ANEMIA DEFISIENSI BESI

Anemia

Klasifikasi
morfologi
Defek
fungsional

Destruksi

Hemolitik

Extrapusculer

Imun
HDN
Reaksi transfusi
AIHA
Drug induce
Infeksi virus

A. mikrositik hipokromik
A. normositik normokromik
A. Makrositik

Hipoproliferatif

Defek maturasi
Blood Loss:
a.Kronik
b.Akut

a.Inti : A. Megaloblastik
b.Sitoplasma :
-Fe : A..Def Besi
-Heme:A.Sideroblastik
-Globin: Thalassemia, Hb Pati

a.Peny. Ss tulang
-Intrinsik : aplastik
-Infiltasi: lekemia
b.Peny. Kronis
c.Peny. Endokrin
d.Peny. Ginjal

Intracorpusculer

Non Imun
H.mekanis: disfungsi
katub, MAHA
Bahan kimia, luka
bakar
Inf.parasit: malaria

Herediter

Didapat

1.Defek struktur globin:

Kuantitas: thalassemia
Kualitas: sickle cell, Hb-pati
2.Defek membran: sferositosis
hered, elliptositosis hered.
3.Defek enzim: def.G6PD, piruvat
kinase

Defek membran
erits: PNH

Definisi Anemia
Defisiensi Besi
Anemia 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)
I. Iron (Fe)

A. In the Body
1. 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

iron distribution in adult

Male(g)

Female(g) % total

Hemoglobin

2.4

1.7

65

Ferritin and
hemosiderin

1.0

0.3

30

Myoglobin

0.15

0.12

3.5

Haem enzymes
(cytokrom, katalase,
peroxidase,
flavoprotein)

0.02

0.015

0.5

0.004

0.003

0.1

Transferrin binding iron

Fe in the Body (cont)

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

Dietary Forms of Iron

Heme iron animal source
meat

fish and poultry

not found in milk or dairy products

Non-heme iron plant sources

found

in plants, animal products

iron supplements

Heme and Non-heme Iron in

Foods

B. Iron Absorbtion and

Metabolism
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 poorly

2. Absorbtion-enhancing factors
* Ascorbic Acid (vit. C) increase nonheme iron,
at same meal

Factors that Increase Iron

Absorbtion
Exercise
Living at altitude
Stomach acid
Iron deficiency
Pregnancy

Iron Absorbtion and

Metabolism (cont)
3. Absorbtion inhibitors
a.
b.
c.
d.
e.

phytates and fibers

calcium and phosphorus
EDTA in food additives
tannic acid (tea)
polyphenols (tea & coffee)

Fase absorbsi besi

Fase luminal: diolah di lambung, diserap di
duodenum
Fase mukosal: proses aktif di mukosa usus
Fase korporeal:
Meliputi:
proses

transportasi besi dalam sirkulasi

utilisasi besi oleh sel yang memerlukan, dan
penyimpanan besi (storage) oleh tubuh.

IRON TRANSPORT PATHWAY

IRON ABSORBTION

Fe Absorbtion

Cycle of Transferin

18

Hb synthesis in erythrocyte
development

apotransferin

Transferin receptor
Ribosom

Release iron

Amino acids

Endosome pH < 55
Iron (Fe)
& chain

Clathrin-coated pit
ferritin

Glycine+B6+

Haem (4x)

2 2 globin

Succinil-CoA

Diferric transferin

-aminoLaevulinic acid

Transferin receptor

porphobilinogen

Haemoglobin
protoporphyrin

coproporphyrinogen

uroporphyrinogen

Prevalensi ADB
Anemia yang paling sering dijumpai
Wanita hamil paling rentan
Di Indonesia perkiraan laki-laki 16 50%
25 84% pada perempuan tidak hamil
Pensiunan PNS di Bali anemia 36% dan
61% karena ADB

Iron Deficiency Anemia:

Etiology:
Inadequate

absorbtion
Blood loss GI and GU bleeding, parasites
Poor diet malnutrition (greens & meat)
Increased need Pregnancy, children

Indication of Iron
Deficiency
Mild Iron Deficiency:

Decreased or absent bone marrow iron

Decreased plasma ferritin, <12 g/L

Iron Deficiency Erythropoiesis

Diminished Iron available for RBC

Increased Total Iron Binding Capacity
Reduced serum Iron & % saturation (<16%)

Iron Deficiency Anaemia

Drop in haemoglobin concentrations

<120 g/L for females
<130 g/L for males
Bone marrow produces larger number of smaller (microcytic)
& paler (hypochromic) RBC.

Normal
iron status

Iron
depletion
Std.1/prelatent Std.2/latent
storage
iron
depletion

Transport
iron
depletion

Std.3/IDA
Functional iron depletion
(iron deficiency anemia)

Iron storage compartment

Iron transport compartment

Functional Iron compartment

Lab.test values

Hb

SI

TIBC

Feriti
n

Development of IDA

23

Conclusion - Pathogenesis:
Decreased Iron stores
Decreased Hb Synthesis
Delayed maturation of erythroblasts (cytopl)
Decreased cell size (microcytes)
Decreased hb content (hypochromia)
Decreased RBC number
Anemia.

Diagnosis
Clinical Signs and Symptoms:
Vary according to time course: acute or chronic
Severity of anemia may alter presentation:
Mild asymptomatic
Moderate fatigue, palpitations
Severe unable to tolerate mild exercise

Diagnosis

Diagnosis
Physical Exam Findings:
Pallor
Tachycardia
Systolic ejection murmur
Increased pulse rate

Gejala klinis
Koilonychia: Kuku sendok (spoon nail), kuku menjadi
rapuh, bergaris vertikal, cekung, mirip sendok
Atrofi papil lidah
Stomatitis angularis (cheilosis): bercak pucat
keputihan di sudut mulut
Disfagia karena kerusakan epitel hipofaring
Atrofi mukosa gaster
Pica: keinginan untuk memakan bahan tak lazim
seperti tanah liat, lem, dll.

Sindrom Plummer
Vison/Sindrom Patterson
Kelly
Kumpulan gejala yang terdiri dari
anemia

hipokromik mikrositer
atrofi papil lidah
disfagia.

Laboratory Tests for IDA

1. Screening for IDA
2. Diagnosis of Iron Deficiency
3. Specialized Tests

30

Laboratory Parameters
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
31

Diagnosis

Diagnosis

Diagnosis

Polychomasia, anysocytosis, poikilocytosis, target

cell, pencil cell
36

2. Diagnosis of Iron Deficiency

Iron studies remain the backbone for dx of iron deficiency used
collectively:
1. Serum Iron (SI) : determine by releasing the iron from transferin

using acid, and then forming measurable colored complex with

ferrozine

2. TIBC : 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 ferrozine

3. Transferrin saturation (%) = SI (g/dL) x 100

TIBC ((g/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
38

ADB

ACD

ACD +
ADB

Indeks
eritrosit

Sebanding
dg berat
anemia

N rendah atau
sedikit

SI

TIBC

N/

%sat

SF

N atau

atau N

hemosideri
n

Penatalaksanaan
Terapi kausatif
Penyebab

perdarahan: cacing tambang,

hemoroid, menoragi.

Preparat besi
Oral
Intra

vena

Recommendation of Fe
Treatment
Priority is always to maximise dietary iron availability

Increase consumption of dietary iron sources

Enhance absorption of these foods
Why? Increased bioavailability, other nutrients also present in foods

Exceptions:

Vegetarian, and efforts made to improve dietary iron from non-meat

sources
Pregnancy, and efforts made to improve dietary intake
Prolonged mild iron deficiency, despite good efforts made to
improved dietary intake
Iron 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 Sulfat
Pilihan pertama
Efektif, murah, aman
Ferrous sulfat 3x200 mg (66 mg besi
elemental/200 mg)
Absorbsi besi 50 mg/hari
Meningkatkan eritropoesis 2 3 kali
nilai normal

Preparat lain
Ferroud gluconate
Ferrous fumarat
Ferrous laktat
Ferrous succinate

Cara Pemberian
Paling baik saat lambung kosong
Pada intoleransi dapat diberikan saat
atau setelah makan
Penyerapan lebih baik bila bersama
Vitamin C.

Besi per oral

Efek samping: gangguan gastrointestinal
(15 20% kasus), berupa mual, muntah,
konstipasi
Dapat diatasi dengan pemberian saat
makan atau dosis menjadi 3x100mg
Lama pemberian 3, 6, sampai 12 bulan.
Bila Hb sudah baik, diberi dosis rumatan
100 200 mg/hari

Besi Parenteral
Efektif
Risiko besar
Mahal

Indikasi besi parenteral

Intoleransi terhadap besi oral
Kepatuhan sangat rendah
Gangguan pencernaan seperti kolitis
ulseratif yang dapat kambuh jika
diberikan besi
Penyerapan besi terganggu seperti
pada gastrektomi

Indikasi besi parenteral 2

Kehilangan darah sangat banyak sehingga tak
cukup dikompensasi pemberian besi oral
Kebutuhan besi sangat besar seperti pada
kehamilan trimester tiga atau sebelum operasi
Defisiensi besi fungsional relatif akibat
pemberian eritropoetin pada anemia gagal
ginjal kronik atau anemia akibat penyakit kronik.

Preparat
Iron dextran complex (50 ml besi/ml)
Iron sorbitol citric acid complex
Iron ferric gluconate
Iron sucrosa

Cara Pemberian
Tujuan: Mengisi besi sebesar 500
1000 mg.
Intra muscular
Nyeri
Warna

hitam pada kulit

Intravena
Flebitis

Rumus
Kebutuhan besi (mg) =
(15 Hb sekarang) x BB x 2.4
ditambah
500 atau 1000

Efek samping:
Anafilaksis

(0.6%)
Sakit kepala
Flushing
Mual
Muntah
Nyeri perut
Sinkop

Pengobatan Lain
Diet
Vitamin C 3x100 untuk meningkatkan absorbsi
besi
Transfusi darah PRC bisa tambah
furosemid untuk menghindari overload
Penyakit

jantung anemik dengan ancaman payah

jantung
Sangat simtomatis
Butuh kenaikan Hb yang cepat

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

Jika respon tidak baik

Pasien tak patuh?
Dosis besi berkurang?
Masih perdarahan?
Penyakit lain?
Salah diagnosis?

Pencegahan
Pendidikan kesehatan
Pemberantasan cacing tambang
Suplemen besi profilaksis untuk yang
rentan (ibu hamil dan balita)
Fortifikasi makanan dengan besi

Selamat Belajar