haematology reference intervals for established and · pdf filehaematology reference intervals...

Both clinical evaluation and monitoring critically depend on knowledge of laboratory reference ranges. With the continuing development of the automated blood count, studies often restrict themselves to standard, time-honoured parameters, limiting the spread of innovation. Here, we present reference interval for a state-of-the-art haema-tology analyser, the Sysmex XE-5000, including a variety of parameters introduced only recently and some for which clinical application is currently under investigation. Blood samples were taken from 176 female and 133 male apparently healthy hospital employees and a broad spectrum of parameters available with the software installed assessed.

1) Reinier de Graaf Zieken- huis, Delft, Netherlands2) Sysmex Europe, Norderstedt, Germany3) Erasmus Medisch Centrum, Rotterdam, Netherlands

Haematology reference intervals for established and novel parameters in healthy adults

J. M. Pekelharing 1, O. Hauss 2, R. de Jonge 3, J. Lokhoff 1, J. Sodikromo 1, M. Spaans 1, R. Brouwer 3, S. de Lathouder 3, R. Hinzmann 2

Diagnostic Perspectives | Volume 1 | page 01 – 11


Introduction

Since the first automated cell counters have been introduced in the haematology laboratory some decades ago, the flow cytometry and aperture technology have steadily been further developed and refined. The first generation of analysers counted only the number of red cells pre-sent in blood, while subsequent models were also able to quantify the white blood cells and the platelets. During the seventies and eighties the ‘three-part WBC differential’ was introduced, later followed by the ‘five-part differential’ which provides the absolute and relative number of leukocyte subsets: the neu-trophilic granulocytes, lymphocytes, monocytes, eosinophils and basophils, next to the number of platelets and erythrocytes 1, 2.

The recently introduced Sysmex XE-5000 analyser has the latest analytical inno-vations on board and is able to quantify 78 parameters in a blood sample of 130 µL in manual mode (or in 40 µL when in capillary mode) in only one minute (manufacturer specifications). It also measures 12 parameters of cells in other body fluids than blood, such as cere-brospinal fluid, peritoneal fluid, ascites and synovial fluid, but that was not a part of this study.

The Sysmex XE-5000 uses laser light to measure on a cell-by-cell basis the side scatter, forward scatter and side fluores-cence light. Additionally, impedance-based counts are performed for RBC and platelet counts. Further counts and measurements use radio frequency and direct current methods and haemoglo-bin colourimetry. Compared to previous generations, the XE-5000 software is able to quantify a number of new para-meters.

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02Diagnostic Perspectives | Volume 1 | page 01 – 11


Blood parameters included in this study

1 WBC – white blood cell concentration

2 RBC – red blood cell concentration

3 HgB – haemoglobin concentration

4 HCt – haematocrit

5 MCV – mean corpuscular volume

6 MCH – mean corpuscular haemoglobin

7 MCHC – mean corpuscular haemoglobin concentration

8 PLt – platelet concentration

9 RDW-SD – RBC distribution width, standard deviation

10 RDW-CV – RBC distribution width, coefficient of variation

11 PDW – platelet distribution width

12 MPV – mean platelet volume

13 P-LCR – platelet-large cell ratio

14 PCt – platelet crit

15 Neut % – percentage of neutrophils

16 Neut # – neutrophil concentration

17 LyMPH % – percentage of lymphocytes

18 LyMPH # – lymphocyte concentration

19 MoNo % – percentage of monocytes

20 MoNo # – monocyte concentration

21 eo % – percentage of eosinophils

22 eo # – eosinophil concentration

23 BaSo % – percentage of basophils

24 BaSo # – basophil concentration

25 Ig % – percentage of immature granulocytes

26 Ig # – immature granulocyte concentration

27 HFLC % – percentage of highly fluorescent lymphocytic cells

28 HFLC # – highly fluorescent lymphocytic cell concentration

29 NRBC % – percentage of nucleated red blood cells

30 NRBC # – nucleated red blood cell concentration

31 Ret% – percentage of reticulocytes

32 Ret# – reticulocyte concentration

33 HFR – percentage of high-fluorescence reticulocytes

34 MFR – percentage of medium-fluorescence reticulocytes

35 LFR – percentage of low fluorescence reticulocytes

36 IRF – immature reticulocyte fraction

37 Ret-He – reticulocyte haemoglobin content

38 WBC-B – WBC from WBC/BASO channel

39 WBC-D – WBC from DIFF channel

40 PLt-o – fluorescence optical platelet concentration

41 PLt-I – impedance platelet concentration

42 IPF % – immature platelet fraction

43 MicroR – percentage of microcytic red blood cells

44 MacroR – percentage of macrocytic red blood cells

45 Neut-X – average side scatter of neutrophils (granularity)

46 RBC-He – mean RBC haemoglobin content from optical RBC count

47 Delta-He – RET-He minus RBC-He

48 FRC % – percentage of fragmented red cells (schistocytes)

49 FRC # – fragmented red cell concentration

50 RPI – reticulocyte production index

51 H-IPF – highly fluorescent IPF

52 IPF # – immature platelet concentration

53 PLt-X – average platelet fluorescence

54 % HyPo-He – percentage of hypo-haemoglobinised red cells

55 % HyPeR-He – percentage of hyper-haemoglobinised red cells

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Before conducting clinical studies to determine the value of each of the new parameters in medical practice, it is im-perative to know in detail what values can be found in the healthy general po-pulation. It was the purpose of this study to determine the exact reference inter-vals for all parameters that are measured by the XE-5000 analyser, including novel parameters not included in the initial release.

The fact that different institutes have established different reference intervals finds its origin in a number of variables, including preanalytical conditions. Most importantly, however, there are diffe-rences in the selection of the reference populations that are used by each insti-tute. For instance, some calculate the reference intervals from a large number of patients who visit the clinics.

Others use a double selection by using for instance, only samples from the eye disease clinics, reasoning that few patients with haematological diseases will be found in this category.

Others use volunteers from the hospital or laboratory staff, while some refine this strategy by paying attention to the age of the volunteer. In short, all these selec-tions will create different reference inter-vals, although the differences are some-times quite small 3–5.

Blood parameters not included in this study

1 NRBC + W – sum of NRBC and WBC

2 RBC-o – optical RBC count

3 Neut-y – average neutrophil fluorescence

4 area % – percentage of haematopoietic progenitor cells

5 area # – haematopoietic progenitor cell concentration

6 IMI # – immature WBC concentration

7 Ret-y – average reticulocyte forward scatter

8 RBC-y – average RBC forward scatter

9 IRF-y – average IRF forward scatter

10 HPC # – haematopoietic progenitor cell concentration

11 Neut % & – NEuT% minus IG%

12 Neut # & – NEuT# minus IG

13 LyMPH % & – LymPH% minus HFLC%

14 LyMPH # & – LymPH# minus HFLC#

Table 1 List of parameters on XE-5000 with brief explanation

We decided to recruit our reference population from the hospital employees after the launch of a publicity campaign, and to exclude some samples on the basis of clearly aberrant results.

Materials and methods

Blood samples for this reference study were collected from employees of the hospital. On three separate days blood was obtained from a total of 176 female and 133 male subjects, 16–63 years of age, apparently healthy employees. Employ-ees were encouraged to donate blood by means of a publicity campaign on the hospital intranet and by information leaflets distributed throughout the hos-pital. Donation was anonymous; however, a small questionnaire had to be filled in. Age, gender, use of multivitamins and the use of drugs, including hormonal contra-ceptives etc. had to be reported. A veni-puncture was performed by qualified personnel. EDTA (7.2 mg K2-EDTA 4 mL, BD Vacutainer, BD, Plymouth, UK) tubes were used for the measurement of hae-mocytometry, serum gel tubes (SST II gel 8.5 mL, BD Vacutainer) were used for additional tests. Tubes were sent to the laboratory for further processing and measurement throughout the day. All measurements were performed the same day, within 2h of venesection.



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All haemocytometry parameters available on XE-5000 (Sysmex, Kobe, Japan) with the software version installed at the time (version 00-04) were measured in closed mode in EDTA tubes. Ferritin, LDH and total-bilirubin were measured in serum on an Architect 8000 (Abbott, North Chicago IL, USA). These were measured to exclude possible pathological samples.

After exclusion of subjects considered non-healthy, samples from 133 male sub-jects and 176 female subjects remained. Reasons for exclusions were abnormal ferritin (< 15 or > 300 µg for males, < 15 or > 150 µg for females), an abnormal WBC DIFF, declaration of having hay fever (1 subject), folic acid deficiency (1 sub-ject), abnormal lactate dehydrogenase (2 subjects), declared use of non-stero-idal anti-inflammatory drugs (NSAIDs) (1 subject), declared use of antibiotics (2 subjects), abnormal bilirubin (1 sub-ject), declared recent infectious disease (1 subject), an abnormal ESR (3 subjects) and declaration of having a hereditary coagulation disorder (1 subject).

The reference intervals were determined as 95% confidence intervals of the popu-lation, by striking the top and bottom 2.5% of samples for each parameter, that is the top and bottom 3 samples for men (2.5% of 133), 4 samples for women (2.5% of 176) and 8 samples overall (2.5% of 309). The intervals for male and female subjects were compared using the Mann-Whitney-U-test and the Analyse-It soft-ware (Analyse-It software Ltd, Leeds, UK) for Microsoft Excel. p-values of 0.05 or lower were considered significant.

For the distribution curves, the intervals were divided into 10 equal classes, with the exception of HFLC, due to an interval too narrow for a meaningful division into 10 classes. The results were then distributed over these classes and the results plotted for men, women, and where no statistically significant differ-ence was found, for the overall population.

Results

The reference intervals determined are compiled in table 2. Reference intervals are listed separately for men and women where a statistically significant (p ≤ 0.05) difference between the intervals was found, otherwise, the interval was calcu-lated over all samples. Table 2 lists these reference intervals and demonstrates the statistically significance – or lack there-of – of differences in reference intervals for male and female samples. Figure 1, 2 and 3 illustrate the distribution of several new WBC, RBC and platelet parameters.

Discussion

While previous studies on reference intervals in haematology do, of course, exist, including for Sysmex X-Class ana-lysers 6, most focus on the standard set of parameters available from most suppliers. Here, for the first time, we report reference intervals for most of the full range of diagnostic parameters on the new XE-5000, including para-meters unique to Sysmex X-Class instru-ments 7, 8. Additionally, we provide inter-vals for some research parameters for which literature exists which suggests clinical usefulness 9.



0

10

20

30

40

50

0.090.080.070.060.050.040.030.020.010

IG#% of reference population

IG# [10 ]

malefemaleoverall

0

10

20

30

40

50

60

70

1.4-

1.5

1.2-

1.3

1.0-

1.1

0.8-

0.9

0.6-

0.7

0.4-

0.5

0.2-

0.3

0-

0.1

IG%% of reference population

IG% [%]

malefemaleoverall

0

10

20

30

40

50

60

0.050.040.030.020.010

HFLC#% of reference population

HFLC# [10 /l]

malefemale

0

5

10

15

20

25

30

35

0.80.70.60.50.40.30.20.10

HFLC%% of reference population

HFLC% [%]

malefemaleoverall

0

5

10

15

20

25

30

35

40

498-

540

455-

497

412-

454

369-

411

326-

368

283-

325

240-

282

197-

239

154-

196

111-

153

PLT-O% of reference population

PLT-O [10 /l]

malefemale

0

5

10

15

20

25

30

35

40

45

2.625-

2.708

2.541-

2.624

2.457-

2.54

2.373-

2.456

2.289-

2.372

2.205-

2.288

2.121-

2.204

2.037-

2.120

1.953-

2.036

1.869-

1.952

RET-He% of reference population

RET-He [fmol]

malefemaleoverall

Figure 1 Distribution curves for selected WBC parameters. Individual distribution curves are given for male and female subjects as well as the overall distribution in the absence of a significant difference. (a) The absolute immature granulocyte (IG) count; (b) the IG percentage of all WBCs; (c) the percentage of highly fluorescent lymphocytic cells (HFLC); (d) NEUT-X, the average side scatter of the neutrophils, i.e. the x-axis projection of the centre of the neutrophil ‘cloud’ in the scattergram, given in channel units of the instrument (ch: channel number).

0

10

20

30

40

50

0.090.080.070.060.050.040.030.020.010


IG# [10 ]

malefemaleoverall

0

10

20

30

40

50

60

70

1.4-

1.5

1.2-

1.3

1.0-

1.1

0.8-

0.9

0.6-

0.7

0.4-

0.5

0.2-

0.3

0-

0.1


IG% [%]

malefemaleoverall

0

10

20

30

40

50

60

0.050.040.030.020.010


HFLC# [10 /l]

malefemale

0

5

10

15

20

25

30

35

0.80.70.60.50.40.30.20.10


HFLC% [%]

malefemaleoverall

0

5

10

15

20

25

30

35

40

498-

540

455-

497

412-

454

369-

411

326-

368

283-

325

240-

282

197-

239

154-

196

111-

153


PLT-O [10 /l]

malefemale

0

5

10

15

20

25

30

35

40

45

2.625-

2.708

2.541-

2.624

2.457-

2.54

2.373-

2.456

2.289-

2.372

2.205-

2.288

2.121-

2.204

2.037-

2.120

1.953-

2.036

1.869-

1.952


RET-He [fmol]

malefemaleoverall

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0

10

20

30

40

50

0.090.080.070.060.050.040.030.020.010


IG# [10 ]

malefemaleoverall

0

10

20

30

40

50

60

70

1.4-

1.5

1.2-

1.3

1.0-

1.1

0.8-

0.9

0.6-

0.7

0.4-

0.5

0.2-

0.3

0-

0.1


IG% [%]

malefemaleoverall

0

10

20

30

40

50

60

0.050.040.030.020.010


HFLC# [10 /l]

malefemale

0

5

10

15

20

25

30

35

0.80.70.60.50.40.30.20.10


HFLC% [%]

malefemaleoverall

0

5

10

15

20

25

30

35

40

498-

540

455-

497

412-

454

369-

411

326-

368

283-

325

240-

282

197-

239

154-

196

111-

153


PLT-O [10 /l]

malefemale

0

5

10

15

20

25

30

35

40

45

2.625-

2.708

2.541-

2.624

2.457-

2.54

2.373-

2.456

2.289-

2.372

2.205-

2.288

2.121-

2.204

2.037-

2.120

1.953-

2.036

1.869-

1.952


RET-He [fmol]

malefemaleoverall

0

5

10

15

20

25

138.5-

139.8

137.1-

138.4

135.7-

137.0

134.3-

135.6

132.9-

134.2

131.5-

132.8

130.1-

131.4

128.7-

130.0

127.3-

128.6

125.9-

127.2

NEUT-X% of reference population

NEUT-X [ch]

malefemaleoverall

0

10

20

30

40

50

60

1.31.21.11.00.90.80.70.60.50.40.30.20.1

%HYPO-He% of reference population

%HYPO-He [%]

malefemale

0

5

10

15

20

25

30

35

40

1.61.51.41.31.21.11.00.90.80.70.6

%HYPER-He% of reference population

%HYPER-He [%]

malefemale

0

10

20

30

40

50

4.7-

5.1

4.2-

4.6

3.7-

4.1

3.2-

3.6

2.7-

3.1

2.2-

2.6

1.7-

2.1

1.2-

1.6

0.7-

1.1

0.2-

0.6

MicroR% of reference population

MicroR [%]

malefemale

0

5

10

15

20

25

30

35

40

45

14.9-

15.9

13.8-

14.8

12.7-

13.7

11.6-

12.6

10.5-

11.5

9.4-

10.4

8.3-

9.3

7.2-

8.2

6.1-

7.1

5.0-

6.0

MacroR% of reference population

MacroR [%]

malefemaleoverall

0

10

20

30

40

50

0.090.080.070.060.050.040.030.020.010


IG# [10 ]

malefemaleoverall

0

10

20

30

40

50

60

70

1.4-

1.5

1.2-

1.3

1.0-

1.1

0.8-

0.9

0.6-

0.7

0.4-

0.5

0.2-

0.3

0-

0.1


IG% [%]

malefemaleoverall

0

10

20

30

40

50

60

0.050.040.030.020.010


HFLC# [10 /l]

malefemale

0

5

10

15

20

25

30

35

0.80.70.60.50.40.30.20.10


HFLC% [%]

malefemaleoverall

0

5

10

15

20

25

30

35

40

498-

540

455-

497

412-

454

369-

411

326-

368

283-

325

240-

282

197-

239

154-

196

111-

153


PLT-O [10 /l]

malefemale

0

5

10

15

20

25

30

35

40

45

2.625-

2.708

2.541-

2.624

2.457-

2.54

2.373-

2.456

2.289-

2.372

2.205-

2.288

2.121-

2.204

2.037-

2.120

1.953-

2.036

1.869-

1.952


RET-He [fmol]

malefemaleoverall

0

5

10

15

20

25

30

35

40

521-

554

487-

520

453-

486

419-

452

385-

418

351-

384

317-

350

283-

316

249-

282

215-

248

Delta-He% of reference population

Delta-He [amol]

malefemaleoverall

0

5

10

15

20

25

30

35

2.099-

2.158

2.039-

2.098

1.979-

2.038

1.919-

1.978

1.859-

1.918

1.799-

1.858

1.739-

1.798

1.679-

1.738

1.619-

1.678

1.559-

1.618

RBC-He% of reference population

RBC-He [fmol]

malefemaleoverall

0

5

10

15

20

25

30

35

40

1.6-

1.7

1.4-

1.5

1.2-

1.3

1.0-

1.1

0.8-

0.9

0.6-

0.7

0.4-

0.5

0.2-

0.3

RPI% of reference population

RPI

malefemale

0

10

20

30

40

50

60

70

80

90

15.3-

16.9

13.6-

15.2

11.9-

13.5

10.2-

11.8

8.5-

10.1

6.8-

8.4

5.1-

6.7

3.4-

5.0

1.7-

3.3

0-

1.6

FRC#% of reference population

FRC# [10 /l]

malefemale

0

10

20

30

40

50

60

70

80

90

0.37-

0.40

0.33-

0.36

0.29-

0.32

0.25-

0.28

0.21-

0.24

0.17-

0.20

0.13-

0.16

0.09-

0.12

0.05-

0.08

0-

0.04

FRC%% of reference population

FRC% [%]

malefemale

0

5

10

15

20

25

30

35

6.9-

7.5

6.2-

6.8

5.5-

6.1

4.8-

5.4

4.1-

4.7

3.4-

4.0

2.7-

3.3

2.0-

2.6

1.3-

1.9

0.5-

1.2

IPF%% of reference population

IPF% [%]

malefemale

0

5

10

15

20

25

30

35

40

521-

554

487-

520

453-

486

419-

452

385-

418

351-

384

317-

350

283-

316

249-

282

215-

248


Delta-He [amol]

malefemaleoverall

0

5

10

15

20

25

30

35

2.099-

2.158

2.039-

2.098

1.979-

2.038

1.919-

1.978

1.859-

1.918

1.799-

1.858

1.739-

1.798

1.679-

1.738

1.619-

1.678

1.559-

1.618


RBC-He [fmol]

malefemaleoverall

0

5

10

15

20

25

30

35

40

1.6-

1.7

1.4-

1.5

1.2-

1.3

1.0-

1.1

0.8-

0.9

0.6-

0.7

0.4-

0.5

0.2-

0.3


RPI

malefemale

0

10

20

30

40

50

60

70

80

90

15.3-

16.9

13.6-

15.2

11.9-

13.5

10.2-

11.8

8.5-

10.1

6.8-

8.4

5.1-

6.7

3.4-

5.0

1.7-

3.3

0-

1.6


FRC# [10 /l]

malefemale

0

10

20

30

40

50

60

70

80

90

0.37-

0.40

0.33-

0.36

0.29-

0.32

0.25-

0.28

0.21-

0.24

0.17-

0.20

0.13-

0.16

0.09-

0.12

0.05-

0.08

0-

0.04


FRC% [%]

malefemale

0

5

10

15

20

25

30

35

6.9-

7.5

6.2-

6.8

5.5-

6.1

4.8-

5.4

4.1-

4.7

3.4-

4.0

2.7-

3.3

2.0-

2.6

1.3-

1.9

0.5-

1.2


IPF% [%]

malefemale

0

5

10

15

20

25

30

35

40

521-

554

487-

520

453-

486

419-

452

385-

418

351-

384

317-

350

283-

316

249-

282

215-

248


Delta-He [amol]

malefemaleoverall

0

5

10

15

20

25

30

35

2.099-

2.158

2.039-

2.098

1.979-

2.038

1.919-

1.978

1.859-

1.918

1.799-

1.858

1.739-

1.798

1.679-

1.738

1.619-

1.678

1.559-

1.618


RBC-He [fmol]

malefemaleoverall

0

5

10

15

20

25

30

35

40

1.6-

1.7

1.4-

1.5

1.2-

1.3

1.0-

1.1

0.8-

0.9

0.6-

0.7

0.4-

0.5

0.2-

0.3


RPI

malefemale

0

10

20

30

40

50

60

70

80

90

15.3-

16.9

13.6-

15.2

11.9-

13.5

10.2-

11.8

8.5-

10.1

6.8-

8.4

5.1-

6.7

3.4-

5.0

1.7-

3.3

0-

1.6


FRC# [10 /l]

malefemale

0

10

20

30

40

50

60

70

80

90

0.37-

0.40

0.33-

0.36

0.29-

0.32

0.25-

0.28

0.21-

0.24

0.17-

0.20

0.13-

0.16

0.09-

0.12

0.05-

0.08

0-

0.04


FRC% [%]

malefemale

0

5

10

15

20

25

30

35

6.9-

7.5

6.2-

6.8

5.5-

6.1

4.8-

5.4

4.1-

4.7

3.4-

4.0

2.7-

3.3

2.0-

2.6

1.3-

1.9

0.5-

1.2


IPF% [%]

malefemale

a) b)

c) d)

a) b)

c) d)



Di

ag

no

st

ic

Pe

rs

pe

ct

iv

es

Figure 2 Distribution curves for selected RBC parameters. Curves given as described for figure 1. (a) The reticulocyte haemoglobin content (RET-He); (b) the difference between the reticulocyte and mature erythrocyte haemoglobin content (Delta-He); (c) the absolute count of fragmented red cells (FRC); (d) the FRC percentage of all erythrocytes; (e) the percentage of hypo-haemoglobinised red cells (% Hypo-He); (f) the percentage of hyper-haemoglobinised red cells (% HypER-He); (g) the percentage of microcytic cells; (h) the percentage of macrocytic cells; (i) the haemoglobin content of mature erythrocytes from the fluorescence optical count (RBC-He); (j) a comparison of RBC-He and the mean cellular haemoglobin calculated from impedance counting and haemoglobin photo-metry. RBC-He is calibrated to MCH during instrument setup.

0

5

10

15

20

25

138.5-

139.8

137.1-

138.4

135.7-

137.0

134.3-

135.6

132.9-

134.2

131.5-

132.8

130.1-

131.4

128.7-

130.0

127.3-

128.6

125.9-

127.2


NEUT-X [ch]

malefemaleoverall

0

10

20

30

40

50

60

1.31.21.11.00.90.80.70.60.50.40.30.20.1


%HYPO-He [%]

malefemale

0

5

10

15

20

25

30

35

40

1.61.51.41.31.21.11.00.90.80.70.6


%HYPER-He [%]

malefemale

0

10

20

30

40

50

4.7-

5.1

4.2-

4.6

3.7-

4.1

3.2-

3.6

2.7-

3.1

2.2-

2.6

1.7-

2.1

1.2-

1.6

0.7-

1.1

0.2-

0.6


MicroR [%]

malefemale

0

5

10

15

20

25

30

35

40

45

14.9-

15.9

13.8-

14.8

12.7-

13.7

11.6-

12.6

10.5-

11.5

9.4-

10.4

8.3-

9.3

7.2-

8.2

6.1-

7.1

5.0-

6.0


MacroR [%]

malefemaleoverall

0

5

10

15

20

25

138.5-

139.8

137.1-

138.4

135.7-

137.0

134.3-

135.6

132.9-

134.2

131.5-

132.8

130.1-

131.4

128.7-

130.0

127.3-

128.6

125.9-

127.2


NEUT-X [ch]

malefemaleoverall

0

10

20

30

40

50

60

1.31.21.11.00.90.80.70.60.50.40.30.20.1


%HYPO-He [%]

malefemale

0

5

10

15

20

25

30

35

40

1.61.51.41.31.21.11.00.90.80.70.6


%HYPER-He [%]

malefemale

0

10

20

30

40

50

4.7-

5.1

4.2-

4.6

3.7-

4.1

3.2-

3.6

2.7-

3.1

2.2-

2.6

1.7-

2.1

1.2-

1.6

0.7-

1.1

0.2-

0.6


MicroR [%]

malefemale

0

5

10

15

20

25

30

35

40

45

14.9-

15.9

13.8-

14.8

12.7-

13.7

11.6-

12.6

10.5-

11.5

9.4-

10.4

8.3-

9.3

7.2-

8.2

6.1-

7.1

5.0-

6.0


MacroR [%]

malefemaleoverall

0

5

10

15

20

25

138.5-

139.8

137.1-

138.4

135.7-

137.0

134.3-

135.6

132.9-

134.2

131.5-

132.8

130.1-

131.4

128.7-

130.0

127.3-

128.6

125.9-

127.2


NEUT-X [ch]

malefemaleoverall

0

10

20

30

40

50

60

1.31.21.11.00.90.80.70.60.50.40.30.20.1


%HYPO-He [%]

malefemale

0

5

10

15

20

25

30

35

40

1.61.51.41.31.21.11.00.90.80.70.6


%HYPER-He [%]

malefemale

0

10

20

30

40

50

4.7-

5.1

4.2-

4.6

3.7-

4.1

3.2-

3.6

2.7-

3.1

2.2-

2.6

1.7-

2.1

1.2-

1.6

0.7-

1.1

0.2-

0.6


MicroR [%]

malefemale

0

5

10

15

20

25

30

35

40

45

14.9-

15.9

13.8-

14.8

12.7-

13.7

11.6-

12.6

10.5-

11.5

9.4-

10.4

8.3-

9.3

7.2-

8.2

6.1-

7.1

5.0-

6.0


MacroR [%]

malefemaleoverall

0

5

10

15

20

25

138.5-

139.8

137.1-

138.4

135.7-

137.0

134.3-

135.6

132.9-

134.2

131.5-

132.8

130.1-

131.4

128.7-

130.0

127.3-

128.6

125.9-

127.2


NEUT-X [ch]

malefemaleoverall

0

10

20

30

40

50

60

1.31.21.11.00.90.80.70.60.50.40.30.20.1


%HYPO-He [%]

malefemale

0

5

10

15

20

25

30

35

40

1.61.51.41.31.21.11.00.90.80.70.6


%HYPER-He [%]

malefemale

0

10

20

30

40

50

4.7-

5.1

4.2-

4.6

3.7-

4.1

3.2-

3.6

2.7-

3.1

2.2-

2.6

1.7-

2.1

1.2-

1.6

0.7-

1.1

0.2-

0.6


MicroR [%]

malefemale

0

5

10

15

20

25

30

35

40

45

14.9-

15.9

13.8-

14.8

12.7-

13.7

11.6-

12.6

10.5-

11.5

9.4-

10.4

8.3-

9.3

7.2-

8.2

6.1-

7.1

5.0-

6.0


MacroR [%]

malefemaleoverall

e) f)

g) h)

0

5

10

15

20

25

30

35

40

521-

554

487-

520

453-

486

419-

452

385-

418

351-

384

317-

350

283-

316

249-

282

215-

248


Delta-He [amol]

malefemaleoverall

0

5

10

15

20

25

30

35

2.099-

2.158

2.039-

2.098

1.979-

2.038

1.919-

1.978

1.859-

1.918

1.799-

1.858

1.739-

1.798

1.679-

1.738

1.619-

1.678

1.559-

1.618


RBC-He [fmol]

malefemaleoverall

0

5

10

15

20

25

30

35

40

1.6-

1.7

1.4-

1.5

1.2-

1.3

1.0-

1.1

0.8-

0.9

0.6-

0.7

0.4-

0.5

0.2-

0.3


RPI

malefemale

0

10

20

30

40

50

60

70

80

90

15.3-

16.9

13.6-

15.2

11.9-

13.5

10.2-

11.8

8.5-

10.1

6.8-

8.4

5.1-

6.7

3.4-

5.0

1.7-

3.3

0-

1.6


FRC# [10 /l]

malefemale

0

10

20

30

40

50

60

70

80

90

0.37-

0.40

0.33-

0.36

0.29-

0.32

0.25-

0.28

0.21-

0.24

0.17-

0.20

0.13-

0.16

0.09-

0.12

0.05-

0.08

0-

0.04


FRC% [%]

malefemale

0

5

10

15

20

25

30

35

6.9-

7.5

6.2-

6.8

5.5-

6.1

4.8-

5.4

4.1-

4.7

3.4-

4.0

2.7-

3.3

2.0-

2.6

1.3-

1.9

0.5-

1.2


IPF% [%]

malefemale

0

5

10

15

20

25

30

35

2.099-

2.158

2.039-

2.098

1.979-

2.038

1.919-

1.978

1.859-

1.918

1.799-

1.858

1.739-

1.798

1.679-

1.738

1.619-

1.678

1.559-

1.618

RBC-He versus MCH% of reference population

[fmol]

overall RBC-He

overall MCH

(j)i) j)



Figure 3 Distribution curves for selected pLT parameters. Curves given as described for figure 1. (a) The absolute count of immature platelets; (b) the immature platelet percentage of all platelets; (c) the most highly fluorescent, i. e. most immature platelet percentage.

Di

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iv

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We confirmed the statistically significant differences of reference intervals for men vs. women for HGB, RBC, HCT, MCHC and the number of platelets reported by others e.g. 6, 10, 11. However, we observed such differences for a far wider range of parameters, including once more the neutrophil count, as already observed by Bain and England in 1975 12. Nonetheless, the differences in these additional cases, while statistically significant, were often such as not being clinically relevant. The reference intervals we report here for those parameters previously published match quite well those found by others. For some parameters, we found inter-vals that are slightly higher than in some publications, but in line with others. Such probably population-based shifts

stress the importance of verifying the applicability of a published reference interval for the population a given hae-matology analyser is used on before use as suggested by IFCC or CLSI 13, 14 – or determining intra-laboratory refer-ence limits directly 3.

0

5

10

15

20

25

30

35

40

2.5-

2.7

2.2-

2.4

1.9-

2.1

1.6-

1.8

1.3-

1.5

1.0-

1.2

0.7-

0.9

0.4-

0.6

0.1-

0.3

H-IPF% of reference population

H-IPF [%]

malefemaleoverall

0

5

10

15

20

25

30

35

15.1-

17.5

14.4-

15.0

12.8-

14.3

11.2-

12.7

9.6-

11.1

7.8-

9.5

6.2-

7.9

4.6-

6.3

3.0-

4.7

1.6-

3.1

IPF#% of reference population

IPF# [10 /L]

malefemaleoverall

0

5

10

15

20

25

30

22.1-

22.9

21.2-

22.0

20.3-

21.1

19.4-

20.2

18.5-

19.3

17.6-

18.4

16.7-

17.5

15.8-

16.6

14.9-

15.7

14.0-

14.8

PLT-X% of reference population

PLT-X [ch]

malefemaleoverall

0

5

10

15

20

25

30

35

40

45

479-

529

438-

478

397-

437

356-

396

315-

355

274-

314

233-

273

192-

232

151-

191

110-

150

PLT-I% of reference population

PLT-I [10 /l]

malefemale

0

5

10

15

20

25

30

35

16.18-

17.57

14.78-

16.17

13.38-

14.77

11.98-

13.37

10.58-

11.97

9.18-

10.57

7.78-

9.17

6.38-

7.77

4.98-

6.37

3.58-

4.97

WBC-B% of reference population

WBC-B [10 /l]

malefemale

0

5

10

15

20

25

30

35

15.34-

16.64

14.03-

15.33

12.72-

14.02

11.41-

12.71

10.10-

11.4

8.79-

10.09

7.48-

8.78

6.17-

7.47

4.86-

6.16

3.55-

4.85

WBC-D% of reference population

WBC-D [10 /l]

malefemale

0

5

10

15

20

25

30

35

40

2.5-

2.7

2.2-

2.4

1.9-

2.1

1.6-

1.8

1.3-

1.5

1.0-

1.2

0.7-

0.9

0.4-

0.6

0.1-

0.3

H-IPF% of reference population

H-IPF [%]

malefemaleoverall

0

5

10

15

20

25

30

35

15.1-

17.5

14.4-

15.0

12.8-

14.3

11.2-

12.7

9.6-

11.1

7.8-

9.5

6.2-

7.9

4.6-

6.3

3.0-

4.7

1.6-

3.1

IPF#% of reference population

IPF# [10 /L]

malefemaleoverall

0

5

10

15

20

25

30

22.1-

22.9

21.2-

22.0

20.3-

21.1

19.4-

20.2

18.5-

19.3

17.6-

18.4

16.7-

17.5

15.8-

16.6

14.9-

15.7

14.0-

14.8

PLT-X% of reference population

PLT-X [ch]

malefemaleoverall

0

5

10

15

20

25

30

35

40

45

479-

529

438-

478

397-

437

356-

396

315-

355

274-

314

233-

273

192-

232

151-

191

110-

150

PLT-I% of reference population

PLT-I [10 /l]

malefemale

0

5

10

15

20

25

30

35

16.18-

17.57

14.78-

16.17

13.38-

14.77

11.98-

13.37

10.58-

11.97

9.18-

10.57

7.78-

9.17

6.38-

7.77

4.98-

6.37

3.58-

4.97

WBC-B% of reference population

WBC-B [10 /l]

malefemale

0

5

10

15

20

25

30

35

15.34-

16.64

14.03-

15.33

12.72-

14.02

11.41-

12.71

10.10-

11.4

8.79-

10.09

7.48-

8.78

6.17-

7.47

4.86-

6.16

3.55-

4.85

WBC-D% of reference population

WBC-D [10 /l]

malefemale

0

5

10

15

20

25

30

35

40

521-

554

487-

520

453-

486

419-

452

385-

418

351-

384

317-

350

283-

316

249-

282

215-

248


Delta-He [amol]

malefemaleoverall

0

5

10

15

20

25

30

35

2.099-

2.158

2.039-

2.098

1.979-

2.038

1.919-

1.978

1.859-

1.918

1.799-

1.858

1.739-

1.798

1.679-

1.738

1.619-

1.678

1.559-

1.618


RBC-He [fmol]

malefemaleoverall

0

5

10

15

20

25

30

35

40

1.6-

1.7

1.4-

1.5

1.2-

1.3

1.0-

1.1

0.8-

0.9

0.6-

0.7

0.4-

0.5

0.2-

0.3


RPI

malefemale

0

10

20

30

40

50

60

70

80

90

15.3-

16.9

13.6-

15.2

11.9-

13.5

10.2-

11.8

8.5-

10.1

6.8-

8.4

5.1-

6.7

3.4-

5.0

1.7-

3.3

0-

1.6


FRC# [10 /l]

malefemale

0

10

20

30

40

50

60

70

80

90

0.37-

0.40

0.33-

0.36

0.29-

0.32

0.25-

0.28

0.21-

0.24

0.17-

0.20

0.13-

0.16

0.09-

0.12

0.05-

0.08

0-

0.04


FRC% [%]

malefemale

0

5

10

15

20

25

30

35

6.9-

7.5

6.2-

6.8

5.5-

6.1

4.8-

5.4

4.1-

4.7

3.4-

4.0

2.7-

3.3

2.0-

2.6

1.3-

1.9

0.5-

1.2


IPF% [%]

malefemale

a) b)

c)



Di

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While we report reference intervals for both PLT-I, the impedance platelet count, and PLT-O, the fluorescence-optical count, it should be noted that the ana-lyser uses a switching algorithm deciding which count is more reliable on a case-by-case basis and reports the more reli-able one as PLT. The same holds true for WBC-B, the WBC count from the WBC-BASO channel, which together with WBC-D, the WBC count from the DIFF channel is interchangeably reported as the actual WBC count, depending on which the system assesses as the more reliable one for the individual case.

For the use of the reference interval for RPI some limitations do apply: interest-ingly, whereas it is usually assumed that a reticulocyte production index (RPI) of ‘ 1’ is normal, our data show that the refer-ence interval can actually reach as low as 0.2 and women, especially, despite the regular blood loss during menstruation, tend to have an RPI significantly below 1. This suggests that the assumptions made in calculating RPI are somewhat questio-nable. They assume a rather monocausal regulation of reticulocyte maturation time in the bone marrow tied directly to the haematocrit. It needs to be em-phasised that RPI should only be used for adult anaemic patients. While an RPI higher than 2 can indeed suggest a sig-nificantly increased haematopoiesis, our data suggests that the clinical value of a low RPI should not be overestimated. Erythropoietic bone marrow activity can alternatively be assessed via the immature reticulocyte function and the reticulocyte haemoglobin content, in addition to, of course, the reticulocyte count itself.



Parameter unit Sex Sysmex Xe-5000

Mann-Whitney p-value

WBC 109/L m 3.91–10.90 0.0013

f 4.49–12.68

RBC 1012/L m 4.44–5.61 <0.0001

f 3.92–5.08

HGB mmoL/L m 8.44–10.49 <0.0001

f 7.39–9.06

g/L m 135–169

f 119–146

HCT % m 40.0–49.4 <0.0001

f 36.6–44.0

mCV fL m 81.8–95.5 <0.0001

f 82.9–98.0

mCH fmol m/f 1.676–2.005 0.9950

pg m/f 27.0–32.3

mCHC mmoL/L m 20.1–21.7 <0.0001

f 19.7–21.5

g/L m 324–350

f 318–347

PLT 109/L m 166–308 <0.0001

f 173–390

RDW-SD fL m 37.1–45.7 <0.0001

f 38.2–49.2

RDW-CV % m 12.0–13.6 0.0002

f 12.1–14.3

PDW fL m 10.1–16.1 0.0003

f 9.9–15.4

mPV fL m 9.3–12.1 0.0006

f 9.1–11.9

P-LCR % m 18.5–42.3 0.0004

f 17.5–42.3

PCT % m 0.17–0.32 <0.0001

f 0.18–0.39

NEuT# 109/L m 1.8–6.98 <0.0001

f 2.1–8.89

LymPH# 109/L m/f 1.26–3.35 0.1170

mONO# 109/L m 0.29–0.95 0.0011

f 0.25–0.84

EO# 109/L m 0.03–0.59 0.0068

f 0.01–0.40

BASO# 109/L m/f 0.01–0.07 0.0780

NEuT% % m 41.0–70.7 <0.0001

f 42.9–74.3

LymPH% % m 19.1–47.9 0.0285

f 18.3–45.7

mONO% % m 5.2–15.2 <0.0001

f 4.2–11.8

EO% % m 0.6–7.6 <0.0001

f 0.2–5.3

BASO% % m 0.1–1.2 0.0009

f 0.1–1.0

Di

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Parameter unit Sex Sysmex Xe-5000

Mann-Whitney p-value

NRBC# 109/L m/f 0–0

NRBC% % m/f 0–0

RET# 109/L m 23.0–70.1 0.0005

f 17.0–63.8

RET% % m/f 0.43–1.36 0.7483

LFR % m/f 89.9–98.4 0.0539

mFR % m/f 1.6–9.5 0.0668

HFR % m/f 0–1.7 0.0649

IRF % m/f 1.6–10.5 0.0539

IG# 109/L m/f 0–0.06 0.5170

IG% % m/f 0–0.6 0.0764

HFLC# 109/L m 0–0.03 0.0120

f 0–0.03

HFLC% % m/f 0–0.4 0.0827

PLT-O 109/L m 173–329 <0.0001

f 174–407

RET-He fmol m/f 1.996–2.407 0.9066

pg m/f 32.1–38.8

Delta-He fmol m/f 0.268–0.451 0.2904

pg m/f 4.31–7.26

RBC-He fmol m/f 1.676–2.023 0.9950

pg m/f 27.0–32.6

RPI m 0.4–1.5 <0.0001

f 0.2–1.1

FRC# 109/L m 0–8.3 0.0011

f 0–11.6

FRC% % m 0–0.17 0.0012

f 0–0.25

IPF% % m 0.8–6.3 0.0348

f 0.8–6.2

H-IPF % m/f 0.2–1.9 0.0559

IPF# 109/L m/f 2.3–12.7 0.3568

PLT-X ch m/f 14.3–20.1 0.3461

PLT-I 109/L m 166–308 <0.0001

f 173–390

WBC-B 109/L m 3.91–10.9 0.0013

f 4.49–12.68

WBC-D 109/L m 3.94–10.76 0.0133

f 4.23–12.71

NEuT-X ch m/f 127.9–138.0 0.3822

%HyPO-He % m 0.1–0.5 0.0468

f 0.1–1.1

%HyPER-He % m 0.9–1.3 <0.0001

f 0.7–1.2

microR % m 0.5–3.0 <0.0001

f 0.3–2.8

macroR % m/f 5.6–11.5 0.1746

Table 2 Reference intervals for the parameters included in the study. one reference interval is listed where no significant difference was found between samples for male and female subjects. p-value as per Mann-Whitney U test is given.

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References

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