Pathophysiology of blood:

anemia and erythrocytosis

RBCs and hemoglobin
 Anemia – decreased amount of
hemoglobin and/or red blood cells
(RBCs) per unit of blood volume

Normal value Males Females

Number of RBCs 4,0 – 5,1×1012/l 3,7 – 4,7×1012/l
Hemoglobin 130 – 160 g/l 120 – 140 g/l
 Classification of anemia

By the mechanism of development:

• Disorders of RBCs formation and differentiation
• Increased destruction of RBCs
• Loss of RBCs (hemorrhage)

By the time course: acute and chronic

By the regenerative activity of the bone marrow:
regenerative, hypo-, aregenerative
By the saturation of RBCs with hemoglobin: normo-, hypo-,
hyperchromic
A model for hematopoiesis
 ERYTHROPOIESIS
Stem cells IL-3
factor Erythropoietin
IL-11

STIMULATION

Proerythroblast Basophilic Polychromatic

erythroblast erythroblast Normoblast Reticulocyte Erythrocyte

INHIBITION

IL-1 TNF IFN- , , γ

IL-8
 Erythropoietin (EPO)
Glycoprotein, 105 кDa,
166 amino acid residues

Belongs to the family of

HIF1α-dependent genes

Half-life time in the blood

4-13 h

Major stimulators of EPO

generation:
· Hypoxia
· Androgens
· Carbon monoxide
· Products of hemolysis

The effect of EPO on erythropoiesis:

· Stimulates differentiation of CFU-Er into proerythroblasts
 “Quick facts” about erythropoiesis and RBC clearance

• Healthy human adults produce

approximately 2 million RBCs every
second

• Average lifespan of RBC is 90-120 days

• “Senescent” RBCs are entrapped by the

macrophages of the reticulo-
endothelial system, mainly splenic
macrophages

Accumulation of “eat me” signals on RBC surface

 Disorders of RBCs formation

• Decrease in the number of hematopoietic cells (bone

marrow aplasia or hypoplasia)
• Disorders in the regulation of proliferation and
differentiation of bone marrow RBC precursors
• Disorder of DNA synthesis in erythroblastic cells
(deficiency of vitamin В12, folic acid)
• Disorder of hemoglobin synthesis (iron deficiency,
vitamin В6, protein starvation ...)
Aplastic anemia
 Etiology of aplastic anemia

• Rare hereditary forms, e.g. Fanconi anemia

• Physical factors: ionizing radiation exposure
• Chemical factors:
- direct myelotoxicity (dose-dependent), e.g. cytostatics, benzene
- immune-mediated (dose-independent) – hapten, type II hypersensitivity
• Biological factors – viruses:
- cytomegalovirus
- Epstein-Barr virus
- hepatitis virus (HCV, HBV)
- parvovirus B19
• Suppression of normal hemopoietic cells in leukemia
• Cancer metastasis into the bone marrow
Vitamin B12-deficient anemia

• Alimentary shortage of
vitamin В12 (vegetarians)
• Disorders of vitamin B12
absorption
• Competitive consumption of
vitamin В12
• Increased requirements in
vitamin В12
Disorders of vitamin В12 absorption and transport
В12 IF

CELL
STOMACH В12-IF
BLOOD
ТC II В12

В12+TCII
В12+ТCII

ENTEROCYTE
V. PORTAE

ILEUM В12-IF В12 + TCII ТCII + В12 LIVER

IF

IF – intrinsic factor Parietal cells

ТC - transcobalamin II Receptor to the complex В12-IF
THE GASTRIC LESION IN PERNICIOUS ANEMIA
THE DEVELOPMENT
OF AUTOIMMUNE
GASTRITIS
 Pathogenesis of vitamin B12-deficient anemia

Vitamin В12 deficiency

Adenosilcobalamin Methylcobalamin
Propionic
acid
Folic acid metabolism

Methylmalonic Thymidine synthesis

acid Succinate

Impaired DNA synthesis

Desynchronization
between maturation Premature death of
Accelerated death of
of nucleus and RBCs in the
RBCs in the bone marrow
cytoplasm circulation
MEGALOBLASTIC
ERYTHROPOIESIS

• Low mitotic activity of

erythrocariocytes
• Decreased longevity of life
in red blood cells
• Myeloblasts and
megalocytes in the
peripheral blood
 Remnants of the nucleus in
the peripheral RBCs
(megaloblastic anemia)
Kebot rings Jolly bodies
DISTRIBUTION OF
IRON IN ADULTS
 MECHANISMS OF COMPENSATION IN
IRON DEFICIENCY

• Increased absorption rate

• Increase in the area of absorption in the intestine
• Mobilization of tissue reserves

Bone marrow

Fe

Parenchymal Fe Transferrin Fe
cells Macrophages

Fe

Intestine

- Iron stores in the forms of hemosiderin and ferritin

CAUSES OF IRON DEFICIT
IN THE ORGANISM

• Deficiency in the food

• Insufficient compensation of
additional losses
• Impaired absorption
(absorption deficiency)
• Chronic blood loss
• Redistribution of the stores
(retention in the form of
ferritin, hemosiderin)
 Major causes of chronic blood loss

• Gastrointestinal tract (most common): chronic peptic ulcer,

colorectal cancer, gastric cancer, ulcerative colitis,
hemorrhoid
• Urinary system: kidney stones, tumors of the kidney and
urinary bladder
• Gynecological disease: metrorrhagia in uterine myoma,
endometriosis etc.
• Pulmonary bleeding: tuberculosis
IRON TRANSPORT
ACROSS THE
INTESTINAL
EPITHELIUM
 TRANSPORT OF THE IRON

• Transferrin is the only protein capable of iron

transportation
• In principle, all cells have receptors to
transferrin and their ability to uptake iron
depends on the number of transferrin
receptors
THE TRANSFERRIN CYCLE
Clinical signs of iron deficiency anemia
Pathophysiological mechanisms of anemia of chronic disease
Regulation of iron metabolism by hepcidin
Types of anemia characterized by microcytosis
HEMOLYTIC ANEMIAS

• Traumatic hemolysis

• Toxic hemolysis

• Osmotic hemolysis

• Immune hemolysis

• Hemolysis as a

consequence of

intracellular parazites

(malaria)
Traumatic hemolysis
(prosthetic heart valve)
Toxic hemolysis
(acute lead poisoning)
 HEMOLYTIC ANEMIAS
ENZYMOPATHIES
Hereditary deficiency of GLU-6p-DH

• Decreased production of NADP

• Decreased production of reduced glutathione (GSH)
• Decrease in antioxidant capacity of RBCs
• Oxygen free radical injury to RBCs
• Increased formation and precipitation of methemoglobin (Heintz
bodies)

Decreased deformability of RBCs, decreased longevity of RBCs,

acceleration of intra- and extra vascular hemolysis.

HEMOLYTIC ANEMIA
 HEMOLYTIC ANEMIAS
ENZYMOPATHIES

Hereditary deficiency of PYRUVATKINASE

• Decreased glycolysis
• Decreased generation of ATP
• Cytoskeletal disorders in RBCs
• Impaired function of K+/Na+ pump

Decreased deformability of RBCs, preterm senescence of RBCs,

acceleration of extra vascular hemolysis.

HEMOLYTIC ANEMIA

ACANTHOCYTOSIS
 HEMOLYTIC ANEMIAS
MEMBRANOPATHIES

Hereditary deficiency of SPECTRIN, ANKYRIN

• Disorder of spectrin polymerization
• Inability to maintain biconcave shape
• Increased permeability of the RBC membrane for Na+ (swelling of
RBCs)
• Increased energy requirements for shape maintenance,
increased consumption of glucose

Microspherocytosis, decreased duration of life of RBCs (5-7 days),

extravascular hemolysis.

HEMOLYTIC ANEMIA
 The red cell membrane cytoskeleton: genetic
defects of spectrin α, β, ankyrin, band 3, and protein
4.2 result in hereditary spherocytosis
 Hereditary spherocytosis: loss of membrane
fragments leads to spherical shape and decreased
deformability
Hereditary spherocytosis (left) and
hereditary elliptocytosis (right)
SICKLE-CELL DISEASE
Normal Production of Hemoglobin
Genotype
CAC GTG GAC TGA GGA CTC CTC …
transcription

RNA Phenotype
translation

Hemoglobin
Protein

DNA Day - Pharmacogenetics 41

 Sickle Cell Anemia
Genotype
CAC GTG GAC TGA GGA CAC CTC …
transcription

RNA Phenotype
translation

Hemoglobin
Protein
The change in the nucleotide causes the hemoglobin molecules to crystallize
when oxygen levels in the blood are low. As a result blood cells sickle and get
stuck in the small blood vessels.
DNA Day - Pharmacogenetics 42
 HEMOLYTIC ANEMIAS
HEMOGLOBINOPATHIES

 - thalassemia
 
Normal hemoglobin    
heme  

HbF (2,2) HbА2 (2,  2)
heme   heme
  - thalassemia
heme  
HbA (2,2)
   
 

HbН (4) Hb-Bart`s (4)

Pathogenesis of thalassemia
 HEMOLYTIC ANEMIAS
CHARACTERISTIC FEATURES
· Hyperregeneration of the RBCs in the bone marrow
· Increased number of reticulocytes in the peripheral
blood
· Increased concentration of indirect bilirubin in the blood
serum
· Increased amount of free hemoglobin in the blood
serum (intravascular hemolysis)
· Increased iron in the blood
· Decreased osmotic resistance of the RBCs
· Decreased longevity of the life of RBCs
· Pathological forms of RBCs (schizocytes, spherocytes,
stomatocytes etc.)
Gene therapy or editing to treat congenital anemia
 MECHANISMS OF COMPENSATION IN
ACUTE POSTHEMORRHAGIC ANEMIA

• Stimulation of erythropoiesis
• Increased absorption of the iron
• Increased use of iron by the erythrocariocytes
(Hb synthesis)
• Increased content of 2,3-diphosphoglycerate in the RBCs
• Formation of RBCs with increased deformability
 Stages of acute posthemorrhagic anemia
Duration Stage Mechanism(s) Blood changes

Vasospasm
0-3 hrs Hemodynamic ↑ cardiac No changes
output

Water moves
3-48 hrs Hydraemic from cells ↓Ht, anemia,
and ECF to normal MCH
blood

EPO → ↑ reticulocytes,
2-5 days Bone marrow stimulation of decreased
erythroid MCH,
progenitors thrombocytosis,
leukocytosis
 Classification of erythrocytosis

Erythrocytosis

Absolute Relative
Increased RBC
Hemoconcentration; RBC
production
production is not increased !

Primary Secondary
(polycythemia
vera) Stimulation of
erythropoiesis by
Intrinsic defect in
EPO
hematopoiesis;
EPO level is normal
 Causes of increased EPO production
• Systemic hypoxia:
chronic respiratory failure
high altitude
smoker’s erythrocytosis
carbon monoxide poisoning
• Renal hypoxia:
renal artery stenosis
polycystic kidney
• Pathologic EPO production:
renal cell carcinoma
hepatocellular carcinoma
pheochromocytoma
• Exogenous EPO:
rEPO administration
androgen administration