1. Lecturer /Sulaimani College of Medicine/ Dept.of Pathology
Anemia
Dr.Sana Delawer Jalal
Lecturer /Sulaimani College of Medicine/ Dept.of Pathology
M.B.Ch.B, F.I.C.M.S.

3. Red Cell Indices Mean Cell Volume (MCV)
It is calculated from PCV and red cell count as follows:
MCV = PCV/RBC ( fl)
Normal value: fl
It decrease in iron deficiency anaemia and haemoglopinopathies
It is increase in megaloblastic anaemia and chronic haemolytic anemia

4. Mean Cell Haemoglobin Concentration (MCHC)
It is calculated from the haemoglobin and PCV as follows:
MCHC = Hb/PCV g/dl
Normal value: g/dl
It is usually decreased in iron deficiency anaemia (microcytic hypochromic anaemia)

5. Mean Cell Haemoglobin (MCH)
It is calculated from the haemoglobin and erythrocyte count as follows:
MCH = Hbx10/RBC pg
Normal value: pg
It is decrease in iron deficiency anemia and thalassaemia (microcytic hypochromic anemia)
It is recognized by the pale colour of the red cell in the peripheral blood film
It is increase in macrocytic anemia (vitamin B 12 and folic acid)

6. Red Cell Distribution width (RDW)
RDW reflects the variation of RBCs volume
it is usually performed by modern analysers
Normal RDW varies between 12 to 17
Severe iron deficiency anemia is associated with increased RDW
Thalassemia and anemia of chronic disease are associated with normal RDW

7. Definition
Anemia is a decrease in the number of RBCs, Hb content, or Hematocrit below the lower limit of the normal range for the age and sex of the individual
In adults, the lower extreme of the normal haemoglobin is taken as 13.0 g/ dl for males and 11.5 g/dl for female
Newborn infants have higher haemoglobin level and, therefore, 15 g/dl is taken as the lower limit at birth

8. Classification of Anemia
Several types of classifications of anemia's have been proposed
Two of the widely accepted classifications are based on :
The pathophysiology
The morphology

9. The Pathophysiological Classification
Depending upon the pathophysiologic mechanism, anemias are classified into 3 groups:
I. Anemia due to increased blood loss.
II. Anemias due to impaired red cell production.
III. Anemias due to increased red cell destruction .(Haemolytic )

10. The Morphological Classification
Based on:
Red cell size,
Haemoglobin content
Red cell indices
Anaemias are classified into 3 types:
I. Microcytic, hypochromic
II. Normocytic, normochromic
III. Macrocytic, normochromic

11. Simplified Classification Of Anemias
1. Deficiency anemias
2. Aplastic anemia
3. Hemolytic anemias
4. Secondary anemias

12. The Pathophysiological Classification

13. Impaired Red Cell Production
A. Disturbance of proliferation and differentiation of stem cells ( aplastic anemia, pure red cell aplasia)
B. Disturbance of proliferation and maturation of erythrocytes:
1.Defective DNA synthesis (megaloblastic anemias)
2.Defective Hb synthesis:
a/. Deficient heme synthesis (iron deficiency)
b/. .Deficient globin synthesis (thalassemia)
3. Unknown or multiple mechanisms (anemia of chronic disease, anemia of marrow replacement)

14. Increased Rate Of Destruction
Intrinsic abnormalities
Hereditary
1. Red cell membrane defects (Hereditary spherocytosis, Hereditary eliptocytosis)
2. Red cell enzyme deficiencies
a/. Glycolytic enzymes: pyruvate kinase, hexokinase
b/. Enzymes of hexose monophosphate shunt:
G-6PD, glutathione synthetase.
3. Disorders of globin synthesis
a/. Deficient globin synthesis (thalassemia)
b/. Structurally abnormal globin synthesis
(sickle cell anemia, unstable hemoglobins)
Acquired
1. Membrane defect: paroxysmal nocturnal hemoglobinuria

15. Increased Destruction Extrinsic Abnormalities
1. Antibody Mediated
a/. Autoantibodies (idiopathic, drug-associated, SLE, malignancies)
b/. Alloantibodies (transfusion reactions, erythroblastosis fetalis)
2. Mechanical Trauma of RBCs
a/. Microangiopathic hemolytic anemias (thrombotic
thrombocytopenic purpura,hemolytic –uremic syndrome )
b/. Cardiac traumatic hemolytic anemia
3. Chemicals and Micro organisms
4. Sequestration in mononuclear phagocytic system
- hypersplenism

16. Morphologic Classification Of Anemias
Type MCV MCHC Common cause
____________________________________________________
Macrocytic anemia increased normal Vitamin B12 deficiency
Folic acid deficiency
Microcytic anemia
- hypochromic decreased decreased Iron deficiency
Thalassemia
- normochromic decreased normal Spherocytosis
or normal
Normocytic anemia normal normal Aplastic anemia
- normochromic Chronic renal failure
Some hemolytic anemia

17. Classification of anemias using MCV

18. Thalassemia Microcytic Anemia MCV<80 fl Iron Deficiency
Sideroblastic
Anemia
Thalassemia
Microcytic Anemia
MCV<80 fl
Anemia of Chronic
Disorder
Lead Poisoning

19. Reduced Erythropoiesis
Stem cells defects/
Reduced Erythropoiesis
Normocytic
Anemias
80-95 fl
Intrinsic
Extrinsic
Hemolytic Anemias
Extrinsic Causes
Intrinsic Defects

20. Drugs Myelodysplastic Alcoholism syndrome Macrocytic Anemias
Megaloblastic anemia
Macrocytic Anemias
MCV> 95 fl
Hypothyrodisim
Liver Disease
Drugs

21. Hypochromic Microcytic

22. Normochromic Normocytic

23. Laboratory Investigation
Anemia is not a diagnosis, but a sign of underlying disease
The objective of the laboratory is to :
determine the type of anemia as an aid in discovering the cause

24. Laboratory Investigation-cont.
Screening is usually done with the CBC or "complete blood count"
Most laboratories now use automated, multiparameter instruments which will provide results for the following parameters:
Hemoglobin
Hematocrit
Red cell count
MCV , MCH ,MCHC
RDW
White cell and platelet count
Differentia WBC count. l

25. Laboratory Investigation of Hemolytic anemia
These are dividing into 4 groups:
I-Tests show increased red cell breakdown
II- Tests show increased red cell production
III- Tests show damage to red cells
IV- Tests show shortened red cell life span

26. Tests Show Increased Red Cells Breakdown
Serum bilirubin-unconjugated (indirect)bilirubin is raised
Urine Urobilinogen is raised
Faecal Stercobilinogen is raised
Serum haptoglobin ( α globulin binding protein) is reduced or absent
Plasma lactic acid dehydrogenase is raised
Evidence of intravascular haemolysis in the form of haemoglobinaemia, haemoglobinuria, haemosiderinuria

27. Tests Show Increased Red Cells Production.
Reticulocyte count reveals reticulocytosis which indicate marrow erythroid hyperplasia
Routine blood film shows macrocytosis, polychromasia, and normoblasts
Bone marrow show erythroid hyperplasia
X ray of bones shows evidence of expansion of marrow spaces especially in tubular bones and skull

28. Tests Revealing Damages To RBCs
Routine blood film shows a variety of abnormal morphological appearances of red cells
Osmotic fragility is increased
Autohaemolysis test
Coomb's antiglobulin test
Electrophoresis for abnormal haemoglobin
Estimation of HbA2

29. Tests Show Shortened Red Cell Life Span
Tested by Cr51 labeling method normal RBC life span of 120 days is shortened to days in moderate haemolysis and 5-20 days in severe haemolysis

30. Special Investigations
Biochemical Tests
biochemical tests are aimed to identifying:
1-Depleted cofactors necessary for normal hematopoiesis (iron, ferritin, folate, B12).
2-Abnormally functioning enzyme (glucose-6-phosphate dehydrogenase, pyruvate kinase), or
3-Abnormal function of the immune system (the direct antiglobulin [Coombs'] test).

31. Thank you