BSE Preparatory Course:

Physiology and Applied Clinical

Physiology

Blood and Hematologic System

Dr Priyia Pusparajah
MBBS(Malaya), MRCPCH (UK), MMedPaeds(Singapore)
Senior Lecturer
Monash University Malaysia
Overview

 Composition of blood and role of its components

 Coagulation pathway
 Bleeding
 Anemia
 Compatibility testing of blood
 The immune system
 Abnormal conditions of blood – haemophilia, sickle cell,
Caisson disease

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 Functions of blood
• Distribution
– Delivering O2 and nutrients
– Transporting metabolic waste products
– Transporting hormones
• Regulation
– Temperature regulation – absorbs and distributes heat
– Maintaining normal pH – buffers
– Maintain adequate circulating fluid volume – salts and proteins
• Protection
– Preventing blood loss
– Preventing infection
Components of blood
Formed elements

 Erythrocytes,
leukocytes, platelets
 Only leukocytes are
true cells
 Mostly survive in
blood only a few
days
 Do not divide –
renewed by division
within bone marrow
 All formed elements
originate from stem
cells

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 Normal blood counts / blood film
Hemoglobin
Female: 12-16g/100ml
Male: 13-18 g/100ml

Mean RBC count

Female: 4.8 million/μl
Male: 5.4 million/μl

Platelet counts 150,000-400,000/μl

Total WBC count 4,000- 11,000/μl

Erythrocytes

 Features:
– Biconcave disc
– No nucleus (in mature cell)
– Few organelles
 Lifespan ~ 120 days
 Function
– mainly in transport of O2
and CO2
– Contain hemoglobin

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Hemoglobin

 The protein which makes

red cells red
 Made up of protein
(globin) bound to red
heme group
 Each heme group has a
molecule of iron
 In the adult, globin
consists of 2α and 2 β
units

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Leucocytes

 Several different types of

WBCs
 Main function - fighting
infection
– Via production of
antibodies
– By direct phagocytosis

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Platelets

 Irregularly shaped
fragments of
megakaryocytes
 No nucleus
 Lifespan 5-9 days
 Function: coagulation

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Case 1

 Muthu is a 63 year old with liver

cirrhosis secondary to chronic
alcoholism. He presents with
massive hematemesis likely
secondary to bleeding
esophageal varices.

 Basic bloods sent off include a

coagulation profile which show
a prolonged PT and APTT
Which component of hemostasis is abnormal based on this
result?
How is this related to his liver disease?

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Hemostasis

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Coagulation cascade

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Origin of various clotting factors

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Analyzing the coagulation profile

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Fibrinolysis

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Anticoagulation

Apixiban

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Case study 2

 Adam is a 10 year old boy who is admitted to the ward

with a painful, swollen right knee. He has had several
episodes of spontaneous hemarthosis before. He also
complains of frequent nose bleeds and gum bleeding
 Which of the following do you think is most likely to be
lacking in Adam?
 A) platelets
 B) vitamin K dependent clotting factors
 C) Factor VIII
 D) Factor IX
E) C and D

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Hemophilia

 One of the most common coagulation disorders

along with von Willebrand disease
 Genetic – X-linked recessive
 2 variants – identical clinical presentation
– Hemophilia A
 Most common of hereditary clotting factor deficiencies
 Factor XIII deficient
– Hemophilia B (Christmas disease)
 Factor IX deficient

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The Royal Disease

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Which would be the best blood product to transfuse into Adam?

FreshFrozen
Plasma – contains
all clotting factors

Cryoprecipitate –
rich in factor VIII,
fibrinogen, vWF

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Case 3

 Johan was involved in a serious MVA and sustained

severe internal bleeding. He needs a blood transfusion
urgently.
 What variant of blood would you give him if you don’t
have time to wait for a GXM?
 A) O positive
 B) AB negative
 C) AB positive
 D) O negative
 E) none of the above
Why?

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 Blood grouping
• Human RBCs bear numerous surface antigens
• Approximately 400 red blood cell group antigens have been
described
• The most important of these are the ABO and Rh groups
• All RBCs in a particular individual carry the same antigens
• The basis of pretransfusion compatibility testing to minimize risk of
haemolytic transfusion reactions
Antibodies in plasma in various blood groups
Agglutination – antigen-antibody reaction

Cells bound by antibody will then be targeted for destruction and undergo
lysis
Hemolytic transfusion reactions
Hemolytic disease of the newborn
Most commonly due to Rh factor
Occurs in Rh negative mothers with Rh positive fetus
Case –(cont)

 Remember Johan? Here’s a bit more of his history…

 Johan is a healthy 21 year old man who was involved in
an MVA. He suffered severe hepatic trauma and a
fractured femur resulting in marked blood loss. He was
transported to hospital very soon after the incident. His
FBC taken prior to any giving any IV fluids showed Hb
14, Hct 42%,MCV 80fL
 Is this the result you would expect?
 If you repeated the result the next day assuming there
was no blood transfusion given what result would you
expect and why?

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 Anemia - definition
• ‘a reduction of hemoglobin concentration in
the blood’ (from Hoffbrand, Essential Hematology, 5th ed 2006)
• WHO definition:
• Men
• Hb < 130 g/L (13g/dL) or PCV < 41 L/L
• Women
• Hb < 120 g/L (12g/dL) or PCV < 36 L/L
• Can be classified based on RBC morphology
Hoffbrand. Essential Hematology, 5th Ed, 2006
 Hypochromic, microcytic
MCV <80 pg, MCH <27 pg
Normocytic
normochromic
MCV 80-100fL, MCHC ≥
27pg

Macrocytic
MCV >100fL
 Classification of anemia
Microcytic, hypochromic Normocytic, macrocytic
normochromic
MCV <80fL MCV 80-100fL MCV >100fL
MCH <27 pg MCH ≥ 27 pg
Iron deficiency Many hemolytic anemias Megaloblastic: vitamin B12
Thalassemia Anemia of chronic disease or folate deficiency
Lead poisoning After acute blood loss*
Renal disease Non-megaloblastic :
Mixed deficiencies alcohol, liver disease,
Bone marrow failure (eg myelodysplasia, aplastic
post-chemotherapy, anemia etc
infiltration from
carcinoma)

*only manifests on FBC

~1 day after the event Adapted from Hoffbrand, Essential Hematology,
5th ed, 2006
 RBC indices

• RBC count
– absolute number of RBCs in a given volume of
blood
• HCT(hematocrit) /PCV (packed cell volume)
– - volume percentage (%) of red blood cells in
blood
 RBC indices (cont)

• Hb
– amount of Hb in a given volume of blood
• MCV (mean cell volume)
– average RBC size
– calculated by dividing the HCT by the RBC count.
The resulting number is then multiplied by 10
• MCH (mean cell Hb)
– average mass of Hb per RBC in a sample of blood
– MCH=(Hb*10)/RBC
• MCHC (mean cell Hb concentration)
– a measure of the concentration of Hb in a given
volume of packed RBCs
– MCH/MCV or Hb/HCT
Reticulocytes

 Reticulocytes are immature RBCs

 Reticulocytes do not have a nucleus (ie no DNA)
 Usually make up ~1% of RBCs in circulation
 Mature in bone marrow and circulate for about 1 day
before developing into mature RBCs
 Tend to be released in larger numbers when marrow is
under stress -> number of reticulocytes is a good
indicator of bone marrow activity because it represents
recent production
 If a person has anemia, the reticulocyte percentage
should be higher than "normal" IF the bone marrow's
ability to produce new blood cells remains

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Causes of anemia

 Decreased production of RBCs

– Lack of substrate
– Genetic defects related to Hb production
– Bone marrow disease
– Lack of erythropoietin
 Increased destruction of RBCs
– Intravascular vs extravascular
 Blood loss
– Acute vs chronic

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Decreased production of RBCs

Hoffbrand. Essential Hematology, 5th Ed, 2006

 Case 4
• Ali is a 65 year old man
who has been
complaining of fatigue,
weight loss, altered
bowel movement for the
last 4-5 months. Fecal
occult blood is positive
and a colonoscope shows
a growth in the
descending colon. How do you explain his FBC?
• His FBC shows a Hb of 9,
MCV 69, MCH 23
 The development of IDA

• Body’s iron stores must be completely

depleted before anemia occurs

Hoffbrand. Essential Hematology, 5th Ed, 2006

 Causes of IDA
• Chronic blood loss
– uterine
– Gastrointestinal
• Peptic ulcer, carcinoma within GI tract, colitis, piles
– Others eg hematuria
• Increased demands
– Pregnancy, growth, prematurity
• Malabsorption
– Gluten induced enteropathy, gastrectomy
• Poor diet
– Contributory factor in many developing countries, rarely
the sole cause except in infants and children
 Haemoglobin abnormalities
• Genetic defects of Hb (eg thalassemia) are the
most common genetic disorders worldwide
• Occur in tropical and subtropical areas
• Appear to have been selected as carrier state
affords some protection against malaria
Vento S, CainelliF, Cesario F. Infections and thalassemia. Lancet Infect
Dis 2006;6:226-33
 Thalassemia

Thalassemia is the commonest single gene disorder

in Malaysia and a paradigm of monogenetic
diseases. In 1995, it was estimated that about 8,000
persons were afflicted with HbE beta Thalassaemia,
and 8,000 with Homozygous beta-Thalassaemia,
about 40% of whom were dependent on regular
blood transfusions for survival (Kaur, 1995). (From
‘report :management of thalassemia, Malaysian MOH)

• about 4.5 to 6% of the Malays and Chinese are

carriers of this genetic disorder (Wong LP et al, BMC Public
Health 2011, 11:193 )
Thalassemia

 Defect with globin

component (vs IDA)
 Main types
– α-thal (lack of alpha units)
– β-thal (lack of beta units)
 There are also other
types of units produced
eg δ,γ

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Globin genes

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 Thalassemia - diagnosis
• α-thal: diagnosis
– DNA analyses
– Hb electrophoresis: normal

• Β- thal : diagnosis
– Hb electrophoresis
• HbA2 (α2δ2) raised (>3.5% is confirmatory)
Hb electrophoresis

 Same principle of gel electrophoresis

 May be used to identify the different types of Hb
and their relative proportions

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Hoffbrand. Essential Hematology, 5th Ed, 2006
 Sickle cell disease (SCD)
• group of inherited red blood cell disorders.
• people with SCD have abnormal hemoglobin,
called hemoglobin S -> causes RBCs to be
distorted into sickle or crescent shape which are
prone to premature lysis
• defect in the gene that directs the production of
the beta globin
• Recessive trait – if inherit 2 copies of HbS -
>sickle cell anemia
Sickle Cell Disease

 May present with

haemolytic anemia or
sickle cell crisis

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 Megaloblastic anemia
• Characteristic abnormality: erythroblasts in
marrow show delayed maturation of nucleus
relative to that of cytoplasm
• Underlying defect: defective DNA synthesis
– Usually due to deficiency of B12 or folate
• Impaired DNA synthesis leads to failure to
complete cell cycle -> leads to continuing cell
growth without division, which presents as
macrocytosis.
• Slow onset compared to other anemias
The role of folate and vit B12 in DNA synthesis

Vitamin B12
is required
for the folate
cycle

The folate cycle provides key

element in nucleic acid synthesis
Macrocytic anemia

Normal PBF
 Hemolytic anemias
• Hemo = blood, lytic = breakdown
• Anemia due to increase in rate of destruction of
circulating RBCs
• May be destroyed in the blood vessels
(intravascular) or elsewhere in the body
(extravascular)
• Has numerous causes
• Red cell destruction may be increased many-fold
before anemia manifests due to erythropoietic
hyperplasia  reticulocytosis
Classification of hemolytic anemias

HEREDITARY ACQUIRED
Membrane Immune
Hereditary spherocytosis, hereditary Autoimmune
elliptocytosis Alloimmune
- hemolytic transfusion reactions
Drug associated
Metabolism Red cell fragmentation syndromes
G6PD deficiency cardiac – prosthetic heart valves
microangiopathic – TTP-HUS, DIVC
Haemoglobin Infections
Genetic abnormalities (eg HbS) Malaria, clostridia
 Case 5
• Adnan slipped into a deep drain and sustained
superficial lacerations over his thigh. He
washed the cuts with tap water and put some
gauze over the area. A few days later the area
over the cut is oozing thick creamy white fluid
and the surrounding area is erythematous
• He can also feel some slightly tender lumps
under the skin on the medial side of the
affected thigh.
• His FBC is normal apart from WBC of 13.5 with
80% neutrophils, 17% lymphocytes
• How do you interpret this result?
Immune system

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White blood cells

 Key part of immune system

 Can be divided into 2 group
– Phagocytes (‘eat’ infectious agents)
 Granulocytes (neutrophils, eosinophils, basophils) + monocytes
– Immunocytes (produce antibodies)
 lymphocytes
 Normally only mature phagocytes and lymphocytes are
found in peripheral blood

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Formed elements in the blood

66 Maried EN, Hoehn K. Pearson Human Anatomy and

Physiology, 7th ed, 2007
Phagocytosis

• Mechanism utilized by innate

arm
• Neutrophils and macrophages

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Leukocyte migration from blood into tissues

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Leukocyte disorders

 Leukocytosis
– Increase in total number of circulating WBCs
– Usually results from infection or malignancy
 Leukopenia
– Absolute reduction in circulating WBCs below the lower limit of
normal values
– May result from reduced production or increased utilization or
destruction
– In clinical practice tends to be synonymous with neutropenia

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Case 5

 Aidan is a 6 year old boy who was admitted to the ward

with a history of 3 weeks of fever, associated with easy
bruising and gum bleeding.
 Examination revealed pallor, multiple bruises over the
shins and forearms, hepatosplenomegaly and diffuse
lymphadenopathy
 FBC shows a Hb 9.4, WBC 79, plt 64
 What is your most likely diagnosis?

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Leukemias

 A group of disorders characterized by the accumulation of

malignant white cells in the bone marrow and blood
 These abnormal cells cause symptoms due to
– Bone marrow failure
 Anemia, neutropenia, thrombocytopenia
– Infiltration of organs
 Liver, spleen, lymph nodes, meninges, brain, skin, testes

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Why does leukaemia develop?

 Multifactorial
 Inherited factors
– Genetics
– Genetic diseases – eg Down syndrome
 Environmental influences
– Chemicals
 eg benzene exposure
– Radiation
 Eg in survivors of atom bomb blasts in Japan
– Infection
 Viruses – eg HIV, Epstein Barr virus

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Classification of leukemias

 Acute vs chronic
 Acute
– the bone marrow cells cannot mature properly.
– Immature leukemia cells continue to reproduce and build up
(normal mechanisms to destroy abnormal cells fail)
 Chronic
– the cells can mature partly but not completely.
– cells may look fairly normal but they are not –
 generally do not fight infection as well as normal WBCs
– survive longer, build up, and crowd out normal cells

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Classification of leukemia

 Acute
– Acute lymphoid leukemia
– Acute myeloid leukemia
 Chronic
– Chronic lymphoid leukemia
– Chronic myeloid leukemia

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Acute leukaemias

 Usually aggressive diseases

 Malignant transformation occurs in the haemopoietic
stem cell or early progenitors
 Accumulation of early bone marrow hemopoietic cells
(blast cells) due to genetic defects resulting in:
– An increased rate of proliferation
– Reduced apoptosis (cell death)
– A block in cellular differentiation
 Defined as the presence of over 20% blast cells in blood
or bone marrow at clinical presentation

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Acute leukaemias (contd)

 Dominant feature is bone marrow failure caused by

accumulation o f blast cells although organ infiltration
also occurs
 Rapidly fatal if untreated BUT paradoxically easier to cure
than chronic leukemias
 Subdivided into ALL and AML on the basis of whether the
blasts are shown to be myeloblasts or lymphoblasts

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Hoffbrand AV. Essential
Hematology, 5th Ed, 2006.
ALL – peripheral blood and bone marrow

Normal bone marrow

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AML – PBF and bone marrow

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CLL - PBF

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Caisson disease

 Decompression disease or the bends

 At greater depths more nitrogen can dissolve in the blood
 As the diver rises to the surface, the nitrogen comes out of solution
and forms bubbles which may cause gas embolisms and prevent
blood flow to various organs
 Type I DCS or ‘the bends’ is characterized by vague symptoms like
generalized weakness, body ache, abdominal pain, and vomiting,
while type II DCS is associated with systemic dysfunction, presenting
with cardiovascular involvement (‘the chokes’) or neurological
features like paraplegia and bladder dysfunction.
 Treatment: hyperbaric oxygen chamber

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THANK YOU