ANAEMIA

Cut-off Hb for normal ranges are arbitrary. Normal ranges depend on age, environment, physiologic state

Mechanisms of anaemia
Reduced red-cell production defective precursor proliferation defective precursor maturation defective proliferation and maturation Increased RBC destruction RBC loss from circulation

DEFECTIVE RBC PRODUCTION

Reduced proliferation of precursors
Fe-deficiency
Anaemia of chronic disorders; Ca, infection, inflammation Reduced EPO production; renal disease Reduced O2 requirements; hypothyroidism, hypopituitarism Reduced O2 affinity for Hb Bone marrow disorders; aplasia, pure RBC aplasia, infiltrative disorders

Defective maturation of precursors

Nuclear maturation; B12 def., folate def.,erythroleukaemia Cytoplasmic maturation; Fe-def., dis. of globin synthesis, dis. of haem or Fe- metabolism, dis. of porphyrin metab

Unknown mechanisms
MDS Infection eg. HIV Cong. Dyserythropoietic anaemias Toxins and chemicals

Finding the cause of anaemia

RBC changes are the most important clues- MCV, MCH, MCHC

AUTOMATED CYTOMETRY
FLOW CYTOMETRY
- High-speed jet of dilute suspension of blood cells flowing perpendicularly to a sensor. The sensor may be impedance(electric current) or light beam detector. As the cell passes through there is interuption to the current or light beam that is proportional to cell size, the magnitude of this interuption is recorded. -Typically, 10,000 cells can be counted in 30-60secs and several variables can be examined at the time. -Data is displayed in histogram/scattergram form.

IMAGE ANALYSIS
-High-speed optics analysis of fixed cells with memory of examined cells.

RBC 5.23

RBC volume distribution in normals is symmetrical, and can be analyzed by Gaussian model/Log-normal model. Biologic heterogeneity can be discrete(>one sub group) or non-discrete(one sub group) RBC heterogeneity is measured by the coefficient of variation ie. The ratio of SD(width of histogram) to the MCV. RDW

50

Hb

15.5

Hct 47.8 MCV 91.4

Relative Frequency (%)

RDW 11.9

25

0 0 30 60 90 120 150

Particle volume, fl.

MICROCYTIC DISORDERS

 Similar changes seen in thalassaemia, sideroblastic anemia but RDW remains normal. Advanced Fe-deficiency with abnormalities in all indices Hypochromic,microcytic

Relative Frequency %

100

RBC 3.19
Hb 6.4

Hct 20.5 MCV 64.4 RDW 18.0 MCH 20.5

50

MCHC 22.2

50

90

120

Particle volume, fl

NORMOCYTIC DISORDERS

 In anaemia of chronic disease there is a failure of erythroid proliferation, hence reduced RBC count but normal histogram. MCV may be lower in a minority but RDW should remain normal. Increased RDW distinguishes Fe-deficiency from ACD and heterozygous thalassemia

Relative Frequency %

RBC Hb Hct

3.83 11.3 33.5

100

MCV 87.0 RDW 11.9

50

50

90

120

Particle volume, fl

MACROCYTIC DISORDERS

 Severe folate/Vit B 12 deficiency shows low RBC count, high MCV, and Increased RDW. The essential defect in folate / Vit B 12 deficiency is nuclear maturation delay.

Relative Frequency %

RBC 2.87 Hb Hct 10.6 31.4

100

MCV 109.6
RDW 17.3

50

50

90

120

Particle volume, fl

HAEMOLYTIC DISORDERS

RBC 3.49

Relative Frequency (%)

Red cell fragmentation Fragments form a plateau to the left. Because of fragments the MCV is less than real value ( approx 90)

50

Hb

10.7

Hct 31.3 MCV 84.1 RDW 16.0

25

0 0 30 60 90 120 150

Particle volume, fl.

50

In sickle cell anaemia and other Haemoglobinopathies there is an inverse correlation between Hb level and RDW. Anisocytosis on blood smear correlates with RDW of automated counter. The counter does not measure shapes, therefore the striking poikilocytosis on blood smear appears severer than the increase in RDW.

RBC 2.10 Hb 6.4 Hct 19.8 MCV 94.0 RDW 22.0

Relative Frequency (%)

25

0 0 30 60 90 120 150

Particle volume, fl.

Mechanisms of Haemolysis
Abnormalities of RBC membrane
Genetic: HS,elliptocytosis Alteration in lipid content: CLD Complement/Ig activation: Immune Increased permeability: G6PD def.

Increased rigidity
Aggregation of Hb eg. Hb SS Decreased solubility of Hb eg. Hb C Inclusion body (Heinz). Thal., unstable Hb, oxidant drugs

Mechanical damage
External trauma eg.march, karate, Turbulent flow eg. Cardiac valves/prosthesis Cleavage by fibrin strands. microangiopathy

Evidence of haemolysis
Red cell breakdown Raised serum bilirubin,unconjugated and bound to albumin Increased urine/faecal urobilinogen Reduced haptoglobin/haemopexin levels from RE removal of saturated Hb-hapto complex. Fragments, microspherocytes etc. Intravascular breakdown Meth-Hb Raised plasma Hb Haemoglobinuria/haemosiderinuria

 Shortened red cell survival. 51Cr Increased RBC production Polychromasia, reticulocytosis, macrocytosis, erythroid hyperplasia,

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