anemia defisiensi besi a
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IRON DEFICIENCY ANEMIADr. Diah Ari Safitri, SpPD
ANEMIA - DEFINITION
REDUCTION OF HEMOGLOBIN CONCENTRATION BELOW REFERENCE VALUE
BLOOD PARAMETERS
Hemoglobin concentration (Hb)○F: 7,2 –10; M: 7,8-11,3 mmol Fe/l (12-18 g/dl)
Erythrocytes count (RBC)○F: 4-5,5; M: 4,5-6 x1012/l (4-6 x106 /μl)
Hematocrit (Hct)○F: 37-47; M: 40-54; (37-54%)
Platelet count (Plt)○150 – 450 x 103/μl (150-450 x 109/l)
Leukocytes count (WBC)○4-10 x 109/l (4-10 x 103/ μl)
Erythrocytes parameters Mean corpuscular volume (MCV)
N: 80-100 fl RDW(Red cell Distribution Width) ○RDW = (Standard deviation ÷ mean cell volume) x 100 A
high RDW indicates that the red blood cells are more variable in volume than normal.
Mean corpuscular hemoglobin (MCH) N: 27-34 pg
Mean corpuscular hemoglobin concentration (MCHC) N: 310 – 370 g/lRBC (31-37 g/dl)
Reticulocytes
RET: 0,5-2% ARC (absolute reticulocyte count) : 25-75x 109/l CRC (corrected reticulocyte count) RPI (reticulocyte production index)
RETIC COUNT X (HB OBSERVED/HB NORMAL) X 0.5
Reticulocyte index (RI) RETIC INDEX= RETIC COUNT X HMT OBSERVED/HMT
NORMAL
RI 1.0% -2.0%○healthy individual.
RI < 1% with anemia ○indicates decreased production of reticulocytes
and therefore red blood cells. RI > 2% with anemia ○indicates loss of red blood cells (destruction,
bleeding, etc.) leading to increased compensatory production of reticulocytes to replace the lost red blood cells
DIETARY SOURCES OF IRONDIETARY SOURCES OF IRON
Inorganic Iron eg lentils Organic iron eg beef
DAILY IRON REQUIREMENT 10-15mg/day
(5-10% absorbed)
IRON DEFICIENCY ANEMIA
IRON METABOLISM ABSORPTION IN DUODENUM TRANSFERRIN TRANSPORTS IRON TO THE CELLS FERRITIN AND HEMOSYDERIN STORE IRON
10% of daily iron is absorbed
Most body iron is present in hemoglobin in circulating red cells
The macrophages of the reticuloendotelial system store iron released from hemoglobin as ferritin and hemosiderin
Small loss of iron each day in urine, faeces, skin and nails and in menstruating females as blood (1-2 mg daily)
BODY IRON CYCLING BODY IRON CYCLING
IRON METABOLISM
Iron concentration (Fe)○N: 50-150 μg/dl
Total Iron Binding Capacity○N: 250-450 μg/dl
Transferrin saturation Transferrin receptor concentration Ferritin concentration
○N: 50-300 μg/l
IRON DEFICIENCY ANEMIA
ETIOLOGY:○CHRONIC BLEEDING
- MENORRHAGIA - PEPTIC ULCER- STOMACH CANCER- ULCERATIVE COLITIS- INTESTINAL CANCER- HAEMORRHOIDS
○DECREASED IRON INTAKE○INCREASED IRON REQUIRMENT (JUVENILE
AGE, PREGNANCY, LACTATION)
IRON DEFICENCY - STAGESPrelatent
reduction in iron stores without reduced serum iron levelsHb (N), MCV (N), iron absorption (↑), transferin saturation (N), serum ferritin (↓), marrow iron (↓)
Latentiron stores are exhausted, but the blood hemoglobin level remains normal
Hb (N), MCV (N), TIBC (↑), serum ferritin (↓), transferrin saturation (↓), marrow iron (absent)
Iron deficiency anemiablood hemoglobin concentration falls below the lower limit of normal
Hb (↓), MCV (↓), TIBC (↑), serum ferritin (↓), transferrin saturation (↓), marrow iron (absent)
BONE MARROW FILM STAINED FOR BONE MARROW FILM STAINED FOR HAEMOSIDERINHAEMOSIDERIN
DIFFERENTIAL DIAGNOSIS: IRON DEFICIENCY ANAEDIFFERENTIAL DIAGNOSIS: IRON DEFICIENCY ANAEMIA
IRON DEFICIENCY ANEMIA GENERAL ANEMIA’S SYMPTOMS:
FATIGABILITY DIZZENES HEADACHE SCOTOMAS IRRITABILITY ROARING PALPITATION CHD, CHF
CHARACTERISTICS SYMPTOMS
GLOSSITIS, STOMATITIS DYSPHAGIA ( Plummer-Vinson syndrome)
ATROPHIC GASTRITIS DRY, PALE SKIN SPOON SHAPED NAILS, KOILONYCHIA, BLUE SCLERAE HAIR LOSS PICA (APETITE FOR NON FOOD SUBSTANCES SUCH AS AN ICE, CLAY)
SPLENOMEGALY (10%) INCREASED PLATELET COUNT
Koilonychia
CHEILITIS
BLOOD AND BONE MARROW SMEAR
BLOOD:microcytosis, hipochromia, anulocytes, anisocytosis
poikilocytosis
BONE MARROWhigh cellularity mild to moderate erythroid hyperplasia (25-35%; N 16 –18%) polychromatic and pyknotic cytoplasm of erythroblasts is
vacuolated and irregular in outline (micronormoblastic erythropoiesis)
absence of stainable iron
Severe microcytic, hypochromic anemia
ManagementHistory and physical examination is sufficient to exclude serious disease (e.g pregnant or lactating women, adolescents)
- CURE ANEMIAHistory and/or physical examination is insufficient (e.g old men, postmenopausal women)
- FIND ETIOLOGY OF ANEMIA AND CURE (CAUSAL TREATMENT)
Benzidine test GastroscopyColonoscopyGynaecological examination
ORAL IRON ABSORPTION TEST
1. baseline serum iron level2. 200 - 400 mg of elemental iron orally3. serum iron level 2-4 hours after ingestion
IRON DEFICIENCY ANEMIA CURE
ORAL 200 mg of iron daily 1 hour before meal (e.g. 100
mg twice daily) How long?○14 days + (Hb required level – Hb current level) x 4
half of the dose - 6 – 9 months to restore iron reserve
Absorption ○is enhanced: vit C, meat, orange juice, fish○is inhibited: cereals, tea, milk
IRON DEFICIENCY ANEMIA CURE
PARENTERAL IRON SUBSTITUTION Bad oral iron tolerance (nausea, diarrhoea) Negative oral iron absorption test Necessity of quick management (CHD, CHF) 50 - 100 mg daily I.v only in hospital (risk of anaphilactic shock) I.m in outpatient department iron to be injected (mg) = (15 - Hb/g%/) x body weight
(kg) x 3
WHEN DOES IRON BECOME A WHEN DOES IRON BECOME A PROBLEM?PROBLEM?
Normally 2.5 – 3.5g of iron in the body.
Tissue damage when total body iron is 7 – 15 g
IRON OVERLOADIRON OVERLOAD
CHRONIC TRANSFUSION CHRONIC TRANSFUSION OVERWHELMS IRON BALANCEOVERWHELMS IRON BALANCE
PRBC is the red cells in a single donation or “unit” of blood
EFFECTS OF IRON OVERLOAD
Non-transferrin-bound iron (NTBI) circulates in the plasma
Excess iron promotes the generation of free hydroxyl radicals,
propagators of oxygen-related tissue damage
Liver cirrhosis/ fibrosis/cancer
Insoluble iron complexes are deposited in body tissues and end-organ
toxicity occurs
Diabetes mellitus
Growth failure
Capacity of serum transferrin to bind iron is exceeded
Iron overload
Cardiac failure
InfertilityHSC senescence
(Fenton Reaction)
O2- + H2O2 O2 + OH- + HO
Types of iron preparationsTypes of iron preparations
Oral iron preparations:Oral iron preparations: Why the oral iron is preferred to preferred to the parenteral?
1. Ferrous sulphate: tablets 300 mg/day (60 mg Elemental iron),20-20-32% iron, 32% iron, Most irritant& Highest bioavailability.
2. Ferrous sulphate syrup 12 mg/5 ml & ped. Drops 25 mg/ml
3. Ferrous fumarate: 200 mg t.d.s. (65 mg)-33% iron
4. Ferrous fumarate pediatric drops.• Ferrous succinate: 200 mg b.i.d. caps (70 mg) 35% iron• Ferrous gluconate: 600 mg/day b.i..d.. (70 mg) 12% iron• Iron choline citrate solution or tablets: Least irritant,suitable for
children.
1. Sustained-release iron preparations.
2. Formulations containing iron + folate
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Dosage, duration, goal, monitorDosage, duration, goal, monitor
Dose:
A.Treatment: 200 mg elemental /day
B. Prophylaxis: 30 mg elemental iron daily What are your goals?
1. Anemia 2. Stores 3. Cause Dose regimen:
Ferrous sulphate 300 mg increasing gradually to be t.d.s during or after meals for 2 months or till normal Hb level is reached and then for another period to fill the stores (3-6 months)
Duration of treatment is from 3-6 months. Why? How can you monitor your therapy?
RC (1w-3w), HB (1.5 gm/3w), Ferritin, transferrin saturation
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Causes of failure of oral iron
1. Incorrect diagnosis (Chronic disorder, thalassaemia)
2. Non-compliance to oral therapy. Solve?
3. Inadequate iron therapy (Slow-release) Solve?
4. Mal-absorption (What are the causes?)
5.5. DrugsDrugs like tetracyclines, methyldopa, thyroxine, Bisphosphonates, Antacids, H2 blockers.
6. Continuing excessive blood loss. Solve?
7. Concurrent deficiency of other hematinics
8. Superimposed infection or inflammation
9. Underlying uremia (CRF)
10.Malignancy
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Indications of iron therapyIndications of iron therapyMild to moderate anemiaMild to moderate anemia
1. Prophylactic: • Pregnancy, infancy, children, menstruating women, after partial
gastrectomy
2. Therapeutic: • Nutritional deficiency: ▼Intake or absorption• Anemia of infancy and pregnancy• Anemia due to acute or chronic blood loss (100 ml= 50 mg)
1. Megaloplastic anemia: Treated with Vit. B12 or Folic acid. Why?
2. Astringent: ferric chloride is used in throat paints
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Adverse effects of oral iron= GITAdverse effects of oral iron= GIT
1.1. GIT upsets (15-50%): GIT upsets (15-50%): • Nausea, vomiting, epigastric pain, colicky pain,
hyperacidity & constipation or diarrhea.
2.2. Black staining of teethBlack staining of teeth.
3.3. Black stoolsBlack stools.
4.4. FailureFailure of oral iron therapy
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Contraindications of iron therapy
1. Hemochromatosis and hemosiderosis.2. Anemia of chronic inflammatory disease, 3. Repeated blood transfusions. Hemolytic anemia 4. Active liver or renal disease5. GIT; enteritis, diverticulitis, colitis, ulcerative
colitis, peptic ulcer
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