Dr.

Erwin Budi Cahyono, SpPD

 Gejala yg ditemukan saat pasien ke dokter

 Dicari latar belakang penyebabnya

 Pengobatan diberikan bila diagnosis sdh jelas

 Masalah klinik & Public Health

Penurunan Sel Darah Merah (SDM)
dan kadar Hemoglobin (Hb)
dibawah nilai normal
Menurut WHO 1972 :
 Ketinggian permukaan laut Hb lebih rendah
11 gr% anak umur 6 bln – 6 thn
12 gr% Usia 6 thn – 14 thn
13 gr% Pria dewasa
12 gr% Wanita dewasa tidak hamil
11 gr% Wanita dewasa hamil
 Pendekatan Penderita Anemia

 Riwayat penyakit sekarang :

(History of Present Illness)
 Status performance
 Obat-obatan
 Demam
 Penurunan BB
 Gejala umum anemia
 Gejala sisten tertentu sesuai penyakit dasar
 Riwayat Penyakit Keluarga

 Informasi penyakit darah yang diturunkan :

 Autosomal dominant
 Autosomal recessive
 Sex linked traits
 Kulit
 Mata
 Mulut
 Kelenjar limfe
 Tulang dada
 Organomegali
 Penyebab / Etiologi
 Morfologik (Berdasarkan indeks Eritrosit,
MCV, MCH, MCHC)
 Berdasarkan nilai hemoglobin
 INDEKS ERITROSIT

• MCV = Ht X 10% ( 80 -96 fl)

E

Hb X 10% ( 27,5 - 33,2 pg )

• MCH =
E

• MCHC = Hb X 100% ( 34,4 - 35,5 )

Ht
 Kehilangan darah (Hemorrhagik)
 Gangguan pembentukan
(Aplasia, Defisiensi, penyakit kronik)
  penghancuran (Hemolitik)
 Mikrositik hipokromik
 Normokromik mikrositik
 Makrositik
• Ringan (mild) : 8 – 10 gr%
• Sedang (moderate) : 5 – 8 gr%
• Berat (severe) : < 5 gr%

• Anemia gravis istilah utk Anemia Berat

• Anemia Refrakter adalah Anemia yg berulang-ulang
 Jarang
 Barat : 1,4 – 2,3 / 1 jt pddk / thn
 Asia timur & tenggara : 7 – 10/ 1 jt pddk/ thn
 50% unknowm

 Klorampenikol, Benzene, Radiasi, Virus

 Kongenital (Fancony Syndrome)

 Gangguan sel induk
 Kegagalan stroma mikroenvironment
 Defisiensi growth factor
 Supresi imun sumsum tulang
 Gejala Anemia
 Gejala Perdarahan
 Gejala Infeksi
 Gejala Anemia & Infeksi
 Organomegali ( - )
 Bila Organomegali (+) pikirkan pnykt lain
 Pansitopenia
 Retikulosit 
 Eritrosil mungkin makrositik
 Neutrofil absolut 
(ANC = Absolute Neutrophil Count)
 Immunosupresi
- Prednison 1 mg/ KgBB/ hari/ oral
- Anti Thymocyte globulin (ATG) 15 – 40 mg/ KgBB/ iv –
4 – 10 hari
- Cyclosporine (CSP) 3 – 7 mg/KgBB/hari/oral 4 – 6 bln
- Kombinasi ATG & CSP
 Terapi Androgen
 Hemopoetic Growth Factor
 Supportive (Transfusi, Antibiotika)
 Transplantasi sumsum tulang
(Bone Marrow Transplantation)
• Medium Survival 3 – 6 bulan
( Tanpa pengobatan )
• Meninggal krn Sepsis & Perdarahan
• Gangguan kronik yg sering dijumpai
• 1/3 s/d ½ wanita sehat di USA cadangan besi
nol
• 10% dari jml ini menderita Anemia defisiensi
Fe
 Tahapan Defisiensi Fe

• Iron depletion (cadangan besi / - )

• Iron deficiency (SI  saturasi transferrin
rendah)
• Iron deficiency Anemia
• Intake yg non adekwat
• Malabsorbsi
• Perdarahan kronik (Chronic Blood Loss)
• Hamil & menyusui
• Hemolisis intravaskular & Hemoglobinuria
• Kombinasi
•  Fe  sintesis Hb  eritropoesis 
•  aktifitas sitokrom
• Disfungsi neurologik
•  sekresi asam lambung
• Atrofi mukosa mulut & lambung
• Gejala umum Anemia
• Korelasi nilai Hb dgn gejala tidak jelas
• Irritabilitas, nyeri kepala
• Perlambatan respons neurologik
• Pucat, lidah licin & merah
• Stomatitis, cheilitis angularis
• Koilonychia
• Perdarahan retina
• Splenomegalia
 Laboratorium (1)
• Anisositosis, ovalositosis ringan, sel target
• Elongasi Elliptositosis Hipokromik (sel pensil)
• Hipokromia progresif (MCH rendah)
• Mikrositosis (MCV rendah)
• Retikulosit rendah / 
 Laboratorium (2)
• Jumlah E, Hb, Ht 
• Trombositosis (50-75% penderita)
• BMA : - Selularitas & ratio ME bervariasi
- Sideroblast  / nol
- Eritroblast kecil
• SI :  / normal
• TIBC : 
• Serum Ferritin : < 10 mg/L
 Laboratorium (1)
• Anamnesis & laboratorium
• Bila dijumpai Chronic Blood Loss diperlukan
pemeriksaan endoskopik saluran cerna

Cause of Hypochromic
SI TIBC %Sat BMSI
Anemia
Iron Deficiency * * * 
Thalassemias -N -N -N -N
Sideroblastic Anemias  -N  
Chronic disease    

SI = Serum Iron, TIBC = Total Iron binding Capacity, Sat = Saturation

BMSI = Bone Marrow Storage Iron
* SI and TIBC occasionally normal in iron deficiency
 Pengobatan
 Oral Iron Therapy
 Diet rendah tdk cukup
 Aman & murah
 Hindari hematinic ganda
 Jgn diberikan bersama makanan, antasida, H2
antagonis
 Diteruskan selama 12 bln sesudah Hb normal
 Dosis total 150-200 mg besi elemental (1 tablet
sulfas ferron (325 mg) mengandung 65 mg
besi elemental)
 Dosis 3 – 4 kali/hari 1 jam sebelum makan
 Efek samping : Intoleransi gastrointestinal
 Pengobatan

 Parenteral Iron Therapy

 Keadaan malabsorbsi
 tidak kooperatif
 Intoleransi thd preparat oral
 Iron Dextram : berisi 50 mg besi elemental im / iv
 Diteruskan selama 12 bln sesudah Hb normal
 Hati-hati reaksi Anaphylaxis
 CLASSIFICATION of MACROCYTIC ANEMIAS

RETICULOCYTE COUNT

Increased
Normal or Decreased

Hemolytic disorder
Hemorrhage
Treated B12/Folate Deficiency
Macrocytic anemia…...

NORMAL OR DECREASED RETICULOCYTE COUNT

Macrocytes round;
no hypersegmented PMNs
Macrocytes oval;
on smear
hypersegmented
PMNs on smear
Bone marrow
nonmegaloblastic
Serum B12 / folate,
Red cell folate ( suspect
treatable megaloblastic
Rule out refractory anemia
disorder
Sideroblastic anemia
Myelodysplasia
Drug/Toxin effect
Aplastic Anemia
Liver disease
 CLASSIFICATION PROTOCOL
FOR MICROCYTIC ANEMIAS

SMEAR REVIEW

NO CHANGES

SUGGESTIVE or DIAGNOSTIC
WHITE CELL/RED CELL CHANGES
 Microcytic Anemia...
NO CHANGES SMEAR REVIEW

RDW, Normal (<16) RDW, Normal (<16)

RDW >16
Red Cell > 5x1012/L red cell < 5x1012/L
Suspect Iron Deficiency Suspect ACD
Suspect Thalassemia
Abnormal Hgb No lab follow up automatic.
Investigate liver, renal, thyroid Order Ferritin
Hb A2 status.
If clinically indicated ( marrow
iron and ferritin useful in
> 4,0% N(<4.0%) differential of ACD

Diagnostic Nondiagnostic
 thal minor order Hb
electrophoresis Ferritin low Ferritin high Iron/IBC
Male : < 22 ng/mL
Female : < 10 ng/mL

Iron deficincy Examine bone marrow

Microcytic Anemia...

SUGGESTIVE OR DIAGNOSTIC
WHITE CELL/RED CELL CHANGES

Sikling,targeting  Hb SS, double heterozygote for S

Thalassemia Minor
Targeting, stipping  Complication of Thalassemia Minor
Marked targeting  HbE, HbC, Obstructive liver disease
Red cell fragments/
polychromatism  Unsuspected hemolysis
Rouleaux  Increase in globulins or decrease
albumin (benign/malignant)
Neutrophils  Hypersegmentation with or without
macrocytes