2. What will we discuss in this chapter?I. Blood composition OUTLINEII. Physical and chemical characteristics of bloodIII. Blood Cells 1. Hemopoietic process and hemopoietic stem cells 2. Hemopoietic microenvironment 3. Erythrocyte Physiology 4. Leukocyte Physiology 5. Platelet or Thrombocyte PhysiologyIV. Physiological Hemostasis 1. Endocrine functions of vessel endothelial cells 2. Physiological Characteristics of Platelet 3. Blood Coagulation 4. FibrinolysisV. Blood Group 1. RBC Agglutination 2. ABO blood group system 3. Rh blood group system 4. Relation between blood volume and clinic 5. Principle of Transfusion and Cross-match test
3. BLOOD AND INTERNAL ENVIRONMENTAL HOMEOSTASIS Blood is that part of extracellular fluid within the cardiovascular system Blood formation During animals’ evolution, extracellular fluid was gradually shaped from the age-old time with ocean which was mainly salty solution. At last, extracellular fluid was differentiated into plasma and interstitial fluid and blood came from plasma and cells. The role of blood in internal environmental = homeostasis Blood, the most active component in extracellular fluid, display functions as follows: (1) transport; (2) pH buffer; (3) temperature or thermal maintenance; (4) immunity and defense
4. I. BLOOD COMPOSITION Blood composed of : plasma + blood cells Hematocrit: the percentage of total blood volume that blood cells occupy. normal value male: 40-50% female: 37-48% newborn: 55%
8. II. PHYSICAL AND CHEMICAL CHARACTERISTICS OF BLOOD Specific gravity: total blood (1.050-1.060) more influenced by red blood cells; plasma (1.025-1.030) more influenced by plasma protein; RBC (1.090-1.092) more influenced by Hb. Viscosity: Blood relative viscosity (4~5) mainly depends on the numbers of red blood cells. Plasma relative viscosity (1.6~2.4) is mainly involved in plasma protein
9. Plasma osmotic pressure is 300 mmol/L or 770kPa (1) Crystal osmotic pressure results from NaCl and modulates water distribution between inside and outside of cells. (2) Colloid osmotic pressure results from albumin and regulates water distribution between inside and outside of capillary. Plasma pH value is about 7.35~7.45, and usually buffer systems are NaHCO3/H2CO3 (20:1), protein salt/protein, Na2HPO4/ NaH2PO4, Hb salt/Hb, HbO salt/ HbO2, K2HPO4/ KH2PO4, KHCO3/H2CO3, etc [lungs and kidney mainly regulate Plasma pH value ].
10. OSMOSIS AND OSMOTIC PRESSURE Osmosis is the movement of water down its concentration gradient. Osmosis is determined by the number of impermeable molecules. Osmotic pressure is the force drawing water down its concentration gradient.
11. OSMOSIS AND OSMOTIC PRESSURE A B Water [Water] > [Water] [Salt] < [Salt] Osmotic Pressure < Osmotic PressureOsmosis is the movement of water from a high concentration to a low concentration. Inthis illustration, two compartments (A and B) are separated by a semipermeablemembrane (broken vertical line). The water concentration in compartment A is greaterthan the concentration in compartment B because of the presence of salt (X) in B.Therefore, water will move down its concentration gradient from A to B. The forceneeded to prevent this water movement is called osmotic pressure.
12. TONICITY The tonicity of a solution refers to the effect of the solution on cell volume. A hypertonic extracellular solution is one in which the water concentration is less outside the cell than inside; water leaves the cell; cell volume decreases. An isotonic extracellular solution is one in which the water concentration is the same inside and outside the cell; no water movement; cell volume does not change. A hypotonic solution is one in which the water concentration is greater outside than inside the cell; water enters the cell; cell volume increases. An isosmotic solution may not be an isotonic solution if the particles are permeable to the cell membrane.
13. III.BLOOD CELLSBlood cells are erythrocyte (red blood cell, RBC),leukocyte (white blood cell, WBC) and thrombocyte(platelet, P).
14. BLOOD CELLS The forming processes of erythrocyte (red blood cell, RBC), leukocyte (white blood cell, WBC) and thrombocyte (platelet, P) originating from hematopoietic stem cells are hemopoiesis. Transfer of blood cells forming place: yolk sac hemopoiesis (early embryo period) → liver and spleen (second embryo month) → marrow↑and liver, spleen↓ (after fourth embryo month) → marrow (fetus birth time) and liver, spleen as complementary role. During adulthood (after 18), red marrow (flat bones, e.g. vertebra,ilium, sternum, rib, skull and long bone ending) rather than yellow marrow has hematopoietic functions.
15. 1. HEMOPOIETIC PROCESS AND HEMOPOIETIC STEM CELLS Hemopoietic processStage one: Hemopoietic stem cellsself renewal, steady numbers, active differentiation.Stage two: committed progenitorsdirectional differentiation (CFU-GEMM, CFU-E, CFU-GM, CFU-MK, CFU-TB). [CFU: colony- forming unitStage three: precursorsmorphologic occurrence of various original blood cells.
16. HEMOPOIETIC STEM CELLS Basic characteristics Self renewal in high degree, constant from young to old age. Multi- directional differentiation Large potential proliferation, Hemopoietic stem cells produce about 1×1011 blood cells releasing to blood for use. Surface sign According to CFU (colony forming unit), using fluorescence- activated cell sorting (FACS), its main surface sign is CD34+CD38- Lin-and CD34-CD38-Lin-. Note CD: cluster of differentiation of antigen on the white blood cells; Lin: systemic specific antigen on the hemopoietic cells.
17. HEMOPOIETIC PROCESS
18. HEMOPOIETIC PROCESS
19. HEMOPOIETIC PROCESS
20. 3.ERYTHROCYTE PHYSIOLOGY Shape and number of red blood cells (RBC) Shape of RBC: like biconcave discIts diameter is about 7~8 µm, peripheral thickness about2.5 µm, central thickness about 1 µm and cubage about90 µm3.
21. REASON FOR SHAPE OF RBCbiconcave disc like
22. ERYTHROCYTE PHYSIOLOGYNumber of RBC: It is most numbers in the blood. Normal value about RBCMale adult, 4.5~5.5×1012/L; average, 5.0×1012/LFemale adult, 3.8~4.6× 1012/L; average, 4.2×1012/LNewborn, ≥ 6.0×1012/LProtein within RBC is hemoglobin (Hb).Hb in male adult, 120~160 g/L;Hb in female adult, 110~150 g/L;Hb in newborn (within 5 days), ≥ 200 g/LPregnant female, numbers of RBC and Hb are relatively less (because of more plasma).Dweller lived in plateau, numbers of RBC and Hb are relatively more (because of compensation for anoxia).
23. PHYSIOLOGICAL CHARACTERISTICS AND FUNCTIONS OF RBC Characteristics of RBC① Permeability: semipermeable membrane, gas and urea freely passing through, negative ions easily in or out of RBC, and positive ions not. There are Na-K ATPase as pump on the membrane of RBC and low-temperature-stored plasma easily has high kalium. Why?② Plasticity and metamorphose:Plasticity and metamorphose depend on: 1) surface area-cubageratio, 2) viscosity of Hb, 3) membrane elasticity and viscosity.
24. PHYSIOLOGICAL CHARACTERISTICS AND FUNCTIONS OF RBC Characteristics of RBC③ Suspension stability: it cab be described by erythrocyte sedimentation rate (ESR) which is RBC descending distance per hour and suspension stability is inverse proportion to ESR. Normal value of ESR: male, 0~15 mm/h; female, 0~20 mm/h. ESR and clinic: some diseases bring about rouleaux formation (mainly involved in plasma component, e.g. globulin, fibrinogen, cholesterol) and speed up ESR.
25. PHYSIOLOGICAL CHARACTERISTICS AND FUNCTIONS OF RBC Characteristics of RBC④ Osmotic fragility: Changes in RBC put into lower osmotic salty solution. Osmotic fragility of aged RBC is large and easily results in rupture (hemolysis and ghost cell). Isosmotic solution, e.g. 0.85% NaCl, 1.4%NaHCO3, 5% glucose, etc. Isotonic solution, e.g. 0.85% NaCl Isosmotic solution does not equal to isotonic solution. Isosmotic solution, isotonic solution and clinic
26. PHYSIOLOGICAL CHARACTERISTICS AND FUNCTIONS OF RBC Functions of RBC RBC can be used for transportation of O2 and CO2 in the blood. RBC can be served as pH buffer.
27. ERYTHROPOIESIS Hemopoietic material for erythropoiesis: iron (Fe++) and protein, [reason for anemia] Influencing factors of RBC maturity: Vitamin B12 and folic acid (DNA metabolism), [clinic relation] Process of erythropoiesis: Hemopoietic stem cells→multi systemic hemopoietic progenitor cells→RBC-committed progenitor cells (BFU-E→CFU-E)→original RBC→ earlier infantile RBC→medium-term infantile RBC→terminal infantile RBC→reticular RBC→mature RBC→blood for circulation. This process requires 6~7 days. [mitosis several times] [apoptosis]
28. PLACE FOR ERYTHROPOIESISMain place for Erythropoiesis is bonemarrow. Aother place is liver.
29. REGULATION OF ERYTHROPOIESIS
30. LIFE AND BREAKAGE OF RBC Life-span: 120 days, about 4 months, each RBC circulates 27 km averagely in vessels, short life-span for aged RBC Breakage: places are liver, spleen and lymphatic node, and after breakage, Hb released from RBC immediately combine with plasma α2-globulin (Hb touched protein) which is taken in by liver for iron reuse. Hb, very toxic if it get into blood, normally, it can be metabolized into bile pigment in liver. Clinic relation.
31. 4.LEUKOCYTE PHYSIOLOGY CLASSIFICATION AND NUMBERS OF LEUKOCYTE Number of Leukocyte (white blood cells, WBC): (4.0~10)×109/L Classification: It is granulocyte (neutrophil, eosinophil, basophil), monocyte and lymphocyte.
32. CLASSIFICATION AND NUMBERS OF LEUKOCYTETABLE. Classification and normal value of Leukocyte Absolute Value (×109/L) Percentage (%)Total numbers of leukocytes 4.0~10.0Neutrophil (bacilliform nucleus) 0.04~0.5 1~5Neutrophil (foliiform nucleus) 2.0~7.0 50~70Eosinophil 0.02~0.5 0.5~5Basophil 0.0~0.1 0~1Monocyte 0.12~0.8 3~8Lymphocyte 0.8~4.0 20~40 For Clinic Use
33. PHYSIOLOGICAL CHANGES IN NUMBERS OF LEUKOCYTE Newborn: Number is higher, 15×109/L, after birth 3 or 4 days to 3 months, being about 10×109/L, mainly, neutrophil, 70%; secondarily, lymphocyte. Circadian changes: Number of WBC is more in the afternoon than in the morning. Food taking, ache and mood excitation: Number of WBC is remarkably higher. Heavy exercise and laboring: Increasing numbers, about 35×109/L, return to original level after action stop. Terminal pregnancy of female: Numbers changes in 12~17×109/L, and during parturition, 34×109/L, and after parturition 2~5 days, number return to original level.
34. PHYSIOLOGICAL CHARACTERISTICS AND FUNCTIONS OF WBC Terminology Diapedisis: Metamorphosed WBCs pass through vessel wall getting into interstitial fluid. Chemotaxis: It is a process that WBCs WBC shift to some chemical material Diapedisis (metabolic production, antigen-antibody complex, bacteria, toxin, etc). Phagocytosis: It is a process that WBCs enclose and engulf exotic or extraneous material, and use intracellular enzyme Blood digesting them. Vessel Metamorphose
35. PHYSIOLOGICAL CHARACTERISTICS AND FUNCTIONS OF WBC ① Neutrophil Another name, polymorphonuclear, PMN, 6~8 h in the vessels, diapedisis, chemotaxis and phagocytosis (using its hydrolyzed enzyme) Function: It plays a very important role in nonspecific cellular immunity system which is against pathogenic microorganism, such as bacteria, virus, parasite, etc. Clinic relation: Number of neutrophil greatly increase occurring in acute inflammation and earlier time of chronic inflammation. number decrease of neutrophil will result in poor resistibility and easily suffering from infection.
36. PHYSIOLOGICAL CHARACTERISTICS AND FUNCTIONS OF WBC ② Eosinophil Circadian changes: Its number is lower in the morning and higher at night. Function: 1. It limits and modulates the effects of basophil on fast allergic reaction. 2. It is involved in immune reaction against worm with opsonization. Clinic relation: Its number increase when person suffers from parasite infection or allergic reaction.
37. PHYSIOLOGICAL CHARACTERISTICS AND FUNCTIONS OF WBC ③ Basophil Circulatory time: 12 hours Basogranules contain heparin, histamine, chemotactic factors and chronic reactive material for allergic reaction. Function: It is also involved in allergic reaction. 1. Heparin serves as lipase cobase and speeds up fatty decomposition. 2. Histamine and chronic reactive material increase permeability of capillary and contract bronchia smooth muscle, and result in allergic reaction such as measles, asthma. 3. Eosinophil chemotactic factor A released by basophil can attract eosinophil collection and modify eosinophil function.
38. PHYSIOLOGICAL CHARACTERISTICS AND FUNCTIONS OF WBC ④ Monocyte Its body is large, diameter about 15~30 µm without granule Function:1. It contains many nonspecific lipase and displays the powerful phagocytosis.2. As soon as monocytes get into tissue from blood , it change name called macrophage activating monocyte- macrophage system to release many cytokins, such as colony stimulating factor (CSF), IL-1, IL-3, IL-6, TNFα, INF-α,β ,etc.3. Cytokins induced by monocyte may modulate other cells growth.4. Monocyte- macrophage system plays a very important role in specific immune responsive induction and regulation.
39. PHYSIOLOGICAL CHARACTERISTICS AND FUNCTIONS OF WBC ⑤ Lymphocyte Classification: It can be separated into T- Lymphocyte and B- Lymphocyte. Function: 1. Lymphocytes serve as a nuclear role in immune responsive reaction. 2. T- Lymphocytes involved in cellular immunity. 3. B- Lymphocytes involved in humoral immunity. Clinic relation: Numbers increase of lymphocytes occur in
40. LEUKOPOIESIS, REGULATION AND BREAKAGE Birth place: bone marrow, originating from hemopoietic stem cells, and leukopoiesis process is similar to RBC. Leukopoiesis, differentiation and growth are influenced by hemopoietic growth factor, HGF which are glycoprotein secreted by lymphocyte, monocyte- macrophage, fibrous cell and endothelial cell. Colony stimulating factor, CSF, such as GM-CSF, G-CSF, M-CSF, Multi-CSF (IL-3) also influence Leukopoiesis. Life span: several hours to 3 or 4 days. Leukocyte breakage: site are liver, spleen and lymphatic node. Pus or purulence forming
41. 5.PLATELET OR THROMBOCYTE PHYSIOLOGY Shape: Biconvex disk like, diameter about 2~4 µm, average cubage 8 µm3. Complicated structure: under the electronic microscope, there are α- granule, dense body, lysin peroxide enzyme, opening tubular system, dense tubular system, canaliculus,etc. Dense body: It contains ADP, ATP, 5-HT, Ca2+, epinephrine,etc. Source: Platelet comes from megakaryocyte fractionlet release in the marrow.
42. NORMAL VALUE AND FUNCTION OF PLATELET Normal value: 100×109 ~ 300×109, range from 6%~10% Normal changes: more number in the afternoon than in the morning, more in winter than in spring, more in the venous blood than capillary, after sport↑, pregnacy↑. *Functions: 1. It maintains capillary endothelial cells smooth and integrated (repairing endothelium and providing nutrition). 2. It is involved in physiological hemostasis. Platelet and clinic relation: decrease of platelet, abnormal immune reaction, will results in hemorrhage or bleeding, purpuric symptom.
43. PLATELET FORMING AND REGULATION Platelet forming: Birth place is bone marrow, originating from hemopoietic stem cells, and differentiating into burst forming unit- megakaryocyte, BFU-MK, then continuously into CFU-MK, and into megakaryocyte, demarcation membrane system, DMS, into fractionlet release to the blood requiring 8~10 days. (one megakaryocyte can produce 200~7700 platelet). Regulation: Protein, Mpl, expressed by c-mpl (oncogene) exists in CD34+ located at hemopoietic stem cells/ committed progenitors, megakaryocyte and platelet, found by Methin in 1993, and its ligand named thrombopoietin, TPO was discovered in 1994 which promoted hemopoietic stem cells differentiating into megakaryocyte as hemopoietic stem cells positive regulating factor.
44. LIFE- SPAN AND BREAKAGE OF PLATELET Life-span: Averagely, 7~14 days in the blood. It can be consumed when it displays physiological functions. Breakage: Aged platelet can be processed by phagocytosis in liver, spleen and lymphatic node.
45. IV. PHYSIOLOGICAL HEMOSTASIS *Definition: The process from vessel bleeding to automatic hemostasia. *Bleeding time: The time from vessel bleeding to automatic hemostasia. Normal time is 1~3 min and it is longer when platelet decrease. Process of hemostasis: 1. Blood vessel contraction or convulsion (induced by neuroreflex; 5-hydroxytryptamine,5-HT; thromboxane A2, TXA2; endothelin, ET ) 2. Platelet thrombosis forming (made by platelet adhesion, aggregation, release and contraction) 3. fibrin, clot forming and maintenance (made by blood coagulation activation)
46. PHYSIOLOGICAL HEMOSTASIS
47. 1.ENDOCRINE FUNCTIONS OF VESSEL ENDOTHELIAL CELLS① Material related to hemostasis are basal membrane, collagen (III, IV), microfibril, elastin, laminin, ectonectin, fibronectin, von Willebrand factor (vWF), protein enzyme, protein enzyme inhibitor, adhesive amylose, etc.② Anticoagulative material: They are prostacyclin (PGI2), endothelium-derived relaxing factor (EDRF or nitric oxide, NO), tissue-type plasminogen activator (tPA), uPA, ADPase, ATIII, heparin sulfate, protein C, thrombomomodulin (TM), plasminogen activator (PA).③ Promoting coagulative material: Tissue factor, vWF, blood clotting factor V, plasminogen activator inhibitor (PAI-1, PAI-2, ATIII), TNFα, interleukin-1 (IL-1).④ Vessel constricting and relaxing modulators: endothelin-1 (ET-1), EDRF (NO), PGI2, etc.
48. ROLES OF VESSEL ENDOTHELIAL CELLS IN PHYSIOLOGICAL HEMOSTASIS Roles are close related to its endocrine functions① Vessel endothelium serves as barrier between underendothelial structure (namely, collagen) and blood. As soon as collagen expose to blood, hemostasis of platelet is immediately activated to form thrombus blocking wounded vessels.② Platelet activation can releases constrictive factors (TXA2, ET-1, 5- HT, etc) making vessel convulsion, lasting about 60 sec.③ Stimulated vessel endothelial cells release coagulative factors and Promoting coagulative material to realize, speed up blood coagulation. At the same time, cells also release anticoagulative factors and fibrinolysis material to modify blood coagulation.
49. INACTIVE PLATELETUnder the electronic microscope
50. ACTIVATED PLATELET FORHEMOSTASIS Under the electronic microscope
51. 2.PHYSIOLOGICAL CHARACTERISTICS OF PLATELET Thrombocyte adhesion: its membrane glycoprotein (GP, GPIb/IX and GPIIa/IIIb), collagen (underendothelial structure), vWF (plasma component), fibrinogen are involved in adhesion. Mechanism: Exposed collagen+vWF →vWF changes →platelet membrane glycoprotein+changed vWF → Thrombocyte adhesion. Thrombocyte aggregation: induced by physiological factors such as ADP, thromboxane A2 (TXA2), epinephrine, 5-HT, histamine, collagen, thrombin, prostacyclin,etc and by pathological factors like bacteria, virus, immune complex, drugs, etc. The process can be separated into two phases: phase one is reversible aggregation and phase two irreversible aggregation. Two phases require Ca2+, fibrinogen and energy consumption. Mechanism : Various factors+corresponding receptors on the platelet →changes in the second messenger within platelet →cAMP↓, Ip3↑, Ca2+↑, cGMP↑→ platelet aggregation. Thrombocyte release: ADP, ATP, 5-HT, Ca2+ released from dense body, and β-platelet globin, PF4, vWF, fibrinogen, PFV, PDGF, thrombin sensitive protein from α-granule, and acid protein hydrolyzed enzyme, tissue hydrolyzed enzyme from lysosome. Thrombocyte contraction: Loose platelet thrombus could turn into compact platelet thrombus by Ca2+ release and cytoskeleton movement (filament/canaliculus) within platelet.
52. ROLES OF PLATELET IN HEMOSTASIS Activation of platelet: Stimulus brings about thrombocyte adhesion, aggregation, release and contraction. Loose platelet thrombus forming: First phase of hemostasis. Blood coagulation activation by platelet: Fibrin net forming, second phase of hemostasis. *Roles of platelet in hemostasis: 1. Activated platelets supply lecithoid (phospholipid) surface for blood clotting factor and involve in activating factor X and prothrombin. 2. Surface of platelet membrane combine with many blood clotting factor, such as fibrinogen, FV, FXI, FXIII to speed up coagulation. 3. Activated platelets release α-granule which contains fibrinogen to intensify fibrin forming and blood coagulation. 4. Activated platelets contract clot with its contractive protein to solidify blood coagulation.
53. TWO PHASES OF PHYSIOLOGICAL HEMOSTASISFirst Phase Second Phase
54. MECHANISM1 OF PLATELET IN HEMOSTASIS
55. MECHANISM2 OF PLATELET IN HEMOSTASIS
56. 3.BLOOD COAGULATION BLOOD CLOTTING FACTOR Definition: The process of blood flow from flowing liquid to gel or gelatin. Serum: Light yellow fluid after blood coagulation. Difference between serum and plasma mainly consists in no fibrinogen in serum. Blood coagulation is a series of complicated biochemical reactions with various enzymes. Blood clotting factor: Material which are directly involved in blood coagulation. There are 12 factors named Roman numerals, except Ca2+, phospholipid，other factors being protein, and except FIII (TF), others are in fresh plasma synthesized by liver with VitK . Blood clotting enzymes have two type: inactive and activated type [FII, FVII, FIX, Fx, FXI, FXII, FXIII].
57. Blood Clotting FactorFactor Name Plasma Synthesizing Half life Chromsome Concentration site site I Fibrinogen 3000 Liver 4~5 d 4 II Prothrombin 100 Liver (with Vit K) 3d 11 III Tissue factor - Endothelial cell - - IV Ca2+ 100 - - - V Proaccelerin 10 Endothelial cell, platelet 12~15 h 1 Ⅶ Proconvertin 0.5 Liver (with Vit K) 4~7 h 13 Ⅷ Antihemophilic factor,AHF 0.1 Liver 8~10 h Ⅹ Ⅸ Plasma thromboplastic 5 Liver (with Vit K) 24 h Ⅹ component,PTC(Christmas factor) Ⅹ Stuart-Prower Factor 10 Liver (with Vit K) 2d 13 Ⅺ Plasma thromoboplastin 5 Liver 2~3 d 4 antecedent,PTA Ⅻ Contact factor or Hageman factor 40 Liver 24 h 5 XIII Fibrin-stabilizing factor 10 Liver, platelet 8d 6,1 - High-molecular weight 80 Liver - 3 kininogen,HMW-K
58. BLOOD COAGULATION Intrinsic pathway of blood coagulation: All blood clotting factors involved in blood coagulation come from blood. Eyewinker surface with negative charges (collagenin) on the endothelium of blood vessel activates blood FXII as beginning of coagulation named surface activation. Extrinsic pathway of blood coagulation: Stimulus activates tissue factor (FIII) as beginning of coagulation. Extrinsic pathway of blood coagulation is faster than intrinsic pathway of blood coagulation because its steps are more simple. *Basic steps of blood coagulation [typical positive feedback]: Prothrombin activator forming [FXa-Va-Ca2+-phospholipid] Step 1 Prothrombin thrombin Step 2 Fibrinogen fibrin (clot) Step 3 Hemophilia A, B, C in the clinic results from deficiency of FVIII, FIX, FXI in the blood, respectively.
59. Process of Blood Coagulation Extrinsic pathway Intrinsic pathway （Tissue Factor，TF） （ Eyewinker surface ） TF+Ⅶ Ⅻ Ⅺ H S Ca2+ K K PK Ⅶ-TF Ⅸ Ⅻa Ⅹa Ca2+ Ca2+ ，PL Ⅺa Ⅶa-TF Ⅸa Ca2+ PL Ca2+ Ⅷa PL Ⅹ ⅩaPL: phospholipid Ca2+ ⅩⅢ ⅤaCL: cross linking fibrin PL Ⅱ ⅡaHK: high molecular weight kininogen ⅩⅢaS: Subendothelium Ca2+PK: prekallikrein Ⅰ Ⅰa CLⅠaK: kallikrein
60. MECHANISM OF BLOODCOAGULATION
61. ANTICOAGULATIVE SYSTEM IN BLOOD Cellular anticoagulative system: Liver cell and reticular endothelial cell could engulf blood clotting factor, tissue factor, prothrombin complex and soluble fibrin monomer. Humoral anticoagulative system: 1. Amino acid protease inhibitors in blood include antithrombin III, Cl-inhibitor, α1 antitrypsin, α2 antiplasmin, α2 huge globin, heparin coenzyme II, protease nexin-1 (PN-1) to combine with FIXa, FXa, FXIa, FXIIa and thrombin and then inactivate them for anticoagulation. Heparin can intensify functions of antithrombin III. 2. Protein C system are protein C (PC), thrombomodulin (TM), protein S and Protein C inhibitors. Main functions of PC consist in ①It inactivates FVa, FVIIIa with phospholipid and Ca2+; ②It blocks FXa combining with platelet phospholipid membrane to reduce prothrombin activation; ③It stimulates plasminogen activators release to trigger fibrinolysis; ④ Protein S is a coenzyme of PC and greatly intensify functions of PC. 3. Tissue factor pathway inhibitor (TFPI) mainly coming from vessel endothelial cells inhibits FXa and inactivates FVIIa-TF complex to block extrinsic pathway of coagulation with negative feed back. 4. Heparin used in the clinic widely is due to ①It combines with antithrombin III to increase functions of antithrombin III; ②It stimulates vessel endothelial cell greatlu releasing TFPI and other anticoagulative material; ③It intensifies PC activation and stimulates vessel endothelial cell releasing plasminogen activators to increase fibrinolysis. [lower molecular weight heparin is less hemorrhage]
62. 4.FIBRINOLYSIS Fibrinolytic system is involved in fibrinolysis, tissue repair and vessel rebirth. Two fibrinolytic systems: cellular one and plasma one. The former is leucocyte, macrophage, endothelial cell, mesothelial cell and platelet to engulf and digest fibrin. The latter is plasminogen activators (PA) and its inhibitors (PAI), plasminogen, plasmin. Basic steps: Kallikrein (Intrinsic pathway) Endothelial cells (Extrinsicpathway ) (Urokinase, uPA) Cl-inhibitors tPA uPA uPAG PAI-1 Plasminogen Plasmin α2-antiplasmin α2-huge globin Fibrin Fibrin or fibrinogen dissolution
63. BLOOD COAGULATION AND FIBRINOLYSIS
64. ANTIFIBRINOLYSIS: FIBRINOLYTIC INHIBITORS AND ITS FUNCTIONS Main fibrinolytic inhibitors: They are plasminogen activator inhibitor type-1 (PAI-1, in platelet), α2-antiplasmin (in liver), α2-huge globin, α1-antitrypsin, antithrombin III, alexin C1 inhibitor. PAI-1 synthesis and release: PAI-1 made by endothelial cell, smooth muscular cell, mesothelial cell, megakaryocyte is stored in platelet with inactive form. Some factors such as thrombin, IL-1, TNFα, etc stimulate its release from platelet. PAI-1 function: It inhibits tPA (tissue-type plasminogen activator) limiting local fibrinolysis of thrombus. α2-antiplasmin characteristics: (1) Quick effect, (2) Inhibit plasminogen adhering to fibrin; (3) Combine with fibrin αchain and block fibrinolysis Clinic relation: Innate deficiency of α2-antiplasmin often brings about serious hemorrhage.
65. V. BLOOD GROUP History: ABO blood group system was firstly found by Landsteiner in 1901. Definition for blood group*: Types of specific antigens on the blood cell. Agglutination: Combination of the same antigen (or named agglutinogen, glycoprotein/glycolipid on the membrane of blood cell) and antibody (or named agglutinin, r-globin in serum) results in harmful immune reactions showing hemolysis. Human leukocyte antigen, HLA have widespread distribution in the body and involves in immune repulsive reaction of organ transplant. Platelet antigens such as PI, Zw, Ko, etc may bring about fever heat when transfusion occur.
67. ANTIGEN OF BLOOD GROUP Antigen: Its genes are located at allele on euchromosome, namely, expressed gene. Genotpye is genetic gene in blood group system and phenotype is antigen produced by corresponding genetic gene and amorph is noneffective allele. Genes in the blood system decide differential specific antigen on the membrane with control of enzymatic activity.
68. ANTIBODY OF BLOOD GROUP Crude antibody: It is the unexposed antibody to correlative RBC, e.g., IgM in ABO blood group system which can not pass through placenta for the sake of big molecule. Immune antibody: Various extraordinary RBC antigens (transfusion or parturition) sensitize lymphatic cells producing antibody such as Rh, Kell, Duffy, kidd, which belong to IgG (small molecule) and IgM (big molecule).
69. BLOOD GROUP OF RBC Number: 23 types, 193 antigens, more important blood groups are ABO, Rh, MNSs, Lutheran, kell, Lewis, duff, kidd, etc and all of them could result in hemolysis during transfusion. ABO blood group system:Blood group Antigen on the RBC Antibody in the serum A A Anti-B B B Anti-A AB A+B O Anti-A+Anti-B
70. 2. ABO BLOOD GROUP SYSTEM Antigen (agglutinogen) and antibody (agglutinin) in ABO blood subgroup systemBlood group Antigen on the RBC Antibody in the serum A A1 A+ A1 Anti-B A2 A Anti-B+ Anti-A1 B B Anti-A AB A1B A+ A1 +B A2B A+B Anti-A1 O Anti-A+Anti-B
71. ABH Antigen chemical structure in ABO blood group systemAntigen of blood group Ushering material O(H)-antigen A-antigen B-Antigen N-acetamide N-acetamide Galactose Glucose galactose Sugar Glucose
72. INHERITANCE OF ABO BLOOD GROUP Inheritance: The A, B, H agglutinogen in ABO blood group system controlled by gene which is located at allele on No.9 chromosome (9q34.1-q34.2). Genotype and Phenotype:Genotype and Phenotype in ABO blood group system Genotype phenotype OO O AA, AO A BB, BO B AB AB
73. INHERITANCE OF ABO BLOOD GROUP Genetic relationship of ABO blood group Parents’ Offspring possible Offspring impossibleblood group blood group blood group O×O O A, B, AB A×A O, A B, AB A×O O, A B, AB B×B O, B A, AB B×O O, B A, AB B×A O, A, B, AB ____ AB×O A,B O, AB AB×A A , B, AB O AB×B A , B, AB O AB×AB A , B, AB O
74. DISTRIBUTION OF ABO BLOODGROUP Mid Europe: Type A 40%, Type O 40%, Type B 10%, Type AB 6%. America aborigines: Type O 90%. China Han nationality: Type A 31.31%, Type B 28.06%, Type AB 9.77%, Type O 30.86%. Other chinese minority is different. Bloog group can be used in research on anthropology
76. 3. RH BLOOD GROUP SYSTEM Rh antigen (Rh factor) is about 40 kinds and Rh factors related to clinic are D, E, C, c, e and most important is D antigen. Membrane of RBC has D antigen meaning Rh Positive, otherwise, Rh negative. Most of people (99％) are Rh Positive and less than 1% persons are Rh negative. Rh blood group characteristics: Immune antobody and incomplete antibody, IgG; while ABO blood group, crude antibody and complete antibody,IgM. Rh blood group system and clinic work Transfusion and pregnacy [Clinic meaning]
77. QUANTIFICATION OF BLOOD VOLUME Blood volume is an important determinant of systemic arterial pressure. Circulatory system is essentially a closed container including a volume of blood equal to approximately 5 liters or 70-80mL/Kg of the body weight (in kilograms).
78. 4. RELATION BETWEEN BLOOD VOLUME AND CLINIC When you donate 10 % of total blood volume, your body compensates so that blood pressure does not change, and the volume is replaced through the normal ingestion of fluids. Volume loss up to 30-40 % of total blood volume can be tolerated if the loss is corrected within 30 min (e.g. artery contraction increases peripheral resistance but artery blood pressure can not maintain the normal levels which occur in symptoms such as light-headed, dazzled, force-lacked, etc) Blood loss more than 40 % of total blood volume will threaten the life, results in shock and the measures in the hospital should be immediately taken for life survival [Transfusion].
79. 5. PRINCIPLE OF TRANSFUSION Transfusion is widely used in clinic treatment. Principle of transfusion*: 1. Identification of blood group must be taken before transfusion. 2. Cross-match test must be done before transfusion. 3. The same tpyes of blood group for transfusion should be firstly considered. 4. The different tpyes of blood group for transfusion should be very careful, small amount and slow import and if condition is better, changes in the same tpyes of blood group for transfusion.
80. CROSS-MATCH TEST FORTRANSFUSION 红细胞 RBC 红细胞 RBC 供 Donator 受 Receiver 血 血 者 者 Serum Serum 血清 血清 主侧凝集反应 Main side of 次侧凝集反应 Subordinary side Decision agglutination of agglutination - - 相合，可以输血 Perfect match, transfusion + +, - 不合，不能输血 × No match, transfusion - + 应急情况下输血 Transfusion under emergency +: Agglutination; -: No agglutination
81. TYPES OF TRANSFUSION According to source of transfusion, allogenetic transfusion (more use), autologous transfusion. According to component of transfusion, whole blood transfusion, transfusion of blood components Autologous transfusion has some advantages: ① It decreases infection. ② It blocks syndrome (fever, hemolysis) induced by allogenetic transfusion. ③ It stimulates bone marrow hemopoiesis towards RBC. Transfusion of blood components is good.
82. SummarizationPLEASE TAKE DOWN
83. Consideration after class 【本章节问题思考】1. Please describe classification and main effects of leucocyte.2. What is the elementary process of blood coagulation and main factors which have participated in blood coagulation?3. Please describe the principle of classification and blood transfusion of ABO blood group system.
84. GUIDE OF REFERENCE 【本章节学习参考书单】1. 姚泰主编. 生理学. 第五版. 北京: 人民卫生出版社, 2000.2. 范少光, 汤浩, 潘伟丰主编. 人体生理学（二版）. 北京: 北京医科大学出版社, 2000.3. 贺石林, 李俊成, 秦晓群主编. 临床生理学. 北京: 科学出版社, 2001.4. 王庭槐主编. 生理学. 全国高等学校医学规划教材, 北京: 高等教育出版社, 2005.5. 吴祖泽, 贺福初, 裴雪涛主编. 造血调控. 上海: 上海医科大学出版社, 2000.6. 李勇, 杨贵贞主编. 人类红细胞血型学实用理论与实验技术. 北京: 中国科学技术出版社, 1999.7. Ding L, Lu S, Batchu R, et al. Bone marrow stromal cells as a vehicle for gene transfer. Gene Ther, 1999, 6(9): 1611-1616.8. Humeau L, Bardin F, Maroc C, et al. Phenotypic, molecular, and functional characterization of human peripheral blood, CD34+/Thy1+ cells. Blood, 1996, 87(3): 949-955.9. Kaushansky K. Thrombopoietin: accumulating evidence for an important biological effect on the hematopoietic stem cell. Ann N Y Acad Sci, 2003, 996: 39-43.10. Berne RM, Levy MN, Koeppen BMI, Stanton BA. Physiology, 5th ed, St Louis: Mosby Electronic Production, 2004.11.Guyton AC, Hall JE. TEXTBOOK OF MEDICAL PHYSIOLOGY, 10th ed, Philadelphia: W.B. Saunders Co, 2000.12. Berardi AC, Wang A, Levine JD, et al. Functional isolation and characterization of human hematopoietic stem cells. Science, 1995, 267(5194): 104-108.13. Fox SI. Human physiology, 7th ed, New York: McGraw-Hill Co Inc, 2002.
85. NAVIGATION FOR WEB ADDRESS 【本章节课后学习导航网站】1.http://bioresearch.ac.uk/browse/mesh/detail/c0005811L000 5811.html2.http://www.inform.umd.edu/EdRes/Colleges/HONR/HONR2 69U/Jenn/3.http://www.ohsu.edu/cliniweb/G9/G9.188.html4.http://www.mednote.co.kr/PHYSIOLOGY%20BLUE.htm5.http://www.fpnotebook.com/HEM38.htm