Professional Documents
Culture Documents
Coulter
Coulter
Coulter
markers such as serum iron, ferritin, and transferrin reticulocytes, expressed in arbitrary units. A mathe-
saturation. However, these parameters are subject to matical transformation applied to RET-Y gives a reticulo-
biological variability, for example, diurnal variation, cyte hemoglobin equivalent (RETHe = 5.5569e0.001RET-Y)
fluctuation with dietary intake and in infection/ expressed in picograms [15, 16]. This parameter is
inflammatory states (acute-phase reactants). dependent on the hemoglobin content of reticulocytes
In recent years, new hematological parameters and shows a high correlation witch CHr and the same
have been developed for the early detection of iron clinical meaning [9, 17].
deficiency. These indices, which in some cases Compared to the mature erythrocyte population,
combine more than one of the classic red cell parame- each with a lifespan of about 120 days, reticulocytes
ters, can be used as a preliminary screening tool in have a greater mean volume and circulate for about
the differential diagnosis of anemia [5]. 1–1.5 days in the blood stream, so reticulocyte-
The latest generation hematology analyzers provide dependent parameters provide a more real-time view
some reticulocyte indices equivalent to the RBC indi- of certain aspects of erythropoiesis that can influence
ces. The study of specific characteristics of the reticu- the dimensions of red cells, such as iron availability.
locyte, such as mean reticulocyte volume (MRV), The Beckman Coulter analyzers (Beckman Coulter
RNA content, reticulocyte hemoglobin content (CHr) Inc., Miami, Fl, USA) identified and classified cells by
and reticulocyte hemoglobin equivalent (Ret-He), can three-dimensional analysis: volume, conductivity, and
give useful information about the iron availability for light scatter (VCS) technology. Using these technol-
erythropoiesis and the erythropoietic activity of the ogy, the Beckman Coulter LH750 has recently pro-
bone marrow [6–9]. Currently, the main limitation in posed two new parameters in the LH series: the red
the use of these indices is the fact that not all instru- blood cell size factor (RSf) and the low hemoglobin
ments can perform them. density (LHD%) [18, 19].
These reticulocyte parameters provide information The RSf combines the mean volume of mature red
that could allow the differential diagnosis of anemia, cells (MCV) and the mean reticulocyte volume, both
the early (latent) detection of iron deficiency, and the related to erythropoietic activity and hemoglobiniza-
real-time monitoring of bone marrow erythropoietic tion, because in both stages of erythrocyte maturation,
activity. Besides aiding the diagnosis of iron-deficiency above 90% of cellular content are represented by
anemia, reticulocyte parameters could potentially be hemoglobin [20].
helpful in monitoring the response of erythropoiesis pffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffi
to iron supplementation [10]. RSf ¼ MCV MRV
The CHr reflects the synthesis of hemoglobin in The LHD% derived from the mean cell hemoglobin
bone marrow precursors and is a measure of the ade- concentration (MCHC) uses the mathematical sigmoid
quacy of iron availability [11]. This parameter has transformation:
been incorporated to National Kidney Foundation qffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffi
Kidney Disease Outcomes Quality Initiative (NKF-K/ LHD% ¼ 100 1 ½1=ð1 þ e 1:8ð30MCHCÞ Þ
DOQI) Guidelines for the monitoring of recombinant
human erythropoietin (rHuEPO) therapy [12]. Excep- The MCHC is a measure of both the availability of
tions are heterozygotes for b-thalassemia whose CHr iron over the preceding 90–120 days and the introduc-
is always reduced independently of iron stores [13]. tion of iron into erythrocyte hemoglobin. In the same
The use of this parameter is limited to the analyzers way, LHD% is related to iron availability and the
of a single manufacturer, Siemens (Siemens Medical hemoglobinization of the mature red cells [19, 21].
Solutions Diagnostics, NY, USA). Unlike biochemical studies such as ferritin, these
A comparable index called RET-Y has been devel- parameters require no extratubes of blood to be
oped by Sysmex Corporation (Japan) [14]. This param- drawn and are calculated without any additional cost.
eter is measured based on automated fluorescent flow These indices could be used as a preliminary screening
cytometry, which in the reticulocyte channel, using a tool to allow confirmatory analysis.
polymethine dye specific for RNA/DNA, measures the The aims of this study were to establish the refer-
mean value of the forward light scatter intensity of ence range for RSf and LHD% in a healthy children
population; to determine the utility of RSf and LHD% variables, the Shapiro–Wilk normality test was used.
in the diagnosis of iron-deficiency anemia; and to A P value <0.05 implies that the data were sampled
compare RSf and LHD% with RET-He that has been from a non-Gaussian distribution. When the parame-
clinically validated. ters under study presented a Gaussian distribution,
correlation coefficients were calculated by Pearson’s
method; independent samples t-test was performed to
M AT E R I A L S A N D M E T H O D S
detect statistical deviations between the groups of
patients. When the parameters under study presented
Study population
a non-Gaussian distribution, correlation coefficients
Two patient groups were analyzed during a 1-year were calculated by Spearman’s method and indepen-
period (March 2010–February 2011). Peripheral blood dent samples Mann–Whitney U-test was performed.
samples from 251 patients collected in K3-EDTA anti- The top 97.5 and bottom 2.5 percentiles were used as
coagulant tubes, 1.3 mL final volume, were randomly the limits of the reference range obtained in the group
selected from the routine workload and prospectively of healthy children (95 central percentiles of the
analyzed. distribution of the recorded values).
Box and whisker plots were created to display the
distributions of RSf and LHD% levels of control and IDA
Control group
groups. Statistical significance was defined as P < 0.05.
Two hundred healthy children who were undergoing Receiver operating characteristic (ROC) curve analysis
minor surgery, with no clinical symptoms of disease, was used to evaluate the diagnostic performance of
exhibited no abnormal hematologic findings in their ferritin, serum iron, transferrin,%Sat, Ret-He, RSf and
complete blood cell count. LHD% for differential diagnosis of iron-deficiency
anemia. Cutoff values were established based on the
optimal combination of sensitivity and specificity.
Iron-deficiency anemia (IDA) group
(a) (b)
REFERENCES indices rapidly reflect an increase in iron 20. Urrechaga E, Borque L, Escanero F. Analy-
availability for erythropoiesis. Haematolog- sis of reticulocytes parameters on the Sys-
1. Walter T, Kovalskys J, Steckel A. Effect of ica 2003;88:1422–3. mex XE5000 and LH750 analyzers in the
mild iron deficiency on infant mental 11. Brugnara C. Iron deficiency and erythro- diagnosis of inefficient erythropoiesis. Int
development scores. J Pediatr 1983;102: poiesis: new diagnostic approaches. Clin Jnl Lab Hem 2011;33:37–44.
519–22. Chem 2003;49:1573–8. 21. Zini G, Machin S, Briggs C, et al. Multicen-
2. Lozoff B, Jimenez E, Wolf A. Long-term 12. NKF-K/DOQI Clinical practice guidelines tric evaluation of Coulter MCH and the
developmental outcome of infants with and clinical practice recommendations for new derived SigMCHC ® parameters versus
iron deficiency. N Engl J Med 1991;325: anemia in chronic kidney disease in adults. CHr and%Hypo for the assessment of iron
687–94. Am J Kidney Dis 2006;47(Suppl. 3):11– metabolism disturbances. 2006. ISLH XIXth
3. Lozoff B, Jimenez E, Hagen J, Mollen E, 145. International Symposium, Amsterdam.
Wolf A. Poorer behavioral and develop- 13. Buttarrello M, Plebani M. Automated blood 22. Thomas I, Franck S, Messinger M, Linssen
mental outcome more than 10 years after cell counts. State of the art. Am J Clin J, Thome M, Thomas C. Reticulocyte
treatment for iron deficiency in infancy. Pathol 2008;130:104–16. haemoglobin measurement – comparison
Pediatrics 2000;105:ES1. 14. Canals C, Remacha A, Sarda M, Pizzuelo J, of two methods in the diagnosis of iron-
4. Finc C. Regulation of iron balance in Rayo MT, Romero MA. Clinical utility of restricted erythropoiesis. Clin Chem Lab
humans. Blood 1994;84:1697–702. the new Sysmex XE 2100 parameter – Med 2005;43:1193–202.
5. Urrechaga E, Borque L, Escanero F. The reticulocyte haemoglobin equivalent – in 23. Garzia M, Di Mario A, Ferraro E, Tazza L,
role of automated measurement of red cell the diagnosis of anemia. Hematologica Rossi E, Luciani G, Zini G. Reticulocyte
subpopulations on the Sysmex XE 5000 2005;90:1133–4. Hemoglobin Equivalent: an indicator of
analyser in the differential diagnosis of 15. Buttarello M, Temporin V, Ceravolo R, reduced iron availability in chronic kidney
microcytic anemia. Int Jnl Lab Hem Farina G, Bulian P. The new reticulocyte diseases during erythropoietin therapy. Lab
2011;33:30–6. parameter (RET-Y) of the Sysmex XE 2100: Haematol 2007;13:6–11.
6. Brugnara C. Use of reticulocyte cellular its use in the diagnosis and monitoring of 24. Brugnara C, Zurakowski D, DiCarzio J,
indices in the diagnosis and treatment of posttreatment sideropenic anemia. Am J Boyd T, Platt O. Reticulocyte haemoglobin
hematological disorders. Int J Clin Lab Res Clin Pathol 2004;121:489–95. content to diagnose iron deficiency in chil-
1998;28:1–11. 16. Franck S, Linssen J, Messinger M, Thomas dren. JAMA 1999;281:2225–30.
7. Mateos Gonzalez M, de la Cruz Bertolo J, I. Potential utility of Ret-Y in the diagnosis 25. Bovy C, Gothot A, Krzesinski JM, Beguin
Lopez Laso E, Valdes Sanchez M, Nogales of iron-restricted erythropoiesis. Clin Chem Y. Mature erythrocyte indices: new mark-
Espert A. Contenido de hemoglobina retic- 2004;350:1240–2. ers of iron availability. Haematologica
ulocitaria para el diagnostico de la ferrope- 17. Mast AE, Blinder MA, Dietzen DJ. Reticu- 2005;90:549–51.
nia. An Pediatr (Barc) 2009;7:103–9. locyte haemoglobin content. Am J Hematol 26. Temporin V, Lachin M, Bulian P, et al. Use-
8. Cortellazzi L, Teixeira S, Borba R, Gervasio 2008;83:307–10. fulness of reticulocyte indices in the early
S, Cintra C, Grotto H. Reticulocyte parame- 18. Urrechaga E. Clinical utility of the new detection of functional iron deficiency and
ters in hemoglobinopathies and iron defi- Beckman-Coulter parameter red blood cell in the response to therapy with vitamin
ciency anemia. Rev Bras Hematol Hemoter size factor in the study of erithropoiesis. Int B12. Automated Blood Cytol 1998;13:13–5.
2003;25:97–102. Jnl Lab Hem 2009;3:623–9. 27. Noronha J, De Souza C, Vigorito A, Aranha
9. Brugnara C, Schiller B, Moran J. Ret He 19. Urrechaga E. The new mature red cell F, Zulli R, Miranda E, Grotto H. Immature
and assessment of iron deficient states. Clin parameter, low haemoglobin density of the reticulocytes as an early predictor of
Lab Hematol 2006;28:303–8. Beckman-Coulter LH750: clinical utility in engraftment in autologous and allogeneic
10. Kotissari S, Romppanen J, Agren U, the diagnosis of iron deficiency. Int Jnl Lab bone marrow transplantation. Clin Lab
Eskelinen S, Punnonen K. Reticulocyte Hem 2010;32:e144–50. Haematol 2003;25:47–54.