Basic Hematology

Basic Hematology (Biology and Physiology of Blood)

Fadel Muhammad Garishah

Diponegoro University School of Medicine In affilia:on Dr. Kariadi General Hospital

Semarang, CJ, Republic of Indonesia

Component of blood

Blood is the term for the liquid substance within vascular system. It consisted of plasma (55%), leukocytes and platelet (<1%) and red blood cells (45%).

Cellular basis of red blood cells

Hemoglobin structure

erythropoiesis

Erythropoiesis is a sequence involving proliferaFon and differenFaFon of commiHed red marrow cells through the erythroblast and normoblast stages to the reFculocytes that are released into the bloodstream, and finally become erythrocytes.

RegulaFon of erythrocyte

89

Plate4.1

Compo

sition

andFu

nction

ofBloo

d

b

a

PO2

PO2

PO2

PO2

“Still good”

MCHC (mean Hb conc. in RBCs)

Hb conc. = (g/LRBC) Hct

MCV (mean volume of one RBC)

Hct = (L/RBC) red cell count

MCH (mean Hb mass/RBC)

Hb conc. = (g/RBC) red cell count

Normal:320 –360g/L

Normal:80–100 fl

Normal:27 –32 pg

Centrifugation

Hemoglobin concentration(g/LBLOOD)

Erythropoietin

Hemolysis

Erythropoietin

Kidney

Bone marrow

High altitude, etc.

2 Hemolysis

1 Hypoxia

Bone marrowLymph nodesSpleenLiver, etc.

Spleen

Blood

Bone marrow

Test

RBC formation

Phagocytosisby

macrophages in:

Sinus

“Too old”

Pulpalarteriole

Life span:120 days

Red cell count (RCC)(quantity/LBLOOD)

Hematocrit (Hct)= b/a(LRBC/LBlood)

Blood sample

Erythrocytes

Spenicpulp

Break-down

B. Life cycle of red blood cellsA. Regulation of RBC production

C. Erythrocyte parameters MCH, MCV and MCHC

Despopoulos, Color Atlas of Physiology © 2003 ThiemeAll rights reserved. Usage subject to terms and conditions of license.

89

Plate4.1

Compo

sition

andFu

nction

ofBloo

d

b

a

PO2

PO2

PO2

PO2

“Still good”








Normal:80–100fl

Normal:27 –32 pg

Centrifugation


Erythropoietin

Hemolysis

Erythropoietin

Kidney

Bone marrow

High altitude, etc.

2 Hemolysis

1 Hypoxia


Spleen

Blood

Bone marrow

Test

RBC formation

Phagocytosisby

macrophages in:

Sinus

“Too old”

Pulpalarteriole

Life span:120 days



Blood sample

Erythrocytes

Spenicpulp

Break-down




Life cycle of erythrocytes

89

Plate4.1

Compo

sition

andFu

nction

ofBloo

d

b

a

PO2

PO2

PO2

PO2

“Still good”








Normal:80–100 fl

Normal:27 –32 pg

Centrifugation


Erythropoietin

Hemolysis

Erythropoietin

Kidney

Bone marrow

High altitude, etc.

2 Hemolysis

1 Hypoxia


Spleen

Blood

Bone marrow

Test

RBC formation

Phagocytosisby

macrophages in:

Sinus

“Too old”

Pulpalarteriole

Life span:120 days



Blood sample

Erythrocytes

Spenicpulp

Break-down




Clinically related erythrocytes parameter

89

Plate4.1

Compo

sition

andFu

nction

ofBloo

d

b

a

PO2

PO2

PO2

PO2

“Still good”








Normal:80–100 fl

Normal:27 –32 pg

Centrifugation


Erythropoietin

Hemolysis

Erythropoietin

Kidney

Bone marrow

High altitude, etc.

2 Hemolysis

1 Hypoxia


Spleen

Blood

Bone marrow

Test

RBC formation

Phagocytosisby

macrophages in:

Sinus

“Too old”

Pulpalarteriole

Life span:120 days



Blood sample

Erythrocytes

Spenicpulp

Break-down




Iron intake and metabolism

91

Plate4.2

Iron

Metab

olism

andErythrop

oiesis

Fe

FeFe

7mg

1 mg

HCI

Fe

Fe

Fe

FeIII FeIII

FeIII

Fe2+ FeIII

Fe2+

H+

Fe stores

Systemicblood

LiverBone

marrow

Hemo-siderin

FerritinHeme

Hb

Erythrocytes

Hemo-pexin

Hapto-globin

Ferritin

Hemo-siderin

Transferrin

Macrophagesin spleen, liver and

bone marrow (extravascular)

Already in bone marrow

Liver

Ileum

Vitamin B120.001mg/day

Folic acid0.05mg/day

Other organs

Stores

Bone marrow

NADP NADPH +H+

Dihydrofolatereductase

Folateregeneration

Thymidylatesynthase

7,8-dihydro-

folate

Tetrahydro-folate

N5-tetra-hydrofolate

Deoxy-uridylate

Deoxy-thymidylate

ErythroblastDNA synthesis

ErythropoiesisStomach

Erythrocytes

Stomach

Liver

Fe absorption:3 –15 % ofFe intake

Normal Fe intake: 10–20 mg/day 5–10 mg/day

Intrinsicfactor

Methyl-cobalamin

Lum

en

Ferritin

Bloo

d

Lyso-some

Cellturnover

Mucosaltransferrin

Apo-

tran

sfer

rinHeme-FeII

Mucosal cells(duodenum)

Tran

s-fe

rrin

Non-absorbed Fe in feces:Normally 85–97% of intake

Heme

FR

FeIII

2 Fe absorption

3 Fe storage and Fe recycling

1 Iron intakeA. Iron intake and metabolism

B. Folic acid and vitamin B12 (cobalamins)


Iron storage and recycling

91Plate4.2

Iron

Metab

olism

andErythrop

oiesis

Fe

FeFe

7 mg

1 mg

HCI

Fe

Fe

Fe

FeIII FeIII

FeIII

Fe2+ FeIII

Fe2+

H+

Fe stores

Systemicblood

LiverBone

marrow

Hemo-siderin

FerritinHeme

Hb

Erythrocytes

Hemo-pexin

Hapto-globin

Ferritin

Hemo-siderin

Transferrin




Liver

Ileum


Folic acid0.05mg/day

Other organs

Stores

Bone marrow

NADP NADPH +H+


Folateregeneration

Thymidylatesynthase

7,8-dihydro-

folate

Tetrahydro-folate


Deoxy-uridylate

Deoxy-thymidylate



Erythrocytes

Stomach

Liver


Normal Fe intake: 10– 20 mg/day 5–10 mg/day

Intrinsicfactor

Methyl-cobalamin

Lum

en

Ferritin

Bloo

d

Lyso-some

Cellturnover

Mucosaltransferrin

Apo-

tran

sfer

rinHeme-FeII


Tran

s-fe

rrin


Heme

FR

FeIII

2 Fe absorption





Folic acid and Cobalamin (B12) metabolism

91

Plate4.2

Iron

Metab

olism

andErythrop

oiesis

Fe

FeFe

7mg

1 mg

HCI

Fe

Fe

Fe

FeIII FeIII

FeIII

Fe2+ FeIII

Fe2+

H+

Fe stores

Systemicblood

LiverBone

marrow

Hemo-siderin

FerritinHeme

Hb

Erythrocytes

Hemo-pexin

Hapto-globin

Ferritin

Hemo-siderin

Transferrin




Liver

Ileum


Folic acid0.05 mg/day

Other organs

Stores

Bone marrow

NADP NADPH +H+


Folateregeneration

Thymidylatesynthase

7,8-dihydro-

folate

Tetrahydro-folate


Deoxy-uridylate

Deoxy-thymidylate



Erythrocytes

Stomach

Liver


Normal Fe intake: 10 – 20 mg/day 5 –10 mg/day

Intrinsicfactor

Methyl-cobalamin

Lum

en

Ferritin

Bloo

d

Lyso-some

Cellturnover

Mucosaltransferrin

Apo-

tran

sfer

rinHeme-FeII


Tran

s-fe

rrin


Heme

FR

FeIII

2 Fe absorption





The blood groups

101

Plate4.7

Bloo

dGroup

s

+

=

O

A

B

AB

O A B AB

lgE

5 10 15 20

21

Rh+

Rh+

Rh+ Rh+

Rh–

Rh–Rh–

Rh–

Rh+

(After Kownatzki)

Days after first antigen exposure

Compatible

Incompatible(agglutination)Anti-AAnti-B

Antig

en o

n re

d bl

ood

cells

Red blood cells

Antibodies

Agglutination

Hemolysis

Conc

entr

atio

n in

blo

od

Antigen-antibodycomplexes

Antigen Symptoms

Freeantibodies

lgEreceptor

Antigen

Histamine, PAF, leukotrienesand other mediators

Granules

Mast cell or basophil

Antibody in serum

Severe hemolysisin fetus

Father Mother

Subsequent Rh+ childrenFirst Rh+ child

Subsequent mismatched Rh+ transfusion

Rh+ red cells

Highanti-Rh+ titer

Damage

Rh+ red cells

Anti-Rh+

Highanti-Rh+ titer

Damage

Anti-Rh+ antibodyBlood

First mismatched Rh+ transfusion

A. Anaphylaxis B. Serum sickness

C. ABO blood group incompatibility

D. Rh sensitization of mother by child or by Rh-mismatched transfusion


Biology of Rhesus

101

Plate4.7

Bloo

dGroup

s

+

=

O

A

B

AB

O A B AB

lgE

5 10 15 20

21

Rh+

Rh+

Rh+ Rh+

Rh–

Rh–Rh–

Rh–

Rh+

(After Kownatzki)

Days after first antigen exposure

Compatible

Incompatible(agglutination)Anti-AAnti-B

Antig

en o

n re

d bl

ood

cells

Red blood cells

Antibodies

Agglutination

Hemolysis

Conc

entr

atio

n in

blo

od

Antigen-antibodycomplexes

Antigen Symptoms

Freeantibodies

lgEreceptor

Antigen

Histamine, PAF, leukotrienesand other mediators

Granules

Mast cell or basophil

Antibody in serum

Severe hemolysisin fetus

Father Mother

Subsequent Rh+ childrenFirst Rh+ child

Subsequent mismatched Rh+ transfusion

Rh+ red cells

Highanti-Rh+ titer

Damage

Rh+ red cells

Anti-Rh+

Highanti-Rh+ titer

Damage

Anti-Rh+ antibodyBlood

First mismatched Rh+ transfusion

A. Anaphylaxis B. Serum sickness

C. ABO blood group incompatibility

D. Rh sensitization of mother by child or by Rh-mismatched transfusion


Plasmaproteins

93

Plate4.3

Flow

Prop

erties

ofBloo

d

IgA 2.25

IgM 1.15

IgD 0.03IgE 0.0002

IgG 11.0g/L

100

50

–3 181512963

IgM

IgGIgAIgDIgE

60% 4% 8% 12% 16%α1 α2 β γ8

6

4

2

1

01 5 10 50 100 500 1000

Na+

K+

1424.3

2.6 (1.3*)1.0 (0.5**)

1534.6

2.8 (1.3)1.0 (0.5)

1454.4

2.5 (1.5)0.9 (0.45)

ca. 12ca. 140< 0,001

1.6150 162 153 ca. 152

Cl–

HCO3–

*) Total plasma Ca: 2.5 mmol/L; **) Total plasma Mg: 0.9 mmol/L

Na+

Ca2+, Mg2+

Cl–

HCO3–

HCO3–

K+

Ca2+,Mg2+Na+K+

mval/L (mmol/L)

104242

145.9

112362.2156.3

117272.30.46.2

ca. 310

ca. 30ca. 54ca. 54

150 162 153 ca. 152

Birth Age (months)

From Mother

(After Hobbs)

Plas

maAlbumin Globulins

Electrophoretic protein fractions

65–

80 g

/LPr

otei

ns (1

00%

)

Cati

ons

Plasma Interstitium CytosolSerumIon

Ani

ons

ProteinsMisc.

Sum

Sum

Proteins,phosphates,etc.

Proteins–

Interstitium CytosolCations Anions Cations Anions

Vis

cosi

ty in

rela

tive

units

Vessel inside diameter (µm)

Blood

Plasma

Water

Free Ca2+

Inorganic phosphate

Inorganicphosphate

Misc.

Free Mg2+

% o

f res

pect

ive

seru

m c

once

ntra

tion

in a

dult

A. Fåhraeus-Lindqvist effect B. Plasmaproteins

C. Ion composition of body fluids

D. Concentrations of immunglobulins in serum


Ion composiFon of body fluids

93Plate4.3

Flow

Prop

erties

ofBloo

d

IgA 2.25

IgM 1.15

IgD 0.03IgE 0.0002

IgG 11.0g/L

100

50

–3 181512963

IgM

IgGIgAIgDIgE

60% 4% 8% 12 % 16%α1 α2 β γ8

6

4

2

1

01 5 10 50 100 500 1000

Na+

K+

1424.3

2.6 (1.3*)1.0 (0.5**)

1534.6

2.8 (1.3)1.0 (0.5)

1454.4

2.5 (1.5)0.9 (0.45)

ca. 12ca. 140<0,001

1.6150 162 153 ca. 152

Cl–

HCO3–


Na+

Ca2+, Mg2+

Cl–

HCO3–

HCO3–

K+

Ca2+,Mg2+Na+K+

mval/L (mmol/L)

104242

145.9

112362.2156.3

117272.30.46.2

ca. 310

ca. 30ca. 54ca. 54

150 162 153 ca. 152

Birth Age (months)

From Mother

(After Hobbs)

Plas

ma

Albumin Globulins


65–

80 g

/LPr

otei

ns (1

00%

)

Cati

ons


Ani

ons

ProteinsMisc.

Sum

Sum


Proteins–


Vis

cosi

ty in

rela

tive

units


Blood

Plasma

Water

Free Ca2+

Inorganic phosphate

Inorganicphosphate

Misc.

Free Mg2+

% o

f res

pect

ive

seru

m c

once

ntra

tion

in a

dult





The immunoglobulin in serum

93

Plate4.3

Flow

Prop

erties

ofBloo

d

IgA 2.25

IgM 1.15

IgD 0.03IgE 0.0002

IgG 11.0g/L

100

50

–3 181512963

IgM

IgGIgAIgDIgE

60% 4% 8% 12% 16%α1 α2 β γ8

6

4

2

1

01 5 10 50 100 500 1000

Na+

K+

1424.3

2.6 (1.3*)1.0 (0.5**)

1534.6

2.8 (1.3)1.0 (0.5)

1454.4

2.5 (1.5)0.9 (0.45)

ca. 12ca. 140<0,001

1.6150 162 153 ca. 152

Cl–

HCO3–


Na+

Ca2+, Mg2+

Cl–

HCO3–

HCO3–

K+

Ca2+,Mg2+Na+K+

mval/L (mmol/L)

104242

145.9

112362.2156.3

117272.30.46.2

ca. 310

ca. 30ca. 54ca. 54

150 162 153 ca. 152

Birth Age (months)

From Mother

(After Hobbs)

Plas

ma

Albumin Globulins


65–

80 g

/LPr

otei

ns (1

00%

)

Cati

ons


Ani

ons

ProteinsMisc.

Sum

Sum


Proteins–


Vis

cosi

ty in

rela

tive

units


Blood

Plasma

Water

Free Ca2+

Inorganic phosphate

Inorganicphosphate

Misc.

Free Mg2+

% o

f res

pect

ive

seru

m c

once

ntra

tion

in a

dult





White blood cells (Leukocytes)

The leukocytes

Leukocytes. (a) Neutrophil. (b) Eosinophil. (c) Basophil. (d) Small lymphocyte. (e) Monocyte. In each case the leukocytes are surrounded by erythrocytes. Note also the three platelets above the lymphocyte in (d). (All 1600×)

The Leukopoiesis

Leukocyte formaFon. Leukocytes arise from ancestral stem cells called hemocytoblasts. (a–c) Granular leukocytes develop via a sequence involving myeloblasts. (d–e) Monocytes, like granular leukocytes, are progeny of the myeloid stem cell and diverge from a myeloblast that can become either a neutrophil or a monocyte. Only lymphocytes arise via the lymphoid stem cell line.

The Thrombopoiesis

The hemocytoblast gives rise to cells that undergo several mitoFc divisions unaccompanied by cytoplasmic division to produce megakaryocytes. The cytoplasm of the megakaryocyte becomes compartmentalized by membranes, and the plasma membrane then fragments, liberaFng the platelets. (Intermediate stages between the hemocytoblast and megakaryoblast are not illustrated.)

Clo]ng factors

102

4Bloo

d

!

Hemostasis

The hemostatic system stops bleeding. Throm-bocytes (platelets), coagulation (or clotting) fac-tors in plasma and vessel walls interact to sealleaks in blood vessels. The damaged vesselconstricts (release of endothelin), and plateletsaggregate at the site of puncture (and attractmore platelets) to seal the leak by a plateletplug. The time required for sealing (ca. 2 to 4min) is called the bleeding time. Subsequently,the coagulation system produces a fibrinmeshwork. Due to covalent cross-linking of fi-brin, it turns to a fibrin clot or thrombus that re-tracts afterwards, thus reinforcing the seal.Later recanalization of the vessel can beachieved by fibrinolysis.Platelets (170–400 · 103 per µL of blood;

half-life !10 days) are small non-nucleatedbodies that are pinched off from megakaryo-cytes in the bone marrow. When an en-dothelial injury occurs, platelets adhere tosubendothelial collagen fibers (!A1) bridgedby von Willebrand’s factor (vWF), which isformed by endothelial cells and circulates inthe plasma complexed with factor VIII. Glyco-protein complex GP Ib/IX on the platelets arevWF receptors. This adhesion activates plate-lets (!A2). They begin to release substances(!A3), some of which promote platelet adhe-siveness (vWF). Others like serotonin, plate-let-derived growth factor (PDGF) andthromboxane A2 (TXA2) promote vasoconstric-tion. Vasoconstriction and platelet contractionslow the blood flow. Mediators released byplatelets enhance platelet activation and at-tract and activate more platelets: ADP, TXA2,platelet-activating factor (PAF). The shape ofactivated platelets change drastically (!A4).Discoid platelets become spherical and exhibitpseudopodia that intertwine with those ofother platelets. This platelet aggregation(!A5) is further enhanced by thrombin andstabilized by GP IIb/IIIa. Once a plateletchanges its shape, GP IIb/IIIa is expressed onthe platelet surface, leading to fibrinogenbinding and platelet aggregation. GP IIb/IIIaalso increases the adhesiveness of platelets,which makes it easier for them to stick to sub-endothelial fibronectin.

I Fibrinogen Half-life (h): 96

II K Prothrombin 72

III Tissue thromboplastin

IV Ionized calcium (Ca2+)

V Proaccelerin 20

VII K Proconvertin 5

VIII Antihemophilic factor A 12

IX K Antihemophilic factor B; plasmathromboplastin component (PTC);Christmas factor 24

X K Stuart–Prower factor 30

XI Plasma thromboplastin antecedent(PTA) 48

XII Hageman factor 50

XIII Fibrin-stabilizing factor (FSF) 250

– Prekallikrein (PKK); Fletcher factor

– High-molecular-weight kininogen(HMK); Fitzgerald factor

Several coagulation factors are involved inthe clotting process. Except for Ca2+, they areproteins formed in the liver (!B and Table).Factors labeled with a “K” in the table (as wellas protein C and protein S, see below) are pro-duced with vitamin K, an essential cofactor inposttranslational γ-carboxylation of gluta-mate residues of the factors. These γ-carboxy-glutamyl groups are chelators of Ca2+. They arerequired for Ca2+-mediated complex forma-tion of factors on the surface of phospholipidlayers (PL), particularly on the platelet mem-brane (platelet factor 3). Vitamin K is oxidizedin the reaction and has to be re-reduced byliver epoxide reductase (vitamin K recycling).Ca2+ ions are required for several steps in theclotting process (!B). When added to bloodsamples in vitro, citrate, oxalate, and EDTAbind with Ca2+ ions, thereby preventing theblood from clotting. This effect is desirablewhen performing various blood tests.Activation of blood clotting (!B). Most coagu-lation factors normally are not active, or zymo-genic. Their activation requires a cascade ofevents (An “a” added to the factor numbermeans “activated”). Thus, even small amountsof a trigger factor lead to rapid blood clotting.The trigger can be endogenous (within a ves-sel) or exogenous (external). Endogenous acti-vation (!B2) occurs at an endothelial defect.XII is activated to XIIa by the contact with


Platelet Mediated Hemostasis

103

Plate4.8

Hem

ostasis

XIIIaXIII

VII

XIa XI

V

Xa

Ca2+, III

PL–Ca2+–VIIa

X

PL–Ca2+–Xa–Va

XII

IXa IX

PL– Ca2+– IXa – VIIIa VIII

vWF

Kollagen

PKK

Complex

Activates

Converts to

Endothelialdamage

Blood

Change in shape

Vasoconstriction

Slowing ofblood flow

1

2

3

5

PL Phospholipids (mainly PLT factor III)

Fibrin mesh-work

Exogenous activation(tissue injury)

Endogenous activation(contact with collagen)

Fibrin monomer

Fibrinogen (I)

Thrombin (IIa)

Prothrombin (II)

Contact phase

Fibrinformation

XIIa

KKHMK

PLT aggregation:Clot formation

4PLT adhesion

Platelet (PLT)

PLT activation

Fibrinogen

Secretion

ADP,PAF

TXA2Serotonin,PDGF

vWF

PLT aggregation

1 2

3

Zymogen

A. Platelet-mediated hemostasis

B. Blood clotting


Health & Medicine

Basic Hematology