CLASSIFICATION OF

ANEMIA
Dairion Gatot

Hematology -Onkology Medical Division

Internal Departement of Medical Faculty
of North Sumatera University /
Haji Adam Malik General Hospital
Medan 2010

HP: +628126030962

Erythrocyte diseases

ANAEMIA :
Is defined as a condition in which the
haemoglobin concentration is below
reference
range for the age, sex, method & altitude
Deficient in O2 carrying capacity
hypoxia

CUT OFF POINT ANAEMIA IN

INDONESIA
Pre school age

11 g/dL

School age

12 g/dL

Pregnant women

11 g/dL

3 month post partum12 g/dL

Female

12 g/dL

Male

13 g/dL

CLASSIFICATION OF ANAEMIA
Morphologic classification :
1. Macrocytic anaemia
2. Microcytic hypochromic
anaemia
3. Normocytic anaemia.

Morphologic classification :
1. Macrocytic anaemia
-Defisiensi Megaloblastic
-Defisiensi Asam Folat
-Probable Haemolytic anemia
-Posible liver disease

Morphologic classification :
2 Microcytic hypochromic anaemia
- Iron defisiensi anemia
- Thalasemia/Hemoglobonopathies
- Sideroblastic anemia

Morphologic classification :
3. Normocytic anemia
-Blood loss
-Autoimmune haemolytic anemia
- Other haemolytic anemia
(Parasites, Hypersplenism, Microangiopathic, haemolysis
Hereditary spherocytosis, Paroxysmal noctural
haemoglobinuria, Enzyme deficiencies, Drug or toxin,
Haemoglobinopathies

-Other
(Renal disease, infection,malnutrition, aplastic anemia,
radiation)

CLASSIFICATION OF ANAEMIA
Etiologic classification :
1. Blood loss
1.1. Acute
1.2. Chronic
2. Impairment of RBC formation
2.1. Insufficient erythropoiesis (nutritional)
2.2. Ineffective erythropoiesis
3. Decreased RBC life span (haemolytic anaemia)
3.1. Congenital defect : membrane, enzyme Hb
defect
3.2. Acquired defect

: malaria, some drugs,

DIAGNOSIS OF ANAEMIA
Basic steps are :
1. Evaluation of clinical information from
a review of the history & physical
examination
2. Evaluation of the basic blood
examination & specialized laboratory
examination
3. When necessary, bone marrow
examination

History
Poorly nourished patient on insufficient diets
Jaundice : haemolytic anaemia, malaria
Ingestion of certain drugs, chemicals exposure
Preexisting of renal diseases
Bleeding : gynaecologic, GI
anaemia

iron deficiency

Ethnic, geographical consideration, genetic back

grounds
Diet
Infectious disease problems.

Physical examination
Pallor, bruising , shock
Organomegaly : spleen, liver, lymph nodes
Jaundice
Leg ulcer in HbS anaemia / thalassaemia
Neurological abnormalities : vit B12
deficiency
Koilonychia, angular cheilosis

Angular cheilosis

Leg ulcer (HbSS)

Koilonychia

Laboratory studies
Hb level, leukocyte, platelet, reticulocytes count,
PCV,
ESR
Red cells indices (MCV, MCH, MCHC)
Examination of peripheral blood film
BM examination
Special tests : Ham & Sugar water tests, G-6PD
tests
SI / TIBC, ferritin

DIAGNOSIS OF MACROCYTIC ANAEMIA

LABORATORY
TEST

INTERPRETATIO
N

Peripheral
smear
Bone
marrow
examination

Macrocytic
anaemia
Megaloblasti
c changes

Reticulocyt
e count

Low

No
megaloblastic
changes
Hig
h

Therapeuti
c response

Respond
s to vit
B12

Responds
to folic
acid

Diagnosi
s

Vit B12
deficiency
(determine
if dietary
or
abnormal

Folic
acid
deficienc
y

Probable
haemolytic
anaemia
(continue
workup)

Low

Possible liver
disease
(evaluate
liver function
tests)

Macrocytic

Microcytic hypochromic

Normocytic
normochromic

Hypersegmentation

Macro ovalocyte with

cabot ring inclusion

DIAGNOSIS OF HYPOCHROMIC MICROCYTIC

ANAEMIA
LABORATORY
TEST
Peripheral
smear
Iron

INTERPRETATIO
N
Hypochromic &
microcytic anaemia
Absent

Increased

(Bone
marrow)

Haemoglobin
electrophoresi
s
Diagnosis
SI/TIBC, PERRITIN

Ringed
sideroblasts
Normal

Iron
deficienc
y
anaemia

Abnormal

Normal

Thalassaemi
a
haemoglobi
no-pathies

Sideroblast
ic anaemia

Causes of microcytic hypochromic

anaemia

DIAGNOSIS
1. BLOOD FILM
RBC

Deficiency Fe

Microcytic : Hb < 10 g/dL Ht < 30%

Thalassaemia major

Markedly microcytic

hypochronic
Hypochrom : Hb < 9 g/dL, Ht < 27%

Anisocytosis, poikilocytosis (pencil cells)

& shape

Target cells :

++ 5-30%

NRBC :

Polychromatophilia :

+
-

Bizarre variation in size

++
-

++

WBC count

normal

increased

Platelet count

normal

increased/normal

Iron deficiency anaemia

Target cells

thalassaemia
major

thalassaemia
minor

2. BONE MARROW
Deficiency Fe
Hypercellular

Thalassaemia major

No iron stores

Hypercellular
Iron stores increased

Anaemia
sideroblastic
Hypercellular
Iron stores
increased
Ring sideroblasts
+

3. IRON
Deficiency Fe
Thalassaemia major
Anaemisideroblastic

SI

TIBC

TS

Ferritin

Iron values in the development of iron deficiency

anaemia

13-16

131
6

12-14
13-16

DIAGNOSIS OF NORMOCYTIC ANAEMIA

LABORATORY TEST

INTERPRETATION

PERIPHERAL SMEAR

NORMOCYTIC
ANAEMIA

RETICULOCYTE
COUNT

INCREASE
D

BLOOD IN STOOL OR
OTHER SOURCE OF
BLEEDING
IDENTIFIED

POSITIV
E

ANTIHUMAN GLOBULIN
(COOMBSTEST)

REDUCED

NEGATIVE

POSITIVE

NEGATIVE

NEGATIVE

BONE MARROW AND

BONE MARROW BIOPSY

HYPERCELLULA
R ERYTHROID
HYPERPLASIA

HYPERCELLULA
R ERYTHROID
HYPERPLASIA

DECREASED
CELLULARITY

DIAGNOSIS

AUTO IMMUNO
HAEMOLYTIC
ANAEMIA

OTHER HAEMOLYTIC
ANAEMIAS

OTHER

BLOOD
LOSS
ANAEMIA

Erythroblastosi
s
foetalis
Transfusion
reaction
Collagen
vascular
disease

Parasites

Renal
disease

Hypersplenism

Infection

Microangiopathic

Malnutrition

haemolysis
Hereditary
spherocytosis
Paroxysmal noctural
haemoglobinuria
Enzyme deficiencies
Drug or toxin
Haemoglobinopathies

Aplastic
anaemia
Radiation

REPLACEMENT
OF NORMAL
MARROW
ELEMENTS
MYELOPHTHISIC
Tumor
Myelofibrosis
Infection
Leukaemia

NORMOCYTIC NORMOCHROMIC ANAEMIA &

RETICULOCYTOSIS

1. Acute blood loss

Phase I
(day 1-3)
Hypovolumic
stage

Bleeding

Post hemorrhagic
anaemia (normocytic
anaemia)
Plasma volume
RBC mass
Haemodilutio
n after 24
hour
Erythropoiesis
activity

Phase II
(day 3-5)
Regeneration stage

BM
hiperplasia
Reticulocytosis
polychromatophilia
RBC macrocytosis

Thrombocytopenia

Thrombocytosis
Leukocytosis
Neutrophilia

2. Haemolytic anaemia

Rate of RBC destruction

RBC production
Reticulocyte counts

Reticulocytosis in
haemolytic anaemia