Documente Academic
Documente Profesional
Documente Cultură
Anemia Defisiensi
Savita handayani
Hematologi-Onkologi Medik
Departemen Ilmu Penyakit Dalam
Steps in Erythropoesis
Early
Proerythroblast
(Pronormoblast)
Intermediate Late
Polychromatophilic
Normoblast
Basophilic
Normoblast
Reticulocyte
Orthochromatophilic
Normoblast
Erythrocyte
Normositik
normokrom Makrositik
80 100 fL
> 27 pg
30 g/dL
MCV= (Ht/Eritosit)x10 fL
MCH=(Hb/Eritrosit)x10 pg
MCHC=(Hb/Ht)x100 g/dL
> 100 fL
> 27 pg
30 g/dL
Mechanism of Anemia :
Decreased Production:
Nutrient Deficiency.
Iron, B12/Folate
Iron Metabolism
Iron Mathematics
IDA - Etiology
Blood loss
Increased need
Decreased Hb Synthesis
Delayed maturation of erythroblasts
(cytoplasmic)
Decreased cytoplasm, more division
(microcytes)
Decreased Hb content (hypochromia)
Anemia.
PATHOGENESIS
Lack of iron interferes with heme synthesis
hemoglobin synthesis and defective erythropoiesis
There is decreased activity of iron-containing proteins
such as the cytochromes and succinic dehydrogenase
Neurologic dysfunction may occur, with impaired
intellectual performance, paresthesias
Gastric acid secretion is reduced, often irreversibly
Atrophy of oral and gastrointestinal mucosa may
occur
Clinical Features:
Angular cheilitis
LABORATORY CHANGES
Red Blood Cells
- Earlist change is anisocytosis and increased red cell
distribution width (RDW)
- Mild ovalocytosis, target cells
- Elongated hypochromic elliptocytes
- Progressive hypochromia (low MCH),microcytosis
(low MCV), MCHC variable
- Reticulocytes normal or reduced
- The erythrocyte count, hemoglobin level and
hematocrit are all proportionately reduced
LABORATORY CHANGES
Leucocytes
Leukopenia (3000 to 4400/l) in some. Differential
count is normal
Platelets
- Thrombocytopenia develops in 28 percent of
children and may occur in adult
- Thrombocytosis found in
- 35 % of children
- 50 to 70 % of adults-usually secondary to
chronic active blood loss
LABORATORY CHANGES
Marrow
- Marrow cellularity and M/E ratio variable
- Decreased to absent sideroblast
- Decreased to absent hemosiderin by Prussian blue
staining
- Erythroblasts may be small, with narrow rim of
ragged cytoplasm and poor hemoglobin formation
LABORATORY CHANGES
Serum Iron Concentration
- Usually low but may be normal
- May be reduced with concomitant acute or chronic
inflammation malignancy, acute myocardial
infarction in the absence or iron deficiency.
- May be elevated 3 to 7 days after therapy
LABORATORY CHANGES
Serum Ferritin
- Level of less than 10 g/liter
- Level of 10 to 20 g/liter are presumptive, but not
diagnostic
- May be elevated with concomitant inflammatory
disease
Free Erythrocyte Protoporphyrin (FEP)
- Concentration is usually increased
- Very sensitive for diagnosis of iron deficiency and
suitable for large scale screening of children, detecting
both iron deficiency and lead poisoning
SI
IST
* 100%
TIBC
Normal limit:
SI
TIBC
Serum feritin
50 -150 g/dL
250-410 g/dL
20-200 ng/mL,
excess >400 ng/mL
DIAGNOSIS
13-16
1316
12-14
13-16
Retikulosit
Hitung Eritrosit
Pria
: Ht x Rasio retikulosit
Wanita
42
Ht
x
39
Rasio retikulosit
Hb
Ht
18
17
16
15
14
13
12
11
10
54
51
48
45
42
39
36
33
30
Rasio Retikulosit ()
Pria
Wanita
4.0 11.8
3.6 11.0
4.2 12.5
3.9 11.7
4.4 13.2
4.1 12.4
4.7 14.1
4.4 13.1
5.0 15.0
4.7 14.0
5.4 16.1
5.0 15.0
5.8 17.3
5.4 16.2
6.3 18.8
5.8 17.5
6.8 20.5
6.4 19.1
TREATMENT
Therapeutic Trial
* Should be via oral route
* Expect
- peak reticulocytosis at 1 to 2 week
- significant increase in Hb concentration at 3-4 weeks
- one-half of Hb deficit corrected at 4-5 weeks
- Hb level normal at 2 to 4 months
TREATMENT
Oral Iron Therapy
* Dietary sources may not be sufficient for treatment
* Safest, cheapest are oral ferrous salt
* Nonenteric coated forms are preferred
* Avoid multiple hematinics
* Do not give with meals or antacids or inhibitor acid productions
* Continue for 12 months after Hb is normal to replenish iron stores
* Daily total 150-200 mg elemental iron in 3 to 4 doses, each 1 h ac
Iron Sucrose
Venofer 100 mg/amp
Cara infusi 100 mg in 100cc NS 1jam
TREATMENT
Parenteral Iron Therapy
* Routine use rarely justified
* Indications are:
- malabsorption
- intolerance to oral iron preparations (colitis, enteritis)
- needs in excess of amount that can be given orally
- patient uncooperative or unavailable for follow-up
* Iron dextran:
- 50 mg elemental iron/ml
- Approximately 70 % readily available for Hb synthesis
- May be given IM or IV
- Be aware of anaphylaxis or other systemic side effects
TREATMENT
Parenteral Iron Therapy
* Continue therapy for 12 months after Hb is normal, in order to
replenish iron stores.
* Therapy may be needed indefinitely if bleeding continues
Megaloblastic anemia:
Malnutrition, vegetarian
Intrinsic factor Ab - Pernicious anemia
Gastrectomy, Ileal resection
Inflammatory bowel disease
Malabsorption syndromes - Sprue
Blind loop syndrome
Diagnosis
-B12 defisiensi
-Folate defisiensi
Deficiency
Folic acid
Serum
vit. B12
Serum
RBC
Folic acid
Vit B12
N /
THERAPEUTIC TRIALS
Usual diet
0,2 mg folic acid oral
1 week
reticulocyte response
reticulocyte response
Management
B12 Defisiensi :
B12 1000 ug IM weekly until 8 weeks,
and B12 1000 ug IM monthly
Folat Defisiensi :
1 mg oral daily ( 5 mg daily maximal dose), treatmane
for 1 until 2 month or defisiensi corected.
Reticulosit Evaluation on day 4 and 5, than peak level
reticulosit on day 7.
Megaloblastic Anemia :