PENENTUAN STATUS GIZI SECARA BIOKIMIAsuyatno.blog.undip.ac.id/files/2009/11/psg-biokimia.pdf · Anemi defisiensi besi (iron deficiency anemia): – Cadangan besi habis ... 50 -99

PENENTUAN STATUS GIZI PENENTUAN STATUS GIZI

SECARA BIOKIMIASECARA BIOKIMIA

Edited by: Edited by: SuyatnoSuyatno, Ir. , Ir. MKesMKes

FakultasFakultas KesehatanKesehatan MasyarakatMasyarakatUniversitasUniversitas DiponegoroDiponegoro

SemarangSemarang

EE--mailmail : : [email protected]@undip.ac.idHp Hp : 08122815730: 08122815730BlogBlog : : suyatno.blog.undip.ac.idsuyatno.blog.undip.ac.id

PSG PSG -- Suyatno FKM UNDIPSuyatno FKM UNDIP 22

Specific Lab TestsSpecific Lab Tests

Measurement of individual Measurement of individual nutrient in body fluids (e.g. nutrient in body fluids (e.g. serum retinol, serum iron, serum retinol, serum iron, urinary iodine, vitamin D) urinary iodine, vitamin D)

Detection of abnormal amount of Detection of abnormal amount of metabolites in the urine (e.g. metabolites in the urine (e.g. urinary urinary creatinine/hydroxyproline ratio)creatinine/hydroxyproline ratio)

Analysis of hair, nails & skin for Analysis of hair, nails & skin for micromicro--nutrients.nutrients.


Advantages of Biochemical MethodAdvantages of Biochemical Method

It is useful in detecting early changes in It is useful in detecting early changes in

body metabolism & nutrition before the body metabolism & nutrition before the

appearance of overt clinical signs.appearance of overt clinical signs.

It is precise, accurate and reproducible.It is precise, accurate and reproducible.

Useful to validate data obtained from Useful to validate data obtained from

dietary methods e.g. comparing salt dietary methods e.g. comparing salt

intake with 24intake with 24--hour urinary excretion.hour urinary excretion.


Limitations of Biochemical MethodLimitations of Biochemical Method

Time consumingTime consuming

ExpensiveExpensive

They cannot be applied on large They cannot be applied on large

scalescale

Needs trained personnel & Needs trained personnel &

facilitiesfacilities


PENGGUNAANPENGGUNAAN PSG BIOKMIAPSG BIOKMIA

•• DptDpt menentukanmenentukan status status gizigizi spesifikspesifik

•• DptDpt membuktikanmembuktikan pemeriksaanpemeriksaan tktk sub sub

klinisklinis

•• SebagaiSebagai pemeriksaanpemeriksaan pelengkappelengkap


PEMERIKSAAN DARAHPEMERIKSAAN DARAH

�� SampelSampel DarahDarah: : KapilerKapiler atauatau VenaVena

1.1. DARAH KAPILERDARAH KAPILER

-- Pd Pd ujungujung jarijari , , DaunDaun TelingaTelinga, , TumitTumit

((BayiBayi))

-- SejumlahSejumlah ±± 0,2 ml 0,2 ml –– 1 ml1 ml

-- DptDpt langsunglangsung dipipetdipipet

2.2. DARAH VENADARAH VENA

-- Pd Vena Pd Vena CubitiCubiti ((lenganlengan))

-- Plasma (+ Plasma (+ AntikoagulanAntikoagulan))

-- Serum (Serum (tanpatanpa AntikoagulanAntikoagulan))


PEMERIKSAAN URINEPEMERIKSAAN URINE

-- LangsungLangsung atauatau dg dg KateterKateter

-- Pd Pd penyimpananpenyimpanan dptdpt ++

pengawetpengawet ((ToluolToluol, , TimolTimol))

-- DptDpt Midstream/Midstream/tidaktidak

-- Media Media ygyg baikbaik utkutk tumbuhtumbuh kumankuman


PEMERIKSAAN FAESESPEMERIKSAAN FAESES

-- DptDpt mengetahuimengetahui gangguangangguan

metabolismemetabolisme zatzat gizigizi (KH, (KH,

LemakLemak))

-- DptDpt mengetahuimengetahui adanyaadanya infeksiinfeksi


Biochemical TestsBiochemical Tests

�� Serum albumin levelSerum albumin level

•• Measures main protein in bloodMeasures main protein in blood

•• Determines protein statusDetermines protein status

�� Serum Serum transferrintransferrin levellevel

•• Indicates ironIndicates iron--carrying protein in bloodcarrying protein in blood

•• ↑↑ indicates iron stores lowindicates iron stores low

•• ↓↓ indicates body lacks proteinindicates body lacks protein


Biochemical TestsBiochemical Tests�� Blood urea nitrogen (BUN)Blood urea nitrogen (BUN)

•• may indicate renal failure, insufficient renal blood supply, or may indicate renal failure, insufficient renal blood supply, or

blockage of the urinary tractblockage of the urinary tract

�� Serum Serum creatininecreatinine•• indicates amount of indicates amount of creatininecreatinine in bloodin blood

•• used to evaluate renal functionused to evaluate renal function

�� CreatinineCreatinine excretionexcretion

•• indicates amount of indicates amount of creatininecreatinine excreted in urine over a 24excreted in urine over a 24--

hour periodhour period

•• used in estimating body muscle massused in estimating body muscle mass

•• muscle mass depleted, as in malnutrition; level will be low muscle mass depleted, as in malnutrition; level will be low


Biochemical TestsBiochemical Tests��Other testsOther tests

•• CBCCBC

��Hemoglobin (Hemoglobin (HgbHgb))

��HematocritHematocrit ((HctHct))

��Red blood cells (Red blood cells (RBCsRBCs))

��White blood cells (White blood cells (WBCsWBCs))

•• Lipid profile Lipid profile

��high & lowhigh & low--density lipoprotein, serum density lipoprotein, serum

triglyceridestriglycerides

•• UrinalysisUrinalysis


BesiBesi dalamdalam TubuhTubuh::

�� Volume Volume darahdarah 4 4 ltrltr

��UmurUmur darahdarah merahmerah 3 3 blnbln

��DarahDarah merahmerah ��turn over: 35 mg turn over: 35 mg

Fe/Fe/harihari

��WanitaWanita HamilHamil butuhbutuh tambahantambahan: 0,5 : 0,5 ––

1 mg/1 mg/harihari

ANEMIA GIZI BESIANEMIA GIZI BESI


Fe dar makanan(1 mg)

Darah Merah(35 mg Fe Turn Over)

Sumsumtulang

haemoglobin

Sel-seljaringan

Sel dm mati

Keringat, urin, feces(1 mg Fe)

34 mg Fe


–– Blood loss:Blood loss:

��MenstruationMenstruation

��Worm infectionWorm infection

–– Increased iron need due to physical Increased iron need due to physical

growth:growth:

��Pregnant womenPregnant women

��ChildrenChildren

–– Low intake of absorbable ironLow intake of absorbable iron

��Plant dietPlant diet

Causes of iron deficiencyCauses of iron deficiency


TingkatanTingkatan AnemiAnemi besibesi(Gibson, 1990)(Gibson, 1990)

�� HilangnyaHilangnya zatzat besibesi (iron (iron deplesiondeplesion) :) :–– Pengurangan jumlah cadangan besi pada hatiPengurangan jumlah cadangan besi pada hati

–– Tingkat transport besi dan Hb normal, tetapi cadangan Tingkat transport besi dan Hb normal, tetapi cadangan besi hilang ditandai dengan rendahnya besi hilang ditandai dengan rendahnya serum ferritinserum ferritin

�� ErythropoiesisErythropoiesis defisiensidefisiensi besibesi (iron (iron deficentdeficenterythropoiesiserythropoiesis):):–– Suplai besi dalam plasma pada sel erythropoisis turun Suplai besi dalam plasma pada sel erythropoisis turun dan akan menyebabkan turunnya saturasi dan akan menyebabkan turunnya saturasi tranferrintranferrin

�� AnemiAnemi defisiensidefisiensi besibesi (iron deficiency anemia):(iron deficiency anemia):–– CadanganCadangan besibesi habishabis

–– TerjadiTerjadi penurunanpenurunan sirkulasisirkulasi besibesi, , ditandaiditandai penurunanpenurunankonsentrasikonsentrasi HbHb didi dalamdalam selsel darahdarah merahmerah..


IronIron

storesstores

Stage of iron deficiencyStage of iron deficiency

Erythron

Normal Iron store Depletes:•Marrow ironabsent

•Serum ferritinConsentration< 12 u g/L

Iron deficientErithropoiesis- Hb drop

Iron deficiencyAnemiaHb < standart


Changes in body iron compartments and laboratory parameters of iron status during development of iron deficiency due to a continuous negative iron balance

Source: International Nutritional Anemia Consultative Group, 1977


INDIKATORINDIKATORANEMIA GIZI BESI ANEMIA GIZI BESI

�� HemoglobiHemoglobi ((HbHb), ),

�� HematokritHematokrit,,

�� Serum Serum BesiBesi/Serum /Serum FerritinFerritin ((SfSf),),

�� TransferinTransferin Saturation (Ts), Saturation (Ts),

�� Free Free ErytrocytesErytrocytes ProtophophyrinProtophophyrin (FEP)(FEP)

�� Unsaturated IronUnsaturated Iron--binding Capacity binding Capacity

SerumSerum


1. HAEMOGLOBIN (1. HAEMOGLOBIN (HbHb) :) :

DptDpt tentukantentukan prevalensiprevalensi AnemiaAnemia

MacamnyaMacamnya::

A.A. METODE SAHLIMETODE SAHLI

-- KesalahanKesalahan 2 2 –– 3 kali3 kali

-- HbHb + + HclHcl ➔➔➔➔➔➔➔➔ GlobinGlobin Fe Fe ++++ HemeHeme ➔➔➔➔➔➔➔➔ O2O2

➔➔➔➔➔➔➔➔ Fe Fe ++++++ HemeHeme + Ion + Ion clcl ➔➔➔➔➔➔➔➔ FerriFerri

HemecloridHemeclorid ((coklatcoklat))

-- SangatSangat subyektifsubyektif


B.B. METODE CYANMETHEMEGLOBINMETODE CYANMETHEMEGLOBIN

-- HbHb OksidasiOksidasi K. K. PeroksidaPeroksida ➔➔➔➔➔➔➔➔MethemoglobinMethemoglobin ➔➔➔➔➔➔➔➔ Ion Ion SianidaSianida ➔➔➔➔➔➔➔➔SianSian –– MethemoglobinMethemoglobin ((merahmerah))

-- HasilHasil lbhlbh obyektifobyektif

�� HARGA NORMALHARGA NORMAL

-- LakiLaki –– LakiLaki : 14 : 14 –– 18 g %18 g %

-- WanitaWanita : 12 : 12 –– 16 g %16 g %

-- WanitaWanita HamilHamil : 11 : 11 grgr %%


2. HEMATOKRIT (HCT)2. HEMATOKRIT (HCT)

-- Volume SDM Volume SDM ygyg terpisahterpisah drdr plasmaplasma

-- EstimasiEstimasi scrscr tdktdk langsunglangsung HbHb (HCT (HCT

3 X 3 X HbHb))


-- LakiLaki –– lakilaki : 40 : 40 –– 54 % 54 % KeplerKepler

-- WanitaWanita : 37 : 37 –– 47 % 47 %

-- lakilaki –– lakilaki : 42 : 42 –– 50 % Wells50 % Wells

-- WanitaWanita : 40 : 40 –– 48 % 48 %


Suggested criteria for diagnosis of anaemia using haemo globin (Hb)and haematocrit (PCV) determinations

32321212Child 6 to 14 yearsChild 6 to 14 years

32321111Child 6 months to 6 yearsChild 6 months to 6 years

30301111Pregnant femalePregnant female

36361212Adult female (nonAdult female (non--

pregnant)pregnant)

42421313Adult maleAdult male

(%)(%)(g/dl)(g/dl)

PCV PCV

belowbelowHbHb

belowbelowSubjectSubject

Source: WHO, 1975a.


3. SERUM FERRITIN (SF)3. SERUM FERRITIN (SF)

-- MenilaiMenilai status status besibesi didi heparhepar

-- SF < 12 SF < 12 µµg /L (g /L (DefisiensiDefisiensi Fe)Fe)

-- MetodeMetode : IRMA, RIA, ELLISA: IRMA, RIA, ELLISA


4. TRANSFERIN SATURATION (TS)4. TRANSFERIN SATURATION (TS)

-- MenilaiMenilai kadarkadar Fe Fe dlmdlm serumserum

-- TS < 16 % (TS < 16 % (DefisiensiDefisiensi Fe)Fe)

-- TIBC TIBC tinggitinggi (Anemia (Anemia GiziGizi BesiBesi))


5. FREE ERYTHROCYTE 5. FREE ERYTHROCYTE

PROTOPHORPHYRIN (FEP)PROTOPHORPHYRIN (FEP)

�� MenilaiMenilai kecukupankecukupan Fe Fe utkutk pembtkpembtk SelSel

DarahDarah MerahMerah didi sumsumsumsum TulangTulang

�� Normal Normal : 35 : 35 –– 50 50 µµg/dl RBCg/dl RBC

�� FEP > 100 FEP > 100 µµg/dl ( g/dl ( DefisiensiDefisiensi Fe)Fe)

�� MetodeMetode : : FlurometicFlurometic


DEFISIENSI FeDEFISIENSI Fe

-- TahapTahap 11 : : CadanganCadangan Fe Fe heparhepar <<<<

-- TahapTahap 22 : Fe << : Fe << utkutk sintesissintesis SDM SDM didi

SSM SSM TulangTulang

-- TahapTahap 33 : : KadarKadar HbHb <<<<


PSG BIOKIMIA KEPPSG BIOKIMIA KEP

�� ANALISIS BIOKIMIA YG DIGUNAKAN ANALISIS BIOKIMIA YG DIGUNAKAN

NilaiNilai Protein & Protein & HasilHasil MetabolitMetabolit

Protein ( Protein ( DarahDarah, Urine), Urine)

�� INDIKATORINDIKATOR

-- HidroksiHidroksi ProlinProlin IndeksIndeks (Urine)(Urine)

-- RasioRasio As Amino As Amino BebasBebas (Plasma)(Plasma)

-- Plasma Protein, Albumin, Pre Plasma Protein, Albumin, Pre ––

AlbuminAlbumin

-- Plasma Plasma TransferinTransferin



-- AlbuminAlbumin : 3,5 : 3,5 –– 5 5 grgr/dl/dl

-- GlobulinGlobulin : 1,5 : 1,5 –– 3 3 grgr/dl/dl

-- FibrinogenFibrinogen : 0,2 : 0,2 –– 0,8 0,8 grgr/dl/dl

�� PRE PRE –– ALBUMINALBUMIN

-- GiziGizi BaikBaik : 23,8 : 23,8 ±± 0,9 mg/dl0,9 mg/dl

-- GiziGizi SedangSedang : 16,5 : 16,5 ±± 0,8 mg/dl0,8 mg/dl

-- GiziGizi KurangKurang : 12,4 : 12,4 ±± 1,0 mg/dl1,0 mg/dl

-- MarasmusMarasmus : 7,6 : 7,6 ±± 0,6 mg/dl0,6 mg/dl

-- Mars Mars –– KwasKwas : 3,3 : 3,3 ±± 0,2 mg/dl0,2 mg/dl

-- KwashiorkorKwashiorkor : 3,2 : 3,2 ±± 0,4 mg/dl 0,4 mg/dl


�� SERUM ALBUMINSERUM ALBUMIN

-- < 1 < 1 ThTh : : CukupCukup > 2,5 > 2,5 grgr/dl/dl

-- 1 1 sdsd 5 5 ThTh : : CukupCukup > 3 > 3 grgr/dl/dl

-- 6 6 sdsd 16 16 ThTh : : CukupCukup > 3,5 > 3,5 grgr/dl/dl

-- 16 16 ThTh

CukupCukup : > 3,5 : > 3,5 grgr/dl/dl

KurangKurang : < 2,8 : < 2,8 grgr/dl/dl

MarginMargin : 2,8 : 2,8 –– 3,4 3,4 grgr/dl/dl

-- WanitaWanita HamilHamil

CukupCukup : > 3,5 : > 3,5 grgr/dl/dl

KurangKurang : < 3,5 : < 3,5 grgr/dl/dl

MarginMargin : 3 : 3 –– 3,4 3,4 grgr/dl/dl


�� SERUM PROTEIN SERUM PROTEIN

-- < 1 < 1 ThTh : : CukupCukup > 5 > 5 grgr/dl/dl

Margin < 5 Margin < 5 grgr/dl/dl

-- 1 1 sdsd 5 5 ThTh : : CukupCukup 5,5 5,5 grgr/dl/dl

Margin < 5,5 Margin < 5,5 grgr/dl/dl

-- 6 6 sdsd 16 16 ThTh : : CukupCukup 6 6 grgr/dl/dl

Margin < 6 Margin < 6 grgr/dl/dl

-- > 16 > 16 ThTh : : CukupCukup 6 6 grgr/dl/dl

KurangKurang 5,5 5,5 grgr/dl/dlMargin 6,5 Margin 6,5 –– 5,9 5,9 grgr/dl/dl

�� INDIKATOR KEPINDIKATOR KEP

AbuminAbumin/Globulin, /Globulin, KolestKolest & & HbHb turunturun


Levels of serum albumin concentrations in malnourished children

PathologicalPathological<< 2.52.5

LowLow2.52.5--2.92.9

SubnormalSubnormal33--3.43.4

NormalNormal> 3.5> 3.5

(g/dl)(g/dl)

InterpretationInterpretationConcentrationConcentration

Source: Alleyne et al., 1977.


PSG BIOKIMIA KVAPSG BIOKIMIA KVA

�� PROSESPROSESCadanganCadangan VitVit A A HeparHepar << << ➔➔➔➔➔➔➔➔DeplesiDeplesi VitVit A A dlmdlm tbhtbh ➔➔➔➔➔➔➔➔ KadarKadar VitVit AA

plasma plasma turunturun ➔➔➔➔➔➔➔➔ DisfungsiDisfungsi RetinaRetina ➔➔➔➔➔➔➔➔perubahanperubahan epitelepitel

�� INDIKATORINDIKATOR1.1. VitVit A Plasma NormalA Plasma Normal : : ≥≥≥≥≥≥≥≥ 30 30 µµg/dlg/dl

KVAKVA : < 5 : < 5 µµg/dlg/dl2.2. VitVit A A HeparHepar NormalNormal : : ≥≥≥≥≥≥≥≥ 15 15 µµg/dlg/dl

KVAKVA : <15 : <15 µµg/dlg/dl3.3. RBPRBP NormalNormal : : ≥≥≥≥≥≥≥≥ 20 20 µµg/dlg/dl

KVAKVA : < 20 : < 20 µµg/dl g/dl


Prevalence criteria for determining public health Prevalence criteria for determining public health significance of vitamin A deficiencysignificance of vitamin A deficiency

55Plasma vitamin A <10 Plasma vitamin A <10 µµg/dlg/dl0.050.05Corneal scarCorneal scar

0.010.01Corneal Corneal xerosisxerosis/corneal /corneal ulceration/ulceration/keratomalaciakeratomalacia

0.50.5Bitot'sBitot's spotsspots11Night blindnessNight blindness

Prevalence above Prevalence above (%)(%)

SignSign

Source: WHO, 1982.


PemeriksaanPemeriksaan GAKIGAKITest Test LaboratoriumLaboratorium ::

–– TSH : TSH : kadarkadar normal 0,4 normal 0,4 –– 4,8 4,8 µµg/mlg/ml

–– Urinary Urinary ExretionExretion Iodine (UEI) :Iodine (UEI) :

BeresikoBeresiko thdthd kesehatankesehatan lebihlebih luasluas

IIH, IIH, AutoimuneAutoimune, , penyakitpenyakit hiperhiper

thyroid thyroid dlldll..

SangatSangat kelebihankelebihan>300>300

ResikoResiko IIH IIH dlmdlm 55--10 10 thth program program

padapada kelkel umurumur tertentutertentu..LebihLebih200200--299299

OptimumOptimumCukupCukup100100--199199

KurangKurang iodiumiodium ringanringanKurangKurang5050--9999

KurangKurang iodiumiodium sedangsedangKurangKurang2020--4949

KurangKurang iodiumiodium beratberatKurangKurang<20<20

Status(giziStatus(gizi) ) iodiumiodiumAsupanAsupan iodiumiodiumMedian UIE Median UIE uug/lg/l


TSH neonatalTSH neonatal

�� SangatSangat pentingpenting untukuntuk kabupaten/kotakabupaten/kota endemikendemiksedangsedang &&beratberat atauatau pernahpernah dinyatakandinyatakanendemikberatendemikberat

�� SatuSatu--satunyasatunya caracara untukuntuk mengetahuimengetahui adanyaadanyakretinkretin barubaru

�� DilakukanDilakukan padapada semuasemua bayibayi barubaru lahirlahir..

�� DapatDapat mendeteksimendeteksi dinidini bayibayi hypothyroid transient hypothyroid transient maupunmaupun permanent.permanent.

�� PerluPerlu keterlibatanketerlibatan bidan/penolongbidan/penolong persalinanpersalinan..

�� MenggunakanMenggunakan bercakbercak darahdarah padapada kertaskertas saringsaring(Blood (Blood spot)atauspot)atau IndekIndek hipothyroidhipothyroid T.T.

�� PerluPerlu disiapkandisiapkan sistemsistem pelaporanpelaporan..


PemeriksaanPemeriksaan Urinary Urinary ExretionExretionIodine (UEI) Iodine (UEI)

�� Sampling random 300 Sampling random 300 orangorang kelompokkelompok

terawan(ibuterawan(ibu hamilhamil) ) untukuntuk diambildiambil urine urine

sesaatsesaat..

�� FrekuensiFrekuensi 1x/1 1x/1 –– 2th2th

�� KirimKirim keke LaboratoriumLaboratorium dgndgn ProsedureProsedure

bakubaku kirimkirim 10 % 10 % u/pemeriksaanu/pemeriksaan duploduplo didi

Lab Lab –– terakreditasi/rujukanterakreditasi/rujukan..

�� HasilHasil urutkanurutkan terendahterendah hinggahingga tertinggitertinggi

�� TentukanTentukan nilainilai median.median.


Severity and public health significance of IDDSeverity and public health significance of IDD

CriticalCritical<20<20>30>30++++++++++++++++(Stage III)(Stage III)

SevereSevere

UrgentUrgent20 4920 492020--29.929.900++++++(Stage II)(Stage II)

ModerateModerate

ImportantImportant>50>50--99995.019.95.019.90000++(Stage l)(Stage l)

MildMild

CretinismCretinismHypothyrHypothyroidismoidism

GoitGoitrere

Need for Need for correctioncorrection

Median Median urinary urinary iodine iodine

((µµg/litreg/litre ))

Typical Typical goitregoitre

prevalence prevalence (%)(%)

Clinical Clinical featuresfeaturesaaSeveritySeverity

Source: Adapted from WHO, 1994.a 0 = absent; + = mild/least severe; ++ = moderate/more severe; +++ = most severe.


BatasanBatasan GOAL GOAL indikatorindikator dalamdalam surveilanssurveilans GAKIGAKI

< 3 %< 3 %

Neonatal TSH Neonatal TSH

ProporsiProporsi bayibayi dengandengan kadarkadar TSH TSH

darahdarah lebihlebih daridari 5 5 mUmU/L/L

< 5%< 5%

GondokGondok

AnakAnak usiausia sekolahsekolah (6(6--12 12 thth))

HasilHasil PalpasiPalpasi/ultrasound)/ultrasound)

< 50%< 50%

< 20%< 20%

IodiumIodium dalamdalam urineurine

ProporsiProporsi dibawahdibawah 100 100 uugg/ L/ L

ProporsiProporsi dibawahdibawah 50 50 uugg/L/L

> 90 %> 90 %

GaramGaram beriodiumberiodium

ProporsiProporsi rumahrumah tanggatangga yang yang mengkonsumsimengkonsumsi

garamgaram beriodiumberiodium ((efektifefektif))

GOALGOALINDIKATORINDIKATOR

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PENENTUAN STATUS GIZI SECARA BIOKIMIAsuyatno.blog.undip.ac.id/files/2009/11/psg-biokimia.pdf · Anemi defisiensi besi (iron deficiency anemia): – Cadangan besi habis ... 50 -99