ANEMII

Definitie:
- scaderea hemoglobinei circulante totale
F Ht < 36% Hb < 12 g%
B Ht < 39% Hb < 13 g%
 EXAMENE DE LABORATOR

1. Nr. eritrocite:4,2-5,5 mil/mmc

2.Ht: 45-54%
3. Hb:12-14 (13-15)g%
4.VEM=Ht(%)x10/GR=85-95 fl (μ ) 3

5.CHEM=Hb(g%)x100/Ht=32-34%
6.HEM=Hb(g%)x10/GR(mil)=30-32pg
 EXAMENE DE LABORATOR

7.Numarare de reticulocite:normal sunt in

jur de 50000/mm3
8.Examenul frotiului din sangele periferic
9.Leucograma si numararea placutelor
sanguine
10.Studiul maduvei osoase hematopoietice
TESTS IN HAEMATOLOGY
6
HEMOGRAMA – CBC (Complete Blood Count)

- Selectie de teste vazand elementele figurate ale sangelui

- eritrocitele
- leucocitele
- placutele sanguine

 in scop diagnostic

7
 ERITROCITELE (Eritrograma)

1. Examinarea / evaluarea frotiului de sange

2. Hematocritul (Ht , HTC) - PCV (Packed Cell Volume), EVF
(Erythrocyte Volume Fraction)
3. Numararea eritrocitelor - RBC count (Red Blood Cells),
hemoglobina (Hb) si indicii eritrocitari
4. Largimea intervalului de distributie a volumului eritrocitelor
- RDW (Red Blood Cells Distribution Width)
5. Numararea reticulocitelor
6. Investigatii specifice

8
HOW TO MAKE A BLOOD SMEAR

9
 PARTILE COMPONENTE PRINCIPALE
ALE UNUI FROTIU DE SANGE

Baza (capul) Monostrat Marginea “in pana”,

cu franjuri

10
 UN BUN FROTIU SANGUIN
Ar trebuie sa prezinte o zona in care morfologia
celulara se poate observa in detaliu, optim (zona
monostrat) pt. ca celulele:

-Sunt dispuse in monostrat (aprox. 50% sunt in

contact una cu alta)

-Nu se suprapun una peste alta (asa cum se intampla

la nivelul bazei/capului frotiului)

-Nu sunt deteriorate sau distorsionate (asa cum se

intampla la nivelul marginii 11“in pana” a frotiului)
ETAPELE EXAMINARII FROTIULUI SANGUIN

-Selectarea ariei monostrat

La magnificatie 100x -Detectarea agregarii plachetare,
rulourilor/aglutinarilor RBC

- Estimarea numarului WBC /

La magnificatie 400x numararea diferentiata (formula
leucocitara)

-Evaluarea detaliata a
La magnificatie 1000x RBC, WBC, si a placutelor
12
2. HEMATOCRITUL
PCV / Ht, Hct / EVF

13
 PACKED CELL VOLUME (PCV)

PCV is the ratio of erythrocyte volume to whole blood volume

- PCV is measured by whole

blood centrifugation
- Haematocrit is calculated from
RBC count and mean cell volume
by electronic cell counters

In clinical terms PCV = Haematocrit

They are used to detect polycythaemia and anaemia

14
*PCV MEASUREMENT PROCEDURE (Microhaematocrit Method)

-Fill the capillar tube up to ¾ of its length

-Seal with plastiline or in a bunsen flame
-Centrifuge for 5 minutes at >10,000 r.p.m. (10 min. in ruminants)
-Calculate PCV= length of packed erythrocytes/total length of blood column

Some sources of error:

-Delay in reading of PCV
- Centrifuge does not reach adequate speed
-Excessive or inadequate filling of capillary tube

* Haematocrit (Hct) Measurement By Electronic Cell Counters:

- Hct may be slightly lower (0.01-0.03 L/L) than obtained by the
microhaematocrit method since there is no trapped plasma between
erythrocytes.
-Counters designed for use with human blood must be validated for animal
species (RBC are smaller in animals, except in the dog). Platelets may be
counted as erythrocytes and yield falsely increased results especially in cats.
15
 ADVANTAGES OF PCV MEASUREMENT
-It is a very simple, precise and accurate method
-It provides more than just a PCV (see next slide)

Erythrocytic area Plasma area

Buffy coat
16
Buffy coat includes leukocytes and platelets
 PRACTICAL USES OF DIFFERENT
SECTIONS OF CAPILLARY TUBE
Packed Cell Volume
ERYTHROCYTIC SECTION
determination

-Increase suggests leukocytosis or thrombocytosis

BUFFY COAT -May be used to make concentrated WBCs smears
and to aid detection of Microfilaria

-Analysis of total plasma proteins/ fibrinogen

-Its colour can provide clinical information:
PLASMA SECTION • icterus, carotene (cows)
• haemolysis
• lipaemia
17
CAPILLARY TUBE SECTIONS AND PLASMA COLOURS
Leukocytosis or
dehydration icterus haemolysis lipaemia thrombocytosis

plasma

buffy
coat

erythrocytes

18
3. Numararea eritrocitelor - RBC
count (Red Blood Cells),
hemoglobina (Hb)
si
indicii eritrocitari

19
 RBC COUNT AND Hb CONCENTRATION
-Pot fi determinate prin:
- metode manuale
- analizoare hematologice:
• numarare de celule cu laser
• analizoare cantitative a buffy coat

-Furnizeaza informatii clinice similare celor indicate de

Ht/Hct (PCV, EVF)

- Sunt utile in calcularea INDICILOR ERITROCITARI

20
 RBC COUNT AND Hb CONCENTRATION
VALORI NORMALE
RBC count
-Barbati adulti: 4.30–5.60x1012/L (4.30–5.60x106/mm3)

-Femei adulte: 4.00–5.20x1012/L (4.00–5.20x106/mm3)

Hb
-Barbati adulti: 133–162 g/L (13.3–16.2 g/dL)

-Femei adulte: 120–158 g/L (12.0–15.8 d/dL)

Hb libera (plasma): 6–50 mg/L (0.6-5.0 mg/dL)

21
 INDICI ERITROCITARI
MCV (MEAN CELL VOLUME, MEAN CORPUSCULAR VOLUME)
Volumul corpuscular (eritrocitar) mediu

- Indica volumul mediu al RBC, exprimat in femtolitri (fL) (1fL = L-12):

MCV = Ht x 10 / Nr. Eritrocite

MCV [fL] = hematocrit [%] x 10 / RBC count [in millions]

MCV (fl) = PCV(L/L) x 1000 / RBC COUNT (1012/L)

• = indica MACROCITOZA

• valorile in intervalul normal de referinta = NORMOCITOZA

(85 ÷ 95 fL)
(79-93.3 fL)
• = indica MICROCITOZA 22
MCV is directly measured by electronic cell counters.
 INDICI ERIROCITARI

MCH (MEAN CORPUSCULAR HAEMOGLOBIN)

Hemoglobina corpusculara (eritrocitara) medie

- Indica cantitatea (masa) medie de hemoglobina din eritrocite,

exprimata in picograme (pg) (1 pg = 1 g-9)

MCH = Hb x 10 / Nr. Eritrocite

MCH [pg] = haemoglobin [g/dL] x 10 / RBC count [in millions]

MCH (pg) = Hb (g/L) / RBC (1012/L)

- Valori normale : 27 ÷ 31 pg (26.7-31.9 pg/celula)

23
MCH is less commonly used in clinical practice
MCHC (MEAN CORPUSCULAR HAEMOGLOBIN CONCENTRATION)
Concentratia medie corpusculara (eritrocitara) de hemoglobina

-Arata concentratia medie a hemoglobinei in eritrocite, exprimata

procentual (%) sau in g/dL (pg):
MCHC = Hb x 100 / Ht

MCHC [%] = haemoglobin [g/dL] x 100 / hematocrit [%]

MCHC [g/dL] = haemoglobin [g/dL] / hematocrit [decimal]

MCHC (g/L) = Hb(g/L) / PCV(L/L)

• = indica HIPOCROMAZIA
• valorile in limita intervalului de referinta = NORMOCROMAZIA
32 ÷ 36 % / 32-36 g/dL
323-359 g/L (32.3-35.9 g/dL)
Apparent hyperchromasia (high MCHC) is usually
24 due to an artifactual increase in the
haemoglobin result, due to haemolysis, lipaemia, or large numbers of Heinz bodies.
5. LARGIMEA INTERVALULUI DE
DISTRIBUTIE A VOLUMULUI
ERITROCITELOR
RDW (Red Blood Cell Distribution
Width)

25
 LARGIMEA INTERVALULUI DE DISTRIBUTIE A
VOLUMULUI ERITROCITELOR
RDW (Red blood cell distribution width)
-Reprezinta o masura cantitativa a ANIZOCITOZEI – variabilitatea
marimii eritrocitelor, evaluata curent prin MCV (Mean Corpuscular
Volume)

- Acest parametru este apreciat automat de catre aparatele care

masoara direct MCV

-Se emite o histograma a volumului eritrocitelor

 RDW = coeficientul de variatie al MCV

RDW [%] = deviatia standard a MCV x 100 / MCV mediu

26
- Valori normale: 11 ÷ 14 % (< 0.145 sau < 14.5%)
 RED CELL DISTRIBUTION WIDTH (RDW)

A numeric representation of the variability in RBC size (RBC

anisocytosis).
Indica de obicei
↑ RDW si MCV Anemie regenerativa

Volum al RBC similar

Variabilitate a RBC = Anizocitoza =
27 RDW ↑
RDW is calculated from Standard Deviation of MCV/Mean of MCV
6. NUMARAREA RETICULOCITELOR
SI
EVALUAREA RETICULOCITELOR

28
Reticulocitele sunt eritrocite tinere (imature) – eliberate
prematur din maduva hematogena in sange
APLICATII CLINICE:
- Evaluarea eritropoiezei la nivelul maduvei osoase hematogene
- Diferentierea anemiilor regenerative de anemiile neregenerative
TEHNICI DE DETECTIE:
- Coloratia Romanowsky
- Albastru metilen

VALORI NORMALE:
-Barbatul adult: 0.008–0.023 / eritrocit sau 0.8–2.3% din eritrocite
-Femeia adulta: 0.008–0.020 / eritrocit sau 0.8–2.0% din eritrocite

-Continutul de Hb al reticulocitelor, RHbC (Reticulocyte Haemoglobin Content)

> 26 pg/celula
29 (reticulocit)
 CLASIFICAREA ANEMIILOR
1.Clasificarea morfologica:
a. Anemii normocrome normocitare
cu VEM = 80-100 fL si CHEM = 32-36%
b. Anemii microcitare,hipocrome
cu VEM sub 80 fL si CHEM < 32%
c. Anemii macrocitare/megalocitare,
normocrome cu VEM > 100 fL si
CHEM > 32%
 CLASIFICAREA ANEMIILOR
2. Clasificarea fiziopatologica:
I. Anemii centrale:
A. prin aneritropoeza sau hipoplazie
B. prin diseritropoieza sau displazie
C. prin mecanisme multiple

II. Anemii periferice:

A. anemii posthemoragice acute
B. anemii hemolitice

III. Anemii mixte

 CLASIFICAREA ANEMIILOR
• CHEIA = NR. RETICULOCITELOR
RETICULOCITELE = globule rosii recent eliberate din MO
-Identificate printr-o coloratie supravitala (pp. ARN ribozomal rezidual – pete albastre,
negre)
-ARN-ul ribozomal rezidual → metabolizat in primele 24-36 h de viata a R in circulatie

-NR. RETICULOCITE CIRCULANTE = 1 – 2% → inlocuirea zilnica

a 0,8 – 1,0% din populatia eritrocitelor circulante
-Interpretarea corecta a NR. ERITROCITELOR CIRCULANTE → evaluarea
corecta a productiei de globule rosii

Nr. reticulocitelor circulante → comparat cu raspunsul reticulocitar

expectat : in cond. in care raspunsul eritropoietinei si al MO
eritroide la anemia moderata (Hb < 100 g/L = 10 g/dL) sunt intacte,
rata productiei eritrocitare ↑ de 2-3x in intervalul a 10 zile de la
debutul anemiei
- O reactie reticulocitara < 2-3x  raspuns medular inadecvat
Calcularea indexului de productie reticulocitara
Corectia #1 pt. anemie:
Aceasta corectie duce la calcularea corecta a numarului absolut de
reticulocite la o persoana anemica.
La o persoana la care numararea reticulocitelor este de 9%,
hemoglobina de 7.5 g/dL, hematocritul 23%, numarul absolut de
reticulocite corectat =
= 9 x (7.5 / 15) sau 9 x (23 / 45)] = 4.5%

Corectia #2 aplicata pentru durata mai lunga de viata in sangele

periferic a reticulocitelor eliberate prematur din MO in sangele periferic.
Aceasta corectie duce la calcularea corecta a indexului de
productie reticulocitara la o persoana anemica.
La o persoana la care numararea reticulocitelor este de 9%,
hemoglobina de 7.5 g/dL, hematocritul 23%, indexul de productie
reticulocitara este =
(7.5 / 15) (corectia hemoglobinei)
= 9 x -------------------------------------------- = 2.25
2 (corectia timpului de maturare)
 Anemie
Hb, Reticulocite
Index < 2.5 Index ≥ 2.5
morfologiaE hemoliza/hemoragie

Normocroma Micro sau

normocitara macrocitara

hipoproliferativa Tulburare de
maturatie
ANEMII HIPOPROLIFERATIVE (index reticulocitar < 2.5)
- Reprezinta ~ 75% din totalul anemiilor
- Reflecta insuficienta absoluta sau relativa a MO – M eritroida nu prolifereaza
adecvat gradului anemiei

Cauze
- Afectare medulara (aplazie, infiltrare, fibroza)
- Statusuri hipometabolice (malnutritia proteinocalorica, deficite
endocrine)
- Deficitul de Fe (inaintea aparitiei microcitelor hipocrome)
- Stimulare inadecvata a EPO
- IRen
-  productiei EPO - CK proinflam. (IL1)
-  necesarului tisular de O2 (hipotiroidism)

-Majoritatea se datoreaza deficitului usor/moderat de Fe / proceselor inflamatorii

 ANEMII HIPOPROLIFERATIVE
-Majoritatea sunt normocitare, normocrome
-Microcitare, hipocrome – in deficitul de Fe, bolile inflamatorii cr. de lunga durata
TESTE DE DIAGNOSTIC DIFERENTIAL
-Sideremia (Fe seric)
-TIBC (capacitatea totala de legare a Fe)
-Feritinemia (Feritina serica)
-Evaluarea functiei renale
-Evaluarea functiei tiroidiene
-Biopsie/Aspirat MO
-Ocazional : determinarea distributiei Fe la nivelul MO – coloratia pt. Fe a
MO
 ANEMII HIPOPROLIFERATIVE
• A. din inflamatiile acute/cronice
- Sideremia (Fe seric) 
- TIBC = N / 
- Saturatia procentuala a transferinei 
- Feritina serica = N / ↑

• A. din deficitul usor/moderat de Fe

- Sideremia (Fe seric) 
- TIBC ↑
- Saturatia procentuala a transferinei 
- Feritina serica 
ANEMIA FERIPRIVA
 Anemia feripriva
• Una dintre cele mai frecvente probleme
medicale
• Cea mai frecventa anemie
• Anemia prin deficit de Fe este ETAPA FINALA
de manifestare a unui proces de deficit de Fe al
organismului
– Depletia de Fe: scaderea/absenta depozitelor de Fe
( feritinemia ↓)
– Deficitul de Fe: depletia depozitelor + scaderea Fe
seric (feritinemia ↓ + sideremia ↓)
– Anemie feripriva (prin deficit de Fe): anemia
dezvoltata la un pacient cu deficit de Fe - Hb ↓, Ht ↓,
microcitoza (VEM ↓) , hipocromie (HEM, CHEM ↓)
 HIDDEN HUNGER
The term was coined by WHO in
1986 & refers to the problems
associated with the deficiency of 3
essential micronutrients:
Iron
Iodine
Vitamin A
 LEARNING OBJECTIVES
At the end of the lecture you will be able
to:
 Discuss iron absorption, transport & stores
 Know the burden of IDA in the world
 Identify the causes & consequences of IDA
 Know how to diagnose IDA
 Recognize the strategies for control &
prevention of IDA
 IRON IN NATURE
Iron is among the abundant minerals on earth.

Of the 87 elements in the earth’s crust, Iron

constitutes 5.6% and ranks fourth behind
Oxygen (46.4%), Silicon (28.4%) and Aluminum
(8.3%).
 In soil, Iron is 100 times more than Ca, Na & Mg
and1000 times more than Zinc and 100,000
times more than Iodine.
 IRON DEFICIENCY
Iron deficiency is the most common
micronutrient deficiency in the world
affecting 1.3 billion people i.e. 24% of the
world population.
In comparison only 275 million are iodine
deficient and 45 million children below age
5 years are Vitamin A deficient.
 IRON DEFICIENCY /2
Iron deficiency can range from sub-clinical
state to severe iron deficiency anemia.
Different stages are identified by clinical
findings & lab tests.
Anemia is defined as a hemoglobin below
the 5th percentile of healthy population.
Most studies showed this cutoff point to be
around 11 g/dl (-2SD below the mean).
HB IN IDA
IRON CYCLE IN THE BODY
ROLE OF IRON IN THE BODY
Iron have several vital functions
Carrier of oxygen from lung to tissues
Transport of electrons within cells
Co-factor of essential enzymatic reactions:
Neurotransmission
Synthesis of steroid hormones
Synthesis of bile salts
Detoxification processes in the liver
Continutul total de Fe din organism
3–5g
 METABOLISMUL Fe

Distributia Fe in organism
Continutul de Fe, mg

Barbatul adult Femeia adulta

(80 kg) (60 kg)

Hemoglobina 2500 1700

Mioglobina/alte enzime 500 300
Fe legat de transferina 3 3
Fe din depozite 600-1000 0-300
 Metabolismul Fe
• Fe este localizat in centrul moleculelor de Hem ale
Hb (continut: 1.5 - 2 gr)
+
• Intra in compozitia mioglobinei
• Intra in compozitia unor sisteme enzimatice tisulare
• Forme de stocare (1gr la barbati ,0.5 gr la femei):
– Feritina
– Hemosiderina
– Locatie: Maduva osoasa, ficat, splina
• Fierul transportat (legat de transferina): aprox. 7 mg
 Metabolismul Fe
• Transferina preia Fe din:
1. Enterocite (celulele epiteliului de absorbtie
intestinala) pt. a-l furniza celulelor formatoare
de Hb
2. Depozite, ca etapa a procesului de recirculare
(reciclare, recuperare) a Fe

• Absorbtia + reciclarea furnizeaza un aport

constant de Fe de 20 mg/zi (pana la 35 mg)
necesar pentru sinteza Hb
 Necesarul zilnic de Fe
Barbati 1 mg
Adolescenti 2-3 mg
Femei in prioada reproductiva 2-3 mg
Femei gravide 3-4 mg
 Metabolismul Fe
• Absorbtia Fe este restrictionata de
necesitatile reale ale organismului

• 1mg de Fe se pierde zilnic prin:

– Transpiratie
– Descuamarea cutaneo-mucoasa (inlocuirea)
– Pierderile menstruale si sarcina/lactatia
reprezinta cauze majore de pierdere de Fe si
de crestere a necesarului zilnic de aport la
femei
 Metabolismul Fe
• Dieta normala contine aprox. 15 mg de Fe/zi
- 6mg Fe elementar / 1000 cal
• 1/10 din Fe ingestionat este absorbit
• HCl din sucul gastric elibereaza Fe din alimente
• Fe este absorbit in forma redusa Fe feros (Fe 2+)
• Vit. C creste rata de absorbtie, prin favorizarea
reducerii: Fe feric (Fe 3+)  Fe feros (Fe 2+)
• Fitatii, tanatii, antiacidele scad rata absorbtiei
intestinale a Fe prin formarea unor complexe cu
Fe
 Metabolismul Fe
• Zonele principale de absorbtie:
– Duoden
– Jejunul superior
• Statusurile malabsobtive sau
gastrojejunostomia scad absorbtia Fe
 Metabolismul Fe
Transportul Fe
– Transferina este principalul transportor al Fe in
plasma
– Transferina e sintetizata de celulele hepatice,
producerea sa fiind crescuta in deficitele de Fe
– Transferina leaga 1-2 molecule de Fe feros
(Fe 2+, Fe redus, bivalent)
– Complexul Transferina-Fe este recunoscut si
legat de receptori specifici de pe S membranei
celulelor producatoare de Hb (MO
eritropoietica), fiind ulterior preluat prin
endocitoza
 Metabolismul Fe
• Total iron binding capacity (TIBC) = capacitatea
totala de legare a Fe
– Transferina se masoara prin cuantificarea situsurilor
disponibile de legare a Fe
– Se mai numeste “Total iron binding capacity”
– TIBC este saturata in proportie de 1/3 in conditii
normale
– Transferina plasmatica (Transferinemia): 300 μg/dL
– Fe seric (Sideremia): 60-180 μg/dL
Cauzele deficitului de Fe
Cresterea necesarului de Fe sau/si al
hematopiezei
- Rata rapida de crestere in primul an de viata si in adolescenta
- Sarcina/Lactatie
- Tratament cu eritropoietina
Pierderi crescute de Fe
- Pierderile cronice, oculte
- Sangerarea mesntruala abundenta
- Pierderile acute de sange (hemoragii)
- Donarea frecventa de sange
- Flebotomia pentru trat. policitemiei
Scaderea aportului, absorbtiei sau utilizarii Fe
- Dieta inadecvata
- Malabsortie (Sprue, Boala Chron)
- Malabsorbtie chirurgicala(post-gastrectomie)
- Afectiuni inflamatorii acute/cronice
Normal Blood Film
MICROCYTES
HYPOCHROMIA
Frotiu normal Hipocromie si microcitoza
Consequences of Iron Deficiency

Increase maternal & fetal mortality.

Increase risk of premature delivery and LBW.
Learning disabilities & delayed psychomotor
development.
Reduced work capacity.
Impaired immunity (high risk of infection).
Inability to maintain body temperature.
Associated risk of lead poisoning because of
pica.
 AT RISK GROUPS
Infants
Under 5 children
Children of school age
Women of child bearing age
 PREVALENCE OF ID
Region 0-4yr 5-12yr Women
South Asia 56% 50% 58%
Africa 56% 49% 44%
Latin Am 26% 26% 17%
Gulf Arabs 40% 36% 38%
Developed 12% 7% 11%
World 43% 37% 35%
 Cauzele cele mai frecvente ale
deficitului de Fe
• Hemoragiile cronice oculte
• Cresterea necesarului de Fe
• Malabsortia Fe
• Aport inadecvat
• Hemoliza intravasculara si hemoglobinuria-
hemosiderinuria
• Combinatii
Cresterea necesarului/cererii
de Fe
• Sarcina
• Lactatie
• Crestere rapida
 Aport deficitar
• Diete deficitare in Fe
– Vegetarianism
– Varstnici (paine-ceai)
– Temporizarea diversificarii alimentatiei NN >
3-4 luni de viata (alimentarea exclusiva cu
lapte matern)
• Absorbtie scazuta
– Chirurgie gastrica
– Aclorhidrie
– Sprue
– Pica
 Pierderi crescute de Fe
• Menoragii
• Hemoragii gastrointstinale
•Angiodisplazia
•Ulcer peptic •Diverticuloza
•Esofagita •Diverticul Meckel
•Varice esofagiene •Colita or colon
•Hernia hiatala iritativ
•Afectiuni maligne •Hemoroizi
•Utilizarea de AINS
•Parazitoze
 Pierderi crescute de Fe
• Afectiuni hemoragipare
• Leziuni pulmonare cu sangerare
• Hemoglobinurie – hemosiderinurie
(hemoliza intavasculara cronica)
• Hemodializa
• Hematuria (cronica)
• Donarea frecventa de sange
– 250 mg Fe / unitate de sange
 Profilaxia deficitului de Fe
(suplimentarea preventiva a aportului
de Fe)
• Gravide (in sapt. 20-24, daca Hb < 11 g/dL
sau doar Feritina )
• Lactatie
• Donatorii de sange (donari frecvente)
• Transfuzii autologe de sange
• Pacientii gastrectomizati
• Tratamentul cronic cu doza mari de AINS
(aspirina)
 DIAGNOSIS OF IDA
Clinical: symptoms (fatigue, dizziness ,
palpitations..etc) & signs (pallor, smooth
tongue, Koilonychia, splenomegaly &
dysphagia in elderly women).
Laboratory
Stainable iron in bone marrow
Response to iron supplements
 Aspecte clinice
• Simptome generale de anemie
• Fatigabilitatea poate fi disproportionata fata de
gradul anemiei, din cauza deficitului de enzime
tisulare dependente de Fe
• Cloroza
• Glosita
• Stomatita angulara
• Sindromul Paterson-Kelly (Plummer Vinson)
(disfagie prin ingustarea esofagului)
 Aspecte clinice

• Atrofie gastrica
• Ozena-anosmie
• Unghii
– fragile, friabile
– Coilonchia(deformare in lingura)
• Caderea parului
• Splenomegalie
 Aspecte clinice

• Pica: apetitul pt. alimente/substante bizare

– Geofagia (pamant, argila)
– Pagofagia (gheata)
– Amilofagia (amidon)
• Probleme de dezvoltare
• Splenomegalie
• SindromTayanc-Prasad
(retardarea cresterii, hipogonadism, hepatosplenomegalie,
deficit de Zn si Fe, geofagie)
• Deficienta imuna
 Dg. de laborator

• Hb, Htc, RBC: Scazute

• VEM (MCV), HEM (MCH), CHEM (MCHC): Scazute
• RDW: Crescuta
• Nr. Reticulocite: Normal / Scazute
• Placute sanguine: Normal / Scazute / Crescute
• WBC: Normal / Scazute
• Frotiu sanguin (Smear): Hipocromie,
anizocitoza,microcitoza, poikilocitoza
 LAB FINDINGS IN IDA
Microcytic hypochromic anaemia
Low Hb level (< 11.0 g/dl)
Low MCV, MCH, MCHC
Low serum ferritin
High RWD
High iron binding capacity
High erythrocyte protoporphyrin
 Anemia feripriva
• Una dintre cele mai frecvente probleme
medicale
• Cea mai frecventa anemie
• Anemia prin deficit de Fe este ETAPA FINALA
de manifestare a unui proces de deficit de Fe al
organismului
– Depletia de Fe: scaderea/absenta depozitelor de Fe
( feritinemia ↓)
– Deficitul de Fe: depletia depozitelor + scaderea Fe
seric (feritinemia ↓ + sideremia ↓)
– Anemie feripriva (prin deficit de Fe): anemia
dezvoltata la un pacient cu deficit de Fe - Hb ↓, Ht ↓,
microcitoza (VEM ↓) , hipocromie (HEM, CHEM ↓)
ANEMIA FERIPRIVA :
-Anemie + dovezi clare de deficit de Fe

ETAPELE
DEFICTULUI
DE FIER
 TESTE DE LABORATOR
1. SIDEREMIA si TIBC
- Fe seric = nivelul Fe circulant legat de Transferina – N = 50 – 150 μg/dL
→ variatie diurna a valorilor
- TIBC = indicator indirect al Transferinei circulante – N = 300 – 360 μg/dL
- Saturatia Transferinei = Fe seric x 100 / TIBC – N = 25 – 50 %
- > 50 % = un nivel disproportionat de ↑ de Fe legat de transferina →
eliberat spre tesuturi noneritroide → daca e de lunga durata = pericol
supraincarcare tisulara cu Fe (intoxicatie cu Fe)

2. FERITINEMIA (FERITINA SERICA)

-Fe liber = toxic pt. celule → mecanisme protective : Fe tisular = legat
-Depozitele intracelulare : FERITINA SI HEMOSIDERINA
-Apoferitina leaga Fe 2+ liber → feritina (Fe 3+)
-Pe masura ce feritina se acumuleaza in celulele SRE → se formeaza agrgate de
proteine = Hemosiderina
-Fe de depozit = interschimbabil (mai  in cazul hemosiderinei)
FERITINA SERICA – continuare
- In conditii de „steady-state“ – nivelul feritinei serice se coreleaza cu depozitele
totale de Fe ale organismúlui  Feritinemia = testul de laborator care estimeaza
depozitele de Fe ale organismului
-Nivelele N ale Feritinei serice depind de varsta si sex
B ~ 100 μg/dL
F ~ 30 μg/dL

- Nivel < 15 μg/dL  absenta rezervelor de Fe

3. EVALUAREA DEPOZITELOR MEDULARE DE Fe

- Desi depozitele de Fe ale SRE pot fi estimate prin coloratia Fe dintr-un aspirat
sau biopsie de MO – FERITINEMIA a inlocuit aceste determinari, fiind un indicator
superior
- Coloratia Fe a aspiratului sau biopsiei de MO → furnizeaza informatii despre
eliberarea eficienta a Fe catre eritroblastele in dezvoltare
-N ~ 40 – 60% dintre eritroblastele in dezvoltare prezinta granulatii vizibile de
feritina in citoplasma = sideroblasti → reprezinta Fe in exces fata de cel necesar
sintezei de Hb
EVALUAREA DEPOZITELOR MEDULARE DE Fe – continuare
- In situatiile in care eliberarea Fe din depozite e blocata – Fe din SRE va fi
detectabil   sau absenta sideroblastilor
- In sindroamele mielodisplazice – apare disfunctia mitocondriala →
acumularea Fe la nivel mitocondrial : sub forma unui lant in jurul nucleului
eritroblastului = sideroblaste inelate

4. NIVELUL PROTOPORFIRINEI ERITROCITARE

-Protoporfirina = intermediar in sinteza Hem
- sintezei Hem-ului → acumularea protoporfirinei in eritrocit → suplimentarea
deficitara cu Fe a precursorilor eritrocitari
-N < 30 μg/dL
-In defcitul de Fe – valori > 100 μg/dL
-Apare si in intoxicatia cu Pb
5. NIVELUL SERIC AL TRP (Transferin Receptor Protein)
-Celulele eritroide au cel mai mare nr. de receptori ai Transferinei
-TRP este eliberata de catre celule in circulatie
-  Nivelul seric al TRP reflecta masa eritroida totala a MO
- N = 4 – 9 μg/L (IA)
-A fost propus ca test de eficienta a terapiei cu rEPO
-In a. feripriva nivelele serice ale TRP 
 Perioada Perioada Anemie feripriva
Laborator Normal
prelatenta latenta Precoce Tardiv
Hb g/dl N N N 8-14 <8
MCV
N N N N,  
(VEM) fl
Feritinemia N  <12 <12 <12
Transferine
N N <16 <16 <16
-mia
Fe din MO N  - - -

FEP N N   
Simptomato-
- - - + +
logie
Ept. change - - - - +
 Diagnostic diferential
• Anemii microcitare
– Anemia feripriva
– Talasemia (anomalii ale Hb - Hb C,Hb E)
– Anenia sideroblastica
– Intoxicatia cu Pb
– Anemia din afectiunile cronice (mai ales de
natira inflamatorie)
DIAGNOSTICUL DIFERENTIAL AL A. HIPOCROME,
MICROCITARE
Diagnosis of Microcytic Anemia
Tests Iron Inflammation Thalassemia Sideroblastic
Deficiency Anemia

Smear Micro/hypo Normal Micro/hypo with Variable

micro/hypo targeting

SI <30 <50 Normal to high Normal to

high
TIBC >360 <300 Normal Normal

Percent <10 10-20 30-80 30-80

saturation
Ferritin <15 30-200 50-300 50-300
(mg/L)
Hemoglobin Normal Normal Abnormal Normal
pattern
 Teste de dg. diferential al anemiilor hipocrome, microcitare

A. feripriva A. din bolile Talasemie A. sidero- Intoxicatia

cronice blastica cu Pb

S.Ferritin  N  N   N

TIBC   N  N N

S.Iron   N   Variable.

T.Satur.   N   N 

FEP   N  

Marrow iron - + + + +
HbA2 Ring
Special tests HbA2  RF etc. ALA, Pb
HbF  Siderobl
 ALTE ANEMII HIPOPROLIFERATIVE
1. A. din afectiunile inflamatorii ac., cr./ infectii - (afectiunile
cronice)
2. A. din afectiunile renale
3. A. din afectiunile endocrine si deficitele nutritionale (statusuri
hipometabolice
4. A. prin afectarea MO
 ANEMIA DIN AFECTIUNILE CRONICE
(inflamatii, infectii. Injurii tisulare – conditii asociate cu eliberarea ↑ de CK
proinflamatorii)

-Una dintre cele mai frecvente a.

-Cea mai importanta in dg. diferential al a. feriprive – majoritatea
caracteristicilor sunt determinate de eliberarea inadecvata de Fe spre MO,
in ciuda unor depozite de Fe N sau chiar ↑
- Fe seric 
-Protoporfirina eritrocitara ↑
-MO hipoproliferativa
-Rata de saturatie a transferinei = 15 – 20 %
-Feritina serica = N sau ↑
-In inflamatie, Feritina serica ↑ de 3x – prin interventia CK proinflamatorii la mai
multe nivele ale eritropoiezei
INTERVENTIA CK PROINFLAMATORII IN
ERITROPOIEZA
 DIAGNOSTICUL DIFERENTIAL AL ANEMIILOR
HIPOPROLIFERATIVE
Diagnosis of Hypoproliferative Anemias
Tests Iron Inflammation Renal Hypometabolic
Deficiency Disease States
Anemia Mild to Mild Mild to Mild
severe severe
MCV (fL) 70-90 80-90 90 90

Morphology Normo- Normocytic Normocytic Normocytic

microcytic
SI <30 <50 Normal Normal

TIBC >360 <300 Normal Normal

Saturation (%) <10 10-20 Normal Normal

Serum ferritin <15 30-200 115-150 Normal

(mg/L)
Iron stores 0 2-4+ 1-4+ Normal
 Important !!!!!!!
• Diagnosticul nu e complet pana la gasirea
ETIOLOGIEI (mecanismului fiziopatologic
al) deficitului de Fe
 MANAGEMENT OF IDA
Blood transfusion if heart failure is
eminent
IV or IM iron in pregnant women
Oral iron 3-5 mg Fe/kg/day
Treat underlying cause
Dietary education
 PREVENTION OF IDA
Dietary modification

Food fortification

Iron supplementation
 PREVENTION OF IDA /2
Diet & nutrition education
eat more fruits and vegetable
no coffee or tea with meals
programmes should be targeted to
at risk groups
reduce phytic content of cereals and
legumes by fermentation
 PREVENTION OF IDA /3
Short term approach:
supplementation with iron tablets.
Long-term approach:
food fortification with iron either for the whole
population (blanket fortification) or for specific
target groups like infants. It requires no
cooperation from users unlike taking iron
supplements.
 FOOD FORTIFICATION
Iron compounds used in food fortification
can be divided into 4 groups
Freely water soluble (ferrous sulphate, gluconate,
lactate & ferric ammonium citrate).
Poorly water soluble (ferrous fumarate, succinate
& saccharate).
Water insoluble (ferric pyrophosphate, ferric
orthophosphate & elemental iron).
Experimental (sodium-iron EDTA & bovine Hb
concentrate).
 Which iron form to use?
The major factors governing the choice of
iron compound include:
Bioavailability
Organoleptic problems
Cost
Safety
Ideally we should go for a safe, cheap,
highly bioavailable iron, which causes no
organoleptic side-effects
 Which iron form to use?
• Freely water soluble iron are the most bio-
available, but causes unacceptable colour &
flavour change in many foods.
• Insoluble iron compounds are inert with no
organoleptic effects but it is poorly absorbed
• Cost-wise elemental iron is the cheapest, ferrous
sulphate costs 10 times more, but most
expensive is EDTA
• Safety is of concern with EDTA & Bovine Hb
only because of potential problems