Clinical Medicine Lecture: _____ Topic: ____________________________________________________________ Date: ______________

Iron Deficiency Anemia Sideroblastic Anemia Anemia of Chronic Disease

1. Dietary Lack Not pathognomonic of any one disease Reduction in proliferation of erythroid
2. Impaired absorption Results from a lack of heme due to poor iron progenitors AND impaired iron utilization
3. Increased requirement incorporation Persistent systemic inflammation associated
Etiology 4. Chronic blood loss with chronic disease leads to impaired RBC
(Pathophysiology): o Most common cause of iron deficiency in production by triggering release of hepcidin
the Western world from the liver making iron less available and
o Internal bleeding may occur as a result of inflammation also inhibits marrow.
cancer
Most common nutritional disorder on Earth Excessive alcohol consumption
o Most common in toddlers, adolescent girls, Myelodysplastic Syndrome (MDS)
Risk Factors and women of childbearing age Mitochondrial disorders
(Demographics): Other copper deficiency, vitamin B-6
(pyridoxine deficiency), lead poisoning, drugs,
hypothermia
S/S of Anemia: S/S of Anemia: S/S of Anemia:
Pallor Pallor Pallor
Fatigue/reduced exercise capacity Fatigue/reduced exercise capacity Fatigue/reduced exercise capacity
Dyspnea on exertion Dyspnea on exertion Dyspnea on exertion
Clinical
the underlying chronic disease
Manifestations
(Signs and
Advanced Iron Deficiency: Sideroblastic Anemia S/S: Most are so mild they have no symptoms
Cheilosis/cheilitis Polyuria, blindness, deafness, optic atrophy
Symptoms):
Koilonychia (associated with DIDMOAD syndrome
Pica diabetes insipidus, diabetes mellitus, optic
Plummer-Vinson Syndrome atrophy, and deafness)
o Esophageal webs (dys/odynophagia)
1. CBC 1. CBC 1. CBC
o Hgb low o Hgb moderately low (9-10) o RBC count decreased
o Hct low o Hct low o Hgb mild to moderate decrease
o MCH, MCHC low o MCH, MCHC low o Hct mild to moderate decrease
o MCV low o MCV low o MCH, MCHC normochromic
2. Peripheral Smear and Reticulocytes 2. Peripheral Smear and Reticulocytes o MCV normocytic
o RBC Appearance microcytic, o RBC Appearance microcytic, o Neutrophilia, monocytosis, and
hypochromic hypochromic thrombocytosis due to underlying disease
Diagnostic Studies:
In severe anemia (7-8 g/dL) o Siderocytes with Pappenheimer bodies 2. Peripheral Smear and Reticulocytes
codocytosis and poikilocytosis o Basophilic stippling of the RBCs is lead o RBC Appearance normocytic,
o Absolute Reticulocytes (0.5-1.5%) poisoning normochromic (75%)
o Reticulocyte Index (1-3%) o Reticulocytes o Reticulocytes
Too few poor RBC production (not Too few poor RBC production (not Too few poor RBC production (not
enough iron) enough heme) enough heme)
3. Iron Studies 3. Iron Studies 3. Iron Studies and Other
o Ferritin low o Ferritin normal o Ferritin increased (as a non-specific
 Most convenient test for estimating
iron stores
o Serum Iron (SI) low
o Total Iron Binding Capacity (TIBC) high
o Transferrin saturation (TSAT) low
4. Other
o Serum erythropoietin level increased
o RBC protoporphyrin levels increased (
100 g/dL, normal is <30 g/dL)
5. Bone Marrow Analysis
o Definitive/Gold Standard (but not
necessary) differentiation between iron
deficiency and sideroblastic anemia
Too few sideroblasts NOT
RINGED
1. Oral iron
o Indications Asymptomatic (no advanced
anemia sx) patient with known iron
deficiency
o Ferrous sulfate 325 mg PO TID for 6-12
months (to achieve marrow iron stores of
0.5-1 g)
Results in absorption of 50 mg of
elemental iron per day, which supports
a RBC production level of 2-3 x normal
o Reticulocyte count should begin to
increase within 4-7 days after initiation of
therapy and peak at 1-1 weeks
Treatment (First & 2. Parenteral Iron
Second Line): o Indications
Inability to tolerate oral iron
Needs are relatively acute
Ongoing iron needs, usually due to
PERSISTENT GI blood loss
o 100 mg of elemental iron weekly x 10
weeks
3. RBC transfusion
o Indications
Symptoms of anemia
Cardiovascular instability
Continued and excessive blood loss
from whatever source and who
require immediate intervention
Referral: PRN
o SI normal inflammatory reactant)
o TIBC normal o SI decrease
o TSAT normal o TIBC increase
4. Hemoglobin electrophoresis (probably) o TSAT decrease
o Normal o Other If these are found, then you can
5. Bone Marrow Analysis suspect that the lever and marrow are
o Definitive/Gold Standard necessary to affected
find the RINGED SIDEROBLASTS C-reactive protein (CRP)
6. Other Erythrocyte sedimentation rate
o Serum lead, ethanol, copper, zinc, - (ESR, Sed Rate)
glutamyltransferase, vitamin B-6 Hepcidin level
Growth differentiation factor 15
4. Plasma erythropoietin level
o May or may not be decreased (EPO levels
<500 mU/mL may respond to an EPO-
stimulating agent)
Considerations: Preferred initial therapy is correction of the
Removal of toxic agents underlying disorder
Pyridoxine, thiamine, and/or folic acid If EPO level decreased and no malignancy
Transfusions (along with antidotes/chelation if and Hgb is <10 g/dL, then EPO (30,000 to
iron overload develops from transfusion) 40,000 SQ once weekly) or darbepoetin (300
Bone marrow transplantation mcg Q 3 weeks)
o LAST RESORT o If using either, should also give
Liver transplantation supplemental iron
o Response Hgb increases 0.5 g/dL by 2-
4 weeks
o Stop when hemoglobin levels reach 12
g/dL
PRBC transfusion if there is insufficient time
for the patient to respond to above treatments
AND symptomatic anemia
Hematology recommended for all Not usually necessary