HEMATOLOGY

Anemia
Dairion Gatot, Savita Handayani,Soegiarto Gani

Divisi Hematologi-Onkologi Medik
Departemen Ilmu Penyakit Dalam FK-USU/
RS H.Adam Malik, Medan 2012
Normal Blood Cells:
RBC disorders (Anemias) :
Anemia is decreased red
cell mass affecting tissue
oxygenation
Practical - Low Hb* or Low Hematocrit*
C.B.C
Haemoglobin
PCV Haematocrit, effective RBC volume - better
RBC count
MCHC Hb/PCV, Hb synthesis within RBC
MCH Average Hb in RBC
MCV PCV/RBC

Mikrositik
hipokrom
Normositik
normokrom
Makrositik
MCV < 80 fL 80 100 fL > 100 fL
MCH 27 pg > 27 pg > 27 pg
MCHC < 30 g/dL 30 g/dL 30 g/dL
Penggolongan menurut Morfologi
volumetrik
MCV= (Ht/Eritosit)x10 fL
MCH=(Hb/Eritrosit)x10 pg
MCHC=(Hb/Ht)x100 g/dL
Mechanism of Anemia :
Decreased Production:
Nutrient Deficiency.
Iron, B12/Folate

Hemopoietic cell damage:
Aplastic, Hypoplastic Neoplasms,
radiation, drugs
Iron Deficiency Anemia:
Most abundant metal but most common
deficiency..!
Common in developing world,
Parasitic Worm infestation + Malnutrition
Chronic blood loss only Iron Deficiency

Iron Metabolism
Limited absorption* and no proper excretory
mech*.
Recycling of iron dead cells to new cells
1mg/day 3-6G body 1mg/day
10% of the 10 to 20 mg of dietary iron.
Iron is absorbed in Jejunum.
Stored as Ferritin & Hemosiderin.

IDA - Etiology
Blood loss
Bleeding Parasites, Gynecologic, ulcers
Increased need
Pregnancy, children
Poor diet / poor absorption
Malnutrition (greens & meat),
malabsorption, intestinal surgery, gastric
atrophy.
IDA - Pathogenesis:
Decreased Iron stores
Decreased Hb Synthesis
Delayed maturation of erythroblasts
(cytoplasmic)
Decreased cytoplasm, more division
(microcytes)
Decreased hb content (hypochromia)
Anemia.
PATHOGENESIS
Lack of iron interferes with heme synthesis, which
leads to reduced hemoglobin synthesis and defective
erythropoiesis
There is decreased activity of iron-containing proteins
such as the cytochromes and succinic dehydrogenase
Neurologic dysfunction may occur, with impaired
intellectual performance, paresthesias
Gastric acid secretion is reduced, often irreversibly
Atrophy of oral and gastrointestinal mucosa may
occur
Clinical Features:
General features of Anemia
Pallor, Weakness, Lethargy,
Breathlessness on exertion
Palpitations heart failure pedal edema
Special features in IDA:
Angular cheilitis, atrophic glossitis,
Oesophageal atrophy/web dysphagia,
Koilonychia, brittle nails, gastric atrophy.
Angular cheilitis
Angular cheilitis & Glossitis
Koilonychia in Iron def.
Koilonychia in Iron def.
LABORATORY CHANGES
Red Blood Cells
- Earlist change is anisocytosis and increased red cell
distribution width (RDW)
- Mild ovalocytosis, target cells
- Elongated hypochromic ellptocytes
- Progressive hypochromia (low MCH),microcytosis
(low MCV), MCHC variable
- Reticulocytes normal or reduced
- The erythrocyte count, hemoglobin level and
hematocrit are all proportionately reduced
LABORATORY CHANGES
Leucocytes
Leukopenia (3000 to 4400/l)is found in a small
number of patients. Differential count is normal

Platelets
- Thrombocytopenia develops in 28 percent of
children and may occur in adult
- Thrombocytosis found in
- 35 % of children
- 50 to 70 % of adults-usually secondary to
chronic active blood loss

LABORATORY CHANGES
Marrow
- Marrow cellularity and M/E ratio variable
- Decreased to absent sideroblast
- Decreased to absent hemosiderin by Prussian blue
staining
- Erythroblasts may be small, with narrow rim of
ragged cytoplasm and poor hemoglobin formation
LABORATORY CHANGES
Serum Iron Concentration
- Usually low but may be normal
- May be reduced with concomitant acute or chronic
inflammation malignancy, acute myocardial
infarction in the absence or iron deficiency.
- May be elevated 3 to 7 days after chemotherapy
Total Iron Binding Capacity (TIBC)
- Usually increased in iron deficiency
- Saturation (Iron/TIBC) is often 15 % or less but this
is not specific for iron deficiency
LABORATORY CHANGES
Serum Ferritin
- Level of less than 10 g/liter
- Level 0f 10 to 20 g/liter are presumptive, but not
diagnostic
- May be elevated wit concomitant inflammatory disease

Free Erythrocyte Protoporphyrin (FEP)
- Concentration is usually increased
- Very sensitive for diagnosis of iron deficiency and
suitable for large scale screening of children, detecting
both iron deficincy and lead poisoning
Anemia Defisiensi Besi
Serum feritin <20 ng/mL, atau
Indeks saturasi transferin (IST)< 15%
(syarat: TIBC within normal limit)



Normal limit:
SI 50 -150 g/dL
TIBC 250-410 g/dL
Serum feritin 20-200 ng/mL,
excess >400 ng/mL
% 100 *
TIBC
SI
IST
DIAGNOSIS
Evaluation of clinical information from a
review of the history & physical
examination
Evaluation of the basic blood
examination & specialized laboratory
examination
Micrositer, Hipochrom
Decreased SI and Elevated TIBC
SI/TIBC <16%
Bone marrow Hemosiderin (-)
Ferritin <12 ug/l

Iron Deficiency Occurs in Stages
Iron depletion: storage iron decreased or absent
Iron deficiency: storage iron decreased or absent
with low serum iron concentration and
transferrin saturation
Iron deficiency: storage iron decreased or absent
with low serum iron concentration and transferrin
saturation and low hemoglobin level and reduced
hematocrit
Iron values in the development of iron deficiency anaemia
1316
13-16
13-16 12-14
C.B.C
Haemoglobin - 152.5, 14 2.5 - g/dl
PCV - 0.47 0.07, 0.42 0.05 - l/l (%)
Haematocrit, effective RBC volume - better
RBC count - 5.5 1, 4.8 1 x1012/l
MCHC - Hb/PCV - 30-36 - g/dl
Hb synthesis within RBC
MCH - Hb/RBC - 29.5 2.5 pg/l
Average Hb in RBC
MCV - PCV/RBC 85 8 - fl

Rasio retikulosit =
Indeks/koreksi retikulosit (Normal: 5-15 .);
Pria :
Wanita :
Retikulosit
Hitung Retikulosit
Hitung Eritrosit
x 1000
Rasio retikulosit x
42
Ht
Rasio Retikulosit ()
Ht Hb
Rasio retikulosit x
39
Ht
Pria Wanita
17 51 4.2 12.5 3.9 11.7
16 48 4.4 13.2 4.1 12.4
15 45 4.7 14.1 4.4 13.1
14 42 5.0 15.0 4.7 14.0
13 39 5.4 16.1 5.0 15.0
12 36 5.8 17.3 5.4 16.2
11 33 6.3 18.8 5.8 17.5
10 30 6.8 20.5 6.4 19.1
18 54 4.0 11.8 3.6 11.0
Microcytic Anemia (IDA)
TREATMENT
Therapeutic Trial
* Should be via oral route
* Expect
- peak reticulocytosis at 1 to 2 week
- significant increase in Hb concentration at 3-4 weeks
- one-half of Hb deficit corrected at 4-5 weeks
- Hb level normal at 2 to 4 months
* Unless there is continued bleeding, absence of these
changes indicates that iron deficiency is not cause of
anemia. Iron treatment should be stopped and
another mechanism sought
TREATMENT
Oral Iron Therapy
* Dietary sources may not be sufficient for treatment
* Safest, cheapest are oral ferrous salt
* Nonenteric coated forms are preferred
* Avoid multiple hematinics
* Do not give with meals or antacids or inhibitor acid
productions
* Continue for 12 months after Hb level is normal to
replenish iron stores
* Daily total 150-200 mg elemental iron in 3 to 4 doses,
each 1 h before meals

Koreksi defisiensi besi serum
Untuk menaikkan Hb sebesar 1 gr/dL dibutuhkan Fe endogen
2,5 mg/kgBB
Kebutuhan initial Fe:
Fe = (D Kadar Fe serum x 0,2 x BB) mg, atau
Fe = (D Hb x 2,5 x BB) mg
Iron Dextran max. 1,5 mg/kgBB/day
Jectofer 75 mg/2mL amp.
Cara 75 mg/deep im
Iron Sucrose
Venofer 100 mg/amp
Cara infusi 100 mg in 100cc NS 1jam
TREATMENT
Parental Iron Therapy
* Routine use rarely justifed
* Indications are:
- malabsorpsi
- intolerance to oral iron preparations (colitis, enteritis)
- needs in excess of amount that can be given orally
- patient uncooperative or unavailable for follow-up
* Iron dextran:
- only product available in United States
- 50 mg elemental iron/ml
- Approximately 70 % readily available for Hb synthesis
- May be given IM or IV
- Be aware of danger anaphylaxis or other systemic side
effects
TREATMENT
Parental Iron Therapy
* Continue therapy for 12 months after Hb level is
normal, in order to replenish iron stores.
* Therapy may be needed indefinitely if bleeding
continues
Failure to respond to therapy
* Wrong oral preparation
* Bleeding not controlled
* Therapy not long enough to show response
* Patient not taking medication
* Concomitant deficiencies (Vit. B12, folate, thyroid)
* Concomitant illness (infection, malignancy, hepatic
disease, renal disease, inflammation)
Differential diagnosis of
Anemia Microcytic
Hipochrome
LABORATORY TEST
INTERPRETATION
Hypochromic & microcytic
anaemia
Absent Increased
Ringed sideroblasts
Normal Abnormal Normal
Peripheral
smear
Iron
(Bone marrow)
Haemoglobin
electrophoresis
Diagnosis
Iron
deficiency
anaemia
Thalassaemia
haemoglobino
-pathies
DIAGNOSIS OF HYPOCHROMIC MICROCYTIC
ANAEMIA
Sideroblastic
anaemia
SI/TIBC, PERRITIN
The only person who
never makes a mistake
is the person who never does
anything!
- Theodore Roosevelt