Illness

• occurrence time of fatigue
• Cause and Inducement
• rate of occurrence
• accompany symptoms
• diagnosis and treatment
• time and therapeutic effects
• outcome of anemia

87

• 2 Past History

• drug history
• occupational exposure
• exposed to special chemical substance
• hemorrhage history
• chronic disease history

88

• 3 Family History

• History of anemia in grandparents, parents and
  children

89

• 4 Nutrition

• dietary constitution
• diet habit
• food preference
• With ot without digestive tract disease

90

• 5 Menstrual and Reproductive History

• increasing amount of menstruation
• severe postpartum hemorrhage

91

• (?)Medical Examination

• Mucocutaneous color
• Scleral color????
• lymph node
• sternal tenderness????
• hepatosplenomegaly
• Other system

92

• (?) Laboratory Tests

93

• 1?Blood Routine

94

• Generally, clinicians request complete
  blood counts in the first batch of blood tests in
  the diagnosis of an anemia

95

• Apart from reporting the number of red
  blood cells and the hemoglobin level, the
  automatic counters also measure the size of the
  red blood cells by flow cytometry, which is an
  important tool in distinguishing between the
  causes of anemia

96

• 2?Blood smear

97

• Examination of a stained blood smear
  using a microscope can also be helpful, and is
  sometimes a necessity in regions of the world
  where automated analysis is less accessible

98

• 3?Reticulocyte

99

• Reticulocyte counts, and the "kinetic"
  approach to anemia, have become more common than
  in the past in the large medical centers, in part
  because some automatic counters now have the
  capacity to include reticulocyte counts

100

• A reticulocyte count is a quantitative
  measure of the bone marrow's production of new
  red blood cells. The reticulocyte production
  index is a calculation of the ratio between the
  level of anemia and the extent to which the
  reticulocyte count has risen in response

101

• Reticulocyte Production Index is
  calculated as follows
• Ret IndexRet Count(hematocrit/normal
  hematocrit)
• A value of 45 is usually used as a normal
  hematocrit

102

• If the degree of anemia is significant,
  even a "normal" reticulocyte count actually may
  reflect an inadequate response

103

• 4?bone marrow

104

• In manual examination, activity of the
  bone marrow can also be gauged qualitatively by
  subtle changes in the numbers and the morphology
  of young RBCs by examination under a microscope

105

• Newly formed RBCs are usually slightly
  larger than older RBCs and show polychromasia.
  Even where the source of blood loss is obvious,
  evaluation of erythropoiesis can help assess
  whether the bone marrow will be able to
  compensate for the loss, and at what rate

106

• 5? other tests

107
RBC production RBC destruction RBC Loss
Ferritin osmotic fragility test Stool-ROB
Serum iron methemoglobin reduction test Urine-R
Transferrin Coombs test
Folate Free hemoglobin
Vit B12 haptoglobin
Hb electrophoresis autohemolysis test
Liver function CD55,CD59
Renal function Urine-R
Chest X rays Urine-Rous test
Abdomenal CT Hb electrophoresis
Bone marrow Bone marrow
Hemosiderin X rays, CT
108

• ??Treatment

109

• Etiological Treatment
• Therapy Against Pathogenesis
• Symptomatic Treatment

110

• (?)Etiological Treatment

• To treat primary disease

111

• (?) Therapy Against Pathogenesis

• Supply hemopoietic elements
• Immunosuppressive therapy
• Application of hemopoietic growth factor
• Splenectomy
• Chemoradiotherapy
• Hemopoietic stem cell transplantation

112

• 1? Iron deficiency anemia

113
Iron deficiency anemia

• This form of anemia is treated with iron
  supplements, which you may need to take for
  several months or longer. If the underlying cause
  of iron deficiency is loss of blood other than
  from menstruation the source of the bleeding
  must be located and stopped. This may involve
  surgery

114

• 2? Vitamin deficiency anemias

115
Vitamin deficiency anemias

• Pernicious anemia is treated with
  injections often lifetime injections of
  vitamin B-12
• Folic acid deficiency anemia is treated
  with folic acid supplements

116

• 3? Anemia of chronic disease

117
Anemia of chronic disease

• There's no specific treatment for this
  type of anemia. Doctors focus on treating the
  underlying disease. Iron supplements and vitamins
  generally don't help this type of anemia

118
Anemia of chronic disease

• If symptoms become severe, a blood
  transfusion or injections of synthetic
  erythropoietin, a hormone normally produced by
  the kidneys, may help stimulate red blood cell
  production and ease fatigue

119

• 4? Aplastic anemia

120
Aplastic anemia

• Treatment for this serious anemia may include
  blood transfusions to boost(??) levels of red
  blood cells. You may need a bone marrow
  transplant if your bone marrow is diseased and
  can't make healthy blood cells

121
Aplastic anemia

• You may need immune-suppressing medications to
  lessen your immune system's response and give the
  transplanted bone marrow a chance to start
  functioning again

122

• 5? Anemias associated with bone marrow disease

123
Anemias associated with bone marrow disease

• Treatment of these various diseases can
  range from simple medication to chemotherapy to
  bone marrow transplantation. Treatment of these
  types of anemia usually involves a consultation
  from a blood specialist (hematologist)

124

• 6? Hemolytic anemias

125
Hemolytic anemias

• Managing hemolytic anemias includes
  avoiding suspect medications, treating related
  infections and taking drugs that suppress your
  immune system, which may be attacking your red
  blood cells

126
Hemolytic anemias

• Short courses of treatment with steroids
  or gamma globulin can help suppress your immune
  system's attack on your red blood cells. If the
  condition has caused an enlarged spleen, you may
  need to have your spleen removed

127
Hemolytic anemias

• The spleen a small organ below your rib
  cage on the left side filters out and stores
  defective red blood cells. Certain hemolytic
  anemias can cause the spleen to become enlarged
  with damaged red blood cells

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• (?)Symptomatic Treatment

• Transfusion
• Hemostasis
• Liver-protection
• Anti-infective
• Others

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Thanks