Hemolytic Anemias Testing

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ORDER
CBC with Platelet Count and
Automated Differential
Reticulocytes, Percent & Number
Lactate Dehydrogenase, Serum or
Plasma
Haptoglobin

INDICATIONS FOR TESTING

Patient with anemia and
evidence of hemolysis

Consider environmental factors,

mechanical cardiac valve,
vasculitis, malignant hypertension
Increased D
Dimer
Decreased
fibrinogen

DIC

no
Proceed based on above findings

Consider
microangiopathic
RBC destruction

Decreased
platelets

Consider
DIC
TTP
HELLP
HUS

ADAMTS13
activity

TTP

Schistocytes

May need molecular

analysis for ankyrin,
spectin

no
Acquired
yes

IgG+

Sickle cells

HPLC

Osmotic
fragility
test
(usually
positive)

Consider
RBC membrane
disorder
(hereditary
spherocytosis,
hereditary
elliptocytosis,
autoimmune
hemolysis)

Unusual red
cell inclusions

Spherocytes,
pyropoikilocytes,
elliptocytes or
acanthocytes

Basophilic
stippling

Polychromasia
only with or
without platelet
decrease

no

Congenital 5'
nucleotidase
deficiency

yes

Consider
lead
poisoning

Consider
PNH

Polychromasia without
other reproducible
morphologic abnormality

yes

Autoimmune
hemolytic anemia
(consider drug
induced, hemolytic
disease of the
newborn, autoimmune
disease)

Cold
agglutinin
disease

Cold
agglutinin
testing

Cold agglutinin
disease,
paroxysmal cold
hemoglobinuria
(PCH)

Confirm PCH with

Donath Landsteiner
testing

+ for
complement

2006-2012 ARUP Laboratories. All Rights Reserved. Revised 8/4/2011

Direct
Coombs
testing

Consider
cold
agglutinin
disease

Heinz
bodies
Agglutination

5' nucleotidase
testing

acquired
Serum lead
level

Paroxysmal Nocturnal Hemoglobinuria

Panel, RBC and WBC

+C3

no

Recluse spider
venom, clostridium
sepsis

Consider Sickle cell disease

diverse genotypes: SS, SC,
SE, S thalassemia, S
Lepore

yes

Consider malaria,
bartonella (oroya
fever), babesia

Direct Coombs
(Anti-Human
Globulin)

Presence of the following may provide clues to the etiology of the anemia
Increased reticulocyte count
Abnormal peripheral smear
Polychromasia, spherocytes, schistocytes, sickle cells, Heinz
bodies, basophilic stippling, unusual red cell inclusions, and
agglutination
Note: lack of any of the above does not rule out hemolytic anemia

Consider
Pyruvate kinase
deficiency
Hexokinase deficiency
Other enzyme defects

Consider
Glucose-6-Phosphate
dehydrogenase
deficiency
Unstable hemoglobin
defects
Glutathione
metabolism defects
Hemoglobin H
disease

Consider one or
more of the
following tests
Pyruvate kinase
Hexokinase
Glucose
phosphate
isomerase

Consider one or more of

the following tests
Isopropanol heat
stability testing
Glucose-6Phosphate
Dehydrogenase
(G6PD) 2 Mutations
Enzymes of
glutathione cycle

For hemoglobin
disorders,
consider HPLC

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