CLASSIFICATION OF ANEMIA

Anemias are generally classified either morphologically or according to pathophysiologic

cause.

PATHOPHYSIOLOGIC CLASSIFICATION OF ANEMIA

The pathophysiologic approach refers to the cause of anemias – whether an anemia is
caused by excessive destruction or diminished production of red blood cells.
A. IMPAIRED RBC PRODUCTION
1. Abnormal bone marrow
1. 1. Aplastic anemia - defective development or congenital absence of an organ or tissue
1.2 Myelophthisis: Myelofibrosis, Leukemia, Cancer metastasis
2. Essential factors deficiency
2.1 Deficiency anemia: Fe, Vit. B12, Folic acid, etc
2.2 Anemia in renal disease: Erythropoietin
3. Stimulation factor deficiency
3.1 Anemia in chronic disease
3.2 Anemia in hypopituitarism
3.3 Anemia in hypothyroidism
B. EXCESSIVE DESTRUCTION OF RBC (Hemolytic Anemia)
1. Intracorpuscular defect
Membrane : Hereditary spherocytosis
Hereditary ovalocytosis, etc.
Enzyme : G-6PD deficiency, PK def., etc.
Hemoglobin : Thalassemia, Hemoglobinopathies
2. Extracorpuscular defect
Mechanical: March hemolytic anemia (physical activity)
MAHA (Microangiopathic HA)
Chemical/Physical
Infection: Clostridium tetani
Antibodies: HTR (Hemolytic Transfusion), SLE
Hypersplenism
C. BLOOD LOSS
1. Acute blood loss: Accident, GI bleeding
2. Chronic blood loss: Hypermenorrhea, Parasitic infestation

MORPHOLOGIC CLASSIFICATION OF ANEMIA

Although pathophysiologic approach is a respected approach, more clinicians are familiar
with the morphologic classification of anemias that relies on the red blood cell indices: MCV, MCH,
MCHC. This classification is readily available using CBC data and can be acted on fairly quickly as
means to begin an investigation into cause.

Three morphologic classifications of anemia:

1. Normochromic, normocytic anemia
a. Blood loss
b. Increased plasma volume - Pregnancy, Overhydration
c. Hemolytic anemia - depend on each cause
d. Hypoplastic marrow - Aplastic anemia, RBC aplasia
 e. Infiltrate BM - Leukemia, Multiple myeloma, Myelofibrosis, etc.
f. Abnormal endocrine - Hypothyroidism, Adrenal insufficiency, etc.
g. Kidney disease / Liver disease / Cirrhosis
2. Microcytic, hypochromic anemia
a. Iron deficiency anemia - Chronic blood loss, Inadequate diet, Malabsorption,
Increased demand, etc.
b. Abnormal globin synthesis - Thalassemia with or without Hemoglobinopathies
c. Abnormal porphyrin and heme synthesis - Pyridoxine responsive anemia
d. Other abnormal Iron metabolism
3. Macrocytic, normochromic anemia
a. Vit. B12 deficiency - Pernicious anemia
b. Folic acid deficiency - Nutritional megaloblastic anemia, Sprue, other malabsorption
c. Inborn errors of metabolism
d. Abnormal DNA synthesis - Chemotherapy, Anticonvulsant, Oral contraceptives

CALCULATIONG RED BLOOD CELL INDICES AND THEIR ROLE IN SAMPLE INTEGRITY

Mean Cell Volume (MCV)

The MCV is the average volume of the red blood cell, expressed in femtoliters (fL), or 10-15 L:
HCT (%) x 10
𝐌𝐂𝐕 =
RBC count (x 1012 /L)
or 𝐌𝐂𝐕 = (HCT ÷ RBC) x 10
For example, if the HCT 5 45% and the RBC count 5 5 3 1012/L, the MCV 5 90 fL.
Reference interval: 80-100 fL (Normocytic); <80 fL – Microcytic; >100 fL - Macrocytic

Mean Cell Hemoglobin (MCH)

The MCH is the average weight of hemoglobin in a red blood cell, expressed in picograms (pg), or
10-12 g:
HGB (g/dL) x 10
𝐌𝐂𝐇 =
RBC count (x 1012 /L)
or 𝐌𝐂𝐇 = (HGB ÷ RBC) x 10

For example, if the hemoglobin = 16 g/dL and the RBC count = 5 x 1012/L, the MCH = 32 pg.
Reference interval: 26-34 pg (the MCH generally is not considered in the classification of
anemias)
a. Increased in macrocytic anemia
b. Decreased in microcytic, hypochromic anemia

Mean Cell Hemoglobin Concentration

The MCHC is the average concentration of hemoglobin in each individual red blood cell. The units
used are grams per deciliter (formerly given as a percentage):
HGB (g/dL) x 10
𝐌𝐂𝐇 =
HCT (%)
or 𝐌𝐂𝐇𝐂 = (HGB ÷ HCT) x 100
For example, if the HGB = 16 g/dL and the HCT = 48%, the MCHC = 33.3 g/dL.
Reference Interval: 32-36 g/dL; < 32 g/dL (hypochromic); >36 g/dL (“hyperchromic”)
VALUE OF THE RED BLOOD CELL DISTRIBUTION WIDTH
RDW is a mathematical calculation that gives insight into the amount of anisocytosis
(variation in size), and to some degree, poikilocytosis (variation in shape) in a peripheral smear.
The RDW is derived as follows:

𝐑𝐃𝐖 = (Standard deviation of RBC volume ÷ MCV) x 100

Reference interval: 11.5% - 14.5%

The standard deviation of red blood cell volume is derived from size histogram data that
plot red blood cell size after a large number of red blood cells have been analyzed by the
instrument. The RDW is useful because in many cases the RDW becomes abnormal earlier in the
anemia process, whereas the MCV is not affected until the later in the anemic process. Because
many anemias develop over time, this parameter may provide a sensitive indicator of red blood
cell size change before the RBC indices become overtly abnormal.

9 PARAMETER CBC
WBC
RBC
HGB
HCT
MCV
MCH
MCHC
RDW
PLATELETS