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BLOOD

Dr. Hoe See Ziau
Department of Physiology
Faculty of Medicine
University of Malaya

210709 Biomed/Pharm 08/09 Blood Lecture 2
ERYTHROCYTE DISORDERS
 Anaemias or polycythaemias

 Anaemia
 Reduction in the Hb concentration below the
lower limit of normal range with respect to age,
gender and race of an individual
 Always associated with
pallor (pale)
CAUSES OF ANAEMIA
 Insufficient number of RBCs
 RBC number < 5 X 106/ µl blood

 Haemorrhagic anaemia
 Results from blood loss

 Haemolytic anaemia
 Results from RBC rupture, or lyse, prematurely

 Aplastic anaemia
 ↓↓ production of RBCs in the bone marrow
 Tumors, drugs & chemicals, x-rays
CAUSES OF ANAEMIA
 Low haemoglobin content
 Hb concentration < 11 – 12 g/dL blood
 Hb molecules are normal, but Hb content in
RBC < normal
 Megaloblastic anaemia
 Microcytic anaemia
CAUSES OF ANAEMIA
 Low haemoglobin content
 Megaloblastic anaemia
 Results from deficiency of vitamin B12 &/or folic
acid
 Pernicious anaemia

 impaired absorption of vitamin B12 due to the
absence of intrinsic factor that caused by
atrophic gastritis and parietal cell loss
Characterised by many large immature,
fragile and dysfunctional RBCs
(megaloblasts)
CAUSES OF ANAEMIA
 Low haemoglobin content
Iron-deficiency anaemia
 Results from inadequate intake of iron-
containing food & impaired iron absorption
 Most common cause of microcytic anaemia

 The RBCs are smaller and paler
(hypochromic) than normal
CAUSES OF ANAEMIA

Normal Blood Film Megaloblastic Anaemia Microcytic Anaemia
• large immature and • RBCs are smaller and
dysfunctional RBCs paler
• hypersegmented or
multisegmented
neutrophils
CAUSES OF ANAEMIA
 Abnormal haemoglobin
 Due to a genetic mutation that alters the Hb
chain
 Thalassaemia
 One of the globin chains is absent or faulty
 Sickle-cell anaemia
 Caused by the abnormal HbS formed – results
from a change in one of the amino acids in a β-
chain of the globin molecule
 In low O2 concentration condition, HbS molecules
interact with each other to form fiberlike structure &
cause RBCs to become sickle shape
ANAEMIA
Sickle cell anaemia
Sickle-shaped RBC

Normal RBC
POLYCYTHAEMIA
 Hb concentration > 16 – 18 g/dL or RBC number
> 8 x 106 /µL blood
 Cancer of the bone marrow causing ↑ production
of RBCs – polycythaemia vera (primary
polycythaemia)
 Conditions causing hypoxia (through EPO) –
secondary polycythaemia:
 Natives living in high altitudes
 Heart disease
 Lung disease
ERYTHROCYTE SENDIMENTATION RATE
(ESR)
 When blood to which an anticoagulant has been
added is allowed to stand in narrow tube, the
RBCs form a pile of aggregates (rouleaux)
 Rouleaux gradually sediment leaving a clear
zone of plasma above
 The length (mm) of the column of clear plasma
after one hour is the measure of ESR
 Normal ESR values:
 Male: 3 – 5 mm
 Female: 4 – 7 mm
FACTORS AFFECTING ESR

 Surface area of falling RBC
 Reduced by rouleaux formation, thus ESR ↑
 Composition of plasma proteins
 Increased plasma proteins (fibrinogen, 2- and -
globulins) → ↑ ESR
 RBC count
 ↑ RBC count → ↓ ESR
 Size and shape of RBC
 ESR is low in sickle cell anaemia and congenital
spherocytosis because abnormal RBCs fail to form
rouleaux
IMPORTANCE OF ESR

 Non-specific indicator of the presence of organic
diseases
 Useful in the evaluation of treatment of various
rheumatic diseases
 Not used for diagnosis of diseases
LEUCOCYTES / WHITE BLOOD
CELLS (WBCs)
 Nucleated cells
 Bigger than RBCs
 4,000 – 11,000 / µL blood
 Crucial role in body’s immune defense
system
 Five types of WBC with varying structure,
function and number
TYPES OF LEUCOCYTES
 The 5 types fall into 2 categories:
DIFFERENTIAL WBC COUNT

Types of Percentage
Cells / µL
WBC Distribution
Neutrophils 3000 – 6000 60 – 70 %

Lymphocytes 1500 – 4000 20 – 40 %

Monocytes 300 – 600 2–6%

Eosinophils 150 – 300 1–4%

Basophils 0 – 100 0 – 0.5 %
LEUKOPOIESIS
CHARACTERISTICS OF LEUKOCYTES

 Chemotaxis
 Attracted to chemicals from pathogens or damaged tissues

 Amoeboid movement
 Allows leukocytes to move through tissues

 Diapedesis
 Leave capillaries by squeezing themselves between
endothelia cells and enter tissues

 Phagocytosis
 Remove pathogens and cell debris by engulfing them
CHARACTERISTICS OF LEUKOCYTES
GRANULOCYTES
 Nuclei segmented into several lobes of varying
shapes
 Cytoplasm contains an abundance of membrane-
enclosed granules
 3 types:
 Neutrophil
 Eosinophil
 Basophil

 Life span:
 <12 hours in transit in the blood before entering tissues
 3 – 4 days in tissues
GRANULOCYTES
Neutrophil
 Lobed nucleus (3 – 6)
 Purplish granules
 Number ↑ (neutrophilia) in acute
bacterial infections
 First WBCs that react to
inflammatory responses triggered
by bacterial infection
 Destroy bacteria by phagocytosis
GRANULOCYTES
Eosinophil  Bilobed, purplish nucleus
 Dark pink granules (contain
histamine, serotonin)
 Number ↑ (eusinophilia) during
allergic diseases (asthma, hay fever,
food allergy), skin diseases &
parasitic infestations (worms)
 Inactivate inflammation-inducing
mediators released from mast cells
during allergic reactions
GRANULOCYTES
Basophil
 Bilobed nucleus
 Dark blue granules (contain
histamine, serotonin, heparin)
 Release histamine with IgE
antibody signal
 Number ↑ (basophilia) in
inflammatory & allergic
reactions
AGRANULOCYTES
 Single, large, non-segmented nucleus
 Few granules
 2 types:
 Monocytes
 Lymphocytes
AGRANULOCYTES
Monocytes
 Life span: months - years
 Dark blue-purple , kidney shape
nucleus; gray-blue cytoplasm
 Digests bacteria, antigen & old or
damaged cells by phagocytosis
 Leave the blood after 1 – 2 days &
enter tissues to become
macrophages
 Number ↑ (monocytosis) in chronic
infections (tuberculosis, syphilis,
malaria)
AGRANULOCYTES
Lymphocytes
 Life span:100 – 300 days
 Spherical dark purple-blue nucleus; pale
blue cytoplasm
 Body immunity
 Protection against bacterial & viral
infections
 B Lymphocytes
 Produce antibodies against different antigens
 T Lymphocytes
 Respond against virus infected cells & tumor
cells
 Release chemicals that destroy the victim
cells
LEUCOCYTE DESTRUCTION

 Aged leucocytes are destroyed in the liver, spleen, bone
marrow and lymph nodes by macrophages
 Large numbers of leucocytes dies in helping to defend
the body against infection, forming together with necrotic
tissues → pus
LEUKOCYTES DISORDERS

 Leukopaenia
 Abnormally low WBC count
 HIV infection, radiation therapy,
chemotherapy, glucocorticoids
LEUKOCYTES DISORDERS

 Leukocytosis
 An increase in the number of leukocytes over
the upper limits
 A modest leukocytosis is normal during an
infection
 Extreme leukocytosis generally indicates
leukaemia
LEUKOCYTES DISORDERS
 Leukaemia
 Cancerous conditions involving WBCs
 Two general types
 myelogenous leukaemia
 Cancerous production of young myelogenous cells in the bone
marrow
 lymphocytic leukaemia
 Cancerous production of lymphoid cells, usually beginning in a
lymph node or other lymphocytic tissue
 Acute and chronic leukaemia
THROMBOCYTES / PLATELETS
 Small non-nucleated cells (2 – 4 m
in diameter)
 Irregularly shaped; stained dark
purple
 Granules contain serotonin, ADP,
von Willebrand factor, fibrinogen
 Produced in bone marrow from
special cells called megakaryocytes
 150- 400 x 103 /µL blood
 Life span: 7 – 14 days
 Destroyed in the spleen and liver
FORMATION OF PLATELETS
Thrombopoiesis
FUNCTIONS OF PLATELETS

 Prevents bleeding

 Coagulation of blood
HAEMOSTASIS

 Prevention of blood loss following an injury

 4 mechanisms involved:
 Vasoconstriction (vascular spasms)
 Formation of platelet plug
 Formation of blood clot
 Permanent repair and fibrinolysis
VASCULAR SPASMS
 First response to vascular injury
 Vasoconstriction of injured vessel due to
contraction of smooth muscle in the wall
of vessel
 Triggered by
 Local myogenic reflexes (direct injury to
vascular smooth muscle)
 Reflexes initiated by local pain receptors
 Vasoconstrictors (serotonin, thromboxane A2)
released by endothelial cells & platelets
 Instantly reduces the flow of blood from the ruptured
vessel
FORMATION OF PLATELET PLUG
 Injury to a vessel disrupts the endothelium
& exposes the tissue collagen molecules
 Platelets adhere to collagen via von
Willebrand factor (vWF)
 Binding of platelets to collagen triggers the
platelets to release ADP & serotonin –
platelet activation
 Platelet activation causes new platelets to
adhere to the old ones – platelet
aggregation
 Platelet aggregation rapidly creates a
platelet plug inside the vessel
 Adhesion of platelet induces synthesis of
thromboxane A2 – which further stimulate
platelet activation & aggregation, and
vasoconstriction
FORMATION OF PLATELET PLUG
FORMATION OF PLATELET PLUG

 Adjacent undamaged endothelial cells synthesis & release
 prostacyclin (PGI2) – profound inhibitor of platelet aggregation
 Nitric oxide (NO2) – vasodilator, inhibitor of platelet adhesion, activation
& aggregation
to prevent the platelet plug from spreading away from the damaged
endothelium along intact endothelium
FORMATION OF BLOOD CLOT:
BLOOD COAGULATION
 Transformation of blood into a solid gel
– clot or thrombus
 Consisting mainly protein polymer
– fibrin
 Occurs locally around the original
platelet plug
 The dominant haemostatic defense
 Three major steps:
 Formation of prothrombin activator
 Conversion of prothrombin to thrombin
 Conversion of fibrinogen to fibrin
BLOOD COAGULATION

Formation of
(Active factor XII) prothrombin
activator
Factor XII

Coagulation

(Fibrin stabilising factor)

Ca2+
BLOOD COAGULATION

 Brought about via intrinsic (blood) and/or
extrinsic (tissue) system
 12 clotting factors (proteins) in the plasma
(Factor I – Factor XIII; no Factor VI)
 Most of the factors are synthesised in the liver
 Under normal condition, all clotting factors are
present in the inactive forms in plasma
CLOTTING FACTORS
CLOT PATHWAYS •Occurs when blood is exposed to
collagen fibres
•Slower
•Can be brought about in vitro

Platelet Factor 3 (PF3)
& Ca2+ are involved in
both pathways

Prothrombin
activator

•Triggered by release of tissue factor
(tissue thromboplastin)
Ca2+
•“shortcut” mechanism

Haemostasis
PERMANENT REPAIR & FIBRINOLYSIS
 Contraction of platelet trapped within the clot
shrinks the fibrin mesh
 Draws the edges of the damaged vessel together
 Serum is squeezed from the clot
(serum: plasma without clotting factors)
 Platelet-derived growth factor (PDGF) –
stimulates fibroblast migration & fibrous tissue
growth → Scar
 The clot is gradually dissolved away (fibrinolysis)
FIBRINOLYSIS
 Dissolution of blood clots
 Brought about by a proteolytic enzyme – plasmin
 Plasmin digests fibrin into soluble fibrin fragments,
thereby dissolve the clot

Plasminogen activators

Plasminogen Plasmin

Soluble fibrin
Fibrin
fragments
BLOOD CLOTTING DISORDERS
 Haemophilia
 Genetically
inherited clotting insufficiency
 Haemophilia A
 Classic haemophilia (85 %)
 An abnormality or deficiency of Factor VIII

 Haemophilia B (Christmas disease)
 15 %
 A deficiency of Factor IX

 Haemophilia C
 Very rare
 A deficiency of Factor XI
BLOOD CLOTTING DISORDERS
 Haemorrhagic disorders that due to
 liver disease
 deficiency of coagulation factors that are
synthesised in the liver (Factors I,II, V, VII, IX and
X)
 Vitamin K deficiency
 Synthesis of Factors II (prothrombin),VII, IX and X
are reduced
 Vitamin K is required as coenzyme for synthesis of
these factors
BLOOD CLOTTING DISORDERS
 Thrombosis
 Formation of clots (thrombus) inside the blood
vessel
 Causes of thrombosis
 Roughed endothelial surface of a vessel
caused by arteriosclerosis, infection, or
trauma
 Blood flow is sluggish and allows activated
coagulation factors to accumulate
 Emboli- freely flowing clots in the blood
stream to other organs and cause damage
ANTICOAGULANT AGENTS
 Agents that prevent clotting of blood
 In vitro and in vivo
 Heparin
 Naturally occurring anticoagulant
 Facilitates the action of antithrombin → inactivates
thrombin and other proteases involved in blood
clotting
 Found in the granules of basophils and mast cells
 Used in vitro and in vivo
ANTICOAGULANT AGENTS
 Chelating agents
 Citrate,
oxalate, flouride, EDTA
 Combine with plasma Ca2+ & form insoluble
complexes
 Used in vitro only
 Agents that inhibit the action of vitamin K
 Coumarin derivatives: warfarin, dicumarol
 Clinically used in vivo only as drug for treatment of
thrombosis
 Arvin (extract from venom of Malayan viper)
 Depletes fibrinogen by forming imperfect fibrin which
is removed by macrophages (defribrination)
BLEEDING TIME
 A medical test done on someone to assess their
platelet function
 The time it takes for bleeding to stop (as thus the
time it takes for a platelet plug to form) is measured
 Normal value: 2 – 9 min
 Bleeding time ↑ when:
 Thrombocytopenia (platelet difficiency)
 Disseminated intravascular coagulation
(DIC)
CLOTTING TIME

 The time taken for blood to clot in vitro
 Normal clotting time: 6 – 12 minutes
 Clotting time ↑ when:
 Clotting factors are ↓ than normal
 ↓ vitamin K
 Chronic liver disease
BLOOD GROUPS

 Two major blood group systems:
 ABO system
 Rhesus system (Rh)

 Based on the presence of antigens on the
RBC membrane
BLOOD GROUP ABO SYSTEM
BLOOD GROUP ABO SYSTEM
 Knowledge of blood group is important for
transfusion purpose

DONOR RECIPIENT
O
A B AB
Antigen (anti-A,
(anti-B) (anti-A) (-)
anti-B)
A (A) X √ X √
B (B) X X √ √
AB (A,B) X X X √
O (-) √ √ √ √
BLOOD GROUP ABO SYSTEM
Universal donor

Universal recipient
RHESUS SYSTEM

 Based on the presence of antigen D on
the RBC membrane

 Presence of antigen D: Rh + (85 – 90 %)

 Absence of antigen D: Rh – (10 -15 %)
RHESUS SYSTEM

 Rh negative individuals:
 Plasma does not contain antibodies to
antigen D

 Cannot produce antibodies naturally or
spontaneously
RHESUS SYSTEM

 Anti-D antibodies can be produced when:

 Rh+ blood is transfused into an Rh- individual

 Rh- mother becomes pregnant with an Rh+
foetus
 Haemolytic disease of the newborn /
erythroblastosis foetalis
RHESUS SYSTEM
2. Rh- individual (no ag. D)

1. Rh+ blood transfusion
(1st time)

3. Body produces anti-D
antibodies in 2 – 3 weeks

4. Rh+ transfusion
(2nd time after 4 – 6 months)

5. Agglutination & haemolysis
RHESUS SYSTEM

1st pregnancy 2nd pregnancy
 Rh- mother becomes pregnant with Rh+ foetus
 Foetal RBC may cross the placental barriers into
maternal circulation – mainly occurs during parturition
 Induce mother to synthesise anti-Rh antibodies
 In future pregnancies, these antibodies may cross the
placenta to attack and haemolyse the RBC of an Rh+
foetus – cause haemolytic disease of newborn
BLOOD TRANSFUSION
 The process of transferring blood or blood-based
products from one person into the circulatory system of
another
 Main reasons for blood transfusion:
 To replenish the volume of blood lost during trauma
 To treat a severe anaemia or thrombocytopenia caused by a
blood disease
 People suffering from hemophilia or sickle-cell disease
BLOOD GROUPING
 Performed to identify a person’s blood group
 Antisera containing Anti-A, anti-B or aniti-D
antibodies are used
 A drop of the blood to be tested is placed on a
microscopic slide and mixed with the antiserum
containing the specific antibody
 After several minutes, the mixtures are observed
under microscope
 If the blood has become clumped (agglutinated)
→ antibody-antigen reaction has resulted
BLOOD GROUPING
CROSS-MATCHING
 Performed to determine the compatibility of a donated unit of blood
for its intended recipient
 Involves testing for agglutination of donor RBCs (antigen) by the
recipient’s plasma (antibody), & of the recipient’s RBCs by the donor
plasma
Donor Recipient
O+ A+

(RBC) No antigen Antigen A

(Plasma) Anti-A & Anti-B Anti-B

 During an emergency, O Rh- blood is used for
transfusion
COMPLICATIONS OF BLOOD
TRANSFUSION
 Allergic reactions: fever, chills
 Hyperkalemia
 Hypocalcemia
 Transmission of infectious diseases: AIDS,
malaria, syphilis, hepatitis B
 Volume overload
 Agglutination, haemolysis, jaundice
TRANSFUSION REACTIONS
 Resulting from mismatched blood types
 Agglutination and haemolysis of RBCs
(particularly those from the donor)
 Agglutinated clumps can plug small vessels
 Haemolysed RBCs release large amount of Hb
which are converted to bilirubin. High bilirubin
concentration in the body fluid can cause jaundice
 Excess free Hb in the plasma leaks through the
glomerular membranes into the kidney tubules →
precipitation of Hb in the tubules and block the
tubules → leading to acute kidney shutdown
TRANSFUSION REACTIONS