實驗診斷學(xué)課件：LABORATORY EVALUATION OF ANEMIA

1LABORATORYEVALUATIONOFANEMIALiu,Yan-FangMD,Ph.D.FirstTeachingHospitalZhengZhouUniv.2RBCdisorders(Anemias)

“Anemiaisdecreasedredcellmassaffectingtissueoxygenation”*LowHb<120g/L(males),<110g/L(females)Congenitaldisorders:Membrane,Hb&enzymedisorders.Acquireddisorders:DecreasedproductionExcessivedestructionoferythrocytesIncreasedloss3CongenitalRBCDisorders:(Hemolysis)MembraneDisorders:Spherocytosis,ElliptocytosisHemoglobinDisorders:Hemoglobinopathies-Sicklecell,HbCetc.ThalassemiaSyndromes-,,Enzymedisorders:G6PD,PKdeficiency1234AcquiredRBCdisorders:DecreasedProduction:DeficiencyanemiasIron,B12,Folate

etc.Aplastic,HypoplasticanemiasMarrowdisease,malignancy,radiationIncreasedloss/destruction:Bloodlossanemias-parasites,bleedingHemolyticanemias-Autoimmune(cold&warmantibody)mechanical,drugs&toxins.(Deficiency,Marrowdisorder,Bloodloss&Hemolytic)5LABORATORYEVALUATION

InitialHematocritRBCIndexReticulocytecount(retic.count)ReviewperipheralbloodsmearNucleatedredcells,reticulocytosis6PathologicalclassificationofhemolyticanemiaExtracorpuscularhemolyticdisease(紅細(xì)胞外在因素) Antibodies,infection,splenicsequestrationanddestruction,drugs,chemicalsandphysicalagents,traumatoredbloodcells.Intracorpuscularhemolyticdesease

(紅細(xì)胞內(nèi)在缺陷) Membrane,enzyme,hemoglobin7ThesiteofhemolysisIntravascularhemalysis(血管內(nèi)溶血)Extravascularhemolysis(血管外溶血)8LABORATORYEVALUATION

SuspectedHemolyticAnemiaBilirubin-directandindirectLactateDehydrogenase(LDH)Serumhaptoglobin,urinalysis血紅蛋白

卟啉

鐵珠蛋白

高膽紅素血癥皮膚黃疸

（肝）直接膽紅素

膽管

糞膽原↑肝腸循環(huán)入血

（腎）尿膽原↑9LABORATORYEVALUATION

Additional/DirectedstudiesCoombs’testHam’stest,Sucrosehemolysistest,RousTestOsmoticfragilitytestHgbelectrophoresisG-6PDassaysEnzymeassaysBonemarrowaspirate/biopsy

ReversedM:EratioUnderlyingdisorders10ReticulocyteCountDEFINITIONThereticulocyteisayoungredbloodcellwhichcontainsresidualribosomalRNAthatcanbestainedwithasupravitaldyesuchasacridineorangeornewmethyleneblue.11ReticulocytecountReticulocytecountgivesanindicationofthelevelofthebonemarrowactivity.Donebystainingaperipheralbloodsmearwithnewmethylenebluetohelpvisualizeremainingribosomes.Thenumberofreticulocytes/1000RBCiscountedandreportedasa%.12Occurrenceinblood*Adult:0.5-1.5%oferythrocytes

NewBorn:2-6%oferythrocytes

AbsoluteCount:(24~84)×109/L*Measuredbystainingthebloodsmear.13AnemiabyReticulocyteIndexImpaired(Ret.↓)Hypoproliferation(AA)Appropriate(Ret.↑)HemolysisorBloodLoss療效觀察14Hematocrit

DifinitionTheproportionofthebloodthatconsistsofpackedredbloodcells.Thehematocritisexpressedasapercentagebyvolume.Theredcellsarepackedbycentrifugation.1516TheReferenceRangesAdultmales:42-49%Adultwomen:37-48%Newborns:55-68%One(1)weekofage:47-65%One(1)monthofage:37-49%Three(3)monthsofage:30-36%One(1)yearofage:29-41%Ten(10)yearsofage:36-40% Dependantontheageand,afteradolescence,thesexoftheindividual.17Whatdoesalowhematocritmean?Alowhematocritisreferredtoasbeinganemic.18Whatdoesahighhematocritmean?Peoplelivingathighaltitudesandinchronicsmokers，Chroniccardiopulmonarydisease.Dehydrationproducesafalselyhighhematocritthatdisappearswhenproperfluidbalanceisrestored.Someotherinfrequentcausesofelevatedhematocritarelungdisease,certaintumors,polycythemiavera,andabuseofthedrugerythropoietin(18Epogen).19MeanCellVolume(MCV)DefinitionMeanvalueCalculationThemeanvolumeofeachredbloodcell.80-100fl(1L=1015fl)hematocrit×1015flRBC(/L)MCV=20MeanCellHemoglobin(MCH)DefinitionMeanvalueCalculationThemeanvalueofHbineachredbloodcell.26-32pg(1g=1012pg)hemoglobin×1012pgRBC(/L)MCH=21MeanCorpuscularHemoglobinConcentration(MCHC)DefinitionMeanvalueCalculationThemeanconcentrationofHbin1literRBC

.310~350g/LHemoglobin(g/L)Hematocrit(L/L)MCHC=22AnemiabyRedCellIndicesMicrocytic(<80fL)IronDeficiencyThalassemiaNormocytic(80-95fL)HemolysisMacrocytic(>95fL)MegaloblastosisLiverDisease23SummaryofMCV,MCH&MCHC

SIGNIFICANCESAnemia MCV MCH MCHC DiseasesNormocytic N N N AA,Acutebloodloss,HA,Macrocytic >100 >32

NmegaloblasticanemiaMicrocytic <80 <26 N anemiaofchronicdiseaseMicrocytes/ <80 <26 <310 IDA,sideroblasticanemia,hypochromic hemoglobinopathy24Redcelldistributionwidth(RDW)Redcelldistributionwidth(RDW)–isameasurementofthevariationinRBCcellsizeTherangefornormalvaluesis＜14.9%Avalue>14.9%meansthatthereisincreasedvariationsincellsizeabovethenormalamount(anisocytosis)AnormalvaluemeansthattheRBCpopulationisuniforminsize.25Osmoticfragilitytest

紅細(xì)胞滲透脆性試驗Osmoticfragilitytest–measurestheRBCsensitivitytoahypotonicsolutionofsaline.Salineconcentrationsof0to0.9%areincubatedwithRBCsatroomtemperatureandthepercentofhemolysisismeasured.26Osmoticfragilitytest

ReferencerangeHemolysisstartat0.42%-0.46%Saline.Hemolysiscompleteat0.28%-0.34%Saline.27Osmoticfragilitytest

ClinicalsignificanceIncrease: HereditarySpherocytosis

Hereditary

Elliptocytosis Theyhavealimitedabilitytakeupwaterinahypotonicsolutionandwill,therefore,lyseatahighersodiumconcentrationthannormalRBCsDecrease:Thalassemia,IDA28Acidifiedserumtest(Ham’stest)

酸溶血試驗Acidifiedserumtest(Ham’stest)–isthedefinitivediagnostictestforPNH.Inacidifiedserum,complementisactivatedbythealternatepathway,bindstoRBCs,andlysestheabnormalRBCsfoundinPNH.29Ham’sTest--PrincipleNormalRBC+Patient’sSerumPNHRBC

＋Patient’sSerumNohemolysisPh6.6-6.837℃lhhemolysisPh6.6-6.837℃lh30ClinicalSignificancesNegative:

NormalindividualsPositive:

ParoxysmalNocturnalHemoglobinuriaHighspecificity,Lowsensitivity31Sucrosehemolysistest

糖水試驗Sucrosehemolysistest–sucroseprovidesalowionicstrengththatpermitsbindingofcomplementtoRBCs.Inparoxysmalnocturnalhemoglobinuria(PNH),theRBCsareabnormallysensitivetothiscomplementmediatedhemolysis.ThisisusedinscreeningforPNH.Highsensitivityandlowspecificity.32(四)含鐵血黃素尿試驗（Rous試驗）原理:鐵離子+低鐵氰化鉀→低鐵氰化鐵(藍(lán)色）正常人:（-）意義:（+）說明慢性血管內(nèi)溶血，常見于PNH33Coombs’(DirectAntiglobulin)test抗人球蛋白試驗Criticalintheevaluationofhemolyticanemia,especiallywhenautoimmuneetiologyissuspectedAnti-globulinreagentpreparedbyinjectinghumanglobulinsintoanimals-antibodyisolatedIgGC3(MarkerforIgM)MixCoombs’reagentwithpatient’sRBCandtestforclottinginthetesttube343536DirectCoombsTestHumanGlobulinAntibodiestoHumanGlobulins+PatientRBCAbAbAbAbAgglutination37ClinicalSignificancesNegative:Normalindividuals.Positive: AIHADirectCoombstest: AIHA,HemolysisininfantsIndirectCoombstest:RhorABOnotmatchedpregnancy.OtherswithpositiveresultsofCoombs’testSLE,R.A.,Lymphoma,Drug-relatedhemolysis38Hemoglobinelectrophoresis

血紅蛋白電泳Hemoglobinelectrophoresis–canbeusedtoidentifythepresenceofanabnormalhemoglobin(calledhemoglobinopathies).Differenthgbswillmovetodifferentregionsofthegelandthetypeofhemoglobinmaybeidentifiedbyitspositiononthegelafterelectrophoresis.39ThelabinvestigationmayalsoincludeAbonemarrowsmearandbiopsyUsedwhenothertestsarenotconclusiveInabonemarrowsample,thefollowingthingsshouldbenoted:MaturationofR