HEMOLYTIC ANEMIADR SANDIP GUPTA
PGT,PEDIATRICS
B.S.M.C.H.
CLASSIFICATION
1.RED CELL ABNORMALITY(INTRACORPUSCULAR DEFECT)A.HEREDITARY1.Membrane defect(spherocytosis,ellipsocytosis)2.Enzyme defect3.Hemoglobinopathies(Thalassemia,SCD, other)
B.ACQUIRED1.Paroxysmal nocturnal hemoglobinuria
2.EXTRA CORPUSCULAR DEFECT
A.IMMUNE HEMOLYTIC ANEMIA1.AUTOIMMUNE HEMOLYTIC ANEMIAWarm antibodiesCold anti bodies2.ALLOIMMMUNE HEMOLYTIC ANEMIAHemolytic disease of newbornIncompatible blood transfusion B.NONIMMUNE HEMOLYTIC ANEMIAMicroangiopathic hemolytic anemias(DIC ,TTP,HUS)Trauma:prosthetic cardiac valveBurns,ECMO,snake biteInfection: malaria, babesiaChemical injury :lead,wilson disease,Hypersplenism
EVALUATION OF ANEMIALow Hgb/Hct
Low Hgb/Hct
Corr. Retic Ct >2%
Corr. Retic Ct >2%
Corr. Retic Ct <2%
Corr. Retic Ct <2%
Acute Blood Loss Acute Blood Loss MCV>100
MCV>100MCV 80-100
MCV 80-100
MCV<80
MCV<80
EVALUATE & TREAT APPRO-
PRIATELY
EVALUATE & TREAT APPRO-
PRIATELY
Evaluate for
Hemolytic Anemias
Evaluate for
Hemolytic Anemias
Evaluate for
microcytic anemias
Evaluate for
microcytic anemias
Evaluate for
macrocytic anemias
Evaluate for
macrocytic anemias
Evaluate for
normocytic anemias
Evaluate for
normocytic anemias
NOYES
STEP BY STEP APPROACH
1. Calculate for Corrected Reticulocyte CountRetic count: 10%Pt’s Hct 29Control Hct 40
Corrected Retic Count = % Retic x Pt’s HctControl Hct
= 10% x 29/ 40 = 7.73 % > 2% if no blood loss Indicates hemolysis
HEMOLYTIC ANEMIA
Premature destruction of RBCs
2. Confirm (+) hemolysis:
a) Corrected retic count > 2% b) Inc indirect bilirubins c) Inc LDH d) Low/absent haptoglobin
3. Look for cause of hemolysis- occult blood in urine, urine hemosiderin- peripheral blood smear- direct antiglobulin test, Hgb electrophoresis,
RBC enzyme analysis
ROLE OF PBS
1 Sickled cells
Bite cells
Schisto-cytes
Acantho-cytes
Sphero-cytes
Target cells
parasiteinclusions
DAT(+)
DAT(-)
Hgb electro-phoresis
G6PDlevel
PT/PTTCrea
platelets
Auto-ImmuneHemo-lytic
Anemia
Heredi-tary
Sphero-cytosis
Sickle CellDs
G6PDDeficient
VsUnstable
Hgbs
Thalas-semiasHemo-
globino-pathy
Liver Ds
LiverDs
MalariaBabe-siosisBarto-nella
TTP-HUSDIC
Prosthe-tic Valve
MalignantHTN
Hemolytic Anemia (CRC>2% + no blood loss)
HEMOLYTIC ANEMIAIntravascular Causes in Red
WITHIN THE RED CELL
1. Membrane defects
- HS
- HE
- Hereditary pyropoikilocytosis
- Hereditary stomatocytosis
2. Enzyme defects
-G6PD
-Pyruvate kinase
3. Hemoglobin defects
- SCA
- Thalassemias
- Unstable hemoglobin
NON-IMMUNE
1. Hypersplenism
2. Fragmentation syndromes - grafts / valves / AS - HTN / Pre-eclampsia - March hemoglobinuria - MAHA - TTP/HUS - DIC - hemangioma
2. Infections/Toxins (Malaria, Babeosis, Bartonella, Clostridium welchii, snakes, spiders)
3. Drugs
4. Liver dz (Spur cell)
5. PNH
AUTO-IMMUNE
1. Warm
2. Cold
3. Transfusion reactions
4. Drug associated
OUTSIDE THE RED CELL
Intravascular Hemolysis
RBC LYSIS
HBG
HAPTOGLOBIN
REMOVED BY LIVER
HEMOGLOBINEMIA
HEMOGLOBINURIA
HBG TAKEN UP BY RENAL TUBULAR CELLS
HEMOSIDERIN
CELLS SLOUGHED IN
URINE 1 WEEK LATER
Features specific to intravascular haemolysis:
• Haemoglobinaemia(haptoglobin and
haemopexin exhausted).• Methaemoglobinaemia.• Haemoglobinuria.• Haemosiderinuria.
HEREDITARY SPHEROCYTOSIS
Incidence:1/5000 in North European population
Autosomal dominant Defect in RBC
cytoskeleton(spectrin,ankyrin) Pathophysiology:A deficiency in
spectrin, ankyrin,protein 3, leads to weakening of the “vertical” interaction of the lipid bilayer & loss of membrane microvescicle . Loss of surface area,↑cation permeability, ATP use,& glycolysis leading to premature destruction in spleen.
CLINICAL FEATURES Neonatal period: anemia+ jaundice, more severe. Infancy&childhood:variable severity. Mild: asymptomatic Moderate: intermittent
jaundice,spleenomegaly,anemia. Severe:tranfusion dependeant,bone expansion,gall
stone LAB. DIAGNOSIS:Anemia(Hb:6-10g
%),PBS :Spherocytes lacking central pallor ,reticulocytes,MCV-N
MCH↑,MCHC >35,RDW>14.5,DCT: NegativeOsmatic fragility& Incubated osmotic fragility test.Differential diagnosis: autoimmune hemolytic anemia, G6PD def,Clostridial sepsis, wilsons disease.
TREATMENT Splenectomy was routine in past. Anemia,reticulocytosis, hyperbilirubinemia resolve. Transfusion requirement↓,risk of gall stone falls. Current approach is to spenectomize pts with severe hemolytic
anemia &those with s/s of anemia, growth failure, skeletal changes, leg ulcer, etramedullary hematopoiesis,
aplastic crises,cardiomegaly . Pt’s with Hb>10%& retic count<10% may not need splenectomy. Partial splenectomy in infants & young children with severe
hemolysis & transfusion dependent anemia has been recently advocated.
Suppoertive therapy : 1mg folic acid daily. Laparoscopic splenectomy. Lifelong antibiotic prophylaxis.
2.HEREDITARY ELLIPTOCYTOSIS
Equatorial Africa, SE Asia AD / AR Functional abnormality in one or more
anchor proteins in RBC membrane- Alpha & beta spectrin& defective spectrin heterodimer self association , Protein 4.1& glycophorinC.
Usually asymptomatic Mx: Similar to H. spherocytosis Variant:
3.SE-Asian ovalocytosis: Common in Malaysia , Indonesia… Asymptomatic-usually Cells oval , rigid ,resist invasion by malarial parasites SAO is associated with protein3 abnormality.
RED CELL ENZYMOPATHIES
Physiology: EM pathway: ATP production HMP shunt pathway: NADPH & Glutathione production
1. Glucose-6-Phosphate Dehydrogenase
( G6PD ) Deficiency Pivotal enzyme in HMP Shunt & produces NADPH to protect RBC
against oxidative stress Most common enzymopathy -10% world’s population 1% of indian males have G6PD deficiency Protection against Malaria X-linked recessive
Clinical Features: Acute drug induced hemolysis:
Aspirin, primaquine, quinine, chloroquine, dapsone…. Chronic compensated hemolysis Infection/acute illness Neonatal jaundice Favism
(Oxidised form)(Reduced form)
Inv:e/o non-spherocytic intravascular
hemolyisP. Smear: Bite cells, blister cells,
irregular small cells, Heinz bodies, polychromasia
G-6-PD level
Treatment: Stop the precipitating drug or treat
the infectionAcute transfusions if required
2. Pyruvate Kinase DeficiencyARDeficient ATP production, Chronic
hemolytic anemiaInv;
P. Smear: Prickle cellsDecreased enzyme activity
Treatment: Transfusion may be required
PAROXYSMAL NOCTURNAL HEMOGLOBINURIA
Clonal cell disorder Ongoing Intra- & Extravascular
hemolysis; classically at night Testing
Acid hemolysis (Ham test)Sucrose hemolysisCD-59 negative (Product of PIG-A gene)
Acquired deficit of GPI-Associated proteins (including Decay Activating Factor)
1.Warm AI Hemolysis: Can occurs at all age groups F > M Causes:
50% IdiopathicRest - secondary causes:
1.Lymphoid neoplasm: CLL, Lymphoma, Myeloma
2.Solid Tumors: Lung, Colon, Kidney, Ovary, Thymoma
3.CTD: SLE,RA4.Drugs: Alpha methyl DOPA, Penicillin , Quinine, Chloroquine
5.Misc: UC, HIV
Inv: e/o hemolysis, MCV P Smear: Microspherocytosis, n-RBC Confirmation: Coomb’s Test / Antiglobulin test
Treatment Correct the underlying cause Prednisolone 1mg/kg po until Hb reaches 10mg/dl then
taper slowly and stop Transfusion: for life threatening problems If no response to steroids Spleenectomy or, Immunosuppressive: Azathioprine, Cyclophosphamide
2. Cold AI Hemolysis
Usually Ig MAcute or Chronic formChronic:
C/F:Elderly patients Cold , painful & often blue fingers, toes, ears, or nose ( Acrocyanosis)
Inv: e/o hemolysis P Smear: Microspherocytosis Ig M
Other causes of Cold Agglutination: Infection: Mycoplasma pneumonia, Infec
Mononucleosis PCH : Rare cause seen in children in association with
viral infection. Demonstrable DONATH LANDSTEINER ANTIBODY
Treatment: Treatment of the underlying cause Keep extremities warm Steroids treatment Blood transfusion
NON-IMMUNE ACQUIRED HEMOLYTIC ANEMIA1. Mechanical Trauma
A). Mechanical heart valves, Arterial grafts: cause shear stress damage
B).March hemoglobinuria: Red cell damage in capillaries of feet
C). Thermal injury: burnsD). Microangiopathic hemolytic anemia (MAHA): by
passage of RBC through fibrin strands deposited in small vessels disruption of RBC eg: DIC,PIH, Malignant HTN,TTP,HUS
ACQUIRED HEMOLYSIS
2.InfectionF. malaria: intravascular hemolysis: severe called ‘Blackwater fever’Cl. perfringens septicemia
3.Chemical/Drugs: oxidant denaturation of hemoglobinEg: Dapsone, sulphasalazine, Arsenic gas, Cu, Nitrates & Nitrobenzene
THALASSEMIAS/ THALASSEMIA SYNDROME Epidimiology :
– Most Common genetic disorder in Pediatric ward– 7% of the world population is carriers of hemoglobin disorder– 1.5% of world population is carriers of ß Thalassemia gene (20 millions in India alone)– 8 to 10 thousand children born
in India with homozygous state for the Thalassemia in every year.
– There are around 65 to 67 thousand Thalassemia patients in our country.
– In India, Prevalence of defective ß gene varies from 1 to 17 %.
Hallmark of Thalassemia is decreased or absent synthesis of Globin chains of Hemoglobin i.e. it is quantitative disorder of Hb Synthesis.
Based on the chain affected Thalassemias are classified as α and ß Thalassemia.
If ß gene is absent, it is term as ß0 Thalassemia. If partially affected, it is called ß+ Thalassemia.
The genetic classification does not necessarily define the phenotype and the degree of Anemia does not always predict the genetic classification.
Thus for the management, the Thalassemias are classified into four groups, each for α & ß depending on clinical severity.
SALIENT FEATURES
α THALASSEMIA SYNDROMES :
Syndrome Clinical Features Hemoglobin Pattern
α-globin genes affected and genotype
Silent carrier No Anemia, normal red cells
1-2% Hb Bart’s(γ4) at birth 1- α/ αα
Thalassemia Trait Mild anemia, hypochromic
5-10 % Hb Bart’s(γ4) at birth, microcytic red cells
2- α/ -α, --/ αα
HbH Disease moderate anemia, Hepatosplenomegaly, malar prominence etc.
5-30 % HbH (ß4) red cells 20-30% Hb Bart’s(γ4) at birth
3--/ -α
Hydrops Fetalis/Hb Bart’s Syndrome
Severe anemia, Hepatosplenomegaly, Cardiac defect, Genito-Urinary Systems abnormality, PET in motherDeath in Utero
Mainly Hb Bart’s 90 %, small amount of HbH, gower 1, gower 2 and portland
4--/--
CLASSIFICATION, CLINICAL & HEMATOLOGICAL FEATURES OF ẞ THALASSEMIA :
Syndrome Clinical Features Hemoglobin Pattern
ß-globin genes affected and genotype
Heterozygous State–Silent Carrier
–Thalassemia trait
No Anemia, normal
Mild anemia, hypochromic, microcytic red cellsHb > 10 gm% RBC > 5.5 x 1012 per liter
Normal, HbF < 5%
Elevated HbA2 (3.6-8 %)
1ß+ / A
1 ß0 / A, ß+ / A
Homozygous State–Thalassemia Intermedia
–Thalassemia Major or Cooley’s Anemia
Moderate anemia, requires some transfusion Hb > 7-10 gm% RBC < 5.5 x 1012 per liter
Severe anemia, transfusion dependentHb < 7 gm% RBC < 4 x 1012 per liter
HbF elevated(20 -100 %)HbA2 < 3.5 %
HbF elevated (90%)HbA2 = 2% HbE = 30-40%
2ß+ / ß+
2ß0 / ß0, ß0 / ß+,
E / ß0
PRINCIPLES OF MANAGEMENTConfirmation of the Diagnosis
By HPLC Diagnose of Complication
Correction of Anemia – Packed Red Blood Cell (PRBC) transfusion
Management of Complications– Iron Overload and Chelation Therapy– Anemia/ Hypoxia
– Arrest of Growth– Infections– Hypersplenism
Pharmacological Methods – Increase gamma chain Synthesis (HbF)
Curative Treatment– Stem cell transplantation
Future Treatment– Gene Replacement therapy
Prevention of Disease
DIAGNOSIS OF COMPLICATION: It is not sufficient to diagnose the case as Thalassemia ONLY.
For complete management of the case, it is necessary to think about its genetic classification, clinical and patho-physiological stage in which it now belongs to.
THALASSEMIA
SpenomegalySkeletal Deformity
&Arrest of Growth
Iron Overload&
Chelation Therapy
Anaemia
Recurrent Blood BormeInfection
DEATH
Why need a Transfusion? Correct Anemia &prevention of hypoxia Reduce Hepatosplenomegaly &Hypersplenism
Reducing ineffective erythropoesis& GI absorption Reduce hemolytic facies& skeletal deformities. Improve growth
BT is Mandatory For All children with Thalassemia Major Thalassemia Intermedia , Hb < 7 gm % Evidence of growth retardation
Types of Transfusion Palliative(8.5g%) Hyper Transfusion(10g%) Super Transfusion(>12g%) Moderate Transfusion(9-10.5g%)
TRANSFUSION THERAPY IN THALASSEMIA
TRANSFUSION THERAPY (CONTD…)
Frequency of Transfusion– Every 3-4 weeks– Shorter interval of 2-3 weeks is more physiological – avg. time taken 3-4 hrs(@5mi/kg/hr).
Amount of Transfusion– 180 ml / kg. / yr in non spenctomised, non-sensitised pt. – 130 ml / kg /yr in spenctomised, sensitised pt. ( 30 % less)
Efficacy of Transfusion– Rate of fall of Hb should not exceed 1 gm / dl /week with spleen– Rate of fall of Hb should not exceed 1.5 gm / dl /week without spleen
Allo immunisation of RBC Hyperspenism Drag induced hemolysis Infection
TRANSFUSION THERAPY (CONTD…)
Adequacy of Transfusion– First decade : normal growth– No. of Normoblast < 5 / 100 WBC
Complication of Transfusion– Non hemolytic febrile Transfusion reaction NHFTR– Allo Immunisation– Plasma Borne Infection– Steps to prevent those infections– Allergic reactionINDICATION OF SPLENECTOMY Annual PRBCc>200-250ml/kg >1.5times basal requirement Massive spleenomegaly hypersplenism
IRON OVERLOAD Causes of Iron Overload
– Treatment with multiple transfusion One bottle blood increases iron store by 200 – 250 mg iron.
– Ineffective erythropoesis– Excessive dietary absorption of Iron
Consequence of Iron overload– Iron overload in Liver
Hepatomegaly, Fibrosis & cirrhosis– Iron overload in Spleen
Splenomegaly, Hypersplenisim– Cardiac complication
Failure & Arrhythmia– Endocrinal Dysfunction
Thyroid, Para-Thyroid, Pituitary, Pancreas, Gonads– Iron overload in Bones
Osteoporosis, Osteopenia
IRON CHELATION THERAPY Iron Chelation Therapy
– Goal Reduce the Iron store & sub sequently maintain it at low level ( < 1000 µg/ml )
– When to start Start after 15-20 transfusion or S.Ferritin > 1000 µg/ml (approx. 3 yrs of age) Needle Biopsy of Liver : 3.2Mg iron per gm of Liver tissue (
– Drugs presently used Inj. Deferrioxamine (SC/IV) : DFO/Desferal Oral Deferiprone Oral Deferasirox
– Newer Iron Chelator Desferrithiocin ( DFT) Hydroxy Benzyl Ethilene Diamine Diacetic acid (HBED) Pyridoxal iso nicotinyl Hydrazone (PIH) GT 56-252 40 SD02 (CHF 1540)
IRON CHELATION THERAPY (CONTD…) Inj. Deferrioxamine (SC/IV) : DFO/Desferal
Dose <2000ug/l→25mg/kg/d,2000-3000ug/kg/d →35mg/kg/d Mode of Delivery s/c:over 8-10 hrs as 10% sol Dipot DFO is more effective & latest. Recently I.V. is used in severe cardiac involvement. Toxicity/ adverse effect
Local reaction Visual abnormality ( 4-10 % of pt.) Sensori-neural hearing loss ( 4-38 % of pt.) Delayed linear growth Pulmonary Infarction
Auditory & Visual Toxicity is reversible Yersinia sp. Infection Vit-c in a dose of 50-200mg/d
CURATIVE TREATMENT
Stem Cell Transplantation This is the only curative therapy available today. Though expensive, it is cost effective as compared
to yearly cost of regular BT & chelation therapy Sources
Bone Marrow Cord Blood Fetal Liver Peripheral Blood
FUTURE TREATMENT Gene Therapy
Aim : Insertion of a normal copy of gene along with key regulatory sequences(LOCUS CONTROL
REGION) in the stem cells of recipients.
Two main approaches Somatic gene therapy in which non-
germ line cells are involved. Transgenic approach
in which transfuse gene can be expressed in subsequent generationsNeed high titre vectors for
sustained expression Lentiviral vector from HIV is a
hope.
SCREENING & PREVENTION
Premarital screening programmes Alternative is to screen pregnant woman in
early pregnancy. PRENATAL DIAGNOSIS: BY CVS AT 9-11WK Recently there has been attempt to isolate
fetal cells from maternal blood. PARENTERAL COUNSELLING