CLASIFICATION OF ANEMIA

Prof. Dr. Adi Koesoema Aman SpPK(KH)

Dr. Malayana Nasutioan Mked.SpPK .
 DEFINITION
• Functions of blood
– Transport of nutrients
– Transport of gases
– Haemostasis
– Defence
• Composition of blood
– Cells (RBC, WBC, Platelets)
– Plasma (Colloids, Crystalloids, Water)
 Definition of Anemia
• From Greek meaning “ without blood”
• Condition where capacity of blood to
transport oxygen to tissues is reduced
– Decreased hemoglobin, RBC count, and
hematocrit
• Anemia is not a disease but a manifestation
of disease
• Treatment depends on discovering
underlying cause
 DEFINITION
• PYSIOLOGICAL DEFINITION
– Decrease in oxygen carrying capacity of blood.
• ANALYTICAL (PATHOLOGICAL)
DEFINITION
– Reduction in total circulating red cell mass
– Reduction in Haemoglobin concentration
and/or Haematocrit
 Functions of erythrocytes
• Transport of respiratory gases

• Large surface area : volume ratio

• Flexible biconcave disc
• Haemoglobin for exchange of gases
• Capable of glycolysis for the source of energy for
cell survival
 Erythrocyte disorders
• Qualitative
• Haemoglobin defect
(Anemia, Thalassaemia, sickle cell anemia etc)
• Membrane & enzyme abnormalities
(G6PD, eliptocytosis, stomato-ovalocytosis)

• Quantitative
• Increased (polycythemia) inherited / acquired
• Decrease (inherited / acquired hypoplasia)
• Bleeding
 Anaemia
• Reduction in Iron anaemia
circulation deficiency

haemoglobin
• Nutritional deficiency
anaemias
– Iron deficiency
– B12 & folate deficiency
anaemia
– Protein deficiency
anaemia
– Scurvy & other element
B12 & folate deficiency
deficiency
 Nutritional deficiency anaemia
clinical application
Angular
Glossitis
Cheilosis
Koilonychia

Marrow iron stores

Plummer-Vinson
syndrome
 Anaemia; Globin chain defects

• Thalassaemias

– Reduced globin chain

synthesis Thalassaemia
• Alpha and Beta chain
synthesis defects

• Haemoglobinopathies

– Abnormal globin chain

synthesis
Sickle cell disease
Anaemia; Globin chain defects

Hemoglobin electrophoresis
for the diagnosis of
thalassaemai
X-ray appearance of
Thalassaemic patient
 Anaemia; Membrane and enzyme
defects
Elliptocytosis
• Membrane defects
– Elliptocytosis
– Hemolysis
– Stomato-ovalocytosis
– Without haemolysis

• Red cell enzymopathies

• G6PD G6PD deficiency
– Hemolysis after
oxidant stress

• Blood loss
 Anaemia; Reduced erythroid bone
marrow Trephine biopsy
(Aplastic Anemia)
• Marrow failure
• Marrow infiltration

Marrow infiltration Normal trephine

 C.B.C
• Haemoglobin - 15±2.5, 14 ±2.5 - g/dl
• PCV - 0.47 ±0.07, 0.42 ±0.05 - l/l (%)
– Haematocrit, effective RBC volume - better
• RBC count - 5.5 ±1, 4.8 ± 1 x1012/l
• MCHC - Hb/PCV - 30-36 - g/dl
– Hb synthesis within RBC
• MCH - Hb/RBC - 29.5 ± 2.5 pg/l
– Average Hb in RBC
• MCV - PCV/RBC 85 ± 8 - fl
Microcytic Anemia (IDA)
Macrocytic Anemia (Meg.):
ANEMIA
Symptoms : Pallor
Jaundice
Fatigue
Palpitation
Dyspnea
Vertigo
Peptic ulcer
Glossitis
Dysphagia
etc
 CLASSIFICATION
• MORPHOLOGICAL CLASSIFICATION
Based on appearance of RBC under the
microscope OR red blood cell indices
• PATHOLOGICAL CLASSIFICATION
Based on abnormality of anatomical,
biochemical or physiological abnormality
• ETIOLOGICAL CLASSIFICATION
Based on specific causative process/agent
 MORPHOLOGICAL
CLASSIFICATION
Normocytic normochromic anaemia
 MORPHOLOGICAL
CLASSIFICATION
Hypochromic Microcytic Anaemia
 HYPOCHROMIC MICROCYTIC
ANAEMIA
• Iron deficiency anaemia
• Thalassaemia minor
• Sideroblastic anaemia
• Anaemia of chronic disorders
MORPHOLOGICAL
CLASSIFICATION
Macrocytic anaemia
 MACROCYTIC ANAEMIA
• Megaloblastic anaemia
• Aplastic anaemia
• Myxoedema
• Chronic Obstructive Pulmonary Disease
• Liver Disease
• Myelodysplastic syndromes
 PATHOLOGICAL
CLASSIFICATION
• Blood loss
– Acute
– Chronic
• Decreased production
– Disturbance of proliferation and differentiation
• Of stem cells
• Of erythroblasts
– Defective Hb synthesis
• Increased destruction
– Intracarpuscular (Intrinsic) defects
– Extracarpuscular (Extrinsic) defects
 ETIOLOGICAL
CLASSIFICATION
• Hereditary
– Blood loss – Hereditary Intestinal telengiectasia
– Decreased production – Pure Red Cell aplasia
– Increased destruction – Membrane, Enzyme and Hb
defects
• Congenital
– Defective production – Congenital dyserythropoietic
anaemia,Congenital sideroblastic anaemia
– Increased destruction – Cardiac defects, vascular
defects
• Acquired
 ACQUIRED ANAEMIAS
• Blood loss
– Acute
– Chronic
• Ulcerative lesions of GIT
• Female reproductive system
• Parasites – Ankylostoma duodenale, Schistosoma
haematobium
 ACQUIRED ANAEMIAS
• Increased destruction of RBC
– Membrane defect (PNH)
– Mechanical trauma (Microangiopathies)
– Antibody mediated (Immune haemolytic
anaemia)
– Parasites (malaria, Aroya fever)
 ACQUIRED ANAEMIAS
• Decreased production
– Deficiency anaemias
• Iron deficiency
• Vitamin B12 and Folate deficiency
– Bone marrow disease/infiltration
– Miscellaneous
• Pyridoxin responsive anaemia
• Sideroblastic anaemia
 Classification of Anemia
I. Etiologic Classification
1. Impaired RBC production
2. Excessive destruction
3. Blood loss
II. Morphologic Classification
1. Macrocytic anemia
2. Microcytic hypochromic anemia
3. Normochromic normocytic anemia
III. Kinetic Classification
IV. Physiologic Classification
 Impaired RBC Production
1. Abnormal bone marrow
1.1 Aplastic anemia
1.2 Myelophthisis : Myelofibrosis, Leukemia,
Cancer metastasis
2. Essential factors deficiency
2.1 Deficiency anemia : Fe, Vit. B12, Folic acid, etc
2.2 Anemia in renal disease : Erythropoietin
3. Stimulation factor deficiency
3.1 Anemia in chronic disease
3.2 Anemia in hypopituitarism
3.3 Anemia in hypothyroidism
 Excessive Destruction of RBC(cont.)
Hemolytic anemia
1. Intracorpuscular defect
1.1 Membrane : Hereditary spherocytosis
Hereditary ovalocytosis, etc.
1.2 Enzyme : G-6PD deficiency, PK def., etc.
1.3 Hemoglobin : Thalassemia, Hemoglobino-
pathies
 Excessive Destruction of RBC
2. Extracorpuscular defect
2.1 Mechanical : March hemolytic anemia
MAHA (Microangiopathic HA)
2.2 Chemical/Physical
2.3 Infection : Clostridium tetani
2.4 Antibodies : HTR, SLE
2.5 Hypersplenism
 Blood Loss

1. Acute blood loss : Accident, GI bleeding

2. Chronic blood loss : Hypermenorrhea
Parasitic infestation
 Macrocytic Anemia
MCV > 94
MCHC > 31
1. Megaloblastic dyspoiesis
1.1 Vit. B12 deficiency : Pernicious anemia
1.2 Folic acid deficiency : Nutritional megaloblas-

tic anemia, Sprue, Other malabsorption

1.3 Inborn errors of metabolism : Orotic aciduria,
etc.
1.4 Abnormal DNA synthesis : Chemotherapy,
Anticonvulsant, Oral contraceptives
 Macrocytic Anemia
MCV > 94
MCHC > 31
2. Non-Megaloblastic dyspoiesis
2.1 Increased erythropoiesis : Hemolytic anemia
response to hemorrhage
2.2 Increased membrane surface area : Hepatic
disease, Obstructive jaundice, Post-
splenectomy
2.3 Idiopathic : Hypothyroidism, Hypoplastic and
Aplastic anemia
Microcytic Hypochromic Anemia
MCV < 80
MCHC < 31
1. Fe deficiency anemia : Chronic blood loss,
Inadequate diet, Malabsorption, Increased
demand, etc.
2. Abnormal globin synthesis : Thalassemia with or
without Hemoglobinopathies
3. Abnormal porphyrin and heme synthesis :
Pyridoxine responsive anemia, etc.
4. Other abnormal Fe metabolism :
Normocytic Normochromic Anemia
MCV 82 - 92
MCHC > 30
1. Blood loss
2. Increased plasma volume : Pregnancy, Overhydration
3. Hemolytic anemia : depend on each cause
4. Hypoplastic marrow : Aplastic anemia, RBC aplasia
5. Infiltrate BM : Leukemia, Multiple myeloma,
Myelofibrosis, etc.
6. Abnormal endocrine : Hypothyroidism, Adrenal
insufficiency, etc.
7. Kidney disease / Liver disease / Cirrhosis
Kinetic Classification of Anemia
1. Insufficient erythropoiesis
Stem cells , Hypoplastic marrow, Infiltrated BM
2. Ineffective erythropoiesis
- Megaloblastic anemia
- Thalassemia
- Sideroblastic anemia
3. Uncompensated hemolytic disease with continued
bleeding
Physiologic Classification of Anemia

1. RPI (Reticulocyte Production Index) < 2

(Ineffective erythropoiesis)
1.1 Hypoproliferative anemia
1.2 Maturation disorder
2. RPI > 3 (Effective erythropoiesis)
2.1 Hemolytic anemia
2.2 Blood loss anemia
Physiologic Classification of Anemia
1. RPI (Reticulocyte Production Index) < 2
(Ineffective erythropoiesis)
1.1 Hypoproliferative anemia
(normocytic normochromic, N/N)
- Hypoplastic anemia - Idiopathic/ Chemical/
Infectious / Drug --> Maturation arrest
- Myelophthisic anemia (Marrow infiltration)
- Refractory anemia (Dysmyelopoietic syndrome)
Physiologic Class. of Anemia RPI < 2
1.1.1 N/N and normal RDW
a) BM failure
b) Decrease marrow stimulation
- Endocrine disease
- Anemia of chronic disease
- Renal disease
1.1.2 Abnormal RBC morphology & RDW
a) Oval macrocyte :- Refractory dysmyelo-
poietic
b) Dacrocytes/ tear drops :- Myelophthisic
Physiologic Class. of Anemia RPI < 2
1.2 Maturation disorder
1.2.1 Microcytic, high RDW
a) Siderblastic (Microcytic dimorphic RBC)
b) Fe def. (Microcytic hypochromic RBC)
1.2.2 Microcytic, normal RDW
a) Heterozygous, thalassemia syndrome
b) Anemia of chronic disease
1.2.3 Macrocytic
a) Liver disease
b) Folate def.
c) Vit. B12 def.
d) Hemolytic anemia (Normocyte
polychromasia)
Physiologic Classification of Anemia
2. RPI > 3
(Effective erythropoiesis)
2.1 Hemolytic anemia
- Intrinsic hereditary disorder
- Extrinsic acquired disorder
2.2 Blood loss
- Acute blood loss
- Chronic blood loss (without treatment --> micro-
cytic, hypochromic anemia)
 Evaluation of Anemia
A. Hematologic
1. Hematocrit (VPRC preferred)
2. Hemoglobin concentration
3. RBC indices : MCV, MCH, MCHC
4. Leukocyte count
5. Reticulocyte count
6. Platelet count
7. ESR (Erythrocyte sedimentation rate)
8. Stained blood smear : RBC morphology
 Evaluation of Anemia
B. Urine analysis
1. Appearance : Color, pH, Clarity, sp gr
2. Test for protein, Bence Jones protein
3. Bilirubin, Uribilinogen
4. Occult blood
5. Microscopic examination
C. Stool
1. Appearance : Color, consistency
2. Occult blood
3. Examination for ova, parasites
 Evaluation of Anemia
D. Serum or Plasma
1. BUN
2. Creatinine, if urea N is abnormal
3. Bilirubin : Direct, indirect
4. Protein
5. SI (Serum iron), TIBC (Total iron binding
capacity)
E. Special tests in hematology
Hb typing / Ham acid test / Coombs’ test, G-6PD,
Ferritin, Sucrose test, Autohemolysis test,
Haptoglobin, etc.