nutritional anemia hematologi 060710 unismuh

Nurpudji A TaslimNutrition Department School of Medicine

Hasanuddin University@2010

Anemia giziAnemia yang disebabkan oleh

defisiensi nutrien yang merupakan faktor eritropoesis dalam pembentukan sel darah merah

Fe, vit.B.12, vit.B6, Vit.C, Cu dan Co, asam folat dan protein

Definisi AnemiaKeadaan dimana kadar hemoglobin darah

lebih rendah dari normal

Penyebab Asupan tidak adekuat ( Primer)Absorbsi tidak adekuat ( TGI disease )Utilisasi tidak adekuat (keganasan, infeksi)Kebutuhan yang meningkat (kehamilan)Eksresi yang meningkat ( peny.hati)

TIPE ANEMIA GIZIBERDASARKAN PEMERIKSAAN HEMATOLOGIK

Anemia mikrositik hipokromikdisebabkan oleh defisiensi zat

besi

Anemia makrositik hiperkromik atau megaloblastik anemia

disebabkan oleh defisiensi vitamin B.12 dan asam folat

NILAI HEMOGLOBIN DAN HEMATOCRIT/PCV DAN MCHC

KELOMPOK UMUR Hb

g/100ml

Ht atau PVC (%)

MCHC

Anak 6 bln -6 th 11 33 34

Anak 6 th – 14 12 36 34

Laki2 dewasa 13 39 34

Wanita dewasa 12 36 34

Bumil 11 33 34

GEJALA KLINIK ANEMIA GIZI

GEJALA KLINIK ANEMIA AKAN

MEMBERIKAN GAMBARAN SERUPA

APAPUN PENYEBABNYA

DEFISIENSI ZAT BESI PADA ANAKDITEMUKAN PADA NEGARA MAJU DAN BERKEMBANG

PADA ANAK

Cadangan besi yang terbatasPertumbuhan yang cepatVariasi makanan yang terbatasMakanan tambahan yang terlambatMetabolisme yang meningkatAbsorbsi yang berkurang

ETIOLOGIANEMIA PADA ANAKBayi < 6 bulan

Cadangan besi tidak adekuat Makanan tambahan terlambat

Umur 1 - 2 tahun Infeksi sal. cerna dan nafas Diet tidak adekuat

5 tahun Infeksi parasit ( ankylostomiasis, trichuris,

amubiasis )

ANEMIA PADA WANITA DEWASA

Keperluan yang meningkat pada masa

menstruasi

Kehamilan

Laktasi

Pada saat menstruasiRata-rata kehilangan darah 30 ml/hariDibutuhkan 0,1 mg FeAbsorbsi dalam makanan 20%, untuk itu

dibutuhkan asupan zat besi sebanyak 10 mg dalam makanan

Absorbsi makanan akan ditingkatkan oleh protein hewani

Akan dihambat oleh kandungan pytat dari tumbuh2an

KEHAMILAN DAN LAKTASIKehilangan besi pada kehamilan normal

Fe foetus 400 mg Persalinan 325 mg Laktasi 175 mg

Total 900 mg

Untuk perode selama 460 hari membutuhkan tambahan 2mg Fe/hari

Patogenesis terjadinya defisiensi zat besi pada wanitaPerubahan metabolisme zat besi selama

kehamilanFaktor lain

Perubahan komposisi darah Perubahan pada sumsum tulang Pertumbuhan dan perkembangan foetus Intake yang kurang Absorbsi meningkat 20-40% ( ibu anemi) Pool bumil yang rendah (jarak hamil dekat)

Total zat besi dalam tubuh4-5gr (dewasa) & 400mg (Bayi)

RBC yang beredar 60%

Ferritin & hemosiderin 30%

Myoglobin 5-10%

Enzym2 haem <1%

Fe plasma 0.1%

KEHILANGAN BESI DARI TUBUH

Bayi 0.3-0.4mg/hr

Anak umur 4 – 12 th 0.4-1.0/hr

Laki2 dewasa 1.0-1.5/hr

Wanita dewasa 1.0-2.5/hr

bumil 2.7mg/hr

IRONHuman body contains 3 to 5 g ironApproximately 2 g as Hemoglobin and 8 mg as

enzymesWell conserved by the body ; approximately

90% is recovered and reused extensively.Highly reactive element that can interact with

oxygen to form intermediates able to damage cell membrane or degrade DNA.

Iron must be tightly bound to proteins to prevent destructive effects.

IRON COMPOUND IN THE BODYMETABOLIC PROTEIN

Heme Proteins

Hemoglobin Oxygen transport from lungs to tissues Myoglobin Transport & store Oxygen in muscle

Enzymes - Heme

Cytochromes Electron transport Cytochrom P-450 Oxidative degradation of drugs Catalase Convert hydrogen peroxide to oxygen and

water

Enzymes-Nonheme

Iron sulfur & metalloproteins Oxidative metabolism

Enzymes-iron dependent Tryptophan pirrolase Oxidation of tryptophan

IRON COMPOUND IN THE BODY, cont…..

TRANSPORT AND STORAGE PROTEINS Transferrin transport of iron and other minerals Ferritin Storage HemosiderinStorage

Two Types IRON in Food:

Heme-Iron: In animals product (hemoglobin &

myoglobin)Well absorbed About 90% of iron consumed

Nonheme-iron : Mainly in plants

Main source of iron in the diet (~10%)Absorption variable affected by other

factors

Iron cont………95% is associated with proteins e.g hemoglobin &

myoglobin

Functions: Respiratory transport of O2 & CO2 (Oxygen binding component of hemoglobin and myoglobin) Co-factor for enzymesInvolved in the immune function and cognitive

performance

Absorption : Well regulatedTransported : TransferrinSources : Meat, seafood, some vegetables

Iron AbsorptionHealthy Individuals: 5-10% absorbedIron deficiency : Up to 40% absorbedFactors that affect absorption:

enhancing factors:acid in the stomachheme ironhigh body demand low body storesmeat protein factorvitamin C

Iron Absorption, cont….

Inhibiting factorsdietary fiber (phytate)tannin in tea

Calcium helps to remove phosphate, oxalate and phytate that would combine with iron and inhibit its absorption

Iron routes in bodyMost iron is recycled.

Some lost with body tissues and must be replaced by eating iron-containing food

Intestinal cells: store excess in ferritin; if body no need iron-----some losses in shed intestinal cells; package iron in transferrin (transport protein)

Blood: transferrin carries Fe in blood; some losses via urine, sweat, skin; some Fe delivered to myoglobin of muscle cells; bone marrow puts Fe into haemoglobin of red blood cells; stores excess in ferritin and haemosiderin

Liver/lien; Dismantle red blood cells and package Fe into transferrin, stores excess as ferritin / haemosiderin

Iron Deficiency and ToxicityDeficiency:

decreased blood hemoglobin (anemia) Low plasma iron increased transferrin and reduction in tissue

iron lethargy

Toxicity Not common, usually due to a genetic disorder

Source of IronAdequate diet contains no more than

6mg/1000kcal of ironRDA 12mg/dayDried beans and vegetables are the best plant

sourcesBest sources dietary iron

Liver, heart, kidney, lean meat oysters, shellfish FishPoultry

COPPERCOMPONENT OF MANY ENZYMES

OXIDIZING IRON BEFORE IT IS TRANSPORTED ( ceruloplasmin, copper containing protein, required for normal mobilization of iron from its storage site to the plasma)

PLAYS ROLE IN MITOCHONDRIAL ENERGY PRODUCTION, PROTECTION FROM OXIDANTS, AND SYNTHESIS PF MELANINE AND CATHECOLAMINE

Source of CopperMost diet provide 2mg/dayRDA 1.5 - 3mg/dayFood high in copper

Oysters, shellfishLiver, KidneysChocolateNutsDried legumes, Dried foodsCerealsPoultry

CobaltA component of vitamin B12 (cobalamin)This vitamin is essential for maturation of red

blood cells and normal functioning of all cellsRequirement expressed in terms of Vit B12 :

1.4-2 ug dailyToxicity : intake of 10 to 20 ug/kg Body weight

: high intake cobalt in animal diet produce polycytemia, bone marrow hyperplasia, reticulocytosis, and increased blood volume

Deficiency: related to Vit B12 deficiency --- macrocytic anemia

Source of CobaltRDA 1.4 - 2.0 ug/dayLiver, kidney,Oysters, clamsPoultryMilk

FOLIC ACIDRDA

Male 200ugFemale 180ug

FunctionsEssential for bio-synthesis of nucleic acids.Essential for normal maturation of RBCFunctions as co-enzyme: tetrahydro-folic acid

Source of Folic acidGreen leafy vegetable,Organ meats (liver), lean beef, Wheat, dry beans, lentils, cowpeasAsparagus, broccoli, collards, yeastSynthesized by intestinal tract

B12 VitaminInvolved in the metabolism of single carbon

fragmentEssential for biosynthesis of nucleic acid and

nucleoproteinsRole in metabolism of nervous tissueInvolved with folate metabolismRelated to growth

B12 Vitamin cont….RDA 2ugLiver, kidneyEggs, fishMilk and dairy productVegans require supplement

Vitamin CNormal kebutuhan 60mgHamil 90mgKeadaan luka atau infeksi kebutuhan

meningkatSumber dari buah2an Fungsi Membantu absorbsi zat besi

CLASSIFICATION OF SOME ANEMIAS

Test B12 Deficiency Folate Deficiency Iron Deficiency Anemia of Chronic Disease

RBC count D D D D

Hemoglobin D D D Slight D

Hematocrit D D D D

MCV I I D N

MCH I I D N

MCHC N N D N

Reticulocyte count N or D N or D N or D N or D

RDW N or I N or I I N

Serum ferritin I I D N or I

TIBC N N N or I N or D

Transferrin N N N or I N or D

Transferrin saturation (%)

N N D N or D

Serum iron N N D D

Serum folate N or I D N N

Red cell folate D D N N

Vitamin B12 D N N N

Red blood cells Normochromic, macrocytic

Normochromic, macrocytic

Hypochromic, microcytic

Hypochromic, microcytic (both mild)

Other Hypersegmented neutrophils, macro-ovalocytes

Hypersegmented neutrophils, macro-ovalocytes

Anisocytosis Poikilocytosis (slight), anisocytosis (moderate)

I = increased; N = normal; D = decreased; TIBC = total iron-binding capacity

Contoh soalSeorang wanita yg menderita anemia

dengan kadar Hb 9 gr%. Berapa kebutuhan Fe yang harus diberikan

untuk menaikkan Hb menjadi 12, jika setiap kenaikan 0.5 gr Hb/100 ml dibutuhkan 85 mg elemental diet?

Dari 9 gr jadi 12 = 6 x 85 mg elemental Fe, plus 50% untuk pool Fe

Total kebutuhan Fe= 510gr el. Fe + 205gr el.Fe

= 715 el.FeTerapi dilanjutkan selama 6 bulan