溶血性贫血
Hemolytic Anemia
华山医院血液科
陈勤奋
HEMOLYTIC ANEMIA
(reduced RBC life span)
?Anemia of increased destruction
? Normochromic,normochromic anemia
? Shortened RBC survival
? Reticulocytosis--Response to
increased RBC destruction
? Increased indirect bilirubin
? Increased LDH
Mechanisms and Causes
?INTRACORPUSCULAR HEMOLYSIS
? Membrane Abnormalities
? Metabolic Abnormalities
? Hemoglobinopathies
?EXTRACORPUSCULAR HEMOLYSIS
? Nonimmune
? Immune
Membrane Defects
?Microskeletal defects
? Hereditary spherocytosis
?Increased sensitivity to complement
? Paroxysmal nocturnal hemoglobinuria
Enzymopathies
?Glucose 6-Phosphate Dehydrogenase
Deficiency
?Pyruvate Kinase Deficiency
Hemoglobinopathies
?Hemoglobinopathy
?Thalassemia
Extracorpuscular Hemolysis
Nonimmune
?Infectious
?Chemical
?Thermal
?Osmotic
Extracorpuscular Hemolysis
Immune
? All require antigen-antibody reactions
? Types of reactions dependent on,
? Class of Antibody
? Number & Spacing of antigenic sites on cell
? Availability of complement
? Environmental Temperature
? Functional status of reticuloendothelial system
? Manifestations
? Intravascular hemolysis
? Extravascular hemolysis
Extracorpuscular Hemolysis
Immune
? Antibodies combine with RBC,& either
1,Activate complement cascade,&/or
2,Opsonize RBC for immune system
? If 1,if all of complement cascade is
fixed to red cell,intravascular cell
lysis occurs
? If 2,&/or if complement is only
partially fixed,macrophages recognize
Fc receptor of Ig &/or C3b of
complement & phagocytize RBC,causing
extravascular RBC destruction
Classification
?Intravascular
?Extravascular
clinical features
?chronic
? pallor,
jaundice,
splenomegaly
? cholelithiasis
? aplastic crisis
?acute
? algor、
hyperpyrexia、
sore waist
? hemoglobinuria
? jaundice、
anaemia
laboratory examination
? Increased RBC destruction
? Reduced RBC life span
? Indirect hyperbilirubinemia
? Erythroid hyperplasia
? Reticulocytosis
? Erythroblasts,anisopoikilocytosis,
spherocytes in blood smear
? Erythroid hyperplasia in bone marrow
diagnosis and
differential diagnosis
?hemolysis or not?
?type of hemolysis
?another anemia?
?another jaundice with anemia?
?another jaundice without anemia?
Treatment
?Remove the causes
?Immunosupressive drug
?Washed RBC transfusion
?Splenectomy
?Symptomatic treatment
Hereditary Spherocytosis
?Defective or absent spectrin
molecule
?Leads to loss of RBC membrane,
leading to spherocytosis
?Decreased deformability of cell
?Increased osmotic fragility
?Extravascular hemolysis in spleen
Hereditary Spherocytosis
?Pathophysiology--RBC membrane protein
defects (spectrin deficiency) resulting
cytoskeleton instability
?Familly history
?Clinical features— splenomegaly
Hereditary Spherocytosis
?Laboratory features
- hemolytic anemia
- blood smear-microspherocytes
- abnormal osmotic fragility test
- positive autohemolysis test
- prevention of increased
autohemolysis by including glucose in
incubation medium
?Treatment--splenectomy
Hereditary Spherocytosis
Hereditary Spherocytosis
Osmotic Fragility
0
20
40
60
80
100
0, 3 0, 4 0, 5 0, 6
N a C l (% o f n o r m a l s a l i n e )
%
H
e
m
o
l
y
s
i
s
N o r m a l HS
Paroxysmal Nocturnal Hemoglobinuria
(PNH)
PNH is an acquired chronic hemolytic
anemia which arises from a somatic
mutation in a hematopoietic stem cell,
Most hematopoitic cell lines may be
affected by the intrinsic membrane defect,
This defect renders the red cells highly
susceptible to complement mediated lysis
resulting in the characteristic hemolysis,
Paroxysmal Nocturnal Hemoglobinuria
(PNH)
?Pathogenesis
- an acquired clonal disease,arising from a
somatic mutation in a single abnormal stem cell
- glycosyl-phosphatidyl- inositol (GPI) anchor
abnormality
- deficiency of the GPI anchored membrane
proteins(CD55 and CD59)
- red cells are more sensitive to the lytic
effect of complement
- intravascular hemolysis
urine aliquot of PNH
clinical manifestation
?pancytopenia
?passage of dark brown urine in the
morning
?venous thrombosis(Budd-Chiari
Syndrome)
Laboratory features
? Pancytopenia
? Chronic urinary iron loss
? Serum iron concentration decreased
? Hemoglobinuria
? Hemosiderinuria
? Positive Ham’s test (acid hemolysis test),
sugar-water test
? Specific immunophenotype of blood
cells(CD59,CD55)
Attention
?AA-PNH syndrome
? AA→PNH
? PNH→AA
? PNH with AA
? AA with PNH
Treatment
?avoid causes
?washed RBC transfusion
?iron therapy
?allogenic bone marrow
transplantation
G-6-PD Deficiency
?acute hemolytic anemia
?congenital nonspherocytic
hemolytic anemia
?neonatal hyperbilirubinemia
（ kernicterus）
?favism
0
0, 2
0, 4
0, 6
0, 8
1
0 20 40 60 80 100 120
R B C A g e (D a y s )
G
6
PD
A
c
ti
v
i
ty
(%
)
N o r m a l (G d B ) B l a c k Va r i a n t (G d A -)
Me d i te r r a n e a n (G d Me d )
Level needed for protection vs ordinary oxidative stress
Autoimmune Hemolysis
?Due to formation of autoantibodies that
attack patient’s own RBC’s
?Type characterized by ability of
autoantibodies to fix complement & site
of RBC destruction
?Often associated with either
lymphoproliferative disease or collagen
vascular disease
Autoimmune Hemolytic Anemia
?warm-reactive
antibodies
? primary
? secondary
?cold-reactive
antibodies
? cold agglutinin
syndrome
? paroxysmal cold
hemoglubinuria
Autoimmune hematolysis
Warm Type
?IgG+C3
?IgG
?C3
Autoimmune hematolysis
Warm Type
? Usually IgG antibodies
? Fix complement only to level of C3,if at all
? Immunoglobulin binding occurs at all temps
? Fc receptors/C3b recognized by macrophages
? Hemolysis primarily extravascular
? 70% associated with other illnesses
? Responsive to steroids/splenectomy
Clinical manifestation
?anemia,jaundice、
splenohepatomegalia
?ITP+AIHA=Evens syndrome
Laboratory examination
?Blood,anemia； Ret?；
erythroblasts,anisopoikilocytosis
?Bone marrow,erythroid hyperplasia
?Coombs Test
Coombs Test - Direct
? Looks for immunoglobulin &/or complement of
surface of red blood cell (normally neither
found on RBC surface)
? Coombs reagent - combination of anti-human
immunoglobulin & anti-human complement
? Mixed with patient’s red cells; if
immunoglobulin or complement are on surface,
Coombs reagent will link cells together and
cause agglutination of RBCs
Coombs Test - Indirect
?Looks for anti-red blood cell
antibodies in the patient’s serum,
using a panel of red cells with known
surface antigens
?Combine patient’s serum with cells from
a panel of RBC’s with known antigens
?Add Coombs’ reagent to this mixture
?If anti-RBC antigens are in serum,
agglutination occurs
Diagnosis
Treatment
?Steroids
?Splenectomy
?Immunosupressive agents
?Transfusion
Autoimmune hematolysis
Cold Type
? Most commonly IgM mediated
? Antibodies bind best at 30o or lower
? Fix entire complement cascade
? Leads to formation of membrane attack
complex,which leads to RBC lysis in
vasculature
? Typically only complement found on cells
? 90% associated with other illnesses
? Poorly responsive to steroids,splenectomy;
responsive to plasmapheresis
Hemolytic anemia
Summary
?Myriad causes of increased RBC
destruction
?Marrow function usually normal
?Often requires extra folic acid to
maintain hematopoiesis
?Anything that turns off the bone
marrow can result in acute,life-
threatening anemia
Hemolytic Anemia
华山医院血液科
陈勤奋
HEMOLYTIC ANEMIA
(reduced RBC life span)
?Anemia of increased destruction
? Normochromic,normochromic anemia
? Shortened RBC survival
? Reticulocytosis--Response to
increased RBC destruction
? Increased indirect bilirubin
? Increased LDH
Mechanisms and Causes
?INTRACORPUSCULAR HEMOLYSIS
? Membrane Abnormalities
? Metabolic Abnormalities
? Hemoglobinopathies
?EXTRACORPUSCULAR HEMOLYSIS
? Nonimmune
? Immune
Membrane Defects
?Microskeletal defects
? Hereditary spherocytosis
?Increased sensitivity to complement
? Paroxysmal nocturnal hemoglobinuria
Enzymopathies
?Glucose 6-Phosphate Dehydrogenase
Deficiency
?Pyruvate Kinase Deficiency
Hemoglobinopathies
?Hemoglobinopathy
?Thalassemia
Extracorpuscular Hemolysis
Nonimmune
?Infectious
?Chemical
?Thermal
?Osmotic
Extracorpuscular Hemolysis
Immune
? All require antigen-antibody reactions
? Types of reactions dependent on,
? Class of Antibody
? Number & Spacing of antigenic sites on cell
? Availability of complement
? Environmental Temperature
? Functional status of reticuloendothelial system
? Manifestations
? Intravascular hemolysis
? Extravascular hemolysis
Extracorpuscular Hemolysis
Immune
? Antibodies combine with RBC,& either
1,Activate complement cascade,&/or
2,Opsonize RBC for immune system
? If 1,if all of complement cascade is
fixed to red cell,intravascular cell
lysis occurs
? If 2,&/or if complement is only
partially fixed,macrophages recognize
Fc receptor of Ig &/or C3b of
complement & phagocytize RBC,causing
extravascular RBC destruction
Classification
?Intravascular
?Extravascular
clinical features
?chronic
? pallor,
jaundice,
splenomegaly
? cholelithiasis
? aplastic crisis
?acute
? algor、
hyperpyrexia、
sore waist
? hemoglobinuria
? jaundice、
anaemia
laboratory examination
? Increased RBC destruction
? Reduced RBC life span
? Indirect hyperbilirubinemia
? Erythroid hyperplasia
? Reticulocytosis
? Erythroblasts,anisopoikilocytosis,
spherocytes in blood smear
? Erythroid hyperplasia in bone marrow
diagnosis and
differential diagnosis
?hemolysis or not?
?type of hemolysis
?another anemia?
?another jaundice with anemia?
?another jaundice without anemia?
Treatment
?Remove the causes
?Immunosupressive drug
?Washed RBC transfusion
?Splenectomy
?Symptomatic treatment
Hereditary Spherocytosis
?Defective or absent spectrin
molecule
?Leads to loss of RBC membrane,
leading to spherocytosis
?Decreased deformability of cell
?Increased osmotic fragility
?Extravascular hemolysis in spleen
Hereditary Spherocytosis
?Pathophysiology--RBC membrane protein
defects (spectrin deficiency) resulting
cytoskeleton instability
?Familly history
?Clinical features— splenomegaly
Hereditary Spherocytosis
?Laboratory features
- hemolytic anemia
- blood smear-microspherocytes
- abnormal osmotic fragility test
- positive autohemolysis test
- prevention of increased
autohemolysis by including glucose in
incubation medium
?Treatment--splenectomy
Hereditary Spherocytosis
Hereditary Spherocytosis
Osmotic Fragility
0
20
40
60
80
100
0, 3 0, 4 0, 5 0, 6
N a C l (% o f n o r m a l s a l i n e )
%
H
e
m
o
l
y
s
i
s
N o r m a l HS
Paroxysmal Nocturnal Hemoglobinuria
(PNH)
PNH is an acquired chronic hemolytic
anemia which arises from a somatic
mutation in a hematopoietic stem cell,
Most hematopoitic cell lines may be
affected by the intrinsic membrane defect,
This defect renders the red cells highly
susceptible to complement mediated lysis
resulting in the characteristic hemolysis,
Paroxysmal Nocturnal Hemoglobinuria
(PNH)
?Pathogenesis
- an acquired clonal disease,arising from a
somatic mutation in a single abnormal stem cell
- glycosyl-phosphatidyl- inositol (GPI) anchor
abnormality
- deficiency of the GPI anchored membrane
proteins(CD55 and CD59)
- red cells are more sensitive to the lytic
effect of complement
- intravascular hemolysis
urine aliquot of PNH
clinical manifestation
?pancytopenia
?passage of dark brown urine in the
morning
?venous thrombosis(Budd-Chiari
Syndrome)
Laboratory features
? Pancytopenia
? Chronic urinary iron loss
? Serum iron concentration decreased
? Hemoglobinuria
? Hemosiderinuria
? Positive Ham’s test (acid hemolysis test),
sugar-water test
? Specific immunophenotype of blood
cells(CD59,CD55)
Attention
?AA-PNH syndrome
? AA→PNH
? PNH→AA
? PNH with AA
? AA with PNH
Treatment
?avoid causes
?washed RBC transfusion
?iron therapy
?allogenic bone marrow
transplantation
G-6-PD Deficiency
?acute hemolytic anemia
?congenital nonspherocytic
hemolytic anemia
?neonatal hyperbilirubinemia
（ kernicterus）
?favism
0
0, 2
0, 4
0, 6
0, 8
1
0 20 40 60 80 100 120
R B C A g e (D a y s )
G
6
PD
A
c
ti
v
i
ty
(%
)
N o r m a l (G d B ) B l a c k Va r i a n t (G d A -)
Me d i te r r a n e a n (G d Me d )
Level needed for protection vs ordinary oxidative stress
Autoimmune Hemolysis
?Due to formation of autoantibodies that
attack patient’s own RBC’s
?Type characterized by ability of
autoantibodies to fix complement & site
of RBC destruction
?Often associated with either
lymphoproliferative disease or collagen
vascular disease
Autoimmune Hemolytic Anemia
?warm-reactive
antibodies
? primary
? secondary
?cold-reactive
antibodies
? cold agglutinin
syndrome
? paroxysmal cold
hemoglubinuria
Autoimmune hematolysis
Warm Type
?IgG+C3
?IgG
?C3
Autoimmune hematolysis
Warm Type
? Usually IgG antibodies
? Fix complement only to level of C3,if at all
? Immunoglobulin binding occurs at all temps
? Fc receptors/C3b recognized by macrophages
? Hemolysis primarily extravascular
? 70% associated with other illnesses
? Responsive to steroids/splenectomy
Clinical manifestation
?anemia,jaundice、
splenohepatomegalia
?ITP+AIHA=Evens syndrome
Laboratory examination
?Blood,anemia； Ret?；
erythroblasts,anisopoikilocytosis
?Bone marrow,erythroid hyperplasia
?Coombs Test
Coombs Test - Direct
? Looks for immunoglobulin &/or complement of
surface of red blood cell (normally neither
found on RBC surface)
? Coombs reagent - combination of anti-human
immunoglobulin & anti-human complement
? Mixed with patient’s red cells; if
immunoglobulin or complement are on surface,
Coombs reagent will link cells together and
cause agglutination of RBCs
Coombs Test - Indirect
?Looks for anti-red blood cell
antibodies in the patient’s serum,
using a panel of red cells with known
surface antigens
?Combine patient’s serum with cells from
a panel of RBC’s with known antigens
?Add Coombs’ reagent to this mixture
?If anti-RBC antigens are in serum,
agglutination occurs
Diagnosis
Treatment
?Steroids
?Splenectomy
?Immunosupressive agents
?Transfusion
Autoimmune hematolysis
Cold Type
? Most commonly IgM mediated
? Antibodies bind best at 30o or lower
? Fix entire complement cascade
? Leads to formation of membrane attack
complex,which leads to RBC lysis in
vasculature
? Typically only complement found on cells
? 90% associated with other illnesses
? Poorly responsive to steroids,splenectomy;
responsive to plasmapheresis
Hemolytic anemia
Summary
?Myriad causes of increased RBC
destruction
?Marrow function usually normal
?Often requires extra folic acid to
maintain hematopoiesis
?Anything that turns off the bone
marrow can result in acute,life-
threatening anemia
