CHAPTER 2:

RBC FORMATION, METABOLISM, AND

DESTRUCTION
 Erythropoiesis
Erythropoiesis • Term used to describe the process of RBC production
description • Occurs in distinct anatomical sites called
erythropoietic islands
• Each island consists of a macrophage surrounded by
a cluster of erythroblasts.
• The macrophage serves to supply the developing red
cells with iron for hemoglobin synthesis.
• Erythroid cells account for 5% to 38% of nucleated
cells in normal bone.
Tissue • Literally means decrease in oxygen content within
hypoxia the tissues
• Produces a dramatic increase in the production of
erythropoietin
• Primary stimulus for the production of RBCs
 Erythropoiesis
Erythron • Refers to all of the stages of erythrocyte
development encompassing the earliest
precursor cells in the bone marrow to
the mature RBCs in the circulating,
peripheral blood and the vascular areas
of organs such as the spleen.
Basic substances • Amino acids (protein)
needed for • Iron
normal • Vitamin B12
erythrocyte and • Vitamin B6
hemoglobin • Folic acid (member of B2 complex)
production • Trace minerals (Cobalt and nickel)
 Erythropoiesis
Erythropoietin • Produced primarily by the kidneys (80% to
(EPO) 90%), liver (10 to 15%)
• Primary source of EPO in the unborn: Liver
• Site of EPO production in kidneys: Peritubular
cells
• Glycoprotein hormone
• MW: 46,000 daltons
• First human hematopoietic growth factor to
be identified
• Blood levels of EPO is inversely related to
tissue oxygenation
• Level can increase up to 20,000 mU/mL in
response to anemia or arterial hypoxemia
• Tissue hypoxia: Produces dramatic increase in
the production of EPO.
• EPO prevents erythroid cell apoptosis
 Erythropoiesis
General • Maturation through nucleated cell stages
Characteristics of in 4 or 5 days
Maturation and • Bone marrow reticulocytes: 2.5 days
Development • Reticulocytes in circulation: 1 day
(represents 0.5% to 1% of the circulating
erythrocytes)
 Radioisotopic Evaluation of Production Sites
Radioactive imaging • One technique used in nuclear
medicine to identify sites of
erythropoiesis as well as other
physiologic characteristics and
tumors
• After radioisotope injection,
total body surface counts are
done with an external probe,
which shows the location of
radioactivity in the body
Radioisotopes used 1. Iron-59
2. Iron-52
3. Technetium-99m sulfur colloid
 Radioisotopic Evaluation of Production Sites
Iron-59 and Iron-52 • Ingested iron normally is bound to transferrin
in the blood, carried to sites of erythrocyte
production, and incorporated into the
erythrocyte to be used in hemoglobin
production

Iron-59
• Has long half-life (45 days), thus exposes the
patient to long-term radiation
• Does not permit good image production

Iron-52
• Has an ideal half-life (8.2 hours)
• Excellent for imaging
Technetium-99m Most widely used radioisotope in clinical imaging
sulfur colloid
 Total Erythropoiesis vs Effective Erythropoiesis
Total Erythropoiesis Effective
Erythropoiesis
• Refers to the total • Production of red
production of red blood cells that reach
blood cells the circulation or
peripheral blood
1. M:E ratio (3:1 to 4:1) 1. Red blood cell iron
2. Fecal urobilinogen turnover (utilization of
3. Plasma iron turnover iron)
2. Reticulocyte count
3. Red blood cell life
span
 Other Notes
Plasma Iron turnover • Uses radioactive 59Fe
intravenously to measure rate
of disappearance
• Measures total erythropoiesis

Red cell turnover • Measures effective

erythropoiesis
• Measures 59Fe radioactivity for
2-3 weeks

RBC lifespan/survival Uses 51Chromium

 Nomenclature for Naming Erythroid Precursors
Normoblastic Erythroblastic Rubriblastic
Pronormoblast Proerythroblast Rubriblast
Basophilic normoblast Basophilic erythroblast Prorubricyte
Polychromatophilic Polychromatophilic Rubricyte
normoblast erythroblast
or Polychromatic or Polychromatic
normoblast erythroblast
Orthochromic Orthochromic Metarubricyte
normoblast erythroblast
Polychromatophilic erythrocyte or Polychromatic erythrocyte or
Reticulocyte (Supravital stain)
Erythrocyte
 RBC Maturation Series
1. • Also known as Rubriblast, Proerythroblast
Pronormoblast • N:C ratio is 8:1
• Fine and uniform chromatin pattern and stains intensely
• It takes approximately 3 days for the pronormoblast to
develop into the orthochromic normoblast
• Earliest recognizable RBC precursor in light microscopy
2. Basophilic • Also known as Prorubricyte, Basophilic erythroblast
normoblast • Slightly smaller than rubriblast
• N:C ratio is 4:1
• Nuclear chromatin becomes more clumped
• Last stage with nucleolus
• Cytoplasm is less but intensely basophilic (due to RNA)
 RBC Maturation Series
3. • Also known as Rubricyte, Polychromatophilic
Pylochromatophilic erythroblast
normoblast • Hemoglobin appear for the first time
• N:C ratio is 1:1
• Muddy, light gray appearance of cell due to variable
amounts of pink coloration mixed with basophilia
• Last stage capable of mitosis
4. Orthochromic • Also known as Metarubricyte, Orthochromic erythroblast
normoblast • Nucleus is tightly condensed and described as pyknotic
(dense or compact)
• In the later period of this stage, the nucleus will be
extruded from the cell
• Last stage with nucleus
 RBC Maturation Series
5. Polychromatophilic • Part of this phase occurs in the bone marrow, and the later
erythrocyte part of the stage takes place in the circulating blood
• Anuclear
• In supravital stain: Reticulocyte
• Last stage capable of hemoglobin synthesis
• After nuclear expulsion, reticulocytes retained in the marrow
for 2 to 3 days
• Same color with mature RBC
6. Mature -
erythrocyte
 Stress or shift reticulocyte
• Increased numbers of reticulocytes are
prematurely released from the bone marrow
under the stimulus of erythropoietin because
of such conditions as acute bleeding.
• When stained with a supravital stain, stress
reticulocytes exhibit a much denser meshlike
network
 Polychromatophilia, polychromasia,
reticulocytosis
• An elevated reticulocyte count accompanies a
shortened RBC survival
 Maturation Series
Earliest recognizable Pronormoblast/Proerythroblast/Rubriblast
Last stage capable of Polychromatophilic normoblast/Polychromatophilic
mitosis erythroblast/Rubricyte
Last stage with a Prorubricyte/Basophilic normoblast/Basophilic
nucleolus erythroblast
Last stage with nucleus Orthochromic normoblast/Orthochromic
erythroblast/Metarubircyte
Last stage that can Reticulocyte
synthesize hemoglobin
 RBC Metabolic Pathway
Emden-Meyerhof • Anaerobic glycolysis
Pathway (EMP) • 90 to 95% of ATP
• 2 ATP is produced for every glucose molecule broken
down to lactic acid
• ATP is used to control the flow of sodium and potassium
into and out of the RBC, maintain the biconcave shape of
the cell, and protect membrane lipids
• Important enzyme: Pyruvate kinase
Shunts or Diversions
1. Hexose Description
Monophosphate • Also known as Pentose phosphate pathway
Pathway (HMP) • Decreased activity of an enzyme in this pathway results in
oxidized hemoglobin, which denatures and precipitates as
Heinz bodies
• Important enzymes: G6PD, Glutathione

Purpose:
1. Prevent oxidative denaturation of hemoglobin by
hydrogen peroxide
2. Aerobic glycolysis (5 to 10%)
2. Methemoglobin • Maintains the iron present in the hemoglobin molecule in
Reductase Pathway a functional reduced state (Fe2+) for oxygen transport
3. Rapoport- • Allows the production of 2,3 diphosphoglycerate (2,3
Luebering Pathway DPG)
• The 2,3 DPG combines reversibly with the deoxygenated
hemoglobin, decreasing the affinity of hemoglobin for
oxygen.
 RBC Membrane
Description • Shape: Biconcave disk
• Cell membrane: 50% protein, 40% lipid, 10%
carbohydrate (BROWN) /52% proteins, 40%
lipids, and 8% carbohydrates (RODAK)
2 classes of 1. Integral/ Transmembrane protein
proteins in the 2. Peripheral/Cytoskeletal/Skeletal protein
membrane
 RBC Membrane
Integral/ Description
Transmembrane • In-contact with both the inner and outer surfaces of the
protein membrane
• Carry various antigens on the membrane surface, while
some antigens are also attached to the glycolipid
portions of the membrane surface
• Serve as transport and adhesion sites and signaling
receptors
• Any disruption in transport protein function changes the
osmotic tension of the cytoplasm, which leads to a rise
in viscosity and loss of deformability
• Proteins: protein 4.1, ankyrin, and Glycophorin A

Glycophorin A (M, N antigen)

• Responsible of the negative charge of the red blood cell
surface
 RBC Membrane
Peripheral/Cyto • Proteins: α-spectrin, β-spectrin, and Actin
skeletal/Skeleta • Do not penetrate the bilayer
l protein • Spectrin = Consists of an α and a β chain in a
helix circular pattern like a spring
• Actin = contractile protein that contributes to
the deformability of the RBC
 Variations
Poikilocytosis Variation in shape
Anisocytosis Variation in size
Anisochromia Variation in hemoglobin
content
 RBC Hemoglobin Content
Anisochromia • Variation in hemoglobin contents of red blood cells
Normochromic RBC with a normal hemoglobin content have a clear pallor
that occupies about 1/3 of the cell diameter
Hypochromic Decreased hemoglobin concentration and increase central
pallor
Hyperchromic • Do not have an area of central pallor because of its
increased thickness
• Seen in spherocytes, sickle cell, Hb CC and Hb SC
 Shifts
RBC shift Shift to the left= Microcytosis
Shift to the right = Macrocytosis
WBC shift Shift to the left = Hyposegmented neutrophil
Shift to the right = Hypersegmented neutrophil
Oxygen dissociation curve Shift to the left = Increased oxygen affinity
Shift to the right = Decreased oxygen affinity
 RBC Shapes
Shape Description Notes
Spherocyte • Spherical in shape • Associated with hemolytic
Bronze cell • Do not have central anemia
pallor • ABO HDN
• Decreased surface • Hereditary spherocytosis
membrane area to
volume ratio
• Increased MCHC
Codocyte • Centrally stained area • Liver disease
Leptocyte with a thin outer rim • Hemoglobinopathies (Sickle
Target cell of hemoglobin cell anemia, hemoglobin CC,
Thin cell • Increases in hemoglobin E, and
Mexican Hat cell cholesterol and hemoglobin SC)
Platycyte phospholipid may be
Bull’s eye cell one cause of target
Greek Helmet cell cells
 RBC Shapes
Shape Description Notes
Stomatocyte • Slit-like (rectangular) area • Acquired stomatocytosis
Mouth cell of central pallor (Liver disease, Alcoholism)
• Lost the indentation on • Electrolyte imbalance
one side • Hereditary stomatocytosis
• Artifact
Schistocyte • Red blood cell fragments • Microangiopathic hemolytic
Schizocyte anemia (DIC, TTP, HUS)
• Uremia
• Severe burns
Dacryocyte • RBC with a single pointed • Myelofibrosis
Teardrop cells extension resembling a • Pernicious anemia
teardrop or pear • Myeloid metaplasia
• Thalassemia
Helmet cell • RBC fragment in shape of a • Microangiopathic hemolytic
Keratocyte helmet anemia
Triangle cell
 RBC Shapes
Shape Description Notes
Drepanocyte • RBC in the shape of a sickle or • Sickle cell anemia
Sickle cell crescent due to the formation • Hemoglobin SC disease
Meniscocyte of rod-like polymers of
hemoglobin S within the cells
Ovalocyte and • Elliptical (cigar-shaped), Oval • Hereditary elliptocytosis or
Elliptocyte (egg-shaped) RBC ovalocytosis
• Iron deficiency anemia
• Thalassemia major
• Myelophthisic anemia
Burr cell • Crenated red blood cells • Uremia
Echinocyte • Have blunt spicules evenly • Severe burns
distributed over the surface • Pyruvate kinase deficiency
of the RBC
 RBC Shapes
Shape Description Notes
Acanthocyte • RBC with irregularly spaced • Neuroacanthocytosis
Spur cell projections (Abetalipoproteinemia)
Thorn cell • These spicules vary in width but • Severe liver disease (Spur cell
usually contain a bulbous, anemia)
rounded end • Lipid metabolism disorder
Folded cell • RBC with membrane folded over • Hemoglobin C disease
Biscuit cell • Hemoglobin SC disease
Bite cell • RBC with one or more • G6PD Deficiency
Degma cell semicircular portions removed
from the cell margin
Anulocyte • RBC with just a thin rim of • Artifact
Pessary cell hemoglobin and a large clear
Ghost cell central area
Rouleaux • “Poker-chip” stacking of RBCs • Cold agglutinins
formation
 Inclusion Bodies
Description Compositio Conditions
n
Howell-Jolly Feulgen stain (DNA stain): DNA • Megaloblastic
bodies Positive anemia
Wright stain: Small, round • Alcoholism
reddish-blue fragments of
nucleus
Cabot rings Wright stain: Reddish-violet, Mitotic • Megaloblastic
thin ringlike, figure eight, loop- spindle anemia
shaped appearance • Lead poisoning
 Inclusion Bodies
Description Composition Conditions
Pappenheimer Wright stain: Iron • Refractory
bodies (Wright • Small, irregular, dark- anemia
stain) / Siderotic staining granules that • Sideroblastic
granules (Prussian appear near the anemia
blue) periphery of a young RBC • Iron overload
• Resembles basophilic (Hemosiderosis,
stippling and must be Hemochromatosi
differentiated by Prussian s)
blue stain
 Inclusion Bodies
Description Composition Conditions
Hemoglobin H Wright stain: Not visible Hemoglobin H (4 Hemoglobin H
Supravital stain beta chains) disease
• Small greenish-blue
inclusion bodies
• Composed of tetramer of β
globin
• “Golf ball” appearance of
RBCs
Hemoglobin SC Wright stain: Fingerlike or Hemoglobin SC Hemoglobin SC
quartzlike crystal of dense crystal disease
hemoglobin protruding from
the RBC membrane
Hemoglobin C Wright stain: Hexagonal Hemoglobin C Hemoglobin C
crystal of dense hemoglobin crystal disease
Malarial Malarial Pigment: Hemozoin Plasmodium spp. Malaria
stippling (GREGORIUS)/Hematin
(BELIZARIO)
 Inclusion Bodies
Description Composition Conditions
Babesia • Maltese cross/ Tetrads Babesia spp. Babesiosis/Piropla
inclusion • Mistaken as Plasmodium smosis/Malaria-
falciparum like infection
• Vector: Hard Tick/Black
Legged Tick/Deer
Tick/Ixodes scapularis
 Malaria
Plasmodium Plasmodium Plasmodium Plasmodium
falciparum ovale vivax malariae
RBC infected Young and old Young Young Old
Asexual <48 hours 48 hours 48 hours 72 hours
cycle/Erythrocy
tic cycle
Disease • Malignant Benign tertian Benign tertian Quartan
tertian malaria malaria malaria
malaria,
Black water
fever
(Cerebral
malaria)
 Malaria
Plasmodium Plasmodium Plasmodium Plasmodium
falciparum ovale vivax malariae
Other Notes • Crescent, • James • Schuffner’s • Ziemann’s
banana or dot/Schuffn dot dot
sausage er’s dot • Enlarged • Fruit pie
shaped • RBCs are RBC • Band form
Gametocyte oval and • Ameboid trophozoite
• Maurer’s enlarged ring
dot or • Malarial trophozoite
Christopher’ relapse • Malarial
s dot relapse
• Applique
• Most severe
malaria
 RBC Other Information
Other name Erythrocyte, Red corpuscle, Red cell, RBC, Discocyte
Color (Wright Salmon pink
stain)
Lifespan 120 ± 20 days or 100 to 140 days
Average (120 days)
Size 6-8 um
Thickness 1.5-2.5 um
Surface area 140 um2
Shape Biconcave disc with central pallor
Function Transports oxygen from the lungs to tissues and to transport
carbon dioxide to the lungs to be exhaled
Volume 80-100 fL
(Normocytic)
Zeta potential • Negative charge between cells due to sialic acid
• Causes the cells to repel each other
Site of Bone marrow
production
Site of Spleen
destruction
 RBC Destruction
Description • As a nonnucleated cell, the mature RBC is unable to generate new
proteins, such as enzymes, so as its cellular functions decline, the
cell ultimately approaches death
• The average RBC has sufficient enzyme function to live 120 days.
• Because RBCs lack mitochondria, they rely on glycolysis for
production of ATP
• The loss of glycolytic enzymes is central to this process of aging,
called senescence, which results in phagocytosis by macrophages
Extravascular • Macrophage-mediated hemolysis
hemolysis • Occurs in the spleen
• 90% of RBC destroyed
 RBC Destruction
Intravascular • Mechanical hemolysis
hemolysis • Although most natural RBC deaths occur in the spleen, a small
portion of RBCs rupture, normally intravascularly (within the
lumen of blood vessels)
• Extremely damaged cells lyse within the circulation before they
reach the liver or spleen
• 10% of RBC destroyed
Culling • Removal of senescent(old) and damaged RBC in the spleen
Pitting • Removal of RBC inclusion bodies in the spleen
• Results to the formation of bite cell
Part 3 Questions
 1. Last stage of RBC precursor with
nucleus:
A. Orthochromic normoblast
B. Reticulocyte
C. Basophilic normoblast
D. Polychromatophilic normoblast
 2. Which of the following is true
regarding 2,3 BPG?
A. It enhances the release of oxygen from
hemoglobin
B. It provides a source of glucose for the RBC
C. It is unnecessary for RBC survival
D. It is the least abundant of all
organophosphates in the RBC
 3. Hypoxia stimulates RBC production
by:
A. Inducing more pluripotent stem cells into the
erythroid lineage
B. Stimulating EPO production by the kidney
C. Increasing the number of RBC mitoses
D. Stimulating the production of fibronectin by
macrophages of the bone marrow
 4. The primary stimulus for the
production of erythrocytes is:
A. The production of thrombopoietin
B. Tissue hypoxia
C. Increased levels of 2,3 DPG in the bone
marrow
D. Oxygenation of th tissues