Αιμοποιητικό σύστημα

Φυσιολογική αιμοποίηση
Παθήσεις ερυθρού αιμοσφαιρίου
Απαραίτητες ουσίες για την αιμοποίηση
Αναιμία
Blood Components
 Blood Components: Cells

• Erythrocytes
– Red Blood Cells (RBC)
– O2 & CO2 transport
• White Blood Cells (WBC)
– Immune defense
– Phagocytosis
• Platelets: clotting
Normal Peripheral Smear
 SITES OF HEMOPOIESIS
• Active Hemopoietic – Appendicular skeleton:
marrow is found, in • Bones of the Upper &
Lower limbs
children throughout the:
• In Adults active
– Axial skeleton:
• Cranium
hemopoietic marrow is
• Ribs. found only in:
• Sternum – The axial skeleton
• Vertebrae – The proximal ends of
• Pelvis the appendicular
skeleton.
 The hematopoietic hierarchy and phenotypic markers associated with
HSCs

Blank, U. et al. Blood 2008;111:492-503

Copyright ©2008 American Society of Hematology. Copyright restrictions may apply.

 ERYTHROID PROGENITOR CELLS
• BFU-E: Burst Forming Unit – Erythrocyte:
– Give rise each to thousands of nucleated erythroid
precursor cells, in vitro.
– Undergo some changes to become the Colony Forming
Units-Erythrocyte (CFU-E)
– Regulator: Burst Promoting Activity (BPA)
 ERYTHROID PROGENITOR CELLS

• CFU-E: Colony Forming Unit- Erythrocyte:

– Well differentiated erythroid progenitor cell.
– Present only in the Red Bone Marrow.
– Can form upto 64 nucleated erythroid precursor cells.
– Regulator: Erythropoietin.
• Both these Progenitor cells cannot be
distinguished except by in vitro culture methods.
 Regulation of Erythropoiesis

Stimulates CFU – E
An
Proerythroblasts example
ERYTHROPOIETIN Mature Erythrocytes of a
Negative
Decreases feed back
Tissue Oxygenation mechanis
Factors decreasing: m
• Hypovolemia
» Anemia
• Poor blood flow
• Pulmonary Disease
 ERYTHROPOIESIS
PROERYTHROBLAST

BASOPHILIC
ERYTHROBLAST

POLYCHROMATOPHILIC
ERYTHROBLAST

ORTHOCHROMATIC
ERYTHROBLAST

RETICULOCYTE

MATURE ERYTHROCYTES
Reticulocytes: Elevated Count
ΔΙΚΤΥΟΕΡΥΘΡΟΚΥΤΤΑΡΑ

 Καρυορρηξία και αποβολή του

πυρήνα των νορμοβλαστών

 Απύρηνα πολυχρωματόφιλα
ερυθροκύτταρα

 Μεγαλύτερα από τα ώριμα ερυθρά,

χωρίς κεντρική ωχρότητα

 Η χρώση με κυανό του μεθυλενίου

βάφει τα ριβοσώματα και επιτρέπει
την καταμέτρησή τους σαν ΔΕΚ
 Glycolysis:
Embden-Myerhof Pathway
• Oxidation of glucose
• Products:
– 2 Pyruvate
– 2 ATP
– 2 NADH
• Cytosolic
11_01.jpg
Hemoglobin Structure Changes

http://www.mfi.ku.dk/PPaulev/chapter8/images/8-3.jpg
Oxygen Dissociation Curve

18
11_02.jpg
 Globin Chain Synthesis

t
r io e n
on ain

p e opm
d
mp c h

b t
en
 cluster - chromosome 16

H g ad u l
l
ve
e
co bin

am

De
o

of
bn
Gl
 2 1

%
Hg
22 Gower 1

22 Portland Embryonic

22 Gower II

22 F Fetal < 1%

22 A2 1.5-3.5%
Adult
22 A > 95%

 G A  
 cluster - chromosome 11
Body Iron Distribution and Storage
Duodenum Dietary iron
(average, 1 - 2 mg
Utilization Utilization
per day)

Plasma
transferrin (TIBC)
(3 mg)
Bone
Muscle marrow
(myoglobin) Circulating (300 mg)
(300 mg) erythrocytes
Storage
iron (hemoglobin)
(Ferritin) (1,800 mg)

Sloughed mucosal cells

Desquamation/Menstruation
Other blood loss
(average, 1 - 2 mg per day) Reticuloendothelial
Liver
(1,000 mg) macrophages
Iron loss (600 mg)
 Απορρόφηση σιδήρου
Ρύθμιση σε 2 επίπεδα
Απορρόφηση από τον Απόδοση στην
εντερικό αυλό κυκλοφορία

Η απορρόφηση σιδήρου
γίνεται κυρίως στο
12δάκτυλο
 Iron Transfer Between Cells and Tissues:
Mediated by Hepcidin
Hepcidin
Iron overload
Anemia of chronic disease
Iron deficiency
Increased iron demand
(hemolysis)

Hentze, et.al, Cell 2004;117:285

Μεταφορά σιδήρου εντός των
κυττάρων της ερυθράς σειράς
Ως αναιμία ορίζεται η ελάττωση
της φυσιολογικής αιμοσφαιρίνης,
η οποία σύμφωνα με τον ορισμό
της WHO βρίσκεται σε επίπεδα
Hb<13g/dL για τους άνδρες και
<12g/dL τις γυναίκες
 Anemia
• Understanding anemia
– Disease - to be treated on its own merits
– Condition - a secondary manifestation of another disease

• Causes
– Decreased production
– Blood loss
– Hemolysis
 Symptoms of Anemia
• Decreased oxygenation
– Exertional dyspnea
– Dyspnea at rest
– Fatigue
– Bounding pulses
– Lethargy, confusion
• Decreased volume
– Fatigue
– Muscle cramps
– Postural dizziness
– syncope
 Classification of Anemia
• Clinical findings
– Acute
– Chronic

• Red cell kinetics

– Determined by reticulocyte count

• Red cell size

– Determined by MCV
 Corpuscular Indices

Calculations that allow the characteristic of

average size and hemoglobin content in
individual erythrocytes to be determined.
– Mean Corpuscular Volume (MCV)
– Mean Corpuscular Hemoglobin (MCH)
– Mean Corpuscular Hemoglobin Concentration (MCHC)
 Normal Values

Mean Corpuscular Volume (MCV) =80 to 90 fl

Mean Corpuscular Hemoglobin (MCH) =27 to 31 pg
MHC Concentration (MCHC) =32 to 36%
Red Cell Distribution Width =11.6 to 14.6%
Reticulocyte Count =0.5 to 2.5 %
MCV κφ
ορθοκυτταρικά ερυθρά

MCV
μικροκυτταρικά ερυθρά

MCV
μακροκυτταρικά ερυθρά
 MCH
(Mean corpuscular hemoglobin)
μέση περιεκτικότητα Hb, 30±2 pg

MCH=Hb/RBC

MCHC
(Mean corpuscular hemoglobin concentration)
μέση πυκνότητα Hb, 30±4 %

MCHC=Hb/Ht
MCH, MCHC κ.φ.
ορθόχρωμα ερυθρά

MCH, MCHC
υπόχρωμα ερυθρά

MCH, MCHC
υπέρχρωμα ερυθρά
 Classification of Anemia Based on RBC
Kinetics and Size
MCV
Microcytic Normocytic Macrocytic
(<80 fl) (80-97 fl) (>98 fl)

Low Common Common Common

Retic
Count
High Uncommon Common Uncommon
Microcytic Hypochromic Anemia: Diagnosis
• Mild (MCV > 70 fl)
– Iron deficiency
– Thalassemia
– Lead toxicity
– Sideroblastic anemia
– Anemia of chronic disease
• Severe (MCV < 70 fl)
– Iron deficiency
– Thalassemia
 Iron Deficiency Anemia
• A world-wide problem
– 3% of toddlers age 1-2 years
– 2-5% of women of child bearing age
• Iron metabolism
• Iron stores
• Laboratory findings of iron deficiency
• Causes of iron deficiency
• Treatment
 Major Iron Compartments
• Metabolic
– Hemoglobin 1800-2500 mg
– Myoglobin 300-500 mg

• Storage
– Iron storage 0-1000 mg

• Transit
– Serum iron 3 mg

• Total 3000-4000 mg
 Causes of Iron Deficiency
Iron deficiency is a symptom, not a disease
• Increased iron requirements • Inadequate iron supply
– Blood loss – Insufficient dietary iron
• Gastrointestinal tract – Impaired iron absorption
• Genitourinary tract • Gastric surgery
• Blood donation • Intestinal malabsorption
– Pregnancy and lactation • Celiac disease
Ferritin: The Best
Marker for
Iron Deficiency
Ferriti
n µg/l

Bone Marrow Iron Stores

 Development of Iron Deficiency
Iron status Ferritin BM iron Fe/TIBC Anemia

Depleted stores Low Absent Normal Absent

Compromised delivery Low Absent Low/High Absent

Iron deficiency anemia Low Absent Low/High Present

Σιδηροπενική Αναιμία

 Υπόχρωμα ερυθρά με μεγάλης

έκτασης κεντρική ωχρότητα
 Μικροκυττάρωση λιγότερο έκδηλη
από την υποχρωμία
 Σπάνια στοχοκύτταρα
 Σχιστοκύτταρα, ερυθροκύτταρα σε
σχήμα πούρου σε βαριές
σιδηροπενίες
 Υπεραφθονία αιμοπεταλίων
 ΑΠΟΥΣΙΑ βασεόφιλης στίξης,
σιδηρωτικών κοκκίων και σωματίων
Pappenheimer
 Systemic Manifestations of Iron Deficiency
• Behavioral and neuropsychiatric • Esophageal webs and strictures
manifestations

• Pica (pagophagia)

• Angular stomatitis
• Koilonychia

• Glossitis
AITIOΛΟΓΙΑ
 Beta Thalassemia: Clinical Manifestations

• Skeletal
– Osteoporosis due to bone marrow expansion
– Pneumatization of the sinuses is delayed by
expanded hematopoiesis
• Dilated cardiomyopathy secondary to severe
anemia

• Growth and development delayed

• Hepatomegaly due to extramedullary

hematopoiesis
β-Μεσογειακή αναιμία
 ΘΑΛΑΣΣΑΙΜΙΕΣ

β-Μεσογειακή αναιμία
 ΘΑΛΑΣΣΑΙΜΙΕΣ
β-Μεσογειακή αναιμία
 ΘΑΛΑΣΣΑΙΜΙΕΣ
Μορφολογία
Επίχρισμα αίματος σε ομόζυγη β-ΜΑ

Μυελός των οστών σε ομόζυγη β-ΜΑ

 ΘΑΛΑΣΣΑΙΜΙΕΣ

α-Μεσογεακή αναιμία
 Alpha Thalassemia: Clinical Features
• Absence of 1-2 alpha chains
– Common X
    X
 
– Asymptomatic XX
– Does not require therapy
   
X
 

• Absence of 3 alpha chains

(Hgb H disease) X
 
– Microcytic anemia (Hgb 7-10) XX
 

– Splenomegaly
• Absence of 4 alpha chains
– Hydrops fetalis (non-viable) XX
 

XX
 
Alpha Thalassemia: Laboratory Findings
Hemoglobin
 Chains Hgb (g/dl) MCV (fl) Analysis

/ Normal Normal Normal

/- 12-14 75-85 Normal
-/- or 11-13 70-75 Normal with Hgb Barts (4);
--/ Hgb H (4) - small
--/- 7-10 50-60 Normal with Hgb Barts (4);
Hgb H (4) - large
--/-- - - Not viable
 Normocytic Anemia with Low Reticulocyte
Count
• Decreased stimulation of RBC production in bone marrow
– Anemia of chronic disease
– Chronic renal insufficiency
• Isolated decrease in RBC precursors (red cell aplasia)
• Bone marrow damage
– Fibrosis
– Stem cell damage
– Infiltration with tumor/infection
 Anemia of Chronic Disease
• Associated conditions Prevalence
– Infection 20-95%
• Viral, bacterial, TB, parasitic, fungal
– Autoimmune disease 8-17%
• RA, SLE, sarcoidosis, IBD, vasculitis
– Cancer 30-77%
– Chronic solid organ rejection 8-70%
• Characteristics
– WBC and platelet counts are normal
– Anemia of variable severity (mild-severe)
– Low erythropoietin level
– Low reticulocyte count
 Anemia of Chronic Disease: Pathogenesis
Cytokines
(IL-1, TNF, IL-4)

Disturbed iron metabolism Decreased RBC Inadequate Epo

Diversion of iron from precursors response
circulation to the RE system
 Iron Transfer Between Cells and Tissues:
Impaired in Anemia of Chronic Disease

X X
Blocked in
Anemia of chronic disease

Hentze, et.al, Cell 2004;117:285

 Anemia of Chronic Renal Disease
• Characteristics
– Widespread - 8% of US population has increased creatinine
– 23% of patients with chronic renal disease have Hct ¡Â 30%
– Long-term anemia is a risk for LVH
– Risk factor for mortality

• Etiology
– Insufficient production of erythropoietin
 Pure Red Cell Aplasia
• Normocytic anemia with reticulocyte count < 0.5%

• Absent erythroid precursors in marrow

• Caused by parvovirus B19

• Clinical setting
– Immunocompetent patients with chronic hemolysis
– Immunodeficient patients with persistent viremia
 Macrocytic Anemia with Low Reticulocyte
Count
• Megaloblastic anemia
– Vitamin B12 deficiency
– Folate deficiency

• Nonmegaloblastic macrocytic anemia

– Liver disease
– Hypothyroidism
– Drug-induced (DNA synthesis block)
– Myelodysplastic syndrome
 Folate and Cobalamin Daily Requirements

Diet

Vitamin B12
(Cobalamin) Folate
Source Animal products Widespread
Body stores 5 mg 5 mg
Daily requirement 2-5 µg 50-200 µg
Daily intake 10-20 µg 400-800 µg
Dietary deficiency Rare Common
Cofactor Activities of Folate and Cobalamin
Methionine
synthetase
Homocysteine Methionine

CH3-Cobalamin Cobalamin
THF THF-CH3

MMA-CoA
mutase
Methylmalonic acid (MMA) Succinyl-CoA

Adenosyl- Cobalamin
Cobalamin
 Enteric Processing and Absorption of
Cobalamin
Stomach Food-Cbl
H + Peptic
digestion
Cbl + R-binder

R-Cbl
Duodenum
Pancreatic
enzymes R-Cbl Cbl-TC complex
IF + Cb OH -

Cbl-IF
Distal ileum IF receptor Cbl + TC
Cbl-IF
 Metabolic Testing for the Diagnosis of
Vitamin B12 and Folate Deficiency

Vitamin B12 Folate Deficiency

Deficiency
Methylmalonic acid Increased Normal

Homocysteine Increased Increased

 Vitamin B12 Deficiency: Common
Mechanisms
• Intragastric events
– Inadequate dissociation of cobalamin from food protein
– Total or partial gastrectomy
– Absent intrinsic factor secretion
• Proximal small intestine
– Impaired transfer of cobalamin from R protein to intrinsic factor
– Usurpation of luminal cobalamin
• Bacterial overgrowth
• Diphylobothrium latum (fish tapeworm)
• Distal small intestine
– Disease of the terminal ileum
 Pernicious Anemia: Laboratory Diagnosis

• Anti-intrinsic factor antibodies (~60% positive)

– Specific but not sensitive
• Anti-parietal cell antibodies (~90% positive)
– Sensitive but not specific
• Schilling test
– Procedure
• Administer IM vitamin B12 to prevent incorporation of radioactive
cobalamin
• Provide PO radiolabeled cobalamin ± Intrinsic factor
• Measure urinary excretion of radioactivity
– Difficult to administer
Macrocytic Anemia: Macro-Ovalocytes
 Folate Deficiency
• Minimum daily folate requirement is 50 µg
• Usual dietary folate 50-500 µg
• Absorption in small intestine
• Causes of folate deficiency
– Dietary (90%)
• Alcohol abuse
• Pregnancy
– Malabsorption
– Drug-induced
• Treatment - oral folic acid supplementation
Normocytic Anemia with High Reticulocyte
Count
• General principles
– Bleeding may have similar lab findings as hemolysis
– High reticulocyte count may lead to macrocytosis
– Clinical manifestations of long term hemolysis
• Cholelithiasis
• Risk of aplastic crisis (parvovirus B19)
• Risk of pulmonary hypertension
– Classification
• Hereditary vs. acquired
• Extravascular vs. intravascular
• Immune vs. nonimmune
 Hemolytic Anemia with Extravascular
Hemolysis
• Extravascular (reticuloendothelial system)
– Hereditary
• Hemoglobinopathies (sickle cell anemia)
• Enzymopathies (G6PD deficiency)
• Membrane defects (hereditary spherocytosis)
– Acquired
• Immune mediated
– Autoimmune hemolytic anemia
• Nonimmune mediated
– Spur cell hemolytic anemia
 Sickle Cell Disease
• Mutation in beta globin (6 Glu Val)

• Inherited as autosomal recessive

• Gene occurs in 8% of African-Americans

(Sickle cell trait)
Pathophysiology of
Sickle Cell Disease
 Sickle Cell Anemia: Clinical Presentations

• Chronic hemolytic anemia

• Susceptible to infection
– S. pneumoniae
– Osteomyelitis
– Staphylococcal infections

• Vaso-occlusion
 ΔΡΕΠΑΝΟΚΥΤΤΑΡΙΚΑ ΣΥΝΔΡΟΜΑ

Κλινική εικόνα
1. Αγγειοαποφρακτικές επώδυνες κρίσεις
2. Απλαστικές κρίσεις
3. Κρίσεις εγκλωβισμού στα σπλάχνα (σπλήνα)
4. Χολολιθίαση
5. Λοιμώξεις
6. Οστά. Νέκρωση κεφαλής μηριαίου
7. Δρεπανοκυτταρικό πνεύμονα
8. Ατονα έλκη κνημών
9. Πριαπισμό
10. Αδυναμία συμπύκνωσης ούρων
11. Καρδιακή ανεπάρκεια
12. κ.ά
 Sickle Cell Trait

• Protection against malaria

• Genitourinary complications
• Hyposthenuria
• Painless hematuria
• UTI during pregnancy
Sickle cell trait areas shown in
• Vaso-occlusive complications orange stripes
• Splenic infarction with hypoxia
• Sudden death during extreme
exertion
• Rhabdomyalysis
 Glucose-6-Phosphate Dehydrogenase
Deficiency
• G-6-PD - reduces NADP/oxidizes glucose-6-phosphate
– Detoxifies free radicals and peroxides
• Sex-linked disorder
• Effects > 200 million people
• Hemolytic anemia occurs in the presence of stress
(infection or drugs)
– African form - mild hemolysis
– Mediterranean form - more severe
• Unique sensitivity to fava beans
 Hereditary Spherocytosis
• Autosomal dominant disorder
• Abnormality in RBC membrane
protein
• Clinical and laboratory findings
– Splenomegaly
– Chronic hemolytic anemia
– Spherocytes on peripheral smear

• Treatment
– Splenectomy
 Acquired Hemolytic Diseases
• Immune mediated hemolytic anemia

• Non-immune mediated
 Autoimmune Hemolytic Anemia
• Warm antibodies (IgG-mediated)
– Primary 45%
– Secondary 40%
• Lymphoproliferative disease
• Connective tissue disease
• Infectious disease
– Drug-induced 15%
• Laboratory testing
– Normocytic/macrocytic anemia
– Peripheral smear - spherocytosis
 Αυτοάνοση αιμολυτική
αναιμία από θερμό αντίσωμα
 Anti-Globulin (Coombs) Testing
Direct antiglobulin testing
+
Anti-C3d
Patients RBCs Anti-IgG

Indirect antiglobulin testing

+ +
Patients serum RBCs Anti-IgG
 Επίκτητη αιμολυτική αναιμία

Non- Immune

Μικροαγγειοπαθητική ΜικροαγγειοπαθητικήΕλονοσία
 Παροξυντική νυχτερινή αιμοσφαιρινουρία

 Επίκτητη χρόνια αιμολυτική αναιμία

 Κλωνική έκπτυξη αρχέγονων αιμοποιητικών
κυττάρων που έχουν υποστεί σωματική μετάλλαξη
στο γονίδιο PIG-A
 H έλλειψη πρωτεϊνών από τη μεμβράνη των
ερυθρών – λόγω έλλειψης του συνδέτη τους-
συνεπάγεται μεγάλη ευαισθησία των ερυθρών στη
λυτική δράση του συμπληρώματος, οδηγώντας στην
αιμόλυση που χαρακτηρίζει το νόσημα

PIG-A φυλοσύνδετο γονίδιο:

Περιέχει την πληροφορία για τη δημιουργία
της GPI (γλυκοσυλ-
φωσφατιδυλινοσιτόλης)- άγκυρας που
συνδέει κάποιες πρωτεΐνες στη μεμβράνη
των κυττάρων
Παροξυντική νυχτερινή
αιμοσφαιρινουρία
• DAF (Decay Accelerating Factor) ή CD55:
αναστέλλει το σχηματισμό ή αποσταθεροποιεί τη
C3 convertase (C4b2a) και τη C5
convertase
• MIRL (Membrane Inhibitor of Reactive
Lysis) ή CD59: προστατεύει τη μεμβράνη από
την επίθεση του MAC (Membrane Attack
Complex: C5-C9 complex) μέσω αναστολής
συσσώρευσης του C9

Τα CD55 και CD59 εκφράζονται ευρέως σε όλα τα

αιμοποιητικά κύτταρα
Η έλλειψη ή η μειωμένη έκφραση των ανωτέρω
πρωτεϊνών καθιστά τα αιμοποιητικά κύτταρα
ευαίσθητα στη δράση του συμπληρώματος
 Hemolytic Anemia with Intravascular
Hemolysis
• Mechanical damage (Microangiopathic hemolytic
anemia)

• Chemical damage (Burns)

• Infection (Malaria or Babesiosis)

• Transfusion reaction (ABO incompatibility)