Hemolytic Anemias

By hemolytic anemias, we mean the anemias in which there is premature destruction of red
blood cells. Here the red blood cells are produced normally or even in increased amounts, but
destruction is exaggerated in these cases. Because of this, the total number of red blood cells
present in the circulation at any one time will be less than normal. Therefore the total amount of
hemoglobin is less than normal, leading to anemia.

Consequently, the amount of oxygen carried to the kidneys is less than normal leading to an
increased erythropoietin level and erythroid hyperplasia.

Hemolytic anemias can be of two major types, depending on the predominant site of red blood
cell destruction:
 Extravascular hemolysis: here the destruction of cells occurs outside the circulation, in
the spleen, liver…
 Intravascular hemolysis: here the destruction of cells occurs inside the blood vessels.
Extravascular hemolysis
This type of hemolysis may be either due to a hyperactive RES, which takes up RBC(s) that are
not too old to be removed, or else there could be a defect in the RBC itself, which leads to its
removal by the RES (Spherocytes, Achantocytes, Sickle Cells…)

When the RBC is taken up by a macrophage, the contents of the RBC are broken down. Thus
inside the RES, the Hemoglobin is broken to its globin part and its Heme part. Globin is then
broken down to amino acids which are returned to the amino acid pool to be used again. On the
other hand, Heme is also broken down to its components, iron and porphyrin, which is then
broken down to bilirubin. Bilirubin is released from the macrophage into the plasma where it
binds to Albumin and is carried to the liver for final elimination. At this stage, it is termed
unconjugated or indirect Bilirubin (it is insoluble in water).

Upon reaching the liver, the bilirubin dissociates from its Albumin carrier and enters the
hepatocyte. In this cell, it is converted to a highly H2O soluble derivative, bilirubin diglucuronide
(conjugation). Bilirubin is conjugated with glucuronic acid by the E, glucuronyl transferase, to
form bilirubin diglucuronide. This is the direct or conjugated bilirubin.

Finally, the conjugated bilirubin is excreted through the bile into the intestines. In the intestines,
the conjugated bilirubin is acted upon by bacteria, which further reduce it to urobilinogen. Most
of the urobilinogen formed is excreted in the feces as stercobilinogen; and some is absorbed in
the blood stream but is then rapidly re-excreted mostly by the liver but some by the kidneys.
Finally, upon exposure to air, stercobilinogen is oxidized to stercobilin which gives the stool its
characteristic color, and urobilinogen is oxidized to urobilin in the urine which also gives it its
color.
+++
As far as the iron portion is concerned, Fe is deposited in the macrophage and forms
+++
complexes of Fe one of which is ferritin. Some comes back to the circulation where it is
bound to transferrin and this transferrin- Fe +++ complex goes to the B.M where it is reutilized to
make new Hemoglobin.
 Excretion of bilirubin by the liver. Bilirubin, which is bound to albumin in the plasma, is taken up into
hepatocytes, conjugated in the smooth endoplasmic reticulum and excreted via the bile ducts into the gut,
where it is converted to urobilinogen. Most of the urobilinogen is oxidized to stercobilin in the colon and
excreted in the stool. Some urobilinogen is absorbed from the small intestine and enters the enterohepatic
circulation. While most is excreted in the bile, some reaches the systemic circulation and is excreted in
the urine.

Intravascular hemolysis
Here the RBC(s) break within the circulation. In the plasma, free Hb (which is initially in the
form of tetramer is not stable. As such it will dissociate to a limited extent into αβ dimers. These
Hb or αβ dimers are relatively small in size with a MW of approximately 32 000 daltons;
therefore because of that size, if they are left as dimers, they will be filtered through the renal
glomerulus. However, normally, there is a substance in the blood called Haptoglobin (produced
by the liver) whose function is to bind the free Hb in circulation  - haptoglobin complex.
This complex is then removed from the circulation at a very fast rate by the RES, most often by
the macrophages of the liver. Within these cells, both the haptoglobin and the globin will be
broken down to a.a(s) and the heme will be broken down again to liberate iron and bilirubin.
Following this, the bilirubin is conjugated and excreted.

If the hemolysis is very severe and the Hb produced is in excess with the haptoglobin present, the
 dimers remain free in the circulation and will be filtered through the renal glomerulus.
In the nephron, the Hb dimers are rapidly reabsorbed by the proximal tubular cells, where they
are degraded in the usual way. The globin is destroyed; the iron is deposited as hemosiderin or
ferritin which is stored in the tubules as iron stores. Then as the cells of the tubules pass into the
urine, we can demonstrate the iron in the urine sediment. Finally, the protoporphyrin ring is
converted to bilirubin, which is released into the blood stream and eventually excreted in the
bile.
The proximal tubular cell, however has a limited capacity to take up  dimers. If this capacity
is exceeded, the free Hb urine (hemoglobinuria).

Intravascular hemolysis usually occurs when the cell membrane has been severely damaged by any of a
number of different mechanisms, including autoimmune phenomena, direct trauma, shear stress (e.g.,
defective mechanical heart valves), and toxins (e.g., clostridial toxins, venomous snake bite). It results in
hemoglobinemia when the amount of Hb released into plasma exceeds the Hb-binding capacity of the
plasma-binding protein haptoglobin, a globulin normally present in concentrations of about 1.0 g/L in
plasma. With hemoglobinemia, unbound Hb dimers are filtered into the urine and reabsorbed by renal
tubular cells. Iron is embedded in hemosiderin within the tubular cells; some of the iron is assimilated for
reutilization and some reaches the urine when the tubular cells slough. ; hemoglobinuria results when
reabsorptive capacity is exceeded.
On the other hand, the other mechanism involves the oxidation of the iron of the circulating Hb.
So, in the plasma, some free Hb is oxidized to methemoglobin, which quickly dissociates into
ferriheme (heme in which Fe is Fe+++) and globin chains. Some of the ferriheme is taken up by
the heme binding protein hemopexin which carries it to the liver for usual processing to iron and
bilirubin. The rest is taken by albumin to form methemalbumin. This ferriheme eventually ends
up in the liver as well where it suffers the same fate.

Within blood vessels, RBC(s) can break easily in the presence of many things:
 Bacterial infection: certain bacterial toxins called lysins can produce hemolysis in
circulation.
 Certain chemicals agents can break down RBC(s) in the circulation such as lead,
chlorate or arsine.
 Artificial valves can destroy cells as they pass through them or RBC(s) get fragmented
when they pass through fibrin strands in small vessels (DIC).
 Severe burns can lead to thermal injury.
 Finally G6PD deficiency can also cause intravascular hemolysis. A deficiency of this
enzyme renders RBC(s) susceptible to destruction and breakage by certain agents.
Diagnosis

Lab diagnosis of hemolysis

Smear examination may be helpful in distinguishing intravascular hemolysis from extravascular

hemolysis, since intravascular hemolysis is associated with schistocytes, while spherocytes are
characteristic of extravascular hemolysis. Other laboratory investigations, including bilirubin,
LDH, haptoglobin, plasma free hemoglobin, urine hemosiderin and hemoglobin confirm the
presence of hemolysis and help differentiate between intravascular and extravascular hemolysis.
Further testing such as direct antiglobulin test, cold agglutinin, hemoglobin electrophoresis,
platelet count, INR/PTT, fibrinogen and d- dimer are guided by the clinical picture and help to
determine the cause of hemolysis. ...
N.B: extravascular hemolysis, the hemolytic process occurs within the reticuloendothelial
system, which is able to metabolize the degradation products more efficiently. Since fewer
degradation products are released into the circulation in extravascular hemolysis, the laboratory
changes are of a lesser magnitude and urine hemosiderin and hemoglobin are negative.