Anemia - Blok HIS-K9

7/29/2019 Anemia - Blok HIS-K9

1/34

NUTRITIONAL CARE IN

ANEMIA

Nutrition DepartementFaculty of MedicineUniversity of North Sumatera


2/34

Definition Deficit of circulating RBC associated with

diminished oxygen-carrying capacity of the

blood

Most common hematologic disorder by far

Hb < 12 g/dL Hb < 13 or 13.5 g/dL


3/34

Classification

Microcytic (small cell)

- Major nutritional cause is iron deficiency

- Minor pirydoxin & copper deficiency

Normocytic anemia

- PEM & various chronic disease

Macrocytic

- Vitamin B12 & folic acid deficiency


4/34

Iron-deficiency anemiaisthemostcommon nutritional anemiaand perhaps

the most common nutritional deficiencydisorder in the world


5/34

Characterized by the production of smallerythrocytes and diminished level of

circulating hemoglobin

Last stage of iron deficiency

Represent the end point of a long period of

iron deprivation


6/34

The greatest risk :

- Between 6 month 4 year

- Early adolescent- During the menstruating years

- During pregnancy


7/34

Causes of Iron Deficiency

Dietary inadequacy the most common cause- poor diet (vegetarian)

Inadequate absorption Diarrhea ; intestinal disease ; atrophic gastritis ; Achlorhydria ; partial or total gastrectomy ; drug interference

Increased Iron requirement Pregnancy Infancy Adolescence

lactation Increased excretion

- excessive menstrual blood- hemorrhage from injury- chronic blood loss


8/34

Dietary Iron

Heme Fe (meat, fish and poultry) best

absorbed

Non-heme Fe (cereal, vegetables) taken up lessavidly

Heme Fe 20% bioavailable, nonheme only 3%

Ionic Fe (Fe++) also well absorbed

>1/3 of Fe from fortification of flour

Tea inhibits Fe absorption


9/34

Iron Absorption

Proximal small bowel, esp duodenum

Enhanced by gastric acid (Fe+2 is valance

absorbed) Heme Fe > non-heme Fe

Reciprocal relationship to iron stores

Direct relationship to erythropoiesis; with

ineffective erythropoiesis Inhibited by inflammation, phytates


10/34

Plasma

Fe

16%

65%

4%

15%


11/34

IRONBody Compartments - 75 kg man

Stores1000 mg

Tissue500 mg

Red Cells2300 mg

30 mgAbsorption < 1 mg/day

Excretion < 1 mg/day


12/34

IRON STORESIron Deficiency Anemia

Stores0 mg

Tissue500 mg

Red Cells1500 mg

3 mg

Absorption 2-10 mg/day

Excretion Dependent on Cause


13/34

Mechanisms for maintaining iron balance :

- continuous reutilization of iron

- regulation of the absorption of iron

- access to specific storage protein (ferritin)


14/34

Typical diet : formerly ~10-15 mg/d,

now ~24 mg/d

10-15% comes from heme sources (meats &

seafood)

85-90% comes from non heme sources (dried

beans, peas, leafy green vegetable)

> 1/3 of Fe from fortification of flour.


15/34

Medical Management

Treatment should focus on the underlying

disease, although this is often difficult

Repletion of iron stores, not merely

alleviation of the anemia should be the

goal


16/34

Therapy

Oral ferrous form

- ferrous sulfate most widely used

- 50 - 200 mg elemental Fe/d (60 mg,

1-3 x / day)

- 6.0 mg elemental Fe/kg per day in children

- Duration- 6 months

Parenteral-Fe dextran 50 mg/ml, 100 mg/d im/iv

- more expensive & not as safe


17/34

IRON THERAPY

Response

Initial response takes 7-14 days

Modest reticulocytosis (7-10%)

Correction of anemia requires 2-3 months

6 months of therapy beyond correction of

anemia needed to replete stores, assuming nofurther loss of blood/iron

Parenteral iron possible, but problematic


18/34

If supplementation fails, maybe that :

1. The patients may not be taking themedication, most likely because ofunpleasant side effect

2. Bleeding may be continuing3. The supplemental iron is not being absorbed

Parenteral route


19/34

Medical Nutrition Therapy

In addition to supplementation, attention

should be given to the amount of absorbable

dietary iron

Liver, kidney, beef, egg yolk, dried fruit, dried

peas and beans, nuts, green leafy vegetables,

whole grain breads and cereals, and fortifiedfood.


20/34

Factorsaffecting absorption

Enhancing factors :

- Ascorbic acid

- MFP

Inhibiting factors :

- Carbonates

- Oxalates

- Phytates

- Tanin


21/34

Prevention

Iron supplementation, i.e. giving iron tablets

to certain target groups Iron fortification of certain foods

Education about food in order to improve the

absorption


22/34

Recommendations :

Improve food choices to increase amount of

total dietary iron

Include a source of vitamin C at every meal Include MFP at every meal if possible

Avoid drinking a large amounts of tea or

coffee with meals


23/34

MACROCYTIC ANEMIAS

Characterized by an MCV greater than 100 3

Also called megaloblastic anemias large,immature red cell precursors (megaloblasts)

accumulate in the bone marrow


24/34

Vitamin B12 Deficiency

Most often caused by impaired absorption

Strict vegetarian (vegans) who consumeno dairy products, eggs or meat

increased risk for deficiencies

The main cause of vitamin B12 deficiency

is PERNICIOUS ANEMIA


25/34

Vitamin B12 deficiency should be

considered when the plasma concentration

< 150 200 pg/ml

If there is a deficiency, the plasma folate

level may be elevated to 15 or 20 ng/ml ~

impaired tissue folate uptake and turnover

(methyl-folate trap)


26/34

The development of vitamin B12 deficiency

First stage, characterized by a negative vitamin B12 balance,

During which the plasma vitamin B12 level is marginal and onlyvitamin B carries in plasma (transcobalamins) may beabnormally low

Subsequently, the plasma vitamin B12 level fallsWhen the level reaches 100 150 pg/ml, neutrophils begins toappear hypersegmented

Finally, macroovalocytes appear, the MCV is elevated and the Hblevel drops

Anemia develops IN THE LATER STAGES of vitamin B12 deficiency like iron deficiency


27/34

Dietary Sources

Found ONLY in food of animal origin Most meat and dairy products contain B12

Beef liver : an especially rich sources

RDA

and 2 g / day

During pregnancy 2,2 g / dayDuring lactation 2,6 g / day


28/34

Remission of the sign & symptoms a singleintramuscular injection of 100 to 1000 g of

cyanocobalamins or hydroxocobalamins

Daily administration of 100 g for several days

For PA patients & other who need continued

parenteral therapy injections of 100 g everymonth


29/34

Folic Acid Deficiency

Large, immature red blood cells

DNA synthesis slows & cells lose their

ability to divide

The nucleus of the cells is not released as normally

immature blood cells are enlarged & oval shaped


30/34

Causes of Folic Acid Deficiency

Insufficient intake

RDA : 180 g / day

200 g / day

During pregnancy 400 g / day

During lactation 260 - 280 g / day

Suboptimal folate intake during early pregnancy (even withoutother manifestations of folate deficiency major risk factor forneural tube birth effects

Person who rarely consume green leafy vegetables or othersources of folate


31/34

Associated with a variety of intestinal disorderssuch as Crohns disease, celiac disease andtropical sprue

Alcoholics

Cigarette smokers

Drug-nutrient interactions (e.g. anticonvulsants,diuretics, antibiotics and antimalarials)


32/34

Dietary Sources

Widely distributed in : Yeast

Liver and other organ meat

Leafy vegetables

Fresh fruit

Enriched bread and cereal products

Oranges juice the highest contributor of folic acid to theAmerican diet

Between 50% and 90% of folate in the food destroyedby prolonged cooking and processing


33/34

Treatment

Plasma level should be usedto guide therapy

Readily resolved with a 1 mg daily oral supplement

In the patients with malabsorption,

Initial treatment parental folate

Maintenance oral therapy


34/34

Anemia - Blok HIS-K9

Documents

Transcript of Anemia - Blok HIS-K9