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1、内科学 贫血总论谢彦晖第1页，共55页，编辑于2022年，星期五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，共55页，编辑于2022年，星期五Hemoglobin(Hb):male(adult)120g/L female(adult)110g/L female(gestation)10
2、0g/LRed cell count male4.5x1012 /L female4.0 x1012 /LHemocrit(HCT)male0.42 female0.37 female(gestation)0.30第3页，共55页，编辑于2022年，星期五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
3、.chronic disease8.Age at onset.第4页，共55页，编辑于2022年，星期五 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
4、in short period.第6页，共55页，编辑于2022年，星期五C.Laboratory 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，共55页，编辑于2022年，星期五2.Hb and RBC may be used to furth
5、er classify the anemia.第8页，共55页，编辑于2022年，星期五II.ClassificationA.Size(MCV)and Hb Concentration(MCHC)1.Normocytic,macrocytic,microcytic.2.Normochromic,hypochromic.(Hyperchromia does not occur)第9页，共55页，编辑于2022年，星期五Type MCV(fl)MCHC(%)MCH(pg)disorderMacro 100 32 32-35 megaloblastic anemia MDSNormo 80-100
6、26-32 32-35 aplastic anemia,blood lost,hemolytic anemiaMicro 80 26 32 iron deficiency anemia sideroblastic anemia thalassemia 第10页，共55页，编辑于2022年，星期五 B.Bone marrow response1.Regenerativea.Bone marrow actively responds by increasing its production of RBCs.b.Findings:(1)Polychromasia.(2)Reticulocytosis
7、第11页，共55页，编辑于2022年，星期五.(3)Macrocytosis(increased MCV)and hypochromia associated with reticulocytosis.(4)Hypercellular bone marrow with a low M/E ratio.(5)Increase in MCV and RDW第12页，共55页，编辑于2022年，星期五c.The presence of regeneration suggests an extramarrow cause.(1)Blood loss(2)Erythrocyte destruction(
8、hemolysis)d.Bone marrow examination would reveal erythropoietic hyperplasia.第13页，共55页，编辑于2022年，星期五2.Non-Regenerativea.Inadequate bone marrow response because of a bone marrow disorder.b.Polychromasia and reticulocytosis are absent.第14页，共55页，编辑于2022年，星期五C.Pathophysiologic mechanism1.Blood losshemorrh
9、agic anemia.2.Accelerated erythrocyte destructionhemolytic anemia.3.Reduced or defective erythropoiesis 第15页，共55页，编辑于2022年，星期五ANEMIA FROM ACCELERATED ERYTHROCYTE DESTRUCTION(HEMOLYTIC ANEMIA)第16页，共55页，编辑于2022年，星期五A.Clinical findings1.Clinical signs of hemorrhage are absent.2.Jaundice may be seen in
10、acute and severe cases.3.Hemoglobinuria and red plasma is seen if significant intravascular hemolysis occurs第17页，共55页，编辑于2022年，星期五B.Laboratory findings1.Reticulocyte counts are higher in hemolytic anemias than externalhemorrhagic anemias 2.Plasma protein concentration is normal or increased.第18页，共55
11、页，编辑于2022年，星期五3.Neutrophilic leukocytosis and monocytosis may occur.4.Evidence of Hb degradation(hyperbilirubinemia,hemoglobinuria).5.Abnormal erythrocyte morphology(Heinz bodies,erythrocytic parasites,spherocytes,or poikilocytes).第19页，共55页，编辑于2022年，星期五I.Differentiation of the Causes of Hemolytic An
12、emiasA.Extravascular hemolysis第20页，共55页，编辑于2022年，星期五1.Mechanismsa.Autoimmune Mediated-Antibody and/or C3 mediated(AIHA,infection,drug,immune system disorder)b.Decreased erythrocyte deformability(a)Shistocytes of microangiopathic anemia(b)Spherocytes of immune-mediated anemia(c)Parasitized erythrocyt
13、es(d)Heinz body-containing cells第21页，共55页，编辑于2022年，星期五c.Reduced glycolysis and ATP content of the erythrocyte(PK deficiency)d.Increased macrophage activity (hypersplenism)第22页，共55页，编辑于2022年，星期五e.Intravascular causes of hemolysis do not lyse all erythrocytes;some altered cells may remain that are rem
14、oved by phagocytosis.第23页，共55页，编辑于2022年，星期五2.Clinical and laboratory characteristics of phagocytic(extravascular)hemolysis.a.Usually chronic with insidious onset.b.A regenerative response.c.Hemoglobinemia and hemoglobinuria are absent.第24页，共55页，编辑于2022年，星期五d.Hyperbilirubinemiae.Neutrophilia,monocyto
15、sis,and thrombocytosisf.Splenomegaly.第25页，共55页，编辑于2022年，星期五h.Low-grade extravascular hemolysis occurs in many anemias that are primarily nonhemolytic(e.g.,anemia of chronic renal disease,iron-deficiency anemia).Referred to as the“hemolytic component”of other types of anemia第26页，共55页，编辑于2022年，星期五B.In
16、travascular 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，共55页，编辑于2022年，星期五1.Mechanisms:The erythrocyte membrane must be significantly disrupted to allow escape of the Hb molecul
17、e into the plasma.Most of the mechanisms of intravascular hemolysis are extrinsic or extracorpuscular defects the erythrocyte is initially normal.第28页，共55页，编辑于2022年，星期五a.Complement-mediated lysis.(neonatal isoerythrolysis and transfusion reactions,PNH)b.Physical injury(Traumatic,microangio-pathic an
18、emia,DIC,Coagulation,Vasculitis)c.Oxidative injury(Heinz body,methemo-globin)d.Osmotic lysis(hypotonic intravenous fluids)第29页，共55页，编辑于2022年，星期五e.Other membrane alterations.(1)Castor beansricin.Causes direct lysis(2)Snake venoms(3)Bacterial toxins(4)Parasites(Babesia)第30页，共55页，编辑于2022年，星期五2.Clinical
19、 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 response occurs,but it may not be evident in
20、early stages.第31页，共55页，编辑于2022年，星期五d.Hemoglobinemia is the principal feature of intravascular hemolysis.(1)Red discoloration of plasma(2)Increased MCHCe.Hemoglobinuria f.Hemosiderinuriag.Hyperbilirubinemia第32页，共55页，编辑于2022年，星期五h.Additional laboratory findings may include schistocytes,keratocytes,Hei
21、nz bodies,erythrocytic parasites,positive Coombs test.第33页，共55页，编辑于2022年，星期五 ANEMIA FROM REDUCED OR DEFECTIVE ERYTHROPOIESIS reduced or defective erythropoisis long or onset insidious clinic course第34页，共55页，编辑于2022年，星期五I.General considerations.A.Mechanisms:1.Precursor cells Nutrients(iron and B vita
22、mins)Stimulation(erythropoietin)第35页，共55页，编辑于2022年，星期五2.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，共55页，编辑于2022年，星期五B.Bone marrow response1.When the number of precursor ce
23、lls or erythropoietic 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，共55页，编辑于2022年，星期五3.All degrees of bone marrow failure can occ
24、ur,from complete aplasia to a suboptimal response of the erythroid marrow following hemorrhage or hemolysis.第38页，共55页，编辑于2022年，星期五II.Differentiation of anemias caused by reduced or defective erythropoiesis.erythrocyte morphology,u blood neutrophil u platelet numbersu bone marrow cellularity.第39页，共55
25、页，编辑于2022年，星期五 A.Normocytic,normochromic anemia;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，共55页，编辑于2022年，星期五 b.Endocrinopath
26、ies (1)Cushings (2)Hypoandrogenism (3)Hypopituitarism第41页，共55页，编辑于2022年，星期五 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，共55页，编辑于2022年，星
27、期五d.Laboratory findings include:(1)Low serum iron (2)Low total iron binding capacity (3)Increased bone marrow macrophage iron (4)Mild-moderate anemia that is usually nonprogressive 第43页，共55页，编辑于2022年，星期五 3.Pure red cell aplasia a.Characterized by a selective loss of erythroid precursors in the bone
28、marrow.b.Thought to be immune mediated.4.Unknown mechanisms a.Liver disease b.Vitamin E deficiency第44页，共55页，编辑于2022年，星期五 B.Normocytic,normochromic anemia;neutropenia and/or thrombocytopenia;M/E ratio is difficult to determine because of hypocellularity.第45页，共55页，编辑于2022年，星期五1.Aplastic anemia a.pancy
29、topenia.b.shorter life spans of the cells.c.Causes (1)Drugs,chemicals,plants (2)Irradiation (3)Cytotoxic T cells or antibody (4)Infectious agents 第46页，共55页，编辑于2022年，星期五 2.Myelophthisic anemia a.The bone marrow is physically replaced by an abnormal proliferation of cells.(1)Myeloproliferative disorde
30、rsleukemias (2)Myelofibrosis (3)Osteosclerosis (4)Diffuse granulomatous osteomyelitis (5)Metastatic cancer第47页，共55页，编辑于2022年，星期五 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，共55页，编辑于2022年，星期五 C.Microcytic,hypochromic anemia;variable neutrophil and platel
31、et number;usually a hypercellular marrow with a variable M/E ratio.第49页，共55页，编辑于2022年，星期五1.Iron deficiency a.Chronic hemorrhage b.Dietary deficiency,especially in young milk-fed c.Ineffective erythropoiesis early;第50页，共55页，编辑于2022年，星期五 d.Laboratory findings:(1)Low serum iron (2)Variable iron-binding
32、 capacity (3)Microcytosis (4)Hypochromasia (5)Poikilocytes (6)Hypercellular bone marrow 第51页，共55页，编辑于2022年，星期五 2.Pyridoxine deficiency.This vitamin is a cofactor in heme synthesis and a deficiency leads to a failure to utilize iron.3.Copper deficiency.Copper-containing ceruloplasmin is important in
33、iron absorption and transfer between gut,macrophages,and transferrin.第52页，共55页，编辑于2022年，星期五 D.Macrocytic,normochromic anemia;variable neutrophil and platelet number;M/E ratio usually low because of hypercellular erythroid marrow.1.Vitamin B12 and folic acid deficiency.2.Erythemic myelosis or erythro
34、leukemia.3.FeLV infection.第53页，共55页，编辑于2022年，星期五 Treatment principle of anemia(1)causes treatment(2)supporting-trnsfusion(3)giving nutrition elements for hematopoiesis 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，共55页，编辑于2022年，星期五THANKSTHANKS第55页，共55页，编辑于2022年，星期五