BLOOD

FUNCTIONS OF BLOOD

The scientific study of blood reveals characteristics as fascinating as any of these

fantasies. Blood performs many functions essential to life and can reveal much about our
health. The heart pumps blood through blood vessels that extend throughout the body.
Blood helps maintain homeostasis in several ways:

1. Transport of gases, nutrients, and waste products. Oxygen centers the blood in
the lungs and is carried to cells. Carbon dioxide, produced by cells, is carried in the blood
to the lungs, from which it is expelled. The blood transports ingested nutrients, ions, and
water from the digestive tract to cells, and the blood transports the waste products of
the cells to the kidneys for elimination.

2. Transport of processed molecules. Many substances are produced in one part

of the body and transported in the blood to another part, where they are modified. For
example, the precursor to vitamin D is produced in the skin and transported by the blood
to the liver and then to the kidneys for processing into active vitamin D. Then the blood
transports active vitamin D to the small intestine, where it promotes the uptake of
calcium. Another example is lactate produced by skeletal muscles during anaerobic
respiration. The blood carries lactate to the liver, where it is converted into glucose.

3. Transport of regulatory molecules. The blood carries many of the hormones and
enzymes that regulate body processes from one part of the body to another.

4. Regulation of pH and osmosis. Buffers, which help keep the blood’s pH within its
normal limits of 7.35–7.45, are found in the blood. The osmotic composition of blood is
also critical for maintaining normal fluid and ion balance.

5. Maintenance of body temperature. Warm blood is transported from the interior of

the body to the surface, where heat is released from the blood. This is one of the
mechanisms that helps regulate body temperature.

6. Protection against foreign substances. Certain cells and chemicals in the blood
constitute an important part of the immune system, protecting against foreign
substances, such as microorganisms and toxins.

7. Clot formation. When blood vessels are damaged, blood clotting protects against
excessive blood loss. When tissues are damaged, the blood clot that forms is also the
first step in tissue repair and the restoration of normal function.
COMPOSITION OF BLOOD

Blood is a type of connective tissue that consists of a liquid matrix containing cells and
cell fragments. The liquid matrix is the plasma, and the cells and cell fragments are
the formed elements. The plasma accounts for slightly more than half of the total blood
volume, and the formed elements account for slightly less than half. The total blood
volume in the average adult is about 4–5 liters (L) in females and 5–6 L in males. Blood
makes up about 8% of total body weight.

PLASMA

Plasma is a pale-yellow fluid that consists of about 91% water, 7% proteins, and 2% other
components, such as ions, nutrients, gases, waste products, and regulatory substances.
Unlike the fibrous proteins found in other connective tissues, such as loose connective
tissue, plasma contains dissolved proteins. Plasma proteins include albumin, globulins,
and fibrinogen. Albumin makes up 58% of the plasma proteins. Although the osmotic
pressure of blood results primarily from sodium chloride, albumin also makes an
important contribution. The water balance between the blood and the tissues is
determined by the movement of water into and out of the blood by osmosis. Globulins
account for 38% of the plasma proteins. Some globulins, such as antibodies and
complement, are part of the immune system. Other globulins and albumin function as
transport molecules because they bind to molecules, such as hormones, and carry them
in the blood throughout the body. Some globulins are clotting factors, which are
necessary for the formation of blood clots. Fibrinogen is a clotting factor that constitutes
4% of plasma proteins. Activation of clotting factors results in the conversion of
fibrinogen to fibrin, a threadlike protein that forms blood clots. Serum is plasma without
the clotting factors.

Plasma volume and composition remains relatively constant. Normally, water intake
through the digestive tract closely matches water loss through the kidneys, lungs,
digestive tract, and skin. Oxygen enters the blood in the lungs, and carbon dioxide
enters the blood from tissues. Other suspended or dissolved substances in the blood
come from the liver, kidneys, intestines, endocrine glands, and immune tissues, such as
the lymph nodes and spleen. The concentration of these substances in the blood is also
regulated and maintained within narrow limits.

Formed Elements
About 95% of the volume of the formed elements consists of red blood cells
(RBCs), orerythrocytes. The remaining 5% of the volume of the formed elements consists
of white blood cells (WBCs), or leukocytes, and cell fragments called platelets,
or thrombocytes. Redblood cells are 700 times more numerous than white blood cells
and 17 times more numerous than platelets. Table 11.2 illustrates the formed elements
of the blood.

Production of Formed Elements

The process of blood cell production is called hematopoiesis. In the fetus,
hematopoiesis occurs in several tissues, including the liver, thymus, spleen, lymph nodes,
and red bone marrow. After birth, hematopoiesis is confined primarily to red bone
marrow, but some white blood cells are produced in lymphatic tissues.

All the formed elements of blood are derived from a single population of cells
called stem cells, or hemocytoblasts. These stem cells differentiate to give rise to
different cell lines, each of which ends with the formation of a particular type of formed
element. The development of each cell line is regulated by specific growth factors. That
is, growth factors determine the types of formed elements derived from the stem cells
and how many formed elements are produced.

Red Blood Cells

Normal red blood cells are disk-shaped, with edges that are thicker than the center of
the cell. The biconcave shape increases the cell’s surface area compared to a flat disk of
the same size. The greater surface area makes it easier for gases to move into and out of
the red blood cell. In addition, the red blood cell can bend or fold around its thin center,
decreasing its size and enabling it to pass more easily through smaller blood vessels.

During their development, red blood cells lose their nuclei and most of their organelles.
Consequently, they are unable to divide. Red blood cells live for about 120 days in males
and 110 days in females. One-third of a red blood cell’s volume is the pigmented
protein haemoglobin, which is responsible for the cell’s red color.

Function

The primary functions of red blood cells are to transport oxygen from the lungs to the
various tissues of the body and to help transport carbon dioxide from the tissues to the
lungs. Oxygen transport is accomplished by hemoglobin, which consists of four protein
chains and four heme groups. Each protein, called a globin, is bound to one heme, a
red-pigmented molecule.

Each heme contains one iron atom, which is necessary for the normal function of
hemoglobin. Each iron in a heme molecule can reversibly bind to an oxygen molecule.
Hemoglobin picks up oxygen in the lungs and releases oxygen in other tissues.
Hemoglobin that is bound to oxygen is bright red, whereas hemoglobin without bound
oxygen is a darker red. Hemoglobin is responsible for 98.5% of the oxygen transported
in blood. The remaining 1.5% is transported dissolved in plasma.

Because iron is necessary for oxygen transport, it is not surprising that two-thirds of the
body’s iron is found in hemoglobin. Small amounts of iron are required in the diet to
replace the small amounts lost in the urine and feces, but otherwise the existing iron is
recycled, as described later in this section. Women need more dietary iron than men do
because women lose iron as a result of menstruation.

Although oxygen is the primary molecule that binds to hemoglobin, other molecules can
also bind to hemoglobin. Carbon monoxide, a gas produced by the incomplete
combustion of hydrocarbons, such as gasoline, is one example. It binds to the iron in
hemoglobin about 210 times more readily than does oxygen and does not tend to
unbind. As a result, the hemoglobin bound to carbon monoxide no longer transports
oxygen. Nausea, headache, unconsciousness, and death are possible consequences of
prolonged exposure to carbon monoxide.

Carbon dioxide is produced in tissues and transported in the blood to the lungs, where
it is removed from the blood. Carbon dioxide transport involves bicarbonate ions,
hemoglobin, and plasma. Approximately 70% of the carbon dioxide in blood is
transported in the form of bicarbonate ions. The enzyme carbonic anhydrase found
primarily inside red blood cells, catalyzes a reaction that converts carbon dioxide (CO 2)
and water (H2O) into a hydrogen ion (H+) and a bicarbonate ion (HCO3−):

CO2 + H2O < -- -- > H+ + HCO3−

Carbon dioxide can bind reversibly to the globin part of hemoglobin. About 23% of the
CO2 in blood is transported bound to hemoglobin or other blood proteins. The
remaining 7% of CO2 is transported dissolved in plasma.

Life History of Red Blood Cells

Under normal conditions, about 2.5 million red blood cells are destroyed every second.
Fortunately, new red blood cells are produced just as rapidly. Stem cells
form proerythroblasts, which give rise to the red blood cell line. Red blood cell
production involves a series of cell divisions. After each cell division, the new cells change
and become more like mature red blood cells. In the later divisions, the newly formed
cells manufacture large amounts of hemoglobin. After the final cell division, the cells lose
their nuclei and become completely mature red blood cells.

The process of cell division requires the B vitamins folate and B12, which are necessary
for the synthesis of DNA. Iron is required for the production of hemoglobin.
Consequently, a lack of folate, vitamin B12, or iron can interfere with normal red blood
cell production.

Red blood cell production is stimulated by low blood oxygen levels. Typical causes of
low blood oxygen are decreased numbers of red blood cells, decreased or defective
hemoglobin, diseases of the lungs, high altitude, inability of the cardiovascular system
to deliver blood to tissues, and increased tissue demand for oxygen, as occurs during
endurance exercises.
Low blood oxygen levels stimulate red blood cell production by increasing the formation
and release of the glycoprotein erythropoietin, primarily by the kidneys. Erythropoietin
stimulates red bone marrow to produce more red blood cells. Thus, when oxygen levels
in the blood decrease, the production of erythropoietin increases, which increases red
blood cell production. The greater number of red blood cells increases the blood’s ability
to transport oxygen. This negative-feedback mechanism increases the blood’s capacity
to transport oxygen and maintains homeostasis. Conversely, if blood oxygen levels rise,
less erythropoietin is released, and red blood cell production decreases.

When red blood cells become old, abnormal, or damaged, they are removed from the
blood by macrophages located in the spleen and liver. Within the macrophage, the
globin part of the hemoglobin molecule is broken down into amino acids that are reused
to produce other proteins. The iron released from heme is transported in the blood to
the red bone marrow and used to produce new hemoglobin. Thus, the iron is recycled.
The heme molecules are converted to bilirubin, a yellow pigment molecule. Bilirubin is
normally taken up by the liver and released into the small intestine as part of the bile. If
the liver is not functioning normally, or if the flow of bile from the liver to the small
intestine is hindered, bilirubin builds up in the circulation and produces jaundice,
a yellowish color to the skin. After it enters the intestine, bilirubin is converted by bacteria
into other pigments.

Some of these pigments give feces their brown color, whereas others are absorbed from
the intestine into the blood, modified by the kidneys, and excreted in the urine,
contributing to the characteristic yellow color of urine.

White Blood Cells

White blood cells are spherical cells that lack hemoglobin. When the components of
blood are separated from one another, whiteblood cells as well as platelets make up
the buffy coat, a thin, white layer of cells between plasma and red blood cells. White
blood cells are larger than red blood cells, and each has a nucleus. Although white blood
cells are components of the blood, the blood serves primarily as a means of transporting
these cells to other body tissues. White blood cells can leave the blood and travel
by ameboid movement through the tissues. In this process, the cell projects a
cytoplasmic extension that attaches to an object. Then the rest of the cell’s cytoplasm
flows into the extension. Two functions of white blood cells are (1) to protect the body
against invading microorganisms and other pathogens and (2) to remove dead cells and
debris from the tissues by phagocytosis.

Each white blood cell type is named according to its appearance in stained preparations.
Those containing large cytoplasmic granules are granulocytes, and those with very small
granules that cannot be seen easily with the light microscope are agranulocytes.

There are three kinds of granulocytes: neutrophils, basophils, and

eosinophils. Neutrophils, the most common type of white blood cells, have small
cytoplasmic granules that stain with both acidic and basic dyes. Their nuclei are
commonly lobed, with the number of lobes varying from two to four. Neutrophils usually
remain in the blood for a short time (10–12 hours), move into other tissues, and
phagocytize microorganisms and other foreign substances. Dead neutrophils, cell debris,
and fluid can accumulate as pus at sites of infections.

Basophils, the least common of all white blood cells, contain large cytoplasmic granules
that stain blue or purple with basic dyes. Basophils release histamine and other chemicals
that promote inflammation. They also release heparin, which prevents the formation of
clots.

Eosinophils contain cytoplasmic granules that stain bright red with eosin, an acidic stain.
They often have a two-lobed nucleus. Eosinophils are involved in inflammatory responses
associated with allergies and asthma. In addition, chemicals from eosinophils are
involved in destroying certain worm parasites.

There are two kinds of agranulocytes: lymphocytes and monocytes. Lymphocytes are
the smallest of the white blood cells. The lymphocytic cytoplasm consists of only a thin,
sometimes imperceptible ring around the nucleus. There are several types of
lymphocytes, and they play an important role in the body’s immune response. Their
diverse activities involve the production of antibodies and other chemicals that destroy
microorganisms, contribute to allergic reactions, reject grafts, control tumors, and
regulate the immune system.

Monocytes are the largest of the white blood cells. After they leave the blood and enter
tissues, monocytes enlarge and become macrophages, which phagocytize bacteria,
dead cells, cell fragments, and any other debris within the tissues. In addition,
macrophages can break down phagocytized foreign substances and present the
processed substances to lymphocytes, causing activation of the lymphocytes.

Platelets
Platelets are minute fragments of cells, each consisting of a small amount of cytoplasm
surrounded by a cell membrane. They are produced in the red bone marrow
from megakaryocytes, which are large cells. Small fragments of these cells break off and
enter the blood as platelets, which play an important role in preventing blood loss.

BLOOD LOSS

When a blood vessel is damaged, blood can leak into other tissues and interfere with
normal tissue function, or blood can be lost from the body. The body can tolerate a small
amount of blood loss and can produce new blood to replace it. But a large amount of
blood loss can lead to death. Fortunately, when a blood vessel is damaged, loss of blood
is minimized by three processes: vascular spasm, platelet plug formation, and blood
clotting.
Vascular Spasm
Vascular spasm is an immediate but temporary constriction of a blood vessel that results
when smooth muscle within the wall of the vessel contracts. This constriction can close
small vessels completely and stop the flow of blood through them. Damage to blood
vessels can activate nervous system reflexes that cause vascular spasm. Chemicals also
produce vascular spasm. For example, platelets release thromboxanes which are derived
from certain prostaglandins, and endothelial (epithelial) cells lining blood vessels release
the peptide endothelin.

Platelet Plug Formation

A platelet plug is an accumulation of platelets that can seal up a small break in a blood
vessel. Platelet plug formation is very important in maintaining the integrity of the blood
vessels of the cardiovascular system because small tears occur in the smaller vessels and
capillaries many times each day. People who lack the normal number of platelets tend
to develop numerous small hemorrhages in their skin and internal organs.

The formation of a platelet plug can be described as a series of steps, but in actuality
many of these steps occur at the same time. First, platelets stick to the collagen exposed
by blood vessel damage; this phenomenon is called platelet adhesion. Most platelet
adhesion is mediated through von Willebrand factor, a protein produced and secreted
by blood vessel endothelial cells. Von Willebrand factor forms a bridge between collagen
and platelets by binding to platelet surface receptors and collagen. After platelets adhere
to collagen, they become activated, change shape, and release chemicals.

In the platelet release reaction, platelets release chemicals, such as ADP and
thromboxane, which bind to their respective receptors on the surfaces of other platelets,
activating the platelets. These activated platelets also release ADP and thromboxane,
which activates more platelets. Thus, a cascade of chemical release activates many
platelets. This is an example of positive feedback. As platelets become activated, they
express surface receptors called fibrinogen receptors, which can bind to fibrinogen, a
plasma protein. In platelet aggregation, fibrinogen forms bridges between the
fibrinogen receptors of numerous platelets, resulting in a platelet plug

Blood Clotting
Blood vessel constriction and platelet plugs alone are not sufficient to close large tears
or cuts in blood vessels. When a blood vessel is severely damaged, blood
clotting, or coagulation, results in the formation of a clot. A clot is a network of
threadlike protein fibers, called fibrin, that traps blood cells, platelets, and fluid.

The formation of a blood clot depends on a number of proteins found within plasma,
called clotting factors. Though normally present in the plasma, the clotting factors are
inactive and do not cause clotting. Following injury, however, the clotting factors are
activated. Clot formation is a complex process involving many chemical reactions, but it
can be summarized in three stages.
1. The chemical reactions can be started in two ways: Inactive clotting factors come in
contact with exposed connective tissue, resulting in their activation, or chemicals, such
as thromboplastin, are released from injured tissues, causing activation of clotting
factors. After the initial clotting factors are activated, they in turn activate other clotting
factors. A series of reactions results in which each clotting factor activates the next until
the clotting factor prothrombinase, or prothrombin activator, is formed.

2. Prothrombinase converts an inactive clotting factor called prothrombin to its active

form, thrombin.

3. Thrombin converts the plasma protein fibrinogen to fibrin.

At each step of the clotting process, each clotting factor activates many additional
clotting factors, resulting in the formation of a clot

Most clotting factors are manufactured in the liver, and many of them require vitamin K
for their synthesis. In addition, many of the chemical reactions of clot formation require
Ca2+ and the chemicals released from platelets. The clotting process can be severely
impaired by low levels of vitamin K, low levels of Ca2+, low numbers of platelets, or
reduced synthesis of clotting factors because of liver dysfunction.

Humans rely on two sources of vitamin K. About half comes from the diet, and the other
half comes from bacteria within the large intestine. Antibiotics taken to fight bacterial
infections sometimes kill these intestinal bacteria, reducing vitamin K levels and causing
bleeding problems. Vitamin K supplements may be necessary for patients on prolonged
antibiotic therapy. Newborns lack these intestinal bacteria and thus routinely receive a
vita-min K injection at birth. Infants can also obtain vitamin K from food, such as milk.
Because cow’s milk contains more vitamin K than does human milk, breast-fed infants
are more susceptible to bleeding than are bottle-fed infants. However, maternal supple-
mentation with vitamin K, such as with oral vitamins, adequately elevates breast-fed
infant vitamin K levels and decreases the risk of bleeding.

Control of Clot Formation

Without control, clotting would spread from the point of its initiation throughout the
blood vessels. Fortunately, the blood contains several anticoagulants, which prevent
clotting factors from forming clots under normal conditions. For
example, antithrombin and heparin inactivate thrombin. Without thrombin, fibrinogen
is not converted to fibrin, and no clot forms. At an injury site, however, the activation of
clotting factors is very rapid. Enough clotting factors are activated that the anticoagulants
can no longer prevent a clot from forming. Away from the injury site, there are enough
anticoagulants to prevent clot formation from spreading.
Clot Retraction and Fibrinolysis

After a clot has formed, it begins to condense into a more compact structure through a
process known as clot retraction. Platelets contain the contractile proteins actin and
myosin, which operate in a fashion similar to that of the actin and myosin in muscle.
Platelets form small extensions that attach to fibrin through surface receptors.
Contraction of the extensions pulls on the fibrin and leads to clot retraction. During clot
retraction, serum, which is plasma without the clotting factors, is squeezed out of the
clot.

Retraction of the clot pulls the edges of the damaged blood vessel together, helping
stop the flow of blood, reducing the prob-ability of infection, and enhancing healing. The
vessel is repaired as fibroblasts move into the damaged area and new connective tissue
forms. In addition, epithelial cells around the wound divide and fill in the torn area.

Clots are dissolved by a process called fibrinolysis. An inactive plasma protein

called plasminogen is converted to its active form, plasmin. Thrombin, other clotting
factors activated during clot formation, and tissue plasminogen activator (t-
PA) released from surrounding tissues can stimulate the conversion of plasminogen to
plasmin. Over a few days, plasmin slowly breaks down the fibrin.

A heart attack can result when a clot blocks blood vessels that supply the heart. One
treatment for a heart attack is to inject certain chemicals into the blood that activate
plasmin. Unlike aspirin and anticoagulant therapies, which are used to prevent heart
attacks, plasmin activators quickly dissolve the clot and restore blood flow

BLOOD GROUPING
If large quantities of blood are lost during surgery or due to injury, a patient can go into
shock and die unless red blood cells are replaced to restore the blood’s oxygen-carrying
capacity. In this event, either a transfusion or an infusion is called for. A transfusion is
the transfer of blood or blood components from one individual to another.
An infusion is the introduction of a fluid other than blood, such as a saline or glucose
solution, into the blood. In many cases, the return of blood volume to normal levels is all
that is necessary to prevent shock. Eventually, the body produces enough red blood cells
to replace those that were lost.

Early attempts to transfuse blood were often unsuccessful because they resulted
in transfusion reactions, characterized by clumping or rupture of blood cells and
clotting within blood vessels. We now know that transfusion reactions are caused by
inter-actions between antigens and antibodies. In brief, the surfaces of red blood cells
have molecules called antigens, and the plasma includes proteins called antibodies.
Antibodies are very specific, meaning that each antibody can bind only to a certain
antigen. When the antibodies in the plasma bind to the antigens on the surface of the
red blood cells, they form molecular bridges that connect the red blood cells together.
As a result, agglutination or clumping of the cells, occurs. The combination of the
antibodies with the antigens can also initiate reactions that cause hemolysis, or rupture
of the red blood cells. The debris formed from the ruptured red blood cells can cause
severe tissue damage, particularly in the kidneys. Hemoglobin released from lysed red
blood cells can damage kidney tissue, reducing its blood-filtering ability. If the damage
is extensive, the lack of kidney function could result in death.

The antigens on the surface of red blood cells have been categorized into blood
groups. Although many blood groups are recognized, the ABO and Rh blood groups are
the most important when discussing transfusion reactions.

ABO Blood Group

• The ABO blood group system is used to categorize human blood. In this blood
group system, there are two types of antigens that may appear on the surface of
the red blood cells, type A antigen and type B antigen. Type A blood has type A
antigens, type B blood has type B antigens, and type AB blood has both types of
antigens. Type O blood has neither A nor B antigens. Antibodies against the
antigens are usually present in the plasma of blood. Plasma from type A blood
contains anti-B antibodies, which act against type B antigens; plasma from type B
blood contains anti-A antibodies, which act against type A antigens. Type AB blood
plasma has neither type of antibody, and type O blood plasma has both anti-A and
anti-B antibodies.
• The ABO blood types do not exist in equal numbers. In caucasians in the United
States, the distribution is type O, 47%; type A, 41%; type B, 9%; and type AB, 3%.
Among African-Americans, the distribution is type O, 46%; type A, 27%; type B,
20%; and type AB, 7%.
• Normally, antibodies do not develop against an antigen unless the body is exposed
to that antigen; however, the anti-A and/or anti-B antibodies are present in the
blood even without exposure to antigens on foreign red blood cells. One possible
explanation for the production of anti-A and/or anti-B antibodies is that type A or
B antigens on bacteria or food in the digestive tract stimulate the formation of
antibodies against antigens that are different from the body’s own antigens. In
support of this explanation, anti-A and anti-B antibodies are not found in the blood
until about 2 months after birth. It is possible that an infant with type A blood
would produce anti-B antibodies against the B antigens on bacteria or food.
Meanwhile, an infant with A antigens would not produce antibodies against the A
antigens on bacteria or food because mechanisms exist in the body to prevent the
production of antibodies that would react with the body’s own antigens.
• When a blood transfusion is performed, the donor is the per-son who gives blood,
and the recipient is the person who receives it. Usually, a recipient can successfully
receive blood from a donor as long as they both have the same blood type. For
example, a per-son with type A blood can receive blood from a person with type
A blood. No ABO transfusion reaction occurs because the recipient has no anti-A
antibodies against the type A antigen. On the other hand, if type A blood were
donated to a person with type B blood, a transfusion reaction would occur because
the person with type B blood has anti-A antibodies against the type A antigen,
causing agglutination.
 • Historically, people with type O blood have been called universal donors because
they can usually give blood to the other ABO blood types without causing an ABO
transfusion reaction. Their red blood cells have no ABO surface antigens and
therefore do not react with the recipient’s anti-A or anti-B antibodies. For example,
if a person with type A blood receives type O blood, the type O red blood cells do
not react with the anti-B antibodies in the recipient’s blood.

However, the term universal donor is misleading. Transfusion of type O blood can still
produce a transfusion reaction in one of two ways: First, mismatching blood groups other
than the ABO blood group can cause a transfusion reaction. To reduce the likelihood of
a transfusion reaction, all the blood groups must be correctly matched. Second,
antibodies in the donor’s blood can react with antigens on the recipient’s red blood cells.
For example, type O blood has anti-A and anti-B antibodies. If type O blood is trans-
fused into a person with type A blood, the anti-A antibodies (in the type O donor blood)
react against the A antigens (on the red blood cells in the type A recipient blood). Usually,
such reactions are not serious because the antibodies in the donor’s blood are diluted in
the large volume of the recipient’s blood. Even though such transfusion reactions seldom
occur, type O blood is given to a person with another blood type only in life-or-death
situations

Rh Blood Group
Another important blood group is the Rh blood group, so named because it was first
studied in the rhesus monkey. People are Rh-positive if they have certain Rh antigens on
the surface of their red blood cells, and they are Rh-negative if they do not have these
Rh antigens. About 85% of caucasians and 95% of African-Americans are Rh-positive.
The ABO blood type and the Rh blood type are usually expressed together. For example,
a person designated as type A in the ABO blood group and Rh-positive is said to be A-
positive. The rarest combination in the United States is AB-negative, which occurs in less
than 1% of the population.

Antibodies against the Rh antigens do not develop unless an Rh-negative person is

exposed to Rh-positive red blood cells. This can occur through a transfusion or by the
transfer of blood across the placenta to a mother from her fetus. When an Rh-negative
person receives a transfusion of Rh-positive blood, the recipient becomes sensitized to
the Rh antigens and produces anti-Rh antibodies. If the Rh-negative person is
unfortunate enough to receive a second transfusion of Rh-positive blood after becoming
sensitized, a transfusion reaction results.

Rh incompatibility can pose a major problem in a pregnancy when the mother is Rh-
negative and the fetus is Rh-positive. If fetal blood leaks through the placenta and mixes
with the mother’s blood, the mother becomes sensitized to the Rh antigen. The mother
pro-duces anti-Rh antibodies that cross the placenta and cause agglutination and
hemolysis of fetal red blood cells. This disorder is called hemolytic disease of the
newborn (HDN), orerythroblastosis fetalis. In the mother’s first pregnancy, there is often
no problem. The leakage of fetal blood is usually the result of a tear in the placenta that
takes place either late in the pregnancy or during delivery. Thus, there is not sufficient
time for the mother to produce enough anti-Rh anti-bodies to harm the fetus. In later
pregnancies, however, a problem can arise because the mother has been sensitized to
the Rh antigen. Consequently, if the fetus is Rh-positive and if any fetal blood leaks into
the mother’s blood, she rapidly produces large amounts of anti-Rh antibodies, which can
cross the placenta to the fetus, result-ing in HDN. Because HDN can be fatal to the fetus,
the levels of anti-Rh antibodies in the mother’s blood should be monitored. If they
increase to unacceptable levels, the fetus should be tested to determine the severity of
the HDN. In severe cases, a transfusion to replace lost red blood cells can be performed
through the umbilical cord, or the baby can be delivered if mature enough.

Prevention of HDN is often possible if the Rh-negative mother is injected with a specific
preparation called Rho(D) immune globulin (RhoGAM), which contains antibodies
against Rh antigens. The injection can be given during the pregnancy, before delivery,
or immediately after each delivery, miscarriage, or abortion. The injected antibodies
bind to the Rh antigens of any fetal red blood cells that may have entered the mother’s
blood. This treatment inactivates the fetal Rh antigens and prevents sensitization of the
mother.

DIAGNOSTIC BLOOD TESTS

Type and Crossmatch

To prevent transfusion reactions, the blood must be typed. Blood typing determines the
ABO and Rh blood groups of a blood sample. Typically, the cells are separated from the
serum and then tested with known antibodies to determine the type of antigen on the
cell surface. For example, if a patient’s blood cells agglutinate when mixed with anti-A
antibodies but do not agglutinate when mixed with anti-B antibodies, the cells have type
A antigen. In a similar fashion, the serum is mixed with known cell types (anti-gens) to
determine the type of antibodies in the serum.

Normally, donor blood must match the ABO and Rh type of the recipient. However,
because other blood groups can cause a transfusion reaction, a crossmatch is performed.
In a crossmatch, the donor’s blood cells are mixed with the recipient’s serum, and the
donor’s serum is mixed with the recipient’s cells.

Complete Blood Count

A complete blood count (CBC) is an analysis of blood that provides much useful
information. A CBC consists of a red blood cell count, hemoglobin and hematocrit
measurements, and a white blood cell count.
Red Blood Count

Blood cell counts are usually performed electronically with a machine, but they can also
be done manually with a microscope. A normal red blood count (RBC) for a male is 4.6–
6.2 million red blood cells per microliter (μL) of blood; for a female, a nor-mal RBC count
is 4.2–5.4 million per μL of blood. (A microliter is equivalent to 1 cubic millimeter [mm3]
or 10−6 L, and one drop of blood is approximately 50 μL). The condition
called erythrocytosis is an overabundance of red blood cells.

Hemoglobin Measurement

The amount of hemoglobin in a given volume of blood is usually expressed in terms of

grams of hemoglobin per 100 mL of blood. The normal hemoglobin measurement for a
male is 14–18 grams(g) per 100 mL of blood, and for a female 12–16 g per 100 mL of
blood. An abnormally low hemoglobin measurement is an indication of anemia, which
is either a reduced number of red blood cells or a reduced amount of hemoglobin in
each red blood cell.

Hematocrit Measurement

The percentage of the total blood volume that is composed of red blood cells is
the haematocrit. One way to determine hematocrit is to place blood in a capillary tube
and spin it in a centrifuge. The formed elements, which are heavier than the plasma, are
forced to one end of the tube. Of these, the white blood cells and platelets form the
buffy coat between the plasma and the red blood cells. The red blood cells account for
40–52% of the total blood volume in males and 38–48% in females. The hematocrit
measurement is affected by the number and size of red blood cells because it is based
on volume. For example, a decreased hematocrit can result from a decreased number of
normal-size red blood cells or a normal number of small red blood cells. The average
size of a red blood cell is calculated by dividing the hematocrit by the red blood cell
count. A number of disorders cause red blood cells to be smaller or larger than normal.
For example, inadequate iron in the diet can impair hemoglobin production.
Consequently, red blood cells do not fill up with hemoglobin during their formation, and
they remain smaller than normal.

White Blood Count

A white blood count (WBC) measures the total number of white blood cells in the
blood. There are normally 5000–9000 white blood cells per microliter of
blood. Leukopenia is a lower than normal WBC resulting from decreased production or
destruction of the red marrow. Radiation, drugs, tumors, viral infections, or a deficiency
of the vitamins folate or B12 can cause leukopenia. Leukocytosis is an abnormally high
WBC. Bacterial infections often cause leukocytosis by stimulating neutrophils to increase
in number. Leukemia, a cancer of the red marrow characterized by abnormal production
of one or more of the white blood cell types, can cause leukocytosis. However, the white
blood cells do not function normally. Because these cells are usually immature or
abnormal and lack normal immunological functions, people with leukemia are very
susceptible to infections. The excess production of white blood cells in the red marrow
can also interfere with the formation of red blood cells and platelets and thus lead to
anemia and bleeding.

Differential White Blood Count

A differential white blood count determines the percentage of each of the five kinds
of white blood cells. Normally, neutrophils account for 60–70%, lymphocytes 20–25%,
monocytes 3–8%, eosinophils 2–4%, and basophils 0.5–1% of all white blood cells. Much
insight into a patient’s condition can be obtained from a differential white blood count.
For example, if a bacterial infection is present, the neutrophil count is often greatly
increased, whereas in allergic reactions, the eosinophil and basophil counts are elevated.

Clotting
The blood’s ability to clot can be assessed by the platelet count and the prothrombin
time measurement.

Platelet Count

A normal platelet count is 250,000–400,000 platelets per microliter of blood. In the

condition called thrombocytopenia, the platelet count is greatly reduced, resulting in
chronic bleeding through small vessels and capillaries. It can be caused by decreased
platelet production as a result of hereditary disorders, lack of vitamin B 12 (pernicious
anemia), drug therapy, or radiation therapy.

Prothrombin Time Measurement

Prothrombin time measurement calculates how long it takes for the blood to start
clotting, which is normally 9–12 seconds. Prothrombin time is determined by adding
thromboplastin to whole plasma. Thromboplastin is a chemical released from injured
tissues that starts the process of clotting. Prothrombin time is officially reported as the
International Normalized Ratio (INR), which standardizes the time it takes to clot on the
basis of the slightly different thromboplastins used by different labs. Because many
clotting factors have to be activated to form fibrin, a deficiency of any one of them can
cause the prothrombin time to be abnormal. Vitamin K deficiency, certain liver diseases,
and drug therapy can increase prothrombin time.

Blood Chemistry
The composition of materials dissolved or suspended in the plasma can be used to assess
the functioning of many of the body’s systems. For example, high blood glucose levels
can indicate that the pancreas is not producing enough insulin; high blood urea nitrogen
(BUN) is a sign of reduced kidney function; increased bilirubin can indicate liver
dysfunction; and high cholesterol levels can signify an increased risk of cardiovascular
disease. A number of blood chemistry tests are routinely done when a blood sample is
taken, and additional tests are available.