Regulation of Erythropoiesis
[EPO] Retic% RBC mass
1 ↓RBC survival
2 Iron Deficiency
3 B12 Deficiency
4 Folate Deficiency
5 Kidney disease
6 Lung disease (↓PaO2)
7 Jak-2 mutation (on)
This is reticulocytotic
↑ ↑ ↓
↑ ↓ ↓ In 2-5 we have anemia
(↓BC mass); it’s due to
↑ ↓ ↓
ineffective hematopoiesis
↑ ↓ ↓ (because we lack the
↓ ↓ ↓ ingredients to make retics.
we have 2o polycythemia
↑ ↑ ↑ (i.e. polycythemia
secondary to lung disease)
EPO uses jak-stat pathway.
When the’re a utation,the
↓ ↑ ↑ receptor will be
onstitutively on; this is
primary polycythemia
Megaloblastic anemia:
1. Mechanism: ↓ DNA syntheisis → ↓nuclear division but normal cytoplasm →
nuclear: cytoplasmic desynchrony → ineffective hematopoiesis→ Intramedullary
HEMOLYSIS, i.e. when fragile red blood cell (RBC) precursors are destroyed in the
BM prior to release into the circulation.
2. Anemia: RPI <2
3. Macrocytosis (↑MCV)
4. Pancytopenia
5. Hypersegemented Neutrophiles (classic for megaloblastic anemia)
6. ↑Homocysteine.
7. ↑ LDH and unconjucated Billirubin.
 HOW B12 and Folate mess up DNA

• Defciency of vitamin B12

traps N5-methyl-FH4 in its
circulating form, which falsely
increases the serum folic acid
in 30% of cases (M-THF trap).
Nitric Oxide (N2O)
Methionine synthase transfers the
blocks this pathway
methyl group of methyl-B12 to
homocysteine, which regenerates
vitamin B12 (cobalamin) and
releases the product methionine.

Methionine synthase removes (-CH3) from

(N5-methyl-FH4), the circulating form of folic acid
PLC Methionine B12 N 5-Methyl-THF in the blood, to produce tetrahydrofolate (FH4)
SAM Methionine and methyl-B12 (methylcobalamin)
synthase Methionine synthase
PLE Homocysteine
Methyl-B12
THF
Serine
Defciency of Glycine Dihydrofolate reductase
folate or B12 -
N 5, N 10-Methylene-FH4 DHT • DHF reductase (DHFR) converts DHF to THF
increases
(MTX, TMP)
homocysteine (DHFR) is inhibited by methotrexate
Thymidylate synthase (MTX) and trimethoprim (TMP)
- (5-FU)
dUMP dTMP DNA

Thymidylate synthase converts

N5,N10-methylene-FH4 to DHT by donating a
CH3 group to dUMP and making dTMP THF mreceives a
Tymidylate synthase is irreversibly inhibited methyl group (-CH3)
from serineto
by 5-fluorouracil (FU).
produce N5,N10-methylene-FH4;
glycine is abyproduct of the reaction.
 RETICULOCYTE COUNT

reticulocyte count is important in figuring out what kind of anemia you're talking about someone
who has a low Hb/HCT and so interpretation of this very simple blood test gives you a lot of
information about how to think about a patient with anemia.
1. In each stage the RBC gets smaller in the BM.
2. green cells erythroblasts develops into the basophilic erythroblast→ polychromatic
→orthochromic (extrusion of the nucleus)
3. orthochromic become reticulocyte ( not quite a red blood cell yet because it still has
residual ribosomes and RNAand some other organelles and those have to be degraded to
make a full room for the hemoglobin that carries oxygen around maximally
4. the reticulocyte comes out into the circulation where it spends about let's say another day
or so before it loses that residual ribosomes an RNA and becomes a baggy essentially of
hemoglobin carrying around oxygen
5. RBC has a lifespan and most people ~ 120 days or so before the membranes get oxidized
they get a little stiffer and spleen capillary microcirculation and macrophages remove the
senescent RBC from a circulation at about a rate of let's just say 1% a day

6. In a healthy person, about 1% of RBC is recycled daily so the BM has to make 1% retics
to make up for it.

7. In anemics, we do a first correction, called corrected reticulocytes count (CRC)

a. We get a retics count and multiply it by pt [Hb]/normal [Hb] or pt Hct/Hct
pt [Hb]
b. 1st correction(CRC) = Retic. Count 𝐗 normal [Hb]
pt Hct
c. 1st correction(CRC) = Retic. Count 𝐗 normal Hct
8. In severe anemics, over stimulation of the marrow that results in and such a massive
stimulation of the marrow that these retics here that normally are supposed to spend about
a day in the marrow roughly come out into the circulation prematurely and call the sort
of young retic they hang out in the circulation for an extra day before they become RBCs
then gives you an erroneous percentage because that's counting an extra day's worth of
production when you're just looking at the production for a day right you have these
extra retics are around that are just it's lingering around for it for an extra pretty much
in this case twice as long so we have to take that into consideration
++

• How do we know if our retics are from one day or two days? There are two
ways:
o 1st: if you see nucleated red cells on the peripheral blood smear if you
had a smear and you saw nucleated red blood cells you can assume that
these retics are leaving the BM too soon and they're falsely elevating your
retics count you shouldn't see those at all though they're supposed to be in
the bone marrow and if you saw those in a peripheral blood smear then
then you can

o alternatively you can look at the hemoglobin/hematocrit if ir is really low

then you can just assume that that's happening you know that's sort of a
way of doing it without the peripheral smear

o either way if there's a really a robust simulation of the marrow we need

to do a second correction to account for those reticulocytes that are
hanging around the circulation longer and so we can call this the second
correction all right and this has a special name this is called the
reticulocyte production index or RPI all right so so the reticulocyte
production index is the first corrected count divided by a correction
factor

𝐶𝑅𝐶
o RPI = 𝐶𝑜𝑟𝑟𝑒𝑐𝑡𝑖𝑜𝑛 𝑓𝑎𝑐𝑡𝑜𝑟 (~2)

• Example anemic Patient Hb=7g/dL and his reticulocyte count=6%,

7𝑔

o 1st correction (CRC)=6% 𝑋 𝑑𝑙

14𝑔 = 3%
𝑑𝐿
3%
o 2ndcorrection (RPI)= = 𝟏. 𝟓%
2
o 1.5% is an inadequate response to this degree of anemia so this is
something like this is saying that the bone marrow is just increasing bone
the red blood cell just a little bit and for someone has such a profound
anemia this is this is terribly inadequate an we would expect that this