Juiandance
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Anemia
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Here is a comprehensive overview of Anemia:
Anemia
Definition
Anemia is a reduction in circulating red blood cell (RBC) mass, resulting in decreased oxygen-carrying capacity of the blood. It is diagnosed when:
- Hemoglobin (Hb) < 12–15 g/dL (varies by sex and age)
- Hematocrit (Hct) < 36–45%
- RBC count < 4–6 × 10⁶/µL
The hematocrit is roughly 3× the Hb value, which is roughly 3× the RBC count — a useful bedside rule.
Classification
Anemia is classified by MCV (cell size), RDW (size variation), and Reticulocyte Production Index (RPI):
By MCV (Morphologic Classification)
| MCV | Category | Common Causes |
|---|---|---|
| < 80 fL | Microcytic | Iron deficiency, thalassemia, anemia of chronic disease (ACD) |
| 80–100 fL | Normocytic | Hemolytic anemia, aplastic anemia, renal failure, acute blood loss |
| > 100 fL | Macrocytic | B12/folate deficiency (megaloblastic), hypothyroidism, liver disease |
By Bone Marrow Response (RPI)
| RPI | Response | Examples |
|---|---|---|
| > 3 | Hyperproliferative | Hemolysis, blood loss |
| < 2 | Hypoproliferative | Iron deficiency, aplastic anemia, renal failure |
Common Types & Key Lab Findings
(From Henry's Clinical Diagnosis and Management by Laboratory Methods)
| Type | Cause | Key Lab Abnormalities |
|---|---|---|
| Microcytic hypoproliferative | Iron deficiency | ↓ Ferritin, ↑ TIBC, ↓ serum iron, ↑ RDW |
| Microcytic hypoproliferative | Anemia of chronic disease | ↑ Ferritin (normal/high), ↓ serum iron, normal RDW |
| Normocytic hyperproliferative | Hemolytic anemia | Schistocytes, ↑ reticulocytes, ↓ haptoglobin, ↑ LDH, ↑ indirect bilirubin, ↑ RDW |
| Normocytic hypoproliferative | Aplastic anemia | Pancytopenia, hypocellular marrow, normal RDW |
| Normocytic hypoproliferative | Renal failure | ↑ BUN/creatinine, ↓ EPO, burr cells |
| Macrocytic megaloblastic | B12/folate deficiency | ↓ B12/folate, hypersegmented neutrophils, macro-ovalocytes, ↑ RDW |
| Macrocytic non-megaloblastic | Hypothyroidism | ↑ TSH, normal RDW |
Peripheral Blood Smear: Normal vs. Iron Deficiency Anemia
Left: Normal RBCs — uniform size, moderate central pallor. Right: Iron deficiency anemia — smaller cells (microcytic), pale (hypochromic), with markedly increased central pallor. — Harrison's Principles of Internal Medicine, p. 1721
Symptoms
- General: Fatigue, weakness, pallor, dyspnea on exertion
- Cardiovascular: Palpitations, tachycardia, high-output heart failure (severe)
- Neurological (B12 deficiency): Paresthesias, subacute combined degeneration of spinal cord
- Specific: Koilonychia, pica, glossitis (iron deficiency); jaundice, dark urine (hemolysis)
Diagnostic Approach
- CBC — Hb, Hct, MCV, MCH, MCHC, RDW, platelet count
- Peripheral blood smear — morphology (hypochromia, macrocytes, schistocytes, spherocytes)
- Reticulocyte count/RPI — assess marrow response
- Targeted labs based on morphology:
- Microcytic → serum iron, ferritin, TIBC, hemoglobin electrophoresis
- Macrocytic → B12, folate, TSH
- Normocytic → reticulocytes, LDH, haptoglobin, Coombs test, BUN/creatinine
Treatment Principles
| Type | Treatment |
|---|---|
| Iron deficiency | Oral ferrous sulfate 60–120 mg elemental iron/day; IV iron if intolerant or malabsorption |
| B12 deficiency | IM cyanocobalamin or high-dose oral B12 |
| Folate deficiency | Oral folic acid 1 mg/day |
| Anemia of CKD | Erythropoiesis-stimulating agents (ESAs) + iron |
| Hemolytic | Corticosteroids (autoimmune), treat underlying cause |
| Aplastic | Immunosuppression, allogeneic stem cell transplant |
Special Contexts
Pregnancy: Physiologic hemodilution lowers Hb normally (plasma volume ↑47%, RBC mass ↑17%). Hb < 11 g/dL or Hct < 33% is considered non-physiologic. Supplemental iron (30 mg/day) is recommended for all pregnant women; treatment dose is 60–120 mg/day for diagnosed IDA. — Textbook of Family Medicine 9e
Sources: Henry's Clinical Diagnosis and Management by Laboratory Methods; Harrison's Principles of Internal Medicine 21e; Textbook of Family Medicine 9e
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