Dans l’apport d’oxygène aux tissus, quel facteur Dans l’apport d’oxygène aux tissus, quel facteur parmi les suivants ne dépend pas de façon parmi les suivants ne dépend pas de façon importante du système hématopoïétique :importante du système hématopoïétique :

1.1. La concentration sanguine en HbLa concentration sanguine en Hb

2.2. L’affinité de l’Hb pour l’oxygèneL’affinité de l’Hb pour l’oxygène

3.3. Le degré de saturation de l’Hb en oxygèneLe degré de saturation de l’Hb en oxygène

4.4. La viscosité sanguineLa viscosité sanguine

Question 1Question 1

Quel est le facteur dont le déficit a le moins Quel est le facteur dont le déficit a le moins d’impact sur la production de globules d’impact sur la production de globules rouges ?rouges ?

1.1. Acide foliniqueAcide folinique

2.2. FerFer

3.3. ErythropoïétineErythropoïétine

4.4. ErythroblastesErythroblastes

Question 2Question 2

Epo

GrowthGrowthfactorsfactors

SRESREFeFe

ERYTHROPOIESISERYTHROPOIESISRegulationRegulation

KidneyKidney Bone marrowBone marrow MacrophagesMacrophages

ERYTHROPOIESISERYTHROPOIESIS

BONE MARROW BLOOD

Stem cellsStem cells ProgenitorsProgenitors PrecursorsPrecursors Mature cellsMature cells

S P P p p

BFU-EBFU-E CFU-ECFU-E ErythroblastErythroblast ReticRetic RBCRBC

PermanentPermanent 4 days4 days4 days4 days 120 days120 days????

< 1< 1x 10x 1066

500500x 10x 1066

300300x 10x 1099

500500x 10x 1099

200200x 10x 1099

20,00020,000x 10x 1099

EPO RESPONSE TO ANEMIA

IRONIRONMETABOLISM METABOLISM

Iron cycleIron cycle

IRON KINETICSIRON KINETICSNormalNormal

PlasmaPlasmaMacrophagesMacrophages MarrowMarrow

Un malade anémique chronique (Hb=9 g/dL) Un malade anémique chronique (Hb=9 g/dL) présente les signes suivants : lequel n’est pas présente les signes suivants : lequel n’est pas du à l’anémie ?du à l’anémie ?

1.1. Pâleur conjonctivalePâleur conjonctivale

2.2. Souffle systoliqueSouffle systolique

3.3. Dyspnée d’effortDyspnée d’effort

4.4. Hypotension orthostatiqueHypotension orthostatique

Question 3Question 3

ANEMIAANEMIA SymptomsSymptoms

Central nervous system Cognitive function Mood

Cardiovascular system Tachycardia Weakness

Cardiorespiratory system Dyspnea following exertion Dyspnea Cardiac decompensation

Skin Reduced perfusion Pale Cold

Kidney function Reduced perfusion Fluid retention

Genitourinary tract Menstrual disturbances Loss of libido Impotence

Immune system Immune deficiency

Ludwig & Strasser, Semin.Oncol. 28(Suppl 8):7, 2001

• PallorPallor : : nailbeds, mucous membranes, palmar creases, conjunctivaenailbeds, mucous membranes, palmar creases, conjunctivae(also influenced by skin thickness, blood distribution, melanin(also influenced by skin thickness, blood distribution, melaninpigmentation)pigmentation)

• Hyperactive heartHyperactive heart : : systolic murmur, forceful apical impulses, systolic murmur, forceful apical impulses, hyperactive heart soundshyperactive heart sounds

• HypovolemiaHypovolemia : : postural hypotension, anxiety, air hunger, sweating, postural hypotension, anxiety, air hunger, sweating, confusion, tachycardia at restconfusion, tachycardia at rest (in case of blood loss)(in case of blood loss)

• Signs related to the specific cause of anemiaSigns related to the specific cause of anemia

ANEMIAANEMIASignsSigns

Une femme de 19 ans avec une Hb = 11.0 g/dL :Une femme de 19 ans avec une Hb = 11.0 g/dL :

quelle la cause la plus fréquente ?quelle la cause la plus fréquente ?

1.1. Anémie inflammatoireAnémie inflammatoire

2.2. HémoglobinopathieHémoglobinopathie

3.3. Anémie ferripriveAnémie ferriprive

4.4. Valeur normale d’Hb pour l’ageValeur normale d’Hb pour l’age

Question 4Question 4

ETIOLOGY OF ANEMIA

• Red cell productionRed cell production-- Erythroid marrowErythroid marrow-- ErythropoietinErythropoietin-- IronIron

TISSUE OXYGEN SUPPLYTISSUE OXYGEN SUPPLYHb concentrationHb concentration

• Red cell lossRed cell loss -- HemolysisHemolysis-- Hemorrhage Hemorrhage

• Maturation defectsMaturation defects -- DNA (folate, B12, …) DNA (folate, B12, …) -- HbHb • Globin• Globin

• Heme• Heme-- Myelodysplasia Myelodysplasia

• Decreased number of erythroid precursorsDecreased number of erythroid precursors -- Marrow damage : Marrow damage : • Global : SAA, chemotherapy, …• Global : SAA, chemotherapy, …

• Pure red cell aplasia • Pure red cell aplasia -- Marrow replacement : myelofibrosis, tumor cellsMarrow replacement : myelofibrosis, tumor cells

• Decreased Epo productionDecreased Epo production -- Renal failureRenal failure-- Hypothyroidism, hypopituitarismHypothyroidism, hypopituitarism

• Decreased iron availabilityDecreased iron availability-- Absolute : IDAbsolute : ID-- Functional : inflammation Functional : inflammation

ANEMIAANEMIADefective red cell productionDefective red cell production

• Defect in DNA synthesisDefect in DNA synthesis -- B12 B12 -- FolateFolate

• Defect in Hb synthesisDefect in Hb synthesis -- Globin : hemoglobinopathiesGlobin : hemoglobinopathies-- Heme : sideroblastic anemia, leadHeme : sideroblastic anemia, lead

• Myelodysplasia (pre-leukemia)Myelodysplasia (pre-leukemia)

ANEMIAANEMIAMaturation defect (ineffective erythropoiesis)Maturation defect (ineffective erythropoiesis)

• Constitutional RBC abnormality :Constitutional RBC abnormality : -- Red cell membrane (spherocytosis …) Red cell membrane (spherocytosis …) -- Enzyme (G-6-PD …) Enzyme (G-6-PD …) -- PNH PNH

• Auto-immuneAuto-immune• External aggression :External aggression : osmotic shock, malaria, drug, toxin, osmotic shock, malaria, drug, toxin,

venom, incompatible transfusion venom, incompatible transfusion

• Fragmentation :Fragmentation : microangiopathy, DIC, valve microangiopathy, DIC, valve

• Hypersplenism :Hypersplenism : liver disease, lymphopathy, myelofibrosisliver disease, lymphopathy, myelofibrosis

ANEMIAANEMIAHemolysisHemolysis

Laquelle parmi ces anémies n’est pas macrocytaire ?Laquelle parmi ces anémies n’est pas macrocytaire ?

1.1. Anémie hemolytiqueAnémie hemolytique

2.2. MyélodysplasieMyélodysplasie

3.3. Anémie aplastiqueAnémie aplastique

4.4. Anémie de BiermerAnémie de Biermer

Question 5Question 5

• Microcytic :Microcytic : serum ironserum iron -- Low :Low : ID or inflammation ID or inflammation-- High :High : maturation defect (globin, heme) maturation defect (globin, heme)

• Normocytic :Normocytic : reticulocytesreticulocytes-- N/low :N/low : acute hemorrhage or decreased erythropoiesis acute hemorrhage or decreased erythropoiesis -- High :High : subacute hemorrhage or hemolysissubacute hemorrhage or hemolysis

• Macrocytic :Macrocytic : reticulocytesreticulocytes -- N/low :N/low : maturation defect (DNA, MDS) maturation defect (DNA, MDS) -- High :High : hemolysishemolysis

ANEMIAANEMIADifferential diagnosisDifferential diagnosis

• Serum ironSerum iron -- Low :Low : iron deficiency iron deficiency

ferritinferritin• Low :• Low : absoluteabsolute iron deficiency iron deficiency• Normal/elevated :• Normal/elevated : functionalfunctional iron deficiency iron deficiency

CRP :CRP : inflammation ? inflammation ?-- High :High : maturation defect (globin or heme) maturation defect (globin or heme)

Hb electrophoresis :Hb electrophoresis : thalassemia ? thalassemia ? marrow examination :marrow examination : sideroblastic anemia ? sideroblastic anemia ?

ANEMIAANEMIAMicrocytic anemiaMicrocytic anemia

• ReticulocytesReticulocytes -- Normal/low :Normal/low :

• acute hemorrhage ?• acute hemorrhage ?• decreased erythropoiesis ?• decreased erythropoiesis ? marrow examinationmarrow examination

creatinine, CRP, thyroid hormonescreatinine, CRP, thyroid hormones -- High : High :

LDH/bilirubinLDH/bilirubin • Normal :• Normal : subacute hemorrhage subacute hemorrhage

• Increased :• Increased : hemolysis hemolysis

ANEMIAANEMIANormocytic anemiaNormocytic anemia

• ReticulocytesReticulocytes -- High :High : hemolysis hemolysis -- Normal/low :Normal/low : maturation defect (DNA, MDS) : maturation defect (DNA, MDS) :

B12/folateB12/folate• Decreased :• Decreased : megaloblastic anemia megaloblastic anemia • Normal :• Normal :

marrow examination : marrow examination : MDS ?MDS ? -GT : -GT : alcohol ?alcohol ? thyroid hormones : thyroid hormones : hypothyroidism ?hypothyroidism ?

ANEMIAANEMIAMacrocytic anemiaMacrocytic anemia

Laquelle parmi ces situations n’est pas cause Laquelle parmi ces situations n’est pas cause d’anémie ferriprive ?d’anémie ferriprive ?

1.1. ColectomieColectomie

2.2. GrossesseGrossesse

3.3. Maladie de Rendu-Osler (télengiectasies)Maladie de Rendu-Osler (télengiectasies)

4.4. HémodialyseHémodialyse

Question 6Question 6

• Increased iron losses Increased iron losses • Decreased iron intakeDecreased iron intake

-- Inadequate diet Inadequate diet -- Impaired absorption : Impaired absorption : achlorhydria, gastric surgery, duodenal disease, picaachlorhydria, gastric surgery, duodenal disease, pica

• Increased iron requirementsIncreased iron requirements-- Infancy (prematurity) Infancy (prematurity) -- PregnancyPregnancy-- Lactation Lactation

IRON DEFICIENCY ANEMIAIRON DEFICIENCY ANEMIAEtiologyEtiology

• Organic pathologyOrganic pathology-- Gastrointestinal Gastrointestinal -- Gynecologic (excessive menstrual flow)Gynecologic (excessive menstrual flow)-- Urinary (hematuria or hemoglobinuria)Urinary (hematuria or hemoglobinuria)-- Pulmonary (alveolar hemorrhage)Pulmonary (alveolar hemorrhage)-- Cutaneo-mucous (telangiectasia)Cutaneo-mucous (telangiectasia)

• Disorders of hemostasisDisorders of hemostasis• Runner’s anemia Runner’s anemia • Blood donation, blood tests, hemodialysisBlood donation, blood tests, hemodialysis• Self-induced bleedingSelf-induced bleeding

IRON DEFICIENCY ANEMIAIRON DEFICIENCY ANEMIAEtiology : increased iron lossesEtiology : increased iron losses

• Stage 1 : depletion of iron storesStage 1 : depletion of iron stores -- Serum ferritin : Serum ferritin : < 12 µg/L < 12 µg/L

• Stage 2 : iron-deficient erythropoiesisStage 2 : iron-deficient erythropoiesis -- Serum iron : Serum iron : < 60 µg%< 60 µg%-- Tf saturationTf saturation < 15 % < 15 % -- % hypochromic RBC % hypochromic RBC > 5 %> 5 %-- CHrCHr < 26 pg < 26 pg -- Soluble TfRSoluble TfR > 7 mg/L> 7 mg/L-- RBC protoporphyrinRBC protoporphyrin > 70 µg%> 70 µg%

• Stage 3 : iron-deficiency anemiaStage 3 : iron-deficiency anemia -- Hemoglobin : Hemoglobin : < 12 gr/dl (F) 13.5 gr/dl (M)< 12 gr/dl (F) 13.5 gr/dl (M)-- Hematocrit :Hematocrit : < 36 % (F) or 41 % (M)< 36 % (F) or 41 % (M)-- RBC :RBC : N then N then -- MCV :MCV : < 80 fl < 80 fl (microcytosis)(microcytosis)-- MCH :MCH : < 28 pg (hypochromia) < 28 pg (hypochromia)

IRON DEFICIENCY ANEMIAIRON DEFICIENCY ANEMIAStagesStages

Quelle est la cause la plus fréquente d’anémie chez Quelle est la cause la plus fréquente d’anémie chez un patient cancéreux ?un patient cancéreux ?

1.1. RadiothérapieRadiothérapie

2.2. Anémie inflammatoire (ACD)Anémie inflammatoire (ACD)

3.3. Anémie ferripriveAnémie ferriprive

4.4. Anémie par envahissement médullaireAnémie par envahissement médullaire

Question 7Question 7

• HemodilutionHemodilution• BleedingBleeding• HypersplenismHypersplenism• HemophagocytosisHemophagocytosis• Hemolysis (autoimmune, microangiopathic,...)Hemolysis (autoimmune, microangiopathic,...)• Nutritional deficiencies (global, iron, folate, B12)Nutritional deficiencies (global, iron, folate, B12)• Marrow damage Marrow damage

(metastases, necrosis, PRCA, myelodysplasia,...)(metastases, necrosis, PRCA, myelodysplasia,...)• Chemotherapy, radiotherapyChemotherapy, radiotherapy

ANEMIA OF CANCERANEMIA OF CANCER EtiologyEtiology

Epo

TNFTNF

SRESREFeFe

ACDACDPathogenesis : cytokinesPathogenesis : cytokines

IL-1IL-1

IFN-IFN- IFN-IFN-

IRON KINETICSIRON KINETICSFunctional iron deficiency : inflammationFunctional iron deficiency : inflammation

PlasmaPlasmaMacrophagesMacrophages MarrowMarrow

SHIFT RETICULOCYTOSIS

RBC INDICESRBC INDICESRBC analysis by flow cytometryRBC analysis by flow cytometry

0 28 41 50 g/dL0 28 41 50 g/dL Hgb Concentration (HC)Hgb Concentration (HC)

0 60 120 200 fL0 60 120 200 fL RBC Volume (V)RBC Volume (V)

0 100 pg0 100 pg Hgb Content (CH)Hgb Content (CH)

RB

C V

olu

me

(fL

)R

BC

Vo

lum

e (

fL)

Hgb Concentration (g/dL)Hgb Concentration (g/dL)

MicroMicro

HypoHypo HyperHyper

MacroMacro

120fL120fL

60fL60fL28g/dL28g/dL 41g/dL41g/dL

Adapted from Brugnara, 2001

• Normal < 5%Normal < 5%• Increased % hypochromic Increased % hypochromic

RBCs (>10-20 %) is an RBCs (>10-20 %) is an indicator of iron deficient indicator of iron deficient erythropoiesiserythropoiesis

• Good indicator of response Good indicator of response to IV iron treatment to IV iron treatment

RBC INDICESRBC INDICESHypochromic erythrocytesHypochromic erythrocytes

% Hypo24.4%

Adapted from Brugnara, 2001

RBC INDICESRBC INDICES RBC and retic parameters : rHuEpo therapyRBC and retic parameters : rHuEpo therapy

rHuEporHuEpo1200 U/kg1200 U/kg

over 10 daysover 10 days

C. Brugnara C. Brugnara et alet al. J Lab Clin Med 1994, 123:660. J Lab Clin Med 1994, 123:660 Adapted from Brugnara, 2001

SERUM ERYTHROPOIETINSERUM ERYTHROPOIETIN

Cazzola et al,Cazzola et al, Blood 89:4250, 1997Blood 89:4250, 1997

SERUM FERRITIN

Laquelle parmi ces pathologies n’est pas cause d’une Laquelle parmi ces pathologies n’est pas cause d’une élévation inappropriée de la ferritine sérique élévation inappropriée de la ferritine sérique (sans relation avec les réserves en fer) ?(sans relation avec les réserves en fer) ?

1.1. HépatiteHépatite

2.2. HypothyroïdieHypothyroïdie

3.3. Insuffisance rénale sévèreInsuffisance rénale sévère

4.4. Aucune des 3Aucune des 3

Question 8Question 8

FERRITINFERRITINSerum ferritinSerum ferritin

• Reflection of iron stores (RES and hepatocytes):Reflection of iron stores (RES and hepatocytes): 1 µg/L = 120 µg/kg iron store1 µg/L = 120 µg/kg iron store

• Normal range varies with age and sexNormal range varies with age and sex• Low ferritin 100% specific for iron deficiency Low ferritin 100% specific for iron deficiency • Falsely elevated serum ferritinFalsely elevated serum ferritin

- - Inflammation : Inflammation : lower limit 40-120 µg/Llower limit 40-120 µg/L- - Renal failure : Renal failure : lower limit 40-100 µg/Llower limit 40-100 µg/L -- Liver damageLiver damage- - HyperthyroidismHyperthyroidism- - Some forms of cancerSome forms of cancer-- Hyperferritin-cataract syndromeHyperferritin-cataract syndrome-- Poorly controlled diabetes mellitus (ferritin glycosylation)Poorly controlled diabetes mellitus (ferritin glycosylation)

TRANSFERRIN SATURATION

La saturation de la transferrine est le plus La saturation de la transferrine est le plus influencée par ?influencée par ?

1.1. L’alimentationL’alimentation

2.2. L’activité érythropoïétique de la moelleL’activité érythropoïétique de la moelle

3.3. Le moment de la journéeLe moment de la journée

4.4. Le taux de transferrine sériqueLe taux de transferrine sérique

Question 9Question 9

IRON KINETICSIRON KINETICSAplasiaAplasia

PlasmaPlasmaMacrophagesMacrophages MarrowMarrow

IRON KINETICSIRON KINETICSFunctional iron deficiency : rHuEpo therapyFunctional iron deficiency : rHuEpo therapy

PlasmaPlasmaMacrophagesMacrophages MarrowMarrow

IRON KINETICSIRON KINETICSHemolysisHemolysis

PlasmaPlasmaMacrophagesMacrophages MarrowMarrow

SOLUBLE TRANSFERRIN RECEPTORSOLUBLE TRANSFERRIN RECEPTORErythropoiesisErythropoiesis

AA CRF Chemo0

2

4

6

8

10

(n=20) (n=61)(n=58)

Normal

sT

fR (

mg

/L)

AIHA HS Thal HbH PC0

10

20

30

40

50

60

70

(n=20) (n=11)(n=72)

Normal

(n=12)(n=8)

sT

fR (

mg

/L)

HyperplasticHyperplastic HypoplasticHypoplastic

7.07.0

Ferritin (µg/L)Ferritin (µg/L)

sTfR

(m

g/L

)sT

fR (

mg/

L)

SOLUBLE TRANSFERRIN RECEPTORSOLUBLE TRANSFERRIN RECEPTORIron deficiencyIron deficiency

IDEIDE FunctionalFunctionalIDID

NormalNormal

1212

StorageStoragedepletiondepletion

3.03.0

7.07.0

Ferritin (µg/L)Ferritin (µg/L)

sTfR

(m

g/L

)sT

fR (

mg/

L)

SOLUBLE TRANSFERRIN RECEPTORSOLUBLE TRANSFERRIN RECEPTORIron deficiencyIron deficiency

IDEIDE FunctionalFunctionalIDID

NormalNormal

1212

StorageStoragedepletiondepletion

50-10050-100

InflammationInflammation

3.03.0

ERYTHROID MARROW FUNCTIONERYTHROID MARROW FUNCTION

ErythroidErythroidmarrowmarrow

RESRES(macrophages)(macrophages)

SeFeSeFeTf saturTf satur

(marrow iron supply)(marrow iron supply)FerritinFerritin

(iron stores)(iron stores)

sTfRsTfRETUETU

(total erythropoiesis)(total erythropoiesis)

BFU-EBFU-ECFU-ECFU-E

(progenitors)(progenitors)

Retic indexRetic index(effective erythropoiesis)(effective erythropoiesis)

CHrCHrHypochromic RBCHypochromic RBC

FEPFEPsTfRsTfR

(functional iron deficiency)(functional iron deficiency)

Hb - Hct -RBCHb - Hct -RBC

EPOEPO