1.

Low Hb
a. Ineffective production
b. Decreased production
c. Hemolytic anemia
d. Blood loss
e. Redistribution (splenomegaly)
f. Dilution
Low serum iron, low iron binding capacity, normal or increased ferritin in infections, ferritin
levels go up rapidly (acute phase reactant proteins), abnormal liver test could result in high
ferritin levels.
2. Diagnosis of anemia of chronic disease
a. Normochromic
i. Normocytic anemia
b. Normal (or near normal) RDW
c. Serum Fe (low)
i. Serum Fe Binding Capacity (low)
ii. % saturation (low)
d. Ferritin (normal to increased)
e. Transferrin receptor (normal)
EPO level is relatively normal and related to Hgb (semi log plot) normal EPO range (4-20
microliter)
EPO level is markedly increased in people with severe anemia (Hgb value 6gm)
In anemia secondary to osteomyelitis, percentage of erythroid precursors in the bone marrow
containing hemosiderin granules will be markedly decreased
You see it in macrophages but not in red cells
To treat osteomyelitis you need antibiotics for 6 weeks
EPO injection wont work in ACD because cytokins will downregulate
Testosterone injection may increase EPO and erythroid precursors but can be down regulated by
cytokines of erythropoeisis
In normal iron in macrophages in hemosiderin (ferritin clumps) and a third have them
Lab Values
Serum few
Fe BC
Ferritin
Transferrin receptor
BM sideroblasts
BM macrophage Fe

Iron Deficiency
Low
Normal or high
Low
High
Low
Low

ACD
Low
Low
Normal or high
Normal
Low to absent
normal

In normochromic individual, RBC count x3 should equal Hgb

Normocytic is by MCV (Hematocrit x 10/RBC)
Effective erythropoiesis is measured by reticulocyte count and is the bone marrow response to
anemia
HbA2 may be falsely low in beta thalassemia minor for superimposed iron deficiency and not a
good measure of iron deficiency anemia
Almost impossible to get severely iron deficient from diet alone
Iron loss due to menses and pregnancy is significant
Could be very heavy
Increased reticulocyte count excludes ineffective erythropoiesis and strongly suggests increased
destruction
Unusual physical findings such as gall stones at an early age would indicate a hereditary
condition
Any hemolytic anemia, whether acquired or genetic, first step is to look at peripheral blood
smears
Hereditary hemolytic anemias
3. Cytoskeletal defects
a. Blood Smear
i. Spherocytosis
ii. Elliptocytosis
iii. Other
4. Abnormal Hb or Hb synthesis
a. Blood smear indices, Heat ppt, isopropyl alcohol
i. Sickle cell diseases
ii. HbE or others
iii. Thalassemia
iv. Unstable
5. Enzymatic defects
a. Basophilic stippling and Heinz bodies
i. Hexose MP shunt
ii. Anaerobic glycolosys
iii. Phyrimidine-5-nucleotidase
iv. Other
Do not secrete HCl in pernicious anemia so stomach pH will be very high

Retic index
Bilirubin
LDH

Hemolytic anemia
High
High normal
+/-

1. Acquired hemolytic anemias

a. Extrinsic
i. Immune
ii. Fragmentation
iii. Infection
iv. Alertaion of plasma lipids
v. Misc (osmotic, thermal, etc)
b. Intrinsic
i. PNH

Acute blood loss

High
LDH
Normal