Download - Abordaje anemia ferropenica
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MARIANELLA RODRIGUEZ MRESIDENTE DEL 1ER NIVEL
UNIVERSIDAD DE CARABOBOPOST GRADO DE MEDICINA INTERNA
HOSPITAL CENTRAL DE MARACAY
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• Ciclo del hierro: Metal vital: Catalasas Peroxidasas Oxigenasas
Riboucléotidos Desoxirribonucléotidos
Ribonucléotido reductasa
ADNPotencial Redox
Andrews NC, Bridges KR. Disorders of iron metabolism and sideroblastic anemia. In: Nathan DG, Orkin SH, eds. Nathan and Oski's hematology of infancy and childhood. 5th ed. Vol. 1.
Philadelphia: W.B. Saunders, 2000:423-61.
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• Distribución del hierro en el organismo: Compartimento A: *.- Hemoglobina 60% *.- Mioglobina 15% *.- Transferrina 0.2% *.- Enzimas 20% Compartimento B: *.- Ferritina *.- Hemosiderina
Cook JD, Barry WE, Hershko C, Fillet G, Finch CA. Iron kinetics with emphasis on iron overload. Am J Pathol 1999;72:337-343. [Medline]
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METABOLISMO DEL HIERRO
Fe+ destrucción SER 20-30mg Ingesta 1-2 mg
Incorpora precursores eritroidesSudorOrinaheces
10% Absorción Proteasas del intestino grupo hemo Poll cell
Kohn LT, Corrigan JM, Donaldson MS, eds. To err is human: building a safer health system. Washington, DC: National Academy Press, 2000.
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Hierro Heminico
Acido ClorhidricoFerroreductasasMemb. Enterocito
F2+ solubleProteina Transport
DMTIIRP
REGION 3 ARNm
IRP FERROPENICA
published: N Engl J Med 2000;342(5):364. Disorders of Iron Metabolism
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Citoplasma Fe+ reduc
Oxidado Cupro
proteina
Hephestina
PlasmaSLCA3Ferroportina IMTPI
Almacenada como ferritina
Disorders of Iron Metabolism published: N Engl J Med 2000;342(5):364.
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Absorción Criptas de LiberkhunEntorocitos inmaduros No intraluminal
Recp de la trasferrina (RcTf)
published: N Engl J Med 2000;342(5):364. Disorders of Iron Metabolism
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• Etapas: A.- Feropenia Pre latente: Fe B.- Ferropenia latente: ferritina C.- Eritropoyesis ferropénica.
Aisen P, Wessling-Resnick M, Leibold EA. Iron metabolism. Curr Opin Chem Biol 2000;3:200 206. [CrossRef][Medline]
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ISLOTE ERITROBLASTICO: UNIDAD FUNCIONAL
ERITROPOYESIS FERROPENICA
MACROFAGOS +ERITROBLASTOS
ROFEOCITOSIS
CEDE FE+
SINTESIS DE Hb ¬ Fe++
ERITROBLASTOS
MICROCITOSISHIPOCRONICA
Aisen P, Wessling-Resnick M, Leibold EA. Iron metabolism. Curr Opin Chem Biol 2000;3:200 206. [CrossRef][Medline]
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•CAUSAS DE FERROPENIA: -INGESTA INADECUADA - MALABSORCION
- HEMOLISIS INTRA VASCULAR
Aisen P, Wessling-Resnick M, Leibold EA. Iron metabolism. Curr Opin Chem Biol 2000;3:200 206. [CrossRef][Medline]
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DEFICIT DEL HIERRO
FASE I :HIPOFERRITINEMIA
PARAMETROS NORMALES
DEFICIT DE HIERRO
[FERRITINA EN PLASMA] < 12 µg/L
Abs Fe++TRANSFERRINA NO CAMBIA
DEPOSITOS DE FE++ ¬
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DEFICIT DEL HIERROFASE II :
CAP. UNION AL METAL
NO ANEMIA
DEFICIT DE HIERRO CON ALTA ERITROPOYESIS
TRANSFERRINA
FE++ SERICO
PLASMA FE++
[TRANSFERRINA INSATURADA]
% SATURACION TRANSFERRINA + FE <15%
PROTOPORFIRINA >100 µg/dl
MEDULA OSEA
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DEFICIT DEL HIERRO
FASE III :
SINTESIS DE HEMOGLOBINA
ANEMIA FERROPRIVA
Aisen P, Wessling-Resnick M, Leibold EA. Iron metabolism. Curr Opin Chem Biol 2000;3:200 206. [CrossRef][Medline]
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• HEPCIDINAS:
- Descritas como LEAP 2000
- Metabolismo FE+ 2001
- Homeostasis del hierro
- Sobrecarga
- Anemia Ferropenica
Andrews NC, Bridges KR. Disorders of iron metabolism and sideroblastic anemia. In: Nathan DG, Orkin SH, eds. Nathan and Oski's hematology of infancy and childhood. 5th ed. Vol. 1.
Philadelphia: W.B. Saunders, 2000:423-61.
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- Aislado en orina
- Sintetizado por el higado
- Propiedades anti-microbianas
- Gen cromosoma 19
- 20-25 aminoacidos
Fleming MD, Trenor CC III, Su MA, et al. Microcytic anaemia mice have a mutation in Nramp2, a candidate iron transporter gene. Nat Genet 2003;16:383-386
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SISTEMA DE HEPCIDINA
HORMONA
SINUSOIDES
HEPCIDINA EN SANGRE
HEPATOCITOS
CITOQUINAS
MACROFAGOS
SAT. TRANSFERRINA
ABSORCION FE++
DUODENO
ORINA (SOBRECARGA, INFECCION, EMFERMEDAD INFALATORIA)
CORRELACIONA FERRITINA
¬
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a) Interrogatorio:
- Tipo de dieta. Déficit en la ingesta de alimentos ricos en hierro. Exceso de carbohidratos y leche.
- Antecedentes de prematurez, embarazos múltiples y déficit de hierro en la madre.
Fleming MD, Trenor CC III, Su MA, et al. Microcytic anaemia mice have a mutation in Nramp2, a candidate iron transporter gene. Nat Genet 2003;16:383-386
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- Antecedentes de patología perinatal.
- Pérdida de sangre: color de heces, epistaxis, disnea, hematuria, hemóptisis, etc.
- Trastornos gastrointestinales: diarrea, esteatorrea, etc.
- Procedencia geográfica: zonas de parasitosis endémicas (uncinariasis).
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b) Examen físico:
- Detención del desarrollo pondoestatural.
- Palidez cutaneomucosa.
- Esplenomegalia leve (10% de los casos).Si la misma es importante, debe plantearsela posibilidad de otra patología.
- Telangiectasias en piel.
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Estudio de laboratorio:c1. Hemograma:
- Concentración de Hb: disminuida.
Hematócrito: disminuido.
-Frotis de sangre periférica: hipocromía,
-policromatofilia o punteado basófilo (eventualmente)
- Reticulocitos: generalmente normales.
Fleming MD, Trenor CC III, Su MA, et al. Microcytic anaemia mice have a mutation in Nramp2, a candidate iron transporter gene. Nat Genet 2003;16:383-386
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-Plaquetas: normales. Si están elevadas, investigar pérdidas por hemorragia.
-Leucocitos: normales.
-Indices hematimétricos:- (VCM) dism.
- (CHCM) dism.
Fleming MD, Trenor CC III, Su MA, et al. Microcytic anaemia mice have a mutation in Nramp2, a candidate iron transporter gene. Nat Genet 2003;16:383-386
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Pruebas que evalúan el hierro del compartimiento funcional:
- Sideremia: disminuida (< 60 μg/dl).
- Capacidad total de saturación del hierro (TIBC): , a menos que coexista proceso infeccioso, inflamatorio o tumoral.
- Porcentaje de saturación: disminuido (< 16%). - Protoporfirina libre eritrocitaria: (> 70 μg/dl).
- Receptores solubles de transferrina: (> 30 nMol/l).
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c3. Pruebas que evalúan el hierro del compartimiento de depósito:
- Ferritina sérica: disminuida (< 12ng/ml), excepto que coexista proceso infeccioso o inflamatorio.
Cook JD, Barry WE, Hershko C, Fillet G, Finch CA. Iron kinetics with emphasis on iron overload. Am J Pathol 2005;72:337-343
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Prueba terapéutica:
- Administrar hierro a dosis terapéuticas y evaluar si hay respuesta reticulocitaria adecuada a los 7-10 días.
Cook JD, Barry WE, Hershko C, Fillet G, Finch CA. Iron kinetics with emphasis on iron overload. Am J Pathol 2005;72:337-343
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PREVENTIVO:
-EVITAR LA FERROPENIA- SUPLEMENTOS DE FE++ POBLACION EN RIESGO-PAISES DESARROLLADOS
VIA ORAL:
-SALES FERROSAS: > ABSORCION 100-200 mg 2-3 TABS BID
-TTO POR 10 SEMANAS-100 mg/DIA POR 3 MESES RESTITUYE MO
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VIA PARENTERAL -CIRUGIA GASTROINTESTINAL HEMORRAGIA ACTIVA
-INTOLERANCIA
Fe (mg)=(Hbi-Hbr)XPESOX2,2+1000
DEXTRAN
Looker AC, Dallman PR, Carroll MD, Gunter EW, Johnson CL. Prevalence of iron deficiency in the United States. JAMA 2007;277:973
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ANEMIA MEGALOBLASTICA
- CONSECUENCIA DE DEFECTO BIOQUIMICO - ENLENTECIMIENTO DE SINTESIS DE AND
- DEFICIT ABSOLUTO O RELATIVO
Toh BH, van Driel I, Gleeson P. Pernicious anemia.
NEJM 2001, 337: 1441-8
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95% CARENCIA DE FOLATOS- COBALAMINA
ACIDO FOLICO: 3 UNIDADES CARACTERISTICAS.
PTERIDINA1 MOLECULA DEACIDO PARA-AMINOBENZOICO1 O MAS RESIDUOS DE ACIDO L GLUTAMICO
Toh BH, van Driel I, Gleeson P. Pernicious anemia.
NEJM 2001, 337: 1441-8
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ANEMIA MEGALOBLASTICA
FUENTES DIETETICAS:
- VEGETALES, HOJAS VERDES Y AMARILLAS
- LEGUMBRES
- CEREALES
- FRUTOS CITRICOS
- HIGADO Y RIÑON -DESTRUIDOS POR LA LUZ Y CALOR
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REQUERIMIENTOS:
-200 mg/dl EN HOMBRES
-180 mg/dl EN MUJERES
ABSORCION:
YEYUNO BORDE CEPILLO MUCOSAPOLIGLUTAMATOS
FOLATOS HIDROLASASMONOGLUTAMATOS
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ANEMIA MEGALOBLASTICA
FUNCION METABOLICA:
- TRANSFIERE FRAGMENTOS DE ATOMO DE CARBONO
- ACTUA COMO CO-ENZIMA
- FORMULACION DE RIBONUCLEOTIDOS
Baik H, Russell R. Vitamin B12 deficiency in the elderly.
Ann Rev Nutr 2007, 19: 357-77
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VALORES NORMALES: DEFICIT:
FOLATOS: 3.1-17.5 mg/dl 2.2 mg/dl
COBALAMINA: > 250 pµ/ml <125pµ/ml
•Kaptan K, Beyan C. Helicobacter pylori-is it a novel causative agent in B12 deficiency?. Arch Intern Med 2007, 160: 1349-53
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HEPTOCORINA
VIT B12
SALIVA
ACIDOS Y PEPTINA
DUODENOENZIMAS PANCREATICAS
(HIDROLIZA)
COBALAMINA + FACTOR INTRINSECOPROTEGE DE ENZIMAS
PROTEOLITICAS
ABSORBE EN ILEON
FACTOR INTRNSECO B12
CEL ENTERICAS
FACTOR INTRINSECO DEGRADADO
COBALAMINA
CIRCULACION PORTAL
TRANSCOBALAMINA II
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ANEMIA MEGALOBLASTICA
DIAGNOSTICO:
- HEMOGRAMA:
SERIE ROJA
MICROSITOSIS CON VCM >100 fl
HCM
OVALOSITOS, DACROSITOS, CUERPOS DE INCLUSION EN SANGRE
INDICE DE ANISOCITOSIS
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ANEMIA MEGALOBLASTICA
DIAGNOSTICO:
- HEMOGRAMA:
SERIE BLANCA
LEUCOPENIA
HIPERSEGMENTACION DE NEUTROFILOS
TROMBOCITOPENIA
•Kaptan K, Beyan C. Helicobacter pylori-is it a novel causative agent in B12 deficiency?. Arch Intern Med 2007, 160: 1349-53
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ANEMIA MEGALOBLASTICA
DIAGNOSTICO:
- ASPIRADO DE MEDULA
HIPERCELULARIDAD PRECURSORES ERITROIDES
NUCLEOS INMADUROS
CITOPLASMA HEMOGLOBINIZADO
•Kaptan K, Beyan C. Helicobacter pylori-is it a novel causative agent in B12 deficiency?. Arch Intern Med 2007, 160: 1349-53
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ANEMIA MEGALOBLASTICA
BIOQUIMICA
-COBALAMINA EN SUERO < 200 pg/ml (DOS DETERMINACIONES)
-ACIDO METILMALONICO Y HOMOCISTEINA
-ACIDO FOLICO EN SANGRE < 4 mg/ml
Nyholm E, Turpin P. Oral vitamin B12 can change our practice. Postgraduate Med J 2003, 79: 218-20
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ANEMIA MEGALOBLASTICA
TRATAMIENTO: (OBJETIVOS)
- CORREGIR LA ANEMIA
- CORREGIR LOS TRANSTORNOS EPITELIALES
- LOS TRANSTORNOS NEUROLOGICOS
Nyholm E, Turpin P. Oral vitamin B12 can change our practice. Postgraduate Med J 2003, 79: 218-20
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ANEMIA MEGALOBLASTICA
TRATAMIENTO:
- CIANOCOBALAMINA V.O 50-150 mg/DIA
PAUTAS:
-VIT B12 1mg IM OD POR 1 SEMANA- VIT B12 1mg SEMANAL DURANTE UN MES- VIT B12 1mg MENSUAL DURANTE TODA LA VIDA
- ACIDO FOLICO: 5-10 mg/DIA HASTA NORMALIZAR
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