BCH 408

THE INTERNAL ENVIRONMENT

The internal environment represents the environmental conditions of the medium in which
the cells of an organism exist in. In multicellular organisms, the aqueous environment that is
outside the cells but inside the body. The internal environment is made up of tissue fluid that
bathes all cells making up the body.

About 60 percent of the adult human body is fluid, mainly a water solution of ions and other
substances. Although most of this fluid is inside the cells and is called intracellular fluid,
about one third is in the spaces outside the cells and is called extracellular fluid. This
extracellular fluid is in constant motion throughout the body. It is transported rapidly in the
circulating blood and then mixed between the blood and the tissue fluids by diffusion through
the capillary walls.

In the extracellular fluid are the ions and nutrients needed by the cells to maintain cell life.
Thus, all cells live in essentially the same environment—the extracellular fluid. For this
reason, the extracellular fluid is also called the internal environment of the body.
Extracellular fluid Is the body fluid outside of cells (20% plasma.80% interstitial fluid),
interstitial fluid is the solution that bathes and surrounds the cells: plasma—colourless watery
fluid of the blood and lymph that contains no cells but which blood cells travel in.

Cells are capable of living, growing, and performing their special functions as long as the
proper concentrations of oxygen, glucose, different ions, amino acids, fatty substances, and
other constituents are available in this internal environment.

Living cells can function only within a narrow range of such conditions as temperature, pH ,
ion concentrations, and nutrient availability, yet living organisms must survive in an
environment where these and other conditions vary from hour to hour, day to day, and season
to season. Organisms therefore require mechanisms for maintaining internal stability in spite
of environmental change. This ability is termed homeostasis (homeo means "the same" and
stasis means "standing or staying").

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Homeostasis is defined as the maintenance of a relatively dynamic constancy of the internal
environment. It has become one of the most important concepts of physiology, physiological
ecology, and medicine.

Most bodily functions are aimed at maintaining homeostasis, and an inability to maintain it
leads to disease and often death. Some of the parameters regulated by homeostatic
mechanisms are: body temperature, arterial blood pressure, and pH, nutrient composition,
reflex acts, cell recognition and the other important systems of the body.

The human body, for example, maintains blood pH within the very narrow range of 7.35 to
7.45. A pH below this range is called acidosis and a pH above this range is alkalosis. Either
condition can be life-threatening. One can live only a few hours with a blood pH below 7.0 or
above 7.7, and a pH below 6.8 or above 8.0 is quickly fatal. Yet the body's metabolism
constantly produces a variety of acidic waste products that challenge its ability to maintain
pH in a safe range.

Homeostasis, is a fundamental property of life and a necessity for survival of all living
things—not just humans but all other animals as well as microorganisms. It enables all living
organisms to maintain internal stability in spite of a ceaselessly changing and challenging
environment.

Extracellular fluid is transported through all parts of the body in two stages. The first stage is
movement of blood through the body in the blood vessels, and the second is movement of
fluid between the blood capillaries and the intercellular spaces between the tissue cells. As
blood passes through the blood capillaries, continual exchange of extracellular fluid also
occurs between the plasma portion of the blood and the interstitial fluid that fills the
intercellular spaces

THE BLOOD

Blood is a bodily fluid in animals that delivers necessary substances such as nutrients and
oxygen to the cells and transports metabolic waste products away from those same cells.
Normally, 7-8% of human body weight is from blood. This essential fluid carries out many
critical functions in the body. These functions include:

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  Supply and transport of oxygen to tissues (bound to hemoglobin, which is carried in
red cells)
 Supply of nutrients such as glucose, amino acids, and fatty acids (dissolved in the
blood or bound to plasma proteins (e.g., blood lipids))
 Removal of waste such as carbon dioxide, urea, and lactic acid
 Immunological functions, including circulation of white blood cells, and detection of
foreign material by antibodies
 Coagulation, the response to a broken blood vessel, the conversion of blood from a
liquid to a semi-solid gel to stop bleeding.
 Messenger functions, including the transport of hormones and the signalling of tissue
damage
 Regulation of body pH
 Regulation of core body temperature
 Hydraulic functions .The restriction of blood flow can also be used in specialized
tissues to cause engorgement, resulting in an erection of that tissue.

Blood is a highly specialized tissue composed of more than 4,000 different kinds of
components. Four of the most important ones are red cells, white cells, platelets, and
plasma. All humans produce these blood components; there are no populational or regional
differences.

Blood plasma

About 55% of blood is blood plasma, a fluid that is the blood's liquid medium, which by itself
is straw-yellow in colour. The blood plasma volume totals of 2.7–3.0 litres in an average
human. It is essentially an aqueous solution containing 92% water, 8% blood plasma proteins,
and trace amounts of other materials. Plasma circulates dissolved nutrients, such as glucose,
amino acids, and fatty acids (dissolved in the blood or bound to plasma proteins), and
removes waste products, such as carbon dioxide, urea, and lactic acid.

Other important components include:

 Serum albumin
 Blood-clotting factors (to facilitate coagulation)

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  Immunoglobulin (antibodies)
 lipoprotein particles
 Various other proteins
 Various electrolytes (mainly sodium and chloride)

The term serum refers to plasma from which the clotting proteins have been removed. Most
of the proteins remaining are albumin and immunoglobulins.

Blood proteins
Plasma proteins, also termed blood proteins, are proteins present in blood plasma. They serve
many different functions, including transport of lipids, hormones, vitamins and metals in the
circulatory system and the regulation of acellular activity and function in the immune system.
Other blood proteins act as enzymes, complement components, protease inhibitors or
precursors. Contrary to popular belief, hemoglobin is not a blood protein, as it is carried
within red blood cells, rather than in the blood serum.

Albumin accounts for 55% of blood proteins, and is a major contributor to maintaining the
osmotic pressure of plasma to assist in the transport of lipids and steroid hormones. Globulins
make up 37-38% of blood proteins and transport ions, hormones and lipids assisting in
immune function. Fibrinogen comprises 7% of blood proteins; conversion of fibrinogen to
insoluble fibrin is essential for blood clotting. The remainder of plasma proteins (1%) is made
up of regulatory proteins such as enzymes, pro-enzymes and hormones. All blood proteins
are synthesized in liver except for the gamma globulins.

Separating proteins by electrophoresis is a valuable diagnostic tool as well as a way to

monitor clinical progress. Current research regarding blood plasma proteins is centered on
performing proteomics analyses of serum/plasma in the search for biomarkers. These efforts
started with two-dimensional gel electrophoresis, efforts in the 1970s and in more recent
times this research has been performed using LC-tandem MS, based proteomics. The normal
laboratory value of serum total protein is around 7 g/dl.

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 RED CELLS

Red cells or erythrocytes are relatively large microscopic cells without nuclei. In this latter
trait, they are similar to the primitive prokaryotic cells of bacteria. Red cells normally make
up 40-50% of the total blood volume. They transport oxygen from the lungs to all of the
living tissues of the body and carry away carbon dioxide. The red cells are produced
continuously in our bone marrow from stem cells at a rate of about 2-3 million cells per
second.

Haemoglobin is the gas transporting protein molecule that makes up 95% of a red cell. Each
red cell has about 270,000,000 iron-rich haemoglobin molecules. People who are anaemic
generally have a deficiency in red cells, and subsequently feel fatigued due to a shortage of
oxygen. The red colour of blood is primarily due to oxygenated red cells. Human fetal
hemoglobin molecules differ from those produced by adults in the number of amino acid
chains. Fetal haemoglobin has three chains, while adults produce only two. As a
consequence, fetal hemoglobin molecules attract and transport relatively more oxygen to the
cells of the body.

White Cells

White cells, or leukocytes exist in variable numbers and types but make up a very small part
of blood's volume. Leukocytes are not limited to blood. They occur elsewhere in the body as
well, most notably in the spleen, liver, and lymph glands.

There are five different types of white blood cells, also called leukocytes, found in the human
bodies. White blood cells all help to defend the body from foreign particles in some way. All
white blood cells are produced in red bone marrow, with the special type lymphocytes also
being formed in lymphatic tissue. White blood cells are not found in the blood in great
numbers, instead they leave the blood and defend in the rest of the tissues of the body.

White blood cells are put into two different groups based on appearance in the microscope,
agranulocytes and granulocytes.

1. Agranulocytes don't have any type of visual grains in their cells, and are the
monocytes and lymphocytes.
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 2. Granulocytes have visual grains in their cells that help with their specific functions,
and are the neutrophils, eosinophils and basophils. Together all these types of white
blood cells coordinate a system that defends the body from infection, damage and
even cancer.

Neutrophils are the most numerous of the white blood cells. They are often called bacterial
slayers because they usually function in killing foreign bacteria in the body. Neutrophils are
the first white blood cell at a cut or when damage is done to the body. They kill bacterial by a
process called phagocytosis, where they surround and consume the bacteria. Neutrophils will
also release a super oxide burst to kill many bacteria at once.

Eosinophils are usually involved in infections of parasitic worms. Instead of doing

phagocytosis, Eosinopils release toxins to kill the parasites .They are also involved in allergic
reactions.

Basophils in other animals are also called mast cells, which are commonly found in the
connective tissues throughout the body. The granules seen in basophils contain histamine and
heparin. Basophils are the white blood cells that help with the inflammatory response when
tissue is damaged. Histamine dilates blood vessels to bring resources into a site of damage.
Histamine can also be involved in allergies. Heparin is an anti-coagulate and stops the blood
from clotting, by not clotting the blood heparin helps to bring in more resources to a damaged
area.

Monocytes are the largest white blood cell. When they leave the blood they're called
macrophages. Most organs in the body have some type of macrophage that can often go by
other names. Macrophages do phagocytosis of foreign particles in the body, such as bacteria.
Macrophages also do phagocytosis of dead neutrophils and dead body cells. They are
involved with cleaning up at the end of an inflammatory response. Macrophages work with
lymphocytes as antigen presenting cells.

Lymphocytes are a special type of white blood cell that are capable of cell division in
lymphatic organs and tissues, such as the tonsils, lymph nodes and spleen, in response to
specific infections in the body. They are the last step in the immune system and allow no long

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term resistance to infections the body has seen before. Lymphocytes come in two main types.
B lymphocytes differentiate in the bone marrow and produce antibodies and do antibody-
mediated resistance. T lymphocytes differentiate in the thymus and perform cell-mediate
resistance. Individual white cells usually only last 18-36 hours before they also are removed,
though some types live as much as a year.

Platelets

Platelets or thrombocytes are cell fragments without nuclei that work with blood clotting
chemicals at the site of wounds. They do this by adhering to the walls of blood vessels,
thereby plugging the rupture in the vascular wall. They also can release coagulating
chemicals which cause clots to form in the blood that can plug up narrowed blood vessels.
Thirteen different blood clotting factors, in addition to platelets, need to interact for clotting
to occur. They do so in a cascading manner, one factor triggering another.

Recent research has shown that platelets also help fight infections by releasing proteins that
kill invading bacteria and some other microorganisms. In addition, platelets stimulate the
immune system. Individual platelets are about 1/3 the size of red cells. They have a lifespan
of 9-10 days. Like the red and white blood cells, platelets are produced in bone marrow from
stem cells.

BLOOD CLOTTING CASCADE SYSTEM

The ability of the body to control the flow of blood following vascular injury is paramount to
continued survival. Because of the importance of blood in regulating pH and the transport of
oxygen, nutrients, carbon dioxide, and wastes, maintaining the integrity of the process is
crucial to life. When ruptures in the system do occur, the process of blood clotting is initiated
as an emergency measure to halt the loss of blood. Biochemically, blood clotting is an
example of signal amplification caused by the simultaneous activation and inhibition of many
enzymes.

Two pathways lead to the formation of a fibrin clot: the intrinsic and extrinsic pathway.
Although they are initiated by distinct mechanisms, the two converge on a common pathway
that leads to clot formation. Both pathways are complex and involve numerous different
proteins termed clotting factors.
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 Primary clotting Factors

Factor Trivial Name(s) Pathway Characteristic

Prekallikrein Functions with HMWK and factor

Fletcher factor Intrinsic
(PK) XII

Co-factor in kallikrein and factor

High molecular XII activation, necessary in factor
contact activation cofactor;
weight XIIa activation of XI, precursor for
Fitzgerald, Flaujeac Intrinsic
kininogen bradykinin (a potent vasodilator
Williams factor
(HMWK) and inducer of smooth muscle
contraction

I Fibrinogen Both

II Prothrombin Both Contains N-term. gla segment

III Tissue Factor Extrinsic

IV Calcium Both

Proaccelerin, labile factor,

V Both Protein cofactor
accelerator (Ac-) globulin

VI (same as Va) Accelerin Both This is Va, redundant to Factor V

Proconvertin, serum
prothrombin conversion
VII Extrinsic Endopeptidase with gla residues
accelerator (SPCA),
cothromboplastin

VIII Antihemophiliac factor A, Intrinsic Protein cofactor

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 antihemophilic globulin
(AHG)

Christmas Factor,
antihemophilic factor
IX Intrinsic Endopeptidase with gla residues
B,plasma thromboplastin
component (PTC)

X Stuart-Prower Factor Both Endopeptidase with gla residues

Plasma thromboplastin
XI Intrinsic Endopeptidase
antecedent (PTA)

XII Hageman Factor Intrinsic Endopeptidase

Protransglutaminase, fibrin
XIII stabilizing factor (FSF), Both Transpeptidase
fibrinoligase

The clotting cascades: The intrinsic cascade (which has less in vivo significance in normal
physiological circumstances than the extrinsic cascade) is initiated when contact is made
between blood and exposed negatively charged surfaces. The extrinsic pathway is initiated
upon vascular injury which leads to exposure of tissue factor, TF (also identified as factor
III), a sub-endothelial cell-surface glycoprotein that binds phospholipid. The green dotted
arrow represents a point of cross-over between the extrinsic and intrinsic pathways. The two
pathways converge at the activation of factor X to Xa. Factor Xa has a role in the further
activation of factor VII to VIIa as depicted by the green arrow. Active factor Xa hydrolyzes
and activates prothrombin to thrombin. Thrombin can then activate factors XI, VIII and V
furthering the cascade. Ultimately the role of thrombin is to convert fribrinogen to fibrin and
to activate factor XIII to XIIIa. Factor XIIIa (also termed transglutaminase) cross-links fibrin
polymers solidifying the clot. (HMWK = high molecular weight kininogen. PK =
prekallikrein. PL = phospholip)

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Intrinsic and Extrinsic Pathways Schematic

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 The Bleeding Disorders

There are so many defects associated with the blood, which includes disorders of volume,
that of circulation, haematological disorders such as anaemia, leukemia and also infectious
disorders of the blood but for the purpose of this study, there will be detailed description of
the disorders arising from the clotting mechanism that is disorders associated with blood
coagulation.

Defects in the process of clotting leading to bleeding disorders have been identified at the
level of the proteins of the clotting cascades, platelet activation and function, contact
activation and anti-thrombin function.

Hemophilia A

Hemophilia A is classic hemophilia (a disease referring to the inability to clot blood). It is an

X-linked disorder resulting from a deficiency in factor VIII, a key component of the
coagulation cascade. There are severe, moderate and mild forms of hemophilia A that reflect
the level of active factor VIII in the plasma.

Individuals with deficiencies in factor VIII suffer joint and muscle hemorrhage, easy bruising
and prolonged bleeding from wounds. Treatment of hemophilia A is accomplished by
infusion of factor VIII concentrates prepared from either human plasma or by recombinant
DNA technology.

Hemophilia B

Hemophilia B results from deficiencies in factor IX. The prevalence of hemophilia B is

approximately one-tenth that of hemophilia A. All patients with hemophilia B have
prolonged coagulation time and decreased factor IX clotting activity. Like hemophilia A,
there are severe, moderate and mild forms of hemophilia B and reflect the factor IX activity
in plasma.

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 Disorders of Fibrinogen and Factor XIII

Several cardivascular risk factors are associated with abnormalities in fibrinogen. As a result
of the acute-phase response or through other poorly understood mechanisms, elevated plasma
fibrinogen levels have been observed in patients with coronary artery disease, diabetes,
hypertension, peripheral artery disease, hyperlipoproteinemia and hypertriglyceridemia. In
addition, pregnancy, menopause, hypercholesterolemia, use of oral contraceptives and
smoking lead to increased plasma fibrinogen levels.

Although rare, there are inherited disorders in fibrinogen. These disorders include
afibrinogenemia (a complete lack of fibrinogen), hypofibrinogenemia (reduced levels of
fibrinogen) and dysfibrinogenemia (presence of dysfunctional fibrinogen). Afibrinogenemia
is characterized by neonatal umbilical cord hemorrhage, ecchymoses, mucosal hemorrhage,
internal hemorrhage, and recurrent abortion. The disorder is inherited in an autosomal
recessive manner. Hypofibrinogenemia is characterized by fibrinogen levels below 100mg/dL
(normal is 250-350mg/dL) and can be either aquired or inherited. Symptoms of
hypofibrinogememia are similar to, but less severe than, afibrinogenemia.
Dysfibrinogenemias are extremely heterogeneous affecting any of the functional properties of
fibrinogen. Clinical consequences of dysfibrinogenemias include hemorrhage, spontaneous
abortion and thromboembolism.

Factor XIII is the proenzyme form of plasma transglutaminase and is activated by thrombin
in the presence of calcium ions. Active factor XIII catalyzes the cross-linking of fibrin
monomers. Factor XIII is a tetramer of two different peptides, A and B (forming A2B2).
Hereditary deficiencies (autosomal recessive) occur resulting in the absence of either subunit.
Clinical manifestation of factor XIII deficiency is delayed bleeding although primary
hemostasis is normal. Deficiency leads to neonatal umbilical cord bleeding, intracranial
hemorrhage and soft tissue hematomas.

von Willebrand Disease

von Willebrand disease (vWD) is due to inherited deficiency in von Willebrand factor (vWF).
vWD is the most common inherited bleeding disorder of humans. Using sensitive laboratory
testing, abnormalities in vWF can be detected in approximately 8000 people per million.

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Clinically significant vWD occurs in approximatley 125 people per million. This is a
frequency at least twice that of hemophilia A.

Deficiency of vWF results in defective platelet adhesion and causes a secondary deficiency in
factor VIII. The result is that vWF deficiency can cause bleeding that appears similar to that
caused by platelet dysfunction or hemophilia.

Factor XI and Contact Activation

When blood makes contact with negatively charged surfaces it triggers a series of interactions
that involve factor XI, prekallikrein and high molecular weight kininogen leading to blood
coagulation. This process is referred to as contact activation. Deficiency in factor XI confers
an injury-related bleeding tendency. This deficiency was identified in 1953 and originally
termed hemophilia C. Factor XI deficiency is inherited as an autosomal disorder with either
homozygosity or compound heterozygosity. Three independent point mutations in factor XI
have been identified.

Antithrombin Deficiency

Antithrombin functions to inhibit several activated coagulation factors including thrombin,

factor IXa and factor Xa, by forming a stable complex with the various factors. Heparin and
heparan sulfates increase the activity of antithrombin at least 1000 fold.

Deficiency in antithrombin is seen in approximately 2% of patients with venous

thromboembolic disease. Inheritance occurs as an autosomal dominant trait. Deficiencies
results from mutations that affect synthesis or stability of antithrombin or from mutations that
affect the protease and/or heparin binding sites of antithrombin.

Clinical manifestations of antithrombin deficiency include deep vein thrombosis and

pulmonary embolism. Thrombosis may occur spontaneously or in association with surgery,
trauma or pregnancy..

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