Anaemia

• Anaemia – from greek meaning ¨lack

of blood¨

• Anaemia= less than the normal quantity of hemoglobin in the blood

• Anaemic syndrome =clinical syndrome caused by tissue hypoxia

male female

Hemoglobin (Hb) 136 – 176 120 - 168 g/l

Hematokrit (HTK) 0,38 – 0,49 0,35 – 0,46

Erythrocyte count (RBC) 4,2 – 5,8 3,8 – 5,2 x1012/l

Reticulocytes 0,7 – 2,8 % (event. 50 -150 x109/l)

Mean corpuscular volume (MCV) 80 – 95 fl

Mean corpuscular hemoglobin (MCH) 26 – 32 pg

Mean corpuscular hemoglobin concentration (MCHC) 0,32 – 0,37

Red cell distribution with (RDW) 11 -15%

NORMAL VALUES OF RED BLOOD CELLSNORMAL VALUES OF RED BLOOD CELLS

male female

Hemoglobin (Hb) 136 – 176 120 - 168 g/l

Hematokrit (HTK) 0,38 – 0,49 0,35 – 0,46

Erythrocyte count (RBC) 4,2 – 5,8 3,8 – 5,2 x1012/l

Reticulocytes 0,7 – 2,8 % (event. 50 -150 x109/l)

Mean corpuscular volume (MCV) 80 – 95 fl

Mean corpuscular hemoglobin (MCH) 26 – 32 pg

Mean corpuscular hemoglobin concentration (MCHC) 0,32 – 0,37

Red cell distribution with (RDW) 11 -15%

NORMAL VALUES OF RED BLOOD CELLSNORMAL VALUES OF RED BLOOD CELLS

Anaemic syndrome - symptomsrom (AS)

• Tissue hypoxia: pallor, fatigue, weakness, dyspnea

• Compensation and adaptation:

Hypercinetic circulation, palpitations, tinnitus

• Secondary :

Cardiovascular symptoms – decompensation of ischemic heart disease, AP, IM, claudications…

Anemický syndrom (AS)

Progress and severity of AS depends on:

1. Absolute value of HbHgb 70-80 g/l = most of patients suffer from

symptoms

2. Speed of onset

3. Age and overall performance of the patient

IRON PROTOPORFYRIN

HAEM + GLOBIN

HAEMOGLOBIN

DNA – B12 ,folic acid, EPO

ANAEMIA - CLASSIFICATION

Morfologic criteria:• According to MCV: (80 – 95 fl) microcytic, normocytic, macrocytic

• According to MCH: (27-32 pg)• normochrome, hypochrome

• According to no of reticulocytes: (0,7 – 2,8 %)

anaemia with lowered, normal or incresed no of reticulocytes

A. MICROCYTIC ANAEMIA Iron deficiency anaemia (IDA)Chronic disease anaemia (ACD)Thalassemia, congenital sideroblastic anaemia

B. MACROCYTIC ANAEMIA Megaloblastic anaemia(lack of B12, folic acid)Macrocytic non-megaloblastic anaemia (usually secondary: alcohol abuse, liver disesae, hypothyreosis, pregnancy, chemotherapy.. )Myelodysplastic syndrome (MDS) – someChronic haemolytic anaemia (AIHA)

C. NORMOCYTIC ANAEMIAPrimary impairment of blood marrow: aplastic anaemia, MDS – some, PNH,myelofibrosis.Secondary impairment of blood marrow :(infiltration, infection, endocrinological and systemic diseases, ACD)Acute bleeding, acute haemolysis

MCV RTC RDW

Iron deficiency anaemia (IDA)

Megaloblastic anaemia (vit. B12 defficiency)

Thalassemia (heteroz.) N

Chron. haemolytic anaemia (AIHA)

Anaemia in chronic diseases (ACD) N, N

Aplastic anaemia N, N

Myelodysplastic syndrome (MDS) N, N,

Morphology based dif. diagnosis of anaemia

Pathofysiological classification

EPO

EPO

TSH

Fe, Fol, B12

C, E

Pathofysiological classification

• Proliferation and differentiation disorder

• Increased destruction of RBC

• Blood loss

• Combined etiology

IRON PROTOPORFYRIN

Iron insufficiency sideroblastic anaemiaACD

HEM + GLOBIN

thalasemia

HEMOGLOBIN

DNA – B12, folic acid, EPO

Iron deficiency

Iron deficiency

• Most frequent cause of anemia (500 000 000 worldwide – WHO)

• 80%of all anaemia

• SA: 10% of fertile women

• Sideropenia: 35-58% of fertile women

Iron deficiency CAVE: influencing not just the blod

count!

• DNA synthesis impairement

• Tissue fosforylation impairement

• Purine metabolism impairement

• Colagen synthesis impairement

• Granulocyte function impairement

• Neurotransmiter function impairement

•

Iron distribution in the organism

Iron metabolism

• Food contents: 15-20mg/den

• Absorption: 1-2mg (duodenum, upper part of jejunum)

• Loss (epitel desqvamation) 1-2mg

• Pregnancy: overall loss: 500-1000mg

• Supply in the organism: 3000-5000mg

Hepcidine

• Acute phase reactant

• Source: hepatic cells, heart,

• Iron stimulates Hepcidine

• Hepcidine inhibits iron absorption in the intestine, iron release from macrophages and iron transport via placenta

• ACD, hereditary hemochromatosis

Iron deficiency

• Insufficient intake - malnutrition

• Absorption impairement

– maldigestion, malabsorption

• Increased loss

• Lowered intake

Insufficient intake

• Malnutrition

• Imbalanced diet

• Vegetarians

- Meat: 25-30% of iron is absorbed

- Vegetables: 5% of iron is absorbed

•

Iron absorption from various foods (%)

Rice

Spinach

Beans

Corn

Lettuce

Wheat

Soya

Ferritin

Veal liver

Fish meat

Haemoglobin

Veal meat

•

Iron absorption from various foods (%)

Rice

Spinach

Beans

Corn

Lettuce

Wheat

Soya beans

Ferritin

Veal liver

Fish meat

Haemoglobin

Veal meat

• Resection of stomach – 65% patients

• Achlorhydria

• Coeliakia

• M. Crohn

• Infection H. Pylori with gastritis

Absorption disorder

Loss

• GIT (h. hernia, gastritis, ulcerous disease, tumours, intestinal inflammmatory diseases, hemorhoids, parasites, diverticulitis…)

• Respiratory tractus

• Urogenital tract Menses = cca 3mg Fe / den

• NSAIDs, hemodialysis, blood testing, self - harming

Increased need

• Pregnancy

• Brest-feeding

• Growth

Symptoms

• Anemic syndrome

• Cefalea, paresthesia, fatigue

• Tongue burning, angulitis

• Odyno-, dysfagia

• Sy Kelly-Patterson

• Brittle hair, nails

• (Pica, pagofagia)

Physical examination

• Pallor – skin, mucous membrane

• Blue sclerae

• Ulcers/ angulitis

• Smooth tongue

• Straight/(spoon-shaped) nails

• Achlorhydria, atrophic gastritis

Laboratory findings

• RDW: high

• Trombocytosis (over 50% of patients)

• BM –staining for iron

- lack of Fe in siderophages

- sideroblasts lower then 10%

Laboratory findings

• MCV under 80fl• MCH under 25ug• MCHC – late symptom• Transferrin -increased• S-ferritin <20ug/l • Transferrin satur. – under15 % (N: 20-40%)• VKFe (TIBC): increased• S-sTfR > 8g/l

Fe TIBC satTRF ferritin TRF receptor _______________________________________________ Iron insuf.   Chronic disease associated anaemia N N N (ACD)

  

Thalasemia N or N or N or N or   

DIFFERENTIAL DIAGNOSIS OF IRON DIFFERENTIAL DIAGNOSIS OF IRON INSUFFICIENCY (mikrocytic anaemia)INSUFFICIENCY (mikrocytic anaemia)

CAVE

Ferritine

• Acute phase reactant

• Nespecific tumorous marker

• Level increases with age

(75ug/l in old people = ? = iron defficiency)

Iron deficiency

• Prelatent

• Latent

• Manifest - SA

Typical patient with IDA

1. Woman 20-45y, fatigue, sleepiness, ear buzzing, hairloss, brittle nails, hyper- polymenorhea or normal menses.

2. Man 50y or older, dysfagia, weightloss, treated with ASA for ICD, blood in stools or urine.

Treatment of IDA

=

Treatment of the cause of iron loss

+ iron supply

Ferrotherapy

• 150-200mg Fe / day

• Until enough supply is formed (ferritin 50ug/l)

• Use on an empty stomach

• CAVE: polyphenols, milk, egg yolk

• Dyspepsia• Parenteral forms (CAVE: anaphylaxis; x new

forms are safer - karboxymaltose)

PŘÍPRAVKY ŽELEZAPŘÍPRAVKY ŽELEZA

tab

název léková složení obsah látky v lékové(výrobce) forma formě

Aktiferrin cps. síran železnatý 34 mg(Merckle,SRN) serin

Aktiferrin sir. síran železnatý 6,8 mg/ml(Merckle,SRN) serin

Aktiferrin gtt. síran železnatý 9,3 mg/ml(Merckle,SRN) serin

Ferrlecit inj komplex Fe 3+ s glukonátem 62,5 mg(Nattermann,SRN) sodným

Ferro-Gradumet tab síran železnatý 105 mg(Galenika,Jugoslávie)

Ferronat susp. fumarát železnatý 10 mg/ml(Galena,ČR)

Ferronat retard tab síran železnatý 105 mg(Léčiva,ČR)

Ferrum lek i.m. inj komplex hydroxidu 100 mg(Lek,Slovinsko) železitého se sacharózou

Maltofer sir. komplex Fe 3+ 10 mg/ml(Vifor,Švýcarsko) s polymaltosou

Maltofer gtt. komplex Fe 3+ 50 mg/ml(Vifor,Švýcarsko) s polymaltosou

Sorbifer durules síran železnatý 100 mg(Egis,Maďarsko) kyselina askorbová

Tardyferon drg síran železnatý 80 mg(Robapharm,Švýcarsko) mukoproteáza

Ferinject (Vifor, Francie) inj. Fe3+ karboxymaltóza 100mg, 500mg

P.o. iron treatment control

- Reticulocyte crisis D 10-14

- Increase of haemoglobin

- Normalisation of MCV a RDW

- Iron supply forming

Ineffective treatment:1. Diagnosis checking :BM examination, GIT examination aso…. Cave

self-harming

2.Switch to i.v. therapy

Thalassemia

IRON PROTOPORFYRIN

Fe insufficiency sideroblastic anemiaACD

HEM + GLOBIN thalasemia

HEMOGLOBIN

DNA – B12 , folic acid

Thalassemia

• + thalasemia, 0 thalassemia

• Fetus: - Hb F α2 γ2

• Adult - Hgb A: α2 β2

- Hgb A2: α2 δ2

- Hgb F: α2 γ2

Thalassemia

• α –thalassemia = α disorder

• β – thalassemia = β disorder

α - Thalassemia

(Normal genotype: α α / α α)

• - α/ α α = silent carrier• - α/- α , - - / α α = carrier (mikrocytosis, erythrocytosis):

= Thalassemia minor

• - - / - α = HbH (β4) (splenomegalia, mikrocytosis, bones)

• - - / - - = hydrops fetalis, sy Hb Bart´s (γ4)

β - Thalassemia

More severe then α–thalassemia

• β – thalassemia minor (β+/ β, β0/ β) Mikrocytosis, anaemia, erythrocytosis

• β – thalassemia intermedia (β+/ β+, β0/ β+)

• β – thalassemia major (β0/ β0, β+/ β+) Severe anemia, anisopoikilocytosis, affected ERY, HbF,

hepatosplenomegalia,bone deformities,permanent transfusion therapy, Fe overload, Tx, splenectomia, HU

BETA THALASsEMIA

• Pathogenesis:Pathogenesis: chains formation impairement chains formation impairement increased synthesis of increased synthesis of and and

• Alpha chains overdose –low solubility, precipitation, agregates deform Alpha chains overdose –low solubility, precipitation, agregates deform cell membranescell membranes

• Hb – easy autooxidation, lower stability Hb – easy autooxidation, lower stability release of release of Fe Fe cell destruction by peroxidative lipid cleavage. cell destruction by peroxidative lipid cleavage.

• Inefective erythropoiesis, large numbers of erytrocytes decline as soon Inefective erythropoiesis, large numbers of erytrocytes decline as soon as the BM + peripheral hemolysis + shortened lifespanas the BM + peripheral hemolysis + shortened lifespan

• Significant compensatory erythropoiesis hyperplasiaSignificant compensatory erythropoiesis hyperplasia corticalis usurationcorticalis usurationbone deformities, fractures, extramedular bone deformities, fractures, extramedular hemopoiesishemopoiesis

• Relative Fe defficiency in BM because of hyperplasticRelative Fe defficiency in BM because of hyperplastic erythropoiesis, at the same time increased Fe supply (coming from erythropoiesis, at the same time increased Fe supply (coming from

destroyed ery in monocyte- macrophage system) destroyed ery in monocyte- macrophage system) increased Fe increased Fe resorption in the intestineresorption in the intestine Fe overload of the organism (together with Fe overload of the organism (together with Fe coming from transfusions).Fe coming from transfusions).

MEGALOBLASTIC ANAEMIA

• Lack of B12of folic acid: 1. Pernicious anaemia - B12 absorption in the distal

ileum disorder due to lack of intrinsic factor (produced by parietal cells of gastric mucosa)

Homocystein-methyl-reductase (methionine synthase)

2. Dihydrofolat reductase inhibitors (MTX, ARA-C)

MEGALOBLASTMEGALOBLASTICIC AN ANAEMIAAEMIA - -CAUSESCAUSES

• Insufficient intake of B12 of folic • Absorption impairement: a) lack of intrinsic factor, intrinsic factor

b) celiakia, Crohn disease, intestinal resection, diverticules, strictures,parasites

c) resorption inhibitors (fenylhydantoin,PAS,pyrimidin, neomycin)

d) selective malabsorption B12 with proteinuria

Transport disorders because of lack of transkobalamin I. and II.• Increased demand (gravidity, growth, anaemia with hyperplasia of

erythropoiesis • Increased loss (hepatic laesions, bleeding)• dihydrofolat reductase inhibitors (MTX,pyrimethamin) pyrimidin antagonists (ARA-C) / purin antagonists (6-MP)

Megaloblastic anaemia

• Blood count– macrocytes (↑MCV, ↑MCH,normal MCHC), ↓RTC, megalocytes, megaloblasts, leukocytosis with left shift, thrombocytopenia.

• Bone marrow– hyperplasia of erytropoiesis, megaloblasts, granulocyte macrocytosis, mgkc. polyploidia dif.dg. MDS (cytogenetics, cytochemistry)

• biochemistry – ↓ B12, ↓folic acid, ↑direct and indirect bilirubin, intrinsic factor antibodies, antibodies against parietal

cells, normal iron supplies

Proteins binding VITAMIN B12

Intrinsic factorB12 absorption in ileum, binding to specific receptor (cubilin)

Secerned by parietal gastric cells In case of lack leads to B12 malabsorption

TRANSCOBALAMIN I

Binds B12 in plasma,binds to B12 in stomach before binding to intrinsic factor, produced by neutrofiles and cells with exocrine secretion, his lack leads to low

serum B12 levels

TRANSCOBALAMIN IIEnables B12 absorption by cells, receptor on all type of cells, produced by

endotelial cells, fibroblasts, ileum cells.., his lack leads to severe B12 deficiency in cells

Pernicious anaemia

Megaloblastic anaemiaDiferential dg.:

• atrofic gastritis / sprue/ inflamations, atrofic gastritis / sprue/ inflamations, parasites/ medication/ liver laesionsparasites/ medication/ liver laesions

• DNA synthesis impairement due to DNA synthesis impairement due to abnormal cell clone– MDSabnormal cell clone– MDS

(bone marrow biopsy,(bone marrow biopsy,

cytogenetics, cytochemistry, B12)cytogenetics, cytochemistry, B12)

TreatmentTreatment

• Substitution - vitamin B12 300 – 1000 μg/d

- maintainance dose

1 x za 6 – 8weeks all life long

reticulocyte crisis : Day 5 - 10 of treatment

rise of reticulocyte count up to 10-30%.

need of iron metabolism parameters, regular

gastroscopy

• Autoimmune disease

• Smooth tongue surface, vitiligo, grey hair

• Not just anaemia, but pancytopenia

• Parenteral substitution of B12

• Reticulocyte crisis

• GSK á 1-2years

HAEMOLYTIC ANAEMIA

- corpuscular: lot of them congenital

- extracorspuscular: majority acquired

CORPUSCULAR HEMOLYTIC ANAEMIA

MEMBRANE DEFECTS

ENZYMOPATIA

HEMOGLOBINOPATIA

Corpuscular Haemolytic Corpuscular Haemolytic anaemiasanaemias

• PathogenesisPathogenesis• Lack of and defects in membrane proteins (ankyrin, spectrin, Lack of and defects in membrane proteins (ankyrin, spectrin,

etc.)etc.) • Decreasesd size of ery surface – spherocyteDecreasesd size of ery surface – spherocyte increased cell membrane permeability ( Na ) increased cell membrane permeability ( Na ) • Increased need for eneregy - Increased need for eneregy - - (Na pump) increased rigidity and loss of flexibility - (Na pump) increased rigidity and loss of flexibility passge through spleen sinusoid more difficult passge through spleen sinusoid more difficult loss of membrane parts – microspherocyteloss of membrane parts – microspherocyte

• cell deth in the spleen cell deth in the spleen

• EXTRAVASCULAR HAEMOLYSISEXTRAVASCULAR HAEMOLYSIS

Hereditary spherocytosisHereditary spherocytosis

• Autosomal dominant ( rarely recesiive) disease with variable gene Autosomal dominant ( rarely recesiive) disease with variable gene expressivity expressivity variable clinical symptoms (phenotype) variable clinical symptoms (phenotype)

( anemia with ićterus, splenomegaly, hemolytic crisis ).( anemia with ićterus, splenomegaly, hemolytic crisis ).

• Diagnostics:Diagnostics:

• Anemia + s reticulocytosis + spherocytes in blood smear, Hyperplůasti Anemia + s reticulocytosis + spherocytes in blood smear, Hyperplůasti erythropoiesis in bone marrow, increased level of both direct and erythropoiesis in bone marrow, increased level of both direct and indirect bilirubin, serum Fe a feritin not increasedindirect bilirubin, serum Fe a feritin not increased

• Osmotic resistance of erythrocytes decreasedOsmotic resistance of erythrocytes decreased• Autohemolýza ( upravuje se po podání glukózy i ATP ) increasedAutohemolýza ( upravuje se po podání glukózy i ATP ) increased• PINK testPINK test

• Dif dg.:Dif dg.: other corpuscular anemias (HE, etc.) other corpuscular anemias (HE, etc.) imunne hemolytic anemiasimunne hemolytic anemias non-immune extracorpuscular hemolytic anemiasnon-immune extracorpuscular hemolytic anemias paroxysmal nocturnal hemoglobinuriaparoxysmal nocturnal hemoglobinuria sometimes MDSsometimes MDS

• Léčba:Léčba: splenectomy splenectomy

ERYTROCYTE ENZYMOPATHYERYTROCYTE ENZYMOPATHY

• Defects in enzymes of anaerobe glykolysisDefects in enzymes of anaerobe glykolysis pyruvate kinase deficiency (PKD) – chronic: haemolytic anemia, with little effect of splnectomia

• Defect in enzymes of pentose cycleDefect in enzymes of pentose cycle glucose-6-phosphate dehydrogenase deficiency increased sensitivity to oxydazing agents –

chronic haemolysis or haemolytic crisis– anemia with Heinz bodies

ANAEROBANAEROBE GLYKOLYSISE GLYKOLYSIS

GLUCOSE-6-PHOSPHATE DEHYDROGENASE defficiency

• Results in: lack of NADPH …. Increased sensitivity to oxydasing agentsResults in: lack of NADPH …. Increased sensitivity to oxydasing agents

• Gene for G6PDH: X – chromosome Gene for G6PDH: X – chromosome , wide physiologic variability of the enzyme, wide physiologic variability of the enzyme• Mutation: mostly point mutation in 1 or to bases Mutation: mostly point mutation in 1 or to bases decreased enzyme production, production of the enzyme with decreased decreased enzyme production, production of the enzyme with decreased activity or production of the enzyme with decreased afinty to the substrate or activity or production of the enzyme with decreased afinty to the substrate or with decreased stabilitywith decreased stability • Wide variability in clinical symptoms :Wide variability in clinical symptoms : Silent carrier severe haemolytic crisis, neonatal icterusSilent carrier severe haemolytic crisis, neonatal icterus

• Diagnostics:Diagnostics:• G-6-PD activity analysisG-6-PD activity analysis• Activity to substrate analysis, mobility in ELFO, stabilityActivity to substrate analysis, mobility in ELFO, stability• Molecular geneticsMolecular genetics• Other: GSH stability test, Heinz body formation testOther: GSH stability test, Heinz body formation test• • Th:Th:• Prevention of exposure to oxydative agents (medication: antimalarics, Prevention of exposure to oxydative agents (medication: antimalarics,

sulfonamides,. Food: vicia fava etc.) , splenectomy, stem cell transplantsulfonamides,. Food: vicia fava etc.) , splenectomy, stem cell transplant

HEMOGLOBINOPATHIES

• Abnormal Hb with mostly one aminoacid (AA) substitution in the globion chaineAbnormal Hb with mostly one aminoacid (AA) substitution in the globion chaine

a/ a/ sicle cell anemiasicle cell anemia – HbS – HbS

b/ b/ Hb C, Hb D, Hb EHb C, Hb D, Hb E – chronic haemolytic anemias often in combination with Hb S or – chronic haemolytic anemias often in combination with Hb S or thal thal

c/ c/ instable haemoglobin diseasesinstable haemoglobin diseases hydrofobe AA hydrofobe AA decreased binding activity of Hb or impaired secondary structure of Hb decreased binding activity of Hb or impaired secondary structure of Hb and contacts between subunitsand contacts between subunits chronic hemolytic anemia with Heinz bodies( denaturation of nestable Hb )chronic hemolytic anemia with Heinz bodies( denaturation of nestable Hb )

d/ d/ methemglobinemiamethemglobinemia Fe3+ stabilisation due to histidine tyrosine in proximity of hem group results in cynosis Fe3+ stabilisation due to histidine tyrosine in proximity of hem group results in cynosis

e/ e/ hemoglobine with increased oxygen affinityhemoglobine with increased oxygen affinity tissue hypoxia, cyanosis, polycythaemia in blood count.tissue hypoxia, cyanosis, polycythaemia in blood count.

• Diagnostics:Diagnostics: elfo Hbelfo Hb isopropanol test, Heinz body tests, isopropanol test, Heinz body tests, methemoglobine tests, afinity to O2 testsmethemoglobine tests, afinity to O2 tests molekular genetics, DNA analysismolekular genetics, DNA analysis

SICLE CELL ANEMIASICLE CELL ANEMIA

• Substitution Substitution glutamate valin on 6. position glutamate valin on 6. position chainchain: Hb polymerisation, deformation of erythrocyte, : Hb polymerisation, deformation of erythrocyte,

tvaru sickle cell. tvaru sickle cell. • hemolýza extravscular + intravascular (small vessel hemolýza extravscular + intravascular (small vessel

obstruction)obstruction)• Autosomal dominant typeAutosomal dominant type• homozygotic form – both homozygotic form – both chains impaired chains impaired • heterozygotic form – one heterozygotic form – one chain impaired chain impaired 25-50% HbS – sickle cell trait25-50% HbS – sickle cell trait

SICLE CELL ANEMIASICLE CELL ANEMIA

• Clinicaly:Clinicaly: Haemolytic + aplastic crisis, splenomegaly, Haemolytic + aplastic crisis, splenomegaly, • DiagnosticsDiagnostics blood count– anaemi with s reticulocytosis blood count– anaemi with s reticulocytosis + sicle erythrocytesery+ sicle erythrocytesery elfo hemoglobin – presence of Hb Selfo hemoglobin – presence of Hb S identification of Hb S by peptic dissolv. of globinidentification of Hb S by peptic dissolv. of globin molecul.genetics – DNA analysis- prenatal caremolecul.genetics – DNA analysis- prenatal care• Treatment:Treatment: Crisis prevention, transfusions, SCTCrisis prevention, transfusions, SCT

NON-IMMUNE ACQUIRED HEMOLYTIC ANAEMIA

MECHANICAL AND PHYSICAL CAUSESheart valve impairementhemoglobinuriamicroangiopatic hemolytic anemiawidespread burns

METABOLIC CAUSESliver disease, alcoholismhypofosfatemiahereditary abetalipoproteinemiamalnutritionCu overloadWilsonś disease

CHEMICAL SUBSTANCESoxidative agents, snake venon

INFECTIONSDirect ery infection – malariasepticemia ( clostridium perfringens aj. )leptospira, borelia

Microiangiopathic haemolytic anaemiaMicroiangiopathic haemolytic anaemia

• Cause:Cause: erythrocytes destructed by going through network of fibrine erythrocytes destructed by going through network of fibrine deposits at the small cell wall schistocytesdeposits at the small cell wall schistocytes

Vasculitis, acute glomerulonephritis, after SCT, tumors, heart valve Vasculitis, acute glomerulonephritis, after SCT, tumors, heart valve surgery, AV malformations, drugs– ticlopidinsurgery, AV malformations, drugs– ticlopidin, , infeinfectionction– Shigatoxin.– Shigatoxin.

• intravascular haemolysis + thrombi formation. Also: DIC may occur intravascular haemolysis + thrombi formation. Also: DIC may occur and make the situation more complicated and make the situation more complicated

• Clinical course:Clinical course: haemolytic anaemia, thrombocytopenia, microtrombi haemolytic anaemia, thrombocytopenia, microtrombi (CNS, kidneys) (CNS, kidneys)

Most prevalent diseases: HUS, TTP, HELLP , DICMost prevalent diseases: HUS, TTP, HELLP , DIC

MICROANGIOPATIC HEMOLYTIC ANAEMIA:MICROANGIOPATIC HEMOLYTIC ANAEMIA:diagnosis and treatment : diagnosis and treatment : TTPTTP (thrombotic (thrombotic

thrombocytopenic purpura)thrombocytopenic purpura)

• Laboratory finding:Laboratory finding:

anaemia, reticulocytosis, schistocytes, akantocytes, spherocytes, anaemia, reticulocytosis, schistocytes, akantocytes, spherocytes,

thrombocytopenia, vWF multimers in ELFO + ADAMTS 13 thrombocytopenia, vWF multimers in ELFO + ADAMTS 13 deficiency (vWF multimers cleavage enzyme), deficiency (vWF multimers cleavage enzyme),

Hyoperbilirubinemia, elevation of LDH (lactate dehydrogenase),Hyoperbilirubinemia, elevation of LDH (lactate dehydrogenase),

proteinuria, Hemoglobinuria, haptoglobin decreased, free Hb proteinuria, Hemoglobinuria, haptoglobin decreased, free Hb increased, kreatinin and urea elevated.increased, kreatinin and urea elevated.

• Léčba:Léčba:

léčba vyvolávající příčiny, u TTP/HUS plasmaferéza se substitucí léčba vyvolávající příčiny, u TTP/HUS plasmaferéza se substitucí čerstvou zmrazenou plasmou, kortikoidy, antikoagulancia, čerstvou zmrazenou plasmou, kortikoidy, antikoagulancia, transfuze erytrocytů. transfuze erytrocytů.

MICROANGIOPATIC HEMOLYTIC ANAEMIA:MICROANGIOPATIC HEMOLYTIC ANAEMIA:diagnosis and treatment : diagnosis and treatment : TTPTTP (thrombotic (thrombotic

thrombocytopenic purpura)thrombocytopenic purpura)

• Laboratory finding:Laboratory finding:

anaemia, reticulocytosis, schistocytes, akantocytes, spherocytes, anaemia, reticulocytosis, schistocytes, akantocytes, spherocytes,

thrombocytopenia, vWF multimers in ELFO + ADAMTS 13 thrombocytopenia, vWF multimers in ELFO + ADAMTS 13 deficiency (vWF multimers cleavage enzyme), deficiency (vWF multimers cleavage enzyme),

Hyoperbilirubinemia, elevation of LDH (lactate dehydrogenase),Hyoperbilirubinemia, elevation of LDH (lactate dehydrogenase),

proteinuria, Hemoglobinuria, haptoglobin decreased, free Hb proteinuria, Hemoglobinuria, haptoglobin decreased, free Hb increased, kreatinin and urea elevated.increased, kreatinin and urea elevated.

• Léčba:Léčba:

léčba vyvolávající příčiny, u TTP/HUS plasmaferéza se substitucí léčba vyvolávající příčiny, u TTP/HUS plasmaferéza se substitucí čerstvou zmrazenou plasmou, kortikoidy, antikoagulancia, čerstvou zmrazenou plasmou, kortikoidy, antikoagulancia, transfuze erytrocytů. transfuze erytrocytů.

SCHISTOCYTES

SCHISTOCYTES

AUTOIMMUNE HEMOLYTIC ANAEMIA Clasification

• HEAT antibodies - idiopatic - secondary (lymfoproliferation, other type of tumours, autoimmune diseases, viral infections, immunodefficiency) -drug induced HA

• COLD antibodies - idiopatic - secondary (lymfoproliferation, viral inf., mykoplasma, autoimmune

diseases - paroxysmal cold haemoglobinuria (lues …)

MIXED HEAT AND COLD antibodies

Pathogenesis of AIHA:

• Cooperation disorder among supresor T helper T lymphocytes and B lymphocytes responsible for immunity control

• Dysregulation of this system leads to insufficient supression of antibody formation against own antigens

IgG – monomér, Fc část – vazebné místo pro C1q složku komplementu a Fcγ receptor makrofágů.

IgM – pentamér, Fc část – vazebné místo pro C1q složku komplementu a Fcγ receptor makrofágů.

HEAT ANTIBODIESHEAT ANTIBODIES

• IgG character – optimal at 370C• Catch up of erythrocytes with binded

antibody by spleen macrophages

• EXTRAVASEXTRAVASCULARCULAR HEMOL HEMOLYSISYSIS

• Activation of complement by high antibody titre

• INTRAVAINTRAVACULARCULAR HEMOL HEMOLYSISYSIS

COLD ANTIBODIESCOLD ANTIBODIES

• IgM character – optimál at 40C• Bound to erytrocytes in colder acral

parts, possibility of complement activation, ery aglutination

INTRAVASINTRAVASCULARCULAR HEMOL HEMOLYSISYSIS

EXTRAVASEXTRAVASCULARCULAR HEMOL HEMOLYSISYSIS

Secondary Secondary AIHA AIHA with heat antibodieswith heat antibodies

• AUTOIMAUTOIMMUNEMUNE DISEASESDISEASES systemic lupus erytematodes, revmatoid arthritis, sclerodermia, ulcerose colitis, syndrome of

antiphospholipid antibodies

HEMATOLOGIC HEMATOLOGIC TUMOURSTUMOURSchronic lymphadenosis,malign lymphomas, rarely acute leucaemia

• OTHER TUMOURScarcinoma, thymoma, Kaposi sarkoma, teratoma

• INFECTIONSINFECTIONS EBV, HIV-1,2, HCV, vaccination (difteria-pertusis-

tetanus)

• IMUNODEFICIENCY IMUNODEFICIENCY congenital and acquired congenital and acquired hypogamaglobulinemia and dysgamaglobulinemia

DRUG-INDUCED HEMOLYTIC DRUG-INDUCED HEMOLYTIC ANAEMIAANAEMIA

• hapten typehapten type • imunocomplex typeimunocomplex type

• De-novo antigen formationDe-novo antigen formation

AIHA –laboratory parameters:AIHA –laboratory parameters:

• Blood count:Blood count: makrocytic anaemia with reticulocytosis• Biochemistry:Biochemistry: direct and indirect bilirubin, urobilinogen in urine• Special tests:Special tests:Direct and indirect antiglobuline test (Coombs test)

INTRAVASCULAR HEMOLYSIS PROOF:INTRAVASCULAR HEMOLYSIS PROOF: free Hb in plasma, levels of haptoglobin and hemopexin in serum, hemoglobinuria

DIRECT COOMBS TESTDIRECT COOMBS TEST

We add : anti IgG Erytrocytes with bound Ab

INDIRECT COOMBS TESTINDIRECT COOMBS TEST

Sérum with free antibodies we add: erythrocytes of particular blood group

we add : anti IgG or anti C3b

AIHA – diferential diagnosis:AIHA – diferential diagnosis:

• CORPUSCULAR HEMOLYTIC ANAEMIACORPUSCULAR HEMOLYTIC ANAEMIA negative Coombs test, positive special tests

(autohemolysis, erytrocyte enzyme tests, elfo Hb, shortened lifespan of autologous, not donor erythrocytes) PAROXYSMÁL NIGHT PAROXYSMÁL NIGHT HAEMOGLOBINURIAHAEMOGLOBINURIA

negative Coombs test, pancytopenia, CD59 and CD55 antigen defficiency on erythrocytes, CD14 antigen def. on the surface of granulocytes and monocytes

• GILBERT DISEASEGILBERT DISEASE- negative hemolysis testsnegative hemolysis tests NON- IMMUNE HEMOLYTIC ANAEMANON- IMMUNE HEMOLYTIC ANAEMA microangiopatic hemolytic anemia

(schistocytes, kidney and CNS affection), anemia from physical and chemical causes

MYELODYSPLASTIC SYNDROMEMYELODYSPLASTIC SYNDROME - hemolytic form morfological dysplastic changes,chromosomal

aberances,cytochemical changes, clonality.

AIHA - treatment:AIHA - treatment:

• Light form ( Hb > 80 g/l ):

PREDNISONEPREDNISONE 1 mg/kg/d 2-3 weeks - in case of good effect decreasing dose every 2-3

days by 10mg until 20 mg/day. - slow reduction of dose (by 5mg in 7-10 days) until

5-10mg every second day. - end of corticooid therapy when repeated direct

Coombs test negativity

When therapy is ineffective or relaps occurs: combination with

CYCLOPHOSPHAMIDECYCLOPHOSPHAMIDE 100-150 mg/d or CYCLOSPORINE ACYCLOSPORINE A 3 mg/kg/d.

AIHA - treatment:AIHA - treatment:

• SEVERE form ( Hb < 80 g/l ):

PREDNISONEPREDNISONE 1-2 g i.v. daily 5 days, after that in case of good response fast decrese of dose to 1 mg/kg.

- combination of corticoids with : CYCLOPHOSPHAMIDECYCLOPHOSPHAMIDE 200 mg i.v./d i.v. IMMUNOGLOBULINSi.v. IMMUNOGLOBULINS 0,5g /kg/d PLASMAPHERESISPLASMAPHERESIS RITUXIMABRITUXIMAB (anti CD20 monoclonal Ab) • Transfusion – together with corticoids , monitored

hospitalised patient, not more then 1 TU/day (unless vital indication)

Thank you