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Developing erythroblasts in marrow

Fecal urobilinogen

Figure 4.4 Intravascular hemolysis: increased bilirubin, decreased haptoglobin, but free hemoglobin present.

Fecal urobilinogen

Figure 4.4 Intravascular hemolysis: increased bilirubin, decreased haptoglobin, but free hemoglobin present.

Ten percent of hemolysis is intravascular, and it occurs as hemoglobin is lysed directly in the blood. Intravascular lysis takes place directly inside the vessel, and hemoglobin is released into the plasma (Fig. 4.5). Hemoglobinemia, red-tinged hemoglobin seen directly in the plasma after the blood sample is centrifuged, is an unusual finding seen only in intravascular lysis. Blood in the urine, hemoglobinuria, may also be a byproduct of direct intravascular lysis that may be complement mediated. If complement is activated as in the case of ABO transfusion reaction, a complex of proteins are introduced that cause additional damage to the red cell membrane.8 Evidence of intravascular lysis indicates a serious condition that must be acted on promptly.

Laboratory Evidence of Hemolysis

Hemolysis can be distinguished in the laboratory by a variety of methods. Most of these measurements are obtained in the hematology and chemistry laboratories by routine laboratory procedures. There is no need to consider expensive reference procedures. The first consideration is to establish whether the patient is hemolyzing. The second consideration is to establish the cause and type of hemolysis. If the patient is experiencing intravascular lysis, these conditions are present:

• Hemoglobin, hematocrit, and red cell count are low.

• Serum bilirubin is elevated.

• Serum haptoglobin is low.

• Hemoglobinemia (free hemoglobin in plasma) may be present.

• Hemoglobinuria (hemoglobin in urine) may be present.

• Reticulocyte count is elevated.

• Lactate dehydrogenase (LDH) is elevated.

Transferin

Developing erythroblasts in marrow

Transferin

Developing erythroblasts in marrow

Amino acid pool

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