AnemiaNYOTO WIDYO A

Subbagian Hematologi-Onkologi Medik,Bagian Ilmu Penyakit Dalam,RSPAD GATOT SOEBROTO, Jakarta

HematopoiesisT Lymphoblast BMegakaryoblastPluripotent stem cellsCFU GMBFU ECFC ECFC BasCFC EosCFC GMCFU MegMyeloblastProerythroblastNormoblast : Basophylic PolychromatophylicReticulocyteErythrocyteT ImmunoblastB ImmunoblastB CentroblastCentrocytePlasma cellLymphoplasmacytoidT cell ThrombocyteMegakaryocytePromyelocyteMyelocyteMetamyelocyteErithroblastOrthochromatophylicSegmenBandProliferasi dan MaturasiMaturasiVisible HbB cellGM-CSFEPOGM-CSFMGDFCFU LCFC MixCFC TLCFC BLIL-11IL-12IL-1IL-2IL-3IL-6IL-4IL-6GM-CSFIL-6IL-2GM-CSFMGDF, TPOEPOPro MegacaryoblastPro BLAKNKIL-2IL-4IL-2IL-6IL-6IL-6IL-6IL-2IL-4IL-2IL-4IL-1INF

Erythropoiesis

Time to circulation of red blood cells from Stem cell in BM have app.120 days2.3 million red blood cells produced every second in human bone marrow138 million every minute18.4 billion between now and lunch-time!Main regulator is erythropoietin (EPO)

Erythropoiesis: Growth Factors___________SCF_______________________ IL-11_________________________ IL-3_________________________________G-CSF _____ _______ GM-CSF______________IL-6_______ _______IL-4_______ _________EPO_________ _______IL-9_______Gabrilove (2000)Quiescentstem cellActivatedstem cellBFU-ECFU-EErythrocyteSCF = stem cell factor; IL = interleukin; G-CSF = granulocyte colony-stimulating factor; GM = granulocyte - monocyte colony-stimulating factor; EPO = erythropoietin;BFU-E = blast-forming units-erythroid; CFU-E = colony-forming units-erythroid

Mechanism of action of EPOIncrease in total RNA synthesisIncrease Transferrin receptors expression Increase iron uptakeIncrease Heme synthesisIncrease rate of transcription of a and b-globin geneIncrease Hemoglobin synthesis

In absence of EPODecrease synthesis of cytochromes, catalase, peroxidaseRapid DNA cleavage apoptosis

IRON ABSORPTION

FerrokinetikFe+3Fe+2DCyt-bDMT1FerritinFerroportinHepaestinFe-transferinApoferritinApotransferinHemosiderinTFRSIcytochrome

HemoglobinNormal:Foetal:Hb F mengandung 2 pasang rantai a dan g (N > 95%), danHb A2 mengandung 2 pasang rantai a dan d (N < 5%)Dewasa:Rantai g Hb F (ag ag) diganti b Hb A1(ab ab)Hb F mengandung 2 pasang rantai a dan g (N < 1 %) Hb A1 mengandung 2 pasang rantai a dan b (N > 95%)Hb A2 mengandung 2 pasang rantai a dan d (N < 3.5%)Intracellular site protein (globins) productB=babiesA=adultBAHbFHbA2HbA1

HemoglobinGenotype involvements normal globinHb F: ag agHb A2: ad adHb A1: ab abDNA inti mRNA Ribosome GlobinDNA Mitochondria mRNA Ribosome HemeCytosol Heme + Globin HemoglobinFungsi globin dalam hemoglobin:Mengikat oksigenHbFHbA2HbA1

Definisi anemiaKeadaan dimana kadar hemoglobin lebih dari 10% dibawah rerata nilai normalWHO:Pria < 13 gr%,Wanita < 12 gr%, danKehamilan 10 gr%.

Grading anemiaDigunakan dalam diagnostik laboratorium sebagai research cutoffTidak dapat digunakan untuk batasan diagnostik klinis

Gejala umum dan khusus anemia

Klasifikasi dan terminologi anemiaGangguan Produksi SDMProliferasi dan pematanganInti MakrositikSitoplasma Mikrositik hipokromDefisiensi eritropoietinDefisiensi ACTHDefisiensi proteinInfiltrasi sel non eritroid kedalam sumsum tulangAplastikPenghancuran SDMDefect corpuscular:Defisiensi enzim eritrosit:ThalasemiaHemoglobinopatiDefect extracorpuscularPerdarahan

Gangguan Produksi SDMGangguan Proliferasi dan pematanganInti (Makrositik):Normal megaloblastik:Defisiensi: B12, Asam folat, Vit.A, Vit.C, CuprumAbnormal megaloblastik:Sindroma mielodisplasia (MDS)Eritrolekemia (AML-M6)Sitoplasma (Mikrositik hipokrom):Defisiensi Fe, Transferin (Protein transport)Gangguan utilisasi Fe (MDS)Gangguan re-utilisasi Fe (ACD, Thalasemia mayor)Defisiensi eritropoietinRenal diseaseDefisiensi ACTHDefisiensi protein

Gangguan Produksi SDM(lanjutan)Infiltrasi sel non eritroid kedalam sumsum tulangfibrosis, kanker, dllAplastikPure red cell aplasia (PRCA, e.g. thymoma)Antibody erythropoietinAntibody erythropoietin receptorsHypoplastik marrow (Anemia aplastik)

Penghancuran SDMDefect corpuscular:Defect membraneCongenitalErythropoietic Porphyria CongenitalElliptocytosis herediterSpherocytosis herediter (congenital hemolytic jaundice)DidapatStomacytosisHypophosphatemiaDefisiensi enzim eritrosit congenitalPyruvate kinase deficient (< 13 mg/gHb)Autosom recessiveDefisiensi G6PD (< 5 mg/gHb)X linkedDefect synthesis GlobinThalasemiaHemoglobinopati

Penghancuran SDM(lanjutan)Defect extracorpuscularHypersplenismImmune hemolysis (AIHA, SLE, APS, PCH)Complement sensitivated (PNH)Mekanik: Penurunan shear rateSistemik: CHFPartial luas: TTP, KID, Vasculitis, Hemangioma, dll.Toksin:Obat-obatan: Sulfonamida, dll.Metabolit: Uremia (HUS), Cyclosporin, dll.Zat kimia: Bahan pewarna (Anilin), dll.Infeksi:Parasit: Malaria, Toxoplasma, dll.Virus: CMV, Mycoplasma pnemoniae, Parvovirus, dll.

Penggolongan menurut Morfologi volumetrikMCV= (Ht/Eritosit)x10 fLMCH=(Hb/Eritrosit)x10 pgMCHC=(Hb/Ht)x100 g/dL

Anemia mikrositik hipokromDiagnostik:Rerata volume eritrosit (VER) < 80 fL danRerata konsentrasi hemoglobin eritrosit (KHER) < 30 g/dL atauRerata konsentrasi hemoglobin (HER) 27 pg/dL.Penyebab:Ineffective metabolisme besi.Hambatan pasokan, transport,defisiensi enzim, dsbPembentukan hemoglobin abnormal:hemoglobinopati,

RetikulositRasio retikulosit = Indeks/koreksi retikulosit (Normal: 5-15 .);Pria:Wanita: Rasio Retikulosit ()HtHb

FLOW CHART ANEMIA MIKROSITIK HIPOKROM Gangguan metabolisme Fe Mielodisplasia (MDS) Anemia of Chronic Diseases (ACD)BMPNormal/TinggiPasokan, Absorpsi ?Defisiensi FeSI/IBC, Transferin, FeritinIndeks retikulosit 15AnemiaMCV

Anemia Defisiensi BesiSerum feritin 400 ng/mL

Defisiensi BesiDefisiensi besi ringanSerum iron 50 mg/dLIndeks saturasi transferin (IST) 15%IBC within normal limit or transferin within normalSerum feritin < 20 ng/mL.Defisiensi besi beratSerum iron 15%IBC below normal limit or transferin below normal limitSerum feritin 20 ng/mL.Defisiensi transferin beratSerum iron < 50 mg/dLIndeks saturasi transferin (IST) >15%IBC below normal limit or transferin below normal limitSerum feritin 20 ng/mL.

Koreksi defisiensi besi serumUntuk menaikkan Hb sebesar 1 gr/dL dibutuhkan Fe endogen 2,5 mg/kgBBKebutuhan initial Fe:Fe = (D Kadar Fe serum x 0,2 x BB) mg, atauFe = (D Hb x 2,5 x BB) mgIron Dextran max. 1,5 mg/kgBB/dayJectofer 75 mg/2mL amp.Cara 75 mg/deep imIron SucroseVenofer 100 mg/ampCara infusi 100 mg in 100cc NS 1jam

Anemia tersering pada kehamilanMakrositer (Normal Megaloblastik) akibat defisiensi asam folat,Suplemen asam folat 0,4 mg/hari danSuplemen vitamin B12 50 mg/hari mulai sejak awal kehamilan. Mikrositik hipokrom akibat defisiensi Fe,Suplemen Fe 30-60 mg/hari mulai kehamilan 18-20 minggu.

Anemia makrositerDiagnostik: MCV > 100 fLPenyebab:Ineffective metabolisme vitamin B12 dan/atau asam folat.Hambatan:Pasokan vit.B12 dan/atau asam folat,Transport vit.B12 dan/atau asam folat, atauPengikatan vit.B12 dan/atau asam folat oleh reseptornya (Defisiensi enzim).

FLOW CHART ANEMIA MAKROSITERMalabsorpsiBaikInapropriate dietKurangAnalisis giziDefisiensi FolatDef. IntrinsikTerkoreksiMalabsorpsiTidak terkoreksiSchilling testDefisiensi B12 Kongenital/ObatMegaloblastikCincin sideroblastik Hipoplastik mieloptisisNon MegaloblastikBMPNormalKadar B12 & FolatIndeks retikulosit 15AnemiaMCV > 100 fl

FLOW CHART ANEMIA NORMOSITIK NORMOKROMNormalAnemia hemolitik/def.Fedalam terapi ?Periksa ACTH Infiltrasi Keganasan Hipoplasia SSTL Cincin sideroblastik ?Abnormal HambatanProduksi/PematanganBMPIndeks retikulosit 15AnemiaMCV 80-100 fL and MCHC 30 g/dL or MCH > 27 pg/dLNormal TinggiPerdarahan ?YaAnemia Hemolitik

Anemia normositik normokromDiagnostik:MCV 80-100 fL danMCH > 27 pg atau MCHC 30 g/dLPenyebab:Kegagalan distribusi.Hambatan produksi,Kehilangan/Destruksi berlebihan.

Anemia Hemolitik Auto ImmunPrimer: IdiopatikSekunder:Terjadi akibat adanya kelainan/ penyakit lain seperti:Induksi obat atau bahan kimiaKelainan limfoproliferatifKankerInfeksi (HIV, Mycoplasma pnemoniae, Parvovirus, dll)Penyakit Autoimmun lain (SLE, APS, dll)

Kriteria Diagnosis AHAIDirect Coombs test positif (C3b &/ anti IgG pada eritrosit).Perexclusionam menyingkirkan kemungkinan AHAI sekunder:Anamnesis obat-obatan, alkohol, bahan kimia (Occupational disease), adakah keganasan ?,Pemeriksaan serologi virus dan bakteria misalnya Dengue, CMF, EBV, HIV, Rubella,Pemeriksaan ACA untuk mengetahui adanya Sindroma Anti Fosfolipid (APS),Pemeriksaan Rematoserologi, C3 dan C4, ANA, Anti dsDNA (Penyakit Auto Immun),Pemeriksaan combs apakah ada IgG/IgM atau C3b pada eritrosit dan/atau antibody terhadap eritrosit, jenis reaktifitas cold type jika bereaksi pada suhu 20oCPemeriksaan sidikan hati, limpa, KGB mediastinum dan para aorta (Limfoma Non Hodgkins),Pemeriksaan Immunoelektroforesis protein (Penyakit proliferasi sel B limfosit atau plasma),BMP Aspirasi dan Biopsi untuk menilai adanya Penyakit limfoproliferasi non sekretorik.

Defect corpuscularDefisiensi enzim eritrosit (G6PD, dll)Pemeriksaan yang diperlukan:Pemeriksaan enzim G6PD or GSH eritrosit intrasel.HemoglobinopatiThalasemia, Sickel cels anemia, dllPemeriksaan yang diperlukan: Morfologi mikroskopik eritrosit,Pemeriksaan Sugar Water Test (SWT), danElektroforesis Hb.Herediter sferositosisPemeriksaan yang diperlukan:Morfologi mikroskopik eritrosit, danResistensi osmotik.

Defect corpuscularPNHPemeriksaan yang diperlukan:Pemeriksaan Hb urin pada urin pagi pertama danAcid test (HAM).PorfiriaPemeriksaan yang diperlukan:Pemeriksaan Porfirin,Pemeriksaa Fosfatidil-inositol.

Defect Extra corpuscularManifestasi dapat:Tanpa atau disertai AHAI.Tanpa atau disertai Defect Intracorpuscular.Penyebab:Mekanik:Penurunan shear rate sistemik (CHF) atauPenurunan shear rate partial luas (TTP, KID, vaskulitis, hemangioma, dll)Toksik:Obat-obatan: Sulfonamida, dll.Metabolit:Sindroma Hemolitik Uremik (Gagal ginjal),Siklosporin, dll.Zat kimia: Bahan pewarna (Anilin), dll.Infeksi mengenai eritrosit:Parasit: Malaria, Toxoplasma dll,Virus: CMV, Mycoplasma pnemoniae, Parvovirus dll.

ThalasemiaThalasemia a : kegagalan produksi globin rantai aThalasemia a: Present Hb H or BartsSingle geneDouble geneTriple geneThalasemia b: kegagalan produksi globin rantai bHeterozygot: defect gene b(allele) single haploidHomozygotes: defect gene b(allele) diploidThalasemia bd: defect gene b dan dHeterozygot: defect gene b and d (allele) single haploidHomozygotes: defect gene b and d (allele) diploidGenotype Hb Barts: gg ggGenotype Hb H: bb bb

Genotype globinsb Heterozygoteb Homozygotebd Heterozygotebd HomozygoteaaaSingle gene deletionDouble gene deletionTriple gene deletionHb F : ag agHb A2 : ad adHb A1 : ab abIntracellular site protein (globins) productB=babiesA=adultBAaaaabbddggaaaddbggddggdbggggq 11q 16

Globin abnormalAbnormal hemoglobin:ThalasemiaInsufficient of normal globinHb Barts (dddd)Hb H (bbbb).

HemoglobinopatiChanges amino acid in normal globinHb C,Hb D,Hb E,Hb G,Hb S, sickle cellHb variant

Thalasemia* Triple gene a deletion

Clinical formThalasemia Silent carrier (no hematologic or clinical symptom)TraitHbH diseaseUnusual formThalasemia MDSThalasemia and Mental retardation syndromesThalasemia Associated with Structural Variants

Clinical formThalasemia bMayor (Homo/Heterozygote) :Transfusion dependent anemiaIntermedia (Homo/Heterozygote) :Transfusion Independent anemiaMinor (Heterozygote) :AsymptomaticMinima (Heterozygote) :Silent carrier (no hematologic or clinical symptom)

Dampak thalasemia pada kehamilanFetal hanya membentuk:Hb F mengandung 2 pasang rantai dan (N > 95%),Hb A2 mengandung 2 pasang rantai dan Thalasemia ; ; ; ; Single genes +++ +++ + Double genes ++ ++ + ++ +Triple genes + + ++ ++ ++Homozygotes +++ +++ +++

Erythroblastosis foetalisHemolytic anemia of the foetusFrequently caused by transplacental transmission of maternal antibody

Immunogenisitas EritrositABO & Rhesus

Antibodi dan antigen eritrositAntibodyABA and BRho(C,D,E)NoneKell (K)Duffy (Fy)hr (c,e)IgG labeled erythrocyteC3b labeled erythrocyteAntigenBANoneNoneRho(C,D,E)NoneNoneNone ? ?Blood typeBAORh-Rh+K-Fy-hrc,e -

Incompatibilitas ABO & Rhesus (erythroblastosis foetalis)Transfusi darahIbu & JaninAntibodi: Ibu JaninAntibodi: Donor ResepienAntibodi: Janin IbuAntigen: Donor Resepien

ResepienDonorOABABO--/+-/+-/+A+-++B++-+AB+++-Rh+Rh-Rh+-+Rh--/+-

JaninIbuOABABO-+++A--++B-+-+AB----Rh+Rh-Rh+--/+Rh-+-

Program kelasi besiTarget feritin serum 300040 mg/kgBW

Potentiation chelatable DFOVitamin CRecommended only in patient with not affected by myocardiopathy50 mg/day for

Gene functionCells ProliferationCells DifferentiationInducersControl(Proto-oncogenes)(Suppressor genes)Protein/Amino acidProtein/Amino acidHyperplasia:Control proliferation Inducers proliferation Hypoplasia:Control proliferation Inducers proliferation

KankerSel kankerSel yang sifat pertumbuhannya berubah menjadi tak terkendaliOnkogenGen sel tumorMuasalProto-onkogen: gen yang akan mengalami penambahan atau relokasi material genetik (amplifikasi).Gen supresor tumor atau gen anti tumor: gen yang akan mengalami kehilangan material genetiknya (LOH).FungsiProduk proteinnya akan mengendalikan pertumbuhan (maturasi dan differensiasi) dan replikasi sel tumor

LeukemiaGeneralized neoplastic disorders of the blood forming tissues, primarily those of the leukocytic seriesMarked proliferationAcuteMinimal differentiation/maturationChronicNormal differentiation/maturation

Cyto-morphology diagnoses by Bone marrow aspirateBlast > 30%Blast 50% Blast > 50% ME ratio 1ME ratio > 1PASNegativePositiveM0M6/M7SBB/POXNegativePositiveBlast with blebs, megakaryocytic fragments are seen in peripheral bloodNSEPositiveALLNegativeM0/ALLAP-L+-B cellT cell

M1Blast > 90% (Blast + myeloid)>3%M2Blast < 90% (Blast + myeloid), and monocytoid < 20% myeloid30%M3Promyelosit > Blast100%M4monocytoid > 20% myeloid, andMonosit perifer > 5000/mm380%M5amonocytoid > 80% myeloid, andBlast > 80% monocytoid90%M5bmonocytoid > 80% myeloid, andBlast < 80% monocytoid90%

Subclassification of ALL

Hypothetical scheme of lymphocyte differentiation

Terima kasih

Immunophenotype

This figure depicts the hematopoietic growth factors that stimulate the proliferation and differentiation of quiescent stem cells to become mature erythrocytes.Some growth factors play a role early in the process when stem cells become committed to the erythroid lineage. Other growth factors, such as erythropoietin, play a role later in the process of erythrocyte development and act to stimulate committed erythroid precursor cells to become fully differentiated red blood cells. Erythropoietin acts to stimulate the expansion of colony-forming units-erythroid from blast-forming units-erythroid and to stimulate colony-forming units-erythroid to become mature erythrocytes.

Gabrilove J. Semin Hematol 2000; 37(4 suppl 6): 13.