Haematopoiesis

 Haematopoiesis is defined as the process of formation, development and differentiation of

blood cells.
 The blood cells are formed from haematopoietic stem cells (HSCs) which are either
multipotent or pluripotent in nature.
 In the prenatal stage, haematopoiesis occurs in the yolk sac during the first weeks of
embryonic development and transitions to the spleen, liver, lymph nodes and finally in the
bone marrow continuing for lifetime.

Hematopoietic stem cells (HSCs) and types

 Haematopoietic stem cells (HSCs) are special type of cell present in rar the bone marrow,
they are rare and their numbers are strictly controlled by a balance of cell division, death,
and differentiation.
 HSCs divide generating daughter cells. Some daughter cells retain the stem-cell
characteristics of the mother cell having property of self self-renewing and able to give rise
to all blood cell types. While other daughter cells differentiate into progenitor cell that lose
their self-renewal capacity and giving rise to a particular blood cell lineage.
 Therefore, early in hematopoiesis, a multipotent stem cells differentiates along one of two
pathways, giving rise to either a common lymphoid progenitor cells or a common myeloid
progenitor cells
 Both the myeloid and lymphoid lineages are engaged in dendritic cell formation.
 Myeloid cells: It consists of-
 Monocytes
 Eosinophils
 Basophils
 Neutrophils
 Macrophages
 Erythrocytes
 Megakaryocytes
 Platelets.
 Lymphoid cells: It consists of-
 B cells
 T cells
 Natural killer cells
 Innate lymphoid cells.

The common myeloid progenitor cells:

 The common myeloid progenitor cell (CFU-GEMM) can differentiate into erythrocytes,
thrombocytes, granulocytes, lymphocytes and monocytes.
 For the differentiation and proliferation of CFU-GEMM from HPCs, Interleukin-3 and
Granulocyte-macrophage colony-stimulating factor (GM-CSF) are implicated.
 Stem cell factor (SCF) is a cytokine that can trigger the growth and total number of CFU-
GEMM.
 CFU-GEMM is the precursor to several colony forming units which finally give rise to
different blast cells.
 These consists of the following:
  CFU-Meg (from which promegakaryoblasts are produced)
 CFU-E (from which proerythroblasts are produced)
 CFU-GM (both monoblasts and myeloblasts are derived from this type of colony
forming unit)

Process of hematopoiesis
  According to the monophyletic theory of hematopoiesis, the pluripotent stem cells multiply
to produce more of the pluripotent stem cells, making sure of the steady and lasting supply
of stem cells.
 Some of the pluripotent stem cells now differentiate into precursor cells that are least
partially dedicated to form one type of mature blood cell.
 Pluripotent cells multiply at low pace into one of the five possible unipotential stem cells.
 These unipotential stem cells then multiply rapidly into the precursor of the destined
specific mature blood cell.
 The typical process of hematopoiesis consists of the differentiation of the multipotential
hematopoietic stem cell into either the common myeloid or lymphoid progenitor.
 Then, relying upon the cytokines and resulting transcription factors that are activated, the
myeloid progenitor can differentiate into a myeloblast.
 This myeloblast leads to granulocyte (basophils, eosinophils, or neutrophils) or monocyte
(macrophages and dendritic cell) development.
 Also, it leads to the differentiation of megakaryocytes into platelets, or erythroblasts into
erythrocytes.
 Lymphoid dendritic cells can form directly from the common lymphoid progenitor.
 Furthermore, the differentiation of the common lymphoid progenitor into a lymphoblast
results the further development of natural killer cells or lymphocytes (T and B cells).
 Once B cells get activated in secondary lymphoid organs, it further differentiate into
plasma cells.
 These plasma cells secrete antibodies.

Regulation of Haematopoiesis:
 Hematopoiesis is largely regulated by the presence of cytokines.
 These cytokines are responsible for regulating the differentiation of multipotential
hematopoietic stem cells into specific cell types by the activation of transcription factors.
 The cytokines is very important for differentiation of particular cell types otherwise animal
dies during embryogenesis.
 Some cytokines that regulates haematopoiesis are:
 Granulocyte macrophage-colony stimulating factor (GM-CSF):
 It enhances the myeloid lineage, finally leading to the differentiation of
granulocytes and macrophages. Such cytokines are termed as growth
factors.
 These growth factors are needed throughout the process of hematopoiesis
functioning in order to activate transcription factors.
 Transcription factor GATA-2:
 It is required for the development of all hematopoietic lineages; in its absence
animals die during embryogenesis.
 Transcriptional regulator Bmi-1:
 It is required for the self-renewal of HSCs, and in its absence animals die
within 2 months of birth because of the failure to repopulate their red and
white blood.
 Other Examples of cytokines involved in haematopoiesis are:
 Colony-stimulating factors (CSFs)
 Erythropoietin (EPO)
 Thrombopoietin (TPO)
 Granulocyte colony-stimulating factor (G-CSF)
  Monocyte colony-stimulating factor (M-CSF)
 Tumor necrosis factor (TNF)
 Transforming growth factor (TGF)
 Stem cell factor (SCF)
 Leukemia inhibitory factor (LIF)
Erythropoiesis:
 The process of formation of red blood cells termed as erythrocytes is known as
erythropoiesis.
 It is enhanced by decreased levels of oxygen in the blood, which signals for the secretion
of erythropoietin.
 Erythropoietin is a hormone central to the formation of red blood cells.
 Erythropoiesis takes on average 2 days to be completed from to form mature red blood
cell from unipotential hematopoietic cell.
 2 million erythrocytes are produced every second in our bodies.
 Hematopoietic cells determined to become red blood cells usually get smaller and more
condensed as they mature until there is finally loss of their nuclei.
 The unipotential cell becomes proerythroblast, which has uncondensed nucleus and has
basophilic or blue cytoplasm.
 Then the cell becomes a basophilic erythroblast, which is followed by a polychromatophilic
erythroblast stage.
 In polychromatophilic erythroblast stage, the nucleus becomes more condensed than the
latter two stages and the cytoplasm is reduced.
 In the succeeding orthochromatophilic erythroblast stage, the nucleus is much smaller
than that of the prior stages having a pinker cytoplasm.
 Then comes the reticulocyte stage, where the red blood cell lacks nucleus, but still stains
somewhat blue because of the remnants of polyribosomes within the cell.
 Ultimately, the erythrocyte is the mature red blood cell, with no nucleus and no
polyribosome remnants and as a result stains pink.
Granulopoiesis
 The process of formation of granulocytes is termed as granulopoiesis.
 Granulocytes are white blood cells having multi-lobular nuclei and cytoplasmic granules.
 The unipotential hematopoietic cell which forms a myeloblast is large.
 It has a cytoplasm that stains blue with a large nucleus.
 This cell gives rise into a promyelocyte that contains azurophilic granules. Then it
becomes a myelocyte, which has a non-indented still rather large nucleus.
 This cell then gives rise to a metamyelocyte, which is alike in size to a mature granulocyte
and the nucleus starts to become indented.
 After this stage is the band cell stage, where the nucleus resembles a horseshoe and has
definitive indentation.
 Ultimately, there is the mature granulocytes having a lobed nucleus and cytoplasmic
granules.
 The entire process occurs over a period of 2 weeks.
Monopoiesis:
 The process by which monocytes are formed is termed as monopoiesis.
 The monoblast is the committed progenitor cell, found only in the bone marrow. Also,
monoblast has a basophilic cytoplasm without granules.
 These monoblasts give rise to promonocytes, which are smaller in size with nuclei that
become slightly indented, before becoming monocytes.
  Monocytes have kidney-shaped nuclei and can develop into dendritic cells or
macrophages.
Lymphopoiesis:
 The formation of lymphocytes, starts from their first committed progenitor cells,
lymphoblasts, this process is called Lymphopoiesis.
 These cells after maturation, are able to differentiate into either B, T or natural killer cells.
Thrombopoiesis:
 Megakaryocytes, which are extremely large cells within the bone marrow forms the
platelets, this process is termed as thrombopoiesis.
 When the plasma membranes of megakaryocytes are fragmented, the origin of individual
platelets take place, thus generating platelets containing many granules.
Antigen
An antigen is any substance that causes your immune system to produce antibodies against it.
This means your immune system does not recognize the substance, and is trying to fight it off.
An antigen may be a substance from the environment, such as chemicals, bacteria, viruses, or
pollen. An antigen may also form inside the body

Antibody
An antibody is a protein produced by the body's immune system when it detects harmful
substances, called antigens. Examples of antigens include microorganisms (bacteria, fungi,
parasites, and viruses) and chemicals.

Antibodies may be produced when the immune system mistakenly considers healthy tissue a
harmful substance. This is called an autoimmune disorder.
 BLOOD GROUP AND BLOOD GROUPING
 Blood grouping is the process of identifying a person‟s blood group by serologic testing of
a blood sample. Also called blood typing.
 Blood is classified into blood groups according to whether certain substances are present
or not.
 These include antigens (types of sugars and proteins) found on the surface of our red
blood cells and antibodies (types of protein) which are mainly found in plasma – the liquid
component of our blood.
 All cells have different combinations of markers or “antigens” on their surface.
 Our immune system has learned to use these to help distinguish the body‟s own cells
(self) from foreign bodies (non-self), like bacteria or toxins.
 Our immune system learns to ignore our own normal antigens, but when it recognizes that
a foreign antigen has entered the body, it releases antibodies, which attach to the foreign
entity and mark it so other parts of the immune system can remove and destroy it.
 In the case of blood cells, if our immune system recognizes that foreign blood cells (i.e.
blood cells that are not our type) have been introduced into our body (such as via a
transfusion), it will mount an immune response using antibodies against the foreign cells.
 The most common systems used for classifying blood are the ABO blood group system
and the Rhesus (Rh) type system.

Red blood cell compatibility

 Blood group AB individuals have both A and B antigens on the surface of their RBCs, and
their blood plasma does not contain any antibodies against either A or B antigen.
Therefore, an individual with type AB blood can receive blood from any group (with AB
being preferable), but cannot donate blood to any group other than AB. They are known as
universal recipients.
 Blood group A individuals have the A antigen on the surface of their RBCs, and blood
serum containing IgM antibodies against the B antigen. Therefore, a group A individual
can receive blood only from individuals of groups A or O (with A being preferable) and can
donate blood to individuals with type A or AB.
 Blood group B individuals have the B antigen on the surface of their RBCs, and blood
serum containing IgM antibodies against the A antigen. Therefore, a group B individual
can receive blood only from individuals of groups B or O (with B being preferable) and can
donate blood to individuals with type B or AB.
 Blood group O(or blood group zero in some countries) individuals do not have either A or B
antigens on the surface of their RBCs and their blood serum contains IgM anti-A and anti-
B antibodies. Therefore, a group O individual can receive blood only from a group O
individual but can donate blood to individuals of any ABO blood group (i.e., A, B, O or AB).
If a patient in a hospital situation needs a blood transfusion in an emergency, and if the
time taken to process the recipient‟s blood would cause a detrimental delay, O negative
blood can be issued. Because it is compatible with anyone, O negative blood is often
overused and consequently is always in short supply.
  No agglutination reaction. Type A blood donated to a type A recipient does not cause an
agglutination reaction because the anti-B antibodies in the recipient do not combine with
the type A antigens on the red blood cells in the donated blood

 Agglutination reaction. Type A blood donated to a type B recipient causes an agglutination

reaction because the anti-A antibodies in the recipient combine with the type A antigens
on the red blood cells in the donated blood

The rhesus (Rh) system

 The other blood typing system commonly used is the Rhesus system, also called Rh
system, named after the Rhesus monkey in which it was first discovered.
 In this system, if we have an antigen called the RhD antigen on the surface of our red
blood cells, we are said to be Rhesus positive (Rh+). If we don‟t, we are said to be Rhesus
negative (Rh-).

Combining our ABO blood group with whether we are Rh+ or Rh- means our blood can be
classified as one of 8 possible types:

 O positive (O+)
 O negative (O-)
 A positive (A+)
 A negative (A-)
 B positive (B+)
 B negative (B-)
 AB positive (AB+)
 AB negative (AB-)

One difference between the Rhesus system and the ABO group system is that Rh negative
people don‟t usually possess antibodies against RhD (unless they have been previously exposed
to it), whereas in the ABO group system if the antigen is absent from the red blood cell, the
antibody against it is present in the plasma.

Erythroblastosis Fetalis
 Testing to see if we are Rh positive or Rh negative is routinely done during pregnancy,
and for blood donors and for people receiving a blood transfusion.
 If a mother is Rh negative but her baby is Rh positive (which can happen if the father is Rh
positive), the mother could produce antibodies that fight the baby‟s red blood cells.
 This can happen if blood from the unborn baby enters the mother‟s circulation.
  When there is a risk of this happening (threatened miscarriage, termination, chorionic
villus sampling (CVS), abdominal trauma, at delivery), an injection called anti-D can be
given to the mother to help prevent these antibodies against Rh positive blood being
produced.

Universal donors and recipients

 It is vital that any blood we receive from a donor is compatible with our own blood. If it is
not, we can get very sick or even die.
 If we need blood, ideally it will come from a donor who is the same ABO and Rh type as
we are.
 However, if it‟s an emergency and an exact match isn‟t available, other types of blood may
be compatible – meaning that our immune system won‟t react against them.
 The table below shows which blood types are compatible.

ABO blood type of recipient ABO blood types recipient can receive
A A, O
B B, O
AB A, B, AB, O
O O
 Universal red cell donors: People with O negative blood don‟t have any A, B or Rh antigens
on their red blood cells, which means they can donate red blood cells to anyone (their
blood cells won‟t trigger the recipient‟s immune system to “fight” the blood). For this
reason, people with O negative blood are referred to as „universal donors‟.
 Universal recipients: People with AB blood group have both A and B antigens on their red
blood cells and don‟t have antibodies against A or B antigens, which means they can
receive red blood cells of any type (their immune system won‟t fight them). For this reason,
they are referred to as „universal recipients.‟
 Universal plasma donor: In addition, people who are blood group AB can donate their
plasma to anyone (because it doesn‟t have any antibodies to other blood groups).

In general, people who are Rh negative should only be given Rh negative blood (as it contains
no RhD antigens). If they are given Rh positive blood (which does carry the RhD antigen), their
immune system will see it as foreign (non-self) and start producing antibodies against the RhD
antigen.

People who are Rh positive can receive either Rh positive or Rh negative blood.
Blood typing method (Blood grouping)

 Blood typing or blood grouping is a method to tell what type of blood we have.
 Blood grouping is done so we can safely donate our blood or receive a blood transfusion.
 It is also done to see if we have a substance called Rh factor on the surface of our red
blood cells.
 Testing to work out which ABO blood group we are in is called ABO blood grouping, and
involves 2 steps.

Forward typing

 A sample of our blood is tested separately against 2 laboratory solutions – one that
contains antibodies against the A antigen (anti-A) and one that contains antibodies against
the B antigen (anti-B).
 The way our blood reacts to the antibodies shows which antigens our blood contains.
 For example, if we have the A antigen on our red blood cells (we are blood group A), when
the solution containing anti-A antibodies is added, our blood cells will react by clumping
together (agglutinating).
 If our blood doesn‟t react to either of the solutions, it must be O type blood.

Reverse typing

 In step 2 („reverse typing‟), our plasma (the fluid part of our blood after the red and white
cells have been removed) is mixed with blood known to be type A, and separately with
blood known to be type B, to check its reaction. Whether or not agglutination takes place
should confirm the results of the forward typing. Both types of test must agree before our
blood type is confirmed

 .
What is a blood transfusion?
A blood transfusion is a procedure that restores blood to the body.
A healthcare professional will pass blood through a rubber tube into a vein using a needle or thin
tube.
The sections below will cover the different types of blood transfusion procedures available, as well as
the different types of blood.

Types of blood transfusions

According to the American Red Cross, there are four common types of blood
transfusions:
Red blood cell transfusions: A person may receive a red blood cell transfusion if they
have experienced blood loss, if they have anemia (such as iron deficiency anemia), or if
they have a blood disorder.
Platelet transfusions: A platelet transfusion can help those who have lower platelet counts,
such as from chemotherapy or a platelet disorder.
Plasma transfusions: Plasma contains proteins important for health. A person may receive a
plasma transfusion if they have experienced severe burns, infections, or liver failure.
Whole blood transfusion: A person may receive a whole blood transfusion if they have
experienced a severe traumatic hemorrhage and require red blood cells, white blood cells, and
platelets.

Why are blood transfusions necessary?

Some people need blood transfusions for certain conditions and disorders,
including:

Anemia: This occurs when a person’s blood does not have enough red blood cells. It can develop for a
number of reasons, such as if a person does not have enough iron in their body. This is known as iron
deficiency anemia.
Hemophilia: This is a bleeding disorder wherein the blood is unable to clot properly.
Cancer: This occurs when cells in the body divide and spread to the surrounding tissues.
Sickle cell disease: This is a group of red blood cell disorders that change the shape of red blood cells.
Kidney disease: This occurs when the kidneys are damaged.
Liver disease: This occurs when the liver stops functioning properly.

Transfusion reactions
Immediate transfusion reactions
Immediate transfusion reactions are those that occur within 24 hours of the
transfusion being administered. They can be broadly categorised into immune and
non-immune causes.
Immune:
Acute haemolytic transfusion reaction (ABO incompatibility)
Transfusion-related acute lung injury (TRALI)
Anaphylaxis
Non-immune:
Bacterial infection
Transfusion-associated circulatory overload (TACO): acute/worsening respiratory
compromise and/or worsening pulmonary oedema up to 12 hours after transfusion
Delayed transfusion reactions
Delayed transfusion reactions are those that occur after 24 hours of the
transfusion being administered. They can be broadly categorised into immune and
non-immune causes.
Immune:
Delayed haemolytic transfusion reaction (DHTR)
Febrile non-haemolytic transfusion reaction (FNHTR)
Post-transfusion purpura (PTP)
Graft versus host disease (GvHD)
Non-immune:
Viral infections
Malaria
Prions

verview of immune-mediated transfusion reactions

Acute haemolytic transfusion reaction (ABO
incompatibility)
pathway ABO incompatibility results in anti-A/B antibodies activating the complement and triggering
the release of inflammatory cytokines.
Early clinical features include fever, hypotension, anxiety and red-coloured urine.
Late clinical features include hypotension and widespread haemorrhage
secondary to disseminated intravascular coagulation.

Transfusion-related acute lung injury (TRALI)

The pathophysiology of TRALI not fully understood but antibodies to human
neutrophil antigens and human leukocyte antigens have been implicated.

The typical presentation of TRALI is the sudden development of dyspnoea,

severe hypoxaemia, hypotension and fever that develop within 6 hours after
transfusion and usually resolve with supportive care within 48 to 96 hours.

Anaphylaxis
Anaphylaxis occurs when the recipient is allergic to protein components
present in the donor transfusion.

Typical clinical features include an itchy rash, angioedema, shortness of

breath, vomiting, lightheadedness, and hypotension.

Anaphylaxis typically develops over minutes to hours and can quickly become
life-threatening.

Delayed haemolytic transfusion reaction (DHTR)

Delayed haemolytic reactions are caused by antibodies to antigens such as
Rhesus or Kidd.

A delayed haemolytic reaction can occur between 3 to 14 days after the

transfusion.

Typical clinical features include a sudden drop in haemoglobin level, fever,

jaundice and haemoglobinuria.

Febrile non-haemolytic transfusion reaction (FNHTR)

The typical clinical features of FNHTR include fever during blood transfusion
with no associated haemolysis.

FNHTR is most commonly caused by antibodies directed against donor

leukocytes and HLA antigens. This is in contrast to transfusion-associated
acute lung injury, in which the donor plasma has antibodies directed against
the recipient HLA antigens, mediating the characteristic lung damage.

FNHTR typically develops in patients who have received multiple transfusions

or in women who have had multiple previous pregnancies.

Post-transfusion purpura (PTP)

PTP is an adverse reaction to a blood transfusion or platelet transfusion that
occurs when the body produces alloantibodies to the introduced platelets’
antigens.
These alloantibodies destroy the patient’s platelets leading to
thrombocytopenia.

PTP usually presents 5–12 days after transfusion.

Graft versus host disease (GvHD)

Graft versus host disease is a medical complication following the receipt of
transplanted tissue from a genetically different individual.

Immune cells (white blood cells) in the donated tissue (the graft) recognize the
recipient (the host) as foreign (nonself). The transplanted immune cells then
attack the host’s cells.

GvHD can occur after a blood transfusion if the blood products used have not
been irradiated or treated with an approved pathogen reduction system.