1

Functions of Blood
Blood performs a number of functions dealing with:
Substance distribution Regulation of blood levels of particular substances Body protection

Blood Functions: Distribution

Blood transports:
Oxygen from the lungs and nutrients from the digestive tract Metabolic wastes from cells to the lungs and kidneys for elimination Hormones from endocrine glands to target organs

Blood Functions: Regulation

Blood maintains:
Appropriate body temperature by absorbing and distributing heat to other parts of the body Normal pH in body tissues using buffer systems Adequate fluid volume in the circulatory system

Blood Functions: Protection

Blood prevents blood loss by:
Activating plasma proteins and platelets Initiating clot formation when a vessel is broken

Blood prevents infection by:

Synthesizing and utilizing antibodies Activating complement proteins Activating WBCs to defend the body against foreign invaders

Physical Characteristics of Blood

Average volume of blood:
56 L for males; 45 L for females (Normovolemia) Hypovolemia - low blood volume Hypervolemia - high blood volume

Viscosity (thickness) - 4 - 5 (where water = 1) The pH of blood is 7.357.45; x = 7.4 Osmolarity = 300 mOsm or 0.3 Osm
This value reflects the concentration of solutes in the plasma

Salinity = 0.85%
Reflects the concentration of NaCl in the blood

Temperature is 38C, slightly higher than normal body temperature Blood accounts for approximately 8% of body weight

Composition of Blood
Blood is the bodys only fluid tissue (a connective tissue) 2 major components
Liquid = plasma (55%) Formed elements (45%)
Erythrocytes, or red blood cells (RBCs) Leukocytes, or white blood cells (WBCs) Platelets - fragments of megakaryocytes in marrow

Components of Whole Blood

Plasma (55% of whole blood) Buffy coat: leukocyctes and platelets (<1% of whole blood)
Erythrocytes (45% of whole blood)

Formed elements

1 Withdraw blood

2 Centrifuge

and place in tube

Hematocrit
Males: 47% 5% Females: 42% 5%

Blood Plasma
Blood plasma components:
Water = 90-92% Proteins = 6-8%
Albumins; maintain osmotic pressure of the blood Globulins
Alpha and beta globulins are used for transport purposes Gamma globulins are the immunoglobulins (IgG, IgA, etc)

Fibrinogen; a clotting protein

Organic nutrients glucose, carbohydrates, amino acids Electrolytes sodium, potassium, calcium, chloride, bicarbonate Nonprotein nitrogenous substances lactic acid, urea, creatinine Respiratory gases oxygen and carbon dioxide

Plasma Protein
Plasma : Albumin, Globulin, Fibrinogenro. Serum ; Albumin, Globulin Electrophoretic separated plasma/serum protein.

Formed Elements
Formed elements comprise 45% of blood Erythrocytes, leukocytes, and platelets make up the formed elements
Only WBCs are complete cells RBCs have no nuclei or organelles, and platelets are just cell fragments

Most formed elements survive in the bloodstream for only a few days Most blood cells do not divide but are renewed by cells in bone marrow

12

Stages of Differentiation of Blood Cells

Figure 17.9

RBC
RBC is the most abundant cell in our body Erythrocyte is the simplest cell in our body The highest specific rate of glucose utilization of any cell in the body (10 g/kg tissue/day : 2,5 for the whole body) It has no sub-cellular organelle Without nucleus its cannot divided, degraded after 120 days Without mitochondria cannot produce energy (the lowest rates of ATP synthesis of any cell in the body) without endoplasmic reticulum can not synthesis protein and lipid without lysosome can not produce digestive enzyme
14

Hemoglobin
Hb is the oxygen carrier of RBC to bring O2 from the lung to the extra pulmonary tissues (reversible) Mb, is found in muscle tissues, where it store oxygen and use in exercise Its consist of Heme and globin Heme consist of Iron and protophorpyrine Oxygenation: Hb + O2 Hb O2 Oxidation: Fe++ of Hb Oxidi into Fe+++
15

Heme group
Heme is the oxygen binding site of Hb and Mb (myoglobin) Heme contain protoporphyrin IX with ferrous iron chelated in the centre. Protoporphyrin contain 4 mol of pyrole rings, held together by methin (-CH=} bridge, decorated with methyl (-CH3), finyl (-CH=CH2), and propionate (-CH2-CH2COO-) side chain.
16

Basic structure of Hb/heme

17

Heme (cont-)
The porphyries ring system contain conjugated double bonds. These are responsible for the color of our blood (affected by the oxygenation state) Oxygenated Hb is red, and deoxy-Hb is blue. Therefore Oxygen deficiency or hypoxia can be recognized as a blue discolorization of the lips and other mucus membrane this is called cyanosis.
18

Heme Iron
The most important part of the heme group is its iron. Ionized iron can form coordinate bonds with the unpaired electron of oxygen or nitrogen atom. In heme, the iron is bounds to nitrogen of 4 pyrole rings Both in Hb and Mb, the iron forms a fifth bond with a nitrogen atom in a histidine side chain of apoprotein . This histidine is called proximal histidine. A sixth coordinate bond can be form with mol O2
19

 Iron can exist in ferrous (Fe++) and ferric state (Fe+++). Ferric state is the oxidized form because it can be formed from ferrous iron by a removal of electron. The heme iron of Hb and Mb is always in ferrous state. Even during oxygen binding, it is not oxidized to the ferric form. It becomes oxygenated but not oxidized
20

RBC
RBCs circulate about 120 days before they scavenged by phagocytic cells in the spleen and other tissue. RBCs have no nucleus there fore unable to divide and synthesized proteins. Also lack of mitochondria they do not consume any of the oxygen they transport. They cover their energy needs by anaerobic metabolism of glucose to lactic acid
21

RBC-Hb
RBCs are bagsfilled with Hb with concentration not less than 33%, dissolved in cytoplasm. Blood cells concentration of whole blood = hematocrit. Patient with an abnormally low Hb concentration are said to have anemia.

22

23

Hbs are tetrametric protein

The most importance difference between Hb and Mb is the sub-unit structure. Mb consist of single polypeptide with its heme group. Hb has four polypeptides each with its own heme. Human have several types of Hb : HbA, HbA2, HbF (HbA has a2b2 polypeptide composition, HbA2 has a2d2 elevated in beta thallasemia = deficiency in beta globin biosynthesis). HbF (a2g2 polypeptide composition)
24

Structure of Hemoglobin

Figure 17.4

SYNTHESIS HEMOGLOBIN
Its start from pro-erythroblast stadium and a bit of reticulocyte stadium Retikulocyte leaving bone marrow to blood stream hemoglobin Suksinil-KoA (Krebs cycle) bind glysin pyrole. 4 pyrole condense to formed protoforfirin IX Protoforfirin IX + Fe++ heme Heme + globin Hemoglobin
26

 Heme + long polypeptida (globin, synthesizes in ribosome) hemoglobin chain (MW 16.000) 4 hemoglobin chain connect together to formed hemoglobin

27

 Chain variation of Hb sub-unit depend on aa array in polypeptide. Chain type : , , gamma dan delta Adult Hb : hemoglobin A (MW 64.458) consisit of 2 and 2 chain combination. 4 atoms of iron Hb, @ connect to 1 molekul O2

28

Chain abnormalities
Would changes physical properties Hb. E.g : cycle cell anemia. aa valine replace by glutamate in each of beta chain, if it is shine by O2 low grade formed long crystal 15 mikrometer in erythrocyte, destroyed erythrocyte membrane.

29

Sintesis Hemoglobin

30

MetHb
Is non funcional oxidized form of Hb The heme iron of Hb bind molecular oxygen only in the ferrous state (Fe++). Its oxidation to the Ferric forms result in met-Hb which is useless as an oxygen transporter. Normally less than 1% of total Hb is in the form of Met-Hb, but oxidizing chemicals (aniline dyes, aromatic nitrous compounds, inorganic and organic nitrous compound) cause excessive met-Hb formation.

Defense mechanism
1. 2. Fortunately the RBCs can defend itself against excessive met-Hb formation e.g Erythrocyte reducing substances (ascorbic acid and glutathion). The binding of heme to the apoprotein, creates a protective environment for the iron. Heme hemin + hydroxyl ion hematin. Met-Hb reductase reduce met-Hb back to Hb using NADH as a reductant. Deficiency of this enzyme Congenital methemoglobinemia. Met-Hbemia is treated with methylene blue which reducing Fe+++ Fe++

3.

Carbon monoxide (CO)

CO compete with oxygen for binding to the heme iron. CO products of incomplete combustion is present in cigarette smoke, automobile exhaust and others source. Even in a small amount formed in our body. CO binds to Fe++ in Hb and Mb Its 200 fold higher affinity for heme than O2 does. Therefore, even a low concentration of CO is sufficient to displace O2 from its binding site on the heme iron and cause a serious poisoning.

CO cont Carbon monoxide binding is reversible: in normally breathing patient with CO poisoning, O2 gradually displaces CO , leading to slow recovery in several hours. The interaction between CO and O2 at the heme iron competitive antagonism CO concentration of only 1/200th of the O2, is sufficient to convert half of oxy-Hb to CO-Hb. Hyperbaric oxygen is the treatment of choice.

BPG is physiological important regulator of oxygen binding to HB

2,3-Bisphosphoglycerate (BPG) is a small organic molecule that present in RBC. Concentration 5 mM Most BPG is noncovalently bond to Hb (one mol BPG/mol Hb) BPG binds only to the T conformation of Hb stabilization of T conformation, which have low binding affinity The observed effect is a decreased oxygenbinding affinity

BPG
BPG concentration in RBC increases during hypoxic condition, including lung disease, severe anemia, and adaptation to high altitude. This increase affect oxygenations in the lung capillaries, but enhances the unloading of oxygen in the tissue.

HbF has oxygen binding affinity higher than HbA

In HbA BPG forms salt bonds to the amino terminal of the -chain and with the side chain of Lys and His in the chain. In the ( gama) chain of HbF His are replace with serine residue that is not able to form salt bond. Therefore BPG binds less tightly to HbF than to HbA reduces the effect of BPG on the oxygen affinity. At physiologic BPG concentration, the P450 of HbF only 20 torr compared with 26 torr for HbA facilitate the transfer of oxygen from the maternal blood to the fetal blood in the capillaries of placenta.

Iron metabolism
Iron exist in 3 formed: functional iron ( Hb, mioglobin & some enzymes), store iron (feritin & hemosiderin) & transport iron (transferin) Total iron : 40 50 mg Fe/kg BW
65% Hb 15 30% stored as feritin (liver) 4% mioglobin 1% heme 0,1% bind to protein transferin in blood plasma.
38

Transport and store

Fe absorbed in all part of small intestine blood plasma + apotransferin transferin Sitoplasma, iron + apoferitin (MW 460.000) feritin (store iron) Hemosiderin, insoluble Fe, formed when more Fe absobed (more than bind by apoferitin.

39

 Transferin bind tightly to membrane receptor erythroblast cell of bone marrow. Transferin-Fe, pass the erythroblast by endositosis, iron to mitochondria Low transferin impaired transport of Fe to eritroblas severe hipochromic anemia Fe excreted 1 mg/day trough feces. Menstrual woman lost about 2 mg/day, lactating 1 mg/day
40

 In the intestine apotrasferin + free Fe transferin receptor membrane intestine epitheel cell by pinositosis. Iron absorbtion depend on body required for Fe: Mechanism of iron absorbtion regulation: Dietary regulator, stores regulator & erythropoetic regulator
Dietary regulator : kind of diet Stores regulator : iron body store Erythropoetic regulator : the rate of erytropoesis

The rate of absorption is so slow mgms/day.

41

Absorbtion
Fe, absorbed in brush border of epithel vili small intestine, specially duodenum & upper part of jejunum Divided to 3 phase : luminal, mukosal & corporeal
Luminal : in gaster and ready to absorbed in doeodenum. Mucosal : absorption in small intestine. Corporeal : transport Fe in sirculation, utilisation by cell. And sore of Fe

Liver secrete apotransferin to the bile duodenum.

42

 Iron absorption depend on : Fe diet, Iron from plan (non heme) absorb 1-7% Heme iron (meat, fish absorp 25-30%), with high bioavailility and easier to absorb.

43

 To increase non heme iron absorpion need trigger factor such as ascorbic acid (lemon,grape, guava, papaya and green vegetable). Inhibite by tannat (tea), coffe and cereal (phitate).

44

Fe deficiency
Deficient of Fe Fe deficiency anemia Caused by : bleeding, worm investation (ankylostomum duodenale ), intake Fe reduce, Fe absorption block etc Hypochromic microcytic anemia.

45

46

Erythrocyte degradation
Ery enzymes NADPH Function of NADPH : - maintain membrane fragility. - maintain ion transport through membrane - maintain Fe of Hb cell in the form of Fe++ - Protect oxidation of protein in Ery.

47

Hemoglobin Degradation
Ery cell lysis/fagocyte by macrophage heme and globin. Heme ring open free iron transport to the blood by transferin biliverdin reduction bilirubin plasma. Bilirubin + albumin, reabsorb to the the liver conjugated to glucoronic acid (biliirubin glucoronate 80% and bil sulfate 10% and with another substance 10%.
48

 Bil secreted to bile canaliculi (active transport) intestine. of conjugated bil. urobilinogen (easier to solute in water. Some reabsorbs by mucosa to the blood. Excretion to by liver and renal. Urobilinogen urine oxidized by air urobilin On feses urobilinogen stercobilin.

49

Life Cycle of Red Blood Cells

51

INTRODUCTION - Hemolytic anemia : a shortened

RBC survival result of increased RBC destruction - Congenital Hemolytic Anemias - Result from mutations influence the function of RBC proteins - Three categories : 1. Membran defect 2. Enzymatic defect 3. Hemoglobin defect

GENERAL DIAGNOSTIC
A. History and physical examination 1. Chronicity of the problem Ethnic, racial background Family history Medical conditions New medication

2. - Jaundice - Splenomegaly

B. Laboratory
1. reticulocyte index respon BM 2. LDH, unconjugated bilirubin, or absent of haptoglobin 3. RBC morphology abnormal ( important clue underlying diseases ) 4. Blood smear rarely pathognomonic

CATEGORY CONGENITAL HEMOLYTIC ANEMIAS

Membrane defect
A. - autosomal dominant inheritance - marked heterogenecity in underlying mutations - marked clinical heterogeneity - generally mild - splenectomy is curative - intrinsic defect - extravascular hemolysis B. - hereditary spherocytosis (HS) - hereditary elliptocytosis (HE) - hereditary pyropoikilocytosis - hereditary stomatocytosis - hereditary acanthocytosis - hereditary xerocytosis

Enzymatic defect
G6PD - X linked - >> Africa - self limited hemolysis by stress, infection or drug - intrinsic & extrinsic defect - extravasculer & intravasculer hemolysis Pyrovat kinase - autosomal recessive disorder - chronic hemolysis

Hemoglobin defect
Thalasemias - quantitative defect - globin chain imbalance ( / ) Sickle cell ds - qualitative defect - amino acid substitution stability Hb

HS
- abnormalities RBC structural protein (Spectrin,Ankyrin,Band) mediate vertical interactions - clinical presentation : a. Jaundice b. Formation of pigment gallstones c. Mild to moderate splenomegaly d. Leg ulcer - Laboratory - peripheral blood smear spherocytes - anemia polychromasia - osmotic fragility test - Treatment - severe anemia splenectomy

HE
- abnormalities RBC Structural protein (Spectrin) mediate horisontal interactions - clinical presentation : a. Jaundice b. Formation of pigment gallstones c. Mild to moderate splenomegaly d. Leg ulcer - Laboratory - peripheral blood smear elliptocytosis - anemia - osmotic fragility normal or abnormal - Treatment - severe anemia splenectomy

Spherocytosis

Elliptocytosis

G6PD Deficiency
X linked inheritance Pathophysiology : - acute hemolysis RBC is exposed to oxidant stress, infection, drugs (page 53) - Glutathion stores oxidative damage to RBC component - Heinzs bodies (+) Hemolysis extravasculer commonly Hemolysis intravasculer severe

PK Deficiency
Autosomal recessive disorder Pathophysiology : - In the glycolytic pathway convert phosphoenolpyruvate to pyruvate accumulation of 2-3 dyphosphoglycerate extremely severe hemolytic anemia intense reticulocytosis, splenomegaly Diagnosis measurement of enzyme Treatment : Splenectomy

oxidant Diagnosis measurement of enzyme

Drugs That Provoke Hemolytic Episodes in individuals deficient in G6PD

- Acetanilid - Sulfacetamide

- Methylene blue - Nalidixic acid - Napthalene (Mothballs) - Niridazole - Nitrofurantoin - Pamaquine - Pentaquine - Phenylhydrazine - Primaquine

- Sulfamethoxasole - Sulfanilamide - Sulfapyridine - Thiazolsulfone - Toluidine blue - trinitrotoluene

Thalassemias
a globin chain imbalace Mutation partially or completely a globin

Sickle Cell disease

mutation in codon 6 of the globin chain Three genotype : SS, SC or Sickle--thalassemia Clinical Features : - sickle cell trait - sickle cell anemia - sickle--thalassemia - hemoglobin SC Cinical presentation - periodic episodes of acute vasculer occlusion (painful crisis) Howell-Jolly bodies Treatment : supportive (hydration, pain medication)

chain imbalance ratio dan globin chain The most common type : - Beta () - Alpha () - Combination with Hb abnormal (HbE) Clinicaly : - Thalassemia major - Thalassemia intermedia - Thalasemia minor / thalassemia trait Treatment ~ clinicaly

Thalassemia

Sickle cell disease

Change in Globin Chain Production


2 2 = 97 % (Hb A)

2 2 4

2 2 4 (Hb H)

2 2 (Hb F)< 1 %

2 2 4 (Hb Bart`s)

2 2 (Hb F) 2 2 (Hb A2) - Thal

2 2 (Hb A2) 2-3 % 2 2 4 ? Normal - Thal

2. Extra vascular hemolytic

occur extra vascular by macrophage phagositosis specialy in the spleen and other RES. This is the most frequent of HE, followed by jaundice and splenomegaly. Unconyugated hyper bilirubinemia is typically present

 Immune-mediated hemolytic disorder: a. auto immune hemolytic anemias: is a groups of disorder that are the result of antibody or complement binding to specific antigen on the RBC membrane, which leads to RBC life spand. This disorder can be primary (idiophatic) or secondary (underlying disease, drug)

Anti-erythrocyte antibody can be devided into 3 catagories: a. IgG warm auto antibodies bound to RBC but failed to agglutinate RBCs b. Cold agglutinin almost are of the IgM subtype and clump RBC at cold temperature. c. Donat-Landsteiner (IgG) antibodies binds to RBC membrane in the cold and activate hemolytic complement cascade when the RBC warmed to 37C

Causes of Acquired Hemolytic Anemias

Immunohemolytic Transfusion of incompatible blood Hemolytic disease of the newborn Warm-antibody autoimmune hemolytic anemia Cold-antibody autoimmune hemolytic anemia Traumatic and microangiopathic Prosthetic valves and other cardiovascular abnormalities Hemolytic uremic syndrome Thrombotic thrombocytopenic purpura Disseminated intravascular coagulation Immunologic phenomena (e.g., graft rejection, immune complex formation) Cancer Infectious agents Protozoa (e.g., malaria, toxoplasmosis, leishmaniasis, trypanosomiasis) Bacteria (e.g., bartonellosis, Clostridia, cholera, typhoid fever) Chemicals, drugs, and venoms Physical agents Burns Hypophosphatemia Paroxysmal nocturnal hemoglobinuria Spur cell anemia (liver disease) Vitamin E deficiency in newborns

Drug-induced immune hemolytic anemia.

Hapten mechanism Clinically, the DAT is positive for IgG, and hemolysis occurs only when the offending drug (e.g., penicillin) is present. Immune complex mechanism . This is the most common mechanism for druginduced (e.g., quinidine, phenacetin) immune hemolytic anemias. The DAT is positive for complement (C3) only. Autoantibody mechanism. The DAT is positive for IgG. As many as 20% of patients treated with methyldopa have a positive DAT, but fewer than 1 % of these patients demonstrate hemolysis. Immunogenic drug-RBC complex mechanism Non-immune protein adsorption mechanism. Proteins (e.g., drugs) may nonspecifically attach to the RBC membrane without causing RBC destruction. Examples include cephalosporins (primarily first generation), albumin, and immunoglobulins (e.g., IVIG).

NONIMMUNE HEMOLYTIC ANEMIAS

The nonimmune hemolytic anemias are generally the result of extrinsic factors or effects on otherwise normal RBCs. Many physical, chemical, and infectious causes make up the differential diagnosis for the nonimmune hemolytic anemias.

Fragmentation hemolysis
Fragmentation hemolysis occurs when mechanical trauma or shear stress disrupts the physical integrity of the RBC membrane.

Etiology
a.Damaged microvasculature with the resulting disorder commonly referred to as microangiopathic hemolytic anemia, b.Arteriovenous malformations (e.g., arteriovenous shunts) c.Cardiac abnormalities (e.g., prosthetic heart valves) d.Drugs (e.g., cyclosporine, cancer chemotherapy agents, ticlopidine, clopidogrel, cocaine)

Clinical presentation of fragmentation hemolysis. Except in cases of extremei ntravascular

fragmentation, these patients typically demonstrate the same clinical findings associated with extravascular hemolysis. These findings include pallor, jaundice, and a loss of a feeling of well-being. Laboratory evaluation of fragmentation hemolysis Laboratory findings are similar to those for extravascular hemolysis; some intravascular hemolysis findings may be present.Diagnosis depends on examination of the peripheral blood smear, which reveals fragmented RBCs (i.e., schistocytes, helmet cells, microspherocytes) and polychromatophilia. Treatment of fragmentation hemolysis a.Therapy is directed at the underlying condition. b.Iron and folic acid supplementation and RBC transfusions are administered as necessary.

Hypersplenism
Hypersplenism is a functional state of hyperactivity of the spleen, including its cellular sequestration activity. For this reason, hypersplenism can lead to a decrease in the life span of RBCs, leukocytes, and platelets. Splenomegaly is an anatomic term for enlargement of the spleen. All of the activities of the spleen are accentuated in a large spleen; therefore, hypersplenism is often associated with splenomegaly. Anemia in these patients is the result of increased RBC destruction and splenic sequestration. Treatment of hypersplenism a.Therapy is directed at the underlying cause of the splenomegaly or hyper splenism. b.Anemia and pancytopenia are not usually severe; if they are severe, sple nectomy typically leads to improvements in the blood counts.

Causes of Hypersplenism
Vascular congestion Right heart failure Hepatic vein thrombosis (Budd-Chiari syndrome) Cirrhosis Portal vein obstruction Splenic vein thrombosis Infection Bacterial endocarditis Tuberculosis Parasites Viruses Fungi Inflammatory diseases Systemic lupus erythematosus Rheumatoid arthritis Hemolytic anemias Congenital (thalassemias, hereditary spherocytosis) Acquired (autoimmune) Neoplasms Lymphomas Hairy cell leukemia Chronic lymphocytic leukemia Myeloproliferative disorders Storage disorders Caucher disease Mucopolysaccharidoses Benign structural abnormalities Cysts Hamartomas Other Amyloidosis Sarcoidosis

Infection
Direct parasitization (e.g., malaria, babesiosis, bartonellosis) can result from an organism infecting the RBC, which leads to intravascular or extravascular hemolysis, or attaching to the RBC membrane, which leads to RBC destruction. Immune mechanisms, such as Mycoplasma pneumoniae, Epstein-Barr virus (mononucleosis), are discussed earlier in the text (see III.C.2.b.). Induction of hypersplenism can occur as a sequela of some infections (e.g.,malaria, schistosomiasis) by immune-mediated and non-immune-mediated mechanisms. Altered RBC surface topology (e.g., Haemophilus influenzae) caused by interactions between the microorganism and the RBC surface can lead to hemolysis. Release of toxins and enzymes by a microorganism (e.g., Clostridium, Escherichia coli 0192) can cause direct damage to the RBC membrane, which leads to shortened RBC survival.

Other causes of nonimmune hemolytic anemias.

Liver disease Severe burns (heat denaturation) Copper deficiency (Wilson disease) Drug-induced oxidative damage

80