CLASSIFICATION OF

ANAEMIA
• Guided By : Respected S K Sharma Sir.
• Dept. of Hematology
• PGIMER , CHD

• Presented By : Vijay Singh

• B.Sc. MLT - III
Anaemia
 Introduction
• Anaemia means lack of blood or decrease in
normal number of RBC`s.
• Anemia is not a specific disease itself. It is always
a sign or indication of a no. of underlying
processes leading to abnormality in RBC number,
structure or function.
 Definition
• It may functionally be defined as
an insufficient RBC mass in
circulation to deliver the
adequate oxygen to peripheral
tissues.
• A red cell count less than 40
million in males and 3.5 million in
females.
OR
• Hb concentration less than 10.8
g/ dl in males and 9.5g/dl in
females is an indication of
Anaemia.
• WHO CRITERIA FOR ANAEMIA ARE AS FOLLOW
Adult male haemoglobin: <13g/dl
Adult females : <12g/dl
Infants and children : <11g/dl
Pregnant women : <11g/dl

• COUNCIL ON FOODS AND NUTRITION HAS

DEFINED ANAEMIA AS
Age Hb PCV
Adult males <14g/dl <42.5%
Adult females <12g/dl <36%
Children <11.5g/dl <34.5%
6 months to 4 yrs <11g/dl <33%
 SEVERITY OF ANAEMEIA
• Some workers have classified the severity of anaemia based
on Hb level
Mild anemia : Hb 9.1-10.5g/dl
Moderate anemia : Hb 6.0-9.0g/dl
Severe anemia : Hb < 6.0g/dl

• In severe anemia hyper dynamic cardiac circulatory system

may fail and as a result there is fluid retention leading to
edema. Correction of anemia results in disappearance of
edema
 RED BLOOD CELL
PARAMETERS OF RED BLOOD CELLS:-
Shape : biconcave disc
Size : 7.2 +/- 0.5 micrometer in diameter in vitro
: 7.8 +/- 0.6 micrometer in diameter in vivo
: 2.1 +/-0.4 micrometer in thickness towards edge
: 0.8 +/- 0.3 micrometer at center
Nucleus : Non nucleated {mature cell}
Life span : 100-120 days
Surface area : (128-144)square micrometer
Normal count : 4.5-6.5x10^6/cumm

Red cell membrane - The matrix of the red cell membrane is formed by
the double layer of the phospholipid. Proteins traverse the lipid
bilayer at places and at other areas, these traverse the membrane
only partially.
• Composition :
Lipid constitute = 40%
Protein constitute = 50%
Carbohydrate =10%
• Monosaccharide are attached to the lipids and proteins and are
present on the outer surface of membrane, on the cytoplasmic
side of the membrane is the network of structural proteins that
form the cytoskeleton of the red cells.
• Cytoskeleton of the red cells :- The cytoskeleton is made up of
spectrin,actin,band 2.1 Band 3, band 4.1,ankyrin and other
proteins. Interconnection of network proteins with the cell
membrane proteins imparts the cell a biconcave shape and
deformability so that the cell can pass through tiny capillaries.
• Red cell antigen:
Blood group antigens are present on both
carbohydrate and protein fractions of the cell
membrane.
• Destruction of the red blood cells :
Old/aged red cells are destroyed in the R.E system i.e
in spleen
 SIGN & SYMPTOMS OF ANEMIA
-Fatigue -Loss of sexual drive
-Weakness -Mild fever
-Fainting -Irritation
-Breathlessness -Weight loss
-Heart palpitation -Pallor skin
-Coldness in hand and feet -Dry skin
-Insomnia -Brittle nails
-Vertigo (giddiness) -Glossitis
-Headache -Sclera jaundice
-Ringing in the ear (tinnitus) -Hypertension
-Difficulty concentration -Dyspnoea
-Chest pain -Blurred vision
-Mental confusion
SIGN & SYMPTOMS OF ANEMIA

AN
ANEMIC
PATIENT
 CLASSIFICATION OF ANEMIA
• ANEMIA CAN BE CLASSIFIED
(A) Morphological classification
(B) Kinetic classification
(C) Etiological classification

• MORPHOLOGICAL CLASSIFICATION
Morphological classification deals with the size and haemoglobin
concentration of the erythrocytes.
• ROLE OF RED CELL INDICES IN CLASSIFICATION
Red cell indices are useful in the diagnosis of anemia. Morphology
of the red cells can be quickly determined by red cell indices or
William constant.
RED CELL INDICES ARE :-
• MCV (mean cell volume)
• MCH (mean cell Hb)
• MCHC (mean cell Hb concentration)
William’s constant:- Wintrobe's introduced calculation for
determining the size and Hb concentration.
They are calculated from------1)Hb
2)PCV
3)Total RBC count
MCV (Mean cell volume) :- it is the average volume of the red cells and has
the unit of femtolitre (fl)

Calculation : PCV X 10
RBC in millions/ul
Normal range = 80-96 fl
Increased value : macrocytic anemia
Decreased value: microcytic anemia
MCH ( mean cell haemoglobin)
It is the weight of Hb of the average sized red cells .it has the unit of picogram
(pg)

Calculation = Hb in g/dl
RBC in millions/ul

Normal range = 27.5-33.2 pg

Increased value : macrocytic anemia
Decreased value : hypochromasia ,microcytic

MCHC (mean cell Hb concentration)

It is the average concentration of Hb in given volume of packed red cells. It has
the unit of g/dl
Calculation = Hb in g/dl
PCV
Normal range = 32-36%
Decreased value : Hypochromic anemia
Increased value : Spherocytosis, macrocytic anemia
 MORPHOLOGICAL CLASSIFICATION OF ANAEMIA

MICROCYTE NORMOCYTE MACROCYTE

HYPERCHROMIC HYPER CHROMIC HYPERCHROMIC
HYPERCHROMIC

MICROCYTE NORMOCYTE MACROCYTE

NORMOCHROMIC NORMOCHROMIC NORMOCHROMIC
NORMOCHROMIC

MICROCYTE NORMOCYTE MACROCYTE

HYPOCHROMIC HYPOCHROMIC HYPOCHROMIC
HYPOCHROMIC

MICROCYTE NORMOCYTE MACROCYTE

SIZE OF RBC
 MCV

MICROCYTIC NORMOCYTIC MACROCYTIC

(<80 fl) (80-96 fl) ( >100 fl)

MCHC

HYPOCHROMIC(<32%) NORMOCHROMIC (32-36%) HYPERCHROMMIC(>36%)

MORPHOLOGICAL CLASSIFICATION OF ANEMIA
 FINDINGS IN MORPHOLOGICAL CLASSIFICATIONS

MICROCYTIC MICROCYTIC MACROCYTIC MACROCYTIC

HYPOCHROMIC NORMOCHROMIC HYPOCHROMIC NORMOCHROMIC

MCV = Decreased MCV=Decreased MCV =Increased MCV =Increased

MCH =Decreased MCH=Decreased MCH =Decreased MCH =increased
MCHC =Decreased MCHC=Normal MCHC =Decreased MCHC = Normal

FOUND IN :- FOUND IN :- FOUND IN :- FOUND IN :-

-IDA -Inflammation -Combination of IDA -Megaloblastic anemia
-THALSSAEMIA -Toxic drugs and and Megaloblastic -Addisonian anemia
chemicals anemia
-Malignancy
-Endocrine disorder
-Chronic disease
NORMOCYTIC RBC
MICROCYTIC RBC
MACROCYTIC RBC
NORMOCHROMIC RBC
HYPOCHROMIC RBC
HEPERCHROMIC RBC
POLYCHROMASIA
SUMMARY OF VARIATIONS IN COLOUR AND SIZE OF RBC
SUMMARY OF VARIATIONS IN THE RBC SHAPE
MACROCYTIC ANEMIA
NORMOCHROMIC NORMOCYTIC ANEMIA
MICROCYTIC HYPOCHROMIC ANEMIA
 KINETIC CLASSIFICATION OF ANEMIA

1. ANEMIA DUE TO IMPAIRED RED CELL PRODUCTION

2.ANEMIA DUE TO EXCESSIVE BLOOD LOSS

• DEFICIENCY OF ESSENTIAL NUTRIENTS

-Iron deficiency (IDA)
-Vitamin B12,folate deficiency(megaloblastic anemia)
-Vitamin c deficiency
• DEFECT IN STEM CELL/ERYTHHROID PRECCURSOR
-Aplastic anemia
-Pure red cell aplasia
• MISCELLANEOUS
-Anemia of chronic disorders
-Marrow suppression due to drugs
2. ANEMIA DUE TO EXCESSIVE BLOOD LOSS
• ACUTE BLOOD LOSS
-Accidental injury
-Surgery
-GI bleeding
-Hematuria
• CHRONIC BLOOD LOSS
-Bleeding ulcer
-GI ulcer
-Hook worm infestation, schistosomiasis, trichuria infection
-Prolonged excessive vaginal bleeding
 (C) KINETIC CLASSIFICATION OF ANEMIA
• ANEMIA DUE TO EXCESSIVE DESTRUCTION OF RED BLOOD
CELLS BUT DECREASED PRODUCTION
• CAUSES: It can be due to
1.Intracorpuscular defect
2. Extra corpuscular defect

INTRACORPUSCULAR DEFECT

HEREDITARY DEFECT
ACQUIRED DEFECT
 HEREDITARY DEFECT
• ENZYME DEFECIENCY (enzyme pathology)
1.G6PD deficiency :- primaquine type drug sensitivity,
congenital non spherocytic hemolytic anemia(Dacie type I)
2.PK deficiency (pyruvate kinase) :- congenital non spherocytic
HA (Dacie type II)

• MEMBRANE DEFECT:- (a) hereditary spherocytosis

(b) hereditary ovalocytosis
(c) hereditary elliptocytosis
• OTHER ENZYME DEFECT :- (a) diphosphoglyceromutase
(b) glutathione reductase
(c) triose phosphate isomerase
(d) ATPase
• HEREDITARY HEMOGLOBINOPATHIES (Hb abnormality)
-Sickle cell anemia and sickle cell trait
-Thalassemia
-Homozygous HbC disease
-Hb S/C disease
Others :- (a) Hb DD disease
(b) Hb H disease
(c) HB S/H diisease
(d) Hb C/B thalassemia
(e) Hb E/B thalassemia

• ACQUIRED DEFECT:
• PNH ( Paroxysmal nocturnal haemoglobinuria)
• Vitamin B12 deficiency
• Secondary to liver disease Infections
 EXTRA CORPUSCULAR DEFECT
• Hereditary ( none known)
• Acquired
ACQUIRED DEFECT
1. Iso antibodies
(a) Transfusion reaction (incompatible blood ABO,Rh)
(b) HDN (haemolytic disease of new born)
2. Auto antibodies
(a) Idiopathic
(b) Secondary
3. Autohemolysis
(a) paroxysmal cold haemoglobinuria (PCH)
4. Infections
(a) bacterial (clostridia welchi)
(b) parasitic (malarial)
(c) viral
5. Chemical agents :- e.g. benzene
6. Burns
7.Hyperspleenism
8.Lead poisoning
9. Drug induced hemolytic anemia
10.None immune mechanism
(a) mechanical hemolytic anemia
(b) cardiac hemolytic anemia
(c) micro angiopathic hemolytic anemia
(d) march haemoglobinuria
11. Immune mechanism AIHA (Autoimmune hemolytic anemia )
-Warm antibody type (react at 37C)
-Cold antibody type (react at <32C)
HEREDITARY SPHEROCYTOSIS
HEREDITARY OVALOCYTOSIS
 SPURIUS ANEMIA OR DILUTIONAL ANEMIA
• This is the term used when red cell concentration decreases due to
haemodilution as in third trimester of pregnancy; however it is not
A disease entity but needs to be differentiated from anemia.
This is due to increase in plasma volume .

• This is found in :---

1. Pregnancy
2.Macroglobulinemia
3.Athletes
4.Post flight astronauts
 ANEMIA OF CHRONIC DISORDER
• Anemia of chromic disorder is the anemia associated with chronic
infections and inflammation and malignancies. Before labeling the
patient as anemia of chronic disorder;anemia due to hemolysis ,marrow
replacement and chronic renal failure should be excluded.
• Diseases causing anemia of chronic disorder
Chronic inflammation – Rheumatoid arthritis ,rheumatic fever, SLE
Chronic infections- Tuberculosis,HIV,UTI
Malignancy associated- Cancer of various organs,
Miscellaneous – Alcoholic liver disease
• Hematological findings
Hb =decreased ,reticulocyte =N/reduced ,red cells=N/N
• Treatments
1. Treatment of underlying chronic disorder
2. Recombinant erythropoietin (EPO) is given in patients who have
moderately severe anemia and require blood transfusion.
 THALASSEMIA
• Thalassemia is a group of disorder which results from an
inherited abnormality of globin production. This is the
commonest form of haemoglobinopathy.
About 250 million people i.e 4.5% of the world population
carry thalassemic gene . Thalassemia syndrome results from
defects in the rate of synthesis of alpha or beta chain.
• Classification of the thalassemmia

thalassemia

Beta thalassemia Alpha thalassemia Misc. thalassemia syndrome

Thalassemia major Hydrops foetalis Hb S thalassemia
Thalassemia intermediate Hb H disease Hb E
Thalassemia trait Alpha thalassemia trait Hb D
THALASSEMIA
SICKLE CELL ANEMIA
• Sickle Cell Anemia is a
hereditary disease which is
cause by a disorder in the
blood, a mutation in the
Hemoglobin Beta Gene
which can be found in the
chromosome 11. This
disease causes the body
to make abnormally
shapes red blood cells. A
normal red blood cell is
shaped as a round donut
while the abnormal red
blood cell has a “ C “ form.
 RISK FACTORS
• A risk factor is what increases the chance of getting a
disease or condition.
• The risk of having sickle cell anemia is that you're risk of
dying of strokes and heart attacks.
• DIAGNOOSTIC TESTS- Routine hematology test
(Haemogram) ,Sickling test, Hb electrophoresis Globin
chain analysis, Hb S solubility test
 Medications and treatment
Hydroxyurea Treatment : it’s a chemical compound
that is use as medication. For sickle cell disease
come in capsule form and it’s administered once a
day.
Antibiotics: (penicillin) for children/helps prevent
infection.
Bone Marrow: Transplant of the bone marrow to
relieve pain.
 HAEMOLYTIC ANEMIA
• Haemolytic anemia are the anemia in which there is increased destruction
of red blood cells. Anemia in such cases developes due to inability of the
bone marrow to compensate for the degree of destruction.
• Normal life of red blood cell is 120 days but in haemolytic anemia it is
about 15 days.
• Old RBC loses membrane sialic acid ,lipids and ATP level decreases.
DESTRUCTION OF RBC

Extravascular Intravascular
80-90% destruction mainly in spleen In circulation releasing Hb in plasma
LAB FINDINGS ---
Haemoglobinemia
Haemosiderinuria
Serum haptoglobin level decreases
S.Bilirubin (unconjugated)
 IMMUNE HAEMOLYTIC ANEMIA
• Immune haemolytic anemia are those anemia in which hemolysis is
mediated by auto antibodies or alloantibodies. Hemolysis is both
intravascular and intravascular.
• Further classification are
1. Auto immune hemolytic anemia :-auto antibodies produced by the
patient’s immune system are directed against the red cell surface antigen.
There are two types of antibodies. They are
(a) Warm antibody type –antibodies react at 37C. These are mainly of
IgG type and do not fix complement. e.g. CLL, SLE,rheumatoid
arthritis.
(b) Cold antibody type –these react with RBC at lower temp.(<32C)
e.g paroxysmal cold haemoglobinuria,infectious mononucleosis.
2. Allo immune hemolytic anemia
(a) hemolytic transfusion reaction – ABO ,Rh mismatched
patient’s serum contain naturally occuring IgM antibodies.
These antibody coat the donar red cell with complement and
activation to C9 results in intravascular hemolysis.
(b) HDN –when mother is Rh-ve and foetus is Rh+ve
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