Bone Marrow

Blood Components

Blood is composed of plasma and cells. Plasma is part of the body’s extracellular fluid. It is similar to the interstitial fluid found between tissue cells, but plasma contains much more protein. The three major types of plasma proteins are albumin, globulins, and fibrinogen.

The RBCs produce hemoglobin (Hgb). Each normal mature RBC contains hundreds of thousands of hemoglobin molecules. The heme part of each hemoglobin molecule needs a molecule of iron to be able to transport up to four molecules of oxygen. Therefore iron is an essential part of hemoglobin. The globin portion of hemoglobin carries carbon dioxide. RBCs also are buffers and help maintain acid-base balance.

Platelets are the third type of blood cells. They are the smallest of the blood cells, formed as fragments of a giant precursor cell in the bone marrow, the megakaryocyte. Platelets stick to injured blood vessel walls and form platelet plugs that can stop the flow of blood from the injured site. They also produce substances important to blood clotting (coagulation), and perform most of their functions by aggregation (clumping together). Platelets help keep blood vessels intact by initiating repair after damage to small blood vessels.

Bone marrow production of platelets also is precisely controlled by the growth factor thrombopoietin. After platelets leave the bone marrow, they are stored in the spleen and then released slowly to meet the body’s needs. Normally, 80% of platelets circulate and 20% are stored in the spleen. Each platelet has a life span of 1 to 2 weeks.

Accessory Organs of Blood Formation

The spleen and liver are important accessory organs for blood production. They help regulate the growth of blood cells and form factors that ensure proper blood clotting.

The spleen is located under the diaphragm to the left of the stomach. It contains three types of tissue: white pulp, red pulp, and marginal pulp. These tissues all help balance blood cell production with blood cell destruction and assist with immunity. White pulp is filled with white blood cells (WBCs), especially lymphocytes and macrophages. It is a major site of antibody production. As whole blood filters through the white pulp, bacteria and old RBCs are removed. Red pulp contains enlarged blood vessels (sinuses) that store RBCs and platelets. Marginal pulp contains the ends of many arteries and other blood vessels.

The spleen destroys old or imperfect RBCs, breaks down the hemoglobin released from these destroyed cells, stores platelets, and filters antigens. Anyone who has had a splenectomy has reduced immune functions and is less able to remove disease-causing organisms, increasing the risk for infection and sepsis.

The liver produces prothrombin and most of the blood clotting factors. In addition, proper liver function and bile production are important in forming vitamin K in the intestinal tract. (Vitamin K is needed to produce blood clotting factors VII, IX, and X and prothrombin.) Large quantities of whole blood and blood cells can be stored in the liver. The liver also stores extra iron within the protein ferritin.

Hemostasis/Blood Clotting

Hemostasis is the multi-step process of controlled blood clotting. With proper hemostasis, localized blood clotting occurs in damaged blood vessels to prevent excessive blood loss while blood continues to circulate to all other areas. This important function is a complex process that balances blood clotting actions with anti-clotting actions. When injury occurs, hemostasis begins with the formation of a platelet plug and continues with a series of events that eventually cause the formation of a fibrin clot. Three sequential processes result in blood clotting: platelet aggregation with formation of a platelet plug, the blood clotting cascade, and the formation of a complete fibrin clot.

Platelet aggregation begins forming a platelet plug by having platelets clump together, a process essential for blood clotting. Platelets normally circulate as individual cell-like structures. They are not attracted to each other and do not clump together until activated. Activation causes platelet membranes to become sticky, allowing them to clump together. When platelets clump, they form large, semisolid plugs in blood vessel lumens and walls, disrupting local blood flow. These platelet plugs are not clots and last only a few hours. Thus they cannot provide complete hemostasis.

Substances that cause platelets to clump include adenosine diphosphate (ADP), calcium, thromboxane A₂, and collagen. Platelets themselves secrete some of these substances, and other activating substances are external to the platelet. Platelet plugs start the cascade reaction that ends with local blood clotting and also are important at most steps within the cascade. When too few platelets are present, blood clotting is impaired, increasing the person’s risk for bleeding and hemorrhage.

Blood clotting is a cascade triggered by the formation of a platelet plug. The beginning of the blood clotting cascade is then rapidly amplified. The final result is much larger than the triggering event. In this sense, the cascade works like a landslide. A few small pebbles rolling down a steep hillside can dislodge large rocks and pieces of soil, causing a final enormous movement of earth. Just like landslides, cascade reactions are hard to stop once set into motion.

Extrinsic factors are outside of the blood that can also activate platelets. The most common extrinsic event is trauma that damages blood vessels and exposes the platelets to collagen. Collagen then activates platelets to form a platelet plug within seconds of the trauma. The blood clotting cascade is started sooner by the extrinsic pathway because some of the steps of the intrinsic pathway are bypassed. Other blood vessel changes that can activate platelets include inflammation, bacterial toxins, or foreign proteins.

Whether the platelet plugs are formed because of abnormal blood (intrinsic factors) or by exposure to inflamed or damaged blood vessels (extrinsic factors), the end result of the cascade is the same: formation of a fibrin clot and local blood coagulation.

The steps of the cascade between the formation of a platelet plug and the formation of a fibrin clot depend on the presence of specific clotting factors. In addition, calcium and more platelets are needed at every step.

Anti-Clotting Forces

Because blood clotting occurs through a rapid cascade process, in theory it keeps forming fibrin clots whenever the cascade is set into motion until all blood throughout the entire body has coagulated. Such widespread clotting would lead to death. Therefore, whenever the blood clotting cascade is started, anti-clotting forces are also started to limit clot formation only to damaged areas so that normal blood flow is maintained everywhere else. When blood clotting and anti-clotting actions are normal and balanced, clotting occurs only where it is needed and normal blood flow elsewhere is maintained. The anti-clotting forces involve two types of actions. One action ensures that activated clotting factors are present only in limited amounts. The other action, fibrinolysis, prevents over-enlargement of the fibrin clot.

When the blood clotting cascade is activated, certain anti-clotting substances are also activated. Known anti-clotting proteins include protein C, protein S, and antithrombin III. Protein C and protein S increase the breakdown of clotting factors V and VIII. Antithrombin III inactivates thrombin and clotting factors IX and X. These actions prevent clots from becoming too large or forming in an area where clotting is not needed. Deficiency of any of these anti-clotting factors increases the risk for pulmonary embolism, myocardial infarction, and strokes.

Hematologic Changes Associated with Aging