Penentuan Status Gizi secara Biokimia - Suyatno, Ir., MKes - Undip

Specific Lab TestsMeasurement of individualnutrient in body fluids (e.g.serum retinol, serum iron,urinary iodine, vitamin D)Detection of abnormal amount ofmetabolites in the urine (e.g.urinarycreatinine/hydroxyproline ratio)Analysis of hair, nails & skin formicro-nutrients.PSG - Suyatno FKM UNDIP 2

Advantages of Biochemical MethodIt is useful in detecting early changes inbody metabolism & nutrition before theappearance of overt clinical signs.It is precise, accurate and reproducible.Useful to validate data obtained fromdietary methods e.g. comparing saltintake with 24-hour urinary excretion.PSG - Suyatno FKM UNDIP 3

Limitations of Biochemical MethodTime consumingExpensiveThey cannot be applied on largescaleNeeds trained personnel &facilitiesPSG - Suyatno FKM UNDIP 4

PENGGUNAAN PSG BIOKMIA• Dpt menentukan status gizi spesifik• Dpt membuktikan pemeriksaan tk subklinis• Sebagai pemeriksaan pelengkapPSG - Suyatno FKM UNDIP 5

PEMERIKSAAN DARAHSampel Darah: Kapiler atau Vena1. DARAH KAPILER- Pd ujung jari , Daun Telinga, Tumit(Bayi)- Sejumlah ± 0,2 ml – 1 ml- Dpt langsung dipipet2. DARAH VENA- Pd Vena Cubiti (lengan)- Plasma (+ Antikoagulan)- Serum (tanpa(Antikoagulan)PSG - Suyatno FKM UNDIP 6

PEMERIKSAAN URINE- Langsung atau dg Kateter- Pd penyimpanan dpt +pengawet (Toluol, Timol)- Dpt Midstream/tidaktidak- Media yg baik utk tumbuh kumanPSG - Suyatno FKM UNDIP 7

Biochemical Tests Blood urea nitrogen (BUN)• may indicate renal failure, insufficient renal blood supply, orblockage of the urinary tract Serum creatinine• indicates amount of creatinine in blood• used to evaluate renal function Creatinine excretion• indicates amount of creatinine excreted in urine over a 24-hour period• used in estimating body muscle mass• muscle mass depleted, as in malnutrition; level will be lowPSG - Suyatno FKM UNDIP 10

Other tests• CBCBiochemical TestsHemoglobin (Hgb(Hgb)Hematocrit(Hct)Red blood cells (RBCs(RBCs)White blood cells (WBCs(WBCs)• Lipid profilehigh & low-density lipoprotein, serumtriglycerides• UrinalysisPSG - Suyatno FKM UNDIP 11

ANEMIA GIZI BESIBesi dalam Tubuh: Volume darah 4 ltr Umur darah merah 3 bln Darah merah turn over: 35 mgFe/hari Wanita Hamil butuh tambahan: : 0,5 –1 mg/hariPSG - Suyatno FKM UNDIP 12

Fe dar makanan(1 mg)Darah Merah(35 mg Fe Turn Over)Sumsumtulang34 mg FeSel-seljaringanSel dm matihaemoglobinKeringat, urin, feces(1 mg Fe)PSG - Suyatno FKM UNDIP 13

Causes of iron deficiency– Blood loss:MenstruationWorm infection– Increased iron need due to physicalgrowth:Pregnant womenChildren– Low intake of absorbable ironPlant dietPSG - Suyatno FKM UNDIP 14

Tingkatan Anemi besi(Gibson, 1990) Hilangnya zat besi (iron deplesion) ) :– Pengurangan jumlah cadangan besi pada hati– Tingkat transport besi dan Hb normal, tetapi cadanganbesi hilang ditandai dengan rendahnya serum ferritin Erythropoiesis defisiensi besi (iron deficenterythropoiesis):– Suplai besi dalam plasma pada sel erythropoisis turundan akan menyebabkan turunnya saturasi tranferrin Anemi defisiensi besi (iron deficiency anemia):– Cadangan besi habis– Terjadi penurunan sirkulasi besi, ditandai penurunankonsentrasi Hb di dalam sel darah merah.PSG - Suyatno FKM UNDIP 15

Stage of iron deficiencyIronstoresErythronNormalIron storeDepletes:•Marrow ironabsent•Serum ferritinConsentration< 12 u g/LIron deficientErithropoiesis- Hb dropIron deficiencyAnemiaHb < standartPSG - Suyatno FKM UNDIP 16

Changes in body iron compartments and laboratory parameters of iron statusduring development of iron deficiency due to a continuous negative iron balanceSource: International Nutritional Anemia Consultative Group, 1977PSG - Suyatno FKM UNDIP 17

INDIKATORANEMIA GIZI BESIHemoglobi (Hb),Hematokrit,Serum Besi/SerumFerritin (Sf),Transferin Saturation (Ts),Free Erytrocytes Protophophyrin (FEP)Unsaturated Iron-binding CapacitySerumPSG - Suyatno FKM UNDIP 18

1. HAEMOGLOBIN (Hb(Hb) ) :Dpt tentukan prevalensi AnemiaMacamnya:A. METODE SAHLI- Kesalahan 2 – 3 kali- Hb + Hcl ➔ Globin Fe ++ Heme ➔ O2➔ Fe +++ Heme + Ion cl ➔ FerriHemeclorid (coklat)- Sangat subyektifPSG - Suyatno FKM UNDIP 19

B. METODE CYANMETHEMEGLOBIN- Hb Oksidasi K. Peroksida ➔Methemoglobin ➔ Ion Sianida ➔Sian – Methemoglobin (merah)- Hasil lbh obyektifHARGA NORMAL- Laki – Laki : 14 – 18 g %- Wanita : 12 – 16 g %- Wanita Hamil : 11 gr %PSG - Suyatno FKM UNDIP 20

2. HEMATOKRIT (HCT)- Volume SDM yg terpisah dr plasma- Estimasi scr tdk langsung Hb (HCT3 X Hb)HARGA NORMAL- Laki – laki : 40 – 54 % Kepler- Wanita : 37 – 47 %- laki – laki : 42 – 50 % Wells- Wanita : 40 – 48 %PSG - Suyatno FKM UNDIP 21

Suggested criteria for diagnosis of anaemia using haemoglobin (Hb)and haematocrit (PCV) determinationsSubjectAdult maleAdult female (non-pregnant)Pregnant femaleChild 6 months to 6 yearsChild 6 to 14 yearsSource: WHO, 1975a.Hbbelow(g/dl)1312111112PCVbelow(%)4236303232PSG - Suyatno FKM UNDIP 22

3. SERUM FERRITIN (SF)- Menilai status besi di hepar- SF < 12 µg g /L (Defisiensi(Fe)- Metode : IRMA, RIA, ELLISAPSG - Suyatno FKM UNDIP 23

4. TRANSFERIN SATURATION (TS)- Menilai kadar Fe dlm serum- TS < 16 % (Defisiensi(Fe)- TIBC tinggi (Anemia Gizi Besi)PSG - Suyatno FKM UNDIP 24

5. FREE ERYTHROCYTEPROTOPHORPHYRIN (FEP) Menilai kecukupan Fe utk pembtk SelDarah Merah di sumsum Tulang Normal : 35 – 50 µg/dl RBC FEP > 100 µg/dl ( Defisiensi Fe)Metode : FlurometicPSG - Suyatno FKM UNDIP 25

DEFISIENSI Fe- Tahap 1 : Cadangan Fe hepar

PSG BIOKIMIA KEP ANALISIS BIOKIMIA YG DIGUNAKANNilai Protein & Hasil MetabolitProtein ( Darah, , Urine) INDIKATOR- Hidroksi Prolin Indeks (Urine)- Rasio As Amino Bebas (Plasma)- Plasma Protein, Albumin, Pre –Albumin- Plasma TransferinPSG - Suyatno FKM UNDIP 27

HARGA NORMAL- Albumin : 3,5 – 5 gr/dl- Globulin : 1,5 – 3 gr/dl- Fibrinogen : 0,2 – 0,8 gr/dl PRE – ALBUMIN- Gizi Baik : 23,8 ± 0,9 mg/dl- Gizi Sedang : 16,5 ± 0,8 mg/dl- Gizi Kurang : 12,4 ± 1,0 mg/dl- Marasmus : 7,6 ± 0,6 mg/dl- Mars – Kwas : 3,3 ± 0,2 mg/dl- Kwashiorkor : 3,2 ± 0,4 mg/dlPSG - Suyatno FKM UNDIP 28

SERUM ALBUMIN- < 1 Th: Cukup > 2,5 gr/dl- 1 sd 5 Th: Cukup > 3 gr/dl- 6 sd 16 Th: Cukup > 3,5 gr/dl- 16 ThCukup : > 3,5 gr/dlKurang : < 2,8 gr/dlMargin : 2,8 – 3,4 gr/dl- Wanita HamilCukup : > 3,5 gr/dlKurang : < 3,5 gr/dlMargin : 3 – 3,4 gr/dlPSG - Suyatno FKM UNDIP 29

SERUM PROTEIN- < 1 Th: Cukup > 5 gr/dlMargin < 5 gr/dl- 1 sd 5 Th: Cukup 5,5 gr/dlMargin < 5,5 gr/dl- 6 sd 16 Th: Cukup 6 gr/dlMargin < 6 gr/dl- > 16 Th: Cukup 6 gr/dlKurang 5,5 gr/dlMargin 6,5 – 5,9 gr/dl INDIKATOR KEPAbumin/Globulin,Kolest & Hb turunPSG - Suyatno FKM UNDIP 30

Levels of serum albumin concentrations in malnourished childrenConcentrationInterpretation(g/dl)> 3.53-3.43.42.5-2.92.9< 2.5NormalSubnormalLowPathologicalSource: Alleyne et al., 1977.PSG - Suyatno FKM UNDIP 31

PSG BIOKIMIA KVA PROSESCadangan Vit A Hepar

Prevalence criteria for determining public healthsignificance of vitamin A deficiencyNight blindnessSignBitot's spotsCorneal xerosis/cornealulceration/keratomalaciaCorneal scarPlasma vitamin A

Pemeriksaan GAKITest Laboratorium :– TSH : kadar normal 0,4 – 4,8 µg/ml– Urinary Exretion Iodine (UEI) :Median UIE ug/l300KurangCukupLebihSangat kelebihanKurang iodium ringanOptimumResiko IIH dlm 5-10th programpada kel umur tertentu.Beresiko thd kesehatan lebih luasIIH, Autoimune, penyakit hiperthyroid dll.PSG - Suyatno FKM UNDIP 34

TSH neonatal Sangat penting untuk kabupaten/kota endemiksedang &beratatau pernah dinyatakanendemikberat Satu-satunyacara untuk mengetahui adanyakretin baru Dilakukan pada semua bayi baru lahir. Dapat mendeteksi dini bayi hypothyroid transientmaupun permanent. Perlu keterlibatan bidan/penolong persalinan. Menggunakan bercak darah pada kertas saring(Blood spot)atau Indek hipothyroid T. Perlu disiapkan sistem pelaporan.PSG - Suyatno FKM UNDIP 35

Pemeriksaan Urinary ExretionIodine (UEI) Sampling random 300 orang kelompokterawan(ibu hamil) untuk diambil urinesesaat. Frekuensi 1x/1 – 2th Kirim ke Laboratorium dgn Prosedurebaku kirim 10 % u/pemeriksaan duplo diLab – terakreditasi/rujukan. Hasil urutkan terendah hingga tertinggi Tentukan nilai median.PSG - Suyatno FKM UNDIP 36

Severity and public health significance of IDDSeverityClinical features aTypicalgoitreprevalence(%)Medianurinaryiodine(µg/litre)Need forcorrectionGoitreHypothyroidismCretinismMild(Stage l)+005.019.9>50-99ImportantModerate(Stage II)+++020-29.929.920 49UrgentSevere(Stage III)++++++++>30

Batasan GOAL indikator dalam surveilans GAKIINDIKATORGaram beriodiumProporsi rumah tangga yang mengkonsumsigaram beriodium (efektif)GOAL> 90 %Iodium dalam urineProporsi dibawah 100 ug/ / LProporsi dibawah 50 ug/LGondokAnak usia sekolah (6-12th)Hasil Palpasi/ultrasound)Neonatal TSHProporsi bayi dengan kadar TSHdarah lebih dari 5 mU/L< 50%< 20%< 5%< 3 %PSG - Suyatno FKM UNDIP 38