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1. Practical Clinical Hematology Fetal Hemoglobin ALKALI DENATURATION 6-1 By: Wael Al Laithi

2. Definition • Is the mainoxygen transport proteinin thefetusduring the last seven months of development in theuterusand in the newborn until roughly 6 months old. • Baby takes about 2 years to completely switch over to adult hemoglobin

3. Hb Development during Pregnancy

4. Function • Fetal hemoglobin differs most fromadult hemoglobinin that it is able to bind oxygen with greater affinity than the adult form, giving the developing fetus better access to oxygen from the mother'sblood stream. • The transfer of oxygen is from the mother (less tightly bond) to the baby (more tightly bond).

5. Characteristic • Hemoglobin F is made up of 2 alpha chains and 2 gamma chains • Hemoglobin F does not turn into hemoglobin A. • Hb F and Hb A are completely different hemoglobin • Fetal hemoglobin is alkali-resistant hemoglobin • Newborn babies with sickle cell disease make hemoglobin F and hemoglobin S • Babies with sickle cell disease experience more problems as hemoglobin F is turned off.

6. In adults, fetal hemoglobin production can be reactivated pharmacologically, which is useful in the treatment of such diseases as sickle cell disease. Hydroxyurea, one of the new drugs used to treat sickle cell disease in adults works by turning hemoglobin F back on.

7. Hb F increased in: • Hereditary persistence of fetal hemoglobin. • Sickle cell anemia. • Acquired a plastic anemia. • Megaloblastic anemia. • Paroxysmal nocturnal hemoglobin.

9. Principle • Hemoglobin F is not denatured in a highly alkaline medium and then canbe separated by filtration after selective precipitation of denatured hemoglobins. • The remaining concentration of the HB F in the solution is photometrically determined and related to the total Hb.

10. Procedure:Hemolysate Preparation • Prepare hemolysate (R1) by add 0.5 ml blood to 9.5ml drapkien then mixed. • Transfer 2.8 ml from R1 to new tube and add 200 µl NaOH (2N) mixed and incubation at R.T 2 min. • At the end of 2 min exactly add 2 ml saturation ammonium sulfate and mixed then incubation 5-10 min at R.T. • Filter the solution by filter paper. • Read the filtrate at 540 nm.

11. AssayProcedure:

12. Calculation:

13. HBF Refernce Range • Normal Reference Range: • Newborn to six months: HbF may be up to 70 percent of total hemoglobin. • Six months to adult: HbF may be up to 2 percent of total hemoglobin. • Hemoglobinopathies HBF ranges: • Sickle cell disease: Hemoglobin S 80–100%, Hgb A 0%, HbF 2%. • Sickle cell trait: Hemoglobin S 20–40%, Hgb A 60–80%, HbF 2%. • Hgb C disease: Hgb C 90–100%, Hgb A 0%, and Hb F 2%. • Thalassemia major: HbF 65–100%, Hgb A 5–25%. • Thalassemia minor: HbF 1–3%, Hgb A 50–90%.

14. Practical Clinical Hematology ACID ELUTION (KLEIHAUER BETKE TEST) 6-2

15. HEMOGLOBIN F STAIN • The acid elution test is employed to assess the distribution of hemoglobin F in the red blood cell: This information is useful in helping to diagnose • Hereditary persistence of fetal hemoglobin • In determining the presence of fetal red cells in the maternal circulation during pregnancy.

16. Reagents and Equipment • Fetal cell fixing solution is Ethyl alcohol, 80%. • Fetal cell buffer solution is Citric acid-phosphate buffer, pH 3.2 to 3.3. • Fetal cell stain: • ErythrosinB (eosin B) stain, 0.1% • Ehrlich's acid hematoxylin. • Coplin jars. • Waterbath, 37° C.

17. Specimen • Make blood smears from venous blood collected in EDTA anticoagulant or from the fingertip (toe or heel). • For best result blood should be less than 6 hours old, although successful staining has been achieve on specimens refrigerated for up to 2 weeks • The smears should be fixed within 2 hours of preparation.

18. Principle • Blood smears are fixed with ethyl alcohol and then incubated in a citric acid-buffer solution In an acid medium (pH 3.2 to 3.3), hemoglobin F is resistant to elution from the red blood cell, while other types are removed from the red cells. • The slides are stained with hematoxylin (stains the white cell nuclei) and erythrosin B (stains the red cells). • The smears are then reviewed microscopically to mine the presence of hemoglobin F, and percentage of red blood cells containing fetal hemoglobin may be assessed.

19. Procedure • Prewarm citric acid-phosphate buffer. Place 50 mL of the buffer solution into a coplin jar and cover. Incubate at 37°C for 30 minutes. (Make certain the level of water in the incubator is level with, or above, the level of buffer in the coplin jar.) • Preparation of blood smears, Patient-Make several thin (a monolayer of cells) blood smears

20. Allow the blood smears to air-dry for at least 10 minutes. • Fix blood smears (patient and controls) in 80% ethyl alcohol for 5 minutes • Rinse the smears carefully in distilled water and allow to air-dry. • Place the dry smears in the prewarmed citric acid-phosphate buffer solution for 5 minutes. At 1 and 3 minutes (of incubation), carefully lift each slide out of the buffer solution and immediately replace. This action will provide a gentle stirring of the solution. • After 5 minutes, remove the slides from the citric acid-phosphate buffer solution and carefully rinse with distilled water. Air-dry.

21. Stain the dry smears in acid hematoxylin for 3 minutes. Rinse with distilled water and remove as much of the water as possible from the smears by gently tapping one end of the slide on an absorbent material. • Counterstain the smears with erythrosin B for 4 minutes. Rinse with distilled water, allow to air-dry, and coverslip (if desired). • Examine the slides microscopically, (oil immersion objective [1000]),

23. Procedure • To determine the percentage of red blood cells containing fetal hemoglobin: • Determine the average # of red cells/ field.

24. Discussion • Reticulocytes may resist elution and would, therefore, give the appearance of cells containing hemoglobin F. • The degree of elution of adult hemoglobin may very from patient to patient. • Ethyl alcohol concentrations above 80% may cause the elution of hemoglobin F, while concentrations below 80% may cause morphologic alterations.

25. Discussion • In hereditary persistence of fetal hemoglobin, the amount of hemoglobin F in each cell is constant and, therefore, all of the red blood cells are consistently stained. Conversely, in diseases such as sickle cell anemia, thalassemia, acquired aplastic anemia, and several other hemoglobinopathies, the amount of hemoglobin F present in the red blood cells varies. This shows up as an inconsistent staining of the red cells.

26. Discussion • The pH of the citric acid-phosphate buffer is critical. A pH below 3.1 may cause elution of hemoglobin F from the red cells, while a pH above 3.3 may retard the elution of non-F hemoglobin from the cells. • A temperature above 25°C during fixation in the ethyl alcohol will inhibit elution of normal hemoglobin.

27. Thanks