Becky & Shef

What is haematopoiesis? The production of mature blood cells

What three processes have to occur? Proliferation (mitosis) Differentiation Maturation

Where is EPO released from? What does it do? Released from the Kidneys in response to hypoxia EPO interacts with the EPO receptor on the surface of RBCs, resulting in proliferation and differentiation of erythroid precursor cells as well as the prevention of these cells Increases the rate of mitoses Decreases the maturation time

What is erythropoiesis? What 4 constituents are needed? EPO Iron Folic acid Vitamin B12

How long does it take for a erythrocyte to mature? How long do they circulate for? 7 days to mature Circulate for 120 days – Why is this significant?*

What changes does a committed stem cell undergo in order to become an erythrocyte? (6) Decrease in cell size Hb production Loss of organelles Acquisition of eosinophilic cytoplasm Extrusion of nucleus Acquisition of biconcave disc shape

What is anaemia? Fewer red blood cells than normal OR less haemoglobin than normal in each red blood cell.

How do we assess erythrocytes? Size (MCV) & Colour (MCH) Affected by: Iron Deficiency leads to microcytic, hypochromic anaemia Vitamin B12 Deficiency leads to macrocytic anaemia Folic acid Deficiency leads to macrocytic anaemia

Full Blood Count Hb Haematocrit MCV MCH MCHC RDW WBC (See notes below for definitions)

#1 Clinical Presentation A 42yo male presents to his GP reporting several episodes of epistaxis (nose bleeds) for the past two weeks. Following examination, the GP noticed blood filled bullae in their mouth along with numerous petechiae on their upper & lower limbs.

HAEMATOLOGY Name: William Jenkins Date of Birth: 11/10/1972Address: 29 Humphrey Road, Birmingham GP/Requesting Clinician: NHS No./Hospital No Clinical Details Provided: Epistaxis, petechiae on upper & lower limbs, blood-filled oral bullae Value Reference Range Hb (g/L) 140 Male Female PCV/haematocrit (L/L) 0.52 Male Female RCC (10 12 /L) 5.50 Male Female MCV(fL) MCH (pg) MCHC (g/dL) RDW (%) WBC (10 9 /L) Platelets (10 9 /L)

Answer: Thrombocytopenia Low platelets (45; Normal ) FBC otherwise normal

Causes of thrombocytopenia Impaired production (in the bone marrow) Viral infections eg rubella Thiazide medication Alcohol toxicity Leukaemias Increased destruction/consumption Medicines eg some antibiotics, digoxin, heparin Sepsis Trauma Burns Pregnancy Splenic sequestration Liver cirrhosis

#2 Clinical Presentation A 34yo female has come to see you and is complaining of abdominal pain which she localises to her lower right lower quadrant (right iliac fossa). She also reports prolonged diarrhoea and has informed you that she has unintentionally lost ‘a few kilos’ over the past fortnight. She describes her stool as slimy and occasionally she notices a small amount of bright red blood. Following investigations, it is noted that she has raised CRP.

HAEMATOLOGY Name: Date of Birth: 04/07/1980Address: 233 Highland Avenue,, Hull GP/Requesting Clinician: NHS No./Hospital No Clinical Details Provided: Value Reference Range Hb (g/L) 140 Male Female PCV/haematocrit (L/L) 0.42 Male Female RCC (10 12 /L) 4.4 Male Female MCV(fL) MCH (pg) MCHC (g/dL) RDW (%) WBC (10 9 /L) Platelets (10 9 /L)

Answer: Folate deficiency / B12 deficiency Macrocytic (Megaloblastic) anaemia (MCV = 114; 80-96) Normochromic (MHC within normal range) Presentation suggestive of Crohn’s Terminal ileum commonly affected Think absorption!

Causes Vitamin B12 deficiency Conditions affecting the small intestine (particularly the terminal ileum as often seen in Crohn’s disease) Iatrogenic (For example gastectomy, medications (eg PPIs)) Autoimmune (Most common causes of B12 deficiency in the UK is pernicious anaemia) Diet (Fish & dairy products are a good source ) Folate deficiency Diet (Sources include broccoli, Brussels sprouts, asparagus, peas, chickpeas and brown rice) Malabsorption (eg Coeliac disease) Medication (eg anticonvulsants) Excessive urination

#3 Clinical Presentation A 47yo woman presents to her GP with fatigue and breast tenderness. She reports that she has been getting heavier periods (menorrhagia) than usual and experiences episodes of hot flushes. Examination findings show that she has a pale conjunctiva.

HAEMATOLOGY Name: Date of Birth:Address GP/Requesting Clinician: NHS No./Hospital No. Clinical Details Provided: Value Reference Range Hb (g/L) 135 Male Female PCV/haematocrit (L/L) 0.28 Male Female RCC (10 12 /L) 3.7 Male Female MCV(fL) MCH (pg) MCHC (g/dL) RDW (%) WBC (10 9 /L) Platelets (10 9 /L)

Answer: Iron deficiency anaemia Microcytic (MCV = 62) Hypochromic (MCH = 20)

What investigation can you carry out to confirm iron deficiency? Serum ferritin measurement Less frequently used: Transferrin saturation index TIBC (total iron binding capacity; increased in anaemia) Serum iron

Causes Pregnancy (Increased demand) Menorrhagia GI blood loss NSAIDs Stomach ulcers GI cancer Chronic kidney disease Trauma

#4 Clinical Presentation A 57yo male diagnosed with colon cancer has been receiving chemotherapy for the passed three months. He has bruises, bleeding gums, fatigue and suffers from frequent infections.

HAEMATOLOGY Name: Ben Franklin Date of Birth: 05/02/1957Address GP/Requesting Clinician: NHS No./Hospital No Clinical Details Provided: Bruising, bleeding gums, recurrent infections Value Reference Range Hb (g/L) 80 Male Female PCV/haematocrit (L/L) 0.20 Male Female RCC (10 12 /L) 2.5 Male Female MCV(fL) MCH (pg) MCHC (g/dL) RDW (%) WBC (10 9 /L) Platelets (10 9 /L)

Answer: Pancytopenia Anaemia - Low haemoglobin (Hb = 80) Thrombocytopenia (Platelets = 55) Neutropenia (WBC = 1.9)

Causes Aplastic anaemia Chemotherapy Autoimmune Viral hepatitis Leukaemia Hypersplenism Severe Folate or vitamin B12 deficiency Systemic lupus erythematosus

#5 Clinical Presentation Ryan brooks was diagnosed with rheumatoid arthritis 3 years ago. He gets easily fatigued and sometimes feels short of breath. An FBC is carried out.

HAEMATOLOGY Name: Ryan Brooks Date of Birth:Address GP/Requesting Clinician: NHS No./Hospital No. Clinical Details Provided: Value Reference Range Hb (g/L) 110 Male Female PCV/haematocrit (L/L) 0.32 Male Female RCC (10 12 /L) 4.0 Male Female MCV(fL) MCH (pg) MCHC (g/dL) RDW (%) WBC (10 9 /L) Platelets (10 9 /L)

Answer: Anaemia of chronic disease Normocytic Normochromic