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Anemia
2nd most presenting manifestation of disease, with pain being the first. It is defined as: low hemoglobin, low RBC count and low RBC mass. Usually presents with pallor, fatigability, weakness and pale conjunctivae In order to properly treat the anemia, you must determine the cause.
Causes of Anemia
2. Excessive breakdown and loss of red blood cells. Hemodilution while not a cause of anemia, it does cause an anemia-like effect.
Bleeding: can be due to an ulcer or in females blood loss due to their menstrual cycle Use of drugs that irritate the GI tract (aspirin) Hemolysis (Hemolytic Anemia) can be caused by:
Autoimmune disease Mechanical (heart valves, microvascular disease) Toxins (e.g., snake venom)
Anemia of end stage renal disease To treat AIDS anemia caused by AZTs suppression of bone marrow Anemia related to cancer chemotherapy Others
To increase RBC levels for autologous blood donation Anemia associated with rheumatoid arthritis
2. Interleukin 3 (IL-3)
Acts synergistically with GM-CSF to stimulate the formation of granulocytes, macrophages, eosinophils and megakaryocytes. Acts synergistically with EPO to stimulate formation of BFU-E colonies Induces CFU-S and leukemic blast cells into cell cycle
5. Thrombopoietin (TSF)
Increases the size and number of megakaryocytes. (IL-11 also useful in stimulating production)
Increases the concentration of early megakaryocytes cells (SACHE+cells) in bone marrow. Produces an increase in megakaryocytes endomitosis.
Iron Cycle
1. Aids in ionization of iron 2. Splits chelated food iron from chelator 3. Maintains iron in soluble form 4. Allows iron to remain in the absorbable form Fe3+
Blood loss
Iron Preparations
Oral Iron
Ferrous Sulfate (Feosol) 300 mg tid Side Effects are extremely mild:
Nausea, upper abdominal pain, constipation or diarrhea.
Parenteral
Iron Dextran (Imferon) IM or IV Indicated for patients who cannot tolerate or absorb oral iron or where oral iron is insufficient to treat the condition ie. Malabsorption syndrome, prolonged salicylate therapy, dialysis patients
5000 deaths/year in the US, usually in children 20% of children presenting with iron toxicity will die 1 to 2 grams are sufficient to cause death At high doses, Iron is absorbed through passive diffusion with no regulation
Early changes
Vomiting, diarrhea Blood Volume HR TPR (reflex) Acidosis from Iron oxidation, Krebs cycle and anaerobic metabolism citric acid and lactic acid
Intermediate changes
Improvement (short lived) profound shock and CV Collapse Hepatic Failure, jaundice, pulmonary edema and death
Late Stage
Toxic levels
ABCs supportive care Bicarbonate for acidosis Fluids for blood loss Ipecac or lavage
Vitamin B12
Source: In food, especially in liver and kidneys. GI Microorganism synthesis, Vitamin Supplements (Cyanocobalamin) Necessary for normal DNA synthesis Absorption of B12
1. Intrinsic Factor (low dose): a protein made by stomach parietal cells that binds to B12 and delivers it from the ileum via a calcium mediated event. 2. Mass Action (High dose): 1000mg/day, absorbed via passive diffusion
B12 Deficiency
A B12 deficiency will cause peripheral neuropathy and a macrocytic anemia, a pernicious anemia. Folic Acid administration can correct the macrocytic anemia but will fail to correct the peripheral neuropathy.
Cobalamin is a cofactor for the enzyme Methylmalonyl-CoA mutase which converts methylmalonyl-CoA to succinyl-CoA. Succinyl-CoA enters the Krebs cycles and goes into nerves to make myelin. If no Vitamin B12, methylmalonyl-CoA goes on to form abnormal fatty acids and causes subacute degeneration of the nerves. Only B12 can correct this problem.
Pernicious Anemia
Impaired GI absorption of B12
Gastrectomy
Corrosive Injury of GI mucosa
Folic Acid
3. Ingestion of drugs that interfere with intestinal absorption and storage of folic acid.
Mechanism- inhibition of the conjugases that break off folic acid from its food chelators. Ex. phenytoin, progestin/estrogens (oral contraceptives)
4. Malabsorption Sprue, Celiac disease, partial gastrectomy. 5. Rheumatoid arthritis increased folic acid demand or utilization.