Anemia caused by increased breakdown of

erythrocytes
 HEMOLYSIS ANEMIA
Erythrocytes live 90-120 days, after which they are removed from the circulation.

About 3 million erythorytes disappear from circulation every second!

Any condition accompanied by a shorter life of erythrocytes due to their

increased or premature decomposition is called hemolysis, and if it is
accompanied by a decrease in the value of hemoglobin below physiological
limits, it is called Hemolytic anemia.
 HEMOLYSIS ANEMIA

• The shortened lifespan of erythrocytes is a consequence of hereditary or acquired

disorders of erythrocytes that make it impossible to maintain their biconcave shape
necessary for flexibility when passing through: pores in the marginal zone and red
pulp of the spleen, i blood vessel gaps in microcirculation that are narrower than
the diameter of erythrocytes.
 Pathophysiological classification of anemia

Increased breakdown of erythrocytes:

Corpuscular anemias:
- erythrocyte membrane disorders (membranopathies)
- enzyme structure disorders (enzymopathies)
- hemoglobin structure disorders (hemoglobinopathy)

Extracorpuscular anemias :
- mechanical,
- caused by physical and chemical factors,
- caused by infections,
- caused by antibodies,
- hypersplenism
 Classification of hemolytic anemias

According to the flow:

- Acute hemolytic anemia
- Chronic hemolytic anemia
 Hemolysis may occur :

Intravascularly erythrocyte lysis in the circulation.

• Extravascular erythrocyte lysis in the macrophage system of the

spleen and liver.
 Pathogenesis of hemolytic anemia

Biconcavity and bendability of erythrocyte is conditional :

• the normal structure of the erythrocyte membrane,

• composition of the proteins of the erythrocyte skeleton,
• glycolysis in erythrocytes and
• fluidity of erythrocyte cytoplasm.
 Hemoglobin catabolism(heme + globin)

Heme catabolism:
• The porphyrin ring is converted into the bile pigment bilirubin
• Bilirubin is excreted via bile (urobilinogen, stercobilinogen), and

• Iron is released:
• One part binds to ferritin and is stored until the next use,
• the other part binds to transferrin and is transported to the bone
marrow where it is used for the synthesis of new hemoglobin

• Globin proteolysis:
Amino acids are released, which are reused for protein synthesis
 Decomposition of erythrocytes
liver, spleen and
bone marrow

phagocytosis and lysis

hemoglobin

globin heme biliverdin

IRON
amino acids
Metabolism in the liver

pool of amino acids

elimination
Metabolism of bilirubin
 Hemoglobin catabolism

• During the catabolism of porphyrin from hemoglobin, CO is created (it is

the only source of CO in the human body).

• 1 mol of decomposed heme produces 1 mol of CO!

• Endogenous formation of CO corresponds to the degree of destruction of

ERYTHROCITES!

• СO in the form of carboxyhemoglobin is carried to the lungs by the blood

(to be removed from the body).
 Reticulocytosis

• Reticulocytosis reflects erythroid hyperplasia of the bone marrow.

 Congenital hemolytic anemia

• Membrane disorders –(membranopathies)

• Enzyme deficiency – (enzymopathies)
• Disorder of hemoglobin synthesis – (hemoglobinopathy)
Congenital hemolytic anemia Membranopathies

•congenital spherocytosis,
•congenital elliptocytosis,
• congenital pyropoikilocytosis,
•congenital stomatocytosis,
• congenital acanthocytosis.
 Congenital spherocytosis (membrane protein
defects)

• A genetically determined disease.

• It is caused by a lack of membrane proteins (spectrin, ankyrin, ...)

• The phospholipid layer of the membrane forms vesicles that are

detached from the surface of the membrane.

• The surface of the membrane decreases, "loss of erythrocyte

membrane" and loss of biconcave shape.
 Congenital spherocytosis (membrane protein
defects)

• 1: 5000 prevalence in Northern Europe

• Inheritance:
• Autosomal dominant (2/3),
• Autosomal recessive,
• de novo mutations.
 Congenital spherocytosis (membrane protein
defects)
• Electron microscopy

ЕRYTHROCYT
spherocyte
 Congenital spherocytosis (membrane protein
defects)

reticulocytes-blue,
spherocytes-red arrows
Reticulocyte
Membranopathies
• Elliptocytosis
• spectrin dimers combine poorly into
tetramers
• Africa and the Mediterranean
• >30%-100% erythrocytes
• Pyropoikilocytosis
• Severe hemolytic anemia in
infants in early childhood,
Pronounced poikilocytosis
(similar to burns)
 Congenital hemolytic anemia

• Membrane disorders – membranopathies

• Enzyme deficiency – enzymopathies
• Disorder of hemoglobin synthesis - hemoglobinopathy
 Congenital hemolytic anemia Enzymopathies
Glycolysis enzyme deficiency :

• Glucose-6-phosphate dehydrogenase,
• hexokinase,
• glucose-phosphate isomerase, phosphofructokinase,
• Aldolase
• triose phosphate isomerase,
• glyceraldehyde-3-phosphate dehydrogenase, phosphoglycerate kinase,
• 2,3 bisphosphoglycerate mutase,
• enolase ,
• pyruvate kinase .
 Glycolysis enzyme deficiency: general
characteristics
• ATP from glycolysis is the only source of energy in the erythrocyte,
• Normal erythrocyte morphology,
• Normal osmotic resistance of fresh erythrocytes, Partial response to
splenectomy,
• Symptoms from other tissues and organs.
Glucose-6-phosphate dehydrogenase
deficiency(G6PD)

Under normal conditions, 1% of G6P goes into the

pentose-monophosphate pathway.
In oxidative stress 10% .
 G6PD and the glutathione cycle
glutathione (GSH) is the main defense agent against oxidative damage by
H2O2,
NADPH is generated in the pentose-phosphate pathway with the help of
G6PD.

H2O2 H2O

Pentose- GSH GSSG

phosphate
pathway

NADP NADPH

G6P
 Clinical manifestations of acute hemolytic
anemia in G6PD

• Outside the period of hemolysis, patients are clinically and hematologically

normal.

• Hemolytic "crises" during oxidative stress.

• Jaundice and dark urine within 6-24 hours.

 Pathophysiology of acute hemolytic anemia in
G6PD
• Effect of exogenous factor

• sulfhydryl groups of hemoglobin are oxidized to disulfide or sulfoxide groups,

• precipitation of denatured hemoglobin, irreversible membrane damage and

lysis,

• Hemolysis can be :

• intravascular (hemoglobinemia and hemoglobinuria),

• extravascular (in the RES of the spleen) in case of greater erythrocyte damage
(splenomegaly).
Congenital hemolytic anemia hemoglobinopathy

• No synthesis (or reduced synthesis) of one or more globin chains.

• Clinical expression is heterogeneous within each syndrome
• 4 alpha and 4 beta thalassemia syndromes :
– 4 α thalassemia syndrome (healthy carrier, ... Hydrops foetalis),
– 4 β thalassemia syndromes (healthy carrier, ..., β thalassemia maior).
 Acquired hemolytic anemia

Etiology :
- traumatic hemolytic anemia,
- hemolytic anemia caused by biological agents,
- hemolytic anemia caused by chemical agents (toxic effects on the
erythrocyte membrane),
- hypersplenism,
- hemolytic anemia mediated by immune mechanisms.
 Traumatic hemolytic anemia

Mechanical hemolysis:

Damage of erythrocytes when passing through very narrow blood vessels on the
surface of the body, under which there is a hard substrate – bone.
 Mechanical hemolysis
• Example: "marsh" hemoglobinemia and hemoglobinuria.

• During a long march, erythrocytes pass through the narrow blood vessels of
the feet and lower legs, which are compressed by shoes and socks.

• Increase in plasma volume and erythrocyte mass.

• Increased extraction of oxygen in the muscles, increased generation of 2,3

DPG by erythrocytes and shift of the oxygen dissociation curve to the right.

• The supply of oxygen to the tissues is improved.

 Traumatic cardiac hemolytic anemia

• Hemolysis in about 10% of patients with an artificial mitral or aortic valve.

• When blood flows through the mechanical valve, erythrocyte damage and
clinical signs of hemolysis occur.

• About to the greater pressure gradient, hemolysis is more pronounced in

patients with an aortic valve.
 Acquired hemolytic anemia

Etiology :
- traumatic hemolytic anemia,
- hemolytic anemia caused by biological agents,
- hemolytic anemia caused by chemical agents (toxic effects on the
erythrocyte membrane),
- hypersplenism,
- hemolytic anemia mediated by immune mechanisms.
 Hemolysis caused by biological agents

• By direct invasion of infectious agents (protozoa - malaria),

• by releasing hemolytic toxins(Clostridium perfringens-Welchii, E.coli,

Salmonella typhi, Hemophilus influenze) ,

• by creating antibodies against erythrocyte antigens of viral infections: (EBV,

Coxacie, CMV, herpes simplex) .
 Malaria as a cause of hemolysis
• The most common form due to direct invasion plasmodium (Р. vivax, malarie,
falciparum)
– intracellular growth,
– oxidative damage of erythrocyte lipids,
– destruction in the spleen.
Caution:
some drugs (primaquine and some sulfonates) as therapy of choice may lead to
hemolysis in G-6-PD deficient patients.
 Clostridium as a cause of hemolysis
• Clostridium:
– common in patients with septic abortion
– occasionally in acute inflammation of the gallbladder (acute cholecystitis)
• synthesizes phospholipase that destroys lecithin (inside the erythrocyte membrane) :
– severe hemolysis occurs, often fatal - more than 50% (serum can be bright red
and urine mahogany in color),
– features: microspherocytosis, leukocytosis with a left shift, thrombocytopenia,
and severe renal and hepatic impairment.
 Hemolytic anemias caused by chemical agents
• Arsenic hydride poisoning, used in the gas industry (severe anemia,
hemoglobinuria and jaundice occur after inhalation).

• Lead poisoning :

– anemia occurs due to the inhibition of heme synthesis,

– due to the inhibition of the pyrimidine 5-nucleotidase enzyme, basophilic
punctures occur in erythrocytes (important in diagnostics).

Excess copper in Wilson's disease or during dialysis (when water with a high
concentration of copper is used): inhibits enzymes in erythrocytes.
 Hypersplenism
• Splenomegaly, increased destruction of blood (and erythrocytes) as a result of
accumulation of blood in a relatively unfavorable environment full of
phagocytes.

• When sequestration of blood in the spleen causes cytopenia :

Hypersplenism

• Inflammatory and congestive splenomegaly is often associated with moderate

shortening of erythrocyte life span, with significant granulocytopenia and
thrombocytopenia.

• Splenectomy is indicated if cytopenias are accompanied by symptoms .

 Autoimmune hemolytic anemias

• The second type of hypersensitivity

• The third type of hypersensitivity
 The second type of hypersensitivity

After binding of antibodies to the cell membrane, the following

occurs:

-activation of the complement system,

-phagocytosis,

-antibody-dependent cytotoxicity(ADCC)
The second type of hypersensitivity
 The second type of hypersensitivity

• Reactions of the second type of hypersensitivity are involved in the

pathogenesis:

- transfusion reactions (in case of blood transfusion of incompatible blood

groups),

- hemolytic disease of the newborn,

- autoimmune hemolytic anemia.

Hemolytic disease of the newborn
 Hemolytic anemias mediated by immune
mechanisms
Origin of anti-erythrocyte antibodies :

• Acquired alloantibodies after transfusion or pregnancy (directed against

allogeneic erythrocytes).

• Antibodies are directed against own erythrocytes that are activated at body
T (37C)
37C = IHA with "warm" (IgG) antibodies.

• Antibodies are directed against own erythrocytes that are activated in the
cold (2-4C) = IHA with "cold" (IgM) antibodies (cold agglutinin disease),
10-20% of patients.
•
Antibodies synthesized after drug administration (autoimmune and hapten
form).
Laboratory evidence that hemolysis is mediated
by immune mechanisms
Coombs antiglobulin test

DIRECT

INDIRECT
 Direct Coombs test

• It is based on the ability of antibodies specific to immunoglobulins

(specifically IgG) or complement components (specifically C3) to agglutinate
RBCs when IgG and C3 are present on the RBC.
•
The test measures the ability of anti-IgG i anti-C3 antisera to bind to the
erythrocyte membrane and cause agglutination.
 Indirect Coombs test

• For proof of free antibodies in the patient's plasma (which are not bound to the
erythrocyte membrane).

• Performing the test: normal erythrocytes are incubated with the patient's blood, and
then a direct Coombs test is performed.