Blood Disorders: Normal Structure & Function

Retno Murwanti DVM, MSc, PhD Faculty of Pharmacy Universitas Gadjah Mada 2012

Blood Disorders: Normal Structure & Function

NORMAL STRUCTURE AND FUNCTION OVERVIEW OF BLOOD DISORDERS

NORMAL STRUCTURE AND FUNCTION

Formed Elements of Blood Coagulation Factors & the Coagulation

Cascade

INTRODUCTION

Blood Composition

Formed elements

red cells, white cells, platelets

Plasma.

Red blood cells

The most common formed elements Function : carrying oxygen to the cells of
the body via their main compound hemoglobin.

White Blood Cells

White blood cells are generally present at about 1/700th the number of erythrocytes to infection or other stimuli of inammation

Function : as mediator immune responses

Platelets

Platelets are the formed elements that

participate in coagulation

Plasma
Plasma is largely water, electrolytes, and
plasma proteins

Most important plasma proteins in blood

clotting : coagulation factors.

FORMED ELEMENTS OF BLOOD

BONE MARROW AND HEMATOPOIESIS

Developed from progenitor cells or Stem

Cells

Hematopoiesis Bone marrow adults (ribs, vertebrae, sternum) children (long bones)

Hematopoiesis

normal peripheral blood

Hematopoiesis: development of the formed elements of blood from bone marrow stem cells. Cells below the horizontal line are found in normal peripheral The principal cytokines that stimulate each cell lineage to differentiate are shown. (EPO, erythropoietin; TPO, thrombopoietin; CSF, colony-stimulating factor; G, granulocyte; M, macrophage; IL, interleukin; SCF, stem cell factor.) See Table 6 1 for details.

Cytokines that Regulate Hematopoiesis

Erythropoietin EPO Thrombopoietin TPO Colony-stimulating Factor CSF Granulocyte G Macrophage M Interleukin IL Stem Cell Factor SCF

Erythropoiesis

Stimulated by erythropoietin (hormon). Produced by the kidneys Function: regulates red blood cell production by a feedback system: When blood hemoglobin levels fall (anemia), delivery to the kidneys falls, and they produce more erythropoietin, causing the marrow to produce more red cells. When hemoglobin levels rise, the kidney produces less erythropoietin and the marrow fewer red cells.

Myelopoiesis

Production of white blood cells (granulocyte) Neutrophils Affected by many cytokines The most important : interleukin-3 (IL-3) granulocyte colony-stimulating factor (G-CSF) granulocyte-macrophage co stimulating factor (GM-CSF)

Thrombopoiesis

Thrombocytes are ligations of the cytoplasm from megakaryocytes (a single megakaryocyte can give rise to thousands of thrombocytes). Thrombopoiesis refers to the process of thrombocyte generation. Thrombopoietin stimulates megakaryopoiesis, process of megakaryocyte maturation and differentiation. Thrombopoietin, upon release, binds to its receptor, c-mpl, found on megakaryocyte progenitor cells. Following binding, intracellular signalling leads to megakaryocyte growth, maturation, membrane stability, platelet granule formation and the demarcation of the cytoplasm into regions destined to fragment into mature platelets. These "proplatelet processes" further fragment into platelets. This last step of proplatelet process and platelet formation, in vitro, has been shown to be independent of thrombopoietin.

Examination
Thin blood smear Cell sorting (FACS, Magnetic beads, etc) Wrights stain

Blood smear
platelets erythrocyte

lymphocyte neutrophil

Normal Values Obtained on Automated Blood CountFormed Elements of Blood.

Element
Hemoglobin Hematocrit (percentage of blood which is erythrocytes) Red cell count Mean corpuscular volume (MCV) White blood cell (total) count Neutrophils Lymphocytes Monocytes Eosinophils Basophils Platelets

Male Adult
1418 g/dL 4250% 4.66 x 106/ L 80100 fL 400011,000/ L 25007500/ L 15003500/ L 200800/ L 60600/ L < 100/ L 150,000400,000/ L

Female Adult
1216 g/dL 3747% 4.25.4 x 106/ L 80100 fL 400011,000/ L 25007500/ L 15003500/ L 200800/ L 60600/ L < 100/ L 150,000400,000/ L

Erythrocytes

Mature red blood cells are biconcave disk-shaped cells lled with hemoglobin, which function as the oxygen-carrying component of the blood. Do not have nuclei at maturity . Erythrocytes with nuclei in the peripheral blood smear suggests an underlying disease state. Biconcave shape gives them enough exibility to slip through small capillaries and deliver oxygen to the tissues. Individual erythrocytes function for about 120 days before they are removed from the circulation by the spleen. Hemoglobin is the most important substance in the erythrocyte. This protein is actually a tetramer, made of two -protein subunits and two -protein subunits (in normal adult hemoglobin, called hemoglobin A). Each - or -subunit contains the actual oxygen-binding portion of the complex, heme ( a compound whose centrally important atom is iron; it is this atom that actually binds oxygen in the lungs and subsequently releases it in the tissues of the body.) A low level of hemoglobin in the blood, from a variety of causes (see later discussion), is anemia, the most common general blood disorder.

Granulocytes: Neutrophils, Eosinophils, and Basophils

The most common white blood cells; of these (neutrophils are most abundant, followed by eosinophils and basophils). Development :

As they mature, their nuclei become more convoluted and multilobed, and each develops a cytoplasm lled with granules. These granules contain a variety of enzymes, prostaglandins, and mediators of inammation, with specic factors dependent on the cell type. Early progenitor cells for each type of granulocyte ("blasts") are indistinguishable on microscopic examination of the bone marrow, but under the inuence of different cytokines, they become morphologically distinct cell types.

Basophils

contain very dark blue or purple granules (r Giemsa's or Wright's stain). Basophil granules are large and usually obscure the nucleus because of their density. Function in hypersensitivity reactions. Their numbers can be increased in diseases not associated with hypersensitivity, such as chronic myelogenous leukemia. contain large, strikingly "eosinophilic" granules (staining red with Wright's or Giemsa's stain). Eosinophil nuclei are usually bilobed. Function as part of the inammatory response to parasites too large to be engulfed by individual immune cells and involved in some allergic reactions. Major function is actually in the tissues; they must leave the blood by inserting themselves between the endothelial cells of the vasculature to reach sites of injury or infection. Granules contain: highly active enzymes such as myeloperoxidase, which, along with the free radical oxygen ions produced by membrane enzymes such as nicotinamide adenine dinucleotide phosphate (NADPH) oxidase, kill bacteria that neutrophils ingest via endocytosis or phagocytosis. They are the "rst line of defense" against bacterial pathogens, and low numbers of them (leukopenia) lead directly to a high incidence of signicant bacterial infections Evidence of their importance and their short survival is commonly manifested, because examination of the blood smear under the microscope in a patient with an active infection may show not only increased numbers of mature, multilobed neutrophils (neutrophilia) but also increased numbers of less mature cells. These less mature cells, released from a large storage pool in the bone marrow, are called bands and have a characteristic horseshoe-shaped nucleus that is not yet fully lobulated. The phenomenon of nding these cells in the peripheral blood is called a left shift of the granulocyte lineage.

Eosinophils

Neutrophils

Platelets

Platelets are fragments of larger, multinucleated cells(megakaryocytes), but platelets have no nuclei of their own. Most platelets remain in the circulation, but a substantial minority are trapped in the spleen; this phenomenon becomes important in a variety of immune-mediated decreases in platelet count (thrombocytopenia). In the setting of a normal platelet count, they have a circulatory half-life of about 10 days. In cases of thrombocytopenia, their half-life decreases, as they are consumed in the routine maintenance of vascular integrity. Platelets are integral components of the coagulation system. Their membranes provide an important source of phospholipids, which are required for the function of the coagulation system proteins), and contain important receptors that allow attachment to endothelial cells (platelet adhesion) so that a platelet plug can be formed in response to blood vessel injury. This prevents further blood loss after trauma and limits the coagulation response to the site of injury rather than letting coagulation proceed inappropriately.

The cytoplasm is also important for platelet function, particularly the intracellular dense granules and alpha granules. The phenomenon of platelet activation is also called "degranulation" and can be initiated by exposure of platelets to the activated blood coagulation factor thrombin,adenosine 5'diphosphate (ADP), or collagen. This last reaction is probably the most important, occurring when collagen, normally in the basement membrane below the endothelial cells, is exposed to the blood after injury. Platelet activation can also be induced by exposure to platelet-activating factor (PAF), a neutrophil-derived phospholipid cytokine. During platelet activation, the dense and alpha granules release further activators of platelet activity, such as ADP, and platelet factor 4, which can also bind to endothelial cells. It is important because it binds to the most commonly used therapeutic anticoagulant, heparin (see later discussion). The last step in platelet activity is platelet aggregation, where platelets stick to each other, rming up the platelet plug. On examination of the blood smear, platelets are small, irregularly shaped blue or purple granular bodies. In conditions in which platelet numbers are rising as a result of increased marrow activity, more immature platelets can be identied by their larger size.

COAGULATION FACTORS & THE COAGULATION CASCADES

Coagulation Factors of Plasma.

Name
Procoagulant factors Factor I (brinogen) Factor II (prothrombin) Factor III (tissue thromboplastin) Factor IV (calcium) Factor V (proaccelerin) Factor VI (obsolete = factor Va) Factor VII (proconvertin) Factor VIII (antihemophilic factor) Factor IX (Christmas factor) Factor X (Stuart-Prower factor) Factor XI (plasma thromboplastin antecedent) Factor XII (Hageman factor) Factor XIII (brin-stabilizing factor) Anticoagulant factors Antithrombin Protein C Protein S Plasminogen Tissue factor pathway inhibitor Liver Liver Liver Liver Endothelial cells Liver Liver Tissue ... Liver ... Liver Endothelial cells Liver Liver Liver Liver Platelets

Production Source

The coagulation system

The coagulation system is remarkably complex in both structure and function. The coagulation system provides for immediate activation when there is blood loss that needs to be stemmed but also connes its activity to the site of blood loss. There are two major components of the coagulation system: platelets the coagulation factors (plasma proteins.)

The end result of coagulation factor activity: the formation of a complex of cross-linked brin molecules and platelets that terminate hemorrhage after injury.

The coagulation factors do not generally circulate in active forms. Most of them are enzymes (serine proteases) and remain dormant until they are needed. Other enzymes (the other proteases in the cascade) cleave the inactive factors into active ones. Presumably, the many interactions in the cascade allow a small increase in the activity of two key early enzymes, factors VII and XI, to be amplied. This results in a timely change in the availability of thrombin, which cleaves brinogen, leaving brin to form the clot.

attachment to endothelial cells (platelet platelet adhesion adhesion) so that a platelet plug can be formed in response to blood vessel injury. This prevents further blood loss after trauma and limits the coagulation response to the site of injury rather than letting coagulation proceed inappropriately.

Coagulation and thrombolytic systems

Figure 6 4

Coagulation and thrombolytic systems, showing balanced activity between them.

Laboratory Testing of the Coagulation Process

In vitro tests of coagulation function, "seconds required to form a clot": the prothrombin time (PT) the test used clinically to monitor the effects of warfarin. The activated partial thromboplastin time (aPTT) Additional if there is an abnormality regarding the increase dose ThePTT is prolonged most easily when there are reduced levels of factor VIII or factor IX activity, The aPTT is also very sensitive to the presence of heparin bound to antithrombin and is used to monitor the anticoagulant effects of unfractionated heparin. The tests are designed in such a way that the results will be prolonged out of the normal range in different pathologic states, but signicant alterations in the coagulation pathway inevitably lead to changes in both tests because of the multiple interactions of the involved factors.

Questions

What are the different formed elements of blood and how can they and their subtypes be distinguished? Name the vitamin Kdependent clotting factors and the organ in which they are synthesized. The extrinsic and intrinsic coagulation pathways converge with the activation of which clotting factor? Describe the two anticoagulant systems that participate in clotting homeostasis.

Thank you