MLS 113A LESSON | 01

HEMATOLOGY Lecture | AJDC | Batch 2024

HEMATOPOIESIS
• Hematopoiesis reaches its peak by the third month of fetal development,
HEMATOPIESIS then gradually declines after the sixth month, retaining minimal activity until
• a term derived from two Greek words:
1 to 2 weeks after birth.
haima blood • The thymus, the first fully developed organ in the fetus, becomes the
poiēsis to produce something major site of T cell production, whereas the kidney and spleen produce
• a continuous, regulated process of blood cell production that includes:
B cells.
o Cell renewal
o Proliferation thymus major site of T cell production
o Differentiation kidney and spleen produce B cells
o Maturation
3. MEDULLARY (MYELOID) PHASE
WHERE IT OCCURS • Prior to the fifth month of fetal development, hematopoiesis occurs in
Healthy Adults Fetus the medulla or inner part of the bone.
Mesoblastic yolk sac to aorta - gonad • myeloid activity is apparent

Phase mesonephros (AGM) region) • myeloid-to-erythroid ratio gradually approaches 3:1 (adult levels)
bone marrow
Hepatic phase Liver Myeloid WBC
Medullary phase bone marrow Erythroid RBC

1. MESOBLASTIC PHASE • by the end of 24 weeks’ gestation, the bone marrow becomes the
• Mesoblast (meso-blast): The mesoblast is the middle germ layer of an primary site of hematopoiesis.
early embryo. It contains cells that will develop into the mesoderm. • measurable levels of the following are seen:
• Hematopoiesis is considered to begin around the nineteenth day of
o erythropoietin (EPO)
embryonic development after fertilization. Early in embryonic o granulocyte colony-stimulating factor (G-CSF)
development, cells from the o granulocyte-macrophage colony-stimulating factor (GM-CSF)
mesoderm migrate to the yolk sac. o hemoglobins F
• Some of these cells form primitive
o Hemoglobin A
erythroblasts in the central cavity of the
yolk sac, while the others (angioblasts) • Cells at various stages of maturation can be seen in all blood cell
surround the cavity of the yolk sac and yolk sac lineages.
eventually form blood vessels.

• Erythroblasts – important in early embryogenesis to produce

hemoglobin needed for delivery of oxygen to rapidly developing
embryonic tissues.
• Cells of mesodermal origin also migrate to the aorta-gonad-

mesonephros (AGM) region and give rise to hematopoietic stem cells

(HSCs) for definitive or permanent adult hematopoiesis.
The site of hematopoiesis (niche) changes over developmental time

Fetal
Blood islands of Medullary hematopoiesis
hematopoiesis
hematopoiesis of or myelopoiesis setting
moves to liver,
AGM axially (pelvis, vertebrae)
spleen

ADULT HEMATOPOIESIS
2. HEPATIC PHASE
Adult hematopoietic tissue
• begins at 5 to 7 gestational weeks
Hematopoietic tissue:
• recognizable clusters of developing erythroblasts, granulocytes, and
• Bone marrow – erythroid, myeloid, megakaryocytic and lymphoid cells
monocytes colonizing the fetal liver, thymus, spleen, placenta, and
• Lymph nodes
ultimately the bone marrow space.
• Spleen
• lymphoid cells begin to appear.
• Liver
• liver is the major site of hematopoiesis during the second trimester of fetal

life. • Thymus

• production of megakaryocytes.

• fetal hemoglobin (Hb F) is the predominant hemoglobin, but detectable

levels of adult hemoglobin (Hb A) may be present.

 MLS 113A LESSON | 01
HEMATOLOGY Lecture | AJDC | Batch 2024

LYMPHOID DEVELOPMENT
• occurs in primary and secondary lymphoid tissue.
• Primary lymphoid tissue consists of the bone marrow and thymus and

is where T and B lymphocytes are derived.

• Secondary lymphoid tissue, where lymphoid cells respond to foreign

antigens, consists of the spleen, lymph nodes, and mucosa-associated

lymphoid tissue (Peyer’s patches).

Primary lymphoid
bone marrow and thymus
tissue
Secondary lymphoid spleen, lymph nodes, and mucosa-
tissue associated lymphoid tissue
LIVER
BONE MARROW • major site of blood cell production during the second trimester of fetal
• Resorption of cartilage and endosteal bone creates a central space development.
within the bone. Projections of calcified bone, called trabeculae, radiate • Hepatocytes functions:

out from the bone cortex into the central space, forming a three- 1. Protein synthesis and degradation
dimensional matrix resembling a 2. Coagulation factor synthesis
honeycomb. The trabeculae provide 3. Carbohydrate and lipid metabolism
structural support for the developing 4. Drug and toxin clearance
blood cells. Spaces in between 5. Iron recycling and storage
houses precursor RBC cells 6. Hemoglobin degradation
• One of the largest organs in the body
SPLEEN
• located within the cavities of the
• The largest lymphoid organ in the body.
cortical bones
• Located directly beneath the diaphragm behind the fundus of the

• Normal bone marrow contains two major components: stomach in the upper left quadrant of the
Red hematopoietically active marrow consisting of the abdomen.
marrow developing blood cells and their progenitors • Vital but not essential for life.

hematopoietically inactive marrow composed • Functions as an indiscriminate filter of the

Yellow primarily of adipocytes (fat cells), with circulating blood.

marrow undifferentiated mesenchymal cells and • Contains about 350 ml of blood.

macrophages.
• The spleen uses two methods for removing senescent or abnormal
• Infancy and early childhood – primarily red (active) marrow.
RBCs from the circulation:
• Between 5 and 7 years of age – adipocytes become more abundant
the cells are phagocytized with subsequent
and begin to occupy the spaces in the long bones previously dominated Culling
degradation of cell organelles
by active marrow.
splenic macrophages remove inclusions or damaged
Pitting
surface membrane from the circulating RBCs
• The process of replacing the active marrow by adipocytes (yellow
marrow) during development is called retrogression and eventually • The spleen also serves as a storage site for platelets.
results in restriction of the active marrow in the adult to the sternum, • In a healthy individual, approximately 30% of the total platelet count is
vertebrae, scapulae, pelvis, ribs, skull, and proximal portion of the long sequestered in the spleen.
bones.
LYMPH NODES
• located along the lymphatic capillaries that
HEMATOPOIETIC MARROW
parallel, but are not part of, the circulatory
• Ca. 5% of body weight system.
• bean-shaped structures (1 to 5 mm in
• Red – active, all red at birth, in adults, flat
diameter) that occur in groups or chains at
bones, especially pelvis, are major red marrow
various intervals along lymphatic vessels
sites
They may be:
• Yellow – inactive & fatty, excludes most
• Superficial Deep
hematopoietic cells, in events of severe
1. Inguinal 1. Mesenteric
hypoxia, blood loss, yellow can turn back to red
2. Axillary 2. Retroperitoneal
3. Cervical
• Adults - inactive yellow marrow is scattered throughout the red marrow 4. Supratrochlear
so that in adults, there is approximately equal amounts of red and
yellow marrow in these areas. THYMUS
o Yellow marrow is capable of reverting back to active marrow in cases • In adults, T cell progenitors migrate to the thymus from the bone marrow
of increased demand on the bone marrow, such as in excessive for further maturation.
blood loss or hemolysis.

Changes in cellularity can indicate disease

 MLS 113A LESSON | 01
HEMATOLOGY Lecture | AJDC | Batch 2024

• Originally there were two theories describing the origin of hematopoietic

JAMES TILL AND ERNEST MCCULLOCH
• The landmark studies of McCulloch and
Till in the 1960s defined the hallmark
properties of stem cells: the ability to self-
renew and differentiate.
• Working with mouse bone marrow cells,
progenitor cells.
1. The monophyletic theory suggests that all blood cells are derived
from a single progenitor stem cell called a pluripotent
hematopoietic stem cell.
2. The polyphyletic theory suggests that each of the blood cell
lineages is derived from its own unique stem cell.

McCulloch and Till developed an assay The monophyletic theory is the most widely accepted theory among
to quantitate a class of early blood-forming progenitor cells and to experimental hematologists today.
define the potential of these cells both to self-renew and to undergo
extensive differentiation into many different blood cell types.
• In 1961, Till and McCulloch conducted a series of experiments in which

they irradiated spleens and bone marrow of mice, creating a state of

aplasia.
• These aplastic mice were given an intravenous injection of marrow

cells.
• Colonies of HSCs were seen 7 to 8 days later in the spleens of the

irradiated (recipient) mice. These colonies were called colony-forming

units–spleen (CFU-S).
• These investigators later showed that these colonies were capable of

self-renewal and the production of differentiated progeny.

• The CFU-S represents what we now refer to as committed myeloid

progenitors or colony-forming unit–granulocyte, erythrocyte,

monocyte, and megakar yocyte (CFU-GEMM). These cells are
capable of giving rise to multiple lineages of blood cells.

• Morphologically unrecognizable hematopoietic progenitor cells

can be divided into two major types:
1. Noncommitted or undifferentiated hematopoietic stem cells
2. Committed progenitor cells
 MLS 113A LESSON | 01
HEMATOLOGY Lecture | AJDC | Batch 2024
• A group of scientists began calling some of the cytokines interleukins,
FACTORS THAT REGULATE HEMATOPOIESIS numbering them in the order in which they were identified (e.g., IL-1, IL-
2). Characteristics shared by interleukins include the following:
CYTOKINES AND GROWTH FACTORS o They are proteins that exhibit multiple biologic activities, such as the
• A group of specific glycoproteins called hematopoietic growth factors regulation of autoimmune and inflammatory reactions and
or cytokines regulate the proliferation, differentiation, and maturation hematopoiesis. *cytokine storm
of hematopoietic precursor cells. o They have synergistic interactions with other cytokines.
• Cytokines are a diverse group of soluble proteins that have direct and o They are part of interacting systems with amplification potential.
indirect effects on hematopoietic cells. o They are effective at very low concentrations.
• The terms cytokine and growth factor are often used synonymously;

cytokines include: SOME TERMINOLOGY

o Interleukins (ILs) • Multipotent hematopoietic stem cell, which gives rise to all blood
o Lymphokines cells, is usually called 'HSC’
o Monokines HSC Hematopoietic Stem Cell
o Interferons CFU-S Colony Forming Unit- Spleen
o Chemokines
o colony-stimulating factors (CSFs). • Some progenitors derived from the HSC
o GEMM, Common Myeloid Progenitor
• Many of these cytokines exert a positive influence on hematopoietic ▪ gives rise to Granulocytes, Erythrocytes, Monocytes and
stem cells and progenitor cells with multilineage potential: Megakaryocytes
1. KIT ligand ▪ GEMM gives rise to Colony Forming Units, CFUS Lymphoid stem
2. FLT3 ligand cell,
3. GM-CSF
4. IL-1 o Common Lymphoid Progenitor: gives rise to B and T lymphocytes
5. IL-3
6. IL-6 • Signaling – control of a discontinuous tissue
7. IL-11 diverse set of protein hormones, generally
Cytokines involved in immune system activities and
• Cytokines that exert a negative influence on hematopoiesis include: hematopoiesis
1. Transforming Growth Factor-β Colony stimulating factors, are cytokines involved
in hematopoiesis
2. Tumor Necrosis Factor-α CSFs
Growth factors, erythropoietin and
3. Interferons thrombopoietin.
• Cytokines are responsible for:
o stimulation or inhibition of production
o Differentiation into various cell lineages
o trafficking of mature blood cells and their precursors.
o growth and survival of hematopoietic progenitor cells.
o prevent hematopoietic precursor cells from dying by inhibiting
apoptosis.
o stimulate hematopoietic precursor cells to divide by decreasing the
transit time from G0 to G1 of the cell cycle.

• When cells do not receive the appropriate cytokines necessary to

prevent cell death, apoptosis is initiated. In some disease states,
apoptosis is “turned on,” which results in early cell death, whereas in
other states apoptosis is inhibited, which allows uncontrolled
proliferation of cells.

COLONY-STIMULATING FACTORS
• CSFs are produced by many different cells. They have a high specificity

for their target cells and are active at low concentrations. The names of References: • Rodak, B. F., Fritsma, G. A., & Keohane, E. M. (2012).
the individual factors indicate the predominant cell lines that respond to Hematology: Clinical principles and applications (4th ed.). St. Louis, Mo.:
their presence. Elsevier Saunders. • Steensma DP, Kyle RA. James Till and Ernest
o CSF-G = Granulocytes McCulloch: Hematopoietic Stem Cell Discoverers. Mayo Clin Proc. 2021
o CSF-MEG = Megakaryocyte Mar;96(3):830-831. doi: 10.1016/j.mayocp.2021.01.016. PMID:
33673940.
INTERLEUKINS
• Interleukins (IL) are a group of naturally occurring proteins(cytokines)

that mediate communication between cells.

• originally were named according to their specific function, such as

lymphocyte-activating factor (now called IL-1), but continued research

showed that a particular cytokine may have multiple actions.
 MLS 113A LESSON | 01
HEMATOLOGY Lecture | AJDC | Batch 2024
ERYTHROKINETICS
ERYTHROKINETICS ERYTHROPOIETIN
• Erythrokinetics is the term describing the dynamics of RBC production STRUCTURE
and destruction. • EPO is a thermostable, nondialyzable, glycoprotein hormone with a

• Erythron is the name given to the collection of all stages of erythrocytes molecular weigt of 34 kD. It consists of a carbohydrate unit that reacts
throughout the body: the developing precursors in the bone marrow and specifically with RBC receptors and a terminal sialic acid unit, which is
the circulating erythrocytes in the peripheral blood and the vascular necessary for biological activity in vivo.
spaces within specific organs such as the spleen. When the term
erythron is used, it conveys the concept of a unified functional tissue.
• The erythron is distinguished from the RBC mass. The erythron is the

entirety of erythroid cells in the body, whereas the RBC mass refers
only to the cells in circulation.
ACTION.
1. EPO is a true hormone, being produced at one location (the kidney)
HYPOXIA
and acting at a distant location (the bone marrow).
• the stimulus to red blood cell production
• The primary oxygen-sensing system of the body is located in
2. It is a growth factor (or cytokine) that initiates an intracellular
peritubular fibroblasts of the kidney.
message to the developing RBCs; this process is called signal
• Hypoxia, too little tissue oxygen, is detected by the peritubular cells,
transduction.
which produce erythropoietin (EPO), the major stimulatory cytokine
for RBCs.
3. EPO must bind to its receptor on the surface of cells to initiate the
• Under normal circumstances, the amount of EPO produced fluctuates
signal or message. The receptor is a transmembrane homodimer
very little, maintaining a level of RBC production that is sufficient to
consisting of two identical polypeptide chains.
replace the approximately 1% of RBCs that normally die each day.
When there is hemorrhage, increased RBC destruction, or other factors
that diminish the oxygen-carrying capacity of the blood, the production
of EPO is increased.

• (1) Decreased RBC number, however, is only one cause of hypoxia.

Another cause is the failure of each RBC to carry as much oxygen
as it should (2). This can occur because the hemoglobin is defective
or because there is not enough hemoglobin in each cell.
• The hypoxia may be unrelated to the RBCs in any way; (3) poor lung Sensitive developing RBCs will hurry in maturation in cases of:
function resulting in diminished oxygenation of existing RBCs is an *hypoxia
example. *anemia
• An elevation of RBC numbers above the reference interval, *bleeding
erythrocytosis, is seen in conditions such as lung disease and cardiac *hemolysis
disease in which the blood is not being well oxygenated.
• Newborns have higher numbers of RBCs because the fetal

hemoglobin in their cells does not unload oxygen to the tissues readily,
so newborns are slightly hypoxic compared with adults. To
compensate, they make more RBCs.
• Hypoxia increases EPO production in peritubular cells mainly by
transcriptional regulation. The EPO gene has a hypoxia-sensitive
region (enhancer) in its 3′ regulatory component. When oxygen tension
in the cell decreases, hypoxia-inducible factor-1, a transcription
factor, is assembled in the cytoplasm, migrates to the nucleus, and
interacts with the 3′ enhancer of the gene. This results in transcription • The binding of EPO, the ligand, to its receptor on erythrocyte
of more EPO messenger RNA molecules, and production of more EPO. progenitors initiates a cascade of intracellular events (“the program”)
that ultimately leads to cell division, maturation, and more red blood
cells entering the circulation.

• EPO’s effects are mediated by Janus-activated tyrosine kinase 2

(JAK2) signal transducers that are associated with the cytoplasmic
domain of the EPO receptor and ultimately affect gene expression in
the RBC nucleus.
o Problem in JAK2, cell production (polycythemia, thrombocytopenia,
leukemia)
 MLS 113A LESSON | 01
HEMATOLOGY Lecture | AJDC | Batch 2024

EPO has three major effects: PROCESS OF APOPTOSIS

1. allowing early release of reticulocytes from the bone marrow • Apoptosis is a sequential process characterized by, among other things, the

-maturing RBCs (reticulocytes)/young degradation of chromatin into fragments of varying size that are multiples of
2. preventing apoptotic cell death (programmed cell death) 180 to 185 base pairs long; protein clustering; and activation of
3. reducing the time needed for cells to mature in the bone marrow. transglutamase. This is in
contrast to necrosis, in which cell
The essence is that EPO puts more RBCs into the circulation at a faster rate injury causes swelling and lysing
than occurs without its stimulation. with release of cytoplasmic
contents that stimulate an
1. EARLY RELEASE OF RETICULOCYTES inflammatory response.
• EPO promotes early release of developing Apoptosis is not associated with
erythroid precursors from the marrow by two inflammation.
mechanisms:
Ribosomal RNA • During the sequential process of
fragments apoptosis, the following morphologic changes can be seen:
1. EPO induces changes in the adventitial cell layer of the marrow/sinus o condensation of the nucleus, causing increased basophilic staining of the
barrier that increase the width of the spaces for RBC egress into the chromatin;
sinus. o nucleolar disintegration
o shrinkage of cell volume with concomitant increase in cell density and
2. RBCs are held in the marrow because they express surface membrane compaction of cytoplasmic organelles, while mitochondria remain
receptors for adhesive molecules located on the bone marrow stroma. normal.
-EPO downregulates the expression of these receptors so that cells can o partition of cytoplasm and nucleus into membrane-bound apoptotic
exit the marrow earlier than they normally would. bodies that contain varying amounts of ribosomes, organelles, and
nuclear material.
• The result is the presence in the circulation of reticulocytes that are still very o The last stage of degradation produces nuclear DNA fragments
basophilic because they have not spent as much time degrading their consisting of multimers of 180 to 185 base pair segments.
ribosomes or making hemoglobin as they o Characteristic blebbing of the plasma membrane is observed.
• The apoptotic cell contents remain membrane-bound and are ingested by
normally would before entering the
bloodstream. These are called shift macrophages, which prevents an inflammatory reaction. The membrane-
reticulocytes because they have been bound vesicles display so-called “eat me” signals on the membrane surface
shifted from the bone marrow early. Their that promote macrophage ingestion.
bluish cytoplasm with Wright stain is
evident, so the overall blood picture is said
to have polychromasia.
Supravital stain – test for reticulocyte
• Even nucleated RBCs (i.e., normoblasts) can be released early in cases
of extreme anemia when the demand for RBCs in the peripheral circulation
is great

2. INHIBITION OF APOPTOSIS
• A second, and probably more important, mechanism by which EPO
increases the number of circulating RBCs is by increasing the number of
cells that will be able to mature into circulating erythrocytes. It does this by
decreasing apoptosis, the programmed death of RBC progenitors.
• CFU-E = RBC
APOPTOSIS: PROGRAMMED CELL DEATH 3. EVASION OF APOPTOSIS BY ERYTHROID PROGENITORS
• As noted previously, it takes about 18 to 21 days to produce an RBC from AND PRECURSORS.
stimulation of the earliest erythroid progenitor (BFU-E) to release from the • One effect of EPO is an indirect avoidance of apoptosis by removing an

bone marrow. In times of increased need for RBCs, such as when there is apoptosis induction signal.
loss from the circulation during hemorrhage, this time lag would be a • Among the crucial molecules in the external messaging system is the death

significant problem. One way to prepare for such a need would be to receptor Fas on the membrane of the earliest RBC precursors, while its
maintain a store of mature RBCs in the body for emergencies. RBCs cannot ligand, FasL, is expressed by more mature RBCs.
be stored in the body for this sort of eventuality, however, because they Young
Fas Pronormoblast, Basophilic normoblast
have a limited life span. Therefore, instead of storing mature cells for RBCs
emergencies, the body produces more CFU-Es than needed at all times. more mature Polychromatic normoblast,
When there is a basal or steady-state demand for RBCs, the extra
FasL
RBCs orthochromatic normoblast
progenitors are allowed to die. When there is an increased demand for
RBCs, however, the RBC progenitors have about an 8- to 10-day head start Fas + FasL = apoptosis (of the younger cell)
in the production process. This process of intentional wastage of cells • When EPO levels are low, cell production should be at a low rate because
occurs by apoptosis, and it is part of the cell’s genetic program.
hypoxia is not present. The excess early erythroid precursors should
undergo apoptosis. This occurs when the older FasL-bearing erythroid
precursors, such as polychromatic normoblasts, cross-link with Fas-marked
immature erythroid precursors, such as pronormoblasts and basophilic
normoblasts, which are then stimulated to undergo apoptosis.
 MLS 113A LESSON | 01
HEMATOLOGY Lecture | AJDC | Batch 2024
REDUCED MARROW TRANSIT TIME.
• Apoptosis rescue is the major way in which EPO increases RBC
mass—by increasing the number of erythroid cells that survive and
mature to enter the circulation. Another effect of EPO is to increase the
rate at which the surviving precursors can enter the circulation. This is
accomplished by two means: increased rate of cellular processes
and decreased cell cycle times.
• Among the processes that are accelerated is hemoglobin production
(1). As mentioned earlier, another accelerated process is bone marrow
egress with the loss of adhesive receptors and the acquisition of
egress-promoting surface molecules.

• The other process that is accelerated is the

cessation of division (2). Cell division
takes time and would delay entry of cells to
the circulation, so cells enter cell cycle
arrest sooner. As a result, the cells spend
less time maturing in the marrow.
• EPO also can reduce the time it takes for cells to mature in the marrow
by reducing individual cell cycle time, specifically the length of time that
• As long as the more mature cells with FasL are present in the marrow, cells spend between mitoses.
erythropoiesis is subdued. If the FasL- bearing cells are depleted, as • With the decreased cell cycle time and fewer mitotic divisions, the time
when EPO stimulates early marrow it takes from pronormoblast to reticulocyte can be shortened by about
release, the younger Fas-positive 2 days total. If the reticulocyte leaves the marrow early, another day
precursors are allowed to develop, can be saved, and the typical 6-day transit time is reduced to fewer
which increases the overall output than 4 days under the influence of increased EPO.
of RBCs from the marrow. Thus
early release of older cells in MEASUREMENT OF ERYTHROPOIETIN.
response to EPO indirectly allows • Quantitative measurements of EPO are performed on plasma and other
more of the younger cells to body fluids. EPO can be measured by chemiluminescence. Although
mature. the reference interval for each laboratory varies, an example reference
interval is 4 to 27 mU/L. Increased amounts of EPO in the urine are
EPO –> stimulate reticulocytes release -> Fas-L will be depleted -> expected in most patients with anemia, with the exception of patients
younger RBCs are allowed to thrive with anemia caused by renal disease (defective peritubular cells)

• A second mechanism for escaping apoptosis exists for RBC
progenitors: direct EPO rescue from apoptosis. This is the major way in
which EPO is able to increase RBC production. When EPO binds to its
receptor on the CFU-E, one of the effects is to reduce production of Fas
ligand. Thus, the younger cells avoid the apoptotic signal from the older
cells.
THERAPEUTIC USES OF ERYTHROPOIETIN.
• Recombinant erythropoietin is used as therapy in certain anemias
such as those associated with chronic kidney disease and
chemotherapy. It is also used to stimulate RBC production prior to
autologous blood donation and after bone marrow transplantation.
• Unfortunately, some athletes illicitly use EPO injections to increase the

oxygen- carrying capacity of their blood to enhance endurance and

stamina, especially in long-distance running and cycling. The use of
EPO is one of the methods of blood doping, and aside from being
banned in organized sports events, it increases the RBC count and
blood viscosity to dangerously high levels and can lead to fatal arterial
and venous thrombosis

OTHER STIMULI TO ERYTHROPOIESIS

• In addition to tissue hypoxia, other factors influence RBC production to
a modest extent. It is well documented that testosterone directly
stimulates erythropoiesis, which partially explains the higher
hemoglobin concentration in men than in women. Also, pituitary42 and
thyroid43 hormones have been shown to affect the production of EPO
and so have indirect effects on erythropoiesis.
 MLS 113A LESSON | 01
HEMATOLOGY Lecture | AJDC | Batch 2024
macrophage as ferritin until transported out. The globin of hemoglobin
ERYTHROCYTE DESTRUCTION
is degraded and returned to the metabolic amino acid pool. The
• All cells experience the deterioration of their enzymes over time due to
protoporphyrin component of heme is degraded through several
natural catabolism. Most cells are able to replenish needed enzymes
intermediaries to bilirubin, which is released into the plasma and
and continue their cellular processes. As a nonnucleated cell, however,
ultimately excreted by the liver in bile.
the mature erythrocyte is unable to generate new proteins, such as
enzymes, so as its cellular functions decline, the cell ultimately
MECHANICAL HEMOLYSIS
approaches death. The average RBC has sufficient enzyme function to
(FRAGMENTATION OR INTRAVASCULAR HEMOLYSIS)
live 120 days. Because RBCs lack mitochondria, they rely on glycolysis
• Although most natural RBC deaths occur in the spleen, a small portion
for production of adenosine triphosphate (ATP). The loss of glycolytic
of RBCs rupture intravascularly (within the lumen of blood vessels).
enzymes is central to this process of cellular aging, called
The vascular system can be traumatic to RBCs, with turbulence
senescence, which culminates in phagocytosis by macrophages. This
occurring in the chambers of the heart or at points of bifurcation of
is the major way in which RBCs die normally.
vessels. Small breaks in blood vessels and resulting clots can also trap
and rupture cells. The intravascular rupture of RBCs from purely
MACROPHAGE-MEDIATED HEMOLYSIS
mechanical or traumatic stress results in fragmentation and release of
(EXTRAVASCULAR HEMOLYSIS)
the cell contents into the plasma; this is called fragmentation or
• At any given time, a substantial volume of blood is in the spleen, which
intravascular hemolysis.
generates an environment that is inherently stressful on cells.
Movement through the red pulp is sluggish. The available glucose in
• When the membrane of the RBC has been breached, regardless of
the surrounding plasma is depleted quickly as the cell flow stagnates,
where the cell is located when it happens, the cell contents enter the
so glycolysis slows. The pH is low, which promotes iron oxidation.
surrounding plasma. Although mechanical lysis is a relatively small
Maintaining reduced iron is an energy-dependent process, so factors
contributor to RBC demise under normal circumstances, the body still
that promote iron oxidation cause the RBC to expend more energy and
has a system of plasma proteins, including haptoglobin and hemopexin,
accelerate the catabolism of enzymes.
to salvage the released hemoglobin so that its iron is not lost in the
• In this hostile environment, aged RBCs succumb to the various
urine.
stresses. Their deteriorating glycolytic processes lead to reduced ATP
production, which is complicated further by diminished amounts of
available glucose. The membrane systems that rely on ATP begin to
fail. Among these are enzymes that maintain the location and reduction
of phospholipids of the membrane. Lack of ATP leads to oxidation of
membrane lipids and proteins.
• Other ATP-dependent enzymes are responsible for maintaining the

high level of intracellular potassium while pumping sodium out of the

cells. As this system fails, intracellular sodium increases and potassium
decreases. The effect is that the
selective permeability of the
membrane is lost and water
enters the cell. The discoid shape
is lost and the cell becomes a
sphere (spherocytes)

• RBCs must remain highly flexible to exit the spleen by squeezing

through the so-called splenic sieve formed by the endothelial cells lining
the venous sinuses and the basement membrane. Spherical RBCs are
rigid and are not able to squeeze through the narrow spaces; they
become trapped against the endothelial cells and basement
membrane. In this situation, they are readily ingested by macrophages
that patrol along the sinusoidal lining

• Some researchers view erythrocyte death as a nonnucleated cell

version of apoptosis, termed eryptosis, that is precipitated by oxidative
stress, energy depletion, and other mechanisms that create membrane
signals that stimulate phagocytosis. It is highly likely that there is no
single signal but rather that macrophages recognize several.
• When an RBC lyses within a macrophage, the major components are

catabolized. The iron is removed from the heme. It can be stored in the