1. Chapter 3 Blood Physiology
Blood composition and properties
Blood cells
Hematopoiesis
RBC: function, anemia.
WBC
Platelet: function, coagulation and fibrinolysis.
Blood grouping and transfusion

2. Introduction Blood volume: 7~8% (70-80ml/kg B.W) Types of blood cells:
Plasma (60%) and cells (40%).
Types of blood cells:
RBC (Erythrocytes), WBC (Leukocytes) and Platelets (Thrombocytes)
Main function:
Maintain homeostasis
Buffering pH
Humoral regulation
Body temperature regulation
Transportation:
Gases, nutrients, hormones, and so on.
Host defense:
Immune reaction, coagulation.

3. Section 1 Components and Characteristic
Water: 93-95%
Plasma: 50-60%
Solutes: 5-7% Proteins:
Nutrients
Products
Electrolytes:
Others: urea, gases.
WBC, Platelet: 1%
RBC: 40-50% (male)
37-48% (female)
Whole
blood

4. Blood Components Water: Electrolytes: Proteins:
93~95% (plasma); 65~68% (RBC); 81~86% (whole blood).
Solvent, humoral balance, osmotic pressure.
Electrolytes:
Na+, K+, Mg2+, Cl-, HCO3-, etc. Cell shape, pH.
Proteins:
Albumin: 40-48g/L. Colloidal osmotic pressure; carrier; buffer pH.
Globulin: 15-30g/L. Immune reaction: antibody; carrier.
Fibrinogen: 2-4g/L. Blood coagulation.

5. Others: Hemoglobin (Hb): 120-160g/L (male), 110-150g/L (female)
Function: carry gases.
Others:
carbohydrates, lipids, amino acid, pigments, hormones, gas (O2, CO2), and others like urea, uric acid.

6. Physical and chemical properties
Blood pH:
Normal interval: 7.35~7.45.
Regulated by lung and kidney.
Viscosity:
Friction of molecules and cells in blood.
Relative viscosity:
Whole blood: 4~5 times to water (RBC).
Plasma: 1.6~2.4 times to water (Proteins).
Anemia or body fluid loss.

7. Osmotic pressure Definition: Composition and roles:
An ability of a liquid to attract and retain water. It drives osmosis. 300mmol/L
Composition and roles:
Crystal osmotic pressure: mmol/L.
Maintain shape and size of cells.
Colloid osmotic pressure: 1.3 mmol/L.
Retain blood volume
Decide distribution of water between blood and interstitial fluid.

8. Section 2 Blood Cells
Red blood cell
White blood cell
Platelet

9. Hemopoiesis The process of blood generation. Cell Lineage Lifespan
Daily Production Rate
RBC
120 days
2.5  109/L
Neutrophil
7 hours
0.85  109/L
Platelet
10 days
2. 5  109/L

10. Ontogeny of Hematopoiesis
Prenatal stages:
First month: yolk sac.
Third month: liver
Fourth month: bone marrow
Postnatal stages:
Bone marrow of almost any bone, predominatantly by flat bones and long bones.

11. 100 100 100 100 Prenatal age (months) Postnatal age (years)
Hemopoitic activity (%)
Bone morrow
Yolk Sac
Liver
Lymph nodes
Spleen 1 2 3 4 5 6 7 8 9
Prenatal age (months)
100
100
Vertebrate
Proportion of Red Morrow (%)
Tibia
Sternum
Femur
Ribs
birth 10 20 30 40 50 60 70 80 90
Postnatal age (years)

14. Stage 1, hemopoietic stem cells: pluripotent uncommitted stem cells.
Stage 2, committed progenitor cell: unipotent committed stem cells. Includes:
Erythrocytic progenitor cell
Megakaryocytic progenitor cell
Granulocytic progenitor cell
Lymphocytic progenitor cell
Stage 3, precursors (cell): immature cells, differentiate functional cells. Including:
Ery. progenitor erythrocytes.
Mega. progenitor  platelets.
Gran. progenitor  granulocytes and monocytes.
Lym. progenitor  T and B lymphocytes.

15. Hematopoietic growth factor and related molecules
Necessary for proliferation and differentation of hematopoietic cells in the marrow.
Colony-stimulating factors (CSF): see a table in next slide.
Cytokines:
IL-1, stem cell factor (SCF), etc.
Extracellular matrix proteins:
Sulfated glycosamimoglycans and heparin sulfate, may concentrate hematopoitic growth factors in local micro environment;
Fibronectin and hemonectin, mediate adhension of cells, and may serve a growth promoting function.

16. Hematopoietic growth factors
Function: stimulate progenitor of the followings:
GM-CSF (granulocyte-macrophage CSF)
Granulocyte-monocyte
G-CSF (granulocyte CSF)
Granulocyte
M-CSF (macrophage CSF)
Monocyte
EPO (Erythropoietin)
Erythrocyte
IL-1,3,6 (Interleukin-3, 1, 6)
Myeloid lineage
TPO (Thrombopoietin)
Platelet

17. Red blood cells (erythrocytes)
Circular, biconcave discs without nuclei. 7~8m, thickness 1~2.5 m.

18. Cell count and volume:
Hematocrit: Percentage of blood volume occupied by packed cell volume.

19. Volume: Physical properties 4.5~5.51012/L, average 5.01012/L (male).
3.8~4.61012/L, average 4.21012/L (female).
Physical properties
Permeability:
Deformation:
Fragility and hemolysis:
Isosmotic solution and lower osmotic solution
Suspension stability:
The erythrocytes are very stable in suspension.
Cause: repelling force of same charge and bigger surface area.

20. Erythrocytes Sedimentation Rate (ESR): Sedimentated distance of RBC after one hour.
0~15 mm/h (male), 0~20 mm/h (female).
Ratio of Surface area/Volume of RBC.
Albumin, globulin, fibrinogen, and cholesterol.
Rouleaux: RBC aggregate.
Function of RBC:
The main constituent of RBC is hemoglobin.
To deliver O2 to tissues by hemoglobin.

21. Hemoglobin (HB)
HB is made up of two polypeptide  chains and  chains.
Each polypeptide has alpha helical segments folded and bent into a globular configuration, with a heme ring within a pocket where the iron molecule can interact with oxygen.

22. Hb formation materials:
Protein: enough intake from food.
Iron: 3-4g/person. Mainly in Hb (70%).
Degrading Hb: 95%.
Absorbed from small intestine: 1mg/d, 5%.
Microcytic hypochromic anemia: Lack of iron.

23. RBC Maturation factors:
Vitamin B12:
Cobalamine, 2~5g/d.
Produced by gut bacteria (esp. in ruminants). Good sources include meat, liver, fish, eggs and milk.
Absorbed in terminal ileum with intrinsic factor’ help.
Function: Improve utilization of FA.
Folic acid:
FA is essential for the synthesis DNA.
Synthesized by microorganisms and higher plants.
Good sources are green leafy vegetables, yeast and organ meats.
Absorbed in the proximal jejunum.

24. Lack of folic acid and vitb12: give rise to immature cells due to DNA synthesis derangement.
Megaloblast anemia.

25. Regulation of erythropoiesis: Hypoxia:  EPO RBC
Hemopoitic stem cell (uncommitted progenitor) 
Erythrocytic progenitor (committed progenitor)
Pronormblast (precursor)
Normoblast, Reticulocyte
Mature RBC (without nucleus)
EPO

26. Erythropoietin (EPO):
A glycoprotein, 34kd. Produced in interstitial cells in cortical kidney such as fibroblast, endothelial cells.
Roles:
Erythrocytic progenitor proliferate and differentiate to precursor.
Accelerate precursor proliferation and differentiation.
Promote bone marrow release reticulocytes.
Renal type anemia: EPO production decrease
Other hormones:
Androgen, thyroid hormone, parathyroid hormone,etc.
RBC destruction:
Life span of RBC is about 120 days. Older cells

27. White blood cells (leucocyte)
WBC:
4~10109/L, average is 7109/L.
Include:
neutrophil, eosinophil, basophil
monocyte, lymphocyte.
Protection, execute specific and non-specific immune reaction.
Physical and chemical properties
Chemotaxis: attracted by chemical substances released by bacteria and foreign substances.
Movement: Move to chemotaxic source
Phagocytosis: engulf and digest

28. Composition and functions
Neutrophil:
10~12m, 2.0~7.0109/L, 60-70%.
Function:
Phagocytosis: older cells, becteria, dead tissues, and other foreign substances.
To execute non-specific immune activity in first front.

29. Monocytes:
15~30m, 0.12 ~ 0.8109/L, 3 ~ 8%.
Monocytes-macrophages system:
Monocytes (in blood) wander into tissues and become macrophages (50 ~ 80 m). Stronger phagocytosis.
Contain many kinds of cytokines such as CSF, ILs, TNF, INF-a,b.
Roles:
Engulf and clear: bacteria, vermins, older, necrotic tissues, dead neutrophils, dead cells and fragments.
Activate lymphocytes to execute specific immune response.
Recognize and kill cancer cells.
Produce CSF, Ils, TNF, INF-, , regulate growth of granulocytes.

30. Lymphocytes: 0.8~4.0109/L, 20 ~ 40%. Development of lymphocyte:
T lymphocyte:
lymphocytic stem cells  T lymphocytes (thymus gland).
B lymphocyte:
lymphocytic stem cells  B lymphocytes (lymphoid tissue).
Functions:
T lymphocytes: cellular type of immunity
B lymphocytes: humoral immunity

31. Eosinophils 0.02~0.5 109/L, 0.5~5%. Functions:
Inhibit allergic reaction induced by basophils:
Produce PGE to inhibit secretion of basophils;
Engulf substances secreted by basophils;
Secrete matters to hydrolyze histamine and 5-HT.
Phagocytic action to some worms.

32. Basophils
0.0~1.0  109/L, 0~1%.
Large cytoplastmic granules contain heparin, 5-hydroxytryptamine and histamine.
Function:
Secrete heparin blood to prevent coagulation.
Wander into tissue and become mast cell.
Induce allergy.

33. Platelet
Hemostasis:
The process of blood clotting and then the subsequent dissolution of the clot.
Platelet  activation  adhension  aggregation  clot  thrombus  FDP
thrombin
fibrin
plasmin
vWF
ADP and TXA2
fibrinogen
Blood Coagulation
Fibrinolysis

34. Anatomic physiology of platelet:
2~4 m, thickness 1m.

35. Fibrinogen
GP IIb/III a
Phospholipid Va
Ca2+
Receptor X
GPI
vWF

36. Membrane: Granules in platelet:
Receptor: For adhension, aggregation and coagulation.
Phospholipid: provides the lipid cofactors needed for coagulation reactions.
Granules in platelet:
-granules: coagulation factors, growth factors (e.g. PDGF).
-granules (dense bodies): Ca2+, ADP and serotonin.
Volume: 100~300 109/L in adult.
Thrombocytopenia: <50 109/L,  hemorrhage
Thrombocytosis: >1000109/L,  Thrombosis

37. Physical properties Adhesion: Mediated by von Willebrand factor (vWF).
vWF is producted and stored in a-granules of platelets. Also synthesized by megakaryocytes.
Function of vWF:
To act as a bridge between glycoprotein on the surface of platelets (GPIb/IX) and collagen fibrils.
Serves as a carrier protein for factor VIII.
von Willebrand Disease (vWD): deficiency in vWF a patient with long bleeding time, a low level of factor vWF/VIII complex.
Bernard-Soulier Syndrome:deficiency of glycoprotein Ib/IX.

38. Aggregation: Activated platelets aggregate together.
Activation of platelets: induced by thrombin.
Thrombin + receptor  initiate signal cascade.
G-protein, and phospholipase C(PLC-g).
PLC-g  IP3 and DAG formation.
IP3  Ca2+ , and DAG  PKC.
Mechanisms:
Ca2+  phospholipase A2 (PLA2) arachidonic acid  thromboxane A2 (TXA2)
PKC ADP  fibrinogen to adhere to two platelet surface glycoproteins (GPIIb and GPIIIa)  fibrinogen-induced platelet aggregation.
Glanzmann-Thrombasthenia, deficiency of glycoprotein IIb/IIIa.

39. Contractile function:
PLC-g  Ca2+  myosin light chain kinase (MLCK)
MLCK  phosphorylation of light chain of myosin
Myosin interacts with actin
Platelet morphology, motility, and clot retraction.

41. Roles of platelet:
Platelet clot formation at the site of vessel injury (primary hemostasis);
Enhance activation of coagulation factors to solidify platelet clot by interlacing with fibrin (secondary hemostasis).

42. Platelet function disorders:
Disorders of platelet adhesion:
Bernard-Soulier Syndrome: deficiency of glycoprotein Ib/IX.
Disorders of platelet aggregation:
Glanzmann-Thrombasthenia, deficiency of glycoprotein IIb/IIIa.
Disorders of platelet secretion:
Alpha or Dense Granules Deficiency.
Disorders of platelet procoagulant activity:
Platelets fail to promote activation of the blood clotting proteins.
Acquired platelet function disorders:
Drugs like aspirin, non-steroidal anti-inflammatory drugs like indomethacin, ibuprofen.

43. Blood coagulation Coagulation factors:
A process of blood from liquid to colloid. A serious of enzymes reactions.
Coagulation factors:
Factors involved in the blood coagulation
Attentions:
FIII come from tissue, others from plasma.
FIV is Ca2+, and others are proteins.
FII, VII, IX, XII exist as proenzymes.

44. High molecular weight kininogen (HMWK)
Factor
Trivial Name(s)
Pathway
Characteristic
Prekallikrein
Fletcher factor
Intrinsic
High molecular weight kininogen (HMWK)
contact activation cofactor; Fitzgerald, Flaujeac Williams factor I
Fibrinogen
Both - II
Prothrombin
Contains N-term. gla segment
III
Tissue Factor
Extrinsic IV
Calcium V
Proaccelerin, labile factor, accelerator (Ac-) globulin
Protein cofactor
VI (Va)
Accelerin
This is Va, redundant to Factor V
VII
Proconvertin, serum prothrombin conversion accelerator (SPCA), cothromboplastin
Endopeptidase with gla residues
VIII
Antihemophiliac factor A, antihemophilic globulin (AHG) IX
Christmas Factor, antihemophilic factor B,plasma thromboplastin component (PTC) X
Stuart-Prower Factor XI
Plasma thromboplastin antecedent (PTA)
Endopeptidase
XII
Hageman Factor
XIII
Protransglutaminase, fibrin stabilizing factor (FSF), fibrinoligase
Transpeptidase

45. Stage 2: Conversion of prothrombin to thrombin.
clotting cascade
Stage 1: Formation of prothrombin activator.
Stage 2: Conversion of prothrombin to thrombin.
Stage 3: conversion of fibrinogen to fibrin

46. Difference of stage 1: Prothrombin-converting enzyme: Xa, Ca2+, V, PL.
Difference of factor Xa:
Intrinsic stage:
Start from XII. The intrinsic pathway requires factors VIII, IX, X, XI, and XII. Also required are the proteins prekallikrein and high-molecular-weight kininogen, as well as Ca2+ and phospholipids secreted from platelets.
Extrinsic stage:
Start from FIII (TF), is initiated at the site of injury in response to the release of TF.
TF is a cofactor in the factor VIIa
Factor VIIa, cleaves factor X to factor Xa

47. Prevention of coagulation
Plasma inhibitors
Fibrinolysis
Role of the endothelial cells

48. Plasma inhibitors Inhibitor Mol. Weight (kD) Action
Plasma Conc. (mg/ml)
Antithrombin III 50
Antiserine protease
240
2-antiplasma 70
Antiplasmin
2-macroglobulin
725
Antiprotease
2500
Protein c 56
Anti-factor V and Viii 5

49. Antithrombin III: Protein C: Nonspecific protease inhibitors
Produced in liver and endothelial cells
Inhibit active sites of FIXa,FXa,FXIa,FXIIa, thrombin.
Protein C:
Vitamin K-dependent protein
Is activated to activited protein C (aPC) by thrombin in presence of endothelial cell-derived cofactor thrombomodulin.
aPC inactivates FV and FVIII in presence of another vitamin K-dependent cofactor: protein S.
See next slide.

50. Anticoagulation pathway
VIII
VIIIa
VIIIi PS
aPC PC X X
+ Va PS V Vi
FII
Thrombin FI
Fibrin

51. Calcium ions precipitants:
Heparin:
A polysaccharide produced in basophilic mast cells
Distributed in the pericapillary tissue.
Abundant in lung, heart, liver, muscle tissues.
Inhibit thrombin conversion.
Promote antithrombin III activity.
Calcium ions precipitants:
Sodium citrate

52. fibrin degradation products
Fibrinolysis
Fibrinolysis:
Process of liquefaction of fibrin
Activator
plasminogen
plasmin
Inhibitor
fibrin
fibrin degradation products
Activator: Tissue plasminogen activator (tPA), urokinase.
Plasmin, a serine protease, is inhibited by 2-antiplasma.

53. plasminogen activator-inhibitors:
tPA:
Released from vascular endothelial cells following injury;
Binds to fibrin and is consequently activated.
Urokinase:
Produced as the precursor, prourokinase by epithelial cells lining excretory ducts.
Role: to activate the dissolution of fibrin clots.
plasminogen activator-inhibitors:
PAI-1 and PAI-2

54. Endothelial cells
Endothelium produces several inhibitors of hemostasis:
Prostaglandin I2:
secreted by endothelial cells and is a potent inhibitor of platelet aggregation.
Thrombomodulin:
Enhances the activiation of protein C by thrombin and results in the inactivation of factor V and VIII.
Heparans:
a heparin-like molecule, produced by endothelial cells. Increase the anticoagulant effect of antithrombin III.
Plasminogen activator:
necessary for dissolution of fibrin clots, such as tPA.

55. Coagulation disorders
Hemophilia A:
Deficiency of FVIII. The disease severity usually parallels the factor VIII levels.
Serve (< 1% VIII): with spontaneous bleeding;
Moderate (1-5% VIII): with occasional bleeding, usually with trauma;
Mild (6-30% VIII): with bleeding only after surgery or trauma.
Therapy: administration of FVIII.

56. Hemophilia B (Christmas Disease):
FIX deficiency.
Treatment requires IX-rich material: fresh frozen plasma (FFP) or lyophilized concentrates proagulatant proteins.
Decreased production of coagulation factors:
E.g. Liver disease, vitamin K malabsorption, dietary deficiency of vitamin K.
Inactivation of coagulation factors:
e.g. specific inhibitors, excessive activation of coagulation (DIC) and/or enzymatic destruction of coagulation factors.

57. Blood grouping and transfusion
The discovery of blood groups:
1901, Austrian Karl Landsteiner discovered human blood groups.
Blood agglutination was an immunological reaction.
Awarded the Nobel Prize in Physiology or Medicine in 1930.

58. Agglutination: RBC grouping: Agglutinogen: antigen on membrane of RBC.
Agglutinin: antibody in the plasma.
RBC grouping:
ABO, Rh, MnSs, lewis
The differences in human blood are due to the presence or absence of certain protein molecules called antigens and antibodies.

59. ABO grouping
Blood group A：A antigens on the surface of RBC, B antibodies in blood plasma.
Blood group B：B antigens on the surface of RBC, A antibodies in blood plasma.
Blood group AB：both A and B antigens on the surface of RBC, no A or B antibodies at all in blood plasma.
Blood group O：neither A or B antigens on the surface of RBC, but you have both A and B antibodies in blood plasma

60. Antigens and antibodies:
A, B.
Carbohydrate
Antibodies: Antibody A and B.
Ig M: congenital,
Bigger Mr.

61. Rh grouping Original discovery: Rh antigen and antibody
Rhesus monkey: Red cells  injected into rabbits  got serum  injected back to Rhesus monkey, or human  agglutination happens.
Rh antigen and antibody
Antigen: D, E, C, c, e.
99% Chinese people are Rh+
Minority in China 2-5% is Rh-
15% western people are Rh-
Antibody: IgG

62. Which blood group do you belong to?
A Rh+
B Rh+
AB Rh+
O Rh+
A Rh-
B Rh-
AB Rh-
O Rh-

63. Blood Transfusion Clinical significance: Cross-match test:
ABO and Rh blood groups must be compatible between the donor blood and the patient blood.
Agglutinated RBC clog blood vessels or crack to becomes toxic when HB outside the cell.
Cross-match test:
Main lateral: donor’s RBC and recipient’s serum.
Co-lateral: donor’s serum and recipient’s RBC.

64. Principle of blood transfusion:
Agglutination of main lateral: absolutely no.
Both of main and co-lateral do not agglutinate:
Co-lateral agglutinates but Main lateral:
slow and less amount of blood transfusion could be recommended.
People with blood group O are called “universal donors”.
People with blood group AB are called “universal receivers”.

65. Clinical importance for Rh group:
Blood transfusion between Rh+ and Rh- persons.
A mother who is Rh- woman give birth a baby who is Rh+.
Preventive measure: given an injection of anti-Rh antibodies.

66. Donor Recipient RBC RBC (co-lateral) Serum Serum (main lateral)
Cross match test