Life of a RBC. 1) Kidney detects O2 levels 2) Kidney secretes Erythropoietin 3) Erythropoietin à stem cells will begin to differentiate

Transcription

1

2 Life of a RBC 1) Kidney detects O2 levels 2) Kidney secretes Erythropoietin 3) Erythropoietin à stem cells will begin to differentiate 4) Cell collects Hgb, loses nucleus, becomes smaller 5) Cell becomes reticulocyte 6) Reticulocyte becomes RBC 7) RBC circulates in blood stream for ~120 day 8) RBC is destroyed

3 RBC Structure and Func3on

4 Terms to Know CBC Complete Blood Count measures RBC, Hgb, Hct, MCV, MCH, RDW, reticulocyte count, platelet count, MPV MCV Mean Corpuscular Volume measures the avg. size of RBCs Hgb Conjugated protein containing 4 heme groups and globin O2 carrying pigment of RBCs Hct Volume % of RBCs in the blood Serum Liquid portion of whole blood w/out coagulating factors Plasma Liquid portion of whole blood w/ coagulating factors

5 Morphologic Classifica3on of Anemia Macrocytic Microcytic Normocytic Hypochromic Normochromic CLASSIFICATION BY SIZE Mean corpuscular volume >94 (Large) MCV < 80 (Small) MCV (Normal) CLASSIFICATION BY HEMOGLOBIN CONTENT Deficient hemoglobin (Pale) Normal hemoglobin (Normal color) Krause s Food, Nutrition, & Diet Therapy. 12 th ed. Philadelphia: Elsevier; 2008:812

6 Iron Anemia Introduc3on Most prevalent of all nutritional anemias Microcytic anemia characterized by small erythrocytes and low amounts of circulating hemoglobin (3) 2 billion people in the world with anemia, half of which have IDA Most in pregnant woman and children ages 1-2 Increases risk of cognitive and physical development, and death. IDA creates a problem with oxygen carrying capacity because of decreased hemoglobin function.

7 E3ology of IDA IDA caused by: Inadequate dietary inadequate absorption resulting from GI distress inadequate utilization of iron increased iron requirement for growth of blood volume (pregnancy) increased excretion of iron with blood loss (menstruation) Defective release of iron from body stores because of chronic inflammation. Ongoing shortage of iron in the body causes a reduction in the production of red blood cells and hemoglobin Particularly problematic in periods of growth

8 Signs, Symptoms, and Diagnosis of IDA Biochemical most prevalent because easy, affordable, and accurate. Hemoglobin- not most effective Ferritin Iron Transferrin protein that transports iron after absorption, so with decreased iron, increased transferrin in blood S/S Fatigue Dizziness Headaches Depression Sensitivity to cold Shortness of breath Restless Leg Syndrome (RLS)

9 Stages of Nega3ve Iron Balance Four stages Stage one: iron stores depleted Stage two: Ferritin, the storage form of iron decreases, but no hemoglobin changes are evident Stage three: lack of iron for erythropoiesis, decreased Fe in Transferrin, increased free Transferrin receptors. Stage Four: continuation of the depleted body stores of iron and decreased levels of hemoglobin, and smaller erythrocytes present.

10 Sources and Absorp3on of Iron Most iron from food sources Absorption depends upon the content of iron in food, current body stores of iron, and the presence of enhancers and inhibitors in the diet. Heme- only animal tissues Non- heme- eggs, enriched bread products, legumes, veggies. Vitamin C will increase absorption of nonheme food sources. Absorption inhibitors Tannins and polyphenols (tea and coffee) Carbonates, oxalates, phosphates, and phytates found in whole grains, soybeans, and some nuts and seeds, because they bind iron.

11 Medical Treatment of IDA Iron supplementation Most prevalent treatment reduced ferrous form because easier on the gut more readily absorbed. Many supplements combined with an amino acid (chelated) to be less affected by iron absorption inhibitors. Patients encouraged to take supplemental iron on an empty stomach if tolerable mg/day for adults for ~3 months 6 mg/kg/day for children for ~3 months If mg iron absorbed per day, increased levels of reticulocytes (young red blood cells) within 2-3 days after onset of treatment.

12 MNT for IDA Focus of encouraging patient to eat readily absorbed sources of iron. Avoid substances that inhibit iron absorption

13 Folate Deficiency Roles Coenzyme needed for new cell synthesis - Helps synthesize DNA Definition Macrocytic and Megaloblastic *Folate levels depleted within 2-4 months Signs and symptoms Anemia glossitis(smooth red tongue) depression mental confusion weakness fatigue irritability headache increased risk of neural tube birth defects

14 E3ology Inadequate ingestion pg 734 Poor diet, Vitamin B12 or vitamin C deficiency, chronic alcoholism Inadequate absorption Celiac disease, tropical sprue, drug interactions, congenital defects Inadequate utilization Antagonists, anticonvulsants, enzyme deficiency, vitamin B12 and vitamin C deficiency, chronic alcoholism Increased requirement Extra tissue demand, infancy, increased hematopoiesis, increased metabolic activity, drugs Increased excretion Vitamin B12 deficiency, liver disease, kidney dialysis Increased destruction Dietary oxidants

15 Pathophysiology Stage 1 Characterized by early negative folate balance. Serum depletion < 3 ng/ml Stage 2 Characterized by negative folate balance with a decrease in erythrocyte folate levels < 160 ng/ml Stage 3 Characterized by damaged folate metabolism with folate- deficient erythropoiesis. Slowed DNA synthesis manifested by an abnormal diagnostic Du suppression test, granulocyte nuclear hypersegmentation and macrovalocytic red cells Stage 4 Characterized by clinical folate- deficiency anemia with elevated MCV and anemia

16 Medical Diagnosis Serum folate < 3 RBC folate- < 100 Diagnostic du Suppression - Abnormal Lobe Average - >3.5 Erythrocytes - macroovalocytic MCV (Mean Corpuscular Volume) - Elevated Hemoglobin - < 12

17 Medical Treatment Correctly identify the cause Folate can mask vitamin B12 deficiency allowing nerve damage to progress to the point of irreversibility Replacement therapy Oral dosage of 1 mg daily for 2-3 weeks to replenish folate stores mcg is required to maintain stores When complicated by alcoholism, increased requirements, or reduced absorption 500 to 600 mcg is required

18 Medical Nutri3onal Therapy Main goal is to increase folate through daily diet *Food sources include green leafy vegetables, liver, meat, legumes, and whole grains Eat at least one fresh, uncooked fruit or vegetable a day *folate is easily destroyed by heat Drink a glass of fruit juice instead *One cup orange juice contains 135 mcg of folic acid RDA for adults is 400 mcg RDA for pregnant women in first trimester is 600 mcg

19 Prognosis Anemia responds well to treatment. Symptoms shows signs of improvement after 24 to 48 hours. Returning hematological values to normal is a gradual process that takes about a month.

20 B12 Roles Coenzyme needed for new cell synthesis Helps maintain nerve cells Definition Macrocytic and Megaloblastic Signs and symptoms *Several years to deplete stores Pernicious anemia, anemia. Smooth tongue, tingling or numbness, fatigue, memory loss, disorientation, degeneration of nerves progressing to paralysis

21 E3ology Inadequate ingestion Poor diet, chronic alcoholism, poverty Inadequate absorption Gastric disorders, small intestine disorders, competition for absorption sires, pancreatic disease, HIV or AIDS Inadequate utilization Vitamin B12 antagonists, congenital or acquired enzyme deficiency, abnormal binding proteins Increased requirement Hyperthyroidism, increased hematopoiesis Increased excretion Inadequate vitamin B12 binding protein, liver disease, renal disease Increased destruction Pharmacologic doses of ascorbic acid by antioxidants

22 Pathophysiology

23 Stages Stage 1 Early negative vitamin B12 balance begins when intake or absorption is low depleting the primary delivery protein, TCII. < 40 pg/ml earliest sign. Stage 2 Vitamin B12 depletion shows a low B12 on TCII and a gradual lowering of B12 in haptocorrin. The storage protein Stage 3 Damaged metabolism and vitamin B12 deficient erythropoiesis Stage 4 Clinical damage occurs Vitamin B12 deficiency anemia

24 Diagnosis Hemoglobin and hematocrit Decreased MVC Increased Serum B12 Decreased Serum Folate levels Methylmalonic acid Increased Schilling test Anti- IF antibodies du Suppression

25 Medical Management Injections for pernicious anemia required due to lack of intrinsic factor Intramuscular or subcutaneous injection of 100 mcg or more of vitamin B12 once per week After an initial response is obtained, frequency is reduced until it can be maintained with just monthly injections of 100 mcg Large oral doses of 1000 mcg daily are effective even in the absence of IF because 1% will be absorbed through diffusion Response to treatment is evidenced by improved appetite, alertness, and cooperation, followed by improved hematologic results within hours of injections

26 MNT A high- protein diet is desirable for liver function and blood regeneration Increase amounts of green leafy vegetables because they contain iron and folic acid Meats (beef and pork), eggs, milk and milk products are rich in B12 If prescribed metformin, increase calcium intake

27 B6 Microcytic, Microchromic Anemia Very rare Plays role in metabolism of amino acids, neurotransmitters, and glycogen Vitamin B6 breaks down homocysteine, the lack of which can lead to: seizures, depression, and cerebrovascular disease peripheral nerve destruction sleeplessness cheilosis and glossitis

28 Vitamin B6 At high risk: anti- tubercular drugs- interference in metabolism of B6 Injections of B6 quickly resolves deficiency Cereals, poultry, beef, bananas, potatoes

29 Protein Normocytic, normochromic Lack of protein to make RBC s and Hemoglobin Aka Kwashiorkor- lack of protein intake Direct loss of oxygen for all cells Loss of lean muscle Confusion, Fatigue, weakness At risk: Elderly, those with little body mass

30 Protein Loss of lean muscle Decrease in muscle mass- overproduction of RBC s Usually includes deficiencies of iron, and folate. Direct loss of oxygen for all cells

31 MNT Turkey, beef, chicken, fish Milk, cheese, and milk products Eggs Peanut butter Dried beans and peas

32 Copper Contained in liver, brain, heart, kidney, and muscle Can be caused by Menkes disease, mal absorption caused by other ions. Excessive zinc can lead to Copper mal- absorption- competition for binding to metallothionein.

33 Copper MNT Cashews ¼ cup Baking chocolate 1 square Mushrooms, cooked, 1 cup Tropical trail mix, 1 cup.61 mg.92 mg.79 mg.74 mg Whole grains and legumes Fruits and vegetables not good sources

34 Stored in liver bound to metallothionein Secreted to blood stream as ceruloplasmin and absorbed in mucosa bound to albumin and other proteins Copper

35 Copper Symptoms come from enzyme failures: skeletal problems, demineralization, elastin, de- pigmented hair and skin Pre- mature infants at special risk, adults have large stores Supplement a.2 mg/kg bw/ day

36 Hemoly3c Anemia of Premature Babies Low vitamin E concentration(.2 mg/100 ml), small reserve in infants Vitamin E acts as anti- oxidant Occurrence of peroxidation in cell membrane Will show hematologic abnormalities Reticulocytosis, thrombocytosis, red cell fragmentation, low hemoglobin Treatment- 200mg- 1000mg vitamin E

37 Hemoly3c Anemia of Premature infants Diagnosis : <0.5 mg/dl vitamin E, > 30% hemolysis Treatment- 200mg- 1000mg vitamin E Rapid recovery (weeks) Formulas with less poly- unsaturated fatty- acids

38 Non- nutri3onal Anemias Sports Pregnancy Sickle Cell Aplastic Anemia of Chronic Disease Thalassemia

39 Sports Anemia Temporary condition caused by ñ plasma volume à ò serum ferritin and Hgb Does not affect athletic performance Low Hgb concentration à eat iron- rich foods Iron deficiency anemia à iron supplementation

40 Anemia of Pregnancy Etiology 20-30% rise in blood volume ñ iron needs Diagnosis S/S typical of all pregnant women CBC to assess Hgb and Hct Treatments Proper nutrition Prenatal supplements Iron supplements

41 Sickle Cell Anemia Genetic disease Most common in people of African, Indian, Hispanic, and Central and S. American descent RBCs contain abnormal Hgb à Rigid structure and C shape Complications: Stroke, organ damage, blindness, abdominal pain, impaired liver function, jaundice, gallstones, decreased renal function Tx: pain relief, transfusions

42 Sickle Cell Anemia MNT ñ caloric needs Intake may be low d/t abdominal pain Zinc à ñ oxygen affinity of RBCs and may prevent growth deficit Folateà ñ RBC production ñ Fluid and ò Sodium ñ protein Vegetable protein in cases of low absorbable protein Not to be confused with iron deficiency anemia Iron supplementation à iron overload in individuals with transfusions Assess for iron deficiency anemia

43 Aplas3c Anemia Bone marrow doesn t make enough new blood cells d/ t damaged stem cells Possible causes: exposure to toxic substances, radiation therapy, chemotherapy, infection, autoimmune disorders

44 Aplas3c Anemia S/S: fatigue, infections, abnormal bruising and bleeding Diagnosis: CBC will show ò RBC, ò WBC, ò platelets Treatment: blood transfusion, bone marrow stem cell transplant, medication

45 Anemia of Chronic Disease Mild, Normocytic Possible disordered iron metabolism à ò RBC production Not to be confused with Iron deficiency anemia à do not supplement with iron Treatment: recombinant erythropoietin therapy (chronic kidney disease), treatment of the disease will cure the anemia

46 Figure 1: In inflammatory diseases, cytokines released by activated leukocytes and other cells exert multiple effects that contribute to the reduction in hemoglobin levels: (A) Induction of hepcidin synthesis in the liver (especially by interleukin-6 [IL-6]... Zarychanski R, Houston D S CMAJ 2008;179: by Canadian Medical Association

47 Thalassemia Microcytic, Microchromic Genetically inherited disorder Caused by defective Hgb synthesisà ñ in plasma volume, splenomegaly, bone marrow expansion ñ iron absorptionà dysfunction of heart, liver and endocrine glands Treatment: transfusions, chelation therapy, bone marrow transplant, increased MNT: ñ calorie intake (corrects impaired growth in children)

48 Case Study Nutrition Assessment Nutrition Diagnosis (PES statement) Sample Diet Alternative Medicine

49 Nutri3on Assessment Take 5 minutes to create a nutrition assessment and then we ll go over it as a class.

50 Sample Diet 1- Day Sample Diet for Iron De3iciency Anemia Breakfast Mg Iron 1 serving citrus fruit 3/4 cup Total Raisin Bran Cereal 18 1 egg 1 slice whole wheat toast 1 1 tsp. buuer or peanut buuer 1 cup lowfat milk Lunch Mg Iron 3 oz. tuna fish 4 2 slices whole grain bread 2 1/2 c. carrots medium apple teaspoon mayonnaise 1 cup lowfat milk Dinner Mg Iron 4 oz. chicken baked potato with skin cups mixed salad tsp. olive oil and vinegar dressing 1/2 c. lowfat milk Snacks 1 cup nonfat yogurt 2 servings fruit TOTAL Mg IRON 31.1 mg TOTAL KCAL 1600

51 Alterna3ve Medicine Possible treatments Spatone natural mineral water Spirulina Alfalfa Dandelion Root Burdock and yellowdock fortify and cleanse the blood Gentian Increases absorption of iron and other nutrients