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DR NILESH KATE
MBBS, MD
ASSOCIATE PROF
DEPT. OF PHYSIOLOGY
HAEMOGLOBIN AND
ANAEMIA.
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At the End of Class Haemoglobin
Structure, function,
variations
Derivatives, synthesis and
degradation of
hemoglobin.
Anemia – Types with
example, c/f , treatment
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Haemoglobin(C712H1130O245N214S2Fe)4
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HAEMOGLOBINIt is a Red pigment Present in RBC of Blood.It is a conjugated protein,
& Chromoprotein.It is made up of Iron and
ProteinIt’s molecular weight is
68000.
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Disadvantages if haemoglobin present in plasma.
Increase viscosity. Increase osmotic
pressure. Rapid destruction by
reticuloendothelial system.
Haemoglobinuria
( excretion through kidney)
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NORMAL VALUES OF HEMOGLOBIN
The Normal Hb level: Fetus – 16-18 gm/dl Newborn – 20-24
gm/dl. Transfusion from
placenta Haemoconcentration
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NORMAL VALUES OF HEMOGLOBIN
1 year – 10-12 gm/dl Males - 14 – 17
gm/100mlFemales- 12 – 15 gm/100ml
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STRUCTURE OF HAEMOGLOBIN. Iron containing pigment
called Haem attached with protein – Globin.
Haeme is Iron – porphyrin complex called IRON-PROTOPORPHYRIN IX.
Globin – Protein.
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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.
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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)
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Structure of Globin. Made up of 4
polypeptide chains. Globin is HbA 2 alpha chains ( ) –
141 amino acids 2 Beta chains ( ) – 146
amino acids.
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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.
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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.
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Succinyl-CoA GlycinePyridoxal phosphate
αAmino -β-ketoadipic acid ALA synthetase
α amino-δ-Laevulinic acid ALA dehydrogenase.
Porphobilinogen Protoporphyrin IX
ferrous Haem globin
haemoglobin
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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.
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ROLE OF IRON. Important for formation of Haeme part of
Haemoglobin. Sources of iron – Dietary iron Other sources – Iron released from degradation of
RBC.
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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.
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Functions of Haemoglobin Transport oxygen to tissues Transport Co2 to lungs Maintains acid base balance ( As a Buffer)
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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.
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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.
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Shift of Oxygen – Haemoglobin Dissociation curve.
Shift to left. Shift to right.
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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.
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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.
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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.
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EFFECTS OF SICKLE CELL SHAPE. Less flexible – blockage
of microcirculation. Increases blood
viscosity. More fragile – More
Hemolysis – Anaemia.
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TREATMENT Drugs – leads to
formation of HbF which decreases polymerization of deoxygenated Hb. Azacytidine Hydroxyurea
Bone Marrow Transplantation.
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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
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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.
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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)
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FATE OF HAEMOGLOBIN
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Tetra pyrrole straight chain with Globin & Iron
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ANAEMIADefinition:
Anemia is defined as a decreased O2 carrying capacity due to quantitative and qualitative Reduction in RBC counts and Hemoglobin levels.
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ANAEMIA ANAEMIA is labelled
when Hb is less than 13gm/dl in Males 11 gm/dl in Females 15gm/dl in Newborn.
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MORPHOLOGICAL CLASSIFICATION:
normochromic
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Etiological Classification
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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
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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%
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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.
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IRON ABSORPTION
Mainly in duodenum & upper jejunum.
MECHANISM Transport across brush
borders Haeme iron Non-haeme iron.
Fate in Enterocytes. Transport in plasma.
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IRON ABSORPTION Transport across brush
borders. Absorption of Haeme
form Absorption of Non-
haeme form Fate in Enterocytes. Transport in plasma.
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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.
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STORAGE OF IRON As ferritin As haemosiderin.
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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.
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APPLIED ASPECTS. Iron deficiency- iron
deficiency Anaemia Iron excess –
Haemosiderin accumulation – Haemosiderosis – damages tissue – Haemochromatosis.
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CAUSES OF IRON DEFICIENCY ANAEMIA.
Inadequate dietary intake.
Increased loss of iron. Increased demand of
iron. Decreased absorption.
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Megaloblastic Anaemia Megaloblast –
abnormally large cells of Erythroid series.
Caused by defective DNA synthesis due to deficiency of Vit B12 & Folic acid.
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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.
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Vit B 12 (Extrinsic Factor) 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.
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Vit B 12 (Extrinsic Factor) Transport – in blood
transported by combining with Transcobalamin-II
Storage – In liver & Muscle
Role – required for synthesis of DNA & maturation of nucleus & cell.
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Folic Acid Folic acid –
Pteroylglutamic acid. Daily requirement –
100 μg. Sources – leafy veg,
pulses, yeasts, liver. From breakdown of
Polyglutamate to Monoglutamates.
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Aetiology. Due to vit B12
deficiency Causes –
Inadequate dietary intake
Malabsorption due to gastric cause
Intestinal Cause.
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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)
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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.
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Special features :
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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
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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.
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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
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MANAGEMENT General – correction
of causative factor if possible.
Special – oral administration of fe salts, FSFA TAB, Intramuscular inj.
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