HAEMOGLOBIN AND ANAEMIA

DR NILESH KATE
MBBS, MD
ASSOCIATE PROF
DEPT. OF PHYSIOLOGY
HAEMOGLOBIN
AND
ANAEMIA.

At the End of Class
 Haemoglobin
 Structure, function,
variations
 Derivatives, synthesis and
degradation of
hemoglobin.
 Anemia – Types with
example, c/f , treatment

Haemoglobin
(C712H1130O245N214S2Fe)4

HAEMOGLOBIN
It is a Red pigment
Present in RBC of Blood.
It is a conjugated protein,
& Chromoprotein.
It is made up of Iron and
Protein
It’s molecular weight is
68000.

Disadvantages if haemoglobin
present in plasma.
 Increase viscosity.
 Increase osmotic
pressure.
 Rapid destruction by
reticuloendothelial
system.
 Haemoglobinuria
( excretion through
kidney)
Tuesday, December 8, 2015

NORMAL VALUES OF
HEMOGLOBIN
 The Normal Hb level:
 Fetus – 16-18 gm/dl
 Newborn – 20-24
gm/dl.
 Transfusion from
placenta
 Haemoconcentration

NORMAL VALUES OF
HEMOGLOBIN
 1 year – 10-12 gm/dl
 Males - 14 – 17
gm/100ml
Females- 12 – 15
gm/100ml

STRUCTURE OF HAEMOGLOBIN.
 Iron containing pigment
called Haem attached
with protein – Globin.
 Haeme is Iron –
porphyrin complex
called IRON-
PROTOPORPHYRIN IX.
 Globin – Protein.

STRUCTURE OF HAEME
IRON-PROTOPORPHYRIN IX.
 IRON
 Ferrous form (Fe2+).
 Iron attached to
nitrogen atom of each
pyrrole ring.
 On iron loose bond for
 Oxygen
 Carbon monoxide.

STRUCTURE OF HAEME
IRON-PROTOPORPHYRIN IX.
 Porphyrin nucleus.
 4 Pyrrole Rings
(Tetrapyrrole)
 Bridges – Methine (CH)
 Side chains – 8
 Methyl (CH3) - 4
 Vinyl (CH.CH2) - 2
 Propionic acid - 2
(CH2.CH2.COOH)

Structure of Globin.
 Made up of 4
polypeptide chains.
 Globin is HbA
 2 alpha chains ( ) –
141 amino acids
 2 Beta chains ( ) – 146
amino acids.

Attachment of Haeme to
Globin.
 4 units of Haeme
attached to 1 unit of
Globin.
 So 1 Haemoglobin
molecules contains 4
Iron Atoms which
carry 4 molecules of
oxygen.

Synthesis of Hemoglobin
i) 2 succinyl – CoA + 2 glysine Pyrrole
ii) 4 Pyrrole Protoporphyrin IX
iii) Protoporphyrin IX + Fe2+ Heme
iv) Heme + Polypeptide Hemoglobin chain (α or β)
v) 2 α chains + 2 β chains Haemoglobin A.

 Succinyl-CoA Glycine
Pyridoxal phosphate
 αAmino -β-ketoadipic acid
ALA synthetase
 α amino-δ-Laevulinic acid
 ALA dehydrogenase.
 Porphobilinogen
 Protoporphyrin IX
ferrous
 Haem globin
 haemoglobin

Factors controlling
Haemoglobin formation.
 Role Of Proteins – First class proteins provide
amino acids.
 Most imp – food of animal origin, liver, spleen,
kidney & heart
 Intermediate value – muscles
 Least – cereals, dairy products, veg & fruits.

ROLE OF IRON.
 Important for formation of Haeme part of
Haemoglobin.
 Sources of iron – Dietary iron
 Other sources – Iron released from degradation of
RBC.

Role of other metals
 Copper – Promotes
Absorption, Mobilization
& Utilization of iron.
 Cobalt – Increases
production of
Erythropoietin.
 Calcium – conserve iron
& subsequent utilization.
 Role of vitamins.
 Vit B12, Folic acid help in
synthesis of nucleic acid.
 & vit C helps in
absorption of iron from
gut. (Fe3+ to Fe2+)
 Role of bile salts.
 Imp for proper
absorption of copper &
nickel.

Functions of Haemoglobin
 Transport oxygen to tissues
 Transport Co2 to lungs
 Maintains acid base balance ( As a Buffer)

Haemoglobin – Oxygen
Binding.
 O2 is attached with
haemoglobin reversibly at
6th
covalent bond.
 Oxygenation of 1st
haem
increases affinity for 2nd
in turn 3rd
& 4th
.
 Reason for O2-Hb
dissociation curve
Sigmoid shape.

Oxygen – Haemoglobin
Dissociation curve.
 As affinity of Hb for O2
falls graph shifted to
right.
 As affinity of Hb for O2
rise graph shifted to
left.
 H+ ion conc, Pco2
temp & 2,3-DPG
affects shift.

Shift of Oxygen – Haemoglobin
Dissociation curve.
 Shift to left.  Shift to right.

VARIETIES OF HAEMOGLOBIN.
 Pathological
(Haemoglobinopathies)
 Sickle Cell Haemoglobin.
 Hb C
 Thallasemia.
 Physiological.
 Adult
 Haemoglobin A --
4 polypeptide chains
2 α (alpha) & 2 β (Beta)
 Haemoglobin A2 -- 2 α
(alpha) & 2 δ (Delta)
 Fetal.

FETAL HAEMOGLOBIN.
 Present in fetal RBC &
disappear in 2-3 months
after birth.
 Structure
 4 polypeptide chains
2 α(alpha) & 2 γ (gamma)
 Characteristics.
 Affinity for oxygen – more
 Resistance to action of alkalies
 Life span – less.

PATHOLOGICAL
(HAEMOGLOBINOPATHIES)
 Sickle cell
haemoglobin.(HbS)
 Substitution of Valine
for Glutamic Acid at 6th
position in beta chain.
 When HbS is reduced (in
low O2 tension)
precipitate into crystals
in RBC changes shape
become Sickle shaped.

EFFECTS OF SICKLE CELL SHAPE.
 Less flexible – blockage
of microcirculation.
 Increases blood
viscosity.
 More fragile – More
Hemolysis – Anaemia.

TREATMENT
 Drugs – leads to
formation of HbF which
decreases
polymerization of
deoxygenated Hb.
 Azacytidine
 Hydroxyurea
 Bone Marrow
Transplantation.

Pathological
(Haemoglobinopathies)
 Haemoglobin C.
 Similar to HbS but not
associated with Sickling.
 Other varieties are
HbE, HbI, HbJ, HbM
 Thalassaemia
 Defect in synthesis of
polypeptide chain.
 Types
 Major
 Minor

DIFFERENCE IN THALASSAEMIA
MAJOR & MINOR.
β Thalassaemia Major
 Less common
 Homozygous transmission
 Complete absence of beta
chain synthesis.
 Anemia – moderate to
severe
 HbF – markedly increased
 Life span – short
 Cooley’s Anaemia
β Thalassaemia Minor.
 More common.
 Heterozygous
transmission.
 Partial Absense.
 Anemia- mild.
 HbF – slightly elevated.
 Life span – comparatively
longer.

DERIVATIVES OF Hb
 1. Hb + O2 HbO2(Oxyhaemoglobin) Iron in ferrous state)
 2. Hb + Cyanide Methaemoglobin Iron in ferric state.
 3. Hb + CO2 Carbamino hemoglobin
 4. Hb + CO Carboxy hemoglobin
 5. Hb + H2S Sulphemoglobin.
 6. Hb + Glucose Glycosylated ( attached to terminal
Valine)

FATE OF HAEMOGLOBIN
Tetra pyrrole straight chain with
Globin & Iron

ANAEMIA
Definition:
 Anemia is defined as a
decreased O2 carrying
capacity due to quantitative
and qualitative Reduction in
RBC counts and Hemoglobin
levels.

ANAEMIA
 ANAEMIA is labelled
when Hb is less than
 13gm/dl in Males
 11 gm/dl in Females
 15gm/dl in Newborn.

MORPHOLOGICAL CLASSIFICATION:
normochromic

DUE TO DECREASED RBC
PRODUCTION.
IRON DEFICIENCY
ANAEMIA.
 Most common in India.
 In women of
reproductive age group
(20-45 yrs)
 In periods of active
growth of infancy,
childhood & adolescence

IRON METABOLISM
 Total body contains 4-5
gms
 Forms –
 Haemoglobin 70%
 Storage iron 20-23% 2/3rd
Ferritin & 1/3rd
Haemosiderin.
 Myoglobin in red muscles
5%
 Intracellular enzymes 2-3%

DAILY REQUIREMENTS &
SOURCES
 5-10 mg/day in Males
 20 mg/day in
Females.
 40 mg/day in
Pregnant & lactating
women.
 Meat, liver, egg, green
leafy veg, Jaggery &
whole wheat.

IRON
ABSORPTION
 Mainly in duodenum &
upper jejunum.
 MECHANISM
 Transport across brush
borders
 Haeme iron
 Non-haeme iron.
 Fate in Enterocytes.
 Transport in plasma.

IRON ABSORPTION
 Transport across brush
borders.
 Absorption of Haeme
form
 Absorption of Non-
haeme form
 Fate in Enterocytes.
 Transport in plasma.

Factors affecting iron
absorption
 Form of dietary iron –
 haem iron
 Non-haem iron – ferrous form (Fe2+) > ferric form
(Fe3+)
 Meat & fish ,Human breast milk ,Acid gastric
juice – enhances absorption.
 Dietary factors – Phytates , phosphates, calcium,
egg white, phenols, tea, coffe wine reduces.
 Iron stores in body – Negative feedback effect.

STORAGE OF IRON
 As ferritin
 As haemosiderin.

REGULATION OF BODY IRON
 Mucosal block theory of absorption.
 Saturation of apoferritin & apotransferrin
 Decresed rate of apoferritin synthesis.
 Role of specific iron receptors in brush borders.

APPLIED ASPECTS.
 Iron deficiency- iron
deficiency Anaemia
 Iron excess –
Haemosiderin
accumulation –
Haemosiderosis –
damages tissue –
Haemochromatosis.

CAUSES OF IRON DEFICIENCY
ANAEMIA.
 Inadequate dietary
intake.
 Increased loss of iron.
 Increased demand of
iron.
 Decreased absorption.

Megaloblastic Anaemia
 Megaloblast –
abnormally large cells
of Erythroid series.
 Caused by defective
DNA synthesis due to
deficiency of Vit B12 &
Folic acid.

Vit B 12 (Extrinsic Factor)
 Vit B12 –
Cyanocobalamin or
extrinsic factor.
 Daily need – 1-2 μg.
 Sources – Milk, Meat,
Liver of Animals
 Also synthesized by
bacterial Flora.

 Absorption – need
Intrinsic Factor Of Castle ,
a glycoprotein secreted by
parietal cells of gastric
mucosa.
 With it form Intrinsic
Factor- Cyanocobalamin
complex
 Bound to sp receptors in
ileum & absorbed by
Endocytosis.

 Transport – in blood
transported by
combining with
Transcobalamin-II
 Storage – In liver &
Muscle
 Role – required for
synthesis of DNA &
maturation of nucleus &
cell.

Folic Acid
 Folic acid –
Pteroylglutamic acid.
 Daily requirement –
100 μg.
 Sources – leafy veg,
pulses, yeasts, liver.
 From breakdown of
Polyglutamate to
Monoglutamates.

Aetiology.
 Due to vit B12
deficiency
 Causes –
 Inadequate dietary
intake
 Malabsorption due to
gastric cause
 Intestinal Cause.

Addisonian Pernicious
Anaemia.
 Aetiology – vit B12
deficiency due to
failure of secretion of
Intrinsic Factor by
stomach due to
Autoimmune
Atrophy of Gastric
Mucosa.
 Features.
 Features of
Megaloblastic anaemia
 Anti-intrinsic factor
antibodies.
 Schilling test.
(abnormal vit B12
absorption test
corrected by addition
of Intrinsic Factor)

Clinical Features:
 General features of Anemia
 Pallor, Weakness, Lethargy,
 Breathlessness on exertion
 Palpitations  heart failure  pedal edema
 Special features :
 Angular cheilitis, Atrophic glossitis,
 Oesophageal atrophy/web  Dysphagia,
 Koilonychia, brittle nails, gastric atrophy.

LAB FINDINGS
 Blood picture & red cell
indices.
 Hb Decreased
 RBC – Microcytic,
Hypochromic in iron
deficiency
 Megaloblastic in vit B12 &
FOLIC ACID deficiency
 Red cell indices – MCV,MCH
& MCHC Decreases

BONE MARROW FINDINGS.
 Iron deficiency
anaemia
 Marrow Cellularity –
Erythroid Hyperplasia.
 Erythropoiesis –
Normoblastic
 Marrow Iron –
Deficient.
 Megaloblastic
anaemia.
 Marrow cellularity –
Megaloblastic
Hyperplasia.
 Marrow iron – by
Prussian Blue staining
increase in size & no of
iron granules.

BIOCHEMICAL FINDINGS.
 Iron deficiency
Anaemia
 Serum iron decreases
(below 50 mg%)
 Serum Ferritin – very
low.
 Total Iron Binding
Capacity – increased.
 Megaloblastic Anaemia.
 serum bilirubin –
increases.
 Urine Urobilinogen –
excretion increases.
 Serum iron & Ferritin –
increases.
 Serum vit B12,Folate levels
- decreased

MANAGEMENT
 General – correction
of causative factor if
possible.
 Special – oral
administration of fe
salts, FSFA TAB,
Intramuscular inj.

HAEMOGLOBIN AND ANAEMIA

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