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1、ANEMIA,Hematology Department,HuashanHospital,Fudan University,ShanghaiXieYan-Hui,ANEMIAHematology Department,Hu,DIAGNOSIS AND CLASSIFICATION Anemia is an absolute decrease in hematocrit , hemoglobin concentration, or the RBC count. Anemia is not a diagnosis, but a sign of underlying disease.,DIAGNOS
2、IS AND CLASSIFICATION,Hemoglobin(Hb): male(adult)120g/L female(adult)110g/L female(gestation)100g/LRed cell count male4.5x1012 /L female4.0 x1012 /LHemocrit(HCT) male0.42 female0.37 female(gestation)0.30,Hemoglobin(Hb): male(adult),Determination of the cause:A. History1. Drug administration.2. Expos
3、ure to toxic chemicals 3. Family occurrence.4. Recent transfusions 5.menstruation(woman)6.ingestion(child)7.chronic disease8. Age at onset.,Determination of the cause:A.,B. Physical findings and complaintsa. Pale mucous membranes and skinsb. Weakness, loss of stamina, and exercise intolerance,Hypers
4、ensitivity to cold ,fever. c. Tachycardia and polypnea,Heart murmur. anemia associated cardiac disease: Hb30g/L more than 2 months heart enlargement ST depression,B. Physical findings and co,d. headache,dizzinesse.anorexia,nauxea,abdominal fullness diarria or constipation, Icterus.f.menstruation dis
5、order or amenorrea hemoglobinuria g. Shock if 1/ 2blood volume lost in short period.,d. headache,dizzinesse.anore,C. Laboratory findings1. The Hct is the easiest, most accurate method for detecting anemia. Its result should be interpreted with knowledge of the hydration status and any alteration cau
6、sed by splenic contraction.,C. Laboratory findings1. The,2. Hb and RBC may be used to further classify the anemia.,2. Hb and RBC may be used to,II. ClassificationA. Size (MCV) and Hb Concentration (MCHC)1. Normocytic, macrocytic, microcytic.2. Normochromic, hypochromic. (Hyperchromia does not occur)
7、,II. ClassificationA. Size (M,Type MCV(fl) MCHC(%) MCH(pg) disorderMacro 100 32 32-35 megaloblastic anemia MDSNormo 80-100 26-32 32-35 aplastic anemia,blood lost, hemolytic anemiaMicro 80 26 32 iron deficiency anemia sideroblastic anemia thalassemia,Type MCV(fl) MCHC(%) MCH(pg),B. Bone marrow respon
8、se1. Regenerativea. Bone marrow actively responds by increasing its production of RBCs.b. Findings:(1) Polychromasia.(2) Reticulocytosis,B. Bone marrow response1.,.(3) Macrocytosis (increased MCV) and hypochromia associated with reticulocytosis.(4) Hypercellular bone marrow with a low M/E ratio.(5)
9、Increase in MCV and RDW,.(3) Macrocytosis (increased,c. The presence of regeneration suggests an extramarrow cause.(1) Blood loss(2) Erythrocyte destruction (hemolysis)d. Bone marrow examination would reveal erythropoietic hyperplasia.,c. The presence of regeneratio,2. Non-Regenerativea. Inadequate
10、bone marrow response because of a bone marrow disorder.b. Polychromasia and reticulocytosis are absent.,2. Non-Regenerative,C. Pathophysiologic mechanismBlood losshemorrhagic anemia.2. Accelerated erythrocyte destructionhemolytic anemia.3. Reduced or defective erythropoiesis,C. Pathophysiologic mech
11、anism,ANEMIA FROM ACCELERATED ERYTHROCYTE DESTRUCTION (HEMOLYTIC ANEMIA),ANEMIA FROM ACCELERATED,A. Clinical findings1. Clinical signs of hemorrhage are absent.2. Jaundice may be seen in acute and severe cases.3. Hemoglobinuria and red plasma is seen if significant intravascular hemolysis occurs,内科学
12、-贫血总论谢彦晖课件,B. Laboratory findings1. Reticulocyte counts are higher in hemolytic anemias than externalhemorrhagic anemias 2. Plasma protein concentration is normal or increased.,B. Laboratory findings,3. Neutrophilic leukocytosis and monocytosis may occur.4. Evidence of Hb degradation (hyperbilirubin
13、emia, hemoglobinuria).5. Abnormal erythrocyte morphology (Heinz bodies, erythrocytic parasites,spherocytes, or poikilocytes).,3. Neutrophilic leukocytosis a,I. Differentiation of the Causes of Hemolytic AnemiasA. Extravascular hemolysis,I. Differentiation of the Caus,1. MechanismsAutoimmune Mediated
14、-Antibody and/or C3 mediated ( AIHA, infection, drug,immune system disorder)b. Decreased erythrocyte deformability(a)Shistocytes of microangiopathic anemia(b) Spherocytes of immune-mediated anemia(c) Parasitized erythrocytes(d) Heinz body-containing cells,1. Mechanisms,c. Reduced glycolysis and ATP
15、content of the erythrocyte( PK deficiency)d. Increased macrophage activity (hypersplenism),c. Reduced glycolysis and AT,e. Intravascular causes of hemolysis do not lyse all erythrocytes; some altered cells may remain that are removed by phagocytosis.,e. Intravascular causes of hem,2. Clinical and la
16、boratory characteristics of phagocytic (extravascular) hemolysis.Usually chronic with insidious onset.b. A regenerative response.c. Hemoglobinemia and hemoglobinuria are absent.,2. Clinical and laboratory cha,d. Hyperbilirubinemiae. Neutrophilia, monocytosis, and thrombocytosisf. Splenomegaly.,d. Hy
17、perbilirubinemia,h. Low-grade extravascular hemolysis occurs in many anemias that are primarily nonhemolytic (e.g., anemia of chronic renal disease,iron-deficiency anemia). Referred to as the “hemolytic component” of other types of anemia,h. Low-grade extravascular hem,B. Intravascular hemolysisEryt
18、hrocytes are destroyed within the circulation, releasing hemoglobin into the plasma where it is either removed by the liver or excreted by the kidneys.,B. Intravascular hemolysisEry,1. Mechanisms: The erythrocyte membrane must be significantly disrupted to allow escape of the Hb molecule into the pl
19、asma. Most of the mechanisms of intravascular hemolysis are extrinsic or extracorpuscular defects the erythrocyte is initially normal.,1. Mechanisms: The erythrocyte,Complement-mediated lysis. (neonatal isoerythrolysis and transfusion reactions, PNH )b. Physical injury(Traumatic ,microangio- pathic
20、anemia, DIC,Coagulation,Vasculitis)c. Oxidative injury (Heinz body,methemo- globin)d.Osmotic lysis( hypotonic intravenous fluids),Complement-mediated lysis.,e. Other membrane alterations.(1) Castor beansricin. Causes direct lysis(2) Snake venoms(3) Bacterial toxins(4) Parasites (Babesia),e. Other me
21、mbrane alterations.,2.Clinical and laboratory characteristics of intravcascular hemolytic anemia.Most cases present as peracute or acute episodes.b. History may reveal exposure to causative drugs or plants, recent transfusion of blood, or recent ingestion of colostrum.c. A regenerative response occu
22、rs, but it may not be evident in early stages.,内科学-贫血总论谢彦晖课件,d. Hemoglobinemia is the principal feature of intravascular hemolysis.(1)Red discoloration of plasma(2) Increased MCHCe. Hemoglobinuria f. Hemosiderinuriag. Hyperbilirubinemia,d. Hemoglobinemia is the princ,h. Additional laboratory finding
23、s may include schistocytes, keratocytes, Heinz bodies, erythrocytic parasites, positive Coombs test.,h. Additional laboratory findi,ANEMIA FROM REDUCED OR DEFECTIVE ERYTHROPOIESIS reduced or defective erythropoisis long or onset insidious clinic course,ANEMIA FROM REDUCED OR DEFE,I. General consider
24、ations.A. Mechanisms: 1. Precursor cells Nutrients (iron and B vitamins) Stimulation (erythropoietin),I. General considerations.,2. Bone marrow failure( intramarrow disease and extramarrow causes) 3. Bone marrow failure may be selective for the erythroid series or may also affect the other cell line
25、s.,2. Bone marrow failure( intram,B. Bone marrow responseWhen the number of precursor cells or erythropoietic stimulation is inadequate, the erythroid marrow is hypocellular.2. Maturation abnormalities which characterize the nutritional deficiencies, are associated with a Hypercellular marrow and in
26、effective erythropoiesis.,B. Bone marrow response,3. All degrees of bone marrow failure can occur, from complete aplasia to a suboptimal response of the erythroid marrow following hemorrhage or hemolysis.,3. All degrees of bone marrow,II. Differentiation of anemias caused by reduced or defective ery
27、thropoiesis. erythrocyte morphology, blood neutrophil platelet numbers bone marrow cellularity.,II. Differentiation of anemias,A. Normocytic, normochromic anemia; normal or increased neutrophil and platelet numbers; increased M/E ratio caused by hypocellular erythroid marrow. 1. Anemia of erythropoi
28、etin lack. a. Chronic renal disease. Anemia proportional to severity of the uremia.,A. Normocytic, normochromi,b. Endocrinopathies (1) Cushings (2) Hypoandrogenism (3) Hypopituitarism,b. Endocrinopathies,2. Anemia of chronic disorders (ACD) a. Occurs in chronic infectious, inflammatory, or neoplasti
29、c disorders. b. Cytokines involved with the inflammatory process initiate the anemia. c. Erythrocyte life span reduced,2. Anemia of chronic disord,d. Laboratory findings include: (1) Low serum iron (2) Low total iron binding capacity (3) Increased bone marrow macrophage iron (4) Mild-moderate anemia
30、 that is usually nonprogressive,d. Laboratory findings include,3. Pure red cell aplasia a. Characterized by a selective loss of erythroid precursors in the bone marrow. b. Thought to be immune mediated. 4. Unknown mechanisms a. Liver disease b. Vitamin E deficiency,3. Pure red cell aplasia,B. Normoc
31、ytic, normochromic anemia; neutropenia and/or thrombocytopenia; M/E ratio is difficult to determine because of hypocellularity.,B. Normocytic, normochromic,1. Aplastic anemia a. pancytopenia. b. shorter life spans of the cells. c. Causes (1) Drugs, chemicals, plants (2) Irradiation (3) Cytotoxic T c
32、ells or antibody (4) Infectious agents,1. Aplastic anemia,2. Myelophthisic anemia a. The bone marrow is physically replaced by an abnormal proliferation of cells. (1) Myeloproliferative disordersleukemias (2) Myelofibrosis (3) Osteosclerosis (4) Diffuse granulomatous osteomyelitis (5) Metastatic can
33、cer,2. Myelophthisic anemia,3. Anemia caused by infectious agents a. Ehrlichiosis(埃里西提病） b. FeLV（猫白血病病毒）,3. Anemia caused by infecti,C. Microcytic, hypochromic anemia; variable neutrophil and platelet number; usually a hypercellular marrow with a variable M/E ratio.,C. Microcytic, hypochromic,1. Iro
34、n deficiency a. Chronic hemorrhage b. Dietary deficiency, especially in young milk-fed c. Ineffective erythropoiesis early;,1. Iron deficiency,d. Laboratory findings: (1) Low serum iron (2) Variable iron-binding capacity (3) Microcytosis (4) Hypochromasia (5) Poikilocytes (6) Hypercellular bone marr
35、ow,d. Laboratory findings:,2. Pyridoxine deficiency. This vitamin is a cofactor in heme synthesis and a deficiency leads to a failure to utilize iron. 3. Copper deficiency. Copper-containing ceruloplasmin is important in iron absorption and transfer between gut, macrophages, and transferrin.,2. Pyri
36、doxine deficiency. T,D. Macrocytic, normochromic anemia; variable neutrophil and platelet number; M/E ratio usually low because of hypercellular erythroid marrow. 1. Vitamin B12 and folic acid deficiency. 2. Erythemic myelosis or erythroleukemia. 3. FeLV infection.,D. Macrocytic, normochromic,Treatm
37、ent principle of anemia (1) causes treatment (2) supporting-trnsfusion (3) giving nutrition elements for hematopoiesis such iron agent,vitamine B12,folate acid (4) immunosuppression agent such glucocorticoid, antithymocyte globulin, cyclosporine A (5) auto -or allogeneic hematopoietic stem cell tran
38、splantation (6) hematopoietic growth hormone(EPO)or stimulating factor(androgen) (7) splenectomy,Treatment principle of anemi,写在最后,成功的基础在于好的学习习惯The foundation of success lies in good habits,55,写在最后成功的基础在于好的学习习惯55,谢谢大家荣幸这一路，与你同行ItS An Honor To Walk With You All The Way,讲师：XXXXXX XX年XX月XX日,谢谢大家讲师：XXXXXX,
