AnemiaDr . Yenny Dian Andayani SpPD -KHOM Divition Hematologic Oncologi Medic Dept Internal Medicine Moh HoesinGeneral Hospital Palembang Faculty of Medicine Sriwijaya University Palembang

Morphological classification of anemias microcytic, hypochromic anemia (decreased MCV)

normocytic, normochromic anemia (normal MCV)

macrocytic, normochromic anemia (increased MCV)

Normochrome normocyter anemia MCH normal MCHC normal MCV normal

MICROCYTIC HYPOCHROME anemia MCV MCH MCHC microcytic, hypochromic RBC in the peripheral blood MCV < 80fl MCH < 27pg

MACROCYTIC anemia MCV MCH MCHC

FLOW CHART ANEMIA NORMOSITIK NORMOKROMAnemia MCV 80-100 fL and MCHC 30 g/dL or MCH > 27 pg/dL

Indeks retikulosit 15

Abnormal Hambatan Produksi/PematanganNormal Anemia hemolitik/def.Fe dalam terapi ? Periksa ACTH Infiltrasi Keganasan Hipoplasia SSTL Cincin sideroblastik ?

BMP

Kehilangan/Penghancuran Berlebihan Periksa: Bilirubin indirek, LDH

Normal Perdarahan ?Tidak Ya

TinggiAnemia Hemolitik Periksa urin

Negatif

Tes coombs, C3/C4 Anti dsDNAHemolisis Ekstravaskular Defect Extra corpuscular Mekanik, Toksin, Infeksi

Positif Hb/ hemosiderin

Positif AIHA Primer or Secunder Negatif Defect Intra corpuscular

Hemolisis Intravaskular

FLOW CHART ANEMIA MIKROSITIK HIPOKROMAnemia MCV 70% yellow marrow

Differential Diagnosis of pancytopenia and hypoplastic marrow

1. Aplastic anemia 2. Hypoplastic myelodysplastic syndrome or hypoplastis AML 3. PNH 4. Hypoplastic antecedent phase of acute lymphocytic leukemia 5.Hypoplastic antecedent of hairy cell leukemia 6. Idiopathic myelofibrosis 7. Pure red cell aplasia 8. Agranulocytosis.

Diagnosis Criteria for Severe AA At least two of following - Absolute neutrophil count < 0,5 x 10 9 /L - Platelet count < 20 x 10 9/L - Anemia with corrected reticulocyte count < 1 %. One of the following - Bone marrow cellularity 12,000 B3. BM Biopsy showing panmyelosis with prominent erythroid & megakaryocytic proliferation

B4.

Low serum EPO levels

Diagnosis : A1+A2 and any other of cathegory. A or A1+A2 and any 2 of cathegory. B or > 99th percentile of method specific reference range of age ,gender,altitude of residence

Criteria Polycythemia Vera study group Category A 1.total red cell mass Male 36 ml/kg Female 32 ml/kg 2.Arterial oxygen saturation 92 % 3. Splenomegaly

Category B 1. Thrombocytosis > 400 x 10 3/ul

2. Leukocytosis 12x 103/ul 3. Increased leukocyte alkaline phosphatase (LAP) 4. Serum B12 > 900 pg/ml or B12 binding capacity > 2200 pg/mlPv Diagnosis : when A1+A+2+A3 and any 2 from category B are present.

PV & Secondary polycythemiaFindingSplenomegaly Leukocytosis Thrombocytosis RBC volume arterial O2 sat B12 level LAP Bone Marrow EPO level Endogenous CFU-E growth

PV+ + + increased normal increased increasedPanhyperplasia decreased +

2nd Polycythemianormal normal normal normal normal normal -

Staging & Prognosis

Hct. > 45%

risk to thrombosis Death

age > 70 yrs. & previous history of thrombosis; important predictor of recurrent thrombotic events

Treatmentaim ; - reduce thrombotic risk & slow leukemic transformation - based on risk of thrombosis

Low risk -age < 60yr. -no Hx thrombosis -Plt. < 1,500,000 -no CVD risk Intermediate risk

High risk-age > 60yr. -Previous Hx. thrombosis -CVD risk(smoking, )

TreatmentTreatment of choice is Phlebotomy

Hct. < 45 % in men , < 42% in women

Hydroxyurea

is supplemented to decreased Hct.

IFN alfa use for cytoreduction in younger ( decreased risk to leukemic transformation of hydroxyurea )

TreatmentBusulfan or P-32 in elderly pt. with hydroxyurea intolerated

Low dose ASA ( 40 mg ) ; alleviate of microvascular sequelae ( headache, vertigo,visual disturbance , erythromelalgia )

Anagrelide ; used in all MPD to lowering platelet count