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Anemia:- Part 1 – Anemia

Classification, Diagnosis, and Routine Lab Tests
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Work up tests/)

Hematology (https://labpedia.net/category/lab-tests/hematology/) Lab Tests Blood b

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Table of Contents Chemic

(https://
1. Anemia tests/ch
1.0.0.1. What sample is needed for an Anemia workup?
1.0.0.2. How will you define Anemia? CSF
1.0.0.3. What are the criteria for anemia? (https://
1.0.1. What are the factors for effective erythropoiesis?
tests/csf
1.0.2. What are the types of Hemoglobin?
1.0.2.1. To understand the anemias, it is better to know the hemoglobin types and structure: Cytology
1.0.2.2. What is the role of hemoglobin in O2 transport (Hb/O2 dissociation curve)? (https://
1.0.2.3. What are the functions of Hemoglobin?
tests/cyt
1.0.3. How will you classify Anemia?
1.0.3.1. Anemia may be classified roughly based on Hb level: Fluid an
1.0.3.2. How will you classify Anemia on the basis of RBC morphology?
(https://
1.0.3.3. How will you classify anemia on the basis of physiologic abnormality?
1.0.3.4. How will you classify the anemia on the basis of etiology? tests/flu
1.0.3.5. Anemia classification based on the category:
Fungi
1.0.3.6. How will you classify the anemia on the basis of RBC indices?
1.0.3.7. What are the Laboratory Criteria for the Diagnosis of Anemias? (https://
1.0.3.8. How will you do the routine workup of the patient with anemias? tests/fun
1.0.3.9. What are the signs and symptoms of anemia?
1.0.3.10. What are the specific Signs of anemia? General
1.0.4. What are the types of Anemias? (https://
1.1. How would you describe Normochromic and normocytic Anemia? tests/gen
1.1.0.1. What are the causes of normochromic and normocytic anemia?
Hemato
1.2. How would you describe microcytic and hypochromic anemia?
1.2.0.1. What are the causes of microcytic hypochromic anemia? (https://
1.2.0.2. How will you diagnose microcytic hypochromic anemia? tests/he
1.3. How would you describe Macrocytic Anemia?
Immun
1.3.0.1. What are the lab findings of macrocytic anemia?
1.3.0.2. What are the causes of macrocytic anemia? (https://
1.4. How would you describe Hemolytic Anemia? tests/im
1.4.0.1. How will you define hemolytic anemia?
1.4.0.2. What are the causes of hemolytic anemia?
Microbi
1.4.0.3. How will you diagnose hemolytic anemia? (https://
1.4.0.4. Table showing findings in various anemias: tests/mi
1.4.0.5. Characteristic findings in various Anemias:
 1.4.0.5.1. Anemia type
1.4.0.5.2. HB
Parasito
1.4.0.5.3. MCV (https://
1.4.0.5.4. MCHC
1.4.0.5.5. Ferritin
tests/pa
1.4.0.5.6. Iron binding capacity
1.4.0.5.7. serum iron
Patholo
1.4.0.6. Classification of anemia based on RDW: (https://
1.4.0.7. Mean corpuscular volume (MCV) and Red cell distribution (RDW) in relation to various tests/pa
diseases:
1.4.0.8. Abnormalities of RBCs and their etiology: Tumor m
1.4.1. Panic values are: (https://
1.4.2. Questions and answers: tests/tum
Urine A

Anemia (https://
tests/ur

What Sample Is Needed For An Anemia Workup? Virology

(https://
1. EDTA blood is needed. tests/vir
2. For RBC morphology, a direct smear is preferred.`
3. Bone marrow is also advised.
4. Also, a bone biopsy may be needed.

How Will You Define Anemia?

1. Anemia is a decrease in hemoglobin concentration depending on the
patient’s age and sex.
1. The diagnostic criteria are low hemoglobin, low hematocrit (Hct), or
decreased RBC count.

(https://labpedia.net/wp-content/uploads/2020/01/Anemia-criteria-1.jpg)
Criteria for the anemia

What Are The Criteria For Anemia?

1. Hemoglobin:
1. Male = Hb <13.5 g/dL.
 2. Female = Hb 11.5 g/dL.
3. 2 years to puberty = 11.0 g/dL.
4. A Newborn = 14.0 g/dL is taken as a lower limit because of the high
Hb.
2. Hematocrit (Hct)
1. Male = <42%.
2. Female = <37%.
3. In a broad sense, anemia is the inability of the blood to supply adequate O2
to the tissue for proper metabolism.
4. These are the most common hematological disorders.
5. The diagnosis is essential for the physician to treat the cause of anemia.

What are the factors for e!ective erythropoiesis?

1. Level of iron and cobalt.
2. Vitamin B12.
3. Vitamin B6.
4. Riboflavin.
5. Thiamine.
6. Vitamin C.
7. Vitamin E.
8. Hormones like:
1. Androgens.
2. Thyroxine.

What are the types of Hemoglobin?

To Understand The Anemias, It Is Better To Know The
Hemoglobin Types And Structure:

Type of hemoglobin Structure of Frequency of the

hemoglobin hemoglobin

At birth

Hb F α2 / γ2 60 to 90%

Hb A α2 / β2 10 to 40%

At adult age

Hb A1 α2 / β2 >95%

Hb A2 α2 / δ2 <3.5%
 Hb F α2 / γ2 <1 to 2%

What Is The Role Of Hemoglobin In O2 Transport (Hb/O2

Dissociation Curve)?
1. The RBCs carry O2 from the lung to the tissue and bring CO2 in the venous
blood to the lung.
2. This is dependent upon the 2,3-diphosphoglycerate (2,3-DPG).
3. When the O2 is unloaded, the β-chain of Hb has pulled apart, permitting the
entry of the metabolites 2,3-DPG resulting in a lower molecule affinity for
O2.

(https://labpedia.net/wp-content/uploads/2020/01/Hb-role-for-oxygen-carrying-2.jpg)
Anemia: Hemoglobin (Hb) role in oxygen carriage

4. O2 saturation is an indicator of the % of Hb saturated with O2.

5. When 92% to 100% of the Hb carries O2, the tissues adequately provide the
O2 supply, which means normal O2 dissociation.
6. Normally O2 exchange takes place:
1. 95% saturated arterial blood with a mean arterial O2 tension of 95
mmHg.
2. 70% saturated venous blood with a mean venous O2 tension of 40
mmHg.
3. So the curve’s normal position depends upon the concentration of 2,3-
 DPG, H+ ions, and CO2 in the RBCs and the Hb molecule structure.

(https://www.labpedia.net/wp-content/uploads/2020/01/Hb-oxy-and-deoxy-1.jpg)
Hemoglobin-Oxy and Deoxy Hemoglobin

What Are The Functions Of Hemoglobin?

1. RBCs in arterial blood carry O2 from the lungs to the tissue and take back
CO2 in the venous blood.
(https://www.labpedia.net/wp-content/uploads/2020/01/RBC-Hb-role-in-oxygenation.jpg)
RBC (Hemoglobin) role in oxygenation

1. This main function is with the help of hemoglobin (Hb) molecules, as the Hb
molecule load and unload the O2.
2. α1β1 and α2β2 globin stabilize the molecule.

How will you classify Anemia?

Anemia May Be Classified Roughly Based On Hb Level:
1. Severe anemia when the Hb is <7 g/dL.
2. Moderate when the Hb is 7 to 10 g/dL. This group will not produce evident
S/S. in most cases.

How Will You Classify Anemia On The Basis Of RBC

Morphology?
1. Normochromic and normocytic anemias are due to:
1. Anemia of acute hemorrhage.
2. Hemolytic anemia.
3. Anemia due to chronic diseases.
2. Hypochromic and microcytic anemias are due to:
1. Iron deficiency anemia.
 2. Thalassemia.
3. Normochromic and macrocytic anemias are due to:
1. Vit. B12 deficiency.
2. Folate deficiency.
1. Normochromic and macrocytic anemia is a late event in
vitamin B12 and folate deficiency.
2. Chatgpt says normochromic or hypochromic.

How Will You Classify Anemia On The Basis Of Physiologic

Abnormality?
1. Defective maturation of erythropoiesis.
2. Hemolytic anemia is where the increased breakdown of the RBCs occurs.
3. Defect due to an increase in RBC precursors compared to the degree of
anemia.

How Will You Classify The Anemia On The Basis Of Etiology?

1. Increased RBC destruction due to intra or extra red blood cell defects.
2. Increased blood loss, which may be acute or chronic.
3. Defective RBC formation due to a lack of factors necessary for
erythropoiesis.

Anemia Classification Based On The Category:

1. Increased destruction of the RBCs
1. Hemolytic anemia (nonimmune).
2. Immune hemolytic anemia.
2. Anemia due to blood loss in hemorrhage.
3. Nutritional deficiency like folate or vitamin B12 deficiency.
4. Toxicity due to drugs.
5. Infections.
6. Infiltration of the bone marrow by the cancer cells.
7. Hereditary or acquired defect in the RBCs.
8. Hematopoietic stem cell arrest or damage.
9. Idiopathic or unknown cause.

How Will You Classify The Anemia On The Basis Of RBC

Indices?
1. Normocytic:
1. MCV is 80 to 100 fl (femtoliter).
2. MCHC = 32 to 36%
2. Macrocytic:
1. MCV = >100 fl.
3. Microcytic and hypochromic.
1. MCV = <80 fl.
 2. MCHC = <32%.

Type of anemia MCV fl MCHC%

Normocytic and 80 to 100 32 to 36

normochromic

Microcytic and <80 <32

hypochromic

Macrocytic >100

Differentiating points of various anemias:

Characteristics Microcytic hypochromic Normocytic normochromic Ma

findings

MCV <80 fl (decreased) 80 to 95 fl (normal) >95

MCH <27 pg (decreased) ≥27 pg (normal) Inc

MCHC Decreased Normal No

Etiological factors 1. Iron deficiency 1. Hemolytic anemias

2. Thalassemia 2. After acute blood loss
3. Sideroblastic anemia 3. Bone marrow failure by
4. Chronic diseases chemotherapy or cancer
5. Lead poisoning infiltrates.
4. Renal diseases

What Are The Laboratory Criteria For The Diagnosis Of

Anemias?
1. Hemoglobin when it is less than 12 to 13 G/dL.
2. Hematocrit when it is less than 36 to 41%.
3. Reticulocyte count was normal at 0.5 to 1.5%.
4. MCV is a better choice for classifying the anemias and their differentiation.
This is useful for the screening of occult alcoholism.
5. If MCV is high, then advise:
1. Reticulocytes count.
2. Vit.B12.
3. Folate level.
 6. If MCV is low, advised:
1. Serum Iron.
2. Iron binding capacity (TIBC).
3. If the above two tests are low, advise Ferritin and Bone marrow
examination.
4. If normal, then advise electrophoresis.
7. If MCV is normal, then advise:
1. Serum Iron.
2. Iron Binding Capacity. (TIBC).
3. Comb’s test.
4. Peripheral blood for RBC morphology.

How Will You Do The Routine Workup Of The Patient With

Anemias?
1. The patient’s detailed clinical history for diagnosis, physical examination,
signs, and symptoms with the following lab workup.
2. Hemoglobin and hematocrit.
3. Red blood cell count.
4. Blood indices.
5. MCH has limited value in the differential diagnosis of anemias. This is
instrumental calibration.
6. MCHC is also instrumental calibration, and changes occur very late in the
iron-deficiency anemia when anemia is very severe.
1. This is better to evaluate hypochromasia than MCH.
7. Red cell distribution width (RDW) helps to classify the anemia with the
help of MCV.
1. RDW is more sensitive to the differentiation of the microcytic anemia
than the macrocytic RBCs cause.
2. This has no value in patients without anemia.
8. Serum iron (Normal = 50 to 150 µg/dL).
1. Serum total iron helps in the diagnosis of anemia.
2. It differentiates between hemochromatosis and hemosiderosis.
3. It should be measured along with TIBC for evaluation of iron
deficiency.
4. This also helps to evaluate acute iron toxicity in children.
9. Total iron-binding capacity (TIBC = Normal = 250 to 450 µg/dL).
1. It helps in the differential diagnosis of anemias.
2. It should be done along with serum iron to evaluate the % saturation
for the diagnosis of iron deficiency anemia.
10. Transferrin: Serum Transferrin level is needed for the D/D of the anemia.
11. Percent transferrin saturation (normal % transferrin saturation = 20% to
50%).
1. Calculation of the % transferrin saturation = Serum iron ÷ TIBC x 100 =
 Transferrin normally 33% is saturated.
2. This is used for the D/D of the anemias.
3. This helps in the screening of hereditary spherocytosis.
12. Ferritin: Serum ferritin (normal = 20 to 250 ng/dL).
1. It correlates with the total body iron stores.
2. It differentiates iron deficiency or excess.
3. It correlates with total body iron stores.
4. It will predict and monitor iron deficiency.
5. It will give an idea about the effectiveness of iron-deficiency anemia
treatment.
6. It differentiates iron deficiency from chronic diseases.
7. It monitors the iron status in patients with chronic kidney diseases
with or without dialysis.
8. It is used to study the population’s iron level and response to iron
supplements.
9. It can detect iron overload and monitor iron accumulation.
10. It can help to guide the response to iron depletion therapy.
13. Peripheral blood smear.
1. This will inform the abnormality of the RBC shape, size, and any
inclusions.
2. There is a dimorphic picture in a mixed deficiency of iron, vitamin
B12, or folate; there are microcytes and macrocytes. In this case, blood
indices may be normal.
3. Also, find the abnormal white cells and the assessment of the platelets.
4. It can find blast cells like normoblast or granulocyte blast cells.
14. Reticulocyte count.

1. The normal range is 0.5 to 2.5%, and the absolute count is 25 to 125 x
109/L.
2. Reticulocytes are raised in anemia because of the raised level of
erythropoietin.
3. After the acute hemorrhage:
1. Erythropoietin level rises in 6 hours.
2. Reticulocyte level increases in 2 to 3 days, and the peak level
reaches 6 to 10 days.
3. Reticulocytes will be raised until the Hb becomes normal.
4. In the case of anemia, if there is no raised reticulocyte count, it means
bone marrow abnormality or lack of erythropoietin stimulus.
15. White blood cells count and platelets count count. This will rule out the
pancytopenia from the anemia.

1. In hemolysis or hemorrhage, the neutrophils and the platelets are

raised.
2. In leukemias, the white cells are also raised.
16. Bone marrow examination.
1. Bone marrow may be aspirated or can take the biopsy.
2. This will give the cellularity like myeloid: erythroid ratio, and the
presence of abnormal cells like cancer cells infiltrate.
3. Can do Special stains like iron.
(https://labpedia.net/wp-content/uploads/2020/01/Anemia-workup-3.jpg)
Anemia workup

What Are The Signs And Symptoms Of Anemia?

Clinically, S/S seen are:

1. The main symptoms are due to cardiovascular system adaptation.

1. Increased stroke volume, tachycardia, and the Hb O2 dissociation
curve changes.
1. Hyperdynamic circulation leads to tachycardia, a bounding
pulse, systolic murmurs, especially at the apex, and
cardiomegaly.
2. Older adults may find S/S of congestive heart failure.
2. In some patients with anemia, there is no S/S, while mild anemia may have
severe S/S.
3. Acute onset effect: There is an effect on the speed of onset; acute onset has
more S/S compared to the slow onset.
4. The severity of the anemia: In the case of mild anemia, there is no S/S.
1. When the Hb is <9 to 10 g/dL, it may show S/S.
2. Even Hb as low as 6 g/dL may not produce severe S/S.
5. Age: Older people tolerate less than young people.
6. There is pallor on the face and better judged from the tongue.
7. The patient will feel weakness and fatigue.
8. There are lethargy and malaise.
9. On exertion, there is dyspnoea and palpitation.
1. The older patients may have cardiac failure, angina, or intermittent
claudication or confusion.
2. This may cause retinal hemorrhage, and this may complicate anemia
of rapid onset.
10. The patient may like to eat clay, ice, and starch.
11. The patient may have syncope after the exercise.
12. They may have dizziness and headaches.
13. There is tinnitus or vertigo.
14. Usually, these patients are irritable.
15. These patients may have gastrointestinal symptoms.
 16. These patients may have difficulty sleeping or concentrating.

What
What Are
Are The
The Specific
Specific Signs
Signs Of
Of Anemia?
Anemia?
1. K0ilonychia, which is spoon-shaped nails. This is usually seen in:
1. Iron-deficiency anemia.
2. Jaundice with hemolytic or megaloblastic anemia.
3. Leg ulcers in Sickle cell anemia.
4. Other hemolytic anemias.
5. Bone deformities are seen in thalassemia and other severe congenital
anemia.
6. There may be infections and bruising with anemia due to bone
marrow failure related to thrombocytopenia and neutropenia.

(https://labpedia.net/wp-content/uploads/2020/01/anemia-koilonychia-1.jpg)
Anemia
Anemia and
and koilonychia
koilonychia

Normal
Normal adult
adult blood
blood indices
indices values:
values:

RBCs
RBCs values
values Male
Male Female
Female

Hemoglobin (Hb g/dL) 13.5 to 17.5 g/dL 11.5 to 15.5 g/dL

 Hematocrit (Hct % or Packed cell volume = PCV) 40 to 52 % 36 to 48%

RBC count 4.5 to 6.5 x1012 /L 3.6 to 5.6 x 1012/L

Mean cell volume (MCV) 80 to 95 fL

Mean cell hemoglobin (MCH) 27 to 34 pg

Mean cell hemoglobin concentration (MCHC) 30 to 35 g/dL

Reticulocytes count 25 to 125 x 109/L

What are the types of Anemias?

Anemia is divided based on RBCs indices (MCV)
MCV) into the following broad
categories:

1. Microcytic, MCV <80 fl.

2. Normocytic, MCV 80 to 100 fl.
3. Macrocytic, MCV >100 fl.

How would you describe Normochromic and

normocytic Anemia?
Lab
Lab findings:
findings:

1. Low hemoglobin.
2. Normal MCV 80 to 95 fL.
3. Normal MCH ≥27 pg.
4. Normal MCHC.
1. Mostly, these are due to acute blood loss.

The
The peripheral
peripheral blood
blood smear shows normal-looking RBCs and normal RBCs
indices.

1. The RBCs produced by the bone marrow are normal, but the number
of RBCs in circulation is reduced for many reasons.
(https://labpedia.net/wp-content/uploads/2020/01/peripheral-blood-smear1-3.jpg)
The
The peripheral
peripheral blood
blood smear
smear shows
shows normochromic
normochromic and
and normocytic
normocytic RBCs
RBCs

What
What Are
Are The
The Causes
Causes Of
Of Normochromic
Normochromic And
And Normocytic
Normocytic
Anemia?
Anemia?
1. Iron deficiency in the early stages.
2. Acute blood loss.
3. Chronic diseases of the kidneys and the liver.
4. Infiltration by leukemia and multiple myeloma.
5. Drugs like chloramphenicol cause aplastic anemia.
6. Acquired hemolytic anemia may be from the prosthetic surgery of the heart.
7. Pregnancy due to increased plasma volume.
8. Overhydration.
(https://labpedia.net/wp-content/uploads/2020/01/Anemia-normocytic-DDcdr-1.jpg)
Anemia
Anemia normocytic
normocytic and
and differential
differential diagnosis
diagnosis

How would you describe microcytic and

hypochromic anemia?
1. These are the most common types of anemia, and iron deficiency is the most
common cause.

What
What Are
Are The
The Causes
Causes Of
Of Microcytic
Microcytic Hypochromic
Hypochromic Anemia?
Anemia?
 1. This is due to iron deficiency caused by decreased iron intake in the diet or
impaired absorption.
2. Iron deficiency anemia.
3. Lead poisoning.
4. Thalassemia.
5. There may be an increased iron loss due to chronic bleeding.
6. There may be an abnormality in iron metabolism.
7. Increased demand by the body in:
1. Infancy.
2. Pregnancy.
3. Lactation.
8. Due to cancer.
9. Hemorrhoids.
10. Hookworms.
11. Drugs like salicylates (aspirin).
(https://labpedia.net/wp-content/uploads/2020/01/Anemia-microcytic-1-DDcdr-4.jpg)
Anemia
Anemia microcytic
microcytic differential
differential diagnosis
diagnosis

How
How Will
Will You
You Diagnose
Diagnose Microcytic
Microcytic Hypochromic
Hypochromic Anemia?
Anemia?
1. Low hemoglobin, males <12 g/dL and females <10 g/dL.
2. Low MCV <80 fL.
3. MCH < 27 pg.
4. Findings in the iron-deficiency anemia:
1. Serum iron is deficient.
2. TIBC is very high.
3. Serum ferritin = <10 ng/dL
4. Free RBCs protoporphyrin is high.
5. RDW is high.
 6. RBC survival time is slightly less.
5. Peripheral blood smears show microcytes and pale, hypochromic RBCs.
1. There may be leucopenia.
2. Platelets are high in case of bleeding.
3. Reticulocytes are lower than expected in the degree of anemia.
6. Bone
Bone marrow
marrow shows erythroid hyperplasia.
1. Iron stain shows deficient iron.

(https://labpedia.net/wp-content/uploads/2020/01/anemia-microcytic-hypochromic-2.jpg)
Anemia
Anemia showing
showing microcytic
microcytic hypochromic
hypochromic RBCs
RBCs

How would you describe Macrocytic Anemia?

1. These are megaloblastic anemias resulting from the deficiency of vitamin
B12, folic acid, or a combination of both.

What
What Are
Are The
The Lab
Lab Findings
Findings Of
Of Macrocytic
Macrocytic Anemia?
Anemia?
1. Low hemoglobin.
2. MCV > 99 fL.
3. The peripheral blood smear shows macrocytosis and many hypersegmented
neutrophils.
4. Occasionally, you may see leucopenia and thrombocytopenia.

What
What Are
Are The
The Causes
Causes Of
Of Macrocytic
Macrocytic Anemia?
Anemia?
1. Vitamin B12 deficiency.
2. Folic acid deficiency.
1. Or a combination of both
3. Chemotherapy side effects.
4. In the case of hydantoin therapy.
(https://labpedia.net/wp-content/uploads/2020/01/anemia-macrocytic-Diff-D.jpg)
Macrocytic
Macrocytic anemia
anemia differential
differential diagnosis
diagnosis

How would you describe Hemolytic Anemia?

How
How Will
Will You
You Define
Define Hemolytic
Hemolytic Anemia?
Anemia?
1. Hemolytic anemia is a disorder associated with the decreased life span of
RBCs.
 2. The shortened life span of RBCs may be an intracorpuscular or
extracorpuscular abnormality.
3. The severity depends on the rate of destruction and the removal of RBCs.
4. The normal bone marrow can increase its work by 6 to 8 folds, so the
anemia may not be apparent until the RBC’s life span reaches only 20 days.

What
What Are
Are The
The Causes
Causes Of
Of Hemolytic
Hemolytic Anemia?
Anemia?
1. Intrinsic defects like:
1. Hereditary defects like:
1. An abnormal RBC membrane detects hereditary spherocytosis.
2. Inherited RBC enzyme disorders like G-6-phosphate
dehydrogenase deficiency.
2. Disorders of abnormal hemoglobin production like sickle cell disease.
3. Thalassemia syndrome.
4. Paroxysmal nocturnal hemoglobinuria.
2. Extrinsic defects like:
1. Chemical and toxic agents.
2. Infection causing hemolysis.
3. Hypersplenism.
4. Immune hemolytic anemia.

How
How Will
Will You
You Diagnose
Diagnose Hemolytic
Hemolytic Anemia?
Anemia?
1. There is a raised bilirubin level.
2. There are increased reticulocytes.
3. There is polychromasia.
(https://labpedia.net/wp-content/uploads/2020/01/polychromasia.jpg)
Hemolytic
Hemolytic anemia
anemia showing
showing polychromasia
polychromasia

Table
Table Showing
Showing Findings
Findings In
In Various
Various Anemias:
Anemias:

Type
Type of
of Hb
Hb MCV
MCV MCH
MCH MCHC
MCHC
anemia
anemia

Iron deficiency low low low low

Megaloblastic low high high normal

Thalassemia low low low low

Chronic illness low low low low

Characteristic
Characteristic Findings
Findings In
In Various
Various Anemias:
Anemias:

MCH
MCH
Anemia
Anemia HB
HB MCV
MCV MCHC
MCHC Ferritin
Ferritin Iron
Iron
Type
Type Binding
Binding
Capacity
Capacity

Iron low low <76 fl low low/normal decreased increased

deficiency
Megaloblastic low high >100 increased low 32 to
fl/cell 36 g/dL
>32 pg

Chronic low low/normal low low normal/ increased normal /

illness decreased

Alpha low or low low low normal normal

Thalassemia normal /increased

Beta low low low low increased/normal normal

Thalassemia

Aplastic low increased normal normal

anemia

Classification
Classification Of
Of Anemia
Anemia Based
Based On
On RDW:
RDW:

Cell
Cell size
size Normal
Normal RDW
RDW High
High RDW
RDW

Microcytosis 1. Thalassemia minor 1. Iron deficiency

2. Chronic diseases, 2. Hb H
3. Some 3. Anemia of chronic diseases
hemoglobinopathy 4. some cases of thalassemia.
trait

Normocytic 1. Hereditary 1. Some early or partially treated iron

spherocytosis deficiency anemia
2. Acute bleeding 2. Sickle cell anemia
3. some chronic diseases
4. Some Hb traits

Macrocytosis 1. Aplastic Anemia 1. Autoimmune hemolytic anemia

2. vit. B or folate deficiency
3. Liver disease
4. thyroid disease
5. Myelodysplasia
6. Alcohol use

Mean
Mean Corpuscular
Corpuscular Volume
Volume (MCV)
(MCV) And
And Red
Red Cell
Cell Distribution
Distribution
(RDW)
(RDW) In
In Relation
Relation To
To Various
Various Diseases:
Diseases:

Red
Red cell
cell distribution
distribution Mean
Mean corpuscular
corpuscular Etiology
Etiology (causes
(causes ))
(RDW)
(RDW) volume
volume (MCV)
(MCV)
Normal Decreased (Low) 1. Thalassemia
2. chronic diseases

Normal Normal 1. Hemoglobinopathies

2. Hereditary
spherocytosis
3. Hemolysis
4. Hemorrhage (acute
bleeding)
5. Transfusion
6. Chronic diseases
(90%)
7. Liver diseases
(cirrhosis)
8. Chronic lymphocytic
leukemia
9. Uremia

Normal Raised (High) 1. Aplastic anemia

2. Preleukemia
3. Alcoholism
4. Myelodysplastic
syndrome

Raised (High) Decreased (Low) 1. Thalassemia

2. S-thalassemia
3. Iron deficiency
anemia (RBCs
fragmentation)
4. Artificial valves
5. Hb H
6. RBC fragmentation

Raised (High) Normal 1. Abnormal

hemoglobin
2. Myelofibrosis
3. Early iron or folate
deficiency
4. Sideroblastic
anemia
5. SS disease (HbS is
 present in both
genes)
6. SC disease (one gene
Hb S is combined
with Hb C)

Raised (High) Raised (High) 1. Folate or B12

deficiency
2. Cold agglutinin
disease
(Mycoplasma
infection)
3. Autoimmune
hemolytic anemia
4. Newborn

Abnormalities
Abnormalities Of
Of RBCs
RBCs And
And Their
Their Etiology:
Etiology:

Type
Type of
of RBC
RBC abnormality
abnormality Etiology
Etiology for
for the
the abnormality
abnormality

Microcytic RBCs 1. Iron-deficiency anemia

2. Thalassemia
3. Sideroblastic anemia
4. Lead poisoning

(https://www.labpedia.net/wp-
content/uploads/2020/01/Anemia-
Microcytic-hypochr-6.jpg)
Sickle
Sickle cell
cell Hb
Hb structure
structure

1. Megaloblastic anemia
Macrocytic 2. Liver diseases
3. Myelodysplastic syndrome
(https://www.labpedia.net/wp- 4. Increased reticulocyte count
content/uploads/2020/01/Anemia-
macrocytic-megaloblastic.jpg)

Spherocytes 1. Hereditary spherocytosis

2. Hemolytic anemia
3. Post transfusion
(https://www.labpedia.net/wp-
content/uploads/2020/01/RBC-
spherocyte-1.jpg)

1. Thalassemia
2. Liver diseases
Target cells
3. Sideroblastic anemia
4. Hemoglobinopathies
(https://www.labpedia.net/wp-
content/uploads/2020/01/RBC-target-cell-
1.jpg)

Teardrop cells 1. Severe anemia

2. Pernicious anemia
3. Myeloproliferative anemia

(https://www.labpedia.net/wp-
content/uploads/2020/01/RBC-tear-drop-
poikilocyte.jpg)

Elliptocytes 1. Hereditary elliptocytosis

2. Thalassemia
3. Iron-deficiency anemia

(https://www.labpedia.net/wp-
content/uploads/2020/01/RBC-
elliptocyte-1.jpg)

Sickle cells 1. Sickle cell anemia

2. Sickle-thalassemia

(https://www.labpedia.net/wp-
content/uploads/2020/01/Sickle-cell-
rbcs.jpg)
Stomatocytes 1. Malignant tumors
2. Acute alcoholism

(https://www.labpedia.net/wp-
content/uploads/2020/01/RBC-
elliptocyte-1-1.jpg)

Burr cells 1. Renal diseases

2. Liver diseases
3. Bleeding gastric ulcer
4. Severe burns

(https://www.labpedia.net/wp-
content/uploads/2020/01/RBC-burr-
cells1.jpg)

Acanthocytes 1. Alcohol intoxication

2. Post splenectomy
3. Vitamin E deficiency
4. Congenital
abetalipoproteinemia
(https://www.labpedia.net/wp-
content/uploads/2020/01/RBC-
acanthocyte1.jpg)

Helmet cells 1. G-6-PD deficiency

2. Pulmonary emboli

(https://www.labpedia.net/wp-
content/uploads/2020/01/RBC-Helmet-
cell.jpg)

1. Hemolytic uremic syndrome

Schistocytes 2. Thrombotic idiopathic
thrombocytopenia (ITP)
3. Disseminated intravascular
(https://www.labpedia.net/wp- coagulopathy (DIC)
content/uploads/2020/01/RBC-
Schistocyte-cell.jpg)
Summary
Summary of
of lab
lab findings
findings in
in various
various anemias:
anemias:

Lab
Lab test
test Iron-
Iron- Pernicious
Pernicious Folic
Folic acid
acid Aplastic
Aplastic Thalassemia
Thalassemia Siderobla
Siderobla
deficiency
deficiency anemia
anemia deficiency
deficiency anemia
anemia anemia
anemia
anemia
anemia

Hemoglobin Low Low Low Low or Low Low

normal

Hematocrit Low Low Low Low or Low Low

normal

MCV Low High High A normal Low Low

or mild
increase

Reticulocytes A normal Low Low Low Increased A normal o

count or mild mild increa
increase

Plasma Iron Low Increased Increased Increased Increased or Increased

normal

TIBC Increased Normal Normal Normal Normal Normal

Ferritin level Low Increased Increased Normal Increased or Increased

normal

Folate level Normal Normal Low Normal Normal Normal

Serum B12 Normal Low Normal Normal Normal Normal

level

Transferrin Low Mild Mild Normal Increased

increase increase

Bilirubin Normal Mild Mild Normal Increased Increased

level increase increase
(https://www.labpedia.net/wp-content/uploads/2020/01/RBC-various-forms.jpg)
Various
Various forms
forms of
of red
red blood
blood cells
cells

Panic values are:

1. Hb = <5 g/dL or >20 g/dL
 2. Hct = <20 % ( leads to heart failure) or > 60% (leads to spontaneous clotting).

Questions and answers:

Question
Question 1:
1: Does red blood cell distribution (RDW) differentiate between
thalassemia, anemia of chronic diseases, and iron deficiency anemia.
Show answer
Question
Question 2:
2: What will happen to the following laboratory parameters in
hemolytic anemia: 1. Reticulocytes 2. RDW 3. Indirect bilirubin 4. Haptoglobin?
Show answer

! Possible References Used (https://www.labpedia.net/references)

‹ Go Back To Hematology (Https://Labpedia.net/Category/Lab-

Tests/Hematology/)

Comments

ismaeel
ismaeel ali
ali Reply
Reply
! April 17, 2020
Thanks

Dr.
Dr. Riaz
Riaz Reply
Reply
! April 17, 2020
Thanks for the appreciation.

bhargavi
bhargavi Reply
Reply
! June 17, 2024
very insightful sir…
Dr.
Dr. Riaz
Riaz Reply
Reply
! June 17, 2024
Thanks.

Trenton
Trenton Skarupa
Skarupa Reply
Reply
! July 16, 2020
Dead written content, Really enjoyed reading through.

Dr.
Dr. Riaz
Riaz Reply
Reply
! July 16, 2020
Thanks

Christine
Christine Reply
Reply
! October 17, 2020
Thank you so much for this. We have a discussion about Anemia in
class and this has helped me a lot.

Dr.
Dr. Riaz
Riaz Reply
Reply
! October 17, 2020
Thanks.

HOR
HOR Setha
Setha Reply
Reply
! May 5, 2021
Many thank.

Dr.
Dr. Riaz
Riaz Reply
Reply
! May 5, 2021
You are welcome.
 sharon
sharon Reply
Reply
! August 21, 2021
really great write up. very informative .thanks

Dr.
Dr. Riaz
Riaz Reply
Reply
! August 21, 2021
Thanks.

Alinaitwe
Alinaitwe Mugabe
Mugabe Reply
Reply
! September 9, 2021
Wow, good work

Dr.
Dr. Riaz
Riaz Reply
Reply
! September 10, 2021
Thanks.

Rhonda
Rhonda Reply
Reply
! January 11, 2022
Dr. Riaz,
This was AWESOME! How in the world did you put this all together?
I want to share this with my classmates. My name is Rhonda and I
am a NP student graduating in August 2022. I so happy that this
popped up into my feed. Thank you so much for the time and effort
you put into this presentation on anemia. I will print this and use
this in my practice years to come. Have you written anything else?

Dr.
Dr. Riaz
Riaz Reply
Reply
! January 11, 2022
Thanks for the remarks. You can see other topics on
labpedia.net.
 Ateeq
Ateeq ullah
ullah Reply
Reply
! February 2, 2022
Helpful for ME thank you

Dr.
Dr. Riaz
Riaz Reply
Reply
! February 2, 2022
Thanks.

Rx
Rx Reply
Reply
! April 4, 2022
thanks!

Harnek
Harnek Lal
Lal Powar
Powar Reply
Reply
! April 15, 2022
Awesome

Dr.
Dr. Riaz
Riaz Reply
Reply
! April 16, 2022
Thanks.

Kyomugisa
Kyomugisa Reply
Reply
! April 17, 2022
I really appreciate this

Dr.
Dr. Riaz
Riaz Reply
Reply
! April 17, 2022
Thanks.
 Yuri
Yuri M
M Reply
Reply
! June 23, 2022
Amazing content! Much appreciated

Dr.
Dr. Riaz
Riaz Reply
Reply
! June 23, 2022
Thanks.

Omer
Omer Alkhateem
Alkhateem Reply
Reply
! August 28, 2022
Thank you for all this information, I really appreciate it.

Dr.
Dr. Riaz
Riaz Reply
Reply
! August 28, 2022
Thanks.

Ali
Ali TT Reply
Reply
! January 21, 2023
Hi, this really was helpful for me , especially the charts! Thanks Dr.
Riaz!

Dr.
Dr. Riaz
Riaz Reply
Reply
! January 21, 2023
Thanks.

Abigail
Abigail D
D Reply
Reply
! February 6, 2023
Thanks ,is really helpful
 Dr.
Dr. Riaz
Riaz Reply
Reply
! February 6, 2023
Thanks.

Monenus
Monenus Kedir
Kedir Reply
Reply
! June 6, 2023
is really helpful notes. thanks for sharing

Dr.
Dr. Riaz
Riaz Reply
Reply
! June 6, 2023
Thanks.

Siddiq
Siddiq Reply
Reply
! October 6, 2023
Assalamu Alaykum,
This was awesome and really captures every important
aspect of Anaemia, may Allah reward your efforts Dr !

Dr.
Dr. Riaz
Riaz Reply
Reply
! October 6, 2023
Thanks.

MOHAMMED
MOHAMMED Reply
Reply
! February 15, 2024
Good morning
I think DR.Riaz in Anemia classification based on RBC morphology:
3-(Normochromic)* and macrocytic anemias are due to:
* I think the correct (Hyperchromic)
 Dr.
Dr. Riaz
Riaz Reply
Reply
! February 16, 2024
I have tried to see many references, but mostly says
normochromic and macrocytic. Please check the topic again. I
have made some changes.

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