Normal red cell destruction

Usually occurs after a mean lifespan of

120 days.
Red cells are removed extravascularly by
the macrophages of RES (B.M, liver and
spleen).
As the cells have no nucleus, enzymes are
degraded and not replaced, red cell
metabolism gradually deteriorates and the
cell become non-viable.
 Red cell destruction

haemoglobin

Globin Haem

Amino acids Co Protoporphyrin

Reutilization Respiration Biliverdin

Bilirubin

Stercobilin urobilinogen
 Definitions

Hemolysis:
is the destruction or removal of red blood
cells from the circulation before their normal
life span of 120 days.
Haemolytic anaemias:
Are a group of anaemias in which red-cell
lifespan is shortened.
 Normaly, about 1% of human red blood cells break
down each day.
When the rate of breakdown increases, the body
compensates by producing more RBCs (compensated
haemolytic disease.
If compensation is inadequate clinical problems can
appear.
Breakdown of RBCs can exceed the rate that the body
can make RBCs and so anemia can develop.
 Classification
Hereditary haemolytic anaemias:
Usually are the result of ‘intrinsic’ red cells
defects:
1. Membrane defect:
• Hereditary spherocytosis.
• Hereditary elliptocytosis.
2. Haemoglobin defect: (haemoglobinopathies)

• Sickle cell disease.

• Thalassaemia
• Hb-C, Hb-D, Hb-E….etc
3. Enzyme defects:
• G6PD deficiency.
• Pyruvate kinase (PK) deficiency.
Acquired haemolytic anaemias:
 Usually are the result of ‘extracorpuscular’
or ‘environmental’ change (except PNH):
1. Immune mediated H.A:
• Autoimmune H.A.
• Alloimmune H.A.
• Drug induced mediated H.A.
2. Non-immune mediated HA:
• Drugs
• Toxins
• Mechanical
• Microangiopathic H.A.
• Infections
• Membrane defect (PNH)
 Mechanism of haemolysis
Extravascular haemolysis:
• excessive removal of red cells by RE cells.
Intravascular haemolysis:
• Destruction of red cells in the circulation.
• Haemoglobinaemia: increased free Hb in
circulation.
• Hb binds to haptoglobin and the complexes are
rapidly taken up by hepatocytes.
• Haptoglobin also play a role in extravascular
haemolysis due to the escape of some Hb from
macrophages when they phagocytosed
damaged red cells.
Haem is released from the Hb and rapidly oxidized
to ‘haematin’.
Oxidized Hb binds to haemopexin and the
complexes are removed by hepatocytes.
When haemopexin saturated, the haematin bind to
albumin to form methaemalbumin.
When haemoglobinaemia is present, some of the
free Hb dissociate to dimers and the dimers pass
through the glomerulus causing haemoglobinuria.
Some of the dimers are taken up by renal tubular
cells and converted to haemosiderin which can be
detected in urine (haemosiderinuria).
 Evidence of haemolysis

Divided into three groups:

1. Features of increased red cell destruction:
• Serum bilirubin: high
• Serum LDH: high
• Urine urobilinogen: high
• Serum haptoglobins: absent
2. Features of increased red cell production:
• P.B: Reticulocytosis and erythroblastaemia.
• B.M: Erythroid hyperplasia.
3. Damaged red cells:
• Morphology: microsphercytes, fragments,…etc
• Shortened red cell survival.
• Special tests:osmotic fragility, autohaemolysis..etc
Main features of intravascular haemolysis:
• Haemoglobinaemia
• Haemoglobinuria
• Haemosiderinuria
• methaemalbuminaemia
The reticulocytes
contain RNA
remainants (retics),
which stained by
supra-vital stains and
can be detected
easily.
Requirements:
Supra-vital stain: New methylene blue or
brilliant cresyl blue.
Water bath
Microscope
Test tubes
Glass slides
spreader
Pasteur pipettes
Procedure:
Deliver 2 or 3 drops of the dye solution into test
tube.
Add 2-4 volumes of patient blood to the dye and
mix well.
Keep the mixture at 37º C for 15-20 min.
Re-suspend the red cells by gentle mixing and
make thin blood film.
Counting and calculations:
The counted area should be chosen where
the cells are undistorted, well distributed and
good staining.
Number of reticulocytes in n fields = x
Average number of red cells per field = y
Total number of red cells in n fields = n X y
Reticulocyte percentage = [x / (n X y)] X 100%
Absolute reticulocyte count = % X RBC
count.
Reference range:
0.2-2%
Comments:
Reticulocytes appear in peripheral blood films
stained with Romanowsky stain as
polychromatic cells.
Increase reticulocytes in the circulation
indicates active erythropoiesis (e.g. as a
response to increase red cell destruction
(haemolysis) or haemorrhage).
Reticulocyte count also can be used as indicator
for successful treatment of nutritional anaemias
(mainly iron deficiency anaemia & megaloblastic
anaemia).