HIV相关的贫血专题知识.ppt

,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,*,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,*,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,*,HIV相关的贫血专题知识,贫血,定义：血红蛋白,Hb,：男性低于,120g/l,，成年女性低于,110g/l,，孕妇低于,100g/l,。,According to The Anemia HIV Working Group(hemoglobin level of 12 g/dL in men and 11 g/dL in women)(,Volberding 2023,).,分类,：,急性、慢性,红细胞形态（大细胞性、正常细胞性、小细胞低色素性）,骨髓增生情况：,增生性贫血（溶血性、缺铁性、巨幼贫）,增生低下贫血（再生障碍性贫血）,病因分类,一、红细胞生成降低,（一）造血干祖细胞异常,再生障碍性贫血,纯红再障,先天性：,Diamond-Black fan,综合征,后天性：,原发,-,部分患者血清中有本身,EPO,或幼红细胞旳抗体,继发,-,药物有关型,、,感染有关型,、,本身免疫病有关型、淋巴细胞增殖,性疾病有关型,先天性细胞生成异常性贫血,造血系统恶性克隆性疾病,（二）造血微环境异常,骨髓基质、基质细胞受损,造血调整因子水平异常：,SCF,、,IL,、,GM-CSF,、,G-CSF,、,EPO,、,TPO,、,TGF,、,TNF,、,IFN,造血原料不足或利用障碍,二、溶血性贫血,三、失血性贫血,Background-2023,Despite important advances in antiretroviral therapy,anemia remains a problem in many HIV-infected patients,Anemia has a deleterious effect on both functional capacity and quality of life,and has been associated with shortened survival.,In February and June of 1998,The Anemia in HIV Working Group,an expert panel of AIDS clinicians from the United States,convened to discuss that,：,the impact of anemia in patients with HIV infection,the available treatment options,the practice strategies and future research directions,Anemia is a common complication of HIV infection,HIV-infected patients treated from January 1990 through August 1996,the l-year incidence of anemia(defined as a hemoglobin level 10 g/dL)was 3.2%in the 6094 cohort members with HIV but not AIDS,12.1%in the 2579 members with immunologic AIDS(CD4+cell count 200/mm3),and 36.9%in the 4624 members with clinical AIDS.,78%were regarded as not drug related,Anemia in HIV Infection:Clinical Impactand Evidence-Based Management Strategies,In 2023,16 members of the Anemia in HIV Working Group,an expert panel of physicians involved in the care of HIV-infected patients that met first in 1998,reconvened to assess new data and to translate these data into evidence-based treatment guidelines,the prevalence of anemia in the highly active antiretroviral therapy era,the risk factors that are independently associated with the development of anemia,the impact of anemia on quality of life,physical functioning,and survival,evidence-based guidelines for treatment of anemia in HIV-infected patients,Anemia association with disease progression and decreased survival,WHAT CAUSES ANEMIA IN HIV INFECTED PERSONS,Blood loss-neoplastic disease,gastrointestinallesions,Other pathophysiology of HIV-associated anemia,decreased RBC production,increased RBC destruction,ineffective RBC production,Decreased RBC production,neoplasm,infection,myelosuppressive medications,HIV infection itself,a decreased production of endogenous erythropoietin,a blunted response to erythropoietin,hypogonadism,抗逆转录病毒药物,-,扎西他滨,-,齐多夫定,抗病毒药,-,更昔洛韦,-,膦甲酸钠,-,西多福韦,抗真菌药物,-,氟胞嘧啶,-,两性霉素,抗肺孢子菌药物,-,磺胺类药物,-,甲氧苄啶,-,乙胺嘧啶,-,喷他脒,抗肿瘤药物,-,环磷酰胺,-,阿霉素,-,甲氨蝶呤,-,紫杉醇,-,长春碱,-,脂质体阿霉素,-,脂质体柔红霉素,免疫反应调整剂,-,干扰素,-a,Increased RBC destruction,RBC destruction in the spleen or the circulator system,RBC autoantibodies,hemophagocytic syndrome,disseminated intravascular coagulation,thrombotic thrombocytopenic purpura,or glucose-6-phosphate dehydrogenase deficiency-Hemolytic anemia,various medications,Ineffective RBC production,Nutritional deficiencies-iron,folic acid,or vitamin B12,WHAT FACTORS ARE ASSOCIATED WITHANEMIA IN HIV-INFECTED PERSONS,zidovudine use,CD4 cell counts of 200cells/mL,increased virus load,and a number of additional factors,Sex-,menstrual blood loss and to the drains on iron stores that occur with pregnancy and delivery,Race-,39%among African American women,19%among white women,31%among African American men,and 12%among white men,（,presence of inherited hematologic disorders,such as sickle cell disease and thalessemia,；,Dietary,）,Zidovudine treatment-,bone marrow suppression,(hemoglobin 12 g/dL)in the pre-HAART era(19931996),use of zidovudine during the HAART era(19962023)was not significantly,(hemoglobin 10g/dL)in 41.6%of subjects receivingzidovudine therapy,compared with 34.3%of those not receivingzidovudine(P .01),Worsening HIV disease parameters,Low CD4 cell counts(200 cells/mL)and higher HIV-1 RNA levels in plasma have each been independently associated with an increased risk of anemia,WHAT IS THE SIGNIFICANCE OF ANEMIAIN HIV-INFECTED PERSONS,association between anemia at baseline,decreased survival,and increased disease progression,THE IMPACT OF ANEMIA IN HIVINFECTEDPERSONS,Impact of fatigue,Impact of correction of anemia-,Small increases in the hemoglobin level(up to 2 g/dL)were associated with a beneficial effect on total quality of life,THE EFFECT OF HAARTON THE PREVALENCE OF ANEMIA,Although the prevalence of severe anemia has decreased since the introduction of HAART,mild-to-moderate anemia continues to be common,Even with use of HAART,anemia remains strongly and consistently associated with HIV disease progression-hemoglobin levels decrease,the risk of disease progression increases,THE CURRENTTREATMENT GUIDELINES FOR ANEMIA,Address correctable causes of anemia,Use of HAART-,HAART was significantly associated with correction of anemia;improvement was noted within 6 months,and a greater resolution occurred after a longer duration,Use of epoetin alfa,Consensus recommendations:,Monitor hemoglobin levels routinely,If the hemoglobin level is lower than normal-rule out or correct treatable causes,Initiate HAART if warranted,If correctable causes of anemia have been ruled out and the hemoglobin level is 13 g/dL in men and 100 mg/L-unlikely to have iron deficiency;supplement with iron for 710 days-re-evaluate the anemia,Treatment Options,Treatment should be chosen to address the underlying cause of this disorder,Blood transfusion-severe anemia,with a hemoglobin level of 8 g/dL.,Epoetin alfa-48 weeks,its efficacy and safety for patients with mild symptomatic or moderate HIV-related anemia,Androgens-increase production of erythropoietin with anemia caused by bone marrow failure,HIV-Associated Autoimmune Hemolytic Anemia,This review article discusses the etiology,pathophysiology,clinical features,diagnosis,treatment,and complications of autoimmune hemolytic anemia(AIHA)associated with HIV infection.,ETIOLOGY,AIHA results from the destruction of erythrocytes by antibodies.,The etiologies for AIHA are various including,idiopathic causes,drugs,infectious agents,neoplasms,or autoimmune disease,Several mechanisms have been postulated to,Explain why AIHA develops in patients with AIDS,presence of erythrocyte autoantibodies or the presence of hypergammaglobulinemia may result in nonspecific coating of over abundant immunoglobulin G(IgG)to autologous erythrocytes,presence of immune complex-associated IgG,may bind to erythrocytes via C3b receptors,abnormal B-cell regulation by HIV-infected T cells,Infectious agents associated with AIDS may be associated with the production of autoantibodies,lymphoma,CLINICAL PRESENTATION,Anemia,pallor,mild jaundice,and splenomegaly-30%,AIHA can be classified as mild,moderate,or severe,Mild hemolytic anemia is characterized by positive direct antiglobulin test results only,Moderate anemia is characterized by anemia and splenomegaly,Severe anemia is characterized by fulminant hemolysis with marked spherocytosis,hyperbilirubinemia,absent or decreased levels of haptoglobin,and hemoglobinuria,DIAGNOSIS,Positive Coombs test,Serologic findings,：,Types of antierythrocyte antibodies-,include the coating of erythrocytes by both IgG and C3,or IgG alone,Concomitant cold and warm antibodies,TREATMENT,monitored for possible progression of the hemolysis,blood transfusion;corticosteroids,immunoglobulins,splenectomy,immunosuppressive therapy,plasmapheresis,and zidovudine.,COMPLICATIONS,Blood transfusion complications-hemoglobinuria,tachycardia,vomiting,back,pain,fever,hypotension,shock,and renal failure,Hypercoagulation-,thromboembolism,Hematological abnormalities in HIV-infected patients,Anemia,neutropenia,and thrombocytopenia are commonly observed in HIV-infected patients,701 HIV-infected patients,Blood cell counts,hemoglobin concentration,CD4 count,and viral load,recorded the mortality rate after 1 year in the groups with CD4 200/l and 200/l according to hemoglobin concentration,RESULTS,37.5%had anemia;61.1%(110/180)were in the low CD4 group and 29.4%(153/521)were in the high CD4 group(p0.01),Mean neutrophil counts were 2.61010(9)/l and 3.20410(9)/l in the low CD4 and high CD4 groups(p0.01),mean platelet counts were 218.63910(9)/l and 234.80710(9)/l for the low CD4 and the high CD4 groups(p=0.03),Patients whose hemoglobin concentration was below the median value had a higher death rate in both the low CD4(14 vs.4 deaths,p=0.013)and high CD4(8 vs.1 death,p=0.0158),CONCLUSIONS,an association between CD4 count and hemoglobin level,neutrophil count,and platelet count,anemia was independently associated with a higher mortality,