Erythropoiesis

Objectives of Current Presentation:

At the end of this lecture, the student should memorize the following key concepts;
1. Define Erythropoiesis and mention its requirements
2. Describe Development of red blood cells
3. Comprehend regulations of erythropoiesis
4. Discuss iron homeostasis and enumerate iron-binding proteins
5. Comprehend erythropoietin
6. Describe hepcidin, ferroportin and erythroferrone
7. Illustrate vitamin B12 metabolism and mention cobolamin-binding proteins
8. Comprehend folate homeostasis

BY
Associate Professor Doctor
Abdou M.A.Ibrahim
 Development of red blood cells, RBCS (Erythropoiesis)

Erythropoiesis is the process by which red blood cells (erythrocytes) are produced.
On average, the body produces an astounding 2.5 billion red cells/kg/day.
Chronological Age Site of RBCs Formation in the developing fetus
First trimester (first 3 months of intrauterine life) Mesodermal cells of yolk sac
Second trimester (4, 5 & 6 months of intrauterine life) Liver and spleen
Third trimester (7, 8 & 9 months of intrauterine life) Red bone marrow of all bones
Pre-school age after birth Red bone marrow of all bones
Late childhood and adolescence Red bone marrow of long bones and all flat bones
Adulthood and rest of life Bones of axial skeleton (skull, sternum, ribs & hip bones)
 Development of red blood cells, RBCS (Erythropoiesis)

 Requirements:
• Nutrients; proteins, minerals (iron, cupper & cobalt) and vitamins (B12 & folate)
• Hormones; androgens especially testosterone and other anabolic hormones
 Regulation:
• Response to renal tissue hypoxia (↓ O2 at kidney tissue→ ↑ Erythropoietin
• Iron homeostasis
• Hepcidin
• Erythroferrone
• Vitamin B12, Cyanocobalamin
• Folic Acid)
 Iron Homeostasis

• Iron is an essential bio element for most forms of life, from bacteria to mammals. It mediates electron transfer. In the ferrous
state (Fe2+), iron acts as an electron donor, while in the ferric state (Fe3+) it acts as an acceptor.
Functions of iron ions:
1. Heme groups of electron transport chain proteins that generate a proton gradient to synthesize ATP (chemiosmosis).
2. Heme groups are part of hemoglobin to transport oxygen from the lungs to other tissues.
3. Heme groups are also present in myoglobin to store and diffuse oxygen in muscle cells.
Body iron: 4 to 5 grams
Total body iron
♂ ∼50 mg iron/kg body weight ♀ ∼40 mg iron/kg body weight
Distribution of body iron
60% in heme of hemoglobin 35% stored in ferritin 5% labile on transferrin

Iron-binding proteins: Site Function

Divalent metal transporter Brush border of enterocytes Fe2+ absorption of ions from intestinal lumen
Ferroportin Basolateral border of all cells Export of absorbed iron from cells → interstitial → blood plasma
Apoferritin Cytoplasm of enterocytes Binds Fe2+ to be converted into Fe3+ storing protein, ferritin
Ferritin Enterocytes, hepatocytes, RES It is the physiological intracellular Fe3+ storing protein
Transferrin Blood plasma Fe2+ carrier protein
Hemosiderin Pathological iron-loaded tissues Pathological distorted ferritin that causes tissue damage
 Iron Homeostasis

Intestinal absorption: only 5-35% of ingested amount is absorbed, depending on circumstances and type of iron.
Apical membrane transporters Basolateral membrane transporters Intracellular transporters
Enterocytes - Divalent metal transporter 1 For free Fe2+ Ferroportin Apoferritin + Fe2+ → Ferritin
- Heme carrier protein 1 For heme-Fe2+
Factors affecting iron absorption:
↑ ↑↑ intestinal iron absorption ↓↓↓ intestinal iron absorption
Fe2+ state of ions in intestinal lumen Fe3+.state of ions in intestinal lumen
Iron of animal sources Iron of plant sources
Vitamin C Excess calcium, zinc, or manganese
Erythropoiesis Inflammation
Erythroferrone, an erythroblast hormone Hepcidin, a hepatocyte hormone
Iron recycling and loss:
• Most of iron in body is hoarded and recycled by reticuloendothelial system, which breaks down aged RBCs.
1-2 mg/day
♂ ∼1 mg iron/day ♀ ∼1.5-2 mg iron/day
Daily iron loss - Gastrointestinal blood loss As male losses +
- Sweating - Menstruation
- Shedding cells of the skin mucosal lining of GIT - Lactation
 Erythropoietin (EPO)
Chemistry; EPO is highly glycosylated protein hormone (40% of total molecular weight), with half-life in blood around 5 h.
Sources;
 Kidney; More than ¾ of EPO is produced by renal interstitial fibroblasts
 Liver; EPO is also produced in perisinusoidal cells in the liver.
NB: Liver production predominates in the fetal and perinatal period; renal production predominates in adulthood.
Mechanism of action;
EPO acts on EPO-receptors on erythroid tissue of red marrow results in differentiation, survival and proliferation of erythroid cells.
NB: In the bloodstream, red cells themselves do not express erythropoietin receptor, so cannot respond to EPO
Functions;
1. EPO is an essential hormone for red blood cell production (with IL-3, IL-6, glucocorticoids, and stem cell factor, SCF).
2. Initiate the synthesis of hemoglobin starting in early erythroblast.
3. EPO promotes cell survival via activation of EPO receptors resulting in anti-apoptotic effects on ischemic tissues
4. EPO has a significant effect on exercise performance
Normal EPO blood level - 4 up to 24 mU/ml (milliunits per milliliter).
Regulation; ↑ EPO blood level due - Too much EPO causes too many red blood cells (polycythemia).
to renal tissue hypoxia - Too much EPO in an athlete may suggest erythropoietin abuse.
Clinical significance; ↓ EPO blood level - Anemia, especially anemia related to kidney disease.
• is a standard part of therapy in patients with kidney disease who require dialysis to both treat and prevent anemia.
 Hepcidin (a hepatic hormone)

Chemistry; a preprohormone (84 AAs), prohormone (60 AAs), and active hormone (25 AAs).
Mechanism of action;
It inhibits iron transport by binding to the iron export channel, ferroportin, which is in the basolateral plasma
membrane of enterocytes and the plasma membrane of reticuloendothelial cells (macrophages), Inhibiting
ferroportin →↓ iron from being exported from the cell.
Functions;
1. Inhibition of intestinal extra absorption of ingested iron in foods
2. Decrease portal blood level of iron to protect hepatocytes from excess iron
3. Has strong antimicrobial activity especially bacteria dependent on iron for multiplication
Regulation; Factors that ↑ - Plasma iron and iron stores
hepcidin blood level - Inflammation
Factors that ↓ - Erythropoietin, a hormone produced by kidneys & liver
hepcidin blood level - Erythroferrone, a hormone produced by erythropoietin-stimulated RBCs
Clinical significance;
• Failure to adequately absorb iron → iron deficiency and iron deficiency anemia.
• The overload of iron is associated with ↓↓ hepcidin in β-thalassemic patients & hemochromatosis.
 Ferroportin (the iron exporter of body cells)

 Ferroportin is calcium-activated iron exporter but does not function as an iron/calcium antiporter.
 Ferroportin is a transmembrane carrier that transports iron from the inside of a cell to its outside.
 Ferroportin is inhibited by hepcidin
Tissue distribution; the basolateral membranes of;
• Enterocytes in the duodenum
• Hepatocytes
• Macrophages of the reticuloendothelial system
• Adipocytes
Functions;
1. Iron transport from storage cells to blood plasma
2. Has a role in female fertility
3. Has an important role in neural tube closure and its absence leads to spina bifida
Clinical significance;
Absence of ferroportin basolateral membranes of relevant cells leads to;
• Iron overload known as type IV haemochromatosis
• African iron overload.
 Erythroferrone (an erythroblast hormone)

 Erythroferrone is an erythroblast-produced protein hormone precursor of 354 amino acids, with a signal
peptide of 28 amino acids.

Mechanism of action;
Erythroferrone inhibits the expression of the liver hormone, hepcidin. and so increases the amount of iron
available for hemoglobin synthesis.

Regulation;
• Synthesis of erythroferrone is stimulated by erythropoietin binding to its receptor on erythroblasts
Functions;
1. increases iron absorption from the intestine
2. Increases mobilization of iron from stores
3. it also promotes lipid uptake into adipocytes and hepatocytes.
Clinical significance;
• Erythroferrone levels in blood is higher after blood loss or erythropoetin administration.
• Patients with beta-thalassemia have very high levels, and these decrease after blood transfusion.
 Vitamin B12 (cobolamin)

• Vitamin B12 is the only vitamin that must be sourced from animal-derived foods. It is heat stable.

Nomenclature; cobolamin, vitamin B12 , maturation factor, and extrinsic factor

Functions; acts as a coenzyme in;
• Adenosylcobolamin is essential for methylmalonyl coenzyme A mutase (MUT) an important isomerase in citric acid cycle
essential for myelination of nerve fibers.
• Methylcobolamin is essential for methyltransferases activity during DNA synthesis, cell-division.
Blood levels; vitamin B12 blood levels average 170–250 pg/mL in adults.
Body stores;
• The total amount of vitamin B12 stored in the body is about 2–5 mg in adults.
• Around 50% of this is stored in the liver.
• Bile is the main form of B12 excretion; most of the B12 secreted in the bile is recycled via enterohepatic circulation.
Daily requirements Vitamin B12 -Binding Proteins
Children aged 1–17 years 1.5 to 3.5 μg/day Secreted in saliva to protect ingested Vitamin B12
Haptocorrin
Adult ♂ or ♀ > 18 years 4.0 μg/day
Intrinsic factor Secreted by gastric parietal cells to enhance Vitamin B12 absorption
Adult pregnant ♀ 4.5 μg/day
Transcobalamin-II A plasma protein that carries Vitamin B12 during blood distribution
Adult pregnant ♀ 5 μg/day

Drugs decrease vitamin B12 absorption; 1. Drugs used for management of peptic ulcer 3. Oral antidiabetic drugs

2. Drugs used for management of seizures 4. Antibiotics inhibit bacterial protein synthesis
 Folate

Nomenclature; Folate, also known as vitamin B9 and folacin. The active is the tetrahydrofolate (THF).
Origin; “Folic" is from Latin word folium (which means leaf) as it was found in dark-green leafy vegetables.
Functions;
• Folate is required for DNA and RNA synthesis and metabolize amino acids necessary for cell division.
• Folic acid is also used as a supplement by women during pregnancy to reduce the risk of neural tube
defects (NTDs) in the baby.
Body levels;
• In adults, normal total body folate is between 10 and 30 mg
• Blood levels is ≥7 nmol/L (3 ng/mL). A serum folate of 3 ng/L or lower indicates deficiency.
Daily requirements; 400 micrograms from foods or dietary supplements.
Clinical significance; if you suspect folate deficiency analyze blood levels of folate, vitamin B12 & homocysteine;

↑↑↑ blood homocysteine level > 15 micromol/L

Causes Tissue folate deficiency vitamin B12 deficiency
Specification Normal methylmalonic acid (MMA) ↑↑↑ methylmalonic acid (MMA) > 0.27 micromol/L