Hemoglobin & Anemias - the basics by Dr.M.Anthony David MD

NOMAD:2006: BP: HBANEM NOMAD:2006: BP: HBANEM 11

ERYTHROCYTES, ERYTHROCYTES, HEMOGLOBIN & ANEMIASHEMOGLOBIN & ANEMIAS

ByBy

Dr.M.Anthony David MDDr.M.Anthony David MD

Professor of PhysiologyProfessor of Physiology

25 Trillion in an average 70 kg adult man.25 Trillion in an average 70 kg adult man. Men have aboutMen have about 4.5 to 5.5 Millions/cu.mm4.5 to 5.5 Millions/cu.mm Women have about Women have about 4 to 5 Millions/cu.mm4 to 5 Millions/cu.mm Decrease in the Erythrocyte Count is Decrease in the Erythrocyte Count is

called Anemiacalled Anemia Increase is called Increase is called PolycythemiaPolycythemia

POLYCYTHEMIAPOLYCYTHEMIA Increase in the number Increase in the number of Erythrocytesof Erythrocytes

Is of two typesIs of two types Primary Polycythemia Primary Polycythemia Secondary Secondary PolycythemiaPolycythemia


ERYTHROCYTE MORPHOLOGYERYTHROCYTE MORPHOLOGY

They are biconcave discs in shape They are biconcave discs in shape about 7.5 Microns in diameterabout 7.5 Microns in diameter

They are about 2 – 3 Microns thickThey are about 2 – 3 Microns thick They have no nuclei.They have no nuclei. Why?Why? They make place for HemoglobinThey make place for Hemoglobin Hemoglobin takes up a third of Hemoglobin takes up a third of

the volume of each erythrocytethe volume of each erythrocyte



HEMOGLOBINHEMOGLOBIN

A A CHROMO PROTEIN CHROMO PROTEIN MOLECULE.MOLECULE. IS PRESENT EXCLUSIVELY IS PRESENT EXCLUSIVELY

WITHIN THE ERYTHROCYTE.WITHIN THE ERYTHROCYTE. ROUGHLY ROUGHLY ONE THIRD OF THE ONE THIRD OF THE

VOLUME VOLUME OF THE ERYTHROCYTE OF THE ERYTHROCYTE IS OCCUPIED BY HEMOGLOBIN.IS OCCUPIED BY HEMOGLOBIN.

IS A COMPLEX PROTEIN WITH IS A COMPLEX PROTEIN WITH TWO MOIETIES: TWO MOIETIES: HEME + GLOBIN.HEME + GLOBIN.


HEMOGLOBIN MOLECULEHEMOGLOBIN MOLECULE


SYNTHESIS OF HEMOGLOBINSYNTHESIS OF HEMOGLOBIN

REQUIRES:REQUIRES: Nutrients such as Proteins, Nutrients such as Proteins,

Vitamins & Minerals.Vitamins & Minerals. TAKES PLACE ONLY WITHIN THE TAKES PLACE ONLY WITHIN THE

NORMOBLASTCELLS.NORMOBLASTCELLS.(INTRACELLULAR)(INTRACELLULAR)

HEMOGLOBIN = HEME + GLOBINHEMOGLOBIN = HEME + GLOBIN HEME = PIGMENTHEME = PIGMENT GLOBIN = PROTEINGLOBIN = PROTEIN


HEMEHEME Iron containing Porphyrin.Iron containing Porphyrin. Iron-Protoporphyrin IXIron-Protoporphyrin IX Porphyrin is formed from 4 Pyrrole Porphyrin is formed from 4 Pyrrole

rings joined by four methane bridges.rings joined by four methane bridges. The side chains 1,3 5, & 8 are Methyl.The side chains 1,3 5, & 8 are Methyl. The side chains 2 & 4 are Vinyl.The side chains 2 & 4 are Vinyl. The side chains 6 & 7 are Propionic The side chains 6 & 7 are Propionic

Acid.Acid.


HEMOGLOBIN CATABOLISMHEMOGLOBIN CATABOLISM

Macrophages, mainly the Kupffer cells in the liver phagocytose Hemoglobin.

HEMOGLOBIN = HEME + GLOBINHEME Fe++ + PORPHYRIN

PORPHYRIN BILVERDIN + CO.CO TO THE LUNGS AND OUT.BILVERDIN REDUCED TO BILIRUBIN AND

SENT TO BLOOD & LIVER FOR EXCRETION.


Fe++ + TRANSFERRIN TO BONE MARROW FOR REUSE.

Fe++ + PORPHYRIN HEME(In the presence of the enzyme,

Heme Oxidase.) HEME + GLOBIN HEME + GLOBIN HEMOGLOBIN

HEMOGLOBIN CATABOLISMHEMOGLOBIN CATABOLISM


HEMOGLOBIN:NORMAL HEMOGLOBIN:NORMAL LEVELSLEVELS

MALES: 14 – 18 Gm%MALES: 14 – 18 Gm% FEMALES: 12 – 15 Gm%FEMALES: 12 – 15 Gm% AT BIRTH: 23 Gm%AT BIRTH: 23 Gm% FALLS TO 10.5Gm% BY THIRD FALLS TO 10.5Gm% BY THIRD

MONTHMONTH RISES GRADUALLY TO 12.5 RISES GRADUALLY TO 12.5

Gm% AT 1 YEAR OF AGE.Gm% AT 1 YEAR OF AGE.


1 Gm OF HEMOGLOBIN, WHEN 1 Gm OF HEMOGLOBIN, WHEN FULLY SATURATED, COMBINES FULLY SATURATED, COMBINES WITHWITH 1.34 ml OF OXYGEN. 1.34 ml OF OXYGEN.

HEMOGLOBIN CONCENTRATION HEMOGLOBIN CONCENTRATION IS THEREFORE AN INDEX OF THE IS THEREFORE AN INDEX OF THE OXYGEN CARRYING CAPACITYOXYGEN CARRYING CAPACITY OF OF THE BLOOD.THE BLOOD.

HEMOGLOBIN LEVELS : HEMOGLOBIN LEVELS : SIGNIFICANCESIGNIFICANCE


HEMOGLOBIN FORMATION: HEMOGLOBIN FORMATION: FACTORSFACTORS

1. PROTEINS:1. PROTEINS: HIGH POTENCY: ANIMAL HIGH POTENCY: ANIMAL

PROTEINS LIKE LIVER, SPLEEN PROTEINS LIKE LIVER, SPLEEN KIDNEY & HEART MOST POTENTKIDNEY & HEART MOST POTENT

MUSCLE PROTEINS MEDIUM MUSCLE PROTEINS MEDIUM POTENTPOTENT

LEAST POTENCY: CEREALS, LEAST POTENCY: CEREALS, DAIRY PRODUCTS, VEGETABLES DAIRY PRODUCTS, VEGETABLES & FRUITS& FRUITS


2. IRON: HEMOGLOBIN HAS 2.5 2. IRON: HEMOGLOBIN HAS 2.5 Gms OF THE TOTAL BODY Gms OF THE TOTAL BODY IRON OF 4 - 5 Gms IN AN IRON OF 4 - 5 Gms IN AN AVERAGE HEALTHY ADULT.AVERAGE HEALTHY ADULT.

HEMOGLOBIN FORMATION: HEMOGLOBIN FORMATION: FACTORSFACTORS


HEMOGLOBIN: STRUCTUREHEMOGLOBIN: STRUCTURE

HAS FOUR POLYPEPTIDE CHAINS OF HAS FOUR POLYPEPTIDE CHAINS OF TWO TYPES: EACH IN DUPLICATE.TWO TYPES: EACH IN DUPLICATE.

HbA: ADULT HEMOGLOBIN HAS:HbA: ADULT HEMOGLOBIN HAS: 2 2 αα CHAINS AND CHAINS AND 2 2 ββ CHAINS. CHAINS.

EACH CHAIN IS ASSOCIATED WITH EACH CHAIN IS ASSOCIATED WITH ONE HEME GROUP.ONE HEME GROUP.

THUS THERE ARE FOUR HEMES TO THUS THERE ARE FOUR HEMES TO THE MOLECULE, A TETRAMER OF MW THE MOLECULE, A TETRAMER OF MW 68,00068,000


STRUCTURE & FUNCTIONSTRUCTURE & FUNCTION

Hb A = Hb A = αα22 ββ22

HEMOGLOBIN COMBINES LOOSELY & HEMOGLOBIN COMBINES LOOSELY & REVERSIBLY WITH OXYGEN.REVERSIBLY WITH OXYGEN.

IT’S AFFINITY TO OXYGEN IS IT’S AFFINITY TO OXYGEN IS DECREASED IN THE PRESENCE OF 2,3, DECREASED IN THE PRESENCE OF 2,3, DIPHOSPHO GLYCERATE (2,3 DPG)DIPHOSPHO GLYCERATE (2,3 DPG)

2,3 DPG IS A PRODUCT OF GLUCOSE 2,3 DPG IS A PRODUCT OF GLUCOSE METABOLISM.METABOLISM.


2,3 DPG 2,3 DPG AFFINITY OF Hb TO O AFFINITY OF Hb TO O22

THIS CAUSES THE OXYGEN TO BE THIS CAUSES THE OXYGEN TO BE FREELY DISSOCIATED.FREELY DISSOCIATED.

THIS HAPPENS AT THE TISSUE THIS HAPPENS AT THE TISSUE LEVEL.LEVEL.

ENSURES FREE AVAILABLITY OF ENSURES FREE AVAILABLITY OF OO2 2 TO THE TISSUES.TO THE TISSUES.

THUS OXYGEN DELIVERY IS A THUS OXYGEN DELIVERY IS A BASIC FUNCTION OF HEMOGLOBINBASIC FUNCTION OF HEMOGLOBIN

STRUCTURE & FUNCTIONSTRUCTURE & FUNCTION


HEMOGLOBIN: VARIETIESHEMOGLOBIN: VARIETIES

HEME IS THE SAMEHEME IS THE SAME VARIETIES ARE DUE TO CHANGES VARIETIES ARE DUE TO CHANGES

IN THE PEPTIDES OF THE GLOBIN IN THE PEPTIDES OF THE GLOBIN MOIETY.MOIETY.

PHYSIOLOGICAL VARIETIES:PHYSIOLOGICAL VARIETIES:1. ADULT Hb: Hb A:1. ADULT Hb: Hb A:

Hb A: Hb A: αα22 ββ22: PREPONDERANT FORM: : PREPONDERANT FORM: 68,00068,000

Hb A2: Hb A2: αα22 δδ2 2 : A MINOR COMPONENT: A MINOR COMPONENT


Hb:PHYSIOLOGICAL Hb:PHYSIOLOGICAL VARIETIESVARIETIES

2. FETAL HEMOGLOBIN:2. FETAL HEMOGLOBIN: Hb F : Hb F : αα22 γγ22 γγ : GAMMA CHAINS HAVE MORE : GAMMA CHAINS HAVE MORE

AFFINITY TO OXYGEN. AFFINITY TO OXYGEN. THIS HELPS THE FETUS TO THIS HELPS THE FETUS TO

ACQUIRE OXYGEN FROM THE ACQUIRE OXYGEN FROM THE MOTHER.MOTHER.


Hb: PATHOLOGICAL : Hb: PATHOLOGICAL : SICKLE CELL DISEASESICKLE CELL DISEASE

CAUSE: ABNORMAL POLYPEPTIDES DUE TO

SUBSTITUTION OF AMINO ACIDS SUPRESSION OF SYNTHESIS OF

POLYPEPTIDE CHAINS. Hb S:

OCCURS IN 0.3 to 1 % OF WEST AFRICAN & AMERICAN BLACK PEOPLE

VALINE IS SUBSTITUTED FOR GLUTAMIC ACID AT 6 POSITION OF BETA CHAIN.


SICKLE CELL DISEASESICKLE CELL DISEASE

WHEN Hb S IS REDUCED, IT BECOMES WHEN Hb S IS REDUCED, IT BECOMES LESS SOLUBLE & ‘GELS’LESS SOLUBLE & ‘GELS’

THIS CHANGES THE SHAPE OF THE THIS CHANGES THE SHAPE OF THE ERYTHROCYTES.ERYTHROCYTES.

THEY BECOME ‘SICKLE’ SHAPEDTHEY BECOME ‘SICKLE’ SHAPED THEY INCREASE THE BLOOD THEY INCREASE THE BLOOD

VISCOSITY AND UNDERGO HEMOLYSIS.VISCOSITY AND UNDERGO HEMOLYSIS. THIS IS A SERIOUS CONDITION, CAN THIS IS A SERIOUS CONDITION, CAN

BE FATAL BY MIDDLE AGE.BE FATAL BY MIDDLE AGE.


A SICKLED ERYTHROCYTEA SICKLED ERYTHROCYTE


Hb: PATHOLOGICAL : Hb: PATHOLOGICAL : THALASSEMIASTHALASSEMIAS

DEFECT IN THE SYNTHESIS OF EITHER DEFECT IN THE SYNTHESIS OF EITHER ALPHA & BETA CHAINS OF GLOBIN.ALPHA & BETA CHAINS OF GLOBIN.

OCCURS IN HOMOZYGOUS OFFSPRING OCCURS IN HOMOZYGOUS OFFSPRING OF HETEROZYGOUS PARENTS.OF HETEROZYGOUS PARENTS.

BETA THALASSEMIA IS MORE COMMON. BETA THALASSEMIA IS MORE COMMON. BETA CHAIN NOT FORMED.BETA CHAIN NOT FORMED.


BETA THALASSEMIABETA THALASSEMIA

ERYTHROCYTES ARE ERYTHROCYTES ARE ABNORMAL: HAVE LESS Hb A ABNORMAL: HAVE LESS Hb A AND MORE OF Hb AAND MORE OF Hb A22 & Hb F. & Hb F.

RAPID HEMOLYSIS OCCURS IN RAPID HEMOLYSIS OCCURS IN VIVO.VIVO.

CAUSES HYPOCHROMIC ANEMIA.CAUSES HYPOCHROMIC ANEMIA. CHILDREN FAIL TO THRIVE.CHILDREN FAIL TO THRIVE. THEY DIE YOUNG.THEY DIE YOUNG.


IRON METABOLISM IRON METABOLISM & ANEMIAS& ANEMIAS

ByBy

Dr.M.ANTHONY DAVID, MDDr.M.ANTHONY DAVID, MD

Professor of Physiology Professor of Physiology


IRON IN THE BODYIRON IN THE BODY

BIOCHEMICAL BIOCHEMICAL FORMFORM

SITESITE CONC.CONC. % OF % OF TOTALTOTAL

HEMOGLOBINHEMOGLOBIN ErythrocytesErythrocytes 2.5 Gms2.5 Gms 60-6560-65

STORAGE Fe STORAGE Fe (ferritin & (ferritin &

hemosiderin)hemosiderin)

Phagocytes & Phagocytes & Hepatic Hepatic

Parenchymal Parenchymal cellscells

1 – 1.5 1 – 1.5 GmsGms

25 -3025 -30

MYOGLOBINMYOGLOBIN

MyohemogloMyohemoglobinbin

Red Muscle Red Muscle FibresFibres

0.2 Gms0.2 Gms

150-150-200mg200mg

44

Trace Heme Trace Heme Tissue Tissue

enzymesenzymes

Tissue CellsTissue Cells < 0.1 < 0.1 GmsGms

11


IRON BALANCEIRON BALANCE ADULT MEN:ADULT MEN: DIET : DIET : 5 – 10 mg/day 5 – 10 mg/day LOSS:LOSS: 0.4 mg : Urine0.4 mg : Urine 0.8 mg : Bile0.8 mg : Bile Traces : Mucosa of GI tract.Traces : Mucosa of GI tract.


HAVE MORE IRON LOSS:HAVE MORE IRON LOSS: Monthly Menstrual Periods: 50 – 80 mlMonthly Menstrual Periods: 50 – 80 ml Child Bearing & Rearing : 15 Months: Child Bearing & Rearing : 15 Months:

900 mg (2mg/day) How?900 mg (2mg/day) How? Fetal Iron Content : 400mg.Fetal Iron Content : 400mg. Iron in Placenta/Uterus : 150mg.Iron in Placenta/Uterus : 150mg. Blood loss in Parturition:170mg.Blood loss in Parturition:170mg. Iron in Breast milk : 180mg.Iron in Breast milk : 180mg. TOTAL : 900mg.TOTAL : 900mg.

IRON BALANCE: womenIRON BALANCE: women


IRON ABSORPTIONIRON ABSORPTION SITE: Duodenum/Upper Jejunum via

brush border. Ferrous form better absorbed than

Ferric form Ascorbic Acid (Vit C) helps absorption. Phosphates/Phytates reduce ionic Iron

absorption by forming insoluble salts. Heme in diet is directly absorbed Iron deficiency states enhance Iron

absorption.


ANEMIASANEMIAS

Deficiency of Hb in the blood caused by either:

RBC Count or Hb in the RBCs


ANEMIAS: CLASSIFICATION

HEMORRHAGIC ANEMIAHEMORRHAGIC ANEMIA APLASTIC ANEMIAAPLASTIC ANEMIA MEGALOBLASTIC ANEMIAMEGALOBLASTIC ANEMIA PERNICIOUS ANEMIAPERNICIOUS ANEMIA HEMOLYTIC ANEMIAHEMOLYTIC ANEMIA SICKLE CELL ANEMIASICKLE CELL ANEMIA IRON DEFICIENCY ANEMIAIRON DEFICIENCY ANEMIA SECONDARY ANEMIA (RENAL)SECONDARY ANEMIA (RENAL)


1. HEMORRHAGIC ANEMIA 1. HEMORRHAGIC ANEMIA (BLOOD LOSS) (BLOOD LOSS)

ACUTEACUTE: Sudden loss of blood: Sudden loss of blood RBC Count decreased for 1 – 3 RBC Count decreased for 1 – 3

daysdays RBCs are restored in 3 – 6 weeksRBCs are restored in 3 – 6 weeks CHRONIC BLOOD LOSSCHRONIC BLOOD LOSS:: They cannot absorb Fe enough to They cannot absorb Fe enough to

form Hbform Hb Have Hypochromic, Microcytic Have Hypochromic, Microcytic

Anemia.Anemia.


2. APLASTIC ANEMIA:2. APLASTIC ANEMIA:

Lack of functioning Red Bone Lack of functioning Red Bone Marrow, the hemopoietic tissue.Marrow, the hemopoietic tissue.

Caused by exposure to gamma ray Caused by exposure to gamma ray radiation (Nuclear Bomb Blast)radiation (Nuclear Bomb Blast)

Excessive exposure to X raysExcessive exposure to X rays Exposure to certain industrial Exposure to certain industrial

chemicals.chemicals.


3. MEGALOBLASTIC ANEMIA:3. MEGALOBLASTIC ANEMIA:

Deficiency of Vit BDeficiency of Vit B12 12 and or Folic Acid.and or Folic Acid. Intrinsic Factor can also be deficient.Intrinsic Factor can also be deficient. Production of Erythrocytes becomes Production of Erythrocytes becomes

slow.slow. They remain large, have odd shapes They remain large, have odd shapes

and are called ‘Megaloblasts’and are called ‘Megaloblasts’ Atropy of Stomach mucosa can cause Atropy of Stomach mucosa can cause

loss of Intrinsic factor & this anemia is loss of Intrinsic factor & this anemia is called Pernicious Anemia. called Pernicious Anemia.


MEGALOBLASTIC ANEMIA:MEGALOBLASTIC ANEMIA:

Intestinal Sprue or Malabsorption Intestinal Sprue or Malabsorption Syndrome can also cause this.Syndrome can also cause this.

Megaloblasts are over sized, Megaloblasts are over sized, anisocytic.anisocytic.

They have fragile membranes and They have fragile membranes and rupture easily.rupture easily.

TREATMENT: Vitamin B12 Folic Acid if TREATMENT: Vitamin B12 Folic Acid if it is nutritional. it is nutritional.


4. HEMOLYTIC ANEMIAS4. HEMOLYTIC ANEMIAS

Mostly heriditary.Mostly heriditary. Cells are fragile, rupture easily as Cells are fragile, rupture easily as

they move through the capillaries.they move through the capillaries. The life span of erythrocytes is The life span of erythrocytes is

reduced.reduced.

HERIDITARY SPHEROCYTOSIS:HERIDITARY SPHEROCYTOSIS: Small spherical erythrocytes.Small spherical erythrocytes. Cannot be compressed even slightlyCannot be compressed even slightly Rupture and are lysed very easily.Rupture and are lysed very easily.


5. SICKLE CELL ANEMIA5. SICKLE CELL ANEMIA Affects 0.3 to 1% of West African & Affects 0.3 to 1% of West African &

African blacks.African blacks. The Beta chains of Hemoglobin are The Beta chains of Hemoglobin are

defective.defective. They have Hb SThey have Hb S Sickling occurs when Hb loses Oxygen.Sickling occurs when Hb loses Oxygen. A vicious circle of events occurs: A vicious circle of events occurs:

Oxygen tension Oxygen tension Sickling Sickling Rupture of Rupture of Erythrocytes Erythrocytes Further Further Oxygen tension Oxygen tension

This is called a crisis in sickle cell This is called a crisis in sickle cell disease.disease.


ERYTHROBLASTOSIS FETALISERYTHROBLASTOSIS FETALIS

Rh Isoimmunisation causes this Rh Isoimmunisation causes this diseasedisease

Antigen antibody reaction causes Antigen antibody reaction causes lysis of erythrocytes.lysis of erythrocytes.

Seen in Neonates and is also Seen in Neonates and is also called Icterus Gravis Neonatorum.called Icterus Gravis Neonatorum.

Excess Bilirubin enters the brain, Excess Bilirubin enters the brain, causing ‘kernicterus’causing ‘kernicterus’

Can become fatal.Can become fatal.


IRON DEFICIENCY ANEMIAIRON DEFICIENCY ANEMIA

The most common type of anemiaThe most common type of anemia.. Caused by nutritional deficiency of Iron.Caused by nutritional deficiency of Iron. Erythrocytes are smaller and have less Erythrocytes are smaller and have less

Hb.Hb. So they are called Microcytic & So they are called Microcytic &

Hypochromic.Hypochromic. Treated by taking Iron rich diets.Treated by taking Iron rich diets. Dark green leafy vegetables: esp Dark green leafy vegetables: esp

Drumstick leaves.Drumstick leaves. Meats like Liver & spleen.Meats like Liver & spleen.


IRON RICH DIETSIRON RICH DIETS


SECONDARY ANEMIA(RENAL)SECONDARY ANEMIA(RENAL)

Renal Diseases can cause Renal Diseases can cause decreased decreased ErythropoietinErythropoietin..

Erythropoietin is essential for Erythropoietin is essential for proper production of erythrocytes proper production of erythrocytes (Erythropoiesis)(Erythropoiesis)

Renal disease thus causes Anemia.Renal disease thus causes Anemia.

REVIEWREVIEW Erythrocytes:Erythrocytes:

4.5 – 5.5 Million/cc of blood in Males4.5 – 5.5 Million/cc of blood in Males 4 – 5 Million/cc of blood in females4 – 5 Million/cc of blood in females

Biconcave discsBiconcave discs 7.5 Microns X 2.5 Microns7.5 Microns X 2.5 Microns No nucleusNo nucleus Hemoglobin takes up a third Hemoglobin takes up a third

volumevolumeNOMAD:2006: BP: HBANEM NOMAD:2006: BP: HBANEM 5050


REVIEWREVIEW Hemoglobin is a chromoprotein Hemoglobin is a chromoprotein

present exclusively within the present exclusively within the erythrocytes.erythrocytes.

Hb synthesis takes place within the Hb synthesis takes place within the normoblasts.normoblasts.

Hemoglobin = Heme + Globin.Hemoglobin = Heme + Globin. Heme is an Iron containing Porphyrin.Heme is an Iron containing Porphyrin. Iron is present in the Ferrous form.Iron is present in the Ferrous form. Oxygen can be loosely attached to Hb.Oxygen can be loosely attached to Hb.


Normal blood levels of Normal blood levels of Hemoglobin:Hemoglobin: Males : 14 – 18 Gm%Males : 14 – 18 Gm% Females : 12 – 15 Gm%Females : 12 – 15 Gm%

1 Gram of Hemoglobin combines 1 Gram of Hemoglobin combines with 1.34 ml of Oxygen.with 1.34 ml of Oxygen.

Varieties of Hemoglobin include: Varieties of Hemoglobin include: Hb A, Hb FHb A, Hb F

Hb S, Hb AHb S, Hb A22

REVIEWREVIEW


Anemia is a decrease in either Hb or Anemia is a decrease in either Hb or RBCs.RBCs.

Types of Anemia:Types of Anemia: HemorrhagicHemorrhagic AplasticAplastic MegaloblasticMegaloblastic PerniciousPernicious HemolyticHemolytic Sickle CellSickle Cell Iron deficiencyIron deficiency Secondary (Renal)Secondary (Renal)

REVIEWREVIEW

Hemoglobin & Anemias - the basics by Dr.M.Anthony David MD

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Transcript of Hemoglobin & Anemias - the basics by Dr.M.Anthony David MD