IRON DEFICIENCY ANEMIA(IDA) 医学学习课件.pptx
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IRON DEFICIENCY ANEMIA(IDA) 医学学习课件.pptx
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IRONDEFICIENCYANEMIA(IDA)山东大学齐鲁医院陈春燕教授仅限学术交流,IDAISTHEMOSTPREVALENTANEMIATHROUGHOUTTHEWORLD!
Epidemiology,Infants:
incorrectfeeding,Pregnantwoman,Teenagersrapidgrowth,CASEREPORT,A36-year-oldwomanpresentedwithgeneralmalaiseforthepast3months.Historyrevealedheavyperiodsforthepastyear.PEapalewell-nourishedladyandchest,heartandabdomanexamarenothingremarkable.LabFindingsCBCHb78g/L,MCV69fl,normalrenalandliverfunction,normalurinalysisandfecalroutine.,QUESTIONS,Whatisyourpreliminaryimpressionofthepatient?
Whatlabtestsshouldbeorderednexttoconfirmthediagnosis?
Doyouthinkabonemarrowtestisneeded?
Whichisthemostusefultest(ortests)forthediagnosisinthispatient?
Afterdiagnosishowdoyouplantotreatthepatient?
Hemoglobin,Hemoglobinprotein4polypeptides2chainsand2chainsEachchaincontainsasinglemoleculeofheme,aniron-containingpigmentTheironioninhemeisabletoreversiblybindanoxygenmolecule.Meaning,O2canbindtoHbatthelungsandthenbereleasedatthetissuesNotethe2chainsandchains.Noticehoweachhasanassociatedhememoleculewithanironatom.,METABOLISMOFIRON,SourceandabsorptionDietaryiron(mainsource,10-15mg/d)10%dietaryironabsorbedbythebodyOnlyFe+2andhemeironcanbeabsorbedAbsorbedfromtheduodenumandupperjejunum.PromotionandinhibitionofironabsorptionVitaminCincreasesabsorptionbyreducingdietaryferrictoferrousiron.Caffeine,cheese,cerealandteadecreaseabsorption.,IRONABSORPTION,Fe3+,heme,Dcytb,DMT1,HCP1,HOxy,IREG1,hephaestin,Fe3+-TF,Fe2+,Hepcidin,HOxy=hemeoxygenase(血红素氧化酶)IREG1(膜铁转运蛋白1)hephaestin(膜结合铁氧化酶)TF=transferrin(运铁蛋白)Hepcidin(铁调素),Dcytb=duodenalcytochromeb(铁还原酶,十二指肠细胞色素b)DMT1=divalentmetaliontransporter-1(二价金属离子转运蛋白1)HCP1=hemecarrierprotein1(亚铁血红素携带蛋白1),Fe2+,heme,Fe2+,IRONHOMOESTASIS,Ferritin,SideroblastIREG1(膜铁转运蛋白);TF=transferrin(运铁蛋白);TfR=transferrinreceptor(运铁蛋白受体),IREG1(膜铁转运蛋白)TransmembraneirontransporterExportsFeintobloodfromgut,liverandmacrophageRegulatesplasmaFeleveltokeeptransferrin35%saturatedCornerstoneoftheinternalironcircuitHepcidinPeptide(25AA)madeprimarilyinliverNegativeregulatorofFereleasefromgut,liverandmacrophageSynthesisinducedbyincreasedFestorageandinflammationSynthesissuppressedbyFedeficiencyandhypoxemia,ADVANCESINIRONMETABOLISM,METABOLISMOFIRON,TransportationofironTransferrin(transportorofiron)totaliron-bindingcapacity(TIBC)Sideroblast(intracellulariron),TfRdependpathway,Sideroblast,METABOLISMOFIRON,DistributionandstorageofironIroninalltissuesofthebodyMalefemale(50mg/kgvs35mg/kg)Hb65%,myoglobin6%,storage25%FerritinHemosiderinironenzymes,hemosiderininmacrophagesofalveolus,RecyclingandexcretionofironDailyrequirement20-25mg(fromRBC)1.0-1.5mg/dfromabsorbedironVeryconservativeinexcretion:
bodycellsmale0.5-1.0mg/d,female1.0-1.5mg/d,METABOLISMOFIRON,ETIOLOGYANDPATHOGENESIS,DYNAMICBALANCEBTWABSORPTIONANDEXCRETION(IRONHOMEOESTASIS).NEGATIVEBALANCERESULTSINIRONDIFICIENCY.,ETIOLOGYANDPATHOGENESIS,InadequateintakeandincreasedrequirementDietaryallowance(M5-10mg,F7-20mg/d)RapidgrowthinchildhoodIncorrectfeeding(non-breastfeeding)MenorrhealossPregnancyLactation,ETIOLOGYANDPATHOGENESIS,DisturbanceinironabsorptionDietarycontents(animalorplant)GastrointestinalfactorsMedication,ETIOLOGYANDPATHOGENESIS,ExcessivelossofironChroniclossofblood(commonest):
Menorrhealoss,GastrointestinalfactorsIncreasedexcretionfromurine(intravascularhemolysis)CopperdeficiencyHemodialysis,ETIOLOGYANDPATHOGENESIS,CLINICALMANIFESTATION,IDAISASIGNOFMANYDISEASES.ITSMANIFESTIONSCONSISTOFTWOPARTSCLINICALPICTURESOFANEMIAUNDERLYINGDISORDER,CLINICALMANIFESTATION,CLINICALMANIFESTATION,Generalpicture(non-specific)PallorFatigue,malaiseHeadache,lightheadednessTinnitus(ringingnoise),CLINICALMANIFESTATION,SkinandmucosaThinorflatnail(spoon-like)AtrophyoflingualpapillaSmoothtongueGlossitis(uncommon),CLINICALMANIFESTATION,SystemicmanifestationsCardiovascularandpulmonary(palpitation,dyspnea)Alimentary(anorexia,loosestool,constipation,pica,gastritis)Increasedsusceptibilitytobacterialinfections,LABORATORYFINDINGS,MorphologyBloodfilmMicrocytichypochromicanemiaEnlargedcentralpallorofRBCNormalWBCNormalplatelet(increasedinsome),NormalBloodSmear,BloodSmearofIDA,anincreasedzoneofcentralpallor.Thisisindicativeofahypochromic(lesshemoglobinineachRBC)microcytic(smallersizeofeachRBC)anemia.,Theyhaveazoneofcentralpallor(about1/3thesizeoftheRBC).,HISTOGRAMofMCVUpper:
NormalMCVLower:
IDAMCV,LABORATORYFINDINGS,MorphologyBonemarrowHypercellularMildormoderateerythroidhyperplasiaNormalmegakeryopoiesisandgranulopoiesisDecreasedorabsenceofironstain,骨髓外铁染色,骨髓内铁染色,LABORATORYFINDINGS,BiochemistryIronmetabolism-Serumiron8.95,mol/L(500g/L),mol/L(3600,g/L),Totalironbindingcapacity64.44Transferrinsaturation15%,Ferritin14g/L-storageofironErythropoiesisinirondeficiencyIncreasedfreeRBCprotoporphyrinIncreasedRBCfreeprotoporphyrin/Hbratio,DIAGNOSISOFIDA,Microcytichypochromicanemia(MCV64.44mol/L(3600g/L)Transferrinsaturation0.9umol/LorFEP/Hb4.5ug/gHbSerumferritin14g/LPositivetreatmenttrialwithiron,DIAGNOSISOFIDA,3phase,DIAGNOSISOFIDA,History&PEare:
SufficienttoexcludeseriousdiseaseChild-carrying-agedwomen(menorrhagia)WomeninpregnancyorlactationIfHbless20g/Lin4weeks,re-evaluatecausesInsufficienttomakediagnosisofIDAOldmen(ysPostmenopausalwomen,DIFFERENTIALDIAGNOSIS,AnemiaduotoabnormalglobinHemoglobinopathiesThalassemiaAnemiaofchronicdisease(ACD)MicrocytichypochromicinpartofptsDecreasedserumironIncreasedferritinandironstorageSideroblasticanemiaCongenitalAcquiredRingedsideroblastsinmarrow15%Increasedserumironandferritin,Ringedsideroblasts,DIAGNOSISANDDIFFERENTIAL,KeystoDiagnosisHistoryofnegativeironbalance(reliability?
)Microcyticanemia(MCV75fl)Serumferritin14g/LMarrowironextracellular(-)Intra15%(onlyindicated)IDAinmenandpost-menopausalwomenJustifiesGIexamorreferraltoGIdoctorMedication,suchasNSAIDs,stoppedifpossible,TREATMENT,Causaltreatment(mostimportant)Ironsupplement,TREATMENT,OralironsupplementFe+2:
ferroussulphate100mgb.i.d1hrbeforemealIncreasedretic7-10daysIncreasedHb2weeksRestoreHblevel1-2months3monthstorestoreironreserve!
SideeffectsNauseaGastricdiscomfortConstipationDiarrheaHeartburnabdominalcrampsGoodideatostartpatientsonsmalldosesandincreasegradually.,TREATMENT,Parenteralironsubstitutionirondextran,ironsucrose,etc.indication-Poortelerancefororaliron(nausea,diarrhea)disorderofgastrointestinaltractbadabsorptionnegativebelanceofiron(hemodialysis)administration50-100mgdailyIvroute,lethalanaphylaxis,avoidedwheneverpossibleImroutemuchsaferTotaldose(mg)=NHb-PHb(g/L)BW(kg)0.24+(500-1000)mg,AnabbreviatedflowchartofthetreatmentofIDA,Oralirontolerated,no,abnormal,Considerfurtherinvestigation;Bloodtransfusionifanaemiaissevere.,CheckFBCmonthlynormal,Oraliron,IDA,Treatcauseifpossible,Considerparenteraliron,RecheckFBCevery3month;Afterafurtheryeargivingafurtherironasnecessary,NormalFBCmaiteined,Continueironforanother3-6monthno,Nofurtheractionunlessfurthersymptons,yes,TREATMENT,Bloodtransfusionisnotindicatedexceptforlife-threateninganemiabecauseofquickrecoveryofanemiaafterirontherapy!
ADVANCESINTHERAPHY,OralirontherapyisthemostwidelyprescribedtreatmentforIDA.issuespreventoralironsupplementation,difficultiesofingestingofthetablet,sideeffects,compliance,boweldisease,gastrointestinaldisturbances,colickypain,nausea,vomiting,diarrhoea,and/orconstipationtheeffectivenessoforalironislargelycompromised,IViron,Now:
typeIIandIIIironbettertoleratedrapidrepletionofironstores。
past:
undesirablesometimesserioussideeffectslimitedinuse,IViron:
aneffective,rapid,andsafetreatmentoption.avoidorreducethedemandforbloodtransfusions;effectiverapidrepletionofironstores,PROPHYLAXIS,PopulationpronetoirondeficiencyWomen(menses,pregnancy,lactation)Child(rapidgrowth)MeasuresTreattheunderlyingdiseasesIncreaseironin-take(iron-richfood)Reduceirondepletors(coffee,teaetc.),Answertothatcase,Q.Whatisyourpreliminaryimpressionofthepatient?
A.IDAshouldbeinconsideration.Q.WhatlabtestsshouldbeorderednexttoconfirmaDx?
A.Serumiron,ferrritinQ.Doyouthinkabonemarrowtestisneeded?
A.No!
Q.Whichisthemostusefultest(tests)fortheDxinthispatient?
A.CBC,ferritinQ.Afterdiagnosishowdoyouplantotreatthepatient?
A.Oralironpreparations,MedicolegalPitfalls,FailuretoinvestigatetheetiologyofIDAcausingadelayedormisseddiagnosisofneoplasmGivingirontopatientswhohaveamicrocyticiron-overloadingdisorder(eg,thalassemia,sideroblasticanemia)FailuretopromptlyandadequatelytreatapatientwithIDAwhoissymptomaticwithacomorbidconditionsuchascoronaryarterydiseaseAnaphylaxiscausedbytheuseofparenteralirontherapyinpatientswhoshouldbetreatedwithoraliron,QUESTIONS,Whatisirondeficiencyanemia?
Howisironabsorbed?
Whatkindoffoodisrichiniron?
WhatarethemorphologicalfeaturesofIDA?
WhichpreparationdoyouprefertousetotreatIDA,oralorinjectionagent?
Howtopreventthepregnantfromirondeficiency?
APLASTICANEMIA(AA),山东大学齐鲁医院血液科陈春燕教授,CASEREPORT,A40-year-oldmaleteachercomplainedofprogressiveLassitudeworseninginthepast3months.Easybruisingwasnotedinrecentdaysandurgedhimtoseekmedicalcare.History-takingNohistoryofexposuretosuspiciouschemicalsormedication.PEApallormanwithotherwisenormalPEexceptforscatteredskinecchymosisonbothlowerextremities.Lab
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