Question 15.1

Angoff score
6.27
Highest mark
9.625
Pass rate
??
Other SAQs in this topic:
Other SAQs in this paper:

The following data refers to a 65-year-old patient with background of active rheumatoid arthritis, admitted to intensive care with septic shock.

Parameter

Patient value

Adult normal range

Haemoglobin

86g/L*

125-180

Serum ferritin

298 ug/L

15-300

Serum iron

7 umol/L*

9-27

Total iron binding capacity (TIBC)

52 umol/L

47-70

Transferrin saturation (Iron/TIBC x 100)

28%

16-40

Erythropoietin level

15 U/L

4-28

C-reactive protein (CRP)

321 mg/L*

<8

a) What abnormality is demonstrated in this patient? Explain your rationale. (2 marks)

b) What is the pathogenesis of these changes? (2 marks)

c) Outline the principles of management? (1 mark)

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College answer

Syllabus topic/section:

2.1.13    Haematological and Oncological Intensive Care: Anaemia: L1


Discussion: 

Many candidates scored extremely well. Excellent answers were discriminated by the additional detail provided for the explanation of the mechanism of the anaemia of chronic disease, and by correctly identifying that treatment is that of the underlying cause and there is a lack of benefit from EPO and iron supplementation in anaemia of inflammation (EPO level was also normal in the stem).

Discussion

a) This is anaemia of inflammation. 

  • Anaemia is present (Hb low)
  • With a meaningless upper-end-of-normal ferritin (because acute phase response)
  • With low serum iron, which is what you'd expect in sepsis,
  • With a normal TIBC and transferrin binding saturation, suggesting the iron stores are replete
  • With a normal EPO, which is not the usual finding in anaemia (you would expect it to be elevated)

a) Pathophysiology, in 2 minutes (40-50 words):

  • Inflammation causes IL6-mediated hepcidin release
  • Hepcidin decreases the availability of iron by promoting "iron trapping" within the bone marrow and macrophages.
  • This suppresses erythropoiesis and reduces sensitivity to erythropoietin

References

Nemeth, Elizabeta, and Tomas Ganz. "Anemia of inflammation." Hematology/Oncology Clinics 28.4 (2014): 671-681.

Hawkins, Stephen F., and Quentin A. Hill. "Diagnostic Approach to Anaemia in Critical Care." Haematology in Critical Care: A Practical Handbook (2014): 1-8.

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