Anemia defisiensi besi

Anemia Defisiensi Ferum

Reza Aditya Digambiro

1. Kehilangan darah

·   Uterus         :Polimetrorhagi, Post partum hemorrhagi

·   Gastro Int     :Varices oesofagus, ulkus peptikum, minum aspirin, gastrektomi, ca lambung / caecum / kolon / rektum, cacing tambang, kolitis, hemorrhoid, devertikulosis

·   Hematuria, Hemoglobinuria

·   Hemosiderosis Pulmonum

2.  Kebutuhan meningkat

·   Kehamilan , pertumbuhan

·   Prematuritas

3.  Malabsorpsi

·   Gastrektomi, penyakit coeliac

4.Diet buruk

Pendekatan Sistemik Anemia Hipokrom Monositer

 

Ferritin	ç	N / æ	N	N / æ
Iron	ç	ç	N	N / æ
TIBC	æ	N / ç	N	N
% Saturation	ç	ç	N	N / æ

                  Def. Fe  An.Peny. Hb.Studies   BMP

                           Kronik

      

                                    Thalasemia   Sideroblastik

                                                  Anemia

Iron Metabolisme Biochemistry

·   Eritropoesis

·   Intra celluler process in all tissues

·   Hemo protein à oxygen transport

·   Four haem à four polypeptide chain

·   Hb à BM : 64.500

·   Myoglobin à17.000 àsingle polypeptide chain + 1 haem group

·   Ferritin àsoluble  protein

·   Apo ferritin : 480.000

·   Hemosiderin à amorf insoluble storage compound à iron content meningkat dari ferritin

·   Transferrin à b globulin – BM 80.000

-    bind 1.3 ug iron / mg protein

-    2.3 gr / l plasma concentrasi

-    diproduksi di hepar

Iron Requirements Daily (mg/day)

	Urine, Sweat Faeces	Mens	Pregnant	Growth	Total
Adult  Y	0,5 - 1	-	-	-	0,5 – 1
Post Meno/ Mens	0,5 - 1	0,5 – 1	-	-	1 – 2
Pregnant	0,5 – 1	-	1 – 2	-	1,5 – 2,5
Children	0,5	-	-	0,6	1,0
Female	0,5 – 1	0,5 - 1	-	0,6	1 – 2,5

Iron Absorption (Duodenum & Less Jejunum)

Factor Favouring	Factor Reducing
•    Ferrous Form •    In Organic iron •    Acids, Hcl, Vit C •    Solobilising Agent, sugar, amino acid •    Iron Def •    Increased Eritropoesis	•    Ferric Form •    Organic Iron •    Alkali – Antacid •    Pancreatic Secretions •    Precipitating Agent •    Fosfat •    Iron Excess •    Decreased Eritropoesis Infection

Iron Balance à jumlah rata-rata dewasa

	Y ( gr )	X ( gr )	% Total
Hb	2,4	1,7	65
Ferritin / Hemosiderin	1,0	0,3	30
Myoglobin	0,15	0,12	3,5
Haem Enzym Catalase. Peroxidase. Flavo protein	0,02	0,015	0,5
Transferin Bound Iron	0,004	0,003	0,1

Karakteristik Anemia Defisiensi Fe & Anemia Penyakit Kronik

	Normal	Anemia Def . Fe	An . Peny Kronik
Morfologi S.I ( Mmol / L ) TIBC % Transferin SAT % Sideroblast Serum Ferritin R.E Iron Eritrosit Protoforferin (uMol/L ) Plasma Copper ( Mmol/L )	N – N 206 ± 8 58 ±4.5 35 ±15 40 – 60 100 ± 60 ( + ) < 700 16 - 31	Hypo – Mikro 30 450 < 15 15 – 30 < 10 ( - ) æ æ	N / Hypo – N < 12.0 44.8 ± 9 10 – 25 5 – 20 >200 æ æ æ

SERUM FERRITIN (µG/L)

Batas normal :

•          Pria                               40 - 340

•          Wanita                             14 - 150

•          Anak – anak                        7 - 140

Defisiensi besi                          0 - 12

Kelebihan besi ( Iron over load )        340 - > 20.000

KELEBIHAN BEBAN BESI

Metode Penilaian Cadangan Besi :

·   serum ferritin

·   serum ion saturated transferin

·   biopsi sum-sum tulang (hemosiderin)

·   biopsi hati (RES store)

·   liver CT scan

·   test ekskresi desferoksamin

·   phlebotomy berulang sampai terjadi defisiensi besi

Penilaian Kerusakan Jaringan Disebabkan Kelebihan Beban Besi

·   Jantung : klinis, x-foto thorax, EKG, ekokardiografi

·   Hati : test faal hati, biopsi hati

·   Endokrin : G.T.T. , test pelepasan gonadotropin, hipofise

Anemia Megaloblastik

Kausal :

·   Defisiensi vitamin B12

·   Defisiensi asam folat

·   Abnormalitas metabolisme vit. B12 atau folat

·   Cacat sintesa DNA

-    defisiensi enzim congenital

-    didapat à terapi hidroksi, sitosin arabinosa

Aspek Nutrisi Vitamin B12 dan Folat

	Vit B 12	Folat
•    Intake dalam makanan •    Makanan utama •    Pemasakan •    Cadangan tubuh •    Penyerapan •    Batas penyerapan •    Bentuk fisiologi intrasel •    Terapi	7 – 30 ug Produk hewan Sedikit pengaruh 2 – 3 mg Ileum 2 –3 ug Metil dan Adenosil Kobalamin Hidroksi Kobalamin	600 – 1000 ug Hati, sayuran hijau, ragi Mudah rusak 10 –12 mg Duodenum Jejunum 50 – 80 % Polyglutamat tereduksi As Folat

Kausal Defisiensi Vitamin B12

·   Veganisme

·   Malabsorbsi

*   Lambung

-    Anemia Pernisiosa

-    Intrinsik factor defisiensi congenital

-    Gastrektomi total/partial

*   Intestinal

-    Intestinal stagnant loop syndrome

-    Divertikulosis Jejunal

-    Blind loop

-    Striktura

-    Kronik tropical sprue

-    Reseksi ileum/penyakit Crohn

-    Malabsorbsi selektif congenital dgn proteinuria

Kausal Defisiensi Asam Folat

1.  Nutrisional

·   umur tua, poor, scorbut, gastrektomi parsial.

2.  Malabsorpsi

·   tropical sprue

·   peny. Celiac

·   reseksi jejunum yg luas

·   peny. crohn

3.  Pemakaian berlebihan

·   Fisiologi à kehamilan, laktasi

·   Patologi à anemia hemolitik, meilosklerosis, keganasan, dll

4.  Pembuangan folat urine >>> CHF

5.  Terapi obat konvulsan

6.  Campuran : penyakit hati, alkoholisme

ANEMIA MEGALOBLASTIK

·   Hematologic Finding

*   Hbl (7-8) g/dl, eritrosit l, Ht (5-15)%

*   Index hematology

-    MCV > normal (95-130) fl

-    MCH k (33-56) pg

-    MCHC normal

*   Lekosit à lekopenia

*   Trombosit l

*   Morfologi :

-    eritrosit à macro ovalocyte, anisositosis, poikilositosis, cabot ring, basofilik, Howell Jolly Bodies.

-    Leukosit à netropenia, hipersegmentasi à shift to the right.

*   Red cell survival time : (1/4 – ½) Nml

*   Sum-sum tulang

-    eritroid hyperplasia : megaloblastosis

-    metarubrisit megalosit

-    granulopoesis abnormal

-    megakariosit inti regular

-    adanya eritro-fagositosis

-    hemosiderin k

·   Non Hematologic Finding

*   Analisa asam lambung

-    histamine fast achlorhydria

-    pepsin (-) : rennin (-), vol. asam total l

-    total gastric failure

-    asam bebas (-)/l , pH k

-    ekskresi factor intrinsic sangat l

*   Serum B12 & asam folat l

*   Serum iron k : TIBC normal/l , S.I. k

*   LDH k ; isoenzim LDH 1 lebih tinggi dari LDH 2

*   Autoantibodi (3 tipe)

-    anti parietal cell antibody

-    anti intrinsic factor antibody block

-    anti intrinsic factor antibody binding

*   Sitogenetik (abnormalkromosom non-spesifik)

Peripheral Blood in Pernicious

●  There are two late megalobalst with nuclear rossete formation and basophil stippling.

●  The red cells show macrocytosis, anisocytosis and poikilocytosis

●  Multi-lobed neutrofil polymorph