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Blood film: chronic renal failure with burr (irregular shaped) cells. ^ www.nephronline.org/standards3/

Eschbach, J.W. et al. (1987) Correction of the anemia of end-stage renal disease with recombinant human erythropoietin. Results of a combined phase I and II clinical trial. N Engl J Med, 316, 73-78; Levin, N., et al. (1997) National Kidney Foundation: Dialysis Outcome Quality Initiative--develop-ment of methodology for clinical practice guidelines. Nephrol Dial Transplant, 12, 2060-2063.

Anaemia and other haematological effects occur in various endocrine disorders. The abnormalities will usually correct as the endocrine abnormality is corrected.

4g Pituitary disorders

Deficiency/hypopituitarism is associated with normochromic, normo-cytic anaemia; associated leucopenia may also occur. Abnormalities correct as normal function is restored, by replacement therapy.

Thyroid disorders

Hypothyroidism may produce a mild degree of anaemia; MCV usually 4 but may be normal. Corrects on restoration of normal thyroid function. Menorrhagia occurs in hypothyroidism and can result in associated Fe deficiency. B12 levels should be checked because of the association with other autoimmune disorders (e.g. pernicious anaemia).

Thyrotoxicosis may be associated with mild degrees of normochromic anaemia in 20% of cases which corrects as function is normalised. Erythroid activity is increased but a disproportionate increase in plasma volume means either no change in Hb concentration or mild anaemia. Haematinic deficiencies occur and should be excluded.

Adrenal disorders

Hypoadrenalism results in normochromic, normocytic anaemia; the plasma volume is 5 which masks the true degree of associated anaemia. The abnormalities are corrected by replacement mineralocorticoids.

Hyperadrenalism (Cushing's) results in erythrocytosis with a typical net increase in Hb (by 1-2g/dL). Occurs whether Cushing's is primary or iatrogenic. Mechanism is unclear.

Parathyroid disorders—hyperparathyroidism may be associated with anaemia from impairment of erythropoietin production, or in some cases from secondary marrow sclerosis.

Sex hormones—androgens stimulate erythropoiesis and are occasionally used to stimulate red cell production in aplastic anaemia. The influence of androgens explains the higher Hb in

Diabetes mellitus when poorly controlled may be associated with anaemia; however, the majority of haematological abnormalities in diabetes mellitus result from secondary disease related complications e.g. renal failure.

Rheumatoid arthritis, psoriatic arthropathy and osteoarthritis may be complicated by anaemia. Various factors contribute to anaemia, commonly more than one is present, especially in rheumatoid arthritis. Some of the mechanisms that give rise to anaemia in rheumatoid also apply in 50 other connective tissue disease, e.g. SLE, polyarteritis nodosa, etc.

Anaemia of chronic disorders (ACD)

ACD is a cytokine-driven suppression of red cell production. The clinical problem is to being able to recognise the presence of other contributory factors in pathogenesis of the anaemia. Bone marrow macrophages fail to pass their stored iron to developing RBCs and a lower than expected rise in erythropoietin suggesting some inhibition in its pathway. Marrow also appears less responsive to Epo. 4 IL-1 has been identified. Detailed studies suggest a synergistic effect of IL-1 with T-cells to produce IFN-g which can suppress erythroid activity. May also be 4 levels of TNF-a which inhibits erythropoiesis through release of IFN-|3 from marrow stromal cells.

Typical features of ACD

• MCV is usually but when longstanding the MCV is moderately 5 (may look like iron deficiency).

• Ferritin usually but may be 4.

• Serum transferrin receptor levels normal.

• Bone marrow Fe stores plentiful.

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