BIOCHEMISTRY

Red Blood Cell Metabolism LE1

Ma. Lilia T. Reyes, M.D. || 08/23/2017

A. BLOOD CHEMISTRY
OUTLINE
I. I. Blood  Total Circulating Blood Volume: 5-6 liters (6-8% of total
A. Blood Chemistry body weight)
B. Blood Composition  Color:
C. Function of Blood → Arterial oxygenated blood: crimson/bright red
D. Plasma and Serum → Venous deoxygenated blood: dark red, purplish
II. Red Blood Cell  pH: 7.35-7.45 (Ave. 7.40)
A. Structure and Characteristics  Specific Gravity: 1.035-1.075
B. RBC Membrane Proteins  Average blood volumes
C. Membrane Transporters  Premature Neonates 95 mL/kg
D. Formation of Erythrocytes  Full Term Neonates 85 mL/kg
III. RBC Metabolism of Glucose
 Infants 80 mL/kg
A. Embden-Meyerhoff Pathway
B. Hexose Monophosphate Pathway
 Adult Men 75 mL/kg
C. Rapaport-Luebering Shunt  Adult Women 65 mL/kg
D. Gluthatione System
IV. Hemoglobin Synthesis B. BLOOD COMPOSITION
A. Hemoglobin
B. Porphyrin ● Formed Elements (40-45% of Blood Composition)
C. Heme → Red Blood Cells (Erythrocytes) - most abundant; delivers
V. Degradation of Hemoglobin oxygen
A. Synthesis of Unconjugated Bilirubin → Buffy Coat (<1%)
B. Metabolism of Bilirubin in the Liver ▪ White Blood Cells (Leukocytes) - fights infection
C. Fate in the Intestines ▪ Platelets (Thrombocytes) - stops bleeding; controls
D. Unconjugated Vs. Conjugated Bilirubin hemostasis (blood clotting)
E. Hyperbilirubinemia ● Plasma (55% of Blood Composition)
F. Jaundice
VI. Porphyrias
A. Types of Porphyrias
B. ALA Synthesis
VII. RBC Disorders
A. Enzyme Deficiencies
B. Hemoglobinopathies
VIII. Review Questions
IX. References

OBJECTIVES

1. Given a patient with abdominal pain and dark urine,
identify the biochemical pathways or processes that are
involved.
2. Apply the biochemical concepts and principles that will
help explain the development of porphyrias
3. Correlate the biochemical or molecular basis with the
clinical manifestation of the disease, the findings on
physical examination of the patient and laboratory
results.
4. Discuss the biochemical basis of the management of
porphyrias
I. BLOOD
 Fluid connective tissue derived from the mesoderm of the
germ layer, which consists of plasma and formed elements
(RBC, WBC, and platelets).
 Formed elements are produced in the red bone marrow
 The proteins in plasma are produced by liver, the enzymes
and antibodies are produced by cellular component of
blood
 Circulates in the body via the blood vessels and heart
Figure 1. Composition of Blood Components.
Hematocrit: Blood volume % occupied by Red blood cells
 Males: 40-45% Females: 38-42%
 Used in diagnosis of anemias and polycythemia
C. FUNCTION OF BLOOD
● Transport
→ Oxygen: lungs to tissue
→ CO2: tissue to lungs
→ Absorbed nutrients (e.g. fats, proteins): intestines to
areas of utilization
→ Hormones: organs of synthesis to distant sites
→ Metabolites and waste products (e.g. urea) for excretion
● Homeostasis
 acid- base balance
 water balance between tissues and circulation
 adequate blood supply and hemostasis
● Regulation (Temperature and Metabolism)
● Defense mechanism of the body (WBCs and circulating
antibodies)

Trans # 5 Group 26: De Torres, Deato, Dee, Del Rosario Trans Head: Canete 1 of 11
 D. PLASMA AND SERUM ● Lifespan: 90-120 days
● Compounds found in RBC
Table 1. Comparison of Plasma and Serum  hemoglobin (iron-binding protein)
 NADH-cytochrome b5 methemoglobin reductase,
Plasma Serum  Nitric Oxide
 Glycolytic enzymes
Whole blood without formed  GSH (reduced glutathione)
Whole blood without elements and clotting factors (I or
formed elements B. RBC MEMBRANE PROTEINS
fibrinogen, II, V, VIII)
● Integral proteins: span the whole length of lipid bilayer
Centrifuged with → Band 3: also known as AE1 (anion exchanger 1); most
Centrifuged coagulated blood
anticoagulant abundant protein in RBC membrane; plays a role in
chloride bicarbonate exchange
Used in reference to → Glycophorin: single pass membrane; heavily
Used in reference to laboratory glycosylated; gives RBC hydrophilic charged coat (for
physiologic or pathological
values repulsion to cells and vessel walls)
processes
● Peripheral proteins: found inside cell, on the cytoplasmic
surface of lipid bilayer; for membrane stability and elasticity.
Blood transfusion, Blood typing, diagnosis, antibody → Spectrin: most abundant protein of RBC; major protein
diagnosis culture of the cytoskeleton of RBC; encompasses whole top part
of membrane; confers flexibility
→ Actin: band 5
● Plasma - non-cellular, fluid component of blood; cloudy, → Ankyrin: binds spectrin; binds tightly to band 3, securing
pale or grayish yellow liquid attachment of spectrin to membrane
→ Band 4.1: globular protein; binds to end of spectrin; may
→ Composed of water and dissolved solutes
interact with membrane phospholipids, connecting lipid
● Serum - blood plasma without clotting factors; clear bilayer to cytoskeleton.
yellowish liquid

Figure 2. Plasma Vs. Serum

Figure 3. RBC Membrane
II. RED BLOOD CELL
C. MEMBRANE TRANSPORTERS
A. STRUCTURE AND CHARACTERISTIC
● Channel: AQP1 (2nd most abundant protein in membrane)
● Non-nucleated and lacks most organelles → Contributes more than half of carbon dioxide permeability
→ Loses its nucleus (enucleated) as it matures to provide → Water transport
more space for hemoglobin ● GLUT-1 (insulin-independent)
→ Absence of nucleus = No DNA and cannot synthesize → Main transporter
RNA; unable to divide or repair themselves → Specific for erythrocytes
→ No mitochondria (anaerobic glycolysis) and other → Substrates: glucose, galactose, mannose
organelles ● Band 3: anion exchanger
● Shape: Biconcave disk
→ Benefits: Increase membrane surface area; confers Importance of Band 3:
flexibility for RBC to undergo changes in shape for easy
passage through capillaries
● Cytoskeleton is highly deformable
→ allows easy flow through the capillary system
→ Not easily lysed or destroyed
● Diameter: 6-9 microns
● Normal RBC count
→ Men: 5-6 million/mm3
→ Women: 4-5 million/mm3

BIOCHEMISTRY Red Blood Cell Metabolism 2 of 11

 D. FORMATION OF ERYTHROCYTES

● Also known as Erythropoiesis

● RBC production is triggered from demand of low oxygen
levels in the body (hypoxia).
● Starts as pluripotent stem cells from the bone marrow
● Interleukin-3: changes pluripotent stem cells to progenitor
cells (Colony Forming Unit – GEMM)
→ G – Granulocyte
→ E – Erythrocyte
→ M – Monocyte
→ M – Megakaryocyte
● Kidneys releases erythropoietin (EPO) which stimulates
formation of erythroid precursors -> erythroblast formation
● RBC loses its nucleus and other organelles as it matures.
● Reticulocytes: young RBC seen in peripheral blood just
as it is released from bone marrow.

Reticulocyte Count
 Immature red blood cells occurs in the circulation
approximately 1%
 Increased reticulocyte count indicates premature
+ blood loss during haemolytic anemia

● Major site or production: bone marrow: pelvis, spine, ribs,

scapula, proximal ends of femur and humerus

Evolution of Cells during Erythropoiesis

 Hemocytoblast (pluripotent stem cell) Figure 5. Stages of Glycolysis
 Common myeloid progenitor (multipotent stem
cell) – can further differentiate into ● Anaerobic Glycolysis
megakaryocyte or myeloid
→ Form of glycolysis utilized by RBC due to lack of
 Unipotent stem cell (proerythroblast) -1st
commited cell mitochondria
 Pronormoblast ○ oxidative phosphorylation cannot take place
○ End product of this pathway is always lactate
 Basophilic normoblast also called an
○ Pyruvate is converted to lactate by enzyme
erythroblast.
lactate dehydrogenase
 Polychromatophilic normoblast
○ NADH is converted back to NAD+
 Orthochromatic normoblast
 Reticulocyte – anucleated
 Erythrocyte – anucleated and biconcave

Figure 4. RBC Formation and Maturation

III. RBC Metabolism of Glucose

Figure 6. Stages of Anaerobic Glycolysis
A. Embden-Meyerhoff Pathway
● Warburg Effect
● Accounts for 90% of glucose metabolism in RBC → Cancer cells predominantly produce energy by a high rate
● Glycolysis provides major source of energy for RBC of glycolysis followed by lactic acid fermentation in the
→ cytoplasmic oxidation of glucose to pyruvate cytosol
→ 2 molecules of ATP are produced for every glucose
molecule

BIOCHEMISTRY Red Blood Cell Metabolism 3 of 11

 B.Hexose Monophosphate Shunt (Pentose IV. HEMOGLOBIN SYNTHESIS
Phosphate Pathway)
A. HEMOGLOBIN
● Aerobic
● Glucose metabolism that happens in 10% of mature RBC ● Found in RBC
● Alternative pathway for production of 5-carbon sugar (like ● Functions:
ribose-5-phosphate) → Transport O2 from lungs to tissues
→ Transport H+ and CO2 from tissues to lungs
 Needed for nucleic acid biosynthesis ● Structure:
● NADPH is formed in the process → Hemoglobin is made up of 4 polypeptide chain
● NADP keeps glutathione reduced -> RBC protected from subunits
oxidative damage -> no RBC hemolysis -> Longer RBC o The most common chain component of Hgb
lifespan in humans are: 2 α chains and 2 β chains
● G-6-P dehydrogenase catalyzes the first or the rate- → Each subunit contains a cofactor called a heme
limiting step of HMP shunt group that has an iron atom center
● Forms of Hgb:
→ Tense (T) form
○ Also called deoxyhemoglobin
○ Two αβ dimers bond though network
of ionic interaction
○ Less affinity for oxygen (incorporates
2,3 BPG)
→ Relaxed (R) form
○ Also called oxyhemoglobin
○ Rupture of some ionic interactions
○ Very high affinity for oxygen (2,3 BPG
is released)

Figure 7. Pentose Phosphate Pathway

C. Rapaport-Luebering Shunt

● Bisphosphoglycerate mutase converts 1,3-

bisphosphoglycerate -> 2,3-bisphosphoglycerate
● 2,3-BPG phosphatase converts 2,3-bisphosphoglycerate
-> 3-phosphoglycerate
● 2,3-BPG forms 1:1 complex with Hemoglobin
→ Increase in 2,3 BPG -> decrease in O2 affinity -> O2 is
easily released in peripheral tissues

D. Glutathione System (Anti-oxidative System of

RBC)
Role of pH due to protonation of Amino acids in
● Major defense against free radicals hemoglobin structure
● Oxidized glutathione reduces protective effects
● GSH is reduced glutathione Hemoglobin v. Myoglobin
● GSSG is oxidized glutathione
● Table 1. DIfferences between hemo- and myoglobin
Hemoglobin Myoglobin

Transport O2 Stores O2 w/in

Function
w/in the blood muscles

4 polypeptide Single
Figure 8. Glutathione System chains: 2α + 2β polypeptide
Structure
chain
Free Radicals Tetramer
 Free radicals are atoms, ions, or molecules that
Increases
contain an unpaired electron. The unpaired electron High affinity
makes them unstable and highly reactive. Affinity for O2 proportionally
even in low [O2]
with [O2]
 Includes Reactive Oxygen Species (ROS)
Number of heme
groups/binding 4 1
sites

BIOCHEMISTRY Red Blood Cell Metabolism 4 of 11

Globin → Forms complexes with metal ions bound to the
● Protein part of the hemoglobin; tetra (4 polypeptide chain) nitrogen atom of the pyrrole rings.
→ Eight side chains serve as substituents on the
● Embryonic
Table 2. Forms of embryonic hemoglobins
porphyrin ring, two on each pyrrole. These side
chains may be acetyl (A), propionyl (P), methyl
Form Chain components (M) or vinyl (V) groups.
Hb-Gower1 δ2ε2 → Porphyrins found in nature are compounds in
which various side chains are substituted for the
HbF α2γ2 eight hydrogen atoms numbered in the porphyrin
nucleus above.
Hb-Gower2 α2ε2 → Examples:
○ Heme (Iron Porphyrin) of Hemoglobin
Hb-Portland δ2γ2 ○ Chlorophyll (Magnesium Porphyrin) of
plants
● Adult
Table 3. Forms of adult hemoglobin
Chain
Form %
components
HbA α2β2 90-97

HbA2 α2δ2 2-5

HbF α2γ2 <2

HbA1c α2β2-glucose 3-9

● "Hemoglobin switching" - proliferation of Hb chains changes

from gestation to adulthood
Table 4. Functions of Porphyrin

→ Porphyrins versus Porphryrinogens

○ Porphyrins: with double bonds
(methine bridges)
○ Porphyrinogens: no double bonds
→ Type 1 vs Type 3 Porphyrin
○ Type 1 porphyrin
■ Completely symmetric
arrangement of the
substituents
■ Found in nature
○ Type 3 Porphyrin
■ Asymmetric substitution
■ More abundant than Type 1
porphyrin
■ Example: Heme-

Figure 9. Graph of proliferation of Hb chains

C. Heme

● Produced in all tissues but most pronounced in bone marrow

B. Porphyrin
● Structure, Chemistry, and Function
→ Cyclic compounds formed by the linkage of four
pyrrole rings through methine (=HC-) bridges
and liver because of the requirements for the incorporation of
the hemoglobin and the cytochrome, respectively (Devlin,
1997)
● Consists of a tetrapyrrole ring (Protoporphyrin IX) and a
ferrous iron (Devlin, 1997)

Figure 9. Porphyrin Structure. Rings labeled as I, II, III, Iv. Methyne Briges
as α β γ δ. Subsituent positions as 1 - 8 Figure 11. Structure of Heme

BIOCHEMISTRY Red Blood Cell Metabolism 5 of 11

● Site of Biosynthesis: Hemoglobin Degradation Pathway
→ RBC (85%)- heme part of hemoglobin is
synthesized in the immature RBCs-
reticulocytes and erythroblasts
■ Hemoglobin
■ Myoglobin (10%); other heme proteins
include catalase, tryptophan,
pyrrolase
→ Liver (15%)- heme is the prosthetic group of
P450 (CYP450 system)
→ Cytosol

Figure 13. Fate of Hemoglobin

How RBCs able to utilize Iron from Fe Pool

The expression of hepcidin, which only occurs in certain
cell types such as hepatocytes, is tightly controlled at the
transcriptional level and it represents the link between
cellular and systemic iron homeostasis due to hepcidin's
role as "gatekeeper" of iron release from enterocytes into
the rest of the body. Erythroblasts produce erythroferrone,
a hormone which inhibits hepcidin and so increases the
availability of iron needed for hemoglobin synthesis

Figure 12. Heme Biosynthesis

V. DEGRADATION OF THE HEMOGLOBIN

● Around 200 billion Red Blood Cells are degraded in the adult A. SYNTHESIS OF UNCONJUGATED BILIRUBIN
human body daily
● The Globin component is degraded and incorporated into the ● This occurs in the reticuloendothelial cells present in the liver,
amino acid pool spleen, and bone marrow.
● The heme is catabolized into bilirubin, a yellowish pigment in ● The iron of the heme group is oxidized in its ferric (Fe3+) form.
the bile. ● The enzyme, Heme oxygenase, converts heme into biliverdin
through the consumption of 3 moles of O2 and 7 electrons,
Transport Proteins and their ligands which are donated by NADH and NADPH-cytochrome P450
reductase.
Table 6. Proteins and Ligands pointed out by Dr. Reyes ● This reaction releases Carbon Monoxide and the Iron, which is
transported using transferrin into the iron pool.
Proteins Ligands ● The methylene bridges found in the center are reduced into
3+ methyl groups using another enzyme, Biliverdin reductase.
Transferrin Fe
This produces unconjugated Bilirubin which is nonpolar or
not water-soluble.
Hemoglobin/protoporphyrin- Heme, bilirubin, bilverdin
● This Unconjugated Bilirubin is bound to albumin and is
binding albumin
transported into the liver.
Haptoglobin Hemoglobin dimers

BIOCHEMISTRY Red Blood Cell Metabolism 6 of 11

 C. FATE IN THE INTESTINES

● Bile is secreted into the intestines

● The glucuronosyl moieties are removed by β-glucuronidases
from bacteria, producing urobilinogen, a colorless tetrapyrrole.
● Urobilinogen:
→ Can be converted into urobilin (orange color) -> excreted in
urine
→ Converted into stercobilinogen -> stercobilin (yellowish
color) -> excreted in stool
● If there is an obstruction of the bile ducts, there will not bilirubin
that can enter the intestines -> producing clay-colored stool

D. UNCONJUGATED VS CONJUGATED BILIRUBIN

● Unconjugated Bilirubin:
→ Indirect reacting to Erlich’s diazo reagent test
Figure 14. Synthesis and Structure of Unconjugated Bilirubin → “Indirect bilirubin”
→ Hydrophobic and can cross the blood brain barrier
B.METABOLISM OF BILIRUBIN IN THE LIVER → Free Bilirubin
● Conjugated Bilirubin:
→ Direct reacting to Erlich’s diazo reagent test
→ “Direct Bilirubin”
→ Hydrophilic and can be excreted from the body
● Importance of Conjugated Bilirubin: It is water – soluble, thus it
can be excreted from the body.

E. HYPERBILIRUBINEMIA

● Bilirubin in the blood is greater than 1 mg/dL

● Causes:
→ Production of bilirubin is greater than what the liver can
excrete
→ Bilirubin is not excreted by the liver in normal amounts
● Types:
→ Retention Hyperbilirubinemia:
▪ Too much production of bilirubin
→ Regurgitation Hyperbilirubinemia
▪ Biliary obstruction causes the reflux of bilirubin into
bloodstream

Table 7. Conjugated & Unconjugated Hyperbilirubinemia

Figure 15. Three Stages of Hepatic Catabolism in Bilirubin
Conjugated Unconjugated
Obstruction of Biliary Tree Hemolytic Anemias
Uptake of Bilirubin by Liver Parenchymal Cells Dubin-Johnson Syndrome Neonatal “Physiological
● The bilirubin dissociates from albumin and enters the liver jaundice”
through the action of the Facilitated Transport System. Rotor Syndrome Crigler-Najjar Syndromes:
● Bilirubin binds with Ligandin (also known as “ S-transferase”), Type I and Type II
a protein in the cytosol of the hepatocytes, to prevent it from Liver diseases such as Gilbert Syndrome
moving back into the bloodstream. various types of hepatitis
Toxic Hyperbilirubinemia
Conjugation of Bilirubin with Glucuronic Acid
● This occurs in the liver. Disorders in the Conjugation Stage (unconjugated)
● The transfer of 2 glucosyl moieties from UDP-glucuronic acid to ● Neonatal “Physiologic Jaundice”
unconjugated bilirubin, makes it polar. This is catalyzed by the → There is a reduction in the bilirubin-glucosyltransferase
enzyme UDP glucuronosyltransferase from the endoplasmic activity and synthesis of UDP-glucuronic acid.
reticulum. → Caused by:
● In the reaction, an intermediate: Bilirubin monoglucuronide is ▪ Accelerated hemolysis
formed and is transformed into the Bilirubin diglucuronide. ▪ An Immature hepatic system for the uptake, conjugation,
● When bilirubin conjugates exist abnormally in the plasma, they and secretion of bilirubin
are predominantly monoglucuronides. ● Toxic Hyperbilirubinemia
→ There is a toxin-induced liver dysfunction caused by
Secretion in the Bile chloroform, arsphenamines, carbon tetrachloride,
● Multispecific organic anion transporter (MOAT) in the acetaminophen, hepatitis virus, cirrhosis, or Amanita
plasma membrane is the protein involved in the transport mushroom poisoning.
Conjugated Bilirubin into the bile. This is an active transport. → Affects bilirubin conjugation
● Crigler-Najjar Syndrome
→ Mutations in the Bilirubin UDP-glucuronosyl Transferase
BIOCHEMISTRY Red Blood Cell Metabolism 7 of 11
 → Type I: absence of the hepatic UDP-glucuronosyl VI. PORPHYRIAS
Transferase
→ Type II: retain some of the hepatic UDP-glucuronosyl ● Porphyrias are defects in the heme synthesis pathway, causing
Transferase buildup of heme precursors
● Gilbert Syndrome: → ↑Pb (lead) →Blocks in this pathway will cause increased
→ Mutations in the Bilirubin UDP-glucuronosyl Transferase levels of precursors prior to the block while decreasing levels
→ Retain some bilirubin UDP-glucuronosyl Transferase of precursors after
→ Harmless → Most commonly caused by defects/defiecient enzymes
→ ↓ferrochelatase activity → ↑protoporphyrin IX/↓heme
Disorders in the Secretion Stage (conjugated)
● Obstruction of Biliary Tree
→ Blockage of hepatic or common bile duct
→ Due to gall stone or cancer of pancreas head
→ Causes Choluric Jaundice (appearance of conjugated
bilirubin in blood and urine)
● Dubin-Johnson Syndrome
→ Autosomal Recessive Disorder
→ Mutations in the gene encoding for the protein which
secretes conjugated bilirubin in the bile.
● Rotor Syndrome
→ Functional uptake and conjugation but removal and excretion
into bile are defective
→ Cause of disease still unknown

F. JAUNDICE

● “Icterus”
● Bilirubin is 2- 2.5 mg/dl in the blood.
● Appears yellowish because the bilirubin diffuses into the tissues

Some Major Causes of Jaundice Figure 16. Heme Synthesis

● Prehepatic Jaundice (Vascular)
→ Major cause: hemolytic anemia
→ Signifies events in the blood stream
● Hepatic Jaundice
→ Indicates events in the liver (hepatitis, or other forms of liver
disease such as cancer)
● Posthepatic Jaundice:
→ Indicates events in the biliary tree
→ Major causes: obstruction of the common bile duct by a
gallstone or by cancer of the head of the pancreas
A. TYPES OF PORPHYRIAS
Based on Clinical Features
● Acute porphyrias cause neuropsychiatric s/sx from
accumulation of heme or precursors (specifically ALA or PBG)
→ Abdominal pain, hypertension, vomiting
→ Similar sx to cholinergic overdose
● Chronic/cutaneous porphyrias can cause photosensitivity via
accumulation of porphyrinogens in skin and tissues, which
spontaneously oxidise to porphyrins

Cholestatic Jaundice Table 8. Porphyrias Based on Organs Affected

● Refers to all cases of Extrahepatic Obstructive Jaundice Type of
● Swollen and Damaged hepatocytes cause the micro-obstruction Porphyria type Deficient enzyme
porphyria
of intrahepatic biliary ductules, thus causing the conjugated
hyperbilirubinemia. X-linked dominant
5-aminolevulinate (ALA)
protoporphyria Erythropoietic
Kernicterus (XLDPP)*
synthase (ALAS)
 Encelopathy due to hyperbilirubinemia
Aminolevulinate
 Accumulation of Bilirubin in the grey matter of CNS dehydratase deficiency
5-aminolevulinate
Hepatic
 Most are caused by unconjugated hyperbilirubinemia during porphyria (ALADP)
dehydratase (ALAD)
the neonatal period
Hydroxymethylbilane
Obstructive vs Hemolytic Jaundice Acute intermittent synthase (HMBS) formerly
● Obstructive Jaundice: Hepatic
porphyria (AIP) porphobilinogen
→ Bilirubin cannot enter the intestine because of a complete deaminase (PBGD)
obstruction of the bile duct. It cannot be converted into
urobilinogen Congenital
uroporphyrinogen
→ In the urine: erythropoietic Erythropoietic
synthase (UROS)
porphyria (CEP)*
▪ Urobilinogen is not present
▪ Conjugated Bilirubin is there. Porphyria cutanea uroporphyrinogen
Hepatic
● Hemolytic Jaundice tarda (PCT)* decarboxylase (UROD)
→ Increased production of bilirubin thus increasing production
Hereditary coproporphyrinogen
of urobilinogen Hepatic
coproporphyria(HCP) oxidase (CPOX)
→ In the urine:
▪ Urobilinogen is present Harderoporphyria
coproporphyrinogen
Erythropoietic
− Caused by increase in the blood destruction oxidase (CPOX)
▪ Bilirubin is not present
BIOCHEMISTRY Red Blood Cell Metabolism 8 of 11
Variegate protoporphyrinogen Glucose-6-Phospate Dehydrogenase Deficiency
Hepatic
porphyria(VP) oxidase (PPOX)  G6PD deficiency or favism
Erythropoietic
Ferrochelatase (FECH) Erythropoietic
 Most common cause of hemolytic anemia
protoporphyria(EPP)*  An X-linked recessive inborn error of metabolism that
Note: Porphyrias with * are chronic porphyrias, the rest are acute. predisposes to hemolysis

Decreased NADPH
↓
Decreased amount of reduced glutathione
↓
Increased conversion of hemoglobin to methemoglobin
↓
Decreased RBC lifespan
↓
HEMOLYTIC ANEMIA

Cytochrome b5 Reductase Deficiency

 Cyt b5 reductase is involved in reducing ferric ion (Fe3+) to
the ferrous state (Fe2+)
 Fe2+ participates in hemoglobin binding to Oxygen. Fe3+ is
more toxic and liable to Fenton chemical reaction that
produces free radicals
Figure 17. S/Sx of porphyrias

Historical Perspective Increased methemoglobin in blood

↓
 Porphyria is called the "vampire disease”; etymology Nonreduction of Fe3+ to Fe2+
comes from inbreeding in Transylvania (due to ↓
photosensitivity) Decreased O2-carrying capacity of blood
 Also associated with werewolves b/c of hypertrichosis or ↓
hairiness Increased congenital methemoglobinemia
↓
B. ALA SYNTHASES Cyanosis but very few clinical symptoms
● ALAS1: hepatic type
→ ↑[ALAS1] during drug metabolism by CYP450 system in liver B. HEMOGLOBINOPATHIES
→ ↓[ALAS1] from glucose loading, administration of hematin
▪ Hematin therefore decreases heme synthesis and toxic Thalassemias
effects brought about by porphyria
● are a group of genetic disorders that have a defect in
→ Undergoes feedback regulation by heme hemoglobin production
● ALAS2: erythroid type ● α-thalassemia: reduced/absent synthesis of α globin chains
→ Not induced by drugs that affect [ALAS1] → heterozygous state is asymptomatic, one gene can still make
→ Does not undergo feedback regulation by heme alpha chains;
→ homozygous state is fatal since no alpha chains can be
VII. RBC DISORDERS made.
→ There are 2 pairs of alpha globin on each chromosome 16
A. ENZYME DEFICIENCIES (total of 4 alpha globin genes at precursor)
 If 1 copy is deleted → reduced size and
Pyruvate Kinase Deficiency concentration of Hb
 Second most common cause of enzyme deficient hemolytic  If 2 copies are deleted → microcytic,
anemia hypochromic (not anemic yet)
 ATP is needed for ion pumps, which maintains the biconcave  If 3 copies are deleted → moderately severe
shape of RBCs, without ATP, cell will lyse and die microcytic hypochromic anemia with
splenomegaly
50% reduction of RBC ATP synthesis  If 4 copies are deleted → hydrops fetalis; fatal in
↓ utero
Decreased efficiency of iron transporters
↓
 β-thalassemia: reduced/absent synthesis of beta globin chains
Decreased gain in Ca2+; loss in K+ and H2O → heterozygous state is asymptomatic, homozygous state can
↓ be treated with blood transfusions
Increased intracellular haemoglobin concentration
↓ Anemia due to Structural Mutation
Increased internal viscosity of blood ● Synthesis of abnormal Hb
↓ → Comes from substitution of amino acids ( usually glutamate
Increased rigidity on codon 6 of the Hb β chain)
↓ → Due to genetic disorders or mutations
Increased damage to RBCs by shear forces of circulation
↓
→ Synthesis of insufficient quantities of normal hemoglobin
HEMOLYTIC ANEMIA
BIOCHEMISTRY Red Blood Cell Metabolism 9 of 11
 Table 9. Abnormal Hb types Anemia due to destruction
Type Substitution Penetration ● Spherocytosis
HbS (sickle cell → molecular defect in one or more of the proteins of the red
Glu → Val Sickle cells
anemia) blood cell cytoskeleton, including spectrin, ankyrin, Band 3,
or Protein 4.2
HbC Glu → Lys "target" cells, HbC → causes RBCs to be sphere in shaped rather than biconcave
crystals → Abnormal RBCs are destroyed in the spleen causing
splenomegaly
HbSC Glu → Val Sickle cells (note: milder ● Hereditary Spherocytosis
than HbS and HbC) → Defect in RBC cell membrane
Glu → Lys → Caused by mutation
→ All red blood cells are spherocytes
HbM His → Tyr in α, β ↑methemoglobin ● Autoimmune Hemolytic Anemia
(methemoglobinemia)
chains → Can be caused by systemic lupus erythematosus or chronic
lymphocytic leukemia
 HbS (Sickle Cell Anemia) Disease ● Acquired Hemolytic Anemia
 Severe when homozygous → Caused by enzyme deficiencies
→ ABO and Rh incompatibility during pregnancy
 Distortions of RBCs → Can be caused by spherocytosis
 Joint pain, anemia thrombosis, fever abd splenomegaly → Drug induced
 RBC morphology: sickle cells, target cells, nucleated RBCs, ● Blood loss Anemia
polychromasia, Howell Jolly bodies, basophilic stippling, → anemia due to trauma or injury
spherocytes → Can be caused by Gastrointestinal tract lesions
 HbC Disease → Can be caused by parasitic infections
 Most common non sickling variant in US
 Mild splenomegaly and mild hemolysis Polycythemia
 RBC morphology: HbC crystals, target cells, nucleated RBCs  ↑hematocrit (above 55%)
and some microcytes  Viscous blood circulation → hypertensions (↑Blood Pressure)
 HbSC Disease ● Polycythemia Vera (Primary Polycythemia)
 Most common compound heterozygous syndrome → Erythemia
 Structural defect of two hemoglobins (HbS and HbC) → Excess RBC production due to abnormality in bone
marrow
 RBC morphology: sickle cells, HbC crystals, target cells
→ Susceptible to formation of unwantedblood clots
 HbM Disease ● Physiologic Polycythemia (Secondary Polycythemia)
 Congenital Methemoglobinemia → Natural or artificial increase in EPO productions
 Mutation changes in amino acids to which heme is attached → Excess RBC production due to abnormality in bone
 Alteration for O2 affiinity and favoring oxidation; hence not marrow Due to lifestyle and environment
able to release O2 to the tissues → People living in high altidude areas because O2 is limited
→ Hypoxic illnesses such as COPD
HbS is known for "painful vaso-occlusive crisis", where → Also evident in people who smokes
sickle cells clump together in small vessels → Susceptible to formation of unwanted blood clots

Anemia due to Impaired Production VIII. REVIEW QUESTIONS

● Erythroblastopenia (pure red cell aplasia)
→ Affects the precursors of Red blood Cells 1. Which hemoglobin chain component is not present in
● Aplastic anemia and Fanconi Anemia adults?
→ Affects all types of blood cells due to bone marrow a. δ
diseases b. δ
● Anemia due to Renal Failure c. α
d. γ
→ Affects production of EPO
2. Which of the following about erythrocytes is true?
● Pernicious Anemia
a. They fight infection.
→ Form of megaloblastic anemia b. They clot blood.
→ Impaired absorption of Vit B12 c. They are produced in the spleen.
● Megaloblastic Anemia d. They lack nucleus.
→ Vit B12 deficiency due to diet 3. Which of the following statements about unconjugated
● Iron-deficiency anemias bilirubin is true?
→ ↓[ascorbic acid]/↓[Vit C] → ↓reduction of Fe3+ to Fe2+ → a. They directly react to Erhlic’s diazo test..
↓iron absorption b. They are hydrophilic.
→ ↓[Vit A] → ↓transferrin synthesis → ↓iron transport → anemia c. They can cross the blood brain barrier.
● B6 deficiency anemia d. They are known as “Direct Bilirubin”.
→ ALA needs B6 as a cofactor 4. When the pH is increased, which form of Hb is more
→ Microcytic (small) abd hypochromic (pale) RBCs active and in which direction will the Hb curve shift?
a. T-form; shift to the left
b. T-form; shift to the right
BIOCHEMISTRY Red Blood Cell Metabolism 10 of
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 c. R-form, shift to the left
d. R-form; shift to the right
5. Which of the following is/are more likely to cause
hemolytic anemia?
a. Blood loss
b. Polycythemia.
c. Spherocytosis
d. All of the above
e. B and C only
6. Which of the following is involved in reduction of free
radicals?
a. GSH
b. HMP shunt.
c. Rapaport-Luebering Shunt
d. A and B
e. A and C
7. Variegate Porphyria is caused by deficiency of what
enzyme?
a. PPOX
b. Ferrochelatase.
c. ALA-synthase
d. None of the above
8. Which of the following does not stimulate
erythropoiesis?
a. IL-3
b. Erythropoietin.
c. Hypoxia
d. COPD
e. None of the above
9. Which anemia is characterized by substitution of
Glutamine to Lys in the 6th position of B chain?
a. HbS
b. HbF
c. HbC
d. HbM
10. Which of the following is found on RBC membrane?
a. AQP2
b. Glut1
c. Carnitine transferase
d. Band 6

Answers: b, d, c, c, c, d, a, e, c, b

IX. REFERENCES
Dr Reyes’ Powerpoint
Transes of 2020A, 2020C
Harper’s Illustrated Biochemistry, 30th Ed.
Mark’s Basic Medical Biochemistry, 4th Ed.

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