Approach to Anemia Notes

1. Requires clinical judgement to determine whether decreased Hgb is pathologic.

a. Strictly speaking, anemia = a decrease in absolute number of circulating RBCs, but exact cutoffs
can be hard to pinpoint as they can vary from source to source
i. Typically characterized by a decrease in hemoglobin concentration, RBC count,
and/or hematocrit
ii. Varies with state of hydration (plasma vol. e.g. preg), gender (M > F), age (children <
adults), altitude (Denver, higher than those at sea level), etc.
2. MCV is the most important parameter in the diagnostic workup of anemia
a. Many frameworks by which one can evaluate anemia: Clinical features (acute blood loss or known
cause for malabsorption) MCV, reticulocyte count (bone marrow is functioning appropriately)
b. Highly conserved across a person’s life and comes with all CBC
c. Start with MCV then based on MCV further testing (e.g. plt count, WBC, WBC differential, etc)
should be performed to determine underlying cause
d. Divided into:
i. < 80 FL: Microcytic
1. Decreased production of Hgb
a. Hgb involves: Heme, Fe, Globulin
i. Heme: Sideroblastic anemia
ii. Fe (2): IDA (MCC) and anemia of chronic disease
iii. Globulin: Thalassemia
2. Approach:
a. Common things common: Start with Fe studies (ferritin or % Sat –
calculated from TIBC and Fe)
i. Ferritin decreased and TIBC increased (or % Sat: Fe/TIBC,
decreased) = IDA
1. To note: Ferritin is an acute phase reactant and can
also be increased if patient has an ongoing chronic
infection or inflammatory process, if TIBC is
increased also, then diagnosis is likely IDA
ii. Ferritin normal (or increased) and TIBC normal (or decreased)
then do 2) Hgb electrophoresis
1. Abnormal (increased HgbA2)? Thalassemia
2. Normal: 3) More Hx + increased CRP/ESR
a. Anemia of chronic disease
i. 4) Hx normal? Or you see
increased Fe, then consider PBS,
Dx of exclusion: Sideroblastic
anemia; PBS +? -> Bone marrow
bx,
ii. 80-100 FL: Normocytic
1. Biggest category
2. Hemolytic (Increased consumption of RBCs)
3. Nonhemolytic (Decreased production)
4. Distinguish each based-on reticulocyte count
a. Increased RC? Hemolytic
i. Immune vs Nonimmune
1. Differentiate with Coombs Test
a. +: Immune (DDx: SLE, CLL, AIHA)
b. -: Nonimmune (Congenital diseases such as
Sickle cell, G6PD def, HS)
 b. Decreased RC? Nonhemolytic
i. Decreased production
ii. Bone marrow Biopsy
1. Primary
a. Hematologic
b. Aplastic anemia
2. Secondary
a. Chronic renal failure
b. Anemia of chronic disease
iii. Normal production
1. Hypersplenism
iii. >100 FL: Macrocytic
1. Abnormalities of DNA synthesis or repair (Generally speaking than can be due
to other causes):
a. 1) Vitamin B12 deficiency
b. 2) Folate deficiency
c. 3) MDS
d. 4) Chemoth
3. Algorithm organizes how to approach and tell physician what to do next
4. Fundamental division between different types of anemia are 1) Decreased Hgb production (Microcytic), 2)
Abnormal DNA synthesis (Macrocytic) 3) Increased loss (Hemolytic) or Decreased production (Non-
hemolytic)