K6 Klasifikasi Anemi(PK)
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Transcript of K6 Klasifikasi Anemi(PK)
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DASAR2 TERJADINYA
ANEMI .
Prof. Adi Koesoema Aman SpPK(KH).
Dr. Tapisari Tambunan SpPK(K)
Divisi Hematologi Departement PatologiKlinik FK USU / RSUP H.A.Malik , Medan
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www.drsarma.in
Definition of Anaemia
Decrease in the number of circulating red
blood cell mass and there by O2carrying
capacity
Most common hematological disorder by far
Almost always a secondary disorder
As such, critical for all practitioners to knowhow to evaluate / determine its cause / treat
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Central Nervous System
Fatigue
Headaches
Dizziness, vertigo
Depression
Retinal changes Impaired cognitive function
Immune System
Impaired T-cell and
macrophage function
Cardiorespiratory System
Exertional dyspnea
Tachycardia, palpitations
Cardiac enlargement, hypertrophy
Increased pulse pressure,
systolic ejection murmur
Risk of life-threatening cardiac
failure
Gastrointestinal System
Anorexia
Nausea
Genital Tract Menstrual problems
Loss of libido
Vascular and Renal Systems
Low skin temperature
Pallid skin, mucous
membranes, and conjunctivae
Edema, swollen legs
Adapted from Ludwig H, Fritz E. Semin Oncol.1998;25:2-6; Ludwig H, Strasser K. Semin Oncol.2001;28:7-14.
Signs and Symptoms of Anemia
TheMEDUWAYTo Care For Patients
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What is Anemia
Important to remember
Anemia is a clinical sign of disease
It is not a single disease by itself
Need to look for the underlying cause !
Will we ignore a fever with out investigation ?
Its diagnosis is not that simple!! Well make it
Its very common and imp. in our practice
Drug Rx. depends on the cause
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Causes of Anaemia
1. Decreased production of Red Cells
- Hypo proliferative, marrow failure
2.Increased destruction of Red Cells- Hemolysis (decreased survival of
RBC)
3. Loss of Red Cells due to bleeding
- Acute / chronic blood loss
(hemorrhagic) .
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ADA 3 PENYEBAB UTAMA ANEMI
1. KEHILANGAN DARAH YG BERLEBIHAN
2. GANGGUAN PEMBENTUKAN ERITROSIT
3. DESTRUKSI ERITROSIT MENINGKAT .
4. BERKURANGNYA FAKTOR YANG MEMBENTUK
ERITROSIT .
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Hypoproliferative Anaemias
Failure of cellmaturation
Nuclear
breakdown
Cytoplasmic
breakdown
Megaloblastic Anaemia
Defective DNA synthesis
Folate or B12deficiency Haem defect Globin defect
Thalassemia
Sickle cell AFe Phorph
IDA, SA
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BESI IRON)
HEME IRONHEMOGLOBINMYOGLOBIN
ENZIM : SITOKROM, KATALASE, PEROKSIDASE
NON HEME IRONFerritin
Hemosiderin
Transferrin
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ZAT BESI DALAM TUBUH
Hemoglobin
Myoglobin
Reaksi redox enzimatik
FerritinTansferin
Hemosiderin
Total Besi
dalam tubuh
4 5 gr
PERAN FISIOLOGIS
CADANGAN
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HEMOLYTIC ANEMIACauses
INTRACORPUSCULAR HEMOLYSIS
Membrane Abnormalities
Metabolic Abnormalities
Hemoglobinopathies
EXTRACORPUSCULAR HEMOLYSIS
Nonimmune
Immune
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HEMOLYTIC ANEMIAMembrane Defects
Microskeletal defects
Hereditary spherocytosis
Membrane permeability defects
Hereditary stomatocytosis
Increased sensitivity to complement
Paroxysmal nocturnal hemoglobinuria
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HEMOLYTIC ANEMIACauses
INTRACORPUSCULAR HEMOLYSIS
Membrane Abnormalities
Metabolic Abnormalities
Hemoglobinopathies
EXTRACORPUSCULAR HEMOLYSIS
Nonimmune
Immune
Mi i thi H l ti
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Microangiopathic Hemolytic
Anemia
Causes
Vascular abnormalities
Thrombotic thrombocytopenic purpura Renal lesionsMalignant hypertension
Glomerulonephritis
Preeclampsia
Transplant rejection
VasculitisPolyarteritis nodosa
Rocky mountain spotted fever
Wegeners granulomatosis
Microangiopathic Hemolytic
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Microangiopathic Hemolytic
Anemia
Causes - #2
Vascular abnormalities
AV FistulaCavernous hemangioma
Intravascular coagulation predominant
Abruptio placentae
Disseminated intravascular coagulation
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IMMUNE HEMOLYTIC ANEMIAGeneral Principles
All require antigen-antibody reactions
Types of reactions dependent on: Class of Antibody
Number & Spacing of antigenic sites on cell Availability of complement
Environmental Temperature
Functional status of reticuloendothelial system
Manifestations Intravascular hemolysis
Extravascular hemolysis
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Aplastic Anemia
Failure of the bone marrow percursors to produce maturecells. Characterized by hypocellular marrow and pancytopenia.
Etiology:
Acquired: More commonInherited: Fanconi anemia
Acquired:1. Drugs
- Cytotoxic drugs - Antibiotics- Chloramphenicol - Anti-inflammatory
- Anti-convulsant - Sulphonamides
- 2-3 months usually between exposure and the development of aplasticanemia.
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Aplastic Anemia: (Cont.)Acquired:
RadiationsChemicals e.g., Benzene and pesticides
Viruses: Hepatitis A, Non-A and Non-B
Herpes simplex
E-B virus
Parvovirus: Transient
Important clinically in patients with hemolytic anemias
5-10% of cases of AA in the West and 10-20% in the Far East.
2-3 months between exposure to the virus and the development
of AA.Immune: SLE, RA (rheumatoid arthritis)
Pregnancy
Idiopathic: 75%
PNH
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Pathogenesis
Potential mechanisms:
Absent or defective stem cells (stem cell failure). Abnormal marrow micro-environment. Inhibition by an abnormal clone of hemopoietic cells.
Abnormal regulatory cells or factors. Immune mediated suppression of hematopoiesis.
It is believed that genetic factors play a role. Thereis a higher incidence with HLA (11) histo comp.
Antigen. Immune mechanism is involved.
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Pathogenesis (Cont)The latest theory is: there is an intrinsic derangement
of hemopoietic proliferative capacity, which is consistentwith life. The immune mechanism attempt to destroythe abnormal cells (self cure) and the clinical course andcomplications depend on the balance. If the immunemechanism is strong, there will be severe pancytopenia.
If not, there will be myelodysplasia.
Forms of disease:Inevitable: dose related e.g. cytotoxic drugs, ionizing radiation.The timing, duration of aplasia and recovery depend on thedose. Recovery is usual except with whole body irradiation.
Idiosyncratic: unpredictable to drugs e.g., anti-inflammatoryantibiotics, anti-epileptic, these agents usually do not producemarrow failure in the majority of persons exposed to theseagents.
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Anemia in the Elderly
Anemia of Chronic Disease
Most common cause of anemia in hospitalized patients.
Anemia correlates with severity of underlying disease.
Serum erythropoietin levels may be inappropriately low.
Response to erythropoietin administration variable.
In selected diseases (e.g. Myeloma, RA, CRF) responses to
erythropoietin possible with serum levels < 200 U/L (N, 12 52).
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Anemia in the Elderly
Anemia of Chronic Disease
Pathogenesis
Impairment of iron utilization
Inhibition of erythropoeisis
Blunted response to erythropoietin
Reduced RBC survival
Possible functional adaptation of innate immune system
Iron sequestration as a microbicidal strategy
Altered macrophage responses
Cytokine mediated
Th1 - IFNg, TNFa, IL-1
Th2 IL-4, IL-10, IL-6
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Anemia in the Elderly
Special Considerations
Multifactorial often with multiple medical problems& polypharmacy.
Onset of symptoms is usually insidious & frequentlynonspecific.
Anemia in the elderly has increased consequences.
RBC indices often unreliable.
Myelosuppression more common & severe.
Quality of life issues may be more pronounced.
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Anemia in the Elderly
Time of Diagnosis
Annual medical examination 7%
Onset of acute medical problem 8%Follow up of a chronic medical problem 9%
Following admission to hospital 75%
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Anemia in the Elderly
Multiple diagnoses 53%No diagnosis 17%
Single diagnosis 30%
Anemia of chronicdisease
10%
Malnutrition 9%
Infection 4%Postoperative bleeding 3%
Alcohol 1%
Iron deficiency 1%Modif ied from Principles of Geri atri c Medicine and Gerontology 4thed. 1999
Anemia in the Elderly
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Anemia in the Elderly
Diseases Associated with Anemia of Chronic
DiseaseAcute infections Malignancy
Chronic infections Metastatic carcinoma
Tuberculosis Hematologic malignancies
Infective endocarditis Leukemia
Chronic urinary tract infection Lymphoma
Chronic fungal infection Myeloma
Chronic inflammatory disorders Chronic renal insufficiency
Rheumatoid disease HypothyroidismCollagen vascular disease Protein-energy malnutrition
Polymyalgia rheumatica
Acute and chronic hepatitis
Decubitus ulcer
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Anemia in the Elderly
Sensitivity & Specificity of Serum Ferritin in Iron DeficiencyAnemia
Serum ferritin
(ug per L) Sensitivity (%) Specificity (%)
Likelihood
ratio*
< 200 94 71 3.2
< 45 85 92 11.1
< 15 59 99 54.5
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Anemia in the Elderly
Iron Def. ACD
Serum iron Reduced Reduced
TIBC Increased Reduced
Transferrin saturation Reduced Normal
Serum ferritin Reduced Normal or
Increased
Plasma transferrinreceptor Increased Normal
Transferrin receptor /
ferritin index
High Low
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Thank You ALL