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Haemopoiesis e the
formation of blood cells

Whats new?

Ted Gordon-Smith


After birth and throughout life haemopoiesis takes place in the bone
marrow. In the early embryo, blood cells, mainly erythrocytes, arise
from blood islands in the yolk sac before more varied cells, including
lymphoid and myeloid stem cells and precursors, are derived from the
aorto-gonad-mesonephron of the para-aortic splanchnopleure. Fetal haemopoiesis occurs mainly in the liver. The haemopoietic stem cell (HSC) is
the pluripotent progenitor cell from which the cells of the blood and
lymphoid systems are ultimately derived. They are capable of selfrenewal as well as proliferation and differentiation. Their proper function
depends on the microenvironment of the haemopoietic organ in which
they develop e the haemopoietic niche. They can migrate to and circulate
in the blood, and home into and repopulate the bone marrow. HSCs give
rise to lymphoid and myeloid precursors. The myeloid precursors differentiate further into the erythrocyte, granulocyte and thrombocyte lineages
that deliver red cells, granulocytes, monocytes and platelets to the circulation. Cell production is tightly controlled through cytokine and humoral
loops and can be increased rapidly in response to demand.

The BM microenvironment1
Haemopoiesis occurs within the microenvironment of the BM
which is composed of cells including mesenchymal stem cells
(MSCs), macrophages, fibroblasts and fat cells, a matrix of
collagen and reticulin fibres, and a variety of extracellular matrix
proteins.2 This complex constitutes the stem cell niche. Bone
turnover, particularly osteoblastic activity, is closely linked to
HSC pathways. Within the active marrow, haemopoiesis is
carefully structured, with the HSCs and early proliferating cells
being located in the paratrabecular part of the marrow space. It is
in this region that the osteoblastic niches essential for quiescent
stem cell function are found.3,4 The relationship between HSC
proliferation and the heterogeneous population of MSCs seems to
be crucial in the control of haemopoiesis.5 Proliferation and
differentiation of blood cell precursors occurs in an orderly
distribution in the marrow so that mature cells can be released
from the extravascular marrow into sinusoids and hence to the
circulation. The control is exercised through a complex of cytokines and growth factors, both humoral and locally produced in
the marrow. Receptors to specific ligands are expressed at
different stages of haemopoiesis; delivery is to a considerable
extent controlled by the microenvironment. A particular pathway
for mobilization involves the CXCL12/CXCR4 ligand receptor
axis. Inhibition of binding of CXCR4 to CXCL12 by drugs such as
plerixafor may increase mobilization of HSCs from BM to
peripheral blood in patients who do not mobilize adequately with
granulocyte colony-stimulating factor (G-CSF) alone, an important observation for mobilizing stem cells for autologous stem
cell transplantation.6

Keywords differentiation; erythropoiesis; granulopoiesis; haemopoiesis;

pluripotent; stem cells; thrombopoiesis

In postnatal life the production of circulating blood cells occurs in

the bone marrow (BM), in the honeycomb spaces of trabecular
bone. In the infant and growing child, haemopoiesis takes place
in all bones of the skeleton. In adults, blood cell production is
confined mainly to the axial skeleton, the skull, vertebrae,
sternum, ribs, scapulae and pelvis. Bone marrow for diagnostic
purposes is usually taken from the posterior iliac crest, although
the sternum is sometimes used for aspirates. In infants and
young children the tibia is preferred. In the child, haemopoietic
tissue occupies most of the BM space whereas in the adult only
about 30% of the active marrow sites are haemopoietic, the
remainder being fat cells (Figure 1). In the inactive (yellow)
marrow all the space is apparently occupied by fat cells. Under
conditions of increased demand, for example chronic haemolytic
anaemias, the adult capacity may be increased up to sixfold both
by increasing the cellularity of haemopoietic tissue and repopulating the yellow marrow. In myeloproliferative disorders haemopoiesis reappears in the liver and spleen e extra-medullary

Ted Gordon-Smith MA FRCP FRCP(Ed) FRCPath FAcadMedSci is Emeritus

Professor of Haematology and Honorary Consultant Physician at
St Georges Hospital Medical School, London, UK. Competing
interests: none declared.


Lifelong, controlled haemopoiesis depends on the interrelationships between the haemopoietic stem cell (HSC) and the
stem cell niche within the bone marrow (BM).
Haemopoiesis is initiated in the endosteal domains of the BM
where the niche concentration is high. The niche is also found
in the sinusoidal regions of the BM.
A number of cells are important for control of haemopoiesis
within the niche including osteoblasts, mesenchymal stem cells
(MSC), macrophages, and possibly megakaryocytes.
HSCs within the endosteal niche have mainly anaerobic respiration in hypoxic conditions. They actively traffic through the
BM, acquire respiratory respiration, may leave the sinusoids to
enter the systemic circulation and re-enter the BM through
sinusoids to occupy an existing niche or previously quiescent
The factors which determine HSC /niche relationships and HSC
trafficking are gradually becoming apparent and offer therapeutic opportunities for HSC mobilization and possibly control
of malignant haemopoiesis.

Haemopoietic stem cell

The HSC is the pluripotent progenitor of the cells of the haemopoietic and lymphopoietic systems. Stem cells depend on the


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received. From the CMP comes the megakaryocyteeerythroid

precursor (MEP), from which separate platelet and red cell differentiation occurs, and the granulocyteemonocyte precursor
(GMP), from which monocyteemacrophage and granulocytic
lineages descend. The lineage-committed cells include the
morphologically recognizable precursors of haemopoiesis seen in
BM preparations (Figure 2). The proliferative capacity of the haemopoietic system far outstrips normal requirements. Apoptosis
(programmed cell death) plays an important part in the homeostatic mechanisms of haemopoiesis. Apoptosis is initiated by
absence of specific cytokines, including erythropoietin (Epo) for
red cells and G-CSF for granulocytes; upregulation of antiapoptotic cytokines leads to rapid increase in mature cell

Normal adult marrow


Fat cell

Granulocyte/monocyte production
Myeloid and lymphoid developments derive from the common
MPP. Subsequent differentiation along the myeloid pathway is
controlled by a series of transcription factors that are induced
by a number of growth factors and cytokines.10 The relationship between specific cell lineages and various cytokines has
been elucidated by in vitro colony assays. Granulocytee
macrophage colony-stimulating factor (GM-CSF) increases
colony formation of all monocyte and granulocyte preparations. G-CSF and its receptor GCSFR act mainly on the
production of neutrophils rather than eosinophils and basophils, whilst monocyte CSF (M-CSF) upregulates monocyte
production. An equally important action of these cytokines is to
activate mature circulating cells when binding to their ligands.
The GCSFR plays an important role in systems other than
neutrophil production, including neutrophil activation and
tissue repair.11 The cytokines that increase granulocyte
production are produced by cells at the site of infection and
inflammation, including macrophages.

Trephine biopsy from posterior superior iliac crest. Giemsa stain.

Note haemopoietic tissue represents < 50% marrow space.

Figure 1

microenvironment niche for their function. In the niche the HSCs

may be in a quiescent phase until cytokines and other signals
switch them to an active phase, from which they may produce
daughter cells capable of developing into lineage-specific
precursors or of returning to the quiescent phase. The ability to
traffic throughout the body is a characteristic of HSCs.7 Small
numbers may be found in the peripheral blood of normal adults.
Numbers are greatly increased by certain cytokines, including GCSF, and during regeneration of marrow following chemotherapy. This property has led to mobilized peripheral blood
HSCs being preferred to BM HSCs in most transplant procedures
because collection of adequate numbers of HSCs is simpler by
this route. Proportionally greater numbers of HSCs are found in
the umbilical cord blood, a discovery that has led to their use for
stem cell transplantation8 (see MEDICINE 2013; 41(5)). HSCs are
identified in mice by their ability to repopulate the BM from
a single or very few cells. In humans the identification depends
on the immunophenotype of colony-forming cells that most
nearly equate to the mouse stem cell.9 The immunophenotype
has both positive (CD34) and negative (lin, CD33, CD38)
characteristics, although there are probably more primitive HSCs
even than this phenotype. As the progeny of the HSC enter the
proliferation and differentiation pathways, so the immunophenotype matures (Figure 2).

Monocytes make up a small part of the BM cellularity. Monocytes
give rise to macrophages. These cells are long-lived, and tissue
macrophages, including Kupffer cells in the liver and alveolar
macrophages, are capable of some division in the tissues so the
turnover is small. In response to cytokines released at sites of
infection, circulating monocytes migrate to the site and mature
into macrophages, which are potent phagocytes in the innate
immune system.
Granulocyte lineages arise from a granulocyte precursor. All
have ligands for GM-CSF.
Eosinophil differentiation depends on the interleukins IL-3
and IL-5.
Neutrophil differentiation requires G-CSF amongst other
ligands. The recognizable myeloid precursors in the BM progress
from the myeloblast through the promyelocyte and myelocyte
stages, where proliferation continues, to the metamyelocyte and
neutrophil, in which final maturation occurs. Neutrophil
precursors are the most numerous nucleated cells in the normal
marrow. The total myeloid:erythroid ratio in the normal BM is
3.1 (range 2.0e8.3).

Proliferation and differentiation

The initial step in differentiation is the multipotent progenitor cell
(MPP), which does not express lineage-specific antigens (lin) but
gives rise to both common myeloid (CMP, CD33, CD38) and
common lymphoid (CLP, CD38, CD10) precursors, which in
turn give rise to specific lineages,10 again depending on signals



2013 Elsevier Ltd. All rights reserved.


Scheme of haemopoiesis
Microenvironment niche
CD34+,CD90+,CD38-,CD33-, linHSCa









CD34+, CD90-CD38-,CD33-, lin-














Dendritic cells






HSC, haemopoietic stem cell; q, quiescent; a, active. Progenitor cells: MPP, multipotent progenitor; CMP, common myeloid progenitor; CLP, common lymphoid
progenitor; MEP, megakaryocyteeythroid progenitor; GMP, granulocytemonocyte progenitor. Lymphoid progenitors: Pro DC dendritic cell, Pro T, NK, B cells.
Some of the surface markers of the differential stages are shown alongside.

Figure 2

Platelet production

for the formation of platelets in the megakaryocyte. It has

considerable homology with erythropoietin (Epo), which also
has some effect on platelet production.

Platelets are derived from mature megakaryocytes. Various

growth factors and cytokines, including thrombopoietin (TPO)
and IL-6, are necessary for the proper maturation of megakaryocytes from the MEP. TPO is produced in the liver and to lesser
extent the kidneys; circulating concentrations are controlled by
platelet numbers. It is also an important growth factor for more
primitive HSCs. The receptor for TPO is Mpl. Agonists for the
TPO receptor, for example eltrombopag and romiplostim, stimulate platelet production and are important additions to the
therapeutic options for the treatment of thrombocytopenia,12
including aplastic anaemia.13 IL-6 is an acute-phase protein
that in part causes the thrombocytosis that accompanies
inflammation. Up to the megakaryoblast phase the precursors
divide and multiply as they progress towards maturity. In the
later stages, DNA replication occurs without cell division so the
cell becomes polyploid (up to 64 N) and very large with abundant cytoplasm, in which mature platelets form, to be subsequently released into the circulation. TPO is the main stimulus


Erythropoiesis often takes place around a macrophage, a so-called
nurse cell, which may be important in regulation, perhaps by
control of cytokines and growth factors.14 The early stages
committed to red cell production are identified by their ability to
form erythrocyte colonies in vitro. Erythroid burst-forming units
(BFUE) give rise to erythroid colony-forming units (CFU-E). The
latter are dependent on Epo for continued viability and progression to the proerythroblast stage, the first morphologically
recognizable erythroid cell type. Epo is produced by peritubular
interstitial cells of the kidney and, to lesser extent, hepatocytes.
The gene for Epo is upregulated by hypoxia-inducible factor 1
(HIF1), an important more general regulator of response to
hypoxia9 (Figure 3). Further proliferation occurs through the
basophilic and early polychromatophilic erythroblast stages. Only


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4 Taichman RS. Blood and bone: two tissues whose fates are intertwined to create the hematopoietic stem-cell niche. Blood 2005; 105:
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osteoblasts directly modulates erythropoiesis through the production of EPO. Cell 2012; 149: 63e74.
6 Martin C, Bridger GJ, Rankin SM. Structural analogues of AMD3100
mobilise haematopoietic progenitor cells from bone marrow in vivo
according to their ability to inhibit CXCL12 binding to CXCR4 in vitro.
Br J Haematol 2006; 134: 326e9.
7 Laird DJ, von Andrian UH, Wagers AJ. Stem cell trafficking in tissue
development, growth, and disease. Cell 2008; 132: 612e30.
8 Broxmeyer HE, Srour EF, Hangoc G, Cooper S, Anderson SA,
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10 Friedman AD. Transcriptional control of granulocyte and monocyte
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11 Liongue C, Wright C, Russell AP, Ward AC. Granulocyte colonystimulating factor receptor: stimulating granulopoiesis and much
more. Int J Biochem Cell Biol 2009; 41: 2372e5.
12 Imbach P, Crowther M. Thrombopoietin-receptor agonists for primary
immune thrombocytopenia. New Engl J Med 2011; 365: 734e41.
13 Olnes MJ, Scheinberg P, Calvo KR, et al. Eltrombopag and improved
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Erythropoietin production and control of

haemoglobin content
Hb synthesis

Epo responsive
cell compartment



CA ml/L
Red cell
Hb content g/dl

Arterial pO2

pO2 inspired air

Alveolar pO2


Lung function

Epo, erythropoietin; HIF1, hypoxia inducible factor 1; CA, arterial O2 content.

Figure 3

maturation occurs through late polychromatophilic erythroblasts,

normoblasts, the nucleated red blood cells (NRBC). In the final
stage before the reticulocyte, the red cell nucleus is extruded.
There may be an important interrelationship between early
differentiation to erythropoiesis at the HSC stage between red cell
demand, HIF and Epo produced by osteoblasts, highlighting the
close relationship between bone and haemopoiesis.5

Escape to the circulation

The main border between the haemopoietic marrow and the
circulation is the endothelial cell layer and partial adventitial
layer of the BM sinusoids. Capillaries from the medullary arterioles flow in to the sinusoids. Blood leaves by post-sinusoidal
capillary venules to the periosteal veins. Mature cells need to
be deformable enough to enter the post-sinusoidal capillaries
through the adventitial and enthothelial layer. Extrusion of the
red cell nucleus occurs before the reticulocyte enters the sinusoid. Megakaryocyte nuclei do enter the circulation and are taken
up by lung macrophages. Under conditions of increased demand
for blood cells the adventitial cells move apart and less deformable cells, including NRBC, myelocytes and even megakaryocytes, enter the circulation. Neutrophil release to the circulation
is controlled by the CXCL12/CXCR4 binding. Inhibition of the
binding accelerates release neutrophils, mutations that increase
the activation binding, prevent release and lead to


Practice points


Haemopoiesis is dependent on the microenvironment of the

bone marrow, including mesenchymal stem cells and
Mobilization of stem cells in to the blood by cytokines such as
granulocyte colony-stimulating factor and inhibitors of the
CXCL12/CXCR4 association (perixafor) provides an important
source of haemopoietic stem cells for transplantation, in
addition to bone marrow and umbilical cord stem cells
New agonists of the thrombopoietin receptor (Mpl) are useful
additions to the management of thrombocytopenias

2013 Elsevier Ltd. All rights reserved.