Learning Outcomes:

1-RBC - (Production, Degradation)

2-Haemoglobin - (Structure, Degradation)
3-Thalassemia - (Aetiology, Pathology, Diagnosis,Management-[splenectomy,
cholecystectomy, etc.], Clinical features)
4-Genetic Counselling (Esp. in consanguineous couples)

LEARNING OUTCOME 1 RBC

a) ERYTHROPOIESIS

b)

LEARNING OUTCOME 2 HAEMOGLOBIN

a) Structure

Hemoglobin
Adult hemoglobin is a [(2):(2)] tetrameric hemeprotein found in
erythrocytes where it is responsible for binding oxygen in the lung and
transporting the bound oxygen throughout the body where it is used in
aerobic metabolic pathways.

For a description of the different types of hemoglobin tetramers see

the section below on Hemoglobin Genes. Each subunit of a hemoglobin
tetramer has a heme prosthetic group identical to that described for
myoglobin. The common peptide subunits are designated , , and
which are arranged into the most commonly occurring functional
hemoglobins.
Although the secondary and tertiary structure of various hemoglobin
subunits are similar, reflecting extensive homology in amino acid
composition, the variations in amino acid composition that do exist impart
marked differences in hemoglobin's oxygen carrying properties. In
addition, the quaternary structure of hemoglobin leads to physiologically
important allosteric interactions between the subunits, a property lacking
in monomeric myoglobin which is otherwise very similar to the -subunit
of hemoglobin.

Comparison of the oxygen binding properties of myoglobin and

hemoglobin illustrate the allosteric properties of hemoglobin that results
from its quaternary structure and differentiate hemoglobin's oxygen
binding properties from that of myoglobin. The curve of oxygen binding to
hemoglobin is sigmoidal typical of allosteric proteins in which the
substrate, in this case oxygen, is a positive homotropic effector. When
oxygen binds to the first subunit of deoxyhemoglobin it increases the
affinity of the remaining subunits for oxygen. As additional oxygen is
bound to the second and third subunits oxygen binding is further,
incrementally, strengthened, so that at the oxygen tension in lung alveoli,
hemoglobin is fully saturated with oxygen. As oxyhemoglobin circulates to
deoxygenated tissue, oxygen is incrementally unloaded and the affinity of
hemoglobin for oxygen is reduced. Thus at the lowest oxygen tensions
found in very active tissues the binding affinity of hemoglobin for oxygen
is very low allowing maximal delivery of oxygen to the tissue. In contrast
the oxygen binding curve for myoglobin is hyperbolic in character
indicating the absence of allosteric interactions in this process.
b) Degradation

Haemoglobin is made up of heme, an iron containing porphyrin and globin, a

protein. Normally the erythrocyte lives about 120 days. Ageing or damaged
erythrocytes are destroyed by the macrophages of the reticuloendothelial system
of the spleen. Other sites notably the, liver and the bone marrow, are also
capable of destroying erythrocytes. As the life span of erythrocytes is not
increased in splenectomized patients, these sites can completely take over the
function in the absence of the spleen. The spleen, unlike other reticuloendothelial
sites, is sensitive to subtle damage to the erythrocytes.
Heme splits into globin and hemin and globin. The amino acids released from the
catabolism of globin chain are reused for protein synthesis. Hemin is acted upon
by heme oxygenase to give biliverdin and iron. The iron is reused for
haemoglobin synthesis. Biliverdin, released from the catabolism of
protoporphyrin, is finally excreted as conjugated bilirubin in the bile (Figure 1).
Biliverdin is converted to bilirubin by biliverdin reductase. Bilirubin is water
insoluble and needs to be conjugated with glycuronic acid in the liver to make it
water soluble and make excretion in bile possible. Unconjugated bilirubin binds
to albumin and is carried to the liver. The hepatocyte takes up the unconjugated
bilirubin by both simple and facilitated diffusion and converts it to bilirubin
diglucuronide in two steps. Some bilirubin monoglucuronide is also formed. The
enzyme uridine diphophate glucuronyl transferase (UDPGT) facilitated bilirubin
conjugation.
Bilirubin is secreted into bile against a concentration gradient. MRP-2 (multidrug
resistance like protein 2) is one of the proteins involved in bilirubin secretion.
In the intestine bilirubin is converted to urobilinogen, a colourless compound, by
the intestinal flora. Urobilinogen is converted to a pigment responsible for the
colour of faeces, urobilin. Some urobilinogen is absorbed and excreted in urine.
Bilirubin metabolism is affected in conjugation defects, secretion defects and in
states of increased haemoglobin catabolism.
1. Bilirubin conjugation defects: Mutations in the UDGPT result in three
syndromes. These are, in decreasing severity, Crigler-Najjar Syndrome I
(CN-I), Crigler-Najjar Syndrome II (CN-II) and Gilberts syndromes. While
CN-I is fatal except in those who undergo liver transplantation, Gilberts
syndrome causes no symptoms otherthan jaundice. Patients with all three
diseases have unconjugated hyperbilirubinemia which may range from
usually >20mg/dL in CN-I, usually <20mg/dL in CN-II and <4mg/dL in
Gilberts syndrome. Gilberts syndrome can mimic haemolysis. The
absence of other evidence of red cell destruction, viz. increase in the LDH
and decrease in the haptoglobin, and the absence reticulocytosis
differentiates it from haemolysis.
2. Bilirubin secretion defects: Defects in secretion of conjugated bilirubin
includeDubin-Johnson syndrome, Rotor syndrome, benign recurrent
intrahepatic cholestasis (types 1 and 2) and progressive familial
intrahepatic cholestasis (types1, 2 and 3). (links take you to the OMIM
page for the disease)

Increased haemoglobin catabolism: Increased haemoglobin catabolism, seen

in patients with haemolytic anaemia and states associated with ineffective
erythropoiesis, increases bilirubin production and overwhelms the hepatic
uptake/conjugation capacity. This increases the unconjugated bilirubin. Increased
bilirubin production in patients with haemolytic anaemia is a result of increased
erythrocyte destruction by the spleen. Typically, hyperbilirubinemia is associated
with extravascular haemolysis. Splenomegaly may accompany unconjugated
hyperbilirubinemia due to haemolysis because of the increased workload.
Patients of haemolytic anaemia show elevated LDH levels and reticulocytosis.
Patients with ineffective erythropoiesis, e.g. megaloblastic anaemia due to
folate/B12 deficiency, have increased haemoglobin catabolism due to destruction
of haemoglobinized precursors in the bone marrow. There is reticulocytopenia,
the increase in LDH is more pronounced than haemolytic anaemia, there is no
splenomegaly. Haemolysis and ineffective erythropoiesis may co-exist in
megaloblastic crises of haemolytic anaemia. Unconjugated hyperbilirubinemia
due to increased bilirubin production is associated with increased urinary
urobilinogen, a features not seen in inherited syndromes of bilirubin conjugation
(CN-I, CN-II and Gilberts syndrome). It is unusual for the bilirubin to increase
beyond 4mg/dL only from increased haemoglobin breakdown. When higher
values are encountered other reasons for an increased bilirubin must be sought.
All patients with increased haemoglobin breakdown do not show
hyperbilirubinemia.
LEARNING OUTCOME

3 THALESSEMIA
The thalassaemias
Thalassaemia is an inherited impairment of haemoglobin
production, in which there is partial or complete failure
to synthesise a specific type of globin chain. In alphathalassaemia,
disruption of one or both alleles on chromosome
16 may occur, with production of some or no
alpha globin chains. In beta-thalassaemia, defective production
usually results from disabling point mutations
causing no (0) or reduced () beta chain production.

Beta-thalassaemia

Failure to synthesise beta chains (beta-thalassaemia) is

the most common type of thalassaemia, most prevalent
in the Mediterranean area. Heterozygotes have thalassaemia
minor, a condition in which there is usually mild
anaemia and little or no clinical disability, which may be

detected only when iron therapy for a mild microcytic

anaemia fails. Homozygotes (thalassaemia major) either
are unable to synthesise haemoglobin A or, at best,
produce very little; after the first 46 months of life, they
develop profound hypochromic anaemia. The diagnostic
features are summarised in Box 24.42. Intermediate
grades of severity occur.

Management and prevention

See Box 24.43. Cure is now a possibility for selected

children, with allogeneic haematopoietic stem cell transplantation
(p. 1017).
It is possible to identify a fetus with homozygous
beta-thalassaemia by obtaining chorionic villous material
for DNA analysis sufficiently early in pregnancy to
allow termination. This examination is only appropriate
if both parents are known to be carriers (beta-thalassaemia
minor) and will accept a termination.

Alpha-thalassaemia

Reduced or absent alpha chain synthesis is common in

Southeast Asia. There are two alpha gene loci on chromosome
16 and therefore each individual carries four
alpha gene alleles.
If one is deleted, there is no clinical effect.
If two are deleted, there may be a mild
hypochromic anaemia.
If three are deleted, the patient has haemoglobin H
disease.
If all four are deleted, the baby is stillborn (hydrops
fetalis).
Haemoglobin H is a beta-chain tetramer, formed
from the excess of beta chains, which is functionally
useless, so that patients rely on their low levels of HbA
for oxygen transport. Treatment of haemoglobin H disease is similar to that of beta-thalassaemia of
intermediate
severity, involving folic acid supplementation,
transfusion if required and avoidance of iron therapy

24^2
(2^2) (2x4x2) (4^2)
(4) (16) (16)
(4) (1) (6) (1) (6)
(4+1) (6+1) (6)
=576

a) Aetiology