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Anemia – Margaret Wheless

General Approach to Diagnosis



Reticulocyte Index > 2%



Extrinsic RBC causes:

Intrinsic RBC causes:


RBC Size Framework

Normocytic Anemia: MCV 80-100

Microcytic anemia: MCV <80(Mnemonic: SALTI)

Disease Etiology Evaluation Considerations
Sideroblastic MDS


ETOH, Lead, Isoniazid,

Cu deficiency | Social hx, work, TB,

consider Lead level

Fe:↑↑  ferritin:↑nl or ↑

TIBC: nl

Smear: basophilic stippling

BMbx: ringed sideroblasts | | | Anemia of chronic disease | Chronic inflammation, malignancy, HIV autoimmune dz, Inflammation (IL6, TNF α)↓ | Fe/TIBC >18%

Fe: ↓↓  ferritin:↑↑  TIBC:↓↓ | Tx: underlying dz

EPO if Hgb <10 and serum EPO <500

Replete Fe if ferritin <100 or TIBC <20% | | Thalassemia | ↓synthesis of α or β chains leads to ↓

erythropoiesis and ↑ hemolysis | Family Hx of anemia

Mentzer’s index: MCV/RBC <13 = thalassemia

Normal Fe studies; can mimic microcytic anemia and  Fe overload from transfusions

Diagnosis: Hb electrophoresis | α thal more common in Asian/African descent

β thal common in Mediterranean descent

Tx: transfusions, folate, Fe chelator depending on severity | | Iron (Fe) deficiency | Chronic bleeding:

colon cancer

heavy menstrual periods, cirrhosis (portal gastropathy)

Supply: malnutrition, Crohn’s dz, celiac dz, subtotal gastrectomy

Demand: pregnancy | Fe/TIBC <18%

Fe:↓↓  TIBC:↑ nl to ↑

ferritin: < 15, <41 w/co-morb.

Mentzer’s index: >13

Consider celiac testing based on clinical suspicion

Investigate for GIB or sources of blood loss | Oral Fe: 6wks to correct anemia, 6mo to replete  stores; dose every other day ( ↑ absorption w/

↓ GI side effects); add Vit C for ↑ absorption

If can’t tolerate PO consider IV Fe (Avoid when bacteremic

HFrEF: IV Fe if ferritin <100 OR 100-300 w/ Fe sat <20% |

Macrocytic Anemia: MCV >100

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