and bone marrow

Chapter 23 Blood and bone marrow



























CELLULAR COMPONENTS


The peripheral blood is investigated by microscopy of a droplet spread evenly over the surface of a glass slide—the blood film. Routinely, the blood film is treated with a combination of stains which allow identification of nuclear and cytoplasmic detail (Fig. 23.1).



Quantitation of blood cells is essential; in modern laboratories this is routinely performed by automated cell-counting equipment. The size and concentration of erythrocytes, and the leukocyte and platelet concentrations are measured. Haemoglobin is automatically measured. Also, the proportion of leukocytes of each category—the differential white cell count—is measured from cell size and granule content.



Erythrocytes


Erythrocytes (red blood cells) are deformable, non-nucleated and biconcave discs (Fig. 23.2). They are the most abundant blood cell. When blood is separated, by centrifugation, into cellular and plasma components, the red cell portion is approximately 45% of the total volume: this is the ‘packed cell volume’ or haematocrit.



The erythrocyte is a special oxygen-carrying cell because it is rich in haemoglobin. The cell membrane is composed of a phospholipid bilayer with integral proteins. The shape of the cell is maintained by structural proteins, such as spectrin, which form a cytoskeleton. Enzyme systems protect the haemoglobin from irreversible oxidation. The mature erythrocyte has no nuclear material, so new protein cannot be synthesised. The mature erythrocyte circulates for around 120 days before it is removed by the reticulo-endothelial system.





Changes in disease


Anaemia is present when the haemoglobin concentration is less than approximately 130g/l in a male or 115g/l in a female (Table 23.1); the haematocrit is also reduced. Conversely, polycythaemia describes an increased red cell concentration; it is usually accompanied by a raised haemoglobin concentration and haematocrit.



Anaemias may be simply classified according to red cell size (MCV) and haemoglobin content (MCH). This classification is of great diagnostic value in most common types of anaemia (Table 23.2). Further diagnostic information is obtained by the microscopic examination of the red cell morphology on a blood smear. Disease of the blood is frequently associated with increased variation in red cell size—anisocytosis—and the presence of erythrocytes of abnormal shape—poikilocytosis (Fig. 23.3). Increased erythrocyte anisocytosis and poikilocytosis are non-specific abnormalities present in many haematological and systemic disorders. An example is the marked aniso-poikilocytosis that occurs in the absence of a functioning spleen, due to surgical removal or secondary to disease. In this situation there are also inclusions in red cells. They are called Howell–Jolly bodies (Fig. 23.4) and are remnants of nuclear material that would normally be removed when newly formed erythrocytes released from bone marrow circulate for the first time through the spleen.




In addition to Howell–Jolly bodies, red cells may contain other inclusions (Fig. 23.4) under certain circumstances. The basophilic stippling of the ‘stipple cell’ is due to the presence of residual RNA; stipple cells may be present in several anaemias, especially thalassaemia. Siderotic granules contain iron and may occur in states of iron overload, for example in chronically anaemic subjects who have received treatment by frequent transfusion of red cells. Occasionally, nucleated red cell precursors may escape into the peripheral blood; when these normoblasts are accompanied by immature neutrophil leukocytes the film is described as leukoerythroblastic. A leukoerythroblastic blood film results from gross marrow disturbance such as infiltration by malignancy, or fibrous tissue (myelofibrosis) or in severe anaemia due to deficiency of vitamin B12 or folate (megaloblastic anaemia).



Supravital staining is used to detect the presence of reticulocytes, as described above. This technique also identifies another type of red cell inclusion—Heinz bodies. These inclusions represent denatured haemoglobin and are seen typically in certain haemolytic anaemias, especially those due to a deficiency in the protective enzyme systems such as glucose-6-phosphate dehydrogenase deficiency.



Leukocytes


The nucleated cells of the peripheral blood are termed white blood cells or leukocytes. Their primary role is protection against infection or infestation of the body. Morphologically, on a stained blood film, five varieties of leukocyte are identified.


The normal concentrations of these are:







These are typical values for healthy adults and older children. The normal counts differ in infants, who have a higher proportion of lymphocytes, for example.


Also, it is important to appreciate how such laboratory normal ranges are established in order to avoid misinterpretation. Cell counts are performed on a large number of healthy subjects and the range is determined from the population mean and two standard deviations above and below the mean. This dictates that, for a particular measurement, 2.5% of healthy subjects have a count just below the lower limit of ‘normal’ and a further 2.5% just above.


The granulocytes and monocytes are phagocytic leukocytes produced from precursor cells in the bone marrow. The lymphocytes are broadly composed of B-cells which mediate humoral immunity via the maturation to immunoglobulin-producing plasma cells; they are produced initially in the bone marrow and subsequently mature by antigen selection in the germinal centres of secondary lymphoid tissues; and T-cells which provide cell-mediated immunity such as killing virally infected cells. T-cells are produced and selected for antigen in the thymus gland. B- and T-cells circulate in the blood as small lymphocytes.









Changes in disease


Changes may be quantitative or qualitative; the former are more important and often of diagnostic value. Knowledge of the causes of increased numbers of the various leukocytes in the peripheral blood is useful clinically.



Quantitative changes


Leukocytosis means an increase in numbers of circulating white blood cells. Depending on the cause, there may be a polymorphonuclear leukocytosis (neutrophilia—increased neutrophil leukocytes), monocytosis, eosinophil leukocytosis (eosinophilia), basophil leukocytosis (basophilia) or lymphocytosis.


Causes of reactive neutrophil leukocytosis include:









Monocytosis may be reactive to:





Eosinophil leukocytosis may be reactive to:






Lymphocytosis is most commonly associated with an infection such as infectious mononucleosis, tuberculosis, etc.


In some disorders the leukocytosis may be extreme (for example 100 × 109/l), particularly in children. There may also be a tendency for immature leukocytes, particularly myelocytes and metamyelocytes, to appear in the peripheral blood. Severe bacterial infection may result in such an extreme reactive picture, which has in the past been referred to as a ‘leukaemoid reaction’ because of the similarity of the blood picture, with immature forms present, to that of chronic myeloid leukaemia. Occasionally, the lymphocyte series may be involved in such an extreme reactive process, especially during childhood viral infection.


A characteristic leukocytosis composed of ‘atypical’ lymphocytes is a feature of infectious mononucleosis (glandular fever). The infection is common in young adults and often manifests as a sore throat with enlarged lymph nodes and spleen and skin rash. It is due to infection with Epstein–Barr (EB) virus and is common between 15 and 25 years of age in developed countries, but occurs in young children in heavily populated developing countries. The major additional features are:







The atypical cells in peripheral blood are recognisable as lymphocytes but are much larger and have abundant cytoplasm and nuclear irregularities (Fig. 23.5). They are probably reactive T-lymphocytes responding to B-lymphocytes containing the virus, are detectable in blood about 7 days after the onset of illness and may persist for 6 weeks or more. Apparently fortuitously, but usefully, antibodies reactive against horse, sheep and ox red cells (heterophile antibodies) typically develop during the second week and may persist for a few months; they are detected in the Paul–Bunnell test or by more convenient commercial screening slide tests such as the ‘Monospot’ test, and are of diagnostic value. A very similar clinical and haematological (but not serological) picture can develop as a result of other infections, especially with human immunodeficiency virus (HIV), cytomegalovirus and toxoplasma.



All of the above are examples of reactive leukocytosis. Increased white cell counts in peripheral blood, often with immature forms present, are also a typical feature of some primary disorders of the bone marrow, especially leukaemias and myeloproliferative disorders.


A reduction in circulating leukocytes is termed leukopenia. Most important is a deficiency of neutrophil granulocytes— neutropenia. Neutropenia is commonly seen in association with a reduction in other blood cells, that is, as part of a pancytopenia. Important causes of pancytopenia are:





Important causes of selective neutropenia are:







In cyclical forms the neutropenia is temporary and recurrent, often with a periodicity of 3–4 weeks. It is an uncommon condition.


Neutropenia with counts of less than 0.5 × 109/l may result in severe sepsis, especially of the mouth, pharynx (Fig. 23.6) and peri-anal regions, and also in disseminated infection. This clinical picture is now most commonly seen in patients receiving drug or irradiation therapy for malignant disorders.





Platelets


On a stained blood film platelets appear as non-nucleated fragments of granular cytoplasm, approximately one-fifth the diameter of erythrocytes and in a concentration of 150–400 × 109/l. Platelets are contractile and adhesive cells, the function of which is the maintenance of vascular integrity. Exposure of vascular subendothelial structures results in rapid adhesion of platelets to the exposed area and aggregation of platelets to each other in the formation of a primary haemostatic plug (Fig. 23.8). Platelets are rich in intracellular granules, which are released during stimulation. The most abundant granules, alpha granules, contain proteins and peptides, including von Willebrand factor, some coagulation factors and growth factors. Platelets deliver these to sites of vascular injury, where they contribute to clot formation and the repair process. Dense bodies are less abundant platelet granules and are rich in calcium, serotonin and adenine nucleotides.



A deficiency of blood platelets is termed thrombocytopenia, the causes and consequences of which are described on page 670. Thrombocytosis, or increased platelet numbers, may be due to a primary bone marrow problem or may be reactive. Examples of reactive thrombocytosis are seen in:•







Thrombocytosis may also occur in primary disorders of bone marrow—the myeloproliferative diseases and chronic myeloid leukaemia. Morphological platelet abnormalities are of minor importance, although ‘giant’ platelets, with a diameter exceeding that of an erythrocyte, are a feature of the myeloproliferative disorders rather than reactive thrombocytosis. Giant platelets are also a feature of some inherited syndromes, including those associated with mutations of the myosin heavy chain gene.




BLOOD PLASMA


Plasma amounts to greater than 50% of blood volume. While changes in the innumerable constituents of plasma are outside the scope of this text, consideration of certain major plasma proteins is necessary for an understanding of the pathology of some blood and systemic disorders. The plasma proteins that are components of the blood coagulation and fibrinolytic systems are considered first.




Blood coagulation


For normal homeostasis, blood must be fluid; however, the capacity to minimise loss of blood through breaches of the vascular system is essential. The rapid plugging of defects in small vessels is the function of platelets (primary haemostasis, Fig. 23.8) but a more permanent and secure seal results from the generation of insoluble fibrillar fibrin from its soluble plasma protein precursor fibrinogen in the process of blood coagulation. Failure of primary haemostasis, due to platelet disorders, or of coagulation due to clotting factor deficiency or presence of a coagulation inhibitor, can each result in life-threatening haemorrhage. In contrast, inappropriate activation of platelets or blood coagulation may result in vascular occlusion, ischaemia and tissue death. A complex system of activators and inhibitors in plasma has therefore evolved in order to allow localised clot formation at sites of injury but to minimise the risk of inappropriate and undesirable clotting, i.e. thrombosis. These are the coagulation and fibrinolytic factors and their inhibitors (Fig. 23.9).



Important features of the haemostatic mechanism are as follows.



Thrombin is a key enzyme in coagulation because it acts in a feedback loop to activate several of the other coagulation factors and is therefore pivotal in the amplification system (Fig. 23.9). In addition it activates platelets through a specific receptor, ensures clot stabilisation by activating factor XIII and helps to address the degree of clot formation by activating the natural anticoagulant activated protein C (aPC).





Coagulation inhibitors limit unwanted clotting and protect against vessel occlusion, especially in veins:








Although the scheme for the initial stages of coagulation activation can be conveniently divided into extrinsic and intrinsic pathways (Fig. 23.9), this is a simplification. Coagulation activation in vivo is initiated through tissue factor, an integral cell membrane protein which is not expressed by vascular endothelial cells in an unstimulated state but is expressed by subendothelial cells and smooth muscle as well as other cells. As soon as blood leaks from a vessel it is exposed to tissue factor. Tissue factor activates factor VII. The much slower pathway for fibrin generation through activation of factor XII on contact with subendothelial components is of minor importance. This partially explains the absence of any increased tendency to haemorrhage in subjects who are congenitally deficient in factor XII. It is the tissue factor–activated factor VII complex that rapidly activates factors X and IX, leading to thrombin generation. When the procoagulant stimulus is sufficiently strong, the degree of amplification through thrombin activation of factors V and VIII overcomes inhibition by activated protein C and fibrin generation proceeds.


The final step in clot formation is the stabilisation of fibrin by cross-linking through the activity of factor XIII.


In the laboratory, the function of the components of the coagulation system can be assessed by the time required for clotting of recalcified plasma prepared from a blood sample anticoagulated with sodium citrate. The citrate binds calcium ions, which are required at several points in the mechanism. Recalcification allows fibrin formation to take place. The two principal screening tests used in clinical practice are:




The pathology and consequences of deficiency of the components of the coagulation and fibrinolytic system are described on page 673.



Rheological considerations


Blood is a viscous fluid and changes in its physical properties accompany some diseases. The major determinant of blood viscosity is the haematocrit.


The plasma fibrinogen concentration is the major determinant of red cell aggregation and is second only to haematocrit as a factor in determination of blood viscosity. Other plasma protein molecules tend to be smaller and more symmetrical than fibrinogen and consequently have a much lesser effect on viscosity. However, when they are present in increased concentrations, blood viscosity may be affected. This may result in a hyperviscosity syndrome, in which there is stasis within the microcirculation and tissue anoxia. Cerebral dysfunction, with headache, visual disturbance and drowsiness progressing to coma may result. Very high plasma immunoglobulin concentration, which is a common feature of the malignant disorders multiple myeloma and macroglobulinaemia, is a common cause of the hyperviscosity syndrome. Numbers of leukocytes and platelets have little influence on blood flow in health. However, when leukocyte counts exceed 300 × 109/l, usually in leukaemia, flow may be adversely affected, resulting in clinical hyperviscosity.


The hyperviscosity syndrome represents an extreme abnormality of blood flow producing organ dysfunction. However, epidemiological studies suggest that even minor increases in blood viscosity, due to increased haematocrit or fibrinogen concentration, may result in a tendency to vascular occlusion, manifesting as an increased incidence of myocardial infarction and cerebral infarction. The concentration of plasma fibrinogen is a risk factor for atherosclerosis and arterial thrombosis that is at least as potent as the level of serum cholesterol. The interplay between rheological and haemostatic changes in thrombotic disease is not yet fully understood.




HAEMOPOIESIS AND BLOOD CELL KINETICS


Haemopoiesis is the formation of blood cells.




Sites of haemopoiesis


In the adult, all blood cells are produced in the red marrow, which is restricted to the bones of the axial skeleton—vertebrae, ribs, sternum, skull, sacrum, pelvis and proximal femora. In these regions the bone marrow is composed of approximately 50% fat, within adipocytes, and 50% blood cells and their precursors (Fig. 23.10). The fatty marrow of other bones is capable of haemopoiesis when requirements for blood cells are increased in some diseases.



In the infant and young child, practically all of the bones contain haemopoietically active marrow.


In fetal life, the liver and spleen are the major haemopoietic organs between about 6 weeks and 6–7 months’ gestation; the yolk sac is the main site before 6 weeks. In disease, the liver and spleen can again become haemopoietic organs, even in adult life; this development is referred to as extramedullary haemopoiesis and is particularly associated with the progressive fibrosis of bone marrow seen in the myeloproliferative disorders.


The bone marrow is examined histologically in two ways. Marrow can be aspirated through a needle inserted into a marrow cavity (usually sternum or pelvis), smeared on a slide and stained in a method similar to that for peripheral blood. Further information, particularly on the structure and cellularity of the marrow, can be obtained by preparation of sections of a marrow trephine biopsy: this is a core of tissue obtained using a wide-bore needle (Fig. 23.10).


Additional investigations carried out on bone marrow samples include staining of individual cells with monoclonal antibodies (immunophenotyping and immunohistochemistry) and genetic analysis including karyotyping, fluorescent in situ hybridisation (FISH) and molecular analysis of individual genes.



Haemopoietic stem cells


Studies of bone marrow in culture lead to the conclusion that erythrocytes, leukocytes (including lymphocytes) and platelets are derived from a common, self-replicating precursor cell or ‘pluripotential stem cell’. By a series of cell divisions, cells committed to each line are produced and further divisions result in mature cells—erythrocytes, granular leukocytes, megakaryocytes and T- and B-lymphocytes (Fig. 23.11). The pluripotential stem cells possess the ability to renew in addition to the capacity to differentiate. It is now clear that bone marrow also contains mesenchymal stem cells which can give rise to connective tissues such as fat cells, fibroblasts, bone and cartilage. The development and preferential survival of a malignant clone of haemopoietic cells, derived from mutated bone marrow stem cells, explains the pathological features of the leukaemias and myelodysplastic syndromes.



If human bone marrow is infused intravenously into a subject without functioning marrow, as during bone marrow transplantation treatment, normal blood cell production returns after a period of several weeks. This finding confirms the presence of pluripotential stem cells in bone marrow and also indicates that the microenvironment of the bone marrow is central to normal blood production; stem cells do not tend to thrive in other sites, and blood production resumes only in the marrow cavities after marrow infusion. Stem cells can be made to circulate in the peripheral blood. This is most conveniently achieved by the administration of one of the cytokines (most commonly G-CSF) responsible for stimulation of haemopoiesis—the colony stimulating factors. Using an extracorporeal centrifugation technique these cells can be harvested and used as an alternative to bone marrow cells in transplantation therapy—a ‘peripheral blood stem cell transplant’. Peripheral blood is used as a source of haemopoietic stem cells more commonly now than bone marrow because engraftment is faster and procurement of peripheral blood stem cells does not require the donor to have a general anaesthetic.


There is great interest in the possibility that marrow stem cells may be able to differentiate into diverse tissue types, including neuronal, muscle, liver and vascular cells. This is referred to as transdifferentiation or stem cell plasticity. Although definitive proof of this is still lacking, should it be confirmed it offers exciting new possibilities for treatment of common disorders through transfer of stem cells. Such studies are ongoing and to date show some benefit in treating damaged myocardium and improving blood flow to ischaemic limbs.







Control of haemopoiesis


Peripheral blood cell counts are normally maintained within close limits. However, the ability of each cell line to respond appropriately to increased requirement is exemplified by the increased red cell production after haemorrhage, the granulocyte leukocytosis in response to sepsis and the enhanced platelet production that results from chronic bleeding.


Erythropoietin is a glycoprotein hormone, produced by peritubular fibroblasts in the kidney, that increases erythropoietic activity. The production of erythropoietin is increased in response to a reduced oxygen tension in the blood reaching the kidney. It results in an increase in the number of cells committed to the erythroid line, reduced maturation time and early release of erythrocytes from the bone marrow. Erythropoietin mediates the physiological response of the bone marrow to anaemia or hypoxia. In pathological states, failure of erythropoietin production is a major contributor to the anaemia of chronic renal failure and this can be corrected by erythropoietin administration; inappropriate erythropoietin production by some renal cysts and tumours results in secondary polycythaemia.


Numerous growth factors have been found to govern production of leukocytes in the bone marrow. They are synthesised mainly by T-lymphocytes, monocytes/macrophages, endothelial cells and fibroblasts of the bone marrow stroma. Examples are interleukins 1, 3 and 6 and the colony stimulating factors. GM-CSF increases stem cell commitment to granulocyte and monocyte production, G-CSF to granulocytes and M-CSF to monocytes. Recombinant forms of some of these cytokines are now in therapeutic use, particularly in cancer chemotherapy, where the duration of drug-induced neutropenia can be limited by cytokine administration.


Thrombopoietin, capable of the stimulation of platelet production, is synthesised principally in the liver. Analogues of thrombopoietin may be of use in stimulating platelet production in bone marrow failure states and as shown recently in immune thrombocytopenic purpura (ITP).



Haemoglobin



Structure, synthesis and metabolism


Some knowledge of haemoglobin structure and metabolism is necessary for an understanding of the pathology of the anaemias. Haemoglobin is the oxygen-carrying pigment. The haem group of haemoglobin is responsible for oxygen carriage and is composed of a protoporphyrin ring structure with an iron atom.


By 1 month of age red cell precursors synthesise predominantly haemoglobin A, composed of four haem groups and four polypeptide (globin) chains (Fig. 23.13), of which two molecular forms are present: alpha and beta chains. Haemoglobin A thus has the structure α2β2. Up to 2.5% of the haemoglobin in adults has delta chains (α2δ2)—haemoglobin A2; and up to 1% of the haemoglobin in adults has gamma chains (α2γ2)—haemoglobin F. Adult blood therefore has predominantly haemoglobin A with some A2 and F (Table 23.3).




In later fetal and early neonatal life haemoglobin F predominates. In early fetal life three other haemoglobins are present: Gower 1, Gower 2 and Portland (Table 23.3).


The whole haemoglobin molecule is thus composed of a tetramer of globin chains, each with a haem group. The complex structure of the molecule is responsible for its oxygen (O2) binding characteristics, the globin chains moving against each other during transfer of O2. The affinity of the haemoglobin molecule for O2 is also controlled by its ability to bind the metabolite 2,3-biphosphoglycerate (2,3-BPG) produced during anaerobic respiration. When 2,3-BPG enters the haemoglobin molecule as the beta chains pull apart during release of O2, the affinity for O2 of the haemoglobin–2,3-BPG complex is reduced, allowing O2 to be given up more readily. Haemoglobin F cannot bind 2,3-BPG and thus has a relatively high O2 affinity, facilitating O2 transfer from maternal blood across the placenta.


At the end of the erythrocyte life-span haemoglobin is metabolised, with conservation of iron and amino acids. Iron is carried by plasma transferrin to the bone marrow and utilised in the synthesis of haem. Globin is degraded to its constituent amino acids, which enter the general pool. Liver, gut and kidneys are all involved in excretion of products of haem breakdown as derivatives of bilirubin.


In the congenital disorders collectively known as haemoglobinopathies, the rate of synthesis of one globin chain type is defective (the thalassaemias) or an abnormal chain is synthesised (the sickle haemoglobinopathies and other haemoglobin variants).




ANAEMIAS




Anaemia is present when the haemoglobin level falls below around 130g/l in a male or 115g/l in a female. The different lower limits of normal haemoglobin concentration for neonates, infants and children should be noted (Table 23.1).


The consequences of anaemia are dependent upon the speed of onset. Thus the rapid loss of 10% or more of the circulating blood volume through haemorrhage will result in shock, i.e. the failure of adequate perfusion of all tissues and organs, with consequent hypoxia. In this situation the subject may not initially be anaemic, as both red cells and plasma are lost through haemorrhage. The plasma component is more rapidly replaced, however, and anaemia will be present after several hours have elapsed.


Anaemia that develops more gradually is better tolerated. A haemoglobin concentration as low as 20g/l may be consistent with survival if it develops over a protracted period. The inevitable result of anaemia, however, is a reduction in the oxygen-carrying capacity of the blood and thus chronic tissue hypoxia.


The general consequences of anaemia are due to the tissue hypoxia, which can result in fatty change, especially in the myocardium and liver, and even infarction. Lethargy, increased breathlessness on exertion, and new or worsened ischaemic phenomena are typical clinical features. Breathlessness at rest implies the development of heart failure, a result of severe anaemia. Expansion of the red marrow is present in those anaemias where a marrow response is possible—generally the haemolytic anaemias. Other features are specific to anaemias resulting from a particular mechanism, such as the jaundice of haemolytic anaemias, or are specific to anaemia of a particular type, such as the nail changes of iron deficiency anaemia. Such pathological features are described in the relevant sections.


A low haemoglobin concentration usually reflects a reduction in the body red cell mass. An important exception is pregnancy, when both red cell mass and plasma volume increase, but the latter to a greater degree. This process results in a haemoglobin concentration in blood that is lower than in the non-pregnant state in the presence of a relatively increased red cell mass and overall oxygen-carrying capacity; this condition is often referred to as the physiological ‘anaemia’ of pregnancy. The increased red cell mass during pregnancy is necessary to support the increased metabolic requirement of the mother and fetus. The reason for the expansion of the plasma compartment is obscure, but it may be explained in part by a need for increased skin perfusion for heat loss due to the increased metabolic rate.


Expansion of the plasma volume, resulting in dilutional anaemia, may also occur when the spleen is pathologically enlarged. (The spleen appears to exert a controlling influence on plasma volume.) Other mechanisms also operate in this situation, however, as described under hypersplenism (p. 654).



Classification


Table 23.4 outlines a classification of anaemias. Anaemias are divided into two categories: those where anaemia is due to failure to produce erythrocytes, and those in which erythrocyte loss is increased but production is normal (or usually increased, in response to the anaemia). While useful, this categorisation is an oversimplification, as both mechanisms are present in some anaemias. Thus, in the megaloblastic states, cell production is defective due to lack of vitamin B12 or folic acid for nucleic acid synthesis but, in addition, the erythrocytes that are produced are abnormal and of diminished survival. In thalassaemia, cell production is not optimal due to abnormal haemoglobin synthesis, and there is also increased erythrocyte destruction.


Table 23.4 A classification of anaemias


































Type Cause
Production failure anaemia
Haematinic deficiency Insufficiency of iron, vitamin B12 or folic acid
Anaemia of chronic disorders Infection, inflammation and neoplasia
Dyserythropoiesis

Hypoplasia  
Marrow infiltration



Increased red cell loss, lysis or pooling







Haemolysis due toabnormality outsidethe red cell



Hypersplenism  

The myeloid and megakaryocytic lines are also involved in some anaemias due to failure of haemopoiesis (megaloblastic anaemia, hypoplastic anaemia) but not in others (iron deficiency anaemia).


Despite these qualifications, the classification described is useful as an aid to determining the cause of the anaemia.



PRODUCTION FAILURE ANAEMIAS


The most commonly encountered anaemias are in the production failure group.



Haematinic deficiency


Haematinics are dietary factors essential for either haemoglobin synthesis or erythrocyte production.



Iron deficiency




Iron deficiency is the commonest cause of anaemia worldwide. It is also the commonest cause of a microcytic hypochromic blood picture, the others being thalassaemias and (rarely) sideroblastic anaemias.



Iron metabolism


Iron is an essential requirement. It is also one of the commonest elements present in the Earth’s crust. Excessive iron deposited in the tissues is, however, toxic, causing damage to the myocardium, pancreas and liver in particular (Ch. 16). As the body has no active method for iron excretion, iron status is controlled largely by its absorption; the capacity to absorb iron is, however, limited and any tendency to increased loss of iron, due to haemorrhage, is highly likely to result in a negative iron balance and iron deficiency. These factors explain the high prevalence of iron deficiency.


Normally, at least 60% of the body iron is in the haemoglobin of erythroid cells. Approximately 30% is stored within the reticulo-endothelial system (also known as the mononuclear phagocyte system), especially in the bone marrow, as ferritin and haemosiderin. A small proportion of total body iron is present in other tissues, especially muscle, and iron-containing enzymes. This tissue iron is relatively conserved during states of iron deficiency. Only a small fraction of the total body iron is in transport, attached to the carrier protein transferrin.


Ferritin is a protein–iron complex. The protein, apoferritin, is a shell made up of 22 subunits. The core is composed of ferric oxyhydride. Haemosiderin consists of partially degraded ferritin aggregates. Ferritin is present in all tissues, but especially in the macrophages of the bone marrow and spleen and in hepatocytes. A small amount is detectable in plasma and, as it is derived from the storage pool of body iron, its concentration is thus an accurate indicator of body iron stores. Low serum ferritin concentration is a useful confirmatory test for iron deficiency. However, because ferritin is an acute phase response protein, the concentration in plasma is not a reliable guide to body iron stores in the presence of infection, inflammation and neoplasia. In those situations serum ferritin may be normal or high despite tissue iron depletion.


Ferritin is water soluble and not visible by light microscopy; haemosiderin is insoluble and forms yellow granules. When exposed to potassium ferrocyanide (Perls’ stain) the granules are blue–black. Examination of aspirated bone marrow stained with Perls’ stain can therefore be used to assess body iron stores reliably. When iron stores are normal, haemosiderin is visible, mainly in the reticulo-endothelial cells of the bone marrow. In iron overload, most of the iron is in the form of haemosiderin and can be easily identified.


Transferrin is an iron-binding beta-globulin responsible for iron transport and delivery to receptors on immature erythroid cells. Each molecule of transferrin can bind two atoms of iron, but normally the transferrin is only one-third saturated (thus the serum iron concentration is normally one-third of the total serum iron-binding capacity). Transferrin is reutilised after delivering its iron. A low transferrin saturation is therefore diagnostic of iron deficiency while high levels are a feature of iron overload with deposition of iron in tissues.


In order to maintain iron balance, sufficient iron must be absorbed to replace that lost from the urinary and gastrointestinal tracts as shed cells and in sweat, together with any extra requirements.


Daily iron requirements are:






Thus, requirements vary with circumstances, extra iron being required for growth during childhood, for the fetus and placenta and expansion of maternal red cell mass during pregnancy, and to compensate for menstrual loss of women of child-bearing age.


As a Western diet contains only 10–20 mg of iron per day and only a maximum of one-third of this can be absorbed, excess losses of iron of just a few milligrams will inevitably result in negative iron balance and eventual depletion of iron stores. One millilitre of blood contains 0.5 mg iron. Thus, loss of 10 ml of blood daily will inevitably exceed the capacity to absorb sufficient iron, even from a good diet. This explains the finding of some degree of iron depletion in 25% or more of menstruating women.


Iron absorption takes place in the duodenum and upper jejunum. Haem iron is present in meat and readily absorbed, with little effect from other dietary components. Inorganic iron in vegetables and cereals is mostly trivalent and may be complexed to amino acids and organic acids, from which it must be released and reduced to the divalent state for absorption. HCl produced by the stomach and ascorbic acid in food favour its absorption. In contrast, phosphates and phytates in some foods form precipitates and prevent absorption.


Mechanisms controlling the rate of iron absorption are becoming better understood. Major influences are the total body iron stores and rate of erythropoiesis. Thus, if iron stores are replete a smaller proportion of available iron is absorbed; when erythropoiesis is more active, due to premature red cell destruction for example, extra iron is absorbed even though total stores may be high. This is a feature in thalassaemia, and iron overload may ensue. A major regulator of iron balance is the liver protein hepcidin. Iron loading leads to rapid production of hepcidin by the liver which, in turn, inhibits intestinal iron absorption and movement of iron from stores. This is achieved by hepcidin downregulating the plasma membrane transfer protein ferroportin. Iron is consequently trapped in iron-exporting cells, including duodenal enterocytes. Plasma iron levels subsequently fall. Conversely, low iron levels lead to downregulation of liver hepcidin and increased iron transfer from the gut and iron-exporting cells so that plasma iron levels rise (Fig. 23.14).


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Jun 16, 2017 | Posted by in GENERAL SURGERY | Comments Off on and bone marrow

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