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Hematology & Blood Transfusion

Anaemia (General Approach)

A condition characterized by inadequate blood haemoglobin (Hb) levels for age and sex, resulting in reduced oxygen-carrying capacity. It is common, often multifactorial, and requires investigation to determine the underlying cause.

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Referral and warning signs

When to refer

Refer to higher level (HC4/Hospital/Specialist) for: Severe anaemia requiring blood transfusion. Anaemia unresponsive to standard treatment. Unclear cause after initial investigation. Suspected haemolysis, bone marrow failure, or malignancy. Need for specialized investigations or treatments (e.g., bone marrow exam, ESAs).

Red flags

  • Severe anaemia (e.g., Hb <7-8 g/dL in adults/older children, <7 g/dL in young children/pregnancy)
  • Signs of heart failure or severe hypoxia
  • Rapid drop in Hb / Signs of acute blood loss / Shock
  • Associated bleeding or bruising (suggests thrombocytopenia/coagulopathy)
  • Signs suggestive of malignancy (weight loss, lymphadenopathy, hepatosplenomegaly)

Signs and symptoms

  • Pallor (paleness) of conjunctivae, mucous membranes, palms, soles.
  • Fatigue, lethargy, weakness.
  • Dizziness, lightheadedness.
  • Headache.
  • Palpitations, tachycardia.
  • Dyspnoea (shortness of breath), especially on exertion.
  • Low exercise tolerance.
  • Anorexia, sometimes weight loss.
  • Signs of heart failure (in severe anaemia): oedema, dyspnoea at rest, tachycardia, murmurs.
  • Symptoms of acute blood loss: Postural hypotension, tachycardia, sweating, restlessness, thirst, shock.
  • Signs related to specific cause: Jaundice (haemolysis), Splenomegaly (haemolysis, infection, malignancy), Signs of nutritional deficiency (glossitis, koilonychia), Signs of chronic disease or bleeding.

Risk factors

  • Nutritional deficiencies (Iron, Folate, Vitamin B12)
  • Infections (Malaria, HIV, TB, Hookworm, Schistosomiasis, Visceral Leishmaniasis)
  • Chronic diseases (Kidney disease, Chronic inflammation, Cancer)
  • Haemoglobinopathies (Sickle Cell Disease, Thalassaemia)
  • Haemolysis (Autoimmune, Drug-induced, G6PD deficiency)
  • Blood loss (Acute: Trauma, Surgery, GI bleed, Postpartum haemorrhage; Chronic: Menorrhagia, GI bleeding, Parasitic infestations)
  • Bone marrow disorders (Aplastic anaemia, Leukaemia, Myelodysplasia)
  • Pregnancy
  • Certain medications

Diagnosis

Clinical assessment

Suspect based on symptoms (pallor, fatigue, dyspnoea) and signs. Assess severity based on clinical signs (pallor extent, vital signs, heart failure signs) and Hb level according to age/sex thresholds (e.g., Severe Adult <8 g/dL, Severe Child <7 g/dL). Identify potential underlying cause through history (diet, bleeding, infections, chronic illness, medications, family history) and examination (jaundice, splenomegaly, etc.). Anaemia is a sign, not a final diagnosis.

Investigations

  • Complete Blood Count (CBC) with Differential: Confirms anaemia (low Hb), provides Red Blood Cell (RBC) indices (MCV, MCH, MCHC), WBC count, Platelet count.
  • Peripheral Blood Film/Smear: Assess RBC morphology (microcytic, macrocytic, normocytic; hypochromic, normochromic; specific shapes like sickle cells, spherocytes, schistocytes), WBC morphology (blasts?), Platelet estimate.
  • Reticulocyte Count: Assess bone marrow response (low in production defects, high in haemolysis/blood loss).
  • Classification based on MCV:
  • - Microcytic (Low MCV): Check Serum Ferritin (low in iron deficiency). Consider Hb Electrophoresis (thalassaemia). Evaluate for chronic blood loss (stool occult blood, parasites). Consider drug causes (isoniazid, chloramphenicol -> sideroblastic).
  • - Macrocytic (High MCV): Check Serum Vitamin B12 and Folate levels. Check TSH (hypothyroidism). Assess alcohol use, medications (AZT, MTX, Hydroxyurea). Consider myelodysplasia.
  • - Normocytic (Normal MCV): Evaluate for acute blood loss, chronic disease (anaemia of chronic disease), renal failure (check Creatinine/eGFR), haemolysis (check Bilirubin, LDH, Haptoglobin, Coomb's test), bone marrow failure (aplastic anaemia - may have pancytopenia).
  • Stool analysis: Ova & Parasites (hookworm, schistosoma), Occult blood.
  • Malaria Test (RDT or Microscopy).
  • HIV testing.
  • Further tests based on suspected cause (e.g., Renal function, Liver function, Bone marrow examination).

Diagnostic criteria

Haemoglobin level below the age- and sex-specific normal range. Further classification based on RBC indices (MCV) and identification of underlying cause.

Management

Non-pharmacological management

  • Identify and Treat the Underlying Cause.
  • Nutritional counseling and support (if deficiency related).
  • Stop causative medications if possible.
  • Manage chronic diseases.

Pharmacological treatment

  • Specific treatment based on cause:
  • - Iron Deficiency Anaemia: Oral Iron supplementation (see HEM002).
  • - Megaloblastic Anaemia: Folic acid and/or Vitamin B12 supplementation (see HEM003).
  • - Anaemia of Chronic Disease: Treat underlying condition. Erythropoiesis-Stimulating Agents (ESAs) may be considered in specific settings (e.g., CKD, malignancy - specialist).
  • - Haemolytic Anaemia: Depends on cause (e.g., steroids for autoimmune, folate for chronic haemolysis).
  • Blood Transfusion:
  • - Indicated based on clinical condition (signs of hypoxia, heart failure, ongoing significant bleeding) AND Hb level thresholds (see UCG 11.2.2.3 for specifics based on age, pregnancy, surgery, sickle cell status).
  • - Not based on Hb level alone.
  • - Transfuse minimum necessary units (often 1 unit at a time in adults, re-assess).
  • - Use packed red cells preferably, or whole blood if packed cells unavailable or massive haemorrhage.

Monitoring

Monitor Hb levels and RBC indices. Monitor clinical symptoms. Monitor response to treatment of underlying cause. Monitor for side effects of treatment (e.g., iron supplements).

Complications

  • Heart failure (high-output failure)
  • Impaired cognitive function and development (especially in children)
  • Reduced exercise tolerance / Poor quality of life
  • Increased susceptibility to infection
  • Worsening of underlying cardiac conditions
  • Complications related to underlying cause
  • Complications of blood transfusion (if required)

Prevention

  • Dietary improvement (iron, folate, B12 rich foods).
  • Iron and folic acid supplementation during pregnancy and early childhood (per national programs).
  • Deworming programs (control hookworm).
  • Malaria prevention and prompt treatment.
  • Control of chronic bleeding.
  • Good hygiene and sanitation.
  • Screening high-risk groups.

Patient education

  • Explain anaemia and its likely cause.
  • Dietary advice.
  • Importance of adherence to supplements (iron, folate, B12) if prescribed, and potential side effects.
  • Need for treating underlying cause (infection, bleeding etc.).
  • Symptoms of worsening anaemia or complications requiring return.
  • Prevention strategies.

Uganda-specific notes

Very high prevalence, often multifactorial (nutrition, malaria, hookworm, HIV, sickle cell). Iron deficiency and anaemia of chronic disease are common. Access to comprehensive investigations (ferritin, B12/folate, Hb electrophoresis, bone marrow) limited. Empirical treatment for common causes often used. Blood transfusion safety and availability critical.

References

  • Uganda Clinical Guidelines (UCG) 2023

    Chapter 11, Section 11.1.1

  • WHO Haemoglobin concentrations for the diagnosis of anaemia and assessment of severity

    WHO/NMH/NHD/MNM/11.1 (Referenced in UCG)

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