ANEMIA HEMOLITIK

Penyaji : Vincentia Maria Iriane Moderator : dr. Hani Susianti, SpPK

Pendahuluan

Pada anemi hemolitik, penghancuran sel darah merah secara signifikan memperpendek masa hidup normal eritrosit dalam sirkulasi perifer, yaitu sekitar 120 hari. Destruksi eritrosit dapat terjadi :
Intravaskular

(eritrosit dihancurkan dalam

vaskuler) Ekstravaskuler (eritrosit dihancurkan oleh makrofag hati, limpa, atau sumsum tulang)

Hemolisis Intravaskuler
Intravascular hemolisis biasanya parah dan timbul dari beberapa mekanisme : Kerusakan mekanis pada sel darah merah yang disebabkan oleh:

Keberadaan fibrin dalam lumen vaskuler (disseminated intravascular coagulation atau vaskulitis) Trauma fisik dari sel darah merah saat melewati katup prostetik atau vaskuler kecil pada kaki Cedera termal pada luka bakar Infeksi, seperti malaria Racun, misalnya racun dari beberapa ular berbisa.

Kerusakan eritrosit karena complement-mediated damage yang disebabkan oleh :

Cold agglutinins Transfusi sel darah merah yang tidak kompatibel Hemoglobinuria nokturnal paroksismal

Hemolisis Ekstravaskuler

Dalam kebanyakan kasus anemia hemolitik, penghancuran sel darah merah terjadi secara ekstravaskuler. Penyebab meliputi:
lingkungan

abnormal dalam sirkulasi karena infeksi, obat-obatan, atau proses imunologi kelainan membran eritrosit kerusakan metabolisme sel darah merah kelainan pada struktur hemoglobin.

Gangguan Intrinsik dan Ekstrinsik

Gangguan intrinsik meliputi:

hemoglobin abnormal, kerusakan enzim, kelainan membran

Gangguan ekstrinsik adalah :

imunologi, faktor mekanis, infeksi dan racun, penyakit hati, hipersplenisme

Laboratorium

Kelainan morfologi sel darah merah mungkin terlihat pada hapusan darah, seperti sel sabit, bite cell, schistocytes, dan spherocytes. Aglutinasi sel darah merah akibat peningkatan IgM Organisme seperti parasit malaria, dan konsumsi eritrosit oleh makrofag (erythrophagocytosis), yang terutama menunjukkan anemi hemolitik imun, tetapi juga dapat terjadi dengan infeksi atau racun. Hapusan darah pada anemia hemolitik menunjukkan polychromatophilia yang disebabkan oleh peningkatan rilis sel darah merah belum matang dari sumsum tulang (Indeks retikulosit > 3 dan jumlah retikulosit > 100.000/mm3) Bilirubin indirek meningkat dan merupakan> 80% dari total bilirubin Serum LDH meningkat

Laboratorium

Pada hemolisis intravaskuler :

Hemoglobin

dilepaskan ke sirkulasi Haptoglobin (menurun) Free hemoglobin dikeluarkan melalui ginjal Hemosiderin urin +

Laboratorium

Pada hemolisis ekstravaskuler :

tes

Coombs mendeteksi imunoglobulin dan komplemen pada permukaan sel darah merah, mengindikasikan hemolisis akibat proses imun. Elektroforesis hemoglobin diindikasikan untuk kecurigaan hemoglobinopathies.

Anemia Hemolitik Autoimun (AIHA)

Pendahuluan

Autoimun anemia hemolitik (AIHA) terjadi ketika pasien memproduksi antibodi patologis yang menempel pada eritrosit dan menyebabkan kehancuran (hemolisis) eritrosit dengan anemia sebagai konsekuensinya.

Antibodi

Cold antibodi

memiliki sedikit aktifitas pada suhu tubuh, aktifitasnya meningkat pada penurunan suhu hingga 0 C IgM, selalu melibatkan komplemen, mengakibatkan kerusakan RBC secara intravaskular atau hepaticmediated clearance
aktifitasnya tinggi pada suhu 37 C biasanya IgG, melibatkan/tidak melibatkan komplemen, terutama menyebabkan kerusakan RBC dengan destruksi splenic sel yang tersensitisasi.

Warm antibodi

Pada pasien dengan mix cold and warm antibodi, umumnya terjadi kerusakan RBC yang parah dan sering berrespon buruk terhadap terapi.

Toleransi Imunologik

adalah suatu keadaan dimana sistem imunitas tidak memberikan respon terhadap antigen yang diinduksi oleh paparan terhadap antigen sebelumnya

Toleransi Imunologi k

AIHA

HLA DQ-6 dikaitkan dengan AIHA Namun, seperti kebanyakan penyakit autoimun lainnya, asosiasi genetik bersifat multifaktorial Inflamasi termasuk infeksi virus dan bakteri diyakini terlibat sebagai pemicu autoimunitas, melalui :
Molecular mimicry Mekanisme yang mungkin lain melibatkan produksi interferon selama infeksi virus yang menyebabkan upregulation FcRI. Infeksi virus dapat menyebabkan perubahan dalam pola ekspresi reseptor Fc sebagai akibat dari aktivasi transkripsi atau mekanisme lain

AIHA

Dalam kasus AIHA, antibodi diarahkan terhadap antigen RBC , yang menyebabkan clearance melalui Fc-reseptor-mediated phagocytosis (hemolisis ekstravaskuler) atau complement-mediated breakdown (hemolisis intravascular) Ada bukti bahwa AIHA terutama akibat selfreactive antibodies terhadap eritrosit band 3, sebuah transporter anion yang ditemukan di membran eritrosit yang juga telah terbukti terlibat dalam penuaan RBC

Klasifika si AIHA

Mekanisme Kerusakan RBCIgM

Dimediasi oleh sistem komplemen :

Secara

langsung oleh sitolisis, menyebabkan hemolisis intravaskular melalui membran attack complex (MAC) pada permukaan RBC Tidak langsung melalui interaksi aktivasi RBCterikat dan degradasi fragmen C3 dengan reseptor spesifik pada sel retikuloendotelial, terutama makrofag hati (sel Kupfer). Gangguan pada aktifitas inhibisi DAF (CD55) dan MIRL (CD59) pada permukaan RBC dan mengakibatkan hemolisis

Mekanisme Kerusakan RBCIgG

Melalui aktivasi jalur komplemen klasik, jarang (pengecualian pada antibodi Donath-Landsteiner pada PCH) Dengan tidak adanya aktivasi komplemen, clearance eritrosit tersensitisasi IgG terutama di limpa
Ikatan pada reseptor Fc oleh makrofag jaringan pada limpa dapat memediasi fagositosis langsung dan lengkap Fagositosis parsial, di mana fagosit menghilangkan sebagian membran, menyebabkan penurunan surface area-to-volume ratio (ct : spherocytes, tanda morfologi klasik anemia hemolitik imun)

KERUSAKAN RBC OLEH IgM dan IgG

Pemeriksaan Laboratorium

Complete blood count (CBC) hapusan darah (spherocytes di warm AIHA atau aglutinasi RBC di cold AIHA) Bilirubin unconjugated laktat dehidrogenase (LDH, terutama isoenzyme 1), haptoglobin, hemoglobin urin atau hemosiderin retikulosit count hemoglobinemia methemalbuminemia

Pemeriksaan Serologi

Antibodi IgM mampu mengaglutinasi salinesuspended RBCs tanpa reagen (complete" antibodi). Sebaliknya, IgG antibodi biasanya membutuhkan antihuman globulin (AHG) (incomplete" antibodi). Pemeriksaan meliputi :
Direct antiglobulin test (DAT, Coombs direk) Indirect antiglobulin test (IAT, Coombs indirek) Elusi Lainnya (Autoadsorption dan fenotip antigenik)

DAT

DAT positif tidak selalu terjadi penurunan RBC survival, harus diintepretasi bersama klinis dan pemeriksaan laboratorium yang lain DAT positif juga dapat dijumpai pada :

alloantibodies pada resipien transfusi RBC atau plasma, antibodi dari sirkulasi ibu yang melintasi plasenta dan melapisi sel darah merah janin, antibodi terhadap obat-obatan tertentu yang mengikat membran RBC (misalnya, penisilin), Adsorbed protein nonspesifik termasuk imunoglobulin dan Wharton's jelly, RBC-terikat komplemen, antibodi yang diproduksi oleh limfosit pada transplantasi organ atau komponen hematopoetik

DAT negatif tidak menyingkirkan AIHA. Kemungkinan penyebab dari DAT negatif dengan bukti klinis hemolisis meliputi autoantibody IgA atau IgM, molekul antibodi terlalu sedikit, dan adanya autoantibodies afinitas rendah

Deteksi IgG

Teknik lainnya :
flow

cytometry, enzyme-linked antiglobulin test, radioimmunoassays menggunakan 125I-labeled anti-IgG atau protein staphylococcal A, Teknik solid-phase dengan microtiter plates, Gel testing

Elusi

Jika DAT positif antibodi pada permukaan RBC bisa dielusi (dihapus) dari RBC dengan bantuan asam atau xylene, kemudian diuji dengan reagen panel RBC. Pada kondisi dimana kehadiran antibodi dicurigai tapi mungkin konsentrasinya terlalu rendah untuk dapat terdeteksi pada sel darah merah, elusi bisa menunjukkan reaktivitas. Elusi cenderung menghasilkan solusi antibodi lebih terkonsentrasi, sehingga reaksi lebih kuat. Setelah antibodi ini dalam larutan, teknik IAT dapat membantu menilai karakteristik antibodi

Autoadsorption

Autoadsorption dan fenotip antigenik dapat membantu membedakan autoantibodies dan alloantibodies, terutama pada pasien yang belum mendapat transfusi
Autoadsorption

negatif : alloantibody Autoadsorption positif : autoantibody

Autoadsorption juga dapat digunakan untuk cross-match donor RBC pada pasien dengan warm autoantibodies (untuk pasien yang belum ditransfusi)

CAD

Cold agglutinin disease (CAD) is associated with IgM antibodies usually directed at the RBC I antigen. CAD typically occurs in adult patients and may be primary or secondary to another disease process, usually infectious Natural cold autoantibodies occur in titers at less than 1:64 at 4C and have no activity at temperatures much higher than that. However, pathologic cold agglutinins typically have titers well over 1:1,000 and may react at 28 31C or even up to 37C

CAD

Mild, chronic hemolytic anemia with exacerbations in the winter is the general rule for CAD. Rarely does the hemoglobin drop below 7 g/dl. Pallor and jaundice. Acrocyanosis can occur from agglutination of RBCs in the cooler vessels of the hands, ears, nose, and feet. Mild splenomegaly or hepatomegaly.

CAD

Mild chronic anemia, but the hemoglobin may fall to 5 to 6 g/dl, especially in the winter months in cold climates. The peripheral smear, may show significant agglutination and RBC clumping. The RBC count is artifactually low and the MCV artifactually elevated, producing a spuriously high MCHC. The reticulocyte count is elevated Bilirubin is mildly elevated and rarely >3 mg/dl. LDH may be increased complement and haptoglobin can be low or absent. hemoglobinuria and hemoglobinemia. The DAT can be positive

PCH

intermittent attacks of pain, fever, and hemoglobinuria following exposure to cold. Paroxysmal cold hemoglobinuria (PCH) is caused by the so-called Donath-Landsteiner antibody, an IgG hemolysin The D-L antibody is a hemolysin that binds to RBCs at low temperatures and fixes complement. When the RBCs are warmed, they are destroyed by complement lysis. The D-L antibody occurs in three clinical syndromes:

chronic PCH associated with late-stage or congenital syphilis, acute transient PCH occurring after an infectious illness, and chronic idiopathic PCH.

PCH

more than 40% of immune hemolytic anemias in children <5 years of age. The sudden onset of fever, back or leg pain, and hemoglobinuria after exposure to the cold Fever. pain or aching in the back, legs, or abdomen, cramps, headache, nausea, vomiting, and diarrhea. The first urine voided after the onset is dark red-to-black and typically clears in a few hours. The spleen may be palpable during an attack and shortly thereafter, and mild jaundice may appear. Vasomotor phenomena manifest as cold urticaria, cyanosis, and Raynaud phenomenon, and even gangrene has been reported.

PCH

severe intravascular hemolysis. Hemoglobins <5 g/dl can be seen. Spherocytes, nucleated RBCs, polychromatophilia, anisocytosis, poikilocytosis, and erythrophagocytosis by neutrophils have been reported. Reticulocytopenia is quite common early in the episode, and reticulocytosis appears in the recovery phase. The plasma is frequently red, reflecting the free hemoglobin. the LDH and bilirubin (mostly unconjugated) are elevated. Complement levels are depressed. The Donath-Landsteiner test + positive DAT with anticomplement antisera.

PCH

The Donath-Landsteiner test is a simple procedure involving incubating the patients serum in melting ice with washed group O, Ppositive RBCs and fresh normal serum as a source of complement. Later, the tube is transferred to 37C for a second incubation. Lysis visible to the naked eye after the warm incubation is a positive test.

Immune Hemolytic Anemias Caused by Mixed Cold- and Warm-Active Antibodies

Some patients with warm AIHA also possess a cold agglutinin. mixed-type AIHA can be either idiopathic or secondary to lymphoproliferative disorders or systemic lupus erythematosis (SLE). Patients usually have a chronic course interrupted by severe exacerbations, which can result in a hemoglobin level <5 g/dl. These exacerbations do not appear to be associated with cold exposure. The laboratory workup demonstrates a DAT that is positive for both IgG and C3. the mixed-type AIHA produces difficulties with the antibody screen and the crossmatch.

AIHA

Autoantibodies with greatest activity at 37C are responsible for the majority of patients with AIHA (70% of all AIHA patients) destroy RBCs by extravascular hemolysis in the spleen AIHA :

Idiopatik Secondary to an underlying disease, certain drugs

AIHA

Warm AIHA has a highly variable clinical presentation. anemic symptoms such as weakness, dizziness, fatigue, and dyspnea on exertion less specific symptoms include fever, bleeding, coughing, abdominal pain, and weight loss. jaundice, pallor, edema, and dark urine (hemoglobinuria). Splenomegaly, hepatomegaly, and lymphadenopathy In cases of secondary disease, the symptoms of the underlying disorder predominate. Symptoms can be precipitated by trauma, surgery, infection, pregnancy, and psychologic stress.

AIHA

Hemoglobin and hematocrit normal to extremely low The MCV is usually elevated Reticulocyte counts are usually elevated The bone marrow is usually hyperplastic Spontaneous agglutination, spherocytes erythrophagocytosis by monocytes, or rarely neutrophils, on the peripheral smear is an indication of AIHA Leukopenia and thrombocytopenia may also be immune-mediated, as shown in some cases by the presence of antileukocyte and antiplatelet antibodies.

AIHA

Serum bilirubin is elevated but rarely >5 mg/dl Hemoglobinemia haptoglobin decreased Urobilinogens are increased, and hemoglobinuria and hemosiderinuria may follow severe hemolysis. Stercobilinogens may turn the stool dark the DAT is positive

Drug-Induced Immune Hemolytic Anemia (DI-IHA)

Hemolysis by immune and nonimmune mechanisms. Second- and third-generation cephalosporins, especially cefotetan and ceftriaxone, have been associated increasingly with cases of immune hemolytic anemia, accounting for 80% of the DI-IHA. Other antibiotic agents associated with immune hemolytic anemia include -lactamase inhibitors (clavulanate, sulbactam, and tazobactam) AIHA has been noted with increased incidence in patients receiving purine nucleoside analogs such as fludarabine, cladribine, and pentostatin for hematologic malignancies. The mechanism by which these drugs cause AIHA is unclear

Drug-Induced Immune Hemolytic Anemia (DI-IHA)

Drug-induced antibodies can be divided into two main groupings :

Drug-dependent antibodies (penicillin type or immune complex type) require the presence of the drug in the test system, Drug-independent antibodies (autoantibodies) do not.

There are three major mechanisms by which drugs can cause immune hemolysis in vivo :

The drug adsorption mechanism, in which the antibody reacts with a drug tightly bound to the RBC membrane The neoantigen or immune complex mechanism, in which the drug combines loosely with the RBC membrane and the antibody reacts with new antigenic site(s) created by the combination of drug and membrane The autoimmune mechanism, which is indistinguishable from true AIHA without drug exposure

Drug-Induced Immune Hemolytic Anemia (DI-IHA)

similar to idiopathic AIHA, including pallor, jaundice, and easy fatigability. Splenomegaly is not uncommon, but lymphadenopathy and hepatomegaly should not be attributed to drug-related hemolysis. Those patients with the neoantigen mechanism are at the greatest risk for hemoglobinuria, and renal failure.

Drug-Induced Immune Hemolytic Anemia (DI-IHA)

Anemia with reticulocytosis and positive DAT Elevated indirect bilirubin and LDH Hemoglobinemia and hemoglobinuria with elevated creatinine The positive DAT may persist for a few weeks to months after stopping the medication responsible, especially with the autoimmune mechanism

Transplant-Associated Immune Hemolytic Anemias

antibodies are generated against endogenous self-antigens That source can be either the lymphocytes and their precursors contained in a stem cell product being utilized for hematopoietic reconstitution, or they can be lymphocytes that are merely passengers contained in the vascular and perivascular regions of a solid organ being transplanted

Acquired Nonimmune Hemolytic Disorders

Hemolysis due to Malaria Infection

Malaria is an acute, chronic, or recurrent febrile disease Caused by four species of Plasmodia: Plasmodia vivax, Plasmodia falciparum, Plasmodia malariae, and Plasmodia ovale. These protozoan microorganisms are capable of parasitizing erythrocytes and other body tissues.

Hemolysis due to Malaria Infection

recurrent paroxysms of chills and fever associated with malaise, headache, vomiting, and other systemic symptoms, recur regularly every 36 to 72 hours. Splenomegaly, jaundice and hepatomegaly may develop in later stages of the illness. Anemia is common Leukocyte numbers may be normal/leukopenia Thrombocytopenia has been observed in about two thirds of patients with P. falciparum malaria, often associated with splenomegaly. The most serious hematologic complication of malaria is acute intravascular hemolytic anemia (blackwater fever), which occurs as a rare event in the course of infection by P. falciparum.

Hemolysis due to Malaria Infection

Hemolysis due to Malaria Infection

Diagnosis traditionally has required identification of parasites on the blood smear.

Single

negative smears do not exclude the disease with certainty in patients with low-grade infections. sensitivity of these tests is probably as good as microscopy.

Simple test strips for diagnosis of malaria.

The

Hemolysis due to Drugs and Chemicals

Certain chemical agents can bring about the oxidative denaturation of hemoglobin, leading to the sequential formation of methemoglobin, sulfhemoglobin, and Heinz bodies. Individuals deficient in G6PD or other components of glutathione-dependent detoxification processes are particularly sensitive to the hemolytic effects of oxidant compounds. Usually the anemia is noted within 1 to 2 weeks after drug therapy The hemolytic process usually disappears within 1 to 3 weeks after use of the offending drug has been discontinued.

Hemolysis due to Drugs and Chemicals

Heinz bodies (seen with brilliant cresyl blue supravital stains of blood during hemolytic episodes) bite cells (seen in routine Wright-stained blood smear) Hemighosts/blister cells and may appear to contain a large vacuole, appear only when hemolysis is brisk, and probably indicate a particularly severe degree of oxidant damage.

Heinz Bodies

Hemolysis due to Drugs and Chemicals

Hemolysis with Venoms-Snake

The problems resulting from snake venoms include neurotoxicity, myotoxicity, renal failure, edema, bleeding due to activation of clotting proteins, and intravascular hemolysis. Hemolysis is seen following evenomation with most poisonous snakes including cobras, Australian king brown snakes, the Tunisian saw-scaled (carpet) viper, U.S. rattlesnakes, habu snakes, and most significantly in the several species of Russell viper (Dabois russelli) found throughout India and the rest of Asia. The clinical presentation of intravascular hemolysis from snake bites can be acute and fulminant, can be delayed for a few hours to days. Hemoglobinemia and hemoglobinuria are present, the severity of which varies with the degree of evenomation and species of snake. The main component of venom responsible for hemolysis is thought to be phospholipase A2, which has direct toxicity for many tissues including the red cell membrane. Venom from the habu snake has additional actions in that it activates complement and cleaves CD55 and CD59 from the red cell membrane, thus leaving the red cell susceptible to complement-induced lysis

Hemolysis with Thermal Injury

Acute hemolytic anemia has been observed after extensive thermal burns. Signs of intravascular hemolysis are associated with schistocytes, spherocytes, and echinocytes in the blood along with increased osmotic and mechanical fragility of the erythrocytes. Hemolysis occurs during the first 24 to 48 hours after the burn and as much as 30% of the circulating red cell mass may be destroyed in this 2-day period. The acute hemolytic reaction in burned patients results from the direct effects of heat on erythrocytes. When red cells are heated to temperatures >47C, irreversible morphologic and functional abnormalities occur

Other Causes of Hemolysis

Hypersplenism

associated with increased filtering, extended macrophage attack, and increased erythrocyte destruction red cell survival relates to portal hypertension and associated splenomegaly abnormalities in lipid metabolism result in RBCs loaded with excess cholesterol. The cholesterol-loaded RBCs have impaired ability to repair peroxidized membrane lipids, and thus they undergo oxidative damage thrombotic microangiopathies normal erythrocytes have a shortened survival in uremic patients while red cells from uremic patients

Liver Disease

Renal Disease

Hypophosphatemia

glycolysis is inhibited, red cell adenosine triphosphate (ATP) is decreased, cell deformability is reduced, and red cell survival is shortened
mechanical factors during surgery complement is activated during the procedure

Postperfusion Syndrome

TERIMA KASIH