To Patient With ANEMIA

2011

Introduction
O2 - Hipoksia
- Anemia
Ginjal
Sel juxtaglomerulus

A. Hemolitik
Eritropoitin (EPO) Ss tlg (Bone Marrow) Eritropoisis (produksi)
Substrat utama: Fe B12 As folat
As amino terganggu

Ery Normal
terganggu

A. Defisiensi

 120 hr

Ery

breakdown

R E S

Limpa
Hati Bone S marrow

H E M O G L O B I N

Bilirubin Heme Fe Pool Fe

REUTILIZATION

Globin AA Pool prot

Maintenance

BM 1/120 sel (retikulosit) Ery pr < lk

Continue release

Retikulosit (sirkulasi) 0.5 1.5 %

Androgen < EPO < Menstrual blood loss

Hb & Hct : pr < lk

ETIOLOGI
Tiga Mekanisme Dasar Terjadinya Anemia Produksi
balance

Destruksi / Loss

Anemia - Hb
- Hct - Ery

Gg. produksi

Deficient erythropoiesis

Pe destruksi
Blood loss

hemolytic

Hemorrhagic

KLASIFIKASI ANEMIA

I. Kinetik
- Gangguan Produksi - Destruksi berlebihan - Perdarahan (blood loss)

II. Patofisiologi
- Gangguan Sumsum Tulang (SIH) - Gangguan proliferasi (DNA / Eritropoitin) - Gangguan maturasi (defisiensi) - Hemolisis - Perdarahan

III. Morfologi
Hapusan Darah Tepi (warna, ukuran, dan bentuk eritrosit) dan Indeks Eritrosit (MCV, MCH, MCHC) - Anemia Hipokrom-Mikrositik - Anemia Normokrom-Normositik - Anemia Makrositik

Contoh :

Anemia Hipokromik Anisositosis

8

Anemia Hipokrom Aniso-poikilositosis, target cell, tear drop , fragmentosit, burr cell
9

Normoblas
sferosit

Ovalosit

10

Classification of Anemia by Cause

1. Gg. Produksi (deficient erythropoiesis) sesuai index eritrosit

Mechanism
Microcytic

Examples
Iron deficiency Iron reutilization defect (chronic diseases) Thalassemias (also classified under excessive hemolysis due to intrinsic RBC defects) Aplastic anemia Hypoproliferation In kidney disease In endocrine failure (thyroid, pituitary) Myelodysplasia Myelophthisis Copper deficiency Folate deficiency Vitamin B12 deficiency Vitamin C deficiency

Normochromicnormocytic

Macrocytic

Classification of Anemia by Cause

2. Peningkatan destruksi (Hemolitik)

Mechanism
Intrinsic RBC defects Membrane alterations, acquired Membrane alterations, congenital

Examples
Hypophosphatemia Paroxysmal nocturnal hemoglobinuria Stomatocytosis Hereditary elliptocytosis Hereditary spherocytosis G6PD deficiency Piruvic acid deficiency

Metabolic disorders

(inherited enzyme deficiencies)

Extrinsic RBC defects Reticuloendothelial hyperactivity with splenomegaly Immunologic abnormalities

Hypersplenism
Autoimmune hemolysis Cold antibody hemolysis (paroxysmal cold hemoglobinuria) Warm antibody hemolysis Isoimmune (isoagglutinin) hemolysis

Classification of Anemia by Cause

Mechanism
Extrinsic RBC defects (cont.) Mechanical injury Infection Trauma
3. Blood Loss

Examples

Mechanism
Acute

Examples
GI bleeding Injuries/accident Childbirth Surgery Heavy menstrual bleeding Ulcers in the stomach or small intestine Hemorrhoid Bladder tumors Kidney tumors Cancer or polyps in GI tract

Chronic

DIAGNOSIS
Anemia bukan D/ tp. suatu sindrom klinik yg ditandai dengan penurunan Hb, Hct/PCV, dan ery (manifestasi dr peny yg mendasari) bl ringan asimptomatik

Dasar Diagnosis: 1. Riwayat/History 2. Pemeriksaan fisik 3. Pemeriksaan laboratorium

PENDEKATAN DIAGNOSIS ANEMIA

Bukti Anemia ? - Hb, PCV, Eritrosit menurun Jenis Anemia ? - HDT dan Indeks Eritrosit (MCV, MCH, MCHC)
tentukan

A. Hipokrom-mikrositik A. Normokrom-normositik A. Makrositik

Kausa Anemia ? - Anamnesis - Pemeriksaan Fisik - Pemeriksaan Penunjang

1. Riwayat/history
History risk factors (faktor resiko) u/ anemia tertentu tanda anemia gejala /manifestasi klinik anemia Faktor resiko: - vegetarian predisposisi def vit B12 - alkoholisme resiko def. asam folat - herediter talasemia, hemoglobinopati - drugs hemolisis - cancer, rheumatic, chronic inflam. supresi BM/splenomgali Tanda anemia tdk sensitif/spesifik: tdk bs membedakan antara tipe-2 anemia

Manifestasi klinik

refleksi respon kompensasi hipoksia jaringan ( biasanya Hb < 7 g/dL) letih, lemah, ber-kunang-2, mengantuk, pingsan, sesak , sakit kepala, dan lain-2

Gejala/tanda yg mendukung anemia: - Perdarahan : epitaksis, hematemesis, hematochezia, melena, menorrhagia - Hemolitik : jaundice/dark urine (tanpa liver dis) - Cancer : BB turun - Stocking-glove paesthesia : def folat / B12 Pendekatan etiologi: - pertama: pikirkan blood loss? akut / kronik; bila (-) - berikutnya: cari penyebab dr gg. produksi atau destruksi!

2. Pemeriks. fisik
Tanda anemia tdk spesifik hanya pucat (bl berat) Tanda dari penyakit yang mendasari lebih akurat Misalnya: GI bleeding, shock hemorrhagic, jaundice, splenomgl infection, cancer, paresthesia, ptechiae, murmur, etc.

3. Pemeriks. Laboratorium
* Darah lengkap htg leko & trombo * Indeks Eritrosit MCV, MCH, MCHC * Retikulosit kompensasi BM * Hapusan Darah Tepi (HDT) morfologi * BMA or BMP bl diperlukan * Pemeriks. khusus lainnya Coombs, OFT, dll