Anaemia in Adults

Scope

Anaemia can be caused by:

  • Iron, folate, and B12 deficiencies
  • Chronic Kidney Disease (CKD)
  • Anaemia of chronic inflammation (ACI)
  • Bone marrow malignancy
  • 10% of people aged over 65 years living in the community have anaemia. After age 50, the prevalence rises rapidly
  • Most anaemia is mild. Only 3% of women and 1.5% of men have haemoglobin levels less than 110 g/L
  • In older people with anaemia, one third have nutrient deficiency, one third have ACI or CKD (or both)

Assessment

History and Examination

History:
  • Weight loss
  • Bone pain
  • Night sweats
Examination:
  • Jaundice
  • Lymphadenopathy
  • Hepatosplenomegaly

Investigations

Determine the most likely cause by arranging or assessing all of the following:

  • Full Blood Count (FBC) (indicates severity and whether other cell lines are involved)
  • Blood film (gives blood cell morphology which helps indicate the likely cause). This needs to be specifically requested on the laboratory form
  • Reticulocyte count (indicates whether bone marrow is active). This needs to be specifically requested on the laboratory form. If reticulocyte count is:
    • low i.e. decreased production - indicates nutritional anaemias, anaemia of chronic inflammation, renal failure, or bone marrow failure or infiltration
    • normal, assess in relation to the mean cell volume (MCV)
    • high i.e. increased destruction - indicates haemolysis or acute blood loss
  • MCV identifies whether macrocytic (MCV more than 98), normocytic (MCV 82 to 98), or microcytic (less than 82)

Further investigations will depend on these results:

  • Increased reticulocytes
    • Look for haemolysis or acute blood loss
    • Haemolysis:
      • Determine whether it is congenital or acquired:
      • Ask about family history e.g. hereditary spherocytosis, thalassaemias, sickle cell anaemia
      • Ask about medications
      • May be auto-immune
  • Macrocytic anaemia
    • Consider alcohol excess, B12 deficiency or folate deficiency, hypothyroidism, primary bone marrow failure or bone marrow malignancy including multiple myeloma and secondary cancers
  • Microytic anaemia
    • Consider iron deficiency or anaemia of chronic inflammation. If neither of these, consider haemoglobinopathy such as thalassemia, and request haemoglobinopathy screen
    • Anaemia of chronic inflammation
      • Previously known as anaemia of chronic disease
      • Can be caused by any systemic inflammatory condition e.g. malignancy, infection, autoimmune conditions
      • May have normal or elevated ferritin and reduced serum iron
      • May have an elevated C-reactive protein (CRP) and other inflammatory markers
      • Can present as either microcytic or normocytic anaemia
  • Normocytic anaemia
    • Consider recent haemorrhage, renal failure, thyroid or other endocrine abnormality, anaemia of chronic inflammation or bone marrow malignancy including multiple myeloma and secondary cancers
  • Cause is not obvious
    • Measure:
      • Ferritin, B12, folate
      • Urea and electrolytes (U&Es) and liver function tests (LFTs)
      • Thyroid-stimulating hormone (TSH)
      • Serum protein electrophoresis plus urine Bence-Jones protein

Note: When iron deficiency coexists with inflammatory disease, ferritin may be spuriously normal - it is an acute phase protein. Requesting additional iron studies may assist in these situations.

Management

Most anaemia is managed in general practice.

  • Identify the cause and treat the underlying problem e.g. blood loss, chronic inflammation, folate, or B12 deficiency.
  • If no identifiable cause, it may be appropriate to monitor until symptomatic or until a treatable cause is found. In the elderly, about one third of anaemias are unexplained.
  • If severe symptomatic anaemia, consider whether the patient may benefit from red cell transfusion.

Referral

Referral Criteria

Most anaemia is managed in general practice, request haematology assessment if anaemia is associated with:

  • Blood film or other findings which are indicative of haematological disease, such as leukaemia, myelodysplasia, myeloma
  • Abnormalities of other blood cell lines, such as thrombocytopenia, neutropenia
  • Investigations suggest haemolysis, such as reticulocytosis, hyperbilirubinaemia, elevated Lactate dehydrogenase (LDH), positive direct antiglobulin test
  • Include FBC, blood film, reticulocytes result, and any other relevant tests, in your referral
  • Urgent or written advice is available

Referral Instructions

e-Referral Service Selection

  • Specialty: Haematology
  • Clinic Type: Not otherwise specified
  • Service: DRSS-Northern-Haematology-NEW Devon CCG

Referral Forms

DRSS Referral Form

Supporting Information

Pathway Group

This guideline has been signed off by NEW Devon CCG.

Publication date: July 2016

 

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