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CDHB

Severe Anaemia

The following investigations are suggested for anaemia in the absence of acute blood loss or shock. Some causes include: iron deficiency, B₁₂ and folate deficiencies, leukaemias, myelodysplastic syndromes, aplasia, haemolysis, renal failure, and bone marrow infiltration.

Investigations

• CBC + diff, film, and reticulocyte count along with standard biochemistry and LDH. Review previous results from Community Laboratory/GP to ascertain duration of anaemia.
• Mean cell volume (MCV) <80 femtolitre - probable iron deficiency or an inflammatory anaemia. Consider thalassaemia. Request iron studies, ferritin and CRP.
• MCV >100 femtolitre - could merely reflect an increased reticulocyte count (haemolysis/blood loss). If retics normal do plasma B₁₂ and folate levels. Consider B₁₂ and folate deficiencies, alcoholism, liver disease, myelodysplasia. In some patients, particularly the elderly, B₁₂ deficiency may be present despite a B₁₂ level in the lower range of normal (<250 pmol/L). Plasma methylmalonic acid measurement may be helpful but is falsely raised in renal impairment.
• MCV 80-100 femtolitre - consider renal failure, hypothyroidism, acute blood loss, malignancy (e.g., do PSA, SPE), and chronic inflammation or infection.

Note: Decide whether a bone marrow is required.

Note: Haemolytic anaemia may be suspected if the reticulocyte count and LDH are raised. A direct Coombs test and liver function tests should be done and if haemolysis is still suspected, the patient should be discussed with the Haematologist.

Treatment

• Once blood samples have been taken, and a bone marrow has either been performed or been deemed unnecessary, treatment may be started with oral iron and/or oral folic acid and/or IM hydroxocobalamin if one of these haematinic deficiencies seem likely. Recommended preparations are ferrous fumarate 200 mg PO BD, folic acid 5 mg PO daily and hydroxocobalamin 1 mg IM every other day for 6 doses, followed by maintenance treatment, usually 1 mg every 3 months.
• Transfusion should be given with extreme caution if a severe deficiency state is present. Close observation and diuretics will be needed. Transfusion may make subsequent diagnosis difficult, particularly in cases of haemolytic anaemia and some deficiency states.
• If in doubt a phone or written consultation with the Haematologist may be helpful as the appearances of the blood film may give further information of practical value (e.g., in haemolytic anaemias).

Topic Code: 1447