anemia is Decrease in one or more of the following.... (4) (briefly say what they are)
(1) PCV (% of blood volume occupied by RBC) (2) Hct (similar to PCV but measure by machine not little glass tube) (PCV and Hct are percents) (3) [RBC] (# of RBC in a specific volume of blood) (4) Hgb (# Hgb molecules in a specific volume of blood)
first figure out theyre anemia, then describe it further with other descriptors/categories, like... (3)
(1) Morphologic features (Visual assessment/Hemogram parameters- ie big, light colored) (2) Marrow Responsiveness (regen non-regen) (3) Pathophysiologic mechanism (Loss, destruction, lack of production, ± iron deficiency, others)
what are some Morphologic features you can use to describe the anemia?
Size, shape, “color”, inclusions, etc…. This can be a Subjective vs. objective assessment..MCV, MCHC versus visual appearance
how does a hemogram tell you about RBCs?
(flow cytometry) one cell at a time through a tube red by a laser and then put on a graph, plots size versus color. Along with telling you the MVC (normochromic, microcytic,macrocytic) and MCHC (normochromic, hypochromic) also tells you RDW (red blood cell distribution width) and HDW (hemoglobin distribution width) which are the bracket measurements on the side of the graph
so if RDW is big, what is it saying?
saying you have a huge range of cells from big to small
what are some anemia adjectives you can use to describe your blood sample when you are manually visualizing it?
Polychromasia, hypochromasia, Anisocytosis, macrocytosis, also at this point look for Heinz bodies, nRBCs, Acanthocytes, schistocytes, etc
what is the only way to be sure if you have a regen versus a nonregen anemia?
Reticulocyte count needed to be sure....he says morphology (like normochromic microcytic or hypochromic macrocytic) is not an accurate indicator. Also consider chronicity---->*remember itll take a few days before you can see the reticulocytes tho, wont be immediately apparent after an accident. So if very acute, might not see reticulocytes, might need to wait for a few days until chronic enough to see
so reticulocytes is the only way to definitively know there is regen....what morphological description is the MOST close to also indicating regeneration?
polychromasia (abnormally high number of red blood cells found in the bloodstream as a result of being prematurely released from the bone marrow during blood formation)
what do reticulocytes look like, how can you visualize them?
stain with NMB, look for Precipitated RNA, mitochondria, organelles (can either be Punctate or aggregate forms) (he said in class only cats do you count the aggregrate forms) (also said remember more dots in cell, younger it is, so punctate have less dots so theyre closer to normal, aggregates have lots of dots, so go from more dots to less dots)
RBCs usually mature __days in bone marrow before being released into blood, but can be released earlier if there is _________
3-4 days, EPO
you can do an absolute reticulocyte count, but then need to go farther and figure out if its an appropriate response or not.
he said > 60,000 – 105,000 / μL (*he uses 80,000) is cutoff to say there IS regeneration
do nRBCs indicate regen anemia?
NO- but often found with regen anemia
what do nRBCs tell you?
not if it's a regen anemia- tell you that there is sthing wrong with the bone marrow. BM NOT supposted to let nRBCs out. (could be severe anemia/hypoxia, or coming from organs if lots of extramedullary hematopoeisis)
If you see lots of nRBCs and not many reticulocytes, you're gonna think...
BONE MAROW DZ. BM should not be releasing nRBCs.
Degree of regenerative response can help predict likely causes...so if the strength of erythropeosis is marked/moderate/minimal/none, what problems might you think are going on?
marked to moderate regenerative response means cause of anemia is prolly...
hemolysis or hge
moderate to minimal regen response means cause of anemia is prolly..
minimal to no regen response means cause of anemia is prolly...
a dec in production of RBCs to begin with
if there is a normocytic normochromic anemia, what problem do you think it is?
production problme- dec production
if there is a macrocytic hypochromic/ macrocytic normochromic anemia, what problem do you think it is?
prolly hge or hemolysis (if macro might also consider viral like FeLV, dec vit B)
if there is microcytic hypochromic/microcytic normochromic anemia, what problem do you think it is?
prolly iron deficiency (might also consider liver dz/angiopathy if micro)
flowchart that shows what things show you there is inc RBC production (hence regen anemia) and what reasons there might have been a need for that inc regen...
causes for hemolysis can be split into what categories?
non-immune mediated, or immune mediated (1* or 2*)
causes of hge/loss can be split into what categories?
Injury / lesion, parasites, coagulopathy
what are some findings you can get which would support your idea that the anemia is due to hemolysis are...
Increased bilirubin*, icterus*, Hemolyzed serum(redraw to make sure not a poor draw as reason), hemoglobinuria, Increased AST*, Spherocytes, acanthocytes, schistocytes, echinocytes, Heinz bodies…Often acute onset - clinical signs more significant for degree of anemia
you need one of three findings to support that it is IMMUNE MEDIATED anemia. what are these?
(1) Spherocytes (2) Agglutination (3) Positive Coombs test
what are some non-immune-mediated reasons for hemolysis?
Zinc toxicity, onion/garlic toxicity…., PK or PFK deficiency, babesia, etc
what are two supportive findings which would tell you the anemia is due to hge/loss?
(1) Low protein!!! *Both albumin and globulins lost (2) If chronic, may develop iron deficiency (Microcytic, hypochromic morphology)
when does iron deficiency cause anemia?
only when it is severe! First see RBC morphology changes, then anemia...
is there regeneration with iron deficiency anemia?
Strongly regenerative initially, progressively less so (which is why anemia is usually not the first sign of iron deficiency, morphology changes are)
what are the changes to morphology like for iron deficiency anemia like?
Progressive decrease in MCV, MCHC.....INC RDW (remember bc saying there is a bigger range of sizes of RBCs), Cats may not show MCHC changes
there are many tests for iron deficiency (because none of them are great) so what are some of the traditional tests? what is probably the BEST thing to test for iron deficiency?
traditional: Total iron binding capacity, % transferrin saturation, Serum iron, serum ferritin, Bone marrow staining (prolly just read these over)......the BEST indicator is prolly Reticulocyte indices ( CHr, rMCV <--are RETICULOCYTES bigger or smaller or diff color etc)
normocytic normochromic anemia, or do a retic count and there is minimal or no reticulocytes
what are the three categories of non-regen anemia?
hypoproliferative, Non-proliferative, Ineffective erythropoiesis (making cells but cells we're making are not good cells)
non-regen--> hypoproliferative--> what are some things that would cause this?
[this category often due to systemic dz, so usually try to ID this first and THEN try to fig out if a prob with the bone marrow] Renal probs, inflammation, endocrine, hepatic?
non-regen--> non-proliferative--> what are some things that would cause this?
Bone marrow probs!!--> PRCA, aplastic anemia, drugs/toxins, viral/rickettsia
non-regen--> ineffective erythropoiesis(making cells but cells we're making are not good cells)--> what are some things that would cause this?
bone marrow probs!!--> idiopathic, myelodysplasia, leukemia
renal dz leading to non-regen anemia usually happens when whats going on with the kidney? what does the blood morphology look like? what is the ANEMIA usually due to?
Typically in CKD cases. Characterized by mild to severe normocytic normochromic anemia and is usually due to a relative EPO deficiency or Other accumulated “suppressive factors”
if the nonregen anemia is due to renal dz, how can you tx?
most common nonregen anemia?
Anemia of Inflammatory disease (AID) aka “anemia of chronic disease”
Anemia of Inflammatory disease (AID) aka “anemia of chronic disease”--> caused by what dzs? how is it characterized by morphology?
caused by Any chronic inflammatory illness, Characterized by: Mild, NC/NC in dogs (occasionally microcytic) and Mild to severe NC/NC in cats (cats are the only ones who usually get the severe anemia...dogs usually dont get severe)
why does anemia of inflammatory dzs lead to anemia? how do you tx AID?
Due to alterations in: (1) Iron homeostasis (Reduced availability- think sequestration) (2) EPO production (3) Erythroid progenitor responses (4) RBC life span..... tx with Control of underlying disease
which endocrine dzs might cause a non-regen anemia? how bad is it/how is it charaterized?
Hypothyroidism, Altered HPA axis. Typically a MILD nc/nc anemia (occasionally macrocytic)
in summary: hypoproliferative causes of non-regen anemia are usually bc of some underlying ____, and is typically due to ___. (does BM play a role?)
usually bc of Underlying systemic disease, and is Typically due to a lack of signal, or suppression of response to signal, for a regenerative response. In general, no overt BM problems
when is the best time to do a bone marrow analysis?
ideally BEFORE you start therapy (Esp. steroids, transfusions, EPO)
If you're gonna do a BM analysis-- what state should the pt be in? how much does it affect the BM after? what equipment would you need?
Does require sedation / anesthesia (mean not to do this), Generally safe with minimal after-effects. will need a Illinois needle and Jamshidi
what sites do you usually take a BM sample form? what are the two ways to take a bm sample? (briefly how do you do them)
take from Humerus and ilium. can be: (1) ASPIRATE: Stylet left until positioned properly in marrow, suction applied, either use EDTA or make a slide FAST. (2) Bx- Stylet out once needle is in cortex, Rotation and wiggling to break off biopsy piece
you will cytology AND histopath of your BM sample. what does each tell you?
Cytology: what individual cells look like (dysplastic? normal? orderly maturation?). Histopath: overall cellularity (does BM have enough cells, not enough cells..is there fat where cells should be?) [[bm might also help you find some viral infectious dzs like FeLV or FIV or tick borne dz]]
(didnt read over specifically, spoke generally about) flowchart that shows how BM analysis can characterize diff problems, and how you might be able to determine cause from that (prolly dont need to regurg this)
drugs/toxins which might cause a non-regen anemia bc cause BM dz...
estrogens, Azathioprine, Chloramphenicol, chemotheraputics are main 4. (prolly low platelets and low white cells too)
hallmark of pure red cell aplasia? bree disposition?
maturation starts, gets to a certian point, and arrests. So hallmark is see early cells, and maybe the next stage or two, and then no cells after that stage. Mini Dachshunds predisposed
Pure red cell aplasia-- when is t 1*? when is it 2*? explain
(1) 1*- idiopathic immune-mediated (cells that are more mature than the first few stages expression some marker that the immune system attacks-- might be what happens) (2) (didnt even talk about this in class, but) Related to administration of rhEPO, maybe viral dz like parvo, FeLV, etc
how do we treat pure red cell aplasia? how do you know if tx is working?
Treatment is similar to IMHA-- Immunosuppressive therapy, +/- thromboprophylaxis. Monitor for reticulocytes, those will be the first things to come back.
what is aplastic anemia?
Unlike pre red cell aplasia, where the cells develop to a point and then stop, aplastic anemia is when they are never there to begin with and you have a hypocellular sample where you arent getting red cell development in the marrow. Usually due to some severe toxic or necrotic insult to BM
how do you treat aplastic anemia?
(where cells never begin to develop) No indication for immunosuppressive tx, unlike for pure red cell aplasia. focus on EPO, GCSF (colony stimulating factors). Stop medication or treat infection in case that is the cause. Then either wait and hope it gets better, or consider Bone marrow transplant
which viral dzs can cause non-regen anemia due to BM dz?
Parvovirus, Panleukopenia, FeLV, FIV
what other agent aside from viral dzs could cause BM dz--> non-regen anemia?
Rickettsial (Ehrlichias (others?))
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