OVERVIEW

HEMOLYTIC ANEMIA

Normal RBC life span is 110-120 days

LIU YANFANG MD Ph D
Professor
Division of Hematology
Department of Medicine

OVERVIEW Definition
• Hemolysis
With age the red blood cell has : – Accelerated rate of red cell destruction (<120 days)
– Decreased membrane lipid component • May be well compensated by increased red cell production
by the bone marrow
– Spherocytic shape – Elevated reticulcoyte count
– Less pliability and deformability
• Hemolytic Anemia
These changes lead to the aged RBC being trapped – Accelerated rate of red cell destruction beyond the
and removed by the RE system ability of the bone marrow to fully compensate

CLINICAL PRESENTATION:
CLINICAL PRESENTATION More commonly associated with hemolytic anemia

Patients may present with a variety of • Jaundice

symptoms due to anemia (not necessarily hemolytic anemia) • Scleral icterus
• Gallstones
– Related to tissue hypoxia – bilirubinate
• Fatigue, weakness, lightheadedness, CP, SOB
• Splenomegaly
– LUQ pain, early satiety
– Related to cardiovascular compensation
• Tachycardia, palpitations • Leg ulcers
• Acute crisis
– Related to underlying etiology – ex. Aplastic crisis
 LABORATORY EVALUATION:
Suspected Hemolytic Anemia

Initial
• CBCP with MCV
• Reticuloctye count (retic. count)
• Review peripheral blood smear
– Nucleated red cells, reticulocytosis
• Bilirubin-direct and indirect
• Lactate Dehydrogenase (LDH)
• Consider haptoglobin, urinalysis

LABORATORY EVALUATION
Increased RBC Destruction
Additional / Directed studies Š ↑ BM Erythroid Production
• Coombs’ test Š Peripheral Blood RBCs
• Underlying disorders - Anemia
• Osmotic fragility test - ↑ Reticulocytes
• Hgb electrophoresis
- Poikilocytosis (Abnormal Shape)
• G-6PD assays
Š Body Retains RBC Products
• Enzyme assays
- Iron (Hemochromatosis)
• Bone marrow aspirate / biopsy
– Reversed M:E ratio
- Bilirubin (Jaundice, Gallstones)

EXTRAVASCULAR
Site of Hemolysis HEMOLYSIS

• 90% of cases

Extravascular • Inappropriate removal of RBC’s by the RE

vs. system

Intravascular • Exaggeration of the normal removal of RBC’s

 Extravascular Hemolysis (Spleen)
Extravascular Pathway for RBC Destruction
(Liver, Bone marrow,
& Spleen)

Phagocytosis & Lysis

Hemoglobin

Globin Heme Bilirubin

Amino acids Fe2+

Amino acid pool Excreted

INTRAVASCULAR INTRAVASCULAR
HEMOLYSIS HEMOLYSIS

• 10% of all cases

• Red cells are disrupted in the general circulation

• Free hemoglobin is released into the plasma

INTRAVASCULAR
HEMOLYSIS
Hemolytic Anemias
By products of intravascular hemolysis Intrinsic RBC Abnormalities:
include: Hereditary
Š Membrane Proteins - Spherocytosis
Hemoglobinemia Š Enzymes - G6PD Deficiency
Hemoglobinuria Š Hemoglobin Synthesis -
Hemosiderinuria Sickle Cell Disorders, Thalassemia
Low haptoglobin Acquired
Š Membrane Defect - PNH
 Hemolytic Anemias Hereditary Spherocytosis
1. Autosomal dominant inheritance; incidence 1/5000.
2. Defective "band 4.1" protein causing decreased spectrin
Extrinsic (Extracorpuscular) Abnormalities in red cell membrane.
Acquired: 3. Clinical manifestations: chronic anemia,
Š Antibody Mediated splenomegaly, gallstones, aplastic crisis.
Š Mechanical Trauma to RBC’s 4. Lab tests: Spherocytes on blood smear, increased
osmotic fragility.
Š Infections (Malaria)
5. Treatment: Splenectomy is essentially curative.

Hereditary Spherocytosis
Hereditary Spherocytosis
Mutation of Ankyrin Gene
Shear forces
(Most Common Defect)
in circulation
↓ membrane membrane
Abnormal Ankyrin Protein stability loss

Chronic
hemolytic MΦ
Deficiency of Spectrin Assembly anemia
splenomegaly spherocyte

Hereditary Spherocytosis
Laboratory Findings
Š PBS - Moderate Anemia
- Spherocytes
- Reticulocytes
Š BM - Erythroid Hyperplasia
Š Coomb’s Test - Negative
Š Osmotic Fragility Test - Sensitivity to Lysis
in Hypotonic Solution
Family History
 Spherocytes

Enzyme Deficiency
Glucose-6-Phosphate Dehydrogenase:
Š Deficiency (>400 Variants)
Š X Linked, Males > Females
- African Americans (Males 10%)
- Mediterranean Groups (↑ Severity)
Š No Symptoms Unless Oxidative Stress
- Therapeutic Drugs, Fava Beans
Š Denatured Hemoglobin Precipitates →
RBCs Removed by Spleen

Hemoglobin Precipitates (Special Stain)

G6PD Deficiency

O- glutathione
*GSH +
hydrogen peroxide

Hemoglobin precipitates
(Heinz bodies)

- plucked out by spleen - bite cells

(RBCs phagocytized in spleen)

Bite Cell - G6PD Deficiency

Hemoglobin Synthesis
Adult hemoglobin - 96% HgA (a2B2)

a2 B2

a2 B2

Clinically significant variant hemoglobins - usually

B abnormalities
 Hemoglobin S Disorders
Hemoglobinopathies
Š Point Mutation of B Globin Gene
Abnormal Hgb Structure (Qualitative) GLU HgA
zHereditary Disorders 6th
HgS
z>300 Types Abnormal Hemoglobin VAL

zHemoglobin S Disorders - Most Prevalent Š Hgb S Gene

- Sickle Cell Disease - Homozygous (SS) - 8% in American Blacks
- Sickle Cell Trait - Heterozygous - 30% in Some African Populations
40% Hgb S, 60% Hgb A (Anemia Rare) - Confers Resistance to plasmodium
falciparum Malaria

Sickle Cells
Sickle Cell Disease
Sickle cell
Deoxyg
enation
(or ↓H 0
2 , ↓pH)

O2
Polymerization
↑ Ca of Hgb S
↓ K, O2

Sickle Cell Disease

Š Irreversibly Sickled Cells are Hemolyzed in

the Spleen (Children - Splenomegaly)
Š Microvascular Occlusion
- Tissue Infarcts and Pain
- Autosplenectomy (Adults)
Š ↑ Infections - Salmonella Osteomyelitis
Š Aplastic Crisis - Usually Parvovirus
 Sickledex Screen
Normal RBCs Sickled RBCs
Sickle Cell Disorders
Diagnosis
Š Hemoglobin Electrophoresis - Identify
Hgb S
Š Sickledex - In Vitro Sickling After
Adding Reducing Agent
Š DNA Analysis - Prenatal Testing

Hemoglobin Thalassemia
Electrophoresis Š Absent or È Synthesis of Globin Chains
(Quantitative)
Š Most Frequent in Mediterranean,
African, or Asian Populations
* Sickle Cell Trait - Š β - Thalassemia - È β Chain Synthesis
Heterozygous (Gene Mutations)
Š α - Thalassemia - È α Chain Synthesis
(1-3 of 4 Genes Deleted) (SE Asians)

β - Thalassemia Minor
β - Thalassemia Major
β È β chain
βo β β No β Chain
β synthesis βo βo
β Synthesis
Chromosome 11
β β
β+ β È β chain β+ β+ È β Chain
β synthesis β Synthesis
Severe Anemia
Mild or no anemia
 β - Thalassemia Major
Š Peripheral Blood Smear
- Severe Hypochromic Microcytic
Anemia (↓ Hgb A → ↓ MCHC)
Š Bone Marrow
- Erythroid Hyperplasia
- Skeletal Deformities
Š Extramedullary Hematopoiesis
- Splenomegaly and Hepatomegaly

α - Thalassemia
β - Thalassemia Major Chromosome 16
α α α α α
Complications:
α α
Š ↑ α Chains - Hemolytic Anemia,
α - thalassemia trait
Ineffective Erythropoiesis Silent carrier
(+/- anemia)
Š Growth Retardation
Š Systemic Iron Overload HbH α
Chronic Blood Transfusions Hb Bart
disease
⇓
Cirrhosis, Cardiomyopathy (Cardiac (severe anemia) Hydrops fetalis
Failure), Death (2nd-3rd Decade) (lethal in utero)

Paroxysmal Nocturnal Hemoglobinuria Hemolytic Anemias

z Acquired Disorder Extrinsic Abnormalities - Acquired:
z 25% Paroxysmal and Nocturnal
z Mutation of Stem Cells - No Anchor Protein Š Antibody Mediated (Spherocytes)
(Chronic Hemolysis) Š Mechanical Trauma (Schistocytes)
- Heart Valves, Microthrombin Fibrin
C Complement- Strands in Vessels (DIC, TTP, HUS)
C
Induced Lysis Š Infections
(Intravascular - Malaria - Organisms Destroy RBCs
C - Hgb in Urine)
 Immune Hemolytic Anemias Immune Hemolytic Anemias
Warm Antibody Type (IgG, 37o C):
Antibody Mediated:
Š IgG Reacts with RBC Surface Antigens
Š RBC Destruction Caused By
Š Primary (Iidiopathic, 60%)
Antibody to RBC Surface Antigen
Š Secondary: Leukemia, Lymphoma, SLE,
Š Phagocytosis in Spleen
Drugs
Š More Common with Aging
Š Spherocytes - Spleen Removes
Š 2 Types - Warm and Cold
Membrane Protein from Ab Coated RBCs
Autoimmune Hemolytic Anemias
Š Positive Direct Coomb’s Test

Spherocytes

Autoimmune Hemolytic Anemia

1. Autoantibodies to own red cells. Associated with underlying
infection or tumor.
2. Two forms exist:
Warm AIHA: IgG antibodies cause acute hemolysis.
Associated with lupus, leukemia, or lymphoma.
Cold AIHA: IgM antibodies cause insidious hemolysis.
Associated with mycoplasma, viruses, or lymphoma.
3. Lab tests: Direct antiglobulin test, followed by antibody
identification.
4. Treatment: Steroids, treat underlying disease.

Direct Coombs Test Immune Hemolytic Anemias

Coombs Test Detects Antibodies Cold Antibody Type (IgM, <30o C)

Š Usually Not Clinically Significant
Human Globulin Agglutination
Š Acute
- mycoplasma pneumoniae
Ab Ab - Infectious Mononucleosis
Ab Ab (Mild Transient Anemia)
Antibodies to Š Chronic
Human Globulins + Patient RBC - Idiopathic, Lymphoma
 Mechanical Trauma - Schistocytes

Malaria
Š Most Common Acquired Hemolytic Anemia
Worldwide
Š Tropical Distribution with Variety of
Species
Š Parasites Destroy RBCs
Š Cyclical Hemolysis Produces Fever and
Chills
Š Splenomegaly - ↑ Mononuclear Cells

Malaria in RBCs NORMAL BILIRUBIN • Uptake of bilirubin by the liver is mediated by a

carrier protein (receptor)
METABOLISM
• Uptake may be competitively inhibited by other
organic anions

• On the smooth ER, bilirubin is conjugated with

glucoronic acid, xylose, or ribose

• Glucoronic acid is the major conjugate - catalyzed by

UDP glucuronyl tranferase

•“Conjugated” bilirubin is water soluble and is secreted

by the hepatocytes into the biliary canaliculi

• Converted to stercobilinogen (urobilinogen) (colorless)

by bacteria in the gut

• Oxidized to stercobilin which is colored

• Excreted in feces

• Some stercobilin may be re-adsorbed by the gut and

re-excreted by either the liver or kidney

Prehepatic (hemolytic) jaundice Intrahepatic jaundice

• Results from excess production of • Impaired uptake, conjugation,
bilirubin (beyond the livers ability or secretion of bilirubin
to conjugate it) following hemolysis

• Excess RBC lysis is commonly the • Reflects a generalized liver

result of autoimmune disease; (hepatocyte) dysfunction
hemolytic disease of the newborn
(Rh- or ABO- incompatibility);
structurally abnormal RBCs (Sickle • In this case,
cell disease); or breakdown of
extravasated blood hyperbilirubinemia is usually
accompanied by other
• High plasma concentrations of abnormalities in biochemical
unconjugated bilirubin (normal markers of liver function
concentration ~0.5 mg/dL)
Posthepatic jaundice
• Caused by an obstruction of the
biliary tree

• Plasma bilirubin is conjugated, and

other biliary metabolites, such as
bile acids accumulate in the plasma

• Characterized by pale colored

stools (absence of fecal bilirubin or
urobilin), and dark urine (increased
conjugated bilirubin)

• In a complete obstruction, urobilin

is absent from the urine