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Key Clinical Questions Anemia

  • image How does peripheral blood smear aid in the diagnosis of anemia?

  • image How do I interpret iron studies?

  • image What are the best tests to diagnose hemolytic anemia?

  • image How do I determine the cause of hemolytic anemia?

  • image When should I investigate for hemoglobinopathy?

  • image What factors suggest the need for bone marrow examination?

  • image What is the most effective way to administer oral iron?

  • image When and how should I use erythropoietin (EPO) in anemia of renal dysfunction or anemia of chronic disease? (How is it dosed and when should I expect a response?)

Polycythemia and Secondary Erythrocytosis
  • image How do I distinguish primary and secondary erythrocytosis in a patient who smokes or has chronic lung disease?

  • image When should I be concerned about carbon monoxide poisoning?

  • image How do I manage secondary erythrocytosis?

  • image What tests should I do to rule out a myeloproliferative disorder?

  • image What complications can occur in patients with myeloproliferative disorders?

  • image When is phlebotomy indicated?

  • image How frequently should phlebotomy be performed and what are the monitoring parameters?

  • image Is there a role for antiplatelet agents and anticoagulants in patients with a myeloproliferative disorder?

Thalassemia and Hemoglobinopathies
  • image Which hemoglobinopathies are considered to be clinically significant?

  • image How is thalassemia differentiated from iron deficiency anemia?

  • image When should one investigate for hemoglobinopathies?

  • image When should transfusion therapy be considered?

  • image What are the common complications in patients with thalassemia?

Sickle Cell Disease
  • image What are triggers for admission in a patient with sickle cell disease?

  • image What is appropriate hydration for acute chest syndrome or painful crisis?

  • image What clinical presentations benefit from red blood cell transfusion or red cell exchange?

  • image What is an appropriate transfusion threshold?

  • image How is pain optimally managed?

  • image What are special considerations in management of sickle cell disease in pregnancy or in labor?

  • image What are special considerations perioperatively?

  • image When should hydroxyurea be used?


Anemia is one of the most common blood disorders worldwide and, in developed countries, commonly affects older adults. The primary function of a red blood cell is to deliver oxygen to the tissues. Red blood cells are made in the bone marrow and must contain adequate amounts of hemoglobin to perform this function. Normal production is dependent on the availability of the required “ingredients” (ie, iron, folic acid, vitamin B12), a normal functioning bone marrow, and erythropoietin for stimulation of red cell production. Anemia can result from defects affecting hemoglobin production, dozens of disease states, including renal impairment and chronic inflammatory conditions, and may also be caused by other external or internal factors influencing the circulatory survival of red blood cells through premature destruction or blood loss. This chapter will provide a framework for investigation in order to navigate the many diagnostic tests and treatment options.

Anemia is defined as a reduction in the number of circulating red cells that results in a hemoglobin level lower than an age- and sex-matched population (Table 169-1).

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