Sri Hastuti
ANEMIA
Definisi:
Penurunan konsentrasi hemoglobin di bawah nilai
normal sesuai jenis kelamin dan umur.
*Essential Haematology, Hoffbrand 6th ed
2. Etiologi (Penyebab)
Seri
Eritrosit
KLASIFIKASI ANEMIA BERDASARKAN MORFOLOGI:
1. Anemia Mikrositik Hipokrom
- MCV < 82 fl, MCH < 27 pg
3. Anemia Makrositik
- MCV > 92 fl
KLASIFIKASI ANEMIA BERDASARKAN ETIOLOGI:
1. Anamnesis:
- Kurang gizi, diet
- Riwayat kuning : anemia hemolitik, malaria
- Konsumsi obat, paparan bahan kimia
- Menderita sakit ginjal kronis
- Riwayat perdarahan (saluran cerna, ginekologis)
- Riwayat infeksi kronis
- Etnis, genetis thalassemia, Hb varian
2. Pemeriksaan fisik:
Pucat, lemah, lesu
Organomegali (hati, limpa, KGB)
Kuning/ikterus anemia hemolitik
Ulkus kaki pada anemia HbS
Koilonikia, angular cheilosis anemia deff besi
Kelainan neurologis anemia defisiensi vit B12
3. Pemeriksaan laboratorium:
a. Kadar Hb, Ht, retikulosit, SADT, MCV, MCH, MCHC
b. Pemeriksaan khusus: SI, TIBC, Feritin, G6PD tes, dll
c. Pemeriksaan sumsum tulang
Pemeriksaan laboratorium untuk mendeteksi anemia:
1. Hemoglobin (Hb)
Suatu protein terkonjugasi yang berfungsi dalam
transport oksigen dan karbondioksida.
Merupakan komponen utama eritrosit.
Setiap gram Hb dapat mengandung 1,34 ml O2
Kadar Hb tergantung umur, jenis kelamin,
geografi, faktor sosial-ekonomi, ras
2. Hematokrit (Ht)
Menggambarkan volume eritrosit per volume darah
Normal: 40 48%, 37 - 43%
5. Indeks eritrosit
Digunakan untuk mengetahui ukuran eritrosit dan
kandungan Hb dalam eritrosit
MCV (Mean Corpuscular Volume/Volume Eritrosit Rata-rata)
(Ht/ jumlah eritrosit) x 10 = .fl
MCH (Mean Corpuscular Haemoglobin/Hb Eritrosit Rata-rata)
(Hb/jumlah eritrosit) x 10 = .pg
MCHC (Mean Corpuscular Haemoglobin Concentration/Konsentrasi Hb
Eritrosit Rata-rata)
Hb/Ht x 100 = .%
ANEMIA MAKROSITIK
MCV / MCH
DIAGNOSIS
LABORATORIUM
ANEMIA MAKROSITIK Sediaan hapus darah tepi: makrositik
Retikulosit
Retikulosit Retikulosit N /
Morfologi ss tulang
Non-megaloblastik Megaloblastik
Perdarahan Anemia
akut hemolitik Th/ Folat & B12
Hipotiroid,
MDS Def. B12
Peny. Hati krn alkohol Def. Folat
Bates I. Approach to the diagnosis and classification of blood diseases. In: Lewis SM, Bain BJ, Bates I, editors. Dacie and Lewis
practical haematology. 9th ed. Philadelphia: Churcill livingstone elsevier; 2001. p. 582
ANEMIA MEGALOBLASTIK
DEFINISI
Megaloblas Ehrlich : istilah untuk prekursor eritrosit
abnormal pada penderita anemia pernisiosa.1
Anemia megaloblas terjadi defek sintesis DNA yg
menyebabkan gangguan pd pertumbuhan & pematangan sel.2
1. Glacer B. Anemia: General Considerations. In: Greer J, Foerster J, Lukens J, Rodgers G, Paraskevas F, Glader
B, editors. Wintrobe's Clinical Hematology. Philadelphia: Lippincott Williams & Wilkins; 2004. p. 955.
2. Rose MG, Berliner N. Red Blood Cell. In Schiffman FJ, editors. Hematologic Pathophysiology. Lippincott, 1998.
p.69
Etiologi :
defisiensi asam folat, B12,
obat yg menghambat sintesis DNA
Kelainan kongenital jarang
leukemia
Sintesis DNA terganggu kromatin inti terhambat
pematangannya sehingga inti tetap membesar Ukuran sel
besar
Sintesis RNA tdk terganggu komponen sitoplasma t.u. Hb
disintesis dalam jumlah normal.
Glacer B. Anemia: General Considerations. In: Greer J, Foerster J, Lukens J, Rodgers G, Paraskevas F, Glader
B, editors. Wintrobe's Clinical Hematology. Philadelphia: Lippincott Williams & Wilkins; 2004. p. 955.
1. Glacer B. Anemia: General Considerations. In: Greer J, Foerster J, Lukens J, Rodgers G, Paraskevas F, Glader
B, editors. Wintrobe's Clinical Hematology. Philadelphia: Lippincott Williams & Wilkins; 2004. p. 955.
2. http://etd.fcla.edu/UF/UFE0000335/Folic_Module.pdf
KLASIFIKASI
1. Defisiensi Vit B12 :
Defisiensi dari asupan (jarang)
Rendahnya faktor intrinsik (reseptor B12)
Anemia pernisiosa
Operasi gaster
Fungsi faktor intrinsik yg abnormal
Kompetisi Vit B12 (Biologis)
Pertumbuhan bakteri berlebihan di usus halus
Peny. Cacing pita
Malabsorbsi Vit B 12 selektif (familial)
Obat yg menginduksi malabsorbsi Vit B12
Peny. Pankreas kronik
Zollinger-Ellison syndrome
Penyakit di Ileum
Riwayat reseksi ileum
Enteritis regional
Glacer B. Anemia: General Considerations. In: Greer J, Foerster J, Lukens J, Rodgers G, Paraskevas F, Glader B,
editors. Wintrobe's Clinical Hematology. Philadelphia: Lippincott Williams & Wilkins; 2004. p. 955.
KLASIFIKASI
2. Defisiensi asam folat :
Asupan kurang
Kebutuhan yg meningkat
Kehamilan
bayi
Anemia hemolitik kronik
Alkoholisme
Malabsorbsi kongenital
Obat yg menginduksi defisiensi asam folat
Reseksi usus halus yg ekstensif, reseksi yeyunum
Glacer B. Anemia: General Considerations. In: Greer J, Foerster J, Lukens J, Rodgers G, Paraskevas F, Glader B,
editors. Wintrobe's Clinical Hematology. Philadelphia: Lippincott Williams & Wilkins; 2004. p. 955.
KLASIFIKASI
3. Defisiensi Vit B12 & asam folat :
Tropical sprue
Gluten-sensitiv enteropathy
4. Gangguan sintesis DNA yg diturunkan :
Orotic aciduria
Lesch-Nyhan syndrome
Anemia megaloblastik yg responsif thd tiamin
Methyl-tetrahydrofolate reductase
Formiminotransferase
Dihydrofolate reductase
Defisiensi Transcobalamin II
Homocystinuria & Methylmalonic aciduria
Glacer B. Anemia: General Considerations. In: Greer J, Foerster J, Lukens J, Rodgers G, Paraskevas F, Glader B,
editors. Wintrobe's Clinical Hematology. Philadelphia: Lippincott Williams & Wilkins; 2004. p. 955.
KLASIFIKASI
5. Obat & Toksin yg menginduksi gangguan
sintesis DNA :
Antagonis folat (methotrexate)
Antagonis purin ( 6-mercaptopurine)
antagonis pirimidin (cystosine arabinoside)
Alkylating agents (cyclophosphamide)
Zidovudine(AZT, cyclophosphamide)
Trimethoprim
Kontrasepsi oral
Nitrous oxide
Arsenic
Chlordane
Erythroleukemia
Glacer B. Anemia: General Considerations. In: Greer J, Foerster J, Lukens J, Rodgers G, Paraskevas F, Glader B,
editors. Wintrobe's Clinical Hematology. Philadelphia: Lippincott Williams & Wilkins; 2004. p. 955.
EPIDEMIOLOGI
Biesalski HK, Grimm P. The Nutrients. In: Pocket Atlas of Nutrition. New York: Thieme; 2005. p. 192-201
FUNGSI ASAM FOLAT DAN B12
1. Carmel, R. Anemia: General Considerations. In: Greer J, Foerster J, Lukens J, Rodgers G, Paraskevas F, Glader B, editors.
Wintrobe's Clinical Hematology. Philadelphia: Lippincott Williams & Wilkins; 2004. p. 1368.
2. Frias JL, Bailey LB. Folic acid guide for physicians. Cited July 25 th 2007. Available from
http://etd.fcla.edu/UF/UFE0000335/Folic_Module.pdf
Hoffbrand 2001
Absorbsi vitamin B 12 dan folat
Dasar biokimiawi anemia megaloblastik
Hoffbrand 2001
DIAGNOSIS ANEMIA
MEGALOBLASTIK
1. Anamnesis:
Konsumsi makanan
< konsumsi sayuran hijau & buah def. folat
< konsumsi produk hewani def. B12
Cara pengolahan makanan
Memasak dlm wkt lama def. folat
Riwayat penyakit pencernaan
Aklorhidria
Ileitis
Infestasi parasit D. latum def. B12
Riwayat gastrektomi / reseksi ileum
Riwayat penyakit keluarga anemia pernisiosa ?
2. Gejala klinis:
Pucat survival eritrosit hemolisis
Ikterus hemolisis ekstravaskuler
Glositis beefy red tongue, stomatitis aptosa, rasa nyeri (oral), def.
B12
Neuropati
Def Folat asimtomatik, pd kehamilan 18 hari defek neural tube.
Rose MG, Berliner N. Red Blood Cells. In: Schiffman FJ. Hematologic pathophysiology. Philadelphia: Lippincott-
Raven, 1998. p. 69 & 71
NEURAL TUBE DEFECT (NTD)
Frias JL, Bailey LB. Folic acid guide for physicians. Cited July 25th 2007. Available from :
http://etd.fcla.edu/UF/UFE0000335/Folic_Module.pdf
KLASIFIKASI NTD
Frias JL, Bailey LB. Folic acid guide for physicians. Cited July 25th 2007.
Available from : http://etd.fcla.edu/UF/UFE0000335/Folic_Module.pdf
3. Laboratorium:
a. Hematologi
Anemia makrositik : MCV (>97 fl) dgn retikulositopenia
Pansitopenia
Sediaan hapus darah tepi :
Eritrosit : makrositik, An berat poikilositosis, tear drop cell, eritrosit
berinti, Howell-Jolly Bodies, Cabot rings.
Leukosit : jumlah , hipersegmentasi neutrofil ( 6 lobus, 4-5 % neutrofil
5 lobus), sel batang raksasa ( Giant Band Cell),
Trombosit : jumlah , morfologi N
Hoffbrand AV. Megaloblastic anemias and other macrocytic anemias. In: Hoffbrand AV, Petit JE, Moss P. Essential
haematology. 4th ed. Oxford: Blackwell Science, 2001. p. 48-50
Sumsum tulang :
Hiperselularitas
Eritropoiesis hiperaktif banyak sel megaloblastik, dominasi
prorubrisit, dissosiasi inti-sitoplasmik
Kromatin inti seperti menghilang kondensasi terhambat
Kromosom abnormal centromere spreading
Carmel, R. Anemia: General Considerations. In: Greer J, Foerster J, Lukens J, Rodgers G, Paraskevas F, Glader
B, editors. Wintrobe's Clinical Hematology. Philadelphia: Lippincott Williams & Wilkins; 2004. p. 1373-4.
Granulopoiesis hiperaktif tampak kelainan
berupa Giant stab, giant metamielosit
Trombopoiesis hiperaktif bentuk kelainan inti
dismorfik, tdk ada pembentukan trombosit
b. Kimia Darah :
LDH
As. Urat Bila Hb< 10 g/dL
Bilirubin indirek
Def. B12 Serum B12 & serum THF N/
Def. folat B12 N & THF
Def. Folat & B12 B12 & THF
Serum Iron N/, Ferritin N/
Carmel, R. Anemia: General Considerations. In: Greer J, Foerster J, Lukens J, Rodgers G, Paraskevas F, Glader
B, editors. Wintrobe's Clinical Hematology. Philadelphia: Lippincott Williams & Wilkins; 2004. p. 1373-4
MAKROSITIK SELAIN
ANEMIA
MEGALOBLASTIK
1.Alkohol
2.Penyakit hati
3. Miksedemia
4.Sindroma mielodisplatik
5.Obat sititoksik
6.Anemia aplastik
7.Kehamilan
8.Merokok
9.Retikulositosis
10.Mieloma dan para proteinemia
11. Neonatus
MEKANISME
MAKROSITIK SELAIN
A. MEGALOBLASTIK
Tidak jelas
Peningkatan deposit lipid pada membran eritrosit
Perubahan waktu pematangan eritroblas dalam sumsum
tulang