Prevalensi

sTfR

ZnPP ,etc

Etiologi

Staging

Definisi ADB

Assesment diagnosis

Black Blood donors > 2 Units/yr women and

3 Units/yr men Low SES AND postpartum Mexican ethnicity Child and adolescent obesity Vegetarian diet

USPSTF recommends screening pregnant women for IDA, but found insufficient evidence to recommend for or against routine screening in other asymptomatic persons.

High-risk infants six to 12 months of age should be given routine iron supplementation. – B

Dietary Reference Intakes (DRI) for iron is 8 mg/day for healthy non-menstruating adults; 18 mg for menstruating women; 16 mg for vegans, and 20 mg for blood donors.

Poverty Black, Native American, or Alaskan Native Immigrants from a developing country Preterm or low birth weight Primary dietary intake is unfortified cow's

milk.

World’s most common nutritional deficiency

2% in adult men (≤ 69 years old) 4% in adult men ≥ 70 years old* 10% in Caucasian, non-Hispanic

women 19% in African-American women

CDC. MMWR. 2002;51:899.

*Value for 1994

WHOWHO CDCCDC

Infants 0.5 to 4.9 yrsInfants 0.5 to 4.9 yrs ---- < 11 g/dL< 11 g/dL

Children 5 to 11.9 yrsChildren 5 to 11.9 yrs -- --

< 11.5 g/dL< 11.5 g/dL

Menstruating WomenMenstruating Women < 12 g/dL< 12 g/dL -- --

Preg 1Preg 1stst or 3 or 3rdrd trimestertrimester

< 11 g/dL< 11 g/dL < 11 g/dL< 11 g/dL

Preg 2Preg 2ndnd trimester trimester < 11 g/dL< 11 g/dL < 10.5 g/dL< 10.5 g/dL

MenMen < 13 g/dL< 13 g/dL -- --

Hemoglobin level

Iron deficiency Thalassemia Sideroblastic anemia Chronic disease Lead poisoning

ANEMIA DEFISIENSI BESI

Anemia Defisiensi Besi (ADB) anemia yang timbul akibat kosongnya cadangan besi tubuh (depleted iron store) penyediaan besi untuk eritropoesis berkurang akhirnya pembentukan hemoglobin (Hb) berkurang.

Worldwide, affects up to 50% of pregnant women› Unfavorable outcomes› Premature delivery› Low birth weight

Children› Impaired cognitive function› Impaired motor development› Language and scholastic development› Increased morbidity

1. Fase Luminal : besi dalam makanan diolah dalam lambung kemudian

siap diserap di duodenum 2. Fase Mukosal : proses penyerapan

dalam mukosa yang merupakan suatu proses aktif

3. Fase Luminal : besi dalam makanan terdapat dalam 2 bentuk, yaitu:

› Besi Heme : terdapat dalam daging dan ikan, tingkat absorbsinya tinggi tidak dihambat oleh bahan penghambat sehingga mempunyai bioavailabilitas tinggi

› Besi non Heme : berasal dari sumber tumbuh-tumbuhan, tingkat absorbsi rendah, dipengaruhi oleh bahan penghambat shg bioavailabilitas rendah.

Yang tergolong sebagai bahan pemacu absorbsi besi adalah “meat factors” dan vitamin C, sedangkan yang tergolong sebagai bahan penghambat ialah tanat, phytat dan serat (fibre)

› Dalam lambung karena pengaruh asam lambung,maka besi dilepaskan dari ikatannya dg senyawa lain, tjd reduksi dari besi bentuk feri ke fero yg siap diserap

Fase Mukosal› Penyerapan besi tjd di mukosa duodenum

dan jejunum proximal Fase Korporeal

› Besi diserap oleh enterosit (epitel usus), melewati bagian basal epitel usus, memasuki kapiler, kemudian ke darah di ikat oleh apotransferin menjadi transferin.

Iron transport pathways

1

2

3

Iron transport pathways

Zat besi diabsorbsi dari makanan akan terikat oleh proteinplasma spesifik (transferrin) membawanya ke jaringan tubuhdan sumsum tulang (± 3 mg besi dalam sirkulasi terikat transferrin

Besi yang dimuat transferrin diikat oleh reseptor transferrin(TfR) pada permukaan sel prekursor eritroid. Aviditas TfR terhadap besi scr genetik diatur oleh protein hemakromatosis transmembran (protein HFE). Kompleks besi-TfR akan bergabung kedalam sel eritroid pada vakuol intrasitoplasmik.

Besi kemudian dilepaskan dan kompleks transferrin-TfR kembali kepermukaan sel besi intraseluler yang bebas kemudian menuju ke mitokondria untuk sintesis heme atau disimpan sebagai Ferritin,suatu protein besi semi kristalin.

4

Fungsi besi

Berperan dalam reaksi oksidasi-reduksi dalam metabolisme energi (pembentukan ATP)

Komponen struktural / fungsional hemoglobin (darah) & myoglobin(otot), serta mengikat O2

1

2

Akhirnya, 80-90% besi akan bergabung ke dalam Hemoglobin untukpembentukan eritrosit baru dengan rentang usia 90-120 hari.Hepcidin, suatu peptida kecil yang dihasilkan hati respons thdsuplai O2, keseimbangan besi dan pengaturan absorbsi besi untukeritropoesis serta pelepasan besi dari sel RE ke transferrin.

Besi Terdapat pada jaringan tubuh, berupa:1. Senyawa besi fungsional, yaitu besi yang

membentuk senyawa yang berfungsi dalam tubuh

2. Besi cadangan, yaitu: senyawa besi yang dipersiapkan bila masukan besi berkurang3. Besi Transport, yaitu: besi yang berikatan

dengan protein tertentu fungsinya untuk mengankut besi dari satu kompatemen ke kompartemen lainnya.

Besi dalam tubuh tidak pernah terdapat dalam bentuk logam bebas (free iron), tetapi selalu berkaitan dengan protein tertentu.

Besi bebas akan merusak jaringan, karena mempunyai sifat seperti radikal bebas.

Dalam keadaan normal seorang laki-laki dewasa mempunyai kandungan besi 50 mg/kgBB, sedangkan perempuan dewasa 35 mg/kbBB.

Jumlah besi pada perempuan pada umumnya lebih kecil oleh karena massa tubuh yang juga lebih kecil.

A. Senyawa besi fungsional Hemoglobin 2300mg

Mioglobin 320mg

Enzim-enzim 80 mg

B. Senyawa besi transportasi

Transferin 3 mg

C. Senyawa besi cadangan Feritin 700 mg

Hemosiderin 300 mg

Total 3803 mg

Stores1000mg

Tissue500 mg

Red Cells2300 mg

3 mgAbsorption < 1 mg/day

Excretion < 1 mg/day

Andrews NC. N Engl J Med. 1999;341:1986–1995.

Dietary iron

Utilization UtilizationDuodenum

(average, 1-2 mgper day)

Muscle(myoglobin;

300 mg)

Liver(1000 mg)

Bone marrow(300 mg)Circulating

erythrocytes(hemoglobin;

1800 mg)

Reticuloendothelialmacrophages

(600 mg)

Sloughed mucosal cellsDesquamation/menstruation

Other blood loss(average, 1-2 mg per day)

Storageiron

Plasma

Iron loss

transferrin(3 mg)

1 to 2 mg of iron enters the body each day.

Most of the iron in the body is incorporated into hemoglobin in erythroid precursors and mature red cells.

Most of the iron found in

the plasma derives from the continuous breakdown of hemoglobin in senescent red cells by RE macrophages.

Each day, approximately 1

to 2 mg of iron are lost from the body.

The remaining body iron is stored, primarily in hepatocytes

Siklus Transferin

Kompleks besi transferin akan masuk kedalam sitoplasma prekusor eritroid melalui proses endositosis.

Sebanyak 80-90% molekul besi masuk kedalam prekusor eritroid ini akan dibebaskan dari endosom dan reseptor transferin akan kembali ke permukaan untuk berfungsi mengikat besi transferin kembali, sedangkan transferrin akan dilepas ke sirkulasi.

Besi yang dilepaskan dari komples tersebut kemudian masuk ke dalam mitokondria untuk diproses menjadi heme setelah bergabung dengan protoporfirin.

Pada sel non eritroid akan tersimpan dalam bentuk ferritin dan hemosiderin (Adrews, 1999).

Kehilangan besi sebagai akibat perdarahan menahun, dapat berasal dari:› Saluran cerna: akibat dari tukak peptik,

pemakaian salisilat atau NSAID, kanker lambung, kanker kolon, divertikulosis, hemoroid dan infeksi cacing tambang

› Saluran genitalia perempuan: menorrhagia atau metrorhagia

› Saluran kemih : hematuria› Saluran nafas : hemoptoe

Faktor Nutrisi : akibat kurangnya jumlah besi total dalam makanan, atau kualitas besi (bioavailabilitas) besi yang tidak baik (makanan banyak serat, rendah vitamin C, dan rendah daging)

Kebutuhan besi meningkat: seperti pada prematuritas, anak dalam masa pertumbuhan dan kehamilan.

Gangguan absorbsi besi: gastrektomi, tropical sprue atau kolitis kronik

Infancy and adolescence1,2

Pregnancy and lactation1,2 › Low socioeconomic status and poverty

greatly increase the prevalence of iron deficiency in this category of populations3

• In patients receiving erythropoietin therapy (= functional iron deficiency)2

1. Adamson JW. In: Kasper DL, ed. Harrison’s Principles Of Internal Medicine. 16th ed. New York: McGraw-Hill; 2005.

2. Hoffman, ed. Hematology: Basic Principles and Practice, 4th ed. 2005.3. CDC. MMWR. 2002;51:899.

Beris P, Tobler A. Schweiz Rundsch Med Prax. 1997;86:1684.Reprinted from Lambert JF, et al. In C Beaumont, P Beris, Y Beuzard, C Brugnara, eds. Disorders of iron homeostasis, erythrocytes, erythropoiesis. Forum service editore, Genoa, Italy, 2006 page 73 figure 1, by permission of European School of Haemotology.

Haemolysis17.5%

Others9%

Iron Deficiency

29%

Chronic Disease27%

Acute Bleeding17.5%

Most common nutritional deficiency worldwide.

Men and non-menstruating women lose 1 mg of iron per day.

Menstruating women can lose an extra 10 mg to 42 mg of iron per cycle.

Pregnancy takes 700 mg of iron 2 packs of whole blood contains 250 mg

of iron.

Increased demand for iron and/or haematopoiesis

Iron loss Decreased iron intake or absorption

Adamson JW. In: Kasper DL, ed. Harrison’s Principles Of Internal Medicine. 16th ed. New York: McGraw-Hill; 2005.

In physiologic conditions› Menstruation

In pathologic conditions› Surgery, delivery› Haemoglobinuria,haemoptysis› Gastrointestinal tract pathology

In therapeutic procedures› Phlebotomy

In blood donation

Adamson JW. In: Kasper DL, ed. Harrison’s Principles Of Internal Medicine. 16th ed. New York: McGraw-Hill; 2005: Hoffman, ed. Hematology: Basic Principles and Practice, 4th ed. 2005.

Vegetarians or malnutrition (low-cost diet)1

Malabsorption syndromes› Sprue, UHC, and Crohn’s disease2

After gastric and intestinal surgery3

Intestinal parasitosis (ankylostomiasis)3

Helicobacter pylori infection2

Autoimmune atrophic gastritis2

1. CDC. MMWR. 1998;47(RR-3);1-36.2. Annabale B, et al. Am J Med. 2001;111:439.3. Hoffman, ed. Hematology: Basic Principles and Practice, 4th ed. 2005.

Fatigue Decreased exercise tolerance Tachycardia Dermatologic manifestations Decreased intellectual performance Dysphagia Depression, increased incidence of

infections Restless legs syndrome

Hoffman, ed. Hematology: Basic Principles and Practice, 4th ed. 2005.Trost LB, et al. J Am Acad Dermatol. 2006;54:824.

Stainable Iron, Bone Marrow Aspirate Serum Ferritin - Low in Iron Deficiency Desaturation of transferrin Serum Iron drops Transferrin (Iron Binding Capacity)

Increases Blood Smear - Microcytic, Hypochromic;

Aniso- & Poikilocytosis Anemia

Stores0 mg

Tissue500 mg

Red Cells1500 mg

3 mgAbsorption 2-10 mg/day

Excretion Dependent on Cause

• Anaemia of chronic disease

– Insufficient iron made available for haemopoiesis

• Haemochromatosis

– Iron deposition liver, endocrine organs, heart & skin

Absorption occurs in jejunum Two forms of dietary iron

› Heme (found in meat) not affected by dietary factors

› Nonheme (plant and dairy) requires acid digestion, enhanced by ascorbate, meat and inhibited by calcium, fiber, tea, coffee, wine

Caused when demand not met by absorption from diet.› Inadequate dietary intake› Hampered absorption› Physiologic losses in woman of

reproductive age› Blood loss, occult or known

Iron deficiency (ID) is a reduction in body Fe to the extent that cellular storage Fe required for metabolic/physiological functions is fully exhausted, with or without anemia.

Iron deficiency anemia (IDA) is defined as ID and a low hemoglobin (Hb).

Tahapan defisiensi besi :

1. Tahap pralaten (iron depletion)

2. Tahap laten (iron deficient erythropoesis)

3. Tahap anemia def.besi (iron deficiency anemia)

Iron-deficient erythropoiesis, or functional iron deficiency

Depletion of iron stores Iron-deficiency anaemia

Grosbois B, et al. Bull Acad Natl Med. 2005;189:1649.

1. Iron store depletion

-Diagnosis terbaik menggunakan serum ferritin dan pewarnaan prussian blue pada preparat BMP.-SF < 40 μg/L curiga iron store depletion Visible iron store ≤ 1+-Selama cadangan besi masih tampak (pada BMP) maka kadar SI, TIBC dan Hb seharusnya juga normal. -STfR / ferritin ratio indikator yang > sensitif untuk evaluasi pada populasi yang berisiko ADB.-Pada pasien iron store depletion dgn komplikasi inflamasi sTfR (rasio sTfR/ferritin) juga akan saat SF turun < 40 μg/L .

2. Iron-deficient erythropoesis

- Didiagnosis dengan SI, TIBC dan serum ferritin- SI < 60 μg/dL SF < 15-20 μg/L TIBC Saturasi transferin < 15% BMP : cadangan besi (-) & sideroblas

-Pada tahap awal, penurunan suplai besi ‘merusak’ kapasitas proliferasi seri eritroid di sumsum tulang

-Kadar Hb 11-12 g/dL-MCV dan MCH masih normal-Morfologi RBC masih normal (normositik-normokromik)

3. Iron deficiency anemia

- Penegakkan diagnosis ADB lebih mudah- SI sangat rendah < 40 μg/dL SF < 12 μg/L TIBC Saturasi transferin < 10% Kadar sTfR BMP : cadangan besi (-) & sideroblas (-)

-Saat Hb < 10 g/dL stimulasi erithropoietin di sumsum tulang menyebabkan produksi eritrosit dengan morfologi yg abnormal mikrositik-hipokromik.

Saat Hb < 9 g/dL morfologi RBC menjadi bizarre dengan munculnya berbagai bentuk RBC (poikilositosis) spt sel sigar, sel pensil dan sel target, yang merupakan pertanda meningkatnya eritropoesis inefektif sebagai respons thd stimulasi eritropoetin.

Catatan:Sel sigar hanya tampak pada ADB, sedangkan sel target diasosiasikan dengan thalassemia.

Tahapan defisiensi besi…

Tahapan defisiensi besi…

48

Storage iron

depletion

Functional iron depletion (iron deficiency anemia)

Transport iron

depletion

Iron depletion

Std.1/prelatent Std.2/latent Std.3/IDA

Iron storage compartment

Iron transport compartment

Functional Iron compartment

Normal iron status

Lab.test values

HbHb NN NN NN SISI NN NN TIBCTIBC NN NN FeritinFeritin NN

Development of IDA

Assessment of Iron Status

Definition of ID states

Bone marrow biopsyHb, Red cell indices

Biochemical parameters

Bone-marrow examination to establish the absence of stainable iron remains the gold standard for the diagnosis of iron deficiency

However, marrow examinations are expensive, uncomfortable, and require technical expertise, and are not performed routinely in practice.

Pemeriksaan besi sumsum tulang

-Baku emas untukmenilai cadangan besi.-Dilakukan thd kandungan hemosiderin yg dicat Prussian blue-Hasil : absen/kosong, menurun, normal atau meningkat.-Keterbatasan : -Hasil tergantung ketrampilan penilaian pemeriksa -Stroma SSTL yang terambil saat aspirasi, invasif, teknik pengecatan, waktu lama, semi kuantitatif.

BMP aspirate : iron stain, absent macrophage iron

Interpretasi pemeriksaan hemosiderin

Pada perbesaran obyektif 40x:

Dalam 10 LP (+) : Normal (+2 / +3) 25 LP baru (+) : Menurun (+1) >25 LP (-) : Negatif (0) setiap LP (+) : Meningkat (+4)

53

Absen

Meningkat Normal

Normal

Serum Ferritin <25 ng/ml › Falls before other indices › Most sensitive for IDA› Falsely elevated in Hepatitis

TIBC rises Serum Iron

› Falls after Serum Ferritin › Falls after TIBC

Transferrin Saturation decreases › Falls after Serum Ferritin

Serum transferrin receptor increased (normal levels in anemia of chronic disease)

DIAGNOSIS ADB

Algoritma Diagnosis

ADB

DIAGNOSIS BANDING ADB

Anemia Defisiensi

Besi

Anemia pada Penyakit Kronis

Thalassemia

Hct ( %) <31-32 28-32MCV Turun < 80 fl Dbn Turun MCH Turun Dbn Turun RDW

>14% NormalNormal atau meningkat

SI Turun Turun NTIBC Meningkat Turun N%sat <10-15 Turun – normal

SF ng/mL <10 Meningkat NBesi sumsum

tulangBerkurang-

absenNormal-

meningkatNormal-

meningkat

DIAGNOSIS BANDING ADB

Diagnosis banding ADB

Hb is a widely used screening test for ID, but used alone has low sensitivity and specificity.

Sensitivity is low; individuals with Hb level near normal need to lose 20–30% of body Fe before their Hb falls below the cut-off for anemia*

Its specificity is low because there are many causes of anemia other than ID.

*Cook JD (2005) Diagnosis and management of iron-deficiency anaemia. Best Pract Res Clin Haematol 18, 319–332.

Hemoglobin merupakan komponen utama eritrosit yang berfungsi mengikat oksigen dan membuang karbondioksida.

Struktur Hb mengandung 2 pasang rantai polipeptida (“globin”) dan molekul heme yang masing-masing mengandung 1 atom Fe 3+.

Age/ Gender Gr

Hb (g/L) HCT (l/l)

6 mo–59 mo 110 0.33

5-11 years 115 0.34

12-14 years 120 0.36

Nonpregnant women

120 0.36

Pregnant women

110 0.33

Men > 15 years 130 0.39

MCV is reliable, but late indicator of ID. CHr has been proposed as a sensitive

indicator that falls within days of the onset of IDE*.

For both MCV and CHr, low specificity (e.g. thalassemia) limits their clinical utility**

* Mast AE, Blinder MA, Lu Q, Flax S & Dietzen DJ (2002) Clinical utility of the reticulocyte hemoglobin content in the diagnosis of iron deficiency. Blood 99, 1489–1491. ** Thomas C & Thomas L (2002) Biochemical markers and hematologic indices in the diagnosis of functional iron deficiency. Clin Chem 48, 1066–1076.

Unit Methods Threshold for ID

Comments

Hb g/l Cyanmeta/ Hemocue

Varies with age

Low specificity & sensitivity

Hct Decimal ratio or %

Centrifugation or AFC*

Varies with age

Low specificity & sensitivity

MCV fl (10 -12 ) HCT/rbc;AFC <82 fl Reliable but late indicator

Reticulocyte Hb conc (CHr)

g/l reticulocyte

AFC Child <27.5Adult <28.0

Sensitive indicator; false value if MCV high

Serum or plasma iron

mcg/dl Colorimetry <40-50 Varies diurnally, low in ACD

Whole blood Zinc protoporphyrin

mmol/mol of heme

haematofluorimeter

>40 (washed erythrocyte)

Useful for survey in children*Automated flow cytometer

.

Unit Methods Threshold for ID

Comments

Serum or plasma ferrtin

mcg/l Immunoassay orimmunoturbidometry

Variable Useful in absence of infection & ACD

Serum or plasma TIBC

mcg/dl

Colorimetry >400 Large overlap between values in N or ID

Transferrin saturation

% Calculated from Serum iron/TIBC

<15% As above

Transferrin receptor

mg/l Immunoassay or immunoturbidometry

Varies with assay

Increases if erythropoesis enhanced; not affected by acute phase response

Body iron stores

mg/kg body wt

Ratio of transferrin receptor to ferritin

Negative indicates tissue fe deficit

Can’t be used in presence of inf./inflamm; assay specific

Hemoglobin Serum ferritin FEP Transferrin

receptor(TfR) ZnPP

Hb + Serum ferritin Hb + TfR Hb + FEP Serum ferritin + TfR Low transferrin

saturation + high ZnPP(+ low SF)*Specificity increases but sensitivity is

low, and they tend to underestimate ID.

Usual Laboratory Screening for ID

Single measures Dual measures*

Hb + Serum ferritin and, if CRP is elevated, TfR and/or ZnPP.

.

* WHO/UNICEF/ICCIDD (2001) Iron Deficiency Anemia: Assessment, Prevention and Control. Geneva: World Health Organisation, WHO/NHD/013.

ZnPP increases in IDE because zinc replaces the missing Fe during formation of the protoporphyrin ring.* The ratio of ZnPP/heme can be measured directly on a drop of blood using a portable hematofluorometer.

Sensitivity is good**, but specificity low as ZnPP increases in chronic diseases, lead poisoning, hemolytic anemia.

*Metzgeroth G, et al.(2005) Soluble transferrin receptor and zinc protoporphyrin – competitors or efficient partners? Eur J Haematol 75, 309–317.

** Labbe RF & Dewanji A (2004) Iron assessment tests: transferrin receptor vis-a-vis zinc protoporphyrin. Clin Biochem 37, 165–174.

Recommended cutoff for washed erythrocytes* and unwashed erythrocytes** are 40 and 80 micromol/mol heme;

Useful for field surveys sp. in children where uncomplicated ID is primary cause of anemia.

*Hastka J, (1992) Washing erythrocytes to remove interferents in measurements of zinc protoporphyrin by front-face hematofluorometry. Clin Chem 38, 2184–2189.**Labbe RF, Vreman HJ & Stevenson DK (1999) Zinc protoporphyrin:a metabolite with a mission. Clin Chem 45, 2060–2072.

EP accumulates in RBC if iron is insufficient to combine with to form heme

Raised EP indicates advance stage of ID

FEP values are 30-40 mcg/dl RBC FEP values >70 mcg/dl RBC and P:H

ratio >32 represent iron deficiency.

Transferrin saturation is a widely used screening test for ID, calculated as the ratio of plasma Fe to total Fe-binding capacity.

Although relatively inexpensive, use is limited by diurnal variation in serum Fe & many clinical disorders that influence transferrin levels.*

* Cook JD (2005) Diagnosis and management of iron-deficiency anaemia. Best Pract Res Clin Haematol 18, 319–332.

SF most useful test; directly proportional to Fe stores in healthy 1mg/l SF corresponds to 8–10mg body Fe or 120mg storage Fe/kg body weight

Value less than 12 mcg/l is highly specific

However, it is an acute phase protein; unreliable in acute/chronic inflammation, liver disease, malignancy, hyperthyroidism, and heavy alcohol intake.

*Mei Z, (2005) Hemoglobin and ferritin are currently the most efficient indicators of population response to iron interventions: an analysis of nine randomized controlled trials. J Nutr 135, 1974–1980.

Chr. Inflamm dis. increase circulating hepcidin levels which blocks Fe release from enterocytes and RE system, even with adequate iron stores*.

CRP >10-30 mg/l is a marker of inflammation. But during infection CRP increase is of short duration than the increase in SF.

If CRP is elevated IDA can be diagnosed in ACD by elevated TfR** and /or ZnPP***

*Nemeth E (2004) IL-6 mediates hypoferremia of inflammation by inducing the synthesis of the iron regulatory hormone hepcidin. J Clin Invest 113, 1271–1276.; **Hastka J, (1992) Washing erythrocytes to remove interferents in measurements of zinc protoporphyrin by front-face hematofluorometry. Clin Chem 38, 2184–2189. ***Skikne BS, (1990) Serum transferrin receptor: a quantitative measure of tissue iron deficiency. Blood 75, 1870–1876.

Serum iron (SI)

-Pengukuran secara langsung jumlah besi yang terikat dengan transferrin dengan metode fotometrik.-Besi yg terikat transferin dilepaskan dg asam kompleks warna dengan ferrozine.-Rentang N : 40 – 160 µg/dL-Hasil dipengaruhi : absorbsi makanan, infeksi, inflamasi.

Hemochromatosis Hemolysis Hemolytic Anemia Hepatic necrosis Hepatitis Ineffective Erythropoiesis Vitamin B12 Deficiency Iron Poisoning or Iron

Overdose

Chronic Gastrointestinal Blood loss

Heavy Menstrual Bleeding Inadequate iron absorption Insufficient Dietary Iron Iron Deficiency Anemia Malabsorption Nephrotic Syndrome Third trimester of pregnancy

Serum Iron

Increased SI Decreased SI

TIBC

-Kapasitas maksimal transferin untuk mengikat besi pengukuran secara tidak langsung thd kadar transferin. -Rentang N: 250-450 µg/dL.

-Sampel serum dijenuhi dg besi untuk mengisi seluruh sisi transferin yang belum mengikat besi, selajutnya kelebihan besi dibuang. Besi dilepaskan dari ikatannya dengan transferin menggunakan asam, kemudian diukur dg ferrozine.-Pengukuran keduanya lebih informatif.

- Iron Deficiency Anemia - Third trimester

Pregnancy - Polycythemia Vera

- Anemia of Chronic Disease

- Hemolytic Anemia - Hemochromatosis - Chronic Liver Disease

or Cirrhosis- Hypoproteinemia - Malnutrition - Pernicious Anemia - Sickle Cell Anemia

Total Iron Binding Capacity

Increased TIBC Decreased TIBC

Saturasi transferrin

-Merupakan proporsi iron-binding site yang terpakai dan merefleksikan transport besi-Saturasi transferrin (%) = SI/TIBC x 100%-N : 1/3 transferin di sirkulasi mengikat besi.-Penurunan <16% tanda kurangnya suplai besi ke ssm tulang

-Transferrin protein spesifik yg membawa besi ekstraseluler-Menurun pada : malnutrisi, inflamasi, infeksi kronik & kanker

- Chronic Iron Deficiency Anemia

- Chronic infection - Advanced malignancy - Collagen-Vascular

Disease - Uremia - Third trimester of

pregnancy

- Hemochromatosis and other iron overload

- Hemolytic Anemia - Starvation - Nephrotic Syndrome - Cirrhosis - Thalassemia minor - Megaloblastic Anemia - Aplastic Anemia or

Sideroblastic Anemia

Saturasi transferrin

IncreasedDecreased

Serum Ferritin

-Merupakan petunjuk kadar cadangan besi dalam tubuh konsentrasi ferritin dalam plasma sebanding dengan cadangan besi tubuh.-Adalah protein yang tdr 22 molekul apoferitin, dimana bagian intinya berupa kompleks fosfat/besi 4000 molekul.-Konsentrasi ferritin dipengaruhi : jenis kelamin, usia & inflamasi-Kadar ferritin : 40-300 µg/L (L) dan 20-150 µg/L (P)-Penurunan ferritin < 12 µg/L deteksi defisiensi besi tanpa komplikasi.

- Iron Deficiency Anemia Inflammatory states Hyperthyroidism Liver disease (necrotic

hepatocytes) Hodgkin's Lymphoma and

Non-Hodgkin's Lymphoma Leukemia Breast Cancer Hemochromatosis Iron Supplementation

Serum Ferritin

Decreased Increased

Soluble transferrin receptor (sTfR)

-TfR merupakan protein transmembran dengan 2 komponen identik, masing-masing dapat mengikat 2 molekul transferrin.

-80% TfR berada di sel eritroid sumsum tulang.-Reseptor transferrin diekspresikan di permukaan sel yang memerlukan besi & bertindak sebagai molekul pengangkut besi-STfR indikator yang sensitif untuk awal perkembangan defisiensi besi (iron restricted erythropoesis). -Kadar sTfR serum proporsional dengan total reseptor transferin jaringan.-STfR tidak dipengaruhi aktivitas fisik, jenis kelamin dan usia. -Defisiensi besi STfR > 5 mg/L.

Reseptor transferrin merupakan protein transmembran dengan 2 komponen yang identik masing-masing dapat mengikat 2 molekul transferrin.

Reseptor ini pada orang dewasa normal 80% berada di sel eritroid sumsum tulang, karena sel eritroid immatur membutuhkan besi dalam jumlah besar.

Reseptor transferrin sangat rentan terhadap proteolisis, akibatnya dihasilkan suatu potongan berbentuk kerucut yang terlarut dalam serum yang disebut dengan soluble transferrin receptor .

Kadar sTfR proporsional dengan total reseptor transferrin dalam jaringan.

Material ini pertama kali ditemukan oleh Pan et al (1983) yang mengamati bahwa pada saat maturasi retikulosit menjadi eritrosit, sel ini kehilangan reseptor transferrinnya dengan melepaskan ke dalam darah.

Reseptor transferrin yang ditemukan dalam serum dg bentuk monomer, BM: 74-kDa, merupakan domain ekstraselular dari reseptor transferin yang dipotong pada Arg 100-leu 101 di dalam endosom.

Kadar sTfR di sirkulasi sebanding dengan ekspresi sellular membrane-associated TfR dan meningkat dengan meningkatnya kebutuhan besi dan proliferasi sel. (Shih et al, 1990)

Transports iron into the cells

Abundant in red cell precursors

Not an acute phase protein

Induced by depletion of intracellular iron.

Beguin, Y. (1992) Haematologica 77:1.

Iron is transported in blood serum bound to the protein transferrin.

The plasma membrane transferrin receptor mediates uptake of the complex of iron with transferrin by cells via receptor mediated endocytosis.

transferrin with bound Fe

transferrin receptor

extracellular space

receptor-mediated endocytosis

pH 5.5A) Uptake (TfR cycle)

C) Storage B) Metabolic Utilization

Extracellular Space

Cytoplasm

D) Export

Heme Iron Containing Proteins

Ferritin

Protoporphyrin IX5-Aminolevulinate

Succinyl-CoA + Glycine

Mitochondrion

Dmt1

Receptor-mediated endocytosis pathway

Receptor

Stipanuk, M. H. 2006. Biochemical, Physiological, and Molecular Aspects of Human Nutrition

The uptake of iron by cells is mediated by a transferrin receptor (TfR) expressed on their external surface. TfR binds diferric transferrin, and the receptor–transferrin complex is internalized into an endosome, where the iron is transferred to the cytosol. After recycling to the cell surface, the apotransferrin dissociates, and the receptor is free to repeat the process. Cells deficient in iron upregulate expression of TfR to compete more successfully for available iron.

Beguin, Y. (1992) Haematologica 77:1.

Soluble TfR is a truncated form of the cellular receptor which is shed by red cell precursors into the circulation.

Transfers circulating Fe into developing RBCs 80% of TfR in the body are found on erythroid

precursors; specific indicator of IDE that is not confounded by inflammation

Values above 9 mg/l considered abnormal ( mean levels 5.6 mg/l)

Age related data scarce, high cost of assay and lack of international standard; Diagnostic value is uncertain in children due to marrow expansion in growth, thalassemia.

Increased when erythropoiesis is increased.

Proportional to cellular TfR. Reduced in situations of iron excess. Differentiate IDA and ACD.

Transferrin receptors are released from the surface of erythroid cells during their development, and the concentration of soluble serum transferrin receptor (sTfR) has been shown to be proportional to the mass of erythroid tissue, as assessed by conventional ferrokinetic studies (Huebers et al,1990).

In many cases, ACD is associated with an IDA which aggravates the chronic disease. › Ferritin unreliable in these cases

Differentiate ACD from IDA+ACD may avoid bone marrow biopsy.

Parameter IDA ACD IDA+ACD

Ferritin Low Normal - High

Normal

Hb Low Low Low

Serum Iron Low Low Low

sTfR High Normal High

CONTROL IDA HEMOLYSIS ACD IRON APLASTIC

EXCESS ANEMIA

By Kari Punnonen

sTfR

Kandungan besi di dalam sel di atur melalui kontrol ambilan besi dan kapasitas penyimpanan yang berjalan harmonis. Apabila kadar besi dalam sel naik, kadar ferritin akan meningkat sedangkan reseptor transferrin akan menurun.

Mekanisme ini di atur oleh IRP (Iron Regulatory Protein), merupakan biosensor kelebihan besi.

IRP sendiri diatur oleh kadar besi dalam sel, yang merupakan iron sulphur protein dengan dua fungsi berbeda tergantung kandungan besi pada bagian sentralnya (4Fe-4S cluster).

Penurunan kandungan besi dalam sitosol menyebabkan kandungan dalam cluster ini juga turun, menyebabkan perubahan konfirmasi protein.

Terbentuknya deep cleft open pada IRP berakibat protein ini mampu mengaktifkan IRE (Iron Responsive Element) yang terletak pada regio 5’UTR (untranslated region) mRNA untuk TfR dan feritin.

Mesenger RNA untuk TfR mempunyai 5 IRE terletak pada 3’UTR. Penempelan IRP pada sisi ini mencegah mRNA dari proses endonuclease cleavage, menstabilkan mRNA dan memperpanjang waktu paruhnya.

Hal tersebut mengakibatkan peningkatan sintesis TfR diikuti ambilan besi ke dalam sel.

Clinical Utility of sTfR

Weiss and Goodnough. Anemia of Chronic Disease. NEJM 2005

Anemia

Evidence of Inflammation

Transferrin Saturation <16%

Ferritin>100 ng/mL

Ferritin<30 ng/mL

Ferritin30-100 ng/mL

sTfR/log F sTfR/log F

IronDeficiency

Anemia

Anemiaof ChronicDisease

ACD with true Iron Deficiency

-STfR pada : ADB, congenital dyserithropoietic anemia, anemia hemolitik, thalassemia major, MDS & pemberian terapi EPO rekombinan.-STfR pada : transfusi kronis, anemia aplastik.

Indeks sTfR / Ferritin

Tahap I : feritin , reseptor transferrin masih stabil. Tahap II : feritin lebih berat, reseptor transferrin Tahap III : tahap ADB, feritin lebih berat, reseptor transferrin lebih tinggi.

-Bermanfaat untuk membedakan antara ACD dengan ADB dan ACD yang koeksis dengan ADB (indeks sTfR/F >2)

H+H+

H+H+Lysosome

Fe+2

Fe+2

Transferrin

Transferrin receptor

A comparison of the analytical performance of an automated immunoturbidimetric assay with two manual ELISA assays found good correlations (r . 0·8); however, TfR values by the immunoturbidimetric assay were on average 30% lower(65).

51. Beguin Y (2003) Soluble transferrin receptor for the evaluation of erythropoiesis and iron status. Clin Chim Acta 329, 9–22.

59. Beesley R, 2000) Impact of acute malaria on plasma concentrations of transferrin receptors. Trans R Soc Trop Med Hyg 94, 295–298.

Enzyme immunoassay dan immunoturbidimetric (Thomas, 2002).

Kaligo et al (1987) mengembangkan RIA (radioimmunoassay)

Orion Diagnostica Finlandia memproduksi 2 macam kit yaitu IDeA® sTfR IEMA (immunoenzymometric microtiter plate assays) yang dikerjakan manual dan IDeA® sTfR-IT (immunoturbidimetric assays) yang dikerjakan dengan alat otomatis (Suominem et al, 1999).

Serum yang diperoleh segera disimpan dalam tabung eppondorf 2 ml pada suhu beku -20˚C dilakukan pemeriksaan dengan alat Hitachi 902

Cara pemeriksaan :› Minimal 200 mikroliter sampel dimasukkan

kedalam anti-sTfR antibody latex ditempatkan pada rak reagen

› Latex-baund anti sTfR antibodies akan bereaksi dengan antigen dalam sampel membentuk komplek Ag-Ab

› Setelah terjadi aglutinasi diukur secara turbidimetri (Anonim, 2005).

STFR is useful in distinguishing anemia of chronic disease from iron deficiency. The STFR will be increased in iron deficiency. Unlike ferritin, STFR is not an acute phase reactant and is not influenced by inflammation.

STFR is also not influenced by acute liver disease or malignancy. In addition to iron deficiency elevated STFR values are also found in polycythemia, hemolytic anemia, thalassemia, hereditary spherocytoses, sickle cell anemia, megaloblastic anemia due to vitamin B12 and folate deficiency, and myelodysplastic syndromes.

Reference ranges are; males: 2.2-4.5 mg/L and females: 1.8-4.6 mg/L. Values tend to be higher in infants and children

Another parameter that can be used to assess iron status is soluble transferrin receptor (sTfR). sTfR results from the proteolysis of TfR at a specific site in the extracellular domain, producing fragments that circulate in the blood complexed to ferritin.

The amount of total, cellular TfR is directly proportional to the concentration of sTfR in plasma or serum, and so sTfR in the plasma accurately reflects the total TfR. Because most TfRs are located on erythroid progenitors, the concentration of sTfR is believed to reflect erythroid turnover, and is determined by the erythroid proliferation rate and iron demand.

sTfR is elevated in patients with thalassemia and sickle cell disease. Caution should be exercised in managing anemia in these individuals based on the sTfR test results.

FEP: mengukur konsentrasi protoporphyrin dalam RBC Metode: hematofluorometri Praktis, namun meningkat pada lead poisoning

ZPP: Mengukur rasio ZPP/heme Metode: hematofluorometri Pada kadar besi yg kurang, produksi ZPP dan rasio ZPP/heme . Nilai normal:<40mg/dL (<80 umol/mol)

Erythrocyte protoporphyrin (EP)

Status besi berdasarkan kadar EP

Gambar . Hubungan antara metabolisme ZPP dan ferrous protoporphyrin (heme)

118

Erythrocyte protoporphyrin (EP)

Consider transfusion for all pts who are symptomatic and for asymptomatic cardiac pts with Hgb < 10 g/dL.

Oral therapy is usually first line.

An increase in Hgb level of 1 g/dL should occur every 2-3 weeks.

Iron stores take up to 4 months to return to normal after Hgb has corrected.

FeSO4 300 mg provides 60 mg of elemental iron.

FeGluconate 325 mg provides 36 mg of elemental iron.

Bone marrow response to iron limited to 20 mg per day of elemental iron.

IV iron available › iron dextran (risk of anaphylaxis)› ferric gluconate (safer)› iron sucrose

Fe

Fe

FeFeFe Ferritin

Hemosiderinslow

Fe

Fe

Fe FeFe

Fe

Fe Fe

Fe

Ferritin Ferritin

Tra

nsfe

rrin

Rec

epto

r

RBC PRECURSOR

CIRCULATING RBCs

Fe Fe

TRANSFERRIN

MONONUCLEARPHAGOCYTES

FeFe

FeFe

Fe FeFe

FeFe

Fe

Fe

Fe

Fe

Fe

Fe

FeFe

FeFe

Fe

Ferritin

Fe Fe

TRANSFERRIN

Transferrin bound iron in plasma delivered to body cells according to cellular iron requirements

Note:

Only 20% of plasma bound iron derived from gut. Most plasma iron is derived from breakdown of senescent red cells.

Haem

Fe+++

Fe++

Ferritin

Tf

Tf-Fe+++

Fe++

Fe++

Enterocyte GutGut

PO iron

Duodenal enterocyte

Fe

Ferroportin

Transferrin

Hepatocyte(Fe storage reservoir)

Transport of Fe to bone marrow for Hb production

Transferrin receptor• Balance maintained by

regulation of absorption & distribution

• No physiological excretion method

Parameter Reference Range

Iron 9-30 umol/L

Transferrin 2.0-3.6 g/L

Transferrin saturation 15-45%

Ferritin 7-140 (women)

30-300 (men)

Serum iron

› Very variable - diurnal variation

› Not very useful for assessing iron stores

Low result: Diurnal

Intercurrent illness

Chronic disease

High result: Diurnal

Iron overload

Iron therapy

Transferrin

› Iron transport molecule

› Deposits iron in any cell expressing transferrin receptors

Low result: Chronic disease

High result: Iron deficiency

Oestrogen therapy

Pregnancy

Transferrin Saturation

› Suggests the amount of iron being actively transported

Low result: Iron deficiency

Chronic disease

High result: Iron overload

Iron therapy

Ferritin

› Reasonable reflection of body stores

› Acute phase protein. Synthesized in the liver

Low result: Iron deficiency

(almost absolutely confirms)

High result: Acute phase

Iron overload

Liver disease

Malignancy

Serum Iron Transferrin Ferritin

Iron Deficiency

ACD

BODY IRON CYCLINGBODY IRON CYCLING

RBC count ↓RBC count normal or↑CRP normal CRP ↑

Ferritin normalFerritin < 50 Ferritin 50-150 Ferritin >150

sTfR/logFerr≥1.55

sTfR/logFerr<1.55

Anaemia of chronic disease Hb

analysis

HbA2 ↑ or HbF ↑

Normal pattern

Family studies,chromosome 16 deletion searchβ-

thalassaemia α-thalassaemia

Ferritin normalFerritin <20

BM examinationRing sideroblasts?

Familial sidero-blastic anaemia

Iron def anaemia

Aetiology? No response to ttt

Consider H. pylori infection

Consider Hb analysis

Reprinted from Lambert JF, et al. In C Beaumont, P Beris, Y Beuzard, C Brugnara, eds. Disorders of iron homeostasis, erythrocytes, erythropoiesis. Forum service editore, Genoa, Italy, 2006 page 73 figure 1, by permission of European School of Haemotology.

Increased production:

› Inflammation (IL-6 driven)

Decreased production:

› Anaemia

› Hypoxia

› Haemochromatosis

PO iron

Duodenal enterocyte

Fe

Ferroportin

Transferrin

Macrophage

RBC

Hepatocyte(Fe storage reservoir)

PO iron

Duodenal enterocyte

Fe

Ferroportin

Transferrin

Macrophage

RBC

Hepatocyte(Fe storage reservoir)

Hepcidin

Increased hepcidin

PO iron

Duodenal enterocyte

Fe

Ferroportin

Transferrin

Macrophage

RBC

Hepatocyte(Fe storage reservoir)

Hepcidin

Decreased hepcidin

Disease Defect Hepcidin Fe abs Transferrin sat Ferritin

Hereditary Haemochromatosis

Regulators of hepcidin or hepcidin gene

↓ ↑ ↑ ↑

Anaemia of inflammation

IL-6 ↑ ↓ ↓ ↑

Produced by hepatocytes

Highly evolutionarily conserved

› Insects› Fish› Mice› Pigs› Humans

Identified due to anti-microbial activity

Produced in the liver Amino acid peptide hormone

› Induced by lipopolysaccharide, IL-6 Regulates dietary iron absorption Increased hepatic iron stores

› Increases hepcidin expression—decrease in absorption

Hereditary Hemochromatosis › Continued absorption and storage of iron

Anemia of chronic disease› Sequestering of iron in RE

HEPCIDIN

FERROPORTIN

degrades

Infections and inflammatory stimuli

Upstream regulators eg. HFE

X

No cellular egress of iron

Transferrin receptors

Apoferritin

Synthesized in liver. Present in blood

Synthesized in the liver.2000 LEAP-1 purified from human blood.2001,isolated from human urine.Lack of hepcidin expression--- iron

overload.No IREs identified in hepcidin transcript.Is a negative regulater of iron absorption

in duodenum &of iron release from macrophage.

Is secreted in response to change in the ratio of diferric Tf in the circulation to TfR1.

Changes detected by TfR2&HFE-TfR1. It directly influences the expression of

DMT1 & ferroportin in enterocytes, there by regulating absorption in response to body iron requirements.

HIGH IRON

Ribosome

IRE TransferrinMessage

Fe Fe

Fe

IREBindingProtein

Fe Fe

Fe

Fe IREBindingProtein

Fe

Fe Fe Fe+

LOW IRONTransferrinIRE

Fe

LOW IRON

Ribosome

IRE FerritinMessage

Fe Fe

Fe

IREBindingProtein

Fe Fe

Fe

Fe IREBindingProtein

Fe

Fe Fe Fe+

HIGH IRONFerritinIRE

Several biological mechanisms potentially link iron deficiency with impaired cognitive performance. Iron deficiency results in decreased body iron stores, including decreased iron in the central nervous system, even before red blood cell production is affected. Disordered cerebral oxidative metabolism attributable to low levels of heme-containing and iron-dependent enzymes.

Iron deficiency anemia is associated with developmental difficulties in infancy and early childhood. Specifically, infants with iron deficiency anemia have lower scores on the Bayley Scale of Mental Development compared with iron-sufficient infants. Furthermore, behavioral and cognitive symptoms often improve with iron-replacement therapy, in many instances before an increase in the hemoglobin concentration