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 HemolysisNonimmune 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 Activate complement cascade, &/or 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 E xtravascular  clinical features  chronic pallor  、jaundice  、splenomegaly cholelithiasis aplastic crisis  acute algor 、hyperpyrexia 、sore waist hemoglobinuria jaundice 、anaemia laboratory examination Increased RBC destruction R educed RBC life span  Indirect h yperbilirubinemia E rythroid hyperplasia  Reticulocytosis E rythroblasts , anisopoikilocytosis, spherocytes in b lood smear  E rythroid 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 W ashed 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 Paroxysmal Nocturnal Hemoglobinuria (PNH) 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 C hronic urinary iron loss S erum iron concentration decreased  Hemoglobinuria  Hemosiderinuria P ositive Ham’s test (acid hemolysis test) , sugar-water test S pecific 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 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 hematolysisWarm 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 ；e rythroblasts , anisopoikilocytosis Bone marrow ：e rythroid 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 Treatment Steroids  Splenectomy I mmunosupressive agents  T ransfusion 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 anemiaSummary 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 Diagnosis * * 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. Level needed for protection vs ordinary oxidative stress *