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NUTRITIONAL ANEMIA Dimyati Burhanuddin TERMS : Heme Hemoglobin : iron protoporphyrin in hb : a conjugated protein (globin)-to form heme group

(the oxgen-carrying of the erythrocytes) Chemochromatosis Hemolytic anemia Hypochromic Macrocytic Megaloblastic Intrinsic factor Microcytic Pernicious anemia : iron overload (genetically) : - shortened survival of mature rbc : hb deficiency in rbc : rbc larger than normal mcv, mch increases : abnormal product of RBC large, immature-(defic.vit B12 folic acid) : a glycoprotein secreted from gastric wall (absorption vit B12) : rbc, smaller, mcv, mch decreases (iron defic.) : -defic.vit B12 -macrocytic -megaloblastic
Morphological Classification of Anemia Clinical Syndromes Pernicious anemia, Nutritional megaloblastic,anemias, Sprue, and other malabsorption syndromes Orotic aciduria Chemotherapeutic agents, aticonvulsants, oral contraceptives

hepatic damage

Morphologic Type of Anemia Macrocytic (MCV > 94, MCHC > 31) Megaloblastic

Underlying Abnormality

Treatment Vitamin B12 folic acid According to nature of disorder Stop o offending drug and administer folic acid Treatment of underlying

Vitamin B12 deficiency Folic acid deficiency inherited disorders of DNA synthesis drug-induced disorders of DNA synthesis

Nonmegaloblastic disease

Accelerated erythropoiesis Hemolytic anemia Increased membrane surface area Obscure

Hypochromic-microcytic correction of

(MCV < 80, MCHC < 31) iron deficiency Disorders of globin synthesis Disorders of porphyn and heme synthesis Other disorders of iron metabolism

Chronic loss of blood, inadequate diet, impaired absorption, increase demands Thallasemia Pyridoxine-responsive anemia

Ferrous sulfate and underlying cause Nonspecific pyridoxine

Normochromic-normocytic (MCV 82-92,MCHC >30) Recent blood loss condition Overexpansion of plasma volume Hemolytic diseases disorder Hypoplastic bone marrow Infiltrated bone marrow Endocrine abnormality disease Chronic disorders disease Renal disease disease Liver disease disease

Various Pregnancy Overhydration Aplastic anemia Pure red blood cell aolasia Leukemia, multiple myeloma, myelofibrosis hypothyroidism, adrenal insufficiency

Transfusion, iron Correct underlying Restore homeostatis According to nature of Transfusions Androgens Chemotherapy Treatment of underlying Treatment of underlying

Renal disease Cirrhosis

Treatment of underlying Treatment of underlying


: -deficiency in size and number of rbc -deficiency in the amount of hemoglobin content

Nutritional anemia

: the deficiencies result from an adequate intake of nutrients (iron,protein,vit B12, folic acid, pyridoxim, ascorbic acid, copper)

IRON DEF.ANEMIA - Small erythrocytes (microcytic) - diminished level of circulating hb. Etilogy: - chronic blood loss peptic ulcer haemorrhoids parasites malignancy - poor iron intake - from diet (consumption) - from malabsorption

- increased iron requirement - infant - adolescence - pregnancy Stages of iron deficiency 1. Depletion of iron stores (ferritin and hemosiderin) depletion of iron in plasma protein vechicle (transferring), reflected In the measurement of tibc (total iron binding capacity) 2. Deficient erythropoesis (decrease of rbc production) 3. Anemia rbc - hypochromic - microcytic Clinical features malfunction of body systems - muscle function - neurologic involment decrease of work performance fatique

- growth abnormalities epithelial disorders (tougue, skin, nails) - respiratory and cardiovascular changes - cardiac failure Diagnosis : Plasma ferritin measure iron stores Transferritin saturation iron suplly to the tissues total iron binding capacity (tibc) erythopoesis ratio Zn PP / heme hb in hematocrit measurement

Treatment Medication : inorganic iron p.o. Fails due to : impleasant side effects continuated bleeding lack absorption in empty stomach g.i side effect

- need p.e administration Nutritional case - Absorbable iron in food (non heme iron) liver kidney beef egg yolk dried fruits dried peas and beans nuts green leavy vegetables cercals

- biovailability of iron iron intake absorption stores - heme iron ; meat, fish, poultry (MFP) - ascorbic acid administration
MFP-containing, high ascorbic acid Total Iron (mg) 2.7 0.4 0.1 0.1 0.2 heme factor 0.40 heme iron (mg) 1.1 non heme iron (mg) 1.6 0.4 0.1 0.1 0.2 ascorbic acid (mg) 0 13 1 2 26

Food Beef-vegetables stew Beef, lean, cooked, 3 oz (85 g) Potatoes, cup Carrots, 2 T Onions, 2 T Green pepper, raw, 2 slices

Breadstick, 2 medium Margarine 2 tsp Peaches, canned, cup Gingerbread Total Ascorbic acid (46 mg) Meat, fish, poultry cooked (85 g) enhancing factors =131

0.3 0 0.4 1.0 5.3 % absorbable iron absorbable iron (mg) total absorbable iron (mg) 1.1 23%0 0.25 0.58

0.3 0 0.4 1.0 4.1 8%0 0.33

trace 0 4 trace 46

Summary improve food choices to increase amount of total dietary iron food sources of vit.C food sources of MFP avoid large amount of tea or coffee (contain tannin) avoid EDTA (ethylendiamine tetra acetic acid) reduce non heme iron absorption

Megaloblastic anemia - disturbance syntesis of DNA - changes morphologic and functional of blood cells - caused by deficiency of vit. B12 and folic acid nucleoprotein - the depletion of folate stores (folate deficient diet)comes earlier ( 2 - 4 mths) than to vit B12 ( after several years) - clinical signs - anemia - laboratory findings - megaloblastic cells - macrocytic (pernicious anemia) the deficiency of vit B12 is commonly caused by a lack of intrinsic factors (IF) ; except diet strict in vegetarians essential to the synthesis of

Diagnosis : - Schilling test - radioactive vit B12 p.o. - urine B12 ? - I.F .p.o. ?

Nutritional care - i.m/s.c injection of vit B12 (50-100 mg/day) - high protein diet - green leavy vegetables liver meat egg yolk milk e.t.c Other anemia caused by copper deficiency copper protein ( ceruloplasmin) essential for the formation of haemoglobin (normalized the mobilization of iron, tissue--plasma) - protein deficiency in PEM essential for the proper production of hb and rbc