Download - Edema Malnutrisi
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Endy ParyantoPrawirohartono
Bagian Ilmu Kesehatan Anak FK UGM/ RS Dr. SardjitoYogyakarta
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Penyakit-penyakit dengan gejala edema pada anak: Tinjauan khusus pada malnutrisi
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Edema pada anak (umum)
Malnutrisi
Kelainan ginjal: sindrom nefrotik
Kelainan hati: sirosis hepatis
Kelainan jantung: gagal jantung
Alergi: edema angioneurotik
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Radang: itis (lokal)
Kalor: panas
Rubor: merah
Tumor: edema
Fungsio lesa: gangguan fungsi
Dolor: nyeri
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Faringitis: radang faring
Kalor: panas
Rubor: merah (hiperemis)
Tumor: edema
Fungsio lesa: gangguan fungsi telan
Dolor: nyeri telan
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Malnutrisi: Gizi Buruk
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Gizi Buruk
Kwashiorkor (edema)
Marasmus (non edema)
Marasmic kwashiorkor (edema)
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Kwashiorkor
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Marasmus
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edema
Marasmic kwashiorkor
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Diagnosis
MTBS (Manajemen Terpadu Balita Sakit)Menggunakan: klasifikasi
Klasifikasi Wellcome
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Klasifikasi MTBS/WHO
Tampak sangat kurus (marasmus)
Edema (kwashiorkor + marasmicKwashiorkor)
* Tidak selalu disebabkan masalah gizi
BB//TB < - 3SD (sangat kurus) atau <70%
TB//U < - 3SD (sangat pendek)*
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SD score = Z score
Ukuran sebenarnya - median
1 SD
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Nilai tengah
Mean = rata-rata
Mode (modus) = paling sering ada
Median = posisi di tengah-tengah
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Mean
BB anak A = 10,0 kgBB anak B = 12,0 kgBB anak C = 8,0 kgBB anak D = 6,0 kgBB anak E = 10,0 kg
Berapa mean?Jawab: (10 + 12 + 8 + 6 + 10) / 5 = 9,2 kg
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Mode (modus)
BB anak A = 10,0 kgBB anak B = 12,0 kgBB anak C = 8,0 kgBB anak D = 6,0 kgBB anak E = 10,0 kg
Berapa mode (modus)?Jawab: 10,0 kg
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Median
BB anak A = 10,0 kgBB anak B = 12,0 kgBB anak C = 8,0 kgBB anak D = 6,0 kgBB anak E = 10,0 kg
Berapa median?Jawab: 10,0 kg
6,0 8,0 10,0 10,0 12,0
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Nilai tengah
Mean = 9,2 kg
Mode (modus) = 10,0 kg
Median = 10,0 kg
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Nilai tengah
MK A: 10 30 100MK B: 10 30 50
Mean MK A = 10 + 30 + 100 = 46,6Median MK A = 30Mean MK B = 30Median MK B = 30
Perbedaan ini karena nilai mahasiswa ke tigaMean dipengaruhi oleh nilai ekstremMedian tidak dipengaruhi oleh nilai ekstrem
Ada 3 mahasiswa dengan nilai ujian:
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SD score = Z score
Ukuran sebenarnya (BB) = 10,0 kgMedian (BB//TB) = 12,0 kg1 SD = 0,9 kg
Berapa SD score?
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Antropometri: SD score
H//A (TB//U):• Normal - 2 SD sampai + 2 SD• Stunted (pendek) < - 2 SD sampai – 3
SD• Severely stunted < - 3 SDW//H (BB//TB):• Obese 2 SD• Normal - 2 SD sampai + 2 SD• Wasted (kurus)- 2 SD sampai – 3 SD• Severely wasted < - 3 SD
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Klasifikasi Wellcome
BB//U Edema (+) Edema (-)(% median)
80 – 60 Kwashiorkor Undernutrition< 60 Marasmic-kwashiorkor Marasmus
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Klasifikasi Wellcome
BB//U Edema (+) Edema (-)(% median)
80 – 60 Kwashiorkor Undernutrition< 60 Marasmic-kwashiorkor Marasmus
BB = 12 kgMedian = 24 kg Termasuk apa?Edema = (+)
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Klasifikasi Wellcome
BB//U Edema (+) Edema (-)(% median)
80 – 60 Kwashiorkor Undernutrition< 60 Marasmic-kwashiorkor Marasmus
BB = 12 kgMedian = 12 kg Termasuk apa?Edema = (-)
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Kwashiorkor
• Dikenalkan pertama kali oleh William (1933), nama dalam bahasa Afrika Barat = ‘penyakit karena dipisah dari ibunya karena ibunya hamil lagi’
• Nama klinis: enfants rouges, culebrilla = kulit ular, karena adanya flaky paint dermatosis yang sering ada, bouffisure d’Annam, syndrome dépigmentation oedème
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Kwashiorkor
• Nama patologis: fatty liver disease• Nama etiologis: dystrofia
pluricarencial (multiple deficiency disease), mehlnährschaden (flour malnutrition), nutritional edema syndrome, malignant malnutrition
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Kwashiorkor
• Dapat terjadi pada bayi, anak atau dewasa (jarang) – kebanyakan pada tahun ke 2
• Penyebabnya bukan hanya karena nutrisi, bisa karena infeksi, atau didukung oleh faktor lain, misalnya psikologis, budaya, dll
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Latihan No. 1
Seorang anak dengan edema karena riwayat makanannya jelek, maka kadar albumin darahnya biasanya:A. 2,1 g/lB. 2,7 g/lC. 2,9 g/lD. 3,2 g/lE. 3,5 g/l
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Latihan No. 2
Seorang anak dengan edema yang bersifat umum kemungkinan karena kelainan:
1. kwashiorkor
2. sindrom nefrotik
3. marasmic kwashiorkor
4. faringitis
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Latihan No. 3
Seorang anak dapat didiagnosis faringtitis secara klinis kalau didapatkan faring hiperemis tanpa perlu melihat tanda lainnya
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Latihan No. 4
Seorang anak dengan BB = 9,0 kg;median = 12,0 kg; ada edema, maka anak dapat didiagnosis sebagai:A. undernutritionB. marasmic kwashiorkorC. normalD. gemuk (obese)E. kwashiorkor
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Latihan No. 5
Seorang anak dengan TB = 100,0 cm;median = 120,0 cm; nilai 1 SD = 6 cm, maka anak dapat didiagnosis sebagai:A. normalB. pendekC. marasmusD. sangat pendekE. kwashiorkor
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Kwashiorkor*
* edematous malnutrition (WHO)
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Bengkak, pada tekanankembali lambat
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Etiologi kwashiorkor adalah defisiensi protein, karena kelainan ini membaik bila penderita diberi diet tinggi protein
Sejak puluhan tahun yang lalu para ahli mengatakan
Heiken GT. Rehabilitation of sick malnourished children. Environment, requirements, prognosis and feasibility. Rozenberg Publisher, 2003.
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Asupan protein kurang
Kadar albumin plasma rendah
Terjadi edema
Waterlow (1948) menjelaskan
Heiken GT. Rehabilitation of sick malnourished children. Environment, requirements, prognosis and feasibility. Rozenberg Publisher, 2003.
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‘When you cure a headache with aspirin, do you say that the cause was aspirin deficiency?’
Gillman (1955) bertanya:
Heiken GT. Rehabilitation of sick malnourished children. Environment, requirements, prognosis and feasibility. Rozenberg Publisher, 2003.
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Pada orang sehat perpindahan cairan dari ruang intra-ke-ekstravaskular dan sebaliknya melalui membran kapilar ditentukan oleh tekanan onkotik
Postulat Starling
Heiken GT. Rehabilitation of sick malnourished children. Environment, requirements, prognosis and feasibility. Rozenberg Publisher, 2003.
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Albumin
Tekanan hidrostatik Tekanan osmotik(onkotik)
Regulasi albumin terhadap keseimbangan cairanplasma dan interstitial
plasma
interstitial
Postulat Starling
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Albumin
Tekanan hidrostatik Tekanan osmotik(onkotik)
Regulasi albumin terhadap keseimbangan cairanplasma dan interstitial
EDEMA
plasma
interstitial
Postulat Starling
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• Hubungan antara kadar albumin rendah dengan hunger-edema tidak konsisten
• Pada hunger-edema dilaporkan ada yang dengan asites yang tidak pernah dijumpai pada kwashiorkor
Penelitian tentang ‘hunger-edema’
Heiken GT. Rehabilitation of sick malnourished children. Environment, requirements, prognosis and feasibility. Rozenberg Publisher, 2003.
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• Asupan makanan anak kwashiorkor sama dengan anak marasmus
• Anak kwashiorkor mempunyai asupan protein lebih tinggi dari kebutuhannya yang diukur dengan standar FAO/WHO
Penelitian asupan makanan menunjukkan
Heiken GT. Rehabilitation of sick malnourished children. Environment, requirements, prognosis and feasibility. Rozenberg Publisher, 2003.
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• Anak marasmus (dengan asupan energi dan juga protein rendah) tidak ada yang menderita edema dan perlemakan hati
• Anak kwashiorkor ada yang dengan BB//TB normal, berarti tidak mengalami defisiensi makronutrien
Penelitian asupan makanan menunjukkan
Heiken GT. Rehabilitation of sick malnourished children. Environment, requirements, prognosis and feasibility. Rozenberg Publisher, 2003.
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Kegagalan adaptasi terhadap asupan protein yang rendah pada anak malnutrisi dengan edema karena harus membentuk protein fase akut bila ada infeksi
Teori ‘dys-adaption’ Waterlow (1960)
Heiken GT. Rehabilitation of sick malnourished children. Environment, requirements, prognosis and feasibility. Rozenberg Publisher, 2003.
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Kegagalan adaptasi terhadap asupan protein yang rendah
Teori dys-adaptation Gopalan’s group (1968)
Heiken GT. Rehabilitation of sick malnourished children. Environment, requirements, prognosis and feasibility. Rozenberg Publisher, 2003.
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• Hypovolemia
• Hypotermia
• Syok septik
• dsb.
Teori dys-adaptation tidak mampu menjelaskan ..
Heiken GT. Rehabilitation of sick malnourished children. Environment, requirements, prognosis and feasibility. Rozenberg Publisher, 2003.
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• Aflatoxin (kontaminan pada makanan, mycotoxin) menginduksi hepatoma pada binatang dan manusia
• Aflatoxin menyebabkan kerusakan hati dan kelainan metabolisme termasuk hipoalbuminemia dan penekanan sistem imunitas
Teori aflatoxin
Heiken GT. Rehabilitation of sick malnourished children. Environment, requirements, prognosis and feasibility. Rozenberg Publisher, 2003.
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• Aflatoxin lebih banyak dijumpai pada biopsi hati penderita kwashiorkor dibandingkan dengan marasmus
• Aflatoxical (metabolit aflatoxin B1) hanya dijumpai dalam darah penderita kwashiorkor
Teori aflatoxin
Heiken GT. Rehabilitation of sick malnourished children. Environment, requirements, prognosis and feasibility. Rozenberg Publisher, 2003.
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• Aflatoxin tidak bisa didetoksifikasi
• Merusak hati
• Timbul hipoalbuminemia
Teori aflatoxin
Heiken GT. Rehabilitation of sick malnourished children. Environment, requirements, prognosis and feasibility. Rozenberg Publisher, 2003.
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• Ada gangguan pompa natrium pada kwashiorkor
• Kandungan natrium leukosit anak kwashiorkor lebih tinggi dibanding marasmus
• Cairan intraselular pindah ke ekstraselular secara pasif
Patrick & Golden (1977): pompa natrium
Heiken GT. Rehabilitation of sick malnourished children. Environment, requirements, prognosis and feasibility. Rozenberg Publisher, 2003.
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Noxae
Radikal bebas
Proteksi tidak adekuat
Reaksi katalisasi oleh Fe
Perbaikan kerusakan tidak baik
Edema, perlemakan hati, lesi kulit, perubahan rambut
TEORI RADIKAL BEBAS
Golden MHN, Ramdath D. Free radicals in the pathogenesis of kwashiorkor. Proceed Nutr Soc 1987;46:53-68.
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• Kadar albumin tidak berubah sebelum dan setelah edema hilang
• Edema hilang tanpa disertai kenaikan kadar albumin
• Defisiensi protein bukan penyebab tunggal edema pada kwashiorkor
Bukan hanya defisiensi protein
Heiken GT. Rehabilitation of sick malnourished children. Environment, requirements, prognosis and feasibility. Rozenberg Publisher, 2003.
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• Edema pada kwashiorkor tidak dapat dijelaskan hanya dengan hipoalbuminemia yang disebabkan oleh asupan protein yang rendah
• Salah satu teori yang ada misalnya adalah teori radikal bebas
Kesimpulan
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