*ANEMIA DEFISIENSI BESI

*AnemiaKlasifikasi morfologiDefek fungsionalA. mikrositik hipokromikA. normositik normokromikA. MakrositikDestruksiBlood Loss:a.Kronikb.AkutHemolitikDefek maturasiHipoproliferatifa.Inti : A. Megaloblastikb.Sitoplasma :Fe : A..Def BesiHeme:A.SideroblastikGlobin: Thalassemia, Hb Patia.Peny. Ss tulangIntrinsik : aplastikInfiltasi: lekemiab.Peny. Kronisc.Peny. Endokrind.Peny. GinjalExtrapusculerIntracorpusculerImunNon ImunHDNReaksi transfusiAIHADrug induceInfeksi virusH.mekanis: disfungsi katub, MAHABahan kimia, luka bakarInf.parasit: malariaHerediter1.Defek struktur globin:Kuantitas: thalassemiaKualitas: sickle cell, Hb-pati2.Defek membran: sferositosis hered, elliptositosis hered.3.Defek enzim: def.G6PD, piruvat kinaseDidapatDefek membran erits: PNH

Definisi Anemia Defisiensi BesiAnemia yang timbul akibat berkurangnya penyediaan besi untuk eritropoesis, karena cadangan besi kosong (depleted iron store), yang pada akhirnya menyebabkan pembentukan hemoglobin berkurang.

I. Iron (Fe)A. In the Body1. Exists in two ionic states a. Ferrous reduced form, has 2 positive charges (Fe+2)b. Ferric oxidized form, has 3 positive charges (Fe+3)c. Forms important in oxidation-reduction reactions d. More importantly forms important in absorption of iron

I. Iron (Fe)

*

iron distribution in adultMale(g)Female(g)% totalHemoglobin2.41.765Ferritin and hemosiderin1.00.3 30Myoglobin0.150.123.5Haem enzymes (cytokrom, katalase, peroxidase, flavoprotein)0.020.0150.5Transferrin binding iron0.0040.0030.1

2. Functions Oxidation-reduction reactions of energy metabolism Part of many enzyme system that create ATP and energyStructural/functional component of hemoglobin (blood) and myoglobin muscle) carries oxygen

Fe in the Body (cont)

Heme iron animal sourcemeat fish and poultry not found in milk or dairy productsNon-heme iron plant sourcesfound in plants, animal products iron supplements

Dietary Forms of Iron

Heme and Non-heme Iron in Foods

1. Heme and Nonheme Iron a. Heme iron meat, fish and poultry and is better absorbed (23%) (hemoglobin)b. Nonheme iron plant foods as well as animal foods and is absorbed poorly2. Absorbtion-enhancing factors* Ascorbic Acid (vit. C) increase nonheme iron, at same mealB. Iron Absorbtion and Metabolism

ExerciseLiving at altitudeStomach acidIron deficiencyPregnancyFactors that Increase Iron Absorbtion

3. Absorbtion inhibitorsa. phytates and fibersb. calcium and phosphorusc. EDTA in food additives d. tannic acid (tea)e. polyphenols (tea & coffee)Iron Absorbtion and Metabolism (cont)

Fase absorbsi besiFase luminal: diolah di lambung, diserap di duodenumFase mukosal: proses aktif di mukosa ususFase korporeal: Meliputi:proses transportasi besi dalam sirkulasiutilisasi besi oleh sel yang memerlukan, dan penyimpanan besi (storage) oleh tubuh.

IRON TRANSPORT PATHWAY

IRON ABSORBTION

Fe Absorbtion

Cycle of Transferin

*

Hb synthesis in erythrocyte development

Glycine+B6+Succinil-CoA-amino-Laevulinic acidHaem (4x)

porphobilinogenuroporphyrinogencoproporphyrinogenprotoporphyrinHaemoglobinferritin

Iron (Fe)

Amino acidsRibosom

& chain2 2 globinTransferin receptorDiferric transferinClathrin-coated pitEndosome pH < 55Release ironTransferin receptorapotransferin

Prevalensi ADBAnemia yang paling sering dijumpaiWanita hamil paling rentanDi Indonesia perkiraan laki-laki 16 50%25 84% pada perempuan tidak hamilPensiunan PNS di Bali anemia 36% dan 61% karena ADB

Iron Deficiency Anemia:Etiology:Inadequate absorbtionBlood loss GI and GU bleeding, parasitesPoor diet malnutrition (greens & meat)Increased need Pregnancy, children

Indication of Iron DeficiencyMild Iron Deficiency:Decreased or absent bone marrow ironDecreased plasma ferritin,

*storage iron depletionFunctional iron depletion (iron deficiency anemia)Transport iron depletionIron depletionStd.1/prelatentStd.2/latentStd.3/IDAIron storage compartmentIron transport compartmentFunctional Iron compartmentNormal iron statusLab.test valuesDevelopment of IDA

HbNNNSINNTIBCNNFeritinN

Conclusion - Pathogenesis:Decreased Iron storesDecreased Hb SynthesisDelayed maturation of erythroblasts (cytopl)Decreased cell size (microcytes)Decreased hb content (hypochromia)Decreased RBC numberAnemia.

DiagnosisClinical Signs and Symptoms:Vary according to time course: acute or chronicSeverity of anemia may alter presentation:Mild asymptomaticModerate fatigue, palpitationsSevere unable to tolerate mild exercise

Diagnosis

DiagnosisPhysical Exam Findings:PallorTachycardiaSystolic ejection murmurIncreased pulse rate

Gejala klinisKoilonychia: Kuku sendok (spoon nail), kuku menjadi rapuh, bergaris vertikal, cekung, mirip sendokAtrofi papil lidahStomatitis angularis (cheilosis): bercak pucat keputihan di sudut mulutDisfagia karena kerusakan epitel hipofaringAtrofi mukosa gaster Pica: keinginan untuk memakan bahan tak lazim seperti tanah liat, lem, dll.

Sindrom Plummer Vison/Sindrom Patterson KellyKumpulan gejala yang terdiri dari anemia hipokromik mikrositeratrofi papil lidahdisfagia.

*Laboratory Tests for IDAScreening for IDADiagnosis of Iron DeficiencySpecialized Tests

*1. Hematologic tests : RBC features : eg, Hgb, MCV readily available, less expensive 2. Biochemical tests : Iron metabolism : eg, [serum ferritin], serum iron able to detect iron deficiency before the onset of anemia Laboratory Parameters

Diagnosis

Diagnosis

Diagnosis

*Polychomasia, anysocytosis, poikilocytosis, target cell, pencil cell

*2. Diagnosis of Iron DeficiencyIron studies remain the backbone for dx of iron deficiency used collectively:Serum Iron (SI) : determine by releasing the iron from transferin using acid, and then forming measurable colored complex with ferrozineTIBC : is indirect measure of transferrin, a serum sample is saturated with iron to fill all transferrin binding site. The excess iron removed, and the iron is released from transferrin with acid and measure with ferrozineTransferrin saturation (%) = SI (mg/dL) x 100TIBC ((mg/dL) 4. Ferritin, provides an intracellular storage repository for metabolically active iron. Serum levels reflect the level of iron stored within cells. It measured with immunoassay

ADBACDACD + ADBIndeks eritrosit Sebanding dg berat anemiaN rendah atau sedikit SITIBCN/%satSFN atau atau Nhemosiderin

PenatalaksanaanTerapi kausatifPenyebab perdarahan: cacing tambang, hemoroid, menoragi.Preparat besiOralIntra vena

Recommendation of Fe TreatmentPriority is always to maximise dietary iron availabilityIncrease consumption of dietary iron sourcesEnhance absorption of these foodsWhy? Increased bioavailability, other nutrients also present in foodsExceptions:Vegetarian, and efforts made to improve dietary iron from non-meat sourcesPregnancy, and efforts made to improve dietary intakeProlonged mild iron deficiency, despite good efforts made to improved dietary intakeIron Deficiency Anaemia, often good to start immediately with supplements as well as improvements in dietary intake. Depends on the case.Note: Supplement regime not always adhered to. High risk of constipation. Consider timing and dose of supplement.

Ferrous SulfatPilihan pertamaEfektif, murah, amanFerrous sulfat 3x200 mg (66 mg besi elemental/200 mg)Absorbsi besi 50 mg/hariMeningkatkan eritropoesis 2 3 kali nilai normal

Preparat lainFerroud gluconateFerrous fumaratFerrous laktatFerrous succinate

Cara PemberianPaling baik saat lambung kosongPada intoleransi dapat diberikan saat atau setelah makanPenyerapan lebih baik bila bersama Vitamin C.

Besi per oralEfek samping: gangguan gastrointestinal (15 20% kasus), berupa mual, muntah, konstipasiDapat diatasi dengan pemberian saat makan atau dosis menjadi 3x100mgLama pemberian 3, 6, sampai 12 bulan.Bila Hb sudah baik, diberi dosis rumatan 100 200 mg/hari

Besi ParenteralEfektifRisiko besarMahal

Indikasi besi parenteralIntoleransi terhadap besi oralKepatuhan sangat rendahGangguan pencernaan seperti kolitis ulseratif yang dapat kambuh jika diberikan besiPenyerapan besi terganggu seperti pada gastrektomi

Indikasi besi parenteral 2Kehilangan darah sangat banyak sehingga tak cukup dikompensasi pemberian besi oralKebutuhan besi sangat besar seperti pada kehamilan trimester tiga atau sebelum operasiDefisiensi besi fungsional relatif akibat pemberian eritropoetin pada anemia gagal ginjal kronik atau anemia akibat penyakit kronik.

PreparatIron dextran complex (50 ml besi/ml)Iron sorbitol citric acid complexIron ferric gluconateIron sucrosa

Cara PemberianTujuan: Mengisi besi sebesar 500 1000 mg. Intra muscularNyeriWarna hitam pada kulitIntravenaFlebitis

RumusKebutuhan besi (mg) =(15 Hb sekarang) x BB x 2.4ditambah500 atau 1000

Efek samping:Anafilaksis (0.6%)Sakit kepalaFlushingMualMuntahNyeri perutSinkop

Pengobatan LainDietVitamin C 3x100 untuk meningkatkan absorbsi besiTransfusi darah PRC bisa tambah furosemid untuk menghindari overloadPenyakit jantung anemik dengan ancaman payah jantungSangat simtomatisButuh kenaikan Hb yang cepat

Respon TerapiRespon baik bila retikulosit naik minggu pertama, puncak hari ke-10, kemudian normal lagi setelah hari ke-14Diikuti kenaikan Hb 0.15 mg/hari atau 2 g/dL selama 3-4 minggu terapiHemoglobin normal setelah 4 minggu

Jika respon tidak baikPasien tak patuh?Dosis besi berkurang?Masih perdarahan?Penyakit lain?Salah diagnosis?

PencegahanPendidikan kesehatanPemberantasan cacing tambangSuplemen besi profilaksis untuk yang rentan (ibu hamil dan balita)Fortifikasi makanan dengan besi

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