Anaemia

Anaemia – from greek meaning ¨lack of blood¨ Anaemia= less than the normal quantity of hemoglobin in the blood Anaemic syndrome =clinical syndrome caused by tissue hypoxia

NORMAL VALUES OF RED BLOOD CELLS men women Haemoglobin (Hb) 136 – 176 120 - 168 g/l Haematocrite (HTK) 0,38 – 0,49 0,35 – 0,46 No of erythrocytes (RBC) 4,2 – 5,8 3,8 – 5,2 x1012/l Volume of erythrocyte (MCV) 80 – 95 fl Mass of Hb in erythrocyte 26 – 32 pg (MCH) Hb concentration in erythrocyte 0,32 – 0,37 (MCHC)

NORMAL VALUES OF RED BLOOD CELLS men women Haemoglobin (Hb) 136 – 176 120 - 168 g/l Haematocrite (HTK) 0,38 – 0,49 0,35 – 0,46 No of erythrocytes (RBC) 4,2 – 5,8 3,8 – 5,2 x1012/l Volume of erythrocyte (MCV) 80 – 95 fl Mass of Hb in erythrocyte 26 – 32 pg (MCH) Concentration of Hb in erythrocyte 0,32 – 0,37 (MCHC)

Anaemic syndrome - symptoms rom (AS) Tissue hypoxia: pallor, fatigue, weakness, dyspnea Compensation and adaptation: Hypercinetic circulation, palpitations, tinnitus Secondary : Cardiovascular symptoms – decompensation of ischemic heart disease, AP, IM, claudications…

Anemický syndrom (AS) Progress and severity of AS depends on: 1. Absolute value of Hb Hgb 70-80 g/l = most of patients suffer from symptoms 2. Speed of onset 3. Age and overall performance of the patient

HAEM + GLOBIN HAEMOGLOBIN DNA – B12 ,folic acid, EPO IRON PROTOPORFYRIN HAEM + GLOBIN HAEMOGLOBIN DNA – B12 ,folic acid, EPO

ANAEMIA - CLASSIFICATION Morfologic criteria: According to MCV: (80 – 95 fl) microcytic, normocytic, macrocytic According to MCH: (27-32 pg) normochrome, hypochrome According to no of reticulocytes: (0,7 – 2,8 %) anaemia with lowered, normal or incresed no of reticulocytes

Iron deficiency anaemia Chronic disease anaemia MICROCYTIC ANAEMIA Iron deficiency anaemia Chronic disease anaemia Thalasemia, sideroblastic anaemia MACROCYTIC ANAEMIA Megaloblaste anaemia(lack of B12, folic acid, MDS) Macrocytic non-megaloblaste anaemia (usually secondary) NORMOCYTIC ANAEMIA Primar impairment of blood marrow: aplastic anaemia, MDS, PNH, myelofibrosis. Secondary impairment of blood marrow :(infiltration, infection, endocrinological and systemic diseases, ACD) D. ANAEMIA WITH RETICULOSIS Haemolytic aneamia corpuscular Haemolytic anaemia extracorpuscular – imunne and non-immune based

Pathofysiological classification

EPO

EPO TSH Fe, Fol, B12 C, E

Pathofysiological classification Proliferation and differentiation disorder Increased destruction of RBC Blood loss Combined etiology

HEM + GLOBIN thalasemia HEMOGLOBIN DNA – B12, folic acid, EPO IRON PROTOPORFYRIN Iron insufficiency sideroblastic anaemia ACD HEM + GLOBIN thalasemia HEMOGLOBIN DNA – B12, folic acid, EPO

Iron defficiency

Iron defficiency Most frequent cause of anemia (500 000 000 worldwide – WHO) 80%of all anaemia SA: 10% of fertile women Sideropenia: 35-58% of fertile women

Iron defficiency CAVE: influencing not just the blod count! DNA synthesis impairement Tissue fosforylation impairement Purine metabolism impairement Colagen synthesis impairement Granulocyte function impairement Neurotransmiter function impairement

Iron distribution in the organism

Iron metabolism Food contents: 15-20mg/den Absorption: 1-2mg (duodenum, upper part of jejunum) Loss (epitel desqvamation) 1-2mg Pregnancy: overall loss: 500-1000mg Supply in the organism: 3000-5000mg

Hepcidine Acute phase reactant Source: hepatic cells, heart, Iron stimulates Hepcidine Hepcidine inhibits iron absorption in the intestine, iron release from macrophages and iron transport via placenta ACD, hereditary hemochromatosis

Iron defficiency Insufficient intake - malnutrition Absorption impairement – maldigestion, malabsorption Increased loss Lowered intake

Insufficient intake Malnutrition Imbalanced diet Vegetarians - Meat: 25-30% of iron is absorbed - Vegetables: 5% of iron is absorbed

Iron absorption from various foods (%) Rice Spinach Beans Corn Lettuce Wheat Soya Ferritin Veal liver Fish meat Haemoglobin Veal meat

Rice Spinach Beans Corn Lettuce Wheat Soya beans Ferritin Veal liver Iron absorption from various foods (%) Rice Spinach Beans Corn Lettuce Wheat Soya beans Ferritin Veal liver Fish meat Haemoglobin Veal meat

Resection of stomach – 65% patients Achlorhydria Coeliakia M. Crohn Absorption disorder Resection of stomach – 65% patients Achlorhydria Coeliakia M. Crohn Infection H. Pylori with gastritis

Loss GIT (h. hernia, gastritis, ulcerous disease, tumours, intestinal inflammmatory diseases, hemorhoids, parasites, diverticulitis…) Respiratory tractus Urogenital tract Menses = cca 3mg Fe / den NSAIDs, hemodialysis, blood testing, self - harming

Increased need Gravidity Brest-feeding Growth

Symptoms Anemic syndrome Cefalea, paresthesia, fatigue Tongue burning, angulitis Odyno-, dysfagia Sy Kelly-Patterson Brittle hair, nails (Pica, pagofagia)

Physical examination Pallor – skin, mucous membrane Blue sclerae Ulcers/ angulitis Smooth tongue Straight/(spoon-shaped) nails Achlorhydria, atrophic gastritis

Laboratory findings RDW: high Trombocytosis (over 50% of patients) BM –staining for iron - lack of Fe in siderophages - sideroblasts lower then 10%

Laboratory findings MCV under 80fl MCH under 25ug MCHC – late symptom Transferrin -increased S-ferritin <20ug/l Transferrin satur. – under15 % (N: 20-40%) VKFe (TIBC): increased S-sTfR > 8g/l

DIFFERENTIAL DIAGNOSIS OF IRON INSUFFICIENCY (mikrocytic anaemia) Fe TIBC satTRF ferritin TRF receptor _______________________________________________  Iron insuf.        Chronic disease associated anaemia   N N N (ACD) Thalasemia N or  N or  N or  N or  

CAVE Ferritine Acute phase reactant Nespecific tumorous marker Level increases with age (75ug/l in old people = ? = iron defficiency)

Iron defficiency Prelatent Latent Manifest - SA

Typical patient with IDA Woman 20-45y, fatigue, sleepiness, ear buzzing, hairloss, brittle nails, hyper- polymenorhea or normal menses. 2. Man 50y or older, dysfagia, weightloss, treated with ASA for ICD, blood in stools or urine.

= Treatment of the cause of iron loss + iron supply Treatment of IDA = Treatment of the cause of iron loss + iron supply

Ferrotherapy 150-200mg Fe / day Until enough supply is formed (ferritin 50ug/l) Use on an empty stomach CAVE: polyphenols, milk, egg yolk Dyspepsia Parenteral forms (CAVE: anaphylaxis; x new forms are safer - karboxymaltose)

PŘÍPRAVKY ŽELEZA tab název léková složení obsah látky v lékové (výrobce) forma formě Aktiferrin cps. síran železnatý 34 mg (Merckle,SRN) serin sir. 6,8 mg/ml gtt. 9,3 mg/ml Ferrlecit inj komplex Fe 3+ s glukonátem 62,5 mg (Nattermann,SRN) sodným Ferro-Gradumet 105 mg (Galenika,Jugoslávie) Ferronat susp. fumarát železnatý 10 mg/ml (Galena,ČR) Ferronat retard (Léčiva,ČR) Ferrum lek i.m. komplex hydroxidu 100 mg (Lek,Slovinsko) železitého se sacharózou Maltofer (Vifor,Švýcarsko) s polymaltosou 50 mg/ml Sorbifer durules (Egis,Maďarsko) kyselina askorbová Tardyferon drg 80 mg (Robapharm,Švýcarsko) mukoproteáza Ferinject (Vifor, Francie) inj. Fe3+ karboxymaltóza 100mg, 500mg

P.o. iron treatment control Reticulocyte crisis D 10-14 Increase of haemoglobin Normalisation of MCV a RDW Iron supply forming Ineffective treatment: Diagnosis checking :BM examination, GIT examination aso…. Cave self-harming Switch to i.v. therapy

Thalassemia

IRON PROTOPORFYRIN HEM + GLOBIN HEMOGLOBIN DNA – B12 , folic acid Fe insufficiency sideroblastic anemia ACD HEM + GLOBIN thalasemia HEMOGLOBIN DNA – B12 , folic acid

Thalassemia + thalasemia, 0thalasemia Fetus: - Hb F α2 γ2 Adult - Hgb A: α2 β2 - Hgb A2: α2 δ2 - Hgb F: α2 γ2

Thalassemia α –thalasemia = α disorder β – thalasemia = β disorder

α - Thalassemia (Normal genotype: α α / α α) - α/ α α = silent carrier - α/- α , - - / α α = carrier (mikrocytosis, erythrocytosis): = Thalassemia minor - - / - α = HbH (β4) (splenomegalia, mikrocytosis, bones) - - / - - = hydrops fetalis, sy Hb Bart´s (γ4)

β - Thalassemia More severe then α–thalassemia β – thalasemia minor (β+/ β, β0/ β) Mikrocytosis, anaemia, erythrocytosis β – thalasemia intermedia (β+/ β+, β0/ β+) β – thalasemia major (β0/ β0, β+/ β+) Severe anemia, anisopoikilocytosis, affected ERY, HbF, hepatosplenomegalia,bone deformities,permanent transfusion therapy, Fe overload, Tx, splenectomia, HU

BETA THALASEMIA Pathogenesis:  chains formation impairement  increased synthesis of  and  Alpha chains overdose –low solubility, precipitation, agregates deform cell membranes Hb – easy autooxidation, lower stability  release of Fe  cell destruction by peroxidative lipid cleavage. Inefective erythropoiesis, large numbers of erytrocytes decline as soon as the BM + peripheral hemolysis + shortened lifespan Significant compensatory erythropoiesis hyperplasia corticalis usurationbone deformities, fractures, extramedular hemopoiesis Relative Fe defficiency in BM because of hyperplastic erythropoiesis, at the same time increased Fe supply (coming from destroyed ery in monocyte- macrophage system)  increased Fe resorption in the intestine Fe overload of the organism (together with Fe coming from transfusions).

MEGALOBLASTIC ANAEMIA Lack of B12of folic acid: 1. Pernicious anaemia - B12 absorption in the distal intestine disorder due to lack of intrinsic factor (produced by parietal cells of gastric mucosa) 2. Dihydrofolat reductase inhibitors (MTX, ARA-C)

MEGALOBLASTIC ANAEMIA -CAUSES Insufficient intake of B12 of folic Absorption impairement: a) lack of intrinsic factor, intrinsic factor b) celiakia, Crohn disease, intestinal resection, diverticules, strictures,parasites c) resorption inhibitors (fenylhydantoin,PAS,pyrimidin, neomycin) d) selective malabsorption B12 with proteinuria Transport disorders because of lack of transkobalamin I. and II. Increased demand (gravidity, growth, anaemia with hyperplasia of erythropoiesis Increased loss (hepatic laesions, bleeding) dihydrofolat reductase inhibitors (MTX,pyrimethamin) pyrimidin antagonists (ARA-C) / purin antagonists (6-MP)

Megaloblastic anaemia Blood count– macrocytes (↑MCV, ↑MCH,normal MCHC), ↓RTC, megalocytes, megaloblasts, leukocytosis with left shift, thrombocytopenia. Bone marrow– hyperplasia of erytropoiesis, megaloblasts, granulocyte macrocytosis, mgkc. polyploidia dif.dg. MDS (cytogenetics, cytochemistry) biochemistry – ↓ B12, ↓folic acid, ↑direct and indirect bilirubin, intrinsic factor antibodies, antibodies against parietal cells, normal iron supplies

Proteins binding VITAMIN B12 Intrinsic factor B12 absorption in ileum, binding to specific receptor (cubilin) Secerned by parietal gastric cells In case of lack leads to B12 malabsorption TRANSCOBALAMIN I Binds B12 in plasma,binds to B12 in stomach before binding to intrinsic factor, produced by neutrofiles and cells with exocrine secretion, his lack leads to low serum B12 levels TRANSCOBALAMIN II Enables B12 absorption by cells, receptor on all type of cells, produced by endotelial cells, fibroblasts, ileum cells.., his lack leads to severe B12 deficiency in cells

Pernicious anaemia

Megaloblastic anaemia Diferential dg.: atrofic gastritis / sprue/ inflamations, parasites/ medication/ liver laesions DNA synthesis impairement due to abnormal cell clone– MDS (bone marrow biopsy, cytogenetics, cytochemistry, B12)

Treatment Substitution - vitamin B12 300 – 1000 μg/d - maintainance dose 1 x za 6 – 8weeks all life long reticulocyte crisis : 5.-7.d of treatment rise of reticulocyte count up to 10-30%. need of iron metabolism parameters, regular GSK and colonoscopy

Autoimmune disease Smooth tongue surface, vitiligo, grey hair Not just anaemia, but pancytopenia Parenteral substitution of B12 Reticulocyte crisis GSK á 1-2years

Anaemia with increased no of reticulocytes HEMOLYTIC ANAEMIA - corpuscular - estracorspuscular bleeding - acute

CORPUSCULAR HEMOLYTIC ANAEMIA MEMBRANE DEFECTS ENZYMOPATIA HEMOGLOBINOPATIA

NON-IMMUNE ACQUIRED HEMOLYTIC ANAEMIA MECHANICAL AND PHYSICAL CAUSES heart valve impairement hemoglobinuria microangiopatic hemolytic anemia widespread burns METABOLIC CAUSES liver disease, alcoholism hypofosfatemia hereditary abetalipoproteinemia malnutrition Cu overload Wilsonś disease CHEMICAL SUBSTANCES oxidative agents, snake venon INFECTIONS Direct ery infection – malaria septicemia ( clostridium perfringens aj. ) leptospira, borelia

Corpuscular Haemolytic anaemias Pathogenesis Lack of and defects in membrane proteins (ankyrin, spectrin, etc.)  Decreasesd size of ery surface – spherocyte increased cell membrane permeability ( Na ) Increased need for eneregy - - (Na pump) increased rigidity and loss of flexibility passge through spleen sinusoid more difficult  loss of membrane parts – microspherocyte cell deth in the spleen  EXTRAVASCULAR HAEMOLYSIS

Hereditary spherocytosis Autosomal dominant ( rarely recesiive) disease with variable gene expressivity  variable clinical symptoms (phenotype) ( anemia with ićterus, splenomegaly, hemolytic crisis ). Diagnostics: Anemia + s reticulocytosis + spherocytes in blood smear, Hyperplůasti erythropoiesis in bone marrow, increased level of both direct and indirect bilirubin, serum Fe a feritin not increased Osmotic resistance of erythrocytes decreased Autohemolýza ( upravuje se po podání glukózy i ATP ) increased PINK test Dif dg.: other corpuscular anemias (HE, etc.) imunne hemolytic anemias non-immune extracorpuscular hemolytic anemias paroxysmal nocturnal hemoglobinuria sometimes MDS Léčba: splenectomy

ERYTROCYTE ENZYMOPATHY Defects in enzymes of anaerobe glykolysis pyruvát kinázy defficiency (PKD) – chronic: haemolytick anemia, with little effect of splnectomia Defect in enzymes of pentos cycle glucose-6-phosphate dehydrogenase defficiency increased sensitivity to oxydazing agents – chronic haemolysis or haemolytic crisis– anemia with Heinz bodies

ANAEROBE GLYKOLYSIS

GLUCOSE-6-PHOSPHATE DEHYDROGENASE defficiency Results in: lack of NADPH …. Increased sensitivity to oxydating agents Gene for G6PDH: X – chromosome , wide physiologic variability of the enzyme Mutation: mostly point mutation in 1 or to bases  decreased enzyme production, production of the enzyme with decreased activity or production of the enzyme with decreased afinty to the substrate or with decreased stability Wide variability in clinical symptoms : Silent carrier severe haemolytic crisis, neonatal icterus Diagnostics: G-6-PD activity analysis Activity to substrate analysis, mobility in ELFO, stability Molecular genetics Other: GSH stability test, Heinz body formation test Th: Prevention of exposure to oxydative agents (medication: antimalarics, sulfonamides,. Food: vicia fava etc.) , splenectomy, stem cell transplant

HEMOGLOBINOPATHIES Abnormal Hb with mostly one aminoacid (AA) substitution in the globion chaine a/ sicle cell anemia – HbS b/ Hb C, Hb D, Hb E – chronic haemolytic anemias often in combination with Hb S or  thal c/ instable haemoglobin diseases hydrofobe AA  decreased binding activity of Hb or impaired secondary structure of Hb and contacts between subunits chronic hemolytic anemia with Heinz bodies( denaturation of nestable Hb ) d/ methemglobinemia Fe3+ stabilisation due to histidine tyrosine in proximity of hem group results in cynosis e/ hemoglobine with increased oxygen affinity tissue hypoxia, cyanosis, polycythaemia in blood count. Diagnostika: elfo Hb identifikace abnormálního Hb tryptickým štěpením isopropanol test, Heinz body tests, methemoglobine tests, afinity to O2 tests molekular genetics, DNA analysis

SICLE CELL ANEMIA Substitution glutamate valin on 6. position  chain: Hb polymerisation, deformation of erythrocyte, tvaru sickle cell. hemolýza extravscular + intravascular (small vessel obstruction) Autosomal dominant type homozygotic form – both  chains impaired heterozygotic form – one  chain impaired 25-50% HbS – sickle cell trait

SRPKOVITÁ ANÉMIE Clinicaly: Hemolytic + aplastic crisis, splenomegaly, Diagnostics krevní obraz – anemie s retikulocytozou a srpkovitými ery elfo hemoglobinu – přítomnost Hb S identifikace Hb S peptickým štěpením globinu molekul.genetika – analýza DNA - v prenatální péči Treatment: Crisis prevention, transfusions, SCT

NEIMUNNÍ ZÍSKANÉ HEMOLYTICKÉ ANÉMIE MECHANICKÉ A FYZIKÁLNÍ PŘÍČINY vadná srdeční chlopeň pochodová hemoglobinurie mikroangiopatické hemolytické anémie rozsáhlé popáleniny METABOLICKÉ PŘÍČINY jaterní choroby, alkoholismus hypofosfatémie hereditární abetalipoproteinemie podvýživa nadbytek mědi, Wilsonova choroba CHEMICKÉ LÁTKY oxidační činidla, hadí jedy INFEKCE přímá infekce erytrocytů: malárie aj. septikémie ( clostridium perfringens aj. ) leptospiry, borelie.

MIKROANGIOPATICKÁ HEMOLYTICKÁ ANÉMIE příčina: rozrušení integrity membrány erytrocytu mechanickou příčinou v průsvitu cévy, nejčastěji depozity fibrinu v místě poškození endotelu cévní stěny. Vaskulitidy, akutní glomerulonefritis, po SCT, nádory, operace chlopní, AV malformace, léky – ticlopidin, infekce – Shigatoxin. fragmentace krvinek – schistocyty – zvýšený zánik ve slezině, při masivní hemolýze – intravaskulární hemolýza při současné aktivaci kaogulačního systému – DIC s tvorbou mikrotrombů v cirkulaci. klinický obraz : dán kombinací hemolytické anémie, trombocytopénie a přítomnosti mikrotrombů (CNS, ledviny ) HUS, TTP, HELLP v graviditě – hemolýza, poruchy jaterních funkcí, trombocytopenie, DIC.

Patofyziologie HUS a diagnostika toxin aktivace endotelu aktivace monocytů zánik endotelií sekrece cytokinů sekrece vWF exprese adhezivních molekul sekrece cytokinů deskvamace endotelií aktivace trombocytů adheze a invaze neutrofilů adheze trombocytů trombocytopenie okluze glomerulů MAHA renální selhání aktivace neutrofilů poškození endotelií elastázy, proteázy, H2O2

MIKROANGIOPATICKÁ HEMOLYTICKÁ ANÉMIE Laboratorní nález: anémie s retikulocytózou, schistocyty, akantocyty, sférocyty, trombocytopenie se známkami DIC, nález multimerů při elfo vWF při TTP, molekulárně genetické vyšetření. Zvýšen přímý i nepřímý bilirubin v séru, zvýšení LDH, proteinurie, Hburie, zvýšen volný Hb, kreatinin, urea. Léčba: léčba vyvolávající příčiny, u TTP/HUS plasmaferéza se substitucí čerstvou zmrazenou plasmou, kortikoidy, antikoagulancia, transfuze erytrocytů.

AUTOIMMUNE HEMOLYTIC ANAEMIA Clasification HEAT antibodies - idiopatic - secondary (lymfoproliferation, other type of tumours, autoimmune diseases, viral infections, immunodefficiency) -drug induced HA COLD antibodies - secondary (lymfoproliferation, viral inf., mykoplasma, autoimmune diseases - paroxysmal cold haemoglobinuria (lues …) MIXED HEAT AND COLD antibodies

Pathogenesis of AIHA: Cooperation disorder among supresor T helper T lymphocytes and B lymphocytes responsible for immunity control Dysregulation of this system leads to insufficient supression of antibody formation against own antigens

IgG – monomér, Fc část – vazebné místo pro C1q složku komplementu a Fcγ receptor makrofágů. IgM – pentamér, Fc část – vazebné místo pro C1q složku komplementu a Fcγ receptor makrofágů.

HEAT ANTIBODIES IgG character – optimal at 370C Catch up of erythrocytes with binded antibody by spleen macrophages EXTRAVASCULAR HEMOLYSIS Activation of complement by high antibody titre INTRAVACULAR HEMOLYSIS

COLD ANTIBODIES IgM character – optimál at 40C Bound to erytrocytes in colder acral parts, possibility of complement activation, ery aglutination INTRAVASCULAR HEMOLYSIS EXTRAVASCULAR HEMOLYSIS

Secondary AIHA with heat antibodies AUTOIMMUNE DISEASES systemic lupus erytematodes, revmatoid arthritis, sclerodermia, ulcerose colitis, syndrome of antiphospholipid antibodies HEMATOLOGIC TUMOURS chronic lymphadenosis,malign lymphomas, rarely acute leucaemia OTHER TUMOURS carcinoma, thymoma, Kaposi sarkoma, teratoma INFECTIONS EBV, HIV-1,2, HCV, vaccination (difteria-pertusis-tetanus) IMUNODEFICIENCY congenital and acquired hypogamaglobulinemia and dysgamaglobulinemia

DRUG-INDUCED HEMOLYTIC ANAEMIA hapten type imunocomplex type De-novo antigen formation

AIHA –laboratory parameters: Blood count: makrocytic anaemia with reticulocytosis Biochemistry:  direct and indirect bilirubin,  urobilinogen in urine Special tests: Direct and indirect antiglobuline test (Coombs test) INTRAVASCULAR HEMOLYSIS PROOF:  free Hb in plasma,  levels of haptoglobin and hemopexin in serum, hemoglobinuria

DIRECT COOMBS TEST Erytrocytes with bound Ab We add : anti IgG

INDIRECT COOMBS TEST Sérum with free antibodies we add: erythrocytes of particular blood group we add : anti IgG or anti C3b

AIHA – diferential diagnosis: CORPUSCULAR HEMOLYTIC ANAEMIA negative Coombs test, positive special tests (autohemolysis, erytrocyte enzyme tests, elfo Hb, shortened lifespan of autologous, not donor erythrocytes) PAROXYSMÁL NIGHT HAEMOGLOBINURIA negative Coombs test, pancytopenia, CD59 and CD55 antigen defficiency on erythrocytes, CD14 antigen def. on the surface of granulocytes and monocytes GILBERT DISEASE- negative hemolysis tests NON- IMMUNE HEMOLYTIC ANAEMA microangiopatic hemolytic anemia (schistocytes, kidney and CNS affection), anemia from physical and chemical causes MYELODYSPLASTIC SYNDROME - hemolytic form morfological dysplastic changes,chromosomal aberances,cytochemical changes, clonality.

AIHA - treatment: Light form ( Hb > 80 g/l ): PREDNISONE 1 mg/kg/d 2-3 weeks - in case of good effect decreasing dose every 2-3 days by 10mg until 20 mg/day. - slow reduction of dose (by 5mg in 7-10 days) until 5-10mg every second day. - end of corticooid therapy when repeated direct Coombs test negativity When therapy is ineffective or relaps occurs: combination with CYCLOPHOSPHAMIDE 100-150 mg/d or CYCLOSPORINE A 3 mg/kg/d.

AIHA - treatment: SEVERE form ( Hb < 80 g/l ): PREDNISONE 1-2 g i.v. daily 5 days, after that in case of good response fast decrese of dose to 1 mg/kg. - combination of corticoids with : CYCLOPHOSPHAMIDE 200 mg i.v./d i.v. IMMUNOGLOBULINS 0,5g /kg/d PLASMAPHERESIS RITUXIMAB (anti CD20 monoclonal Ab) Transfusion – together with corticoids , monitored hospitalised patient, not more then 1 TU/day (unless vital indication)

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