NUTRITIONAL CARE IN ANEMIA

Transcription

1 االله الرحمن الرحيم بسم NUTRITIONAL CARE IN ANEMIA Nutrition Departement Faculty of Medicine University of North Sumatera

2 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 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 Iron-deficiency anemia is the most common nutritional anemia and perhaps p the most common nutritional deficiency disorder in the world

5 Characterized by the production of small erythrocytes and diminished level of circulating hemoglobin Last stage of iron deficiency Represent the end point of a long period of iron deprivation

6 The greatest risk : - Between 6 month 4 year - Early adolescent - During the menstruating years - During pregnancy

7 Causes of Iron Deficiency Dietary inadequacy the most common cause - poor diet (vegetarian) Inadequate absorption Diarrhea ; intestinal ti 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 Dietary Iron Heme Fe (meat, fish and poultry) best absorbed Non-heme Fe (cereal, vegetables) taken up less avidly 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 Iron Absorption Proximal small bowel, esp duodenum Enhanced by gastric acid (Fe +2 is valance absorbed) b Heme Fe > non-heme Fe Reciprocal relationship to iron stores Direct relationship to erythropoiesis; with ineffective erythropoiesis Inhibited by inflammation, phytates

10 Fe Plasma 4% 16% 15% 65%

11 IRON Body Compartments - 75 kg man Stores 1000 mg Tissue 500 mg 30 mg Absorption < 1 mg/day Excretion < 1 mg/day Red Cells 2300 mg

12 IRON STORES Iron Deficiency i Anemia Stores 0 mg Tissue 500 mg 3 mg Absorption 2-10 mg/day Excretion Dependent on Cause Red Cells 1500 mg

13 Mechanisms for maintaining iron balance : - continuous reutilization of iron - regulation of the absorption of iron - access to specific storage protein (ferritin)

14 Typical diet : formerly ~ mg/d, now ~24 mg/d 10-15% 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 ot cato of flour. lou.

15 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 Therapy Oral ferrous form - ferrous sulfate most widely used mg elemental Fe/d (60 mg, 1-3 x / day) 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 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 no further loss of blood/iron Parenteral iron possible, but problematic

18 If supplementation fails, maybe that : 1. The patients may not be taking the medication, most likely because of unpleasant side effect 2. Bleeding may be continuing 3. The supplemental e iron is not being absorbedbed Parenteral route

19 Medical Nutrition Therapy In addition to supplementation, attention should be given to the amount of absorbable dietary iron Liver, kidney, beef, egg yolk, dried d fruit, dried d peas and beans, nuts, green leafy vegetables, whole grain breads and cereals, and fortified food.

20 Factors affecting absorption Enhancing factors : Inhibiting factors : - Ascorbic acid - MFP - Carbonates - Oxalates - Phytates - Tanin

21 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 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 MACROCYTIC ANEMIAS Characterized by an MCV greater than 100 μ 3 Also called megaloblastic anemias large, immature red cell precursors (megaloblasts) accumulate in the bone marrow

24 Vitamin B12 Deficiency Most often caused by impaired absorption Strict t vegetarian (vegans) who consume no dairy products, eggs or meat increased risk for deficiencies i i The main cause of vitamin B12 deficiency is PERNICIOUS ANEMIA

25 Vitamin B12 deficiency should be considered when the plasma concentration < pg/ml If there is a deficiency, the plasma folate y, p level may be elevated to 15 or 20 ng/ml ~ impaired tissue folate uptake and turnover (methyl-folate trap)

26 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 only vitamin B carries in plasma (transcobalamins) may be abnormally low Subsequently, the plasma vitamin B12 level falls When the level reaches pg/ml, neutrophils begins to appear hypersegmented Finally, macroovalocytes appear, the MCV is elevated and the Hb level drops Anemia develops IN THE LATER STAGES of vitamin B12 deficiency like iron deficiency

27 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 μg / day During pregnancy 22μg 2,2 / day During lactation 2,6 μg / day

28 Remission of the sign & symptoms a single intramuscular injection of 100 to 1000 μg of cyanocobalamins or hydroxocobalamins Daily administration of 100 μg for several days For PA patients & other who need continued parenteral therapy injections of 100 μg every month

29 Folic Acid Deficiency i Large, immature red blood cells DNA synthesis slows & cells lose their ability to divideid The nucleus of the cells is not released as normally immature blood cells are enlarged & oval shaped

30 Causes of Folic Acid Deficiency e cy Insufficient intake RDA : 180 μg / day 200 μg / day During pregnancy 400 μg /d day During lactation μg / day Suboptimal folate intake during early pregnancy (even without t other manifestations of folate deficiency major risk factor for neural tube birth effects Person who rarely consume green leafy vegetables or other sources of folate

31 Associated with a variety of intestinal disorders such as Crohn s disease, celiac disease and tropical sprue Alcoholics Cigarette Cgaettesmokers es Drug-nutrient interactions (e.g. anticonvulsants, diuretics, antibiotics and antimalarials) i l

32 Widely distributed in : Dietary Sources Yeast Liver and other organ meat Leafy vegetables Fresh fruit Enriched bread and cereal products Oranges juice the highest h contributor t of folic acid to the American diet Between 50% and 90% of folate in the food destroyed by prolonged cooking and processing

33 Treatment Plasma level should be used to guide therapy Readily resolved with a 1 mg daily oral supplement In the patients with malabsorption, Initial treatment parental folate Maintenance oral therapy

34 الحمد الله