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1、内科学 贫血总论谢彦晖第1页，此课件共55页哦DIAGNOSIS AND CLASSIFICATION Anemia is an absolute decrease in hematocrit,hemoglobin concentration,or the RBC count.Anemia is not a diagnosis,but a sign of underlying disease.第2页，此课件共55页哦Hemoglobin(Hb):male(adult)120g/L female(adult)110g/L female(gestation)100g/LRed cell count
2、 male4.5x1012 /L female4.0 x1012 /LHemocrit(HCT)male0.42 female0.37 female(gestation)0.30第3页，此课件共55页哦I.Determination of the cause:A.History1.Drug administration.2.Exposure to toxic chemicals 3.Family occurrence.4.Recent transfusions 5.menstruation(woman)6.ingestion(child)7.chronic disease8.Age at on
3、set.第4页，此课件共55页哦 B.Physical findings and complaintsa.Pale mucous membranes and skinsb.Weakness,loss of stamina,and exercise intolerance,Hypersensitivity to cold,fever.c.Tachycardia and polypnea,Heart murmur.anemia associated cardiac disease:Hb1/2blood volume lost in short period.第6页，此课件共55页哦C.Labora
4、tory findings1.The Hct is the easiest,most accurate method for detecting anemia.Its result should be interpreted with knowledge of the hydration status and any alteration caused by splenic contraction.第7页，此课件共55页哦2.Hb and RBC may be used to further classify the anemia.第8页，此课件共55页哦II.ClassificationA.
5、Size(MCV)and Hb Concentration(MCHC)1.Normocytic,macrocytic,microcytic.2.Normochromic,hypochromic.(Hyperchromia does not occur)第9页，此课件共55页哦Type MCV(fl)MCHC(%)MCH(pg)disorderMacro 100 32 32-35 megaloblastic anemia MDSNormo 80-100 26-32 32-35 aplastic anemia,blood lost,hemolytic anemiaMicro 80 26 32 ir
6、on deficiency anemia sideroblastic anemia thalassemia 第10页，此课件共55页哦 B.Bone marrow response1.Regenerativea.Bone marrow actively responds by increasing its production of RBCs.b.Findings:(1)Polychromasia.(2)Reticulocytosis第11页，此课件共55页哦.(3)Macrocytosis(increased MCV)and hypochromia associated with retic
7、ulocytosis.(4)Hypercellular bone marrow with a low M/E ratio.(5)Increase in MCV and RDW第12页，此课件共55页哦c.The presence of regeneration suggests an extramarrow cause.(1)Blood loss(2)Erythrocyte destruction(hemolysis)d.Bone marrow examination would reveal erythropoietic hyperplasia.第13页，此课件共55页哦2.Non-Rege
8、nerativea.Inadequate bone marrow response because of a bone marrow disorder.b.Polychromasia and reticulocytosis are absent.第14页，此课件共55页哦C.Pathophysiologic mechanism1.Blood losshemorrhagic anemia.2.Accelerated erythrocyte destructionhemolytic anemia.3.Reduced or defective erythropoiesis 第15页，此课件共55页哦
9、ANEMIA FROM ACCELERATED ERYTHROCYTE DESTRUCTION(HEMOLYTIC ANEMIA)第16页，此课件共55页哦A.Clinical findings1.Clinical signs of hemorrhage are absent.2.Jaundice may be seen in acute and severe cases.3.Hemoglobinuria and red plasma is seen if significant intravascular hemolysis occurs第17页，此课件共55页哦B.Laboratory f
10、indings1.Reticulocyte counts are higher in hemolytic anemias than externalhemorrhagic anemias 2.Plasma protein concentration is normal or increased.第18页，此课件共55页哦3.Neutrophilic leukocytosis and monocytosis may occur.4.Evidence of Hb degradation(hyperbilirubinemia,hemoglobinuria).5.Abnormal erythrocyt
11、e morphology(Heinz bodies,erythrocytic parasites,spherocytes,or poikilocytes).第19页，此课件共55页哦I.Differentiation of the Causes of Hemolytic AnemiasA.Extravascular hemolysis第20页，此课件共55页哦1.Mechanismsa.Autoimmune Mediated-Antibody and/or C3 mediated(AIHA,infection,drug,immune system disorder)b.Decreased er
12、ythrocyte deformability(a)Shistocytes of microangiopathic anemia(b)Spherocytes of immune-mediated anemia(c)Parasitized erythrocytes(d)Heinz body-containing cells第21页，此课件共55页哦c.Reduced glycolysis and ATP content of the erythrocyte(PK deficiency)d.Increased macrophage activity (hypersplenism)第22页，此课件共
13、55页哦e.Intravascular causes of hemolysis do not lyse all erythrocytes;some altered cells may remain that are removed by phagocytosis.第23页，此课件共55页哦2.Clinical and laboratory characteristics of phagocytic(extravascular)hemolysis.a.Usually chronic with insidious onset.b.A regenerative response.c.Hemoglob
14、inemia and hemoglobinuria are absent.第24页，此课件共55页哦d.Hyperbilirubinemiae.Neutrophilia,monocytosis,and thrombocytosisf.Splenomegaly.第25页，此课件共55页哦h.Low-grade extravascular hemolysis occurs in many anemias that are primarily nonhemolytic(e.g.,anemia of chronic renal disease,iron-deficiency anemia).Refer
15、red to as the“hemolytic component”of other types of anemia第26页，此课件共55页哦B.Intravascular hemolysisErythrocytes are destroyed within the circulation,releasing hemoglobin into the plasma where it is either removed by the liver or excreted by the kidneys.第27页，此课件共55页哦1.Mechanisms:The erythrocyte membrane
16、 must be significantly disrupted to allow escape of the Hb molecule into the plasma.Most of the mechanisms of intravascular hemolysis are extrinsic or extracorpuscular defects the erythrocyte is initially normal.第28页，此课件共55页哦a.Complement-mediated lysis.(neonatal isoerythrolysis and transfusion react
17、ions,PNH)b.Physical injury(Traumatic,microangio-pathic anemia,DIC,Coagulation,Vasculitis)c.Oxidative injury(Heinz body,methemo-globin)d.Osmotic lysis(hypotonic intravenous fluids)第29页，此课件共55页哦e.Other membrane alterations.(1)Castor beansricin.Causes direct lysis(2)Snake venoms(3)Bacterial toxins(4)Pa
18、rasites(Babesia)第30页，此课件共55页哦2.Clinical and laboratory characteristics of intravcascular hemolytic anemia.a.Most cases present as peracute or acute episodes.b.History may reveal exposure to causative drugs or plants,recent transfusion of blood,or recent ingestion of colostrum.c.A regenerative respon
19、se occurs,but it may not be evident in early stages.第31页，此课件共55页哦d.Hemoglobinemia is the principal feature of intravascular hemolysis.(1)Red discoloration of plasma(2)Increased MCHCe.Hemoglobinuria f.Hemosiderinuriag.Hyperbilirubinemia第32页，此课件共55页哦h.Additional laboratory findings may include schisto
20、cytes,keratocytes,Heinz bodies,erythrocytic parasites,positive Coombs test.第33页，此课件共55页哦 ANEMIA FROM REDUCED OR DEFECTIVE ERYTHROPOIESIS reduced or defective erythropoisis long or onset insidious clinic course第34页，此课件共55页哦I.General considerations.A.Mechanisms:1.Precursor cells Nutrients(iron and B v
21、itamins)Stimulation(erythropoietin)第35页，此课件共55页哦2.Bone marrow failure(intramarrow disease and extramarrow causes)3.Bone marrow failure may be selective for the erythroid series or may also affect the other cell lines.第36页，此课件共55页哦B.Bone marrow response1.When the number of precursor cells or erythrop
22、oietic stimulation is inadequate,the erythroid marrow is hypocellular.2.Maturation abnormalities which characterize the nutritional deficiencies,are associated with a Hypercellular marrow and ineffective erythropoiesis.第37页，此课件共55页哦3.All degrees of bone marrow failure can occur,from complete aplasia
23、 to a suboptimal response of the erythroid marrow following hemorrhage or hemolysis.第38页，此课件共55页哦II.Differentiation of anemias caused by reduced or defective erythropoiesis.erythrocyte morphology,u blood neutrophil u platelet numbersu bone marrow cellularity.第39页，此课件共55页哦 A.Normocytic,normochromic a
24、nemia;normal or increased neutrophil and platelet numbers;increased M/E ratio caused by hypocellular erythroid marrow.1.Anemia of erythropoietin lack.a.Chronic renal disease.Anemia proportional to severity of the uremia.第40页，此课件共55页哦 b.Endocrinopathies (1)Cushings (2)Hypoandrogenism (3)Hypopituitari
25、sm第41页，此课件共55页哦 2.Anemia of chronic disorders(ACD)a.Occurs in chronic infectious,inflammatory,or neoplastic disorders.b.Cytokines involved with the inflammatory process initiate the anemia.c.Erythrocyte life span reduced第42页，此课件共55页哦d.Laboratory findings include:(1)Low serum iron (2)Low total iron b
26、inding capacity (3)Increased bone marrow macrophage iron (4)Mild-moderate anemia that is usually nonprogressive 第43页，此课件共55页哦 3.Pure red cell aplasia a.Characterized by a selective loss of erythroid precursors in the bone marrow.b.Thought to be immune mediated.4.Unknown mechanisms a.Liver disease b.
27、Vitamin E deficiency第44页，此课件共55页哦 B.Normocytic,normochromic anemia;neutropenia and/or thrombocytopenia;M/E ratio is difficult to determine because of hypocellularity.第45页，此课件共55页哦1.Aplastic anemia a.pancytopenia.b.shorter life spans of the cells.c.Causes (1)Drugs,chemicals,plants (2)Irradiation (3)C
28、ytotoxic T cells or antibody (4)Infectious agents 第46页，此课件共55页哦 2.Myelophthisic anemia a.The bone marrow is physically replaced by an abnormal proliferation of cells.(1)Myeloproliferative disordersleukemias (2)Myelofibrosis (3)Osteosclerosis (4)Diffuse granulomatous osteomyelitis (5)Metastatic cance
29、r第47页，此课件共55页哦 3.Anemia caused by infectious agents a.Ehrlichiosis(埃里西提病）埃里西提病）b.FeLV（猫白血病病毒）（猫白血病病毒）第48页，此课件共55页哦 C.Microcytic,hypochromic anemia;variable neutrophil and platelet number;usually a hypercellular marrow with a variable M/E ratio.第49页，此课件共55页哦1.Iron deficiency a.Chronic hemorrhage b.Di
30、etary deficiency,especially in young milk-fed c.Ineffective erythropoiesis early;第50页，此课件共55页哦 d.Laboratory findings:(1)Low serum iron (2)Variable iron-binding capacity (3)Microcytosis (4)Hypochromasia (5)Poikilocytes (6)Hypercellular bone marrow 第51页，此课件共55页哦 2.Pyridoxine deficiency.This vitamin is
31、 a cofactor in heme synthesis and a deficiency leads to a failure to utilize iron.3.Copper deficiency.Copper-containing ceruloplasmin is important in iron absorption and transfer between gut,macrophages,and transferrin.第52页，此课件共55页哦 D.Macrocytic,normochromic anemia;variable neutrophil and platelet n
32、umber;M/E ratio usually low because of hypercellular erythroid marrow.1.Vitamin B12 and folic acid deficiency.2.Erythemic myelosis or erythroleukemia.3.FeLV infection.第53页，此课件共55页哦 Treatment principle of anemia(1)causes treatment(2)supporting-trnsfusion(3)giving nutrition elements for hematopoiesis
33、such iron agent,vitamine B12,folate acid(4)immunosuppression agent such glucocorticoid,antithymocyte globulin,cyclosporine A (5)auto-or allogeneic hematopoietic stem cell transplantation(6)hematopoietic growth hormone(EPO)or stimulating factor(androgen)(7)splenectomy第54页，此课件共55页哦THANKSTHANKS第55页，此课件共55页哦