Deze samenvatting vat het boek 'Hematologie voor de basisarts' van prof P. Vandenberghe samen, aangevuld met info vanuit de slides en lesnotities. Enkel hoofdstuk 11 'Ziekten van de bloedstolling' staat er niet in, want dit wordt niet in de les gezien. De verschillende hematologische aandoeningen w...
Hoofdstukken die in de les besproken werden (h1-10, h12-13)
May 28, 2024
June 12, 2024
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2023/2024
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hematologie
p vandenberghe
kuleuven
e0c12a
1ste master geneeskunde
hemato oncologie
hemato onco
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20
Hematologie
PROF. PETER VANDENBERGHE
ELLA COOMANS
,Inhoudsopgave
HOOFDSTUK 1: HET HEMATOPOËTISCHE STELSEL EN ZIJN ONDERZOEK .............................................................. 5
1.1 BLOED EN HEMATOPOËSE ....................................................................................................................................... 5
1.1.1 BLOED ........................................................................................................................................................... 5
1.1.2 HET BEENMERG ............................................................................................................................................... 7
1.2 DIAGNOSTIEK VAN HEMATOLOGISCHE AANDOENINGEN ................................................................................................. 7
1.2.1 ANAMNESE EN KLINISCH ONDERZOEK BIJ HEMATOLOGISCHE AANDOENINGEN ............................................................... 7
1.2.2 ONDERZOEK VAN CELLEN ................................................................................................................................... 8
1.2.3 BEELDVORMEND ONDERZOEK BIJ HEMATOLOGISCHE AANDOENINGEN .......................................................................10
HOOFDSTUK 2: RODE BLOEDCELLEN (ERYTROCYTEN) EN HUN ZIEKTEN ............................................................ 11
2.1 DE ERYTROCYT ...................................................................................................................................................11
2.2 RODEBLOEDCELPARAMETERS.................................................................................................................................11
2.3 FYSIOLOGIE VAN DE ERYTROCYT .............................................................................................................................11
2.4 DE ERYTROPOËSE ................................................................................................................................................11
2.5 ANEMIE OF BLOEDARMOEDE .................................................................................................................................12
2.5.1 DEFINITIE .....................................................................................................................................................12
2.5.2 EPIDEMIOLOGIE .............................................................................................................................................12
2.5.3 ANAMNESE ...................................................................................................................................................12
2.5.4 KLINISCH ONDERZOEK .....................................................................................................................................12
2.5.5 INITIËLE DIAGNOSTISCHE AANPAK VAN ANEMIE .....................................................................................................13
2.5.6 HYPOPRODUCTIEVE ANEMIE – ANEMIE DOOR GEDAALDE ERYTROPOËSE .....................................................................13
2.5.7 HEMOLYTISCHE ANEMIE: ANEMIE MET VERKORTE LEVENSDUUR VAN DE ERYTROCYT .....................................................19
2.5.8 AFWIJKENDE HEMOGLOBINES EN ZIEKTEN VAN DE HEMOGLOBINESYNTHESE ...............................................................25
2.6 POLYCYTEMIE, POLYGLOBULIE OF ERYTROCYTOSE ......................................................................................................29
2.6.1 DEFINITIE .....................................................................................................................................................29
2.6.2 OORZAKEN VAN (ECHTE) POLYGLOBULIE .............................................................................................................29
2.6.3 DIAGNOSE ....................................................................................................................................................30
2.6.4 BEHANDELING ...............................................................................................................................................30
HOOFDSTUK 3: BLOEDPLAATJES (TROMBOCYTEN) EN HUN ZIEKTEN ................................................................ 31
3.1 VORMING VAN BLOEDPLAATJES (TROMBOPOËSE) ......................................................................................................31
3.2 EIGENSCHAPPEN VAN BLOEDPLAATJES .....................................................................................................................31
3.3 TROMBOCYTOPENIE ............................................................................................................................................31
3.3.1 KLINIEK VAN TROMBOPENIE .............................................................................................................................31
3.3.2 LABORATORIUMDIAGNOSE VAN TROMBOPENIE ....................................................................................................32
3.3.3 OORZAKEN VAN TROMBOPENIE .........................................................................................................................32
3.4 TROMBOCYTOSE .................................................................................................................................................35
HOOFDSTUK 4: LEUKOCYTEN EN HUN ZIEKTEN ................................................................................................ 36
4.1 OVERZICHT VAN DE WITTE BLOEDCELLEN IN PERIFEER BLOED ........................................................................................36
4.2 GRANULOCYTEN .................................................................................................................................................36
4.2.1 LEVENSCYCLUS ..............................................................................................................................................36
4.2.2 ANALYSES VAN HET MYELOÏDE COMPARTIMENT ....................................................................................................37
4.2.3 TEKORT AAN GRANULOCYTAIRE FUNCTIE .............................................................................................................37
4.2.4 GRANULOCYTAIRE LEUKOCYTOSE .......................................................................................................................38
4.3 MONOCYTEN .....................................................................................................................................................39
4.3.1 MONOCYTOSE ...............................................................................................................................................39
4.4 HET LYMFOÏDE COMPARTIMENT .............................................................................................................................39
4.4.1 LYMFOCYTEN ................................................................................................................................................39
4.4.2 LYMFEKLIEREN, LYMFEKLIERVERGROTING EN LYMFADENOPATHIE .............................................................................41
4.4.3 PRAKTISCHE AANPAK VAN LYMFADENOPATHIE......................................................................................................42
4.4.4 DE MILT .......................................................................................................................................................43
HOOFDSTUK 5: PANCYTOPENIE EN BEENMERGFALEN ...................................................................................... 44
5.1 DEFINITIE ..........................................................................................................................................................44
5.2 BICYTOPENIE EN PANCYTOPENIE .............................................................................................................................44
5.3 CONGENITAAL BEENMERGFALEN ............................................................................................................................44
5.3.1 GATA2-DEFICIËNTIE ......................................................................................................................................44
2
, 5.3.2 DYSKERATOSIS CONGENITA ..............................................................................................................................44
5.3.3 ANEMIE VAN FANCONI ....................................................................................................................................44
5.3.4 SYNDROOM VAN SCHWACHMAN-DIAMOND ........................................................................................................44
5.3.5 ANEMIE VAN BLACKFAN-DIAMOND ...................................................................................................................44
5.4 VERWORVEN BEENMERGFALEN ..............................................................................................................................46
5.4.1 APLASTISCHE ANEMIE......................................................................................................................................46
5.4.2 PURE RED CELL APLASIE ...................................................................................................................................47
5.4.3 MYELODYSPLASTISCHE NEOPLASMEN .................................................................................................................47
5.4.4 PAROXISMALE NACHTELIJKE HEMOGLOBINURIE (PNH) ..........................................................................................49
5.4.5 OVERLAPPING EN OVERGANG TUSSEN AA, PNH EN HYPOPLASTISCHE MDS ..............................................................50
HOOFDSTUK 6: MYELOPROLIFERATIEVE NEOPLASMEN .................................................................................... 51
6.1 DE PATHOGENESE EN NORMALE CELLULAIRE TEGENHANGER VAN MYELOPROLIFERATIEVE NEOPLASMEN ................................51
6.2 CHRONISCHE MYELOÏDE LEUKEMIE..........................................................................................................................51
6.3 POLYCYTHEMIA VERA, ESSENTIËLE TROMBOCYTEMIE EN PRIMAIRE MYELOFIBROSE: DE ‘KLASSIEKE’ BCR::ABL1-NEGATIEVE
MYELOÏDE NEOPLASMEN ..................................................................................................................................................... 52
6.3.1 POLYCYTHEMIA VERA ......................................................................................................................................52
6.3.2 ESSENTIËLE TROMBOCYTEMIE ...........................................................................................................................54
6.3.3 PRIMAIRE MYELOFIBROSE ................................................................................................................................55
HOOFDSTUK 7: CHRONISCHE LYMFOCYTAIRE LEUKEMIEËN.............................................................................. 57
7.1 DEFINITIE ..........................................................................................................................................................57
7.2 CHRONISCHE LYMFOCYTAIRE LEUKEMIEËN VAN B-CELORIGINE......................................................................................57
7.2.1 CHRONISCHE LYMFATISCHE LEUKEMIE VAN B-CELORIGINE (B-CLL), MONOKLONALE B-CELLYMFOCYTOSE EN KLEINCELLIG B-
LYMFOCYTAIR LYMFOMA (SMALL LYMPHOCYTIC LYMPHOMA, SLL) ......................................................................................... 57
7.2.2 PROLYMFOCYTAIRE LEUKEMIE VAN B-CELORIGINE (B-PLL) .....................................................................................59
7.2.3 HAIRY CELL LEUKEMIA (HCL) ............................................................................................................................59
7.3 CHRONISCHE LYMFOCYTAIRE LEUKEMIEËN VAN T-/NK-CELORIGINE ..............................................................................60
7.3.1 LARGE GRANULAR LYMPHOCYTIC (LGL) LEUKEMIA ................................................................................................60
7.3.2 PROLYMFOCYTAIRE LEUKEMIE VAN T-CELORIGINE (T-PLL) .....................................................................................60
HOOFDSTUK 8: LYMFOMEN ............................................................................................................................. 61
8.1 ALGEMENE PRINCIPES VAN DIAGNOSTIEK EN BEHANDELING VAN LYMFOMEN ...................................................................61
8.1.1 DEFINITIE .....................................................................................................................................................61
8.1.2 DE NORMALE CELLULAIRE TEGENHANGERS VAN LYMFOMEN: BASIS VAN HUN INDELING ................................................61
8.1.3 PATHOGENESE ...............................................................................................................................................61
8.1.4 DIAGNOSTIEK VAN LYMFOMEN..........................................................................................................................61
8.2 DE ZIEKTE VAN HODGKIN – HODGKINLYMFOOM ........................................................................................................62
8.3 NON-HODGKINLYMFOOM (NHL) ...........................................................................................................................63
8.4 OVERZICHT NHL ................................................................................................................................................65
8.4.1 BEHANDELINGSPRINCIPES VAN NHL ..................................................................................................................67
HOOFDSTUK 9: PARAPROTEÏNE: MGUS, MYELOOM, IMMUNOCYTOOM EN VERWANTE AANDOENINGEN ....... 68
9.1 STRUCTUUR EN LABODIAGNOSTIEK VAN IMMUNOGLOBULINES .....................................................................................68
9.1.1 STRUCTUUR VAN IMMUNOGLOBULINES ..............................................................................................................68
9.1.2 LABODIAGNOSTIEK VAN ABNORMALE EIWITTEN ....................................................................................................68
9.2 NORMALE CELLULAIRE TEGENHANGER .....................................................................................................................69
9.3 MONOCLONAL GAMMOPATHY OF UNDETERMINED SIGNIFICANCE (MGUS) ....................................................................69
9.4 MULTIPLE MYELOOM ...........................................................................................................................................70
9.5 ANDERE PLASMACELAANDOENINGEN ......................................................................................................................73
9.5.1 SOLITAIR MYELOOM VAN HET BOT .....................................................................................................................73
9.5.2 LICHTEKETENAMYLOÏDOSE (AL-AMYLOÏDOSE) ......................................................................................................73
9.6 IMMUNOCYTOOM, LYMFOPLASMOCYTAIR LYMFOOM, ZIEKTE VAN WALDENSTRÖM, WALDENSTRÖMS MACROGLOBULINEMIE ..73
HOOFDSTUK 10: ACUTE LEUKEMIE ..................................................................................................................... 74
10.1 NORMALE CELLULAIRE TEGENHANGER .....................................................................................................................74
10.2 DEFINITIE EN PATHOGENESE ..................................................................................................................................74
10.3 EPIDEMIOLOGIE ..................................................................................................................................................74
10.4 KLINISCH BEELD ..................................................................................................................................................74
10.5 LABORATORIUMDIAGNOSE....................................................................................................................................75
10.5.1 PERIFEER BLOED ........................................................................................................................................75
3
, 10.5.2 BEENMERG ..............................................................................................................................................75
10.6 NATUURLIJK VERLOOP EN PROGNOSE ......................................................................................................................75
10.7 BEHANDELING ....................................................................................................................................................75
10.7.1 SUPPORTIEVE THERAPIE ..............................................................................................................................75
10.7.2 ANTILEUKEMISCHE BEHANDELING .................................................................................................................76
HOOFDSTUK 11: TRANSFUSIE EN TRANSFUSIEGENEESKUNDE ............................................................................ 78
11.1 INLEIDING..........................................................................................................................................................78
11.2 ALGEMENE PRINCIPES BIJ TRANSFUSIE VAN BLOEDCOMPONENTEN ................................................................................78
11.2.1 SELECTIE VAN DONOREN .............................................................................................................................78
11.2.2 ALGEMENE TRANSFUSIERICHTLIJN .................................................................................................................78
11.3 BLOEDCOMPONENTEN .........................................................................................................................................78
11.4 TRANSFUSIE VAN ERYTROCYTENCONCENTRAAT..........................................................................................................78
11.4.1 ERYTROCYTENCONCENTRAAT .......................................................................................................................78
11.5 TRANSFUSIE VAN BLOEDPLAATJESCONCENTRAAT .......................................................................................................80
11.6 TRANSFUSIE VAN VERS INGEVROREN VIRUSGEÏNACTIVEERD MENSELIJK PLASMA (VPVIM) .................................................80
11.7 MOGELIJKE NEVENWERKINGEN VAN TRANSFUSIE .......................................................................................................81
11.7.1 ONMIDDELLIJKE HEMOLYTISCHE TRANSFUSIEREACTIE ........................................................................................81
11.7.2 UITGESTELDE HEMOLYTISCHE TRANSFUSIEREACTIE............................................................................................81
11.7.3 TRANSFUSIEGEASSOCIEERDE CIRCULATOIRE OVERBELASTING (TACO) ..................................................................81
HOOFDSTUK 12: HEMATOPOËTISCHE STAMCELTRANSPLANTATIE EN ANDERE CELLULAIRE THERAPIEËN ........... 82
12.1 INLEIDING..........................................................................................................................................................82
12.2 HET CONCEPT VAN HEMATOPOËTISCHE STAMCELTRANSPLANTATIE ................................................................................82
12.3 DONORKEUZE BIJ HEMATOPOËTISCHE STAMCELTRANSPLANTATIE ..................................................................................82
12.4 AUTOLOGE STAMCELTRANSPLANTATIE ALS HEMATOPOËTISCHE RESCUE NA HOOGGEDOSEERDE CHEMOTHERAPIE ....................82
12.5 ALLOGENE STAMCELTRANSPLANTATIE .....................................................................................................................83
12.6 KUNNEN WE ONS IMMUUNSYSTEEM BETER WAPENEN IN DE STRIJD TEGEN MALIGNE AANDOENINGEN ..................................84
4
,Hoofdstuk 1: Het hematopoëtische stelsel en zijn onderzoek
1.1 Bloed en hematopoëse
1.1.1 Bloed
1.1.1.1 Rode bloedcellen of erythrocyten
Normoblast Reticulocyt Erytrocyt
DNA + - -
RNA + + -
Diameter (µm) 10-15 8-12 6-8
In beenmerg + + +
In perifeer bloed Erg zelden + +
a) Erytrocyt: biconcaaf, kernloos, grote fractie in perifeer bloed à = matuur
Bevat hemoglobine:
- Tetrameer waarvan elke keten een heemkern (hier bindt O2)
- Heemkern: protoporfyrine + Fe2+ (loodintoxicatie verhindert vorming protoporfyrines)
- Volwassenen HbA: α2β2
- Foetus HbF: α2γ2
b) Reticulocyt: kernloos, wel RNA (aantonen met kleuring à reticulair patroon), kleine fractie in
perifeer bloed
c) Normoblast: kern, sterk basofiel cytoplasma, wel RNA, enkel in beenmerg
1.1.1.2 Witte bloedcellen of leukocyten
Aantal
Diameter Verblijf in
Celtype Afbeelding (x % Functie
(µm) bloedbaan
109/L)
Granulocyten
Antibacterieel en
1) Neutrofiel 12-15 6-10 u 4-10 38-77
antifungaal
2) Eosinofiel 12-15 Enkele dagen ≤ 0,4 ≤ 6.0 Antihelmintisch
3) Basofiel 12-15 Enkele dagen ≤ 0,1 ≤ 1.0 Mestcelvoorloper
5
, Lymfocyten 1,2-3,6 20-50
Celgemedieerde
immuniteit
1) T-lymfocyten 7-9 Jaren
(tegen virussen
en tumorcellen)
Humorale
2) B-lymfocyten 7-9 Jaren immuniteit
(antistoffen)
Bescherming
3) Natural killer
10-20 Dagen tegen virussen en
cellen
kanker
Fagocyten,
Monocyten 12-20 1-2 d 0.2-0.8 2-10 voorloper
macrofagen
1) Granulocyten: korrelig granulair cytoplasma à kan neutrofiel, eosinofiel of basofiel
aankleuren
a. Neutrofielen: grootste fractie, korte verblijfsduur, dus constante granulopoëse
b. Eosinofielen: veel kleinere fractie
c. Basofielen: veel kleinere fractie
à innate immunity: tegen bacteriën, fungi en parasieten
2) Lymfocyten en de perifere lymfeklieren: 2de grootste fractie na neutrofielen, dense ronde kern,
dun randje cytoplasma, obv monoklonale Ab onderscheid tussen:
a. B-lymfocyten
b. T-lymfocyten
c. Natural killer-cellen
à verworven antigeenspecifieke immuniteit: aanmaak in lymfeklieren en milt
3) Monocyten en het reticulo-endotheliale systeem: kleine fractie, verlaten snel perifere bloed
naar de perifere weefsels
Ontwikkelen tot: fagocyten of gespecialiseerde cellen zoals mesangiale cellen nier, microglia
hersenen, alveolaire macrofagen long, Küpffercellen lever, dendritische cellen (APC’s)
à innate immunity: tegen bacteriën en fungi
1.1.1.3 Bloedplaatjes of trombocyten
Afbeelding Diameter (µm) Verblijf in Aantal Functie
bloedbaan (x 109/L)
Bloedplaatjes
Bloedstelping
0.5-3 10 dagen 150-350
(1ste fase)
Trombocyten: cytoplasma basofiel en granulair, kernloos
6
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