Clinical Biochemistry 53 (2018) 132–138

Contents lists available at ScienceDirect

Clinical Biochemistry
journal homepage: www.elsevier.com/locate/clinbiochem

Performance evaluation of the new measurement channels on the automated T

Sysmex XN-9000 hematology analyzer
⁎
E. Schapkaitza, , S. Raburabub
a
Department of Molecular Medicine and Haematology, University of Witwatersrand Medical School, Johannesburg, South Africa
b
Department of Molecular Medicine and Haematology, National Health Laboratory Service, Johannesburg, South Africa

A R T I C L E I N F O A B S T R A C T

Keywords: Background: The automated Sysmex XN-9000 hematology system has been designed to meet the throughput and
Hematology analyzer efficiency requirements of high volume laboratories with predominantly abnormal samples. New measurement
Morphology flags channels have been introduced namely the white cell nucleated (WNR), white cell differential (WDF), white cell
Full blood count precursor (WPC) and fluorescent platelet (PLT-F) channels.
Verification
Methods: The performance of the new measurement channels was evaluated with regards to precision, accuracy,
Sysmex XN-9000
linearity, carryover, throughput and stability. 275 slides were assessed for morphology flagging. Adult and
pediatric samples with normal and abnormal hematology profiles were included.
Results: The XN-9000 demonstrated acceptable imprecision, good linearity for high and low ranges and no
carryover. The full blood count and reticulocyte on the XN-9000 correlated well with the reference ADVIA(2)
120. The PLT-F (127 ± 84 × 109/l) compared with the optical platelet count (131 ± 76 × 109/l) (r = 0.97)
and the imprecision was < 4% on thrombocytopenic samples. The low white blood cell (WBC) mode reported
accurate differentials for samples with a WBC count < 0.5 × 109/l (r = 0.93). The nucleated red blood cell
count from the WNR (1.22 ± 3.96%) showed an excellent correlation with the manual method
(1.12 ± 4.79%) (r = 0.99). The WPC channel showed 100% sensitivity for the detection of blasts and abnormal
lymphocytes. Further, the WPC correctly suppressed the initial blast/abnormal lymphocyte flag in 34% of the
reflexed samples.
Conclusion: The XN-9000 showed enhanced analytical performance and workflow efficiency for a wide range of
patient samples which can be attributed to the incorporation of new measurement channels.

1. Background
The XN-9000 (Sysmex Corporation, Kobe, Japan) is the most recent
fully automated Sysmex hematology system which has been designed to
meet the throughput, work space and efficiency requirements of high
volume laboratories with predominantly abnormal samples [1]. The
instrument uses various technologies namely impedance, conductivity
and optical detection to determine the parameters of a full blood count
(FBC), six-part differential (DIFF) and reticulocyte count (Ret). Its
components include sorting and archiving, an automated slide-maker
and stainer, an extended information processing unit and up to nine
personalized analyzer modules. Several improvements and new mea-
surement channels have been introduced on the XN-9000. These in-
clude the white cell nucleated (WNR), white cell differential (WDF),
white cell precursor (WPC) and fluorescent platelet (PLT-F) channels.
Reflex use of these tests in routine analysis is of clinical value in early
diagnosis and follow-up of most hematology and oncology conditions.
In the dedicated WPC channel, immature white blood cells (WBC) such
as blasts and abnormal lymphocytes can be reliably distinguished using
fluorescent dyes and specific lysing agents. New cluster analysis algo-
rithms have been developed for the identification and flagging of these
abnormal WBC populations [2]. Further it is possible to obtain a more
accurate DIFF from a low WBC count using the extended counting se-
quence in the instrument's low WBC mode. The nucleated red blood cell
(NRBC) count measured on all samples in the new WNR channel is
automatically included in the FBC thereby reducing the manual per-
ipheral blood smear (PBS) review rate. In addition, the PLT-F is more
reliable for low platelet counts in order to optimize the management of
patients with thrombocytopenia. The XN also offers advanced clinical
parameters available on the preceding Sysmex XE analyzers such as the
immature myeloid information (IMI) channel for counting immature
granulocytes, the reticulocyte hemoglobin content (Ret-He) as an early
measure of iron deficiency and the immature platelet fraction (IPF).
This study was designed to verify the diagnostic and clinical utility

⁎
Corresponding author at: PO Box 28985, Sandringham 2131, South Africa.
E-mail address: elise.schapkaitz@nhls.ac.za (E. Schapkaitz).

https://doi.org/10.1016/j.clinbiochem.2018.01.014
Received 31 October 2017; Received in revised form 18 January 2018; Accepted 20 January 2018
0009-9120/ © 2018 The Canadian Society of Clinical Chemists. Published by Elsevier Inc. All rights reserved.
E. Schapkaitz, S. Raburabu Clinical Biochemistry 53 (2018) 132–138

of the new measurement channels on the Sysmex XN-9000 automated Table 1

system at the Charlotte Maxeke Johannesburg Academic Hospital Precision analysis for normal, abnormal high and low control material.
(CMJAH), Johannesburg, South Africa according to the Clinical
Normal Abnormal Abnormal State of the art
Laboratory Standards Institute (CLSI) and International Council for control control high control low performance limits
Standardization in Hematology (ICSH) guidelines and the ISO 15189
standard [3–6]. Between run precision analysis
Parameter CV (%) CV (%) CV (%) CV (%)
(n = 10)
2. Materials and methods 9
WBC, ×10 /l 0.90 1.06 1.44 2,50, 1.50, 6.00
RBC, × 1012/l 0.86 0.57 0.05 1.10
2.1. Analyzers Hb, g/l 0.38 0.34 0 0.90
Hct, l/l 1.19 0.16 1.29 1.20
PLT-I, ×109/l 1.80 1.86 3.22 3.00, 3.00, 4.50
The Sysmex XN-9000 was installed and calibrated by the manu-
PLT-F, × 109/ 2.30 1.60 3.70 3.00, 3.00, 4.50
facturer over a three-day period. This was designed with two XN-10 and l
one XN-20 modules directly connected to two SP-10 automated slide Ret, % 1.87 1.80 4.29 10.00
makers and stainers. The system has the following dimensions: 7.82 m Within run precision analysis
wide × 1.58 m high × 1.15 m deep. This is a smaller footprint than the Parameter CV (%) CV (%) CV (%) CV (%)
ADVIA analyzers and automated-slidemakers and could be accom- (n = 20)
modated by the laboratory's space requirements. The workflow was WBC, ×109/l 1.16 0.65 1.27 2,50, 1.50, 6.00
RBC, × 1012/l 0.80 0.53 0.49 1.10
programmed by the middleware information processing unit (IPU) Hb, g/l 0.33 0.59 0.81 1.00
which is user-friendly stores up to 100,000 patient results. Laboratory Hct, l/l 1.12 0.55 0.62 1.40
9
staff members were trained on instrument operation, troubleshooting PLT-I, ×10 /l 2.13 1.24 3.03 3.00, 3.00, 4.50
and maintenance procedures. Daily quality control measurements were PLT-F, × 109/ 1.60 1.80 1.90 3.00, 3.00, 4.50
l
performed. This study was approved by the Human Research Ethics
Ret, % 2.48 2.10 3.98 10.00
Committee of the University of the Witwatersrand (M090688).
CV, coefficient of variation; SD, standard deviation; WBC, white blood cell; RBC, red
2.2. Principles blood cell; Hb, hemoglobin; Hct, hematocrit; PLT-I, platelet (impedance); PLT-F, platelet
(fluorescent); Ret, reticulocyte count.
On the XN-9000, red blood cells (RBC) and platelets are counted and
sized by direct current impedance with hydrodynamic focusing. The determined from the mean and standard deviation for each level of
hematocrit is determined from the RBC pulse height. The hemoglobin quality control was compared to the manufacturer's and state of the art
(Hb) is measured using sodium lauryl sulphate (SLS) spectro- precision limits [7].
photometry. The WBC and DIFF are determined by fluorescence flow
cytometry. The WBC subpopulations are separated on the basis of cell
complexity (side-scattered fluorescent intensity), cell size (forward 2.5. Stability
scattered light) and fluorescence signal (side fluorescent light). On the
XN-20, the dedicated WPC channel separates blasts and abnormal Stability analysis was performed on 10 samples: five normal and
lymphocyte flags generated by the WDF channel according to differ- five abnormal. Analysis was performed at time zero (< 2 h from col-
ences in fluorescent dye uptake and fluorescence signal. Similarly, Ret lection time) on the XN-9000. The samples were then divided into
are subdivided according to their fluorescence intensity to represent the aliquots and stored at room temperature (RT) and at 4–8 °C. Subsequent
different stages of maturity. The fluorescent platelet count is measured testing was performed after 12, 24, 48 and 72 h of storage. Stability of a
by reflex analysis in the PLT-F channel. The SP-10 prepares blood parameter was defined in accordance with the CLSI definition, namely
smears according to the hematocrit (Hct) value of each sample using when the difference between the means exceeds the standard error of
May-Grunwald-Giemsa stain. the first mean at 95% confidence intervals [8].

2.3. Samples
The samples used included commercial controls (Sysmex
Corporation, Kobe, Japan) and residual specimens referred for routine
laboratory testing. These samples included both normal and abnormal
hematology profiles representative of the patient population.
Microtainer samples from children were also included. A total of 300
samples were randomly selected from the workload. Aged and in-
sufficient samples were excluded (n = 9). Stability analysis was per-
formed on ten patient samples, carryover analysis on four patient
samples, linearity on two patient samples and the comparison analysis
on 275 patient samples. Samples were collected in K2EDTA tubes
(Vacutainer®, Becton Dickinson, Plymouth, UK) for analysis. Samples
were stored at room temperature and analyzed by a dedicated tech-
nologist within 4 h of collection.
2.4. Precision
Between run imprecision analysis was performed with normal and
abnormal high and low quality control material once a day over a
period of ten days. Within run imprecision was performed twenty times
using the same sample aliquot. The co-efficient of variation (% CV)
2.6. Carryover
Carryover was determined for WBC, RBC, Hb and PLT-I. Carryover
from a patient sample with high counts to a patient sample with low
counts was assessed by analyzing the high sample three times (H1, H2
and H3) followed by three consecutive analyses of the low sample (L1,
L2 and L3) [3,7–8]. Carry-over was calculated from the formula: Car-
ryover (%) = (L1 − L3) / (H3 − L3) × 100.
2.7. Linearity
Linearity for WBC, Hb and PLT-I was performed by carrying out
serial dilutions of a patient sample with high counts (WBC,
127.72 × 109/l; Hb, 180 g/l; PLT-I, 780 × 109/l). For WBC and pla-
telet parameters, linearity was also tested with a patient sample with
low counts (WBC, 1.30 × 109/l; PLT-I, 29 × 109/l). The WBC
of < 0.5 × 109/l were analyzed on the instrument's low WBC mode.
The patient samples were diluted with normal saline using the fol-
lowing dilutions - 1:2; 1:4; 1:8 and 1:16 and measured in duplicate
[3,7–8].

133
E. Schapkaitz, S. Raburabu Clinical Biochemistry 53 (2018) 132–138

Fig. 1. a. Boxplot of the mean percentage difference during

22 storage at room temperature for the hematocrit.
A Horizontal box within the boxplot is the mean of all differences,
20 larger boxes represent the standard deviations and whiskers
represent the 95% confidence interval.
18 b. Boxplot of the mean percentage difference during storage at
4–8 °C for the hematocrit.
Horizontal box within the boxplot is the mean of all differences,
16
larger boxes represent the standard deviations and whiskers
represent the 95% confidence interval.
14

12

10

0
12 hours 24 hours 48 hours 72 hours

Storage temperature (hours)

16
B
14

12

10

-2

-4

-6

-8

-10
12 hours 24 hours 48 hours 72 hours

Storage temperature (hours)

2.8. Throughput
In this study, the throughput of the autosampler for FBC and DIFF
was assessed using 40 randomly selected patient samples submitted as a
batch in order to represent the typical workload experienced in a large
sized academic laboratory. Patient samples were loaded on sample
racks. Each sample rack holds ten samples. Throughput was defined as
the time measured from bar code reading of the first patient sample to
the last patient sample reaching the output tray.
2.9. Comparison study
For comparison of the Sysmex XN-9000 with the ADVIA (2)120
(Siemens Healthcare Diagnostics, Tarrytown, USA) for the FBC and
RET, 120 samples were analyzed in parallel during a two-week period.
Samples were run in single, due to limited sample volume. The per-
formance of the PLT-F channel was evaluated using samples selected by
the impedance platelet count (PLT-I) for reflex analysis and compared
to the optical platelet count. The Sysmex XN-9000 was compared with
the manual DIFF count on 60 samples. The DIFF counts were manually
performed by two competent morphologists by counting 200 cells [5].
Statistical analysis was performed with XLStat software (Addinsoft,
New York, USA) using the Bland-Altman method and Passing-Bablok
regression statistical methods.
Morphological flagging efficiency was evaluated on 275 samples.
Samples with a wide range of pathology were included. Consensus

134
E. Schapkaitz, S. Raburabu Clinical Biochemistry 53 (2018) 132–138

Table 2 (Table 1). There was no difference when compared to the precision
Linearity. limits provided by the manufacturer and state of the art criteria.
Parameter Range Correlation coefficient Intercept Slope
(r) 3.2. Stability

WBC, × 109/l 11.38–127.72 0.99 1.5 0.99 The Ret and FBC parameters (with the exception of the mean cell
(high)
volume (MCV) and Hct) were stable for at least 72 h after collection
WBC, × 109/l (low) 0.10–1.30 1.00 0 1.00
Hb, g/l 1.20–18.00 0.99 0.1 0.99 when stored at RT and 4–8 °C. During storage at RT, the Hct was stable
PLT-I, × 109/l 61–780 1.00 2.0 0.99 until 12 h (Fig. 1a). Storage at 4–8 °C showed a reduction in the degree
(high) of osmotic swelling over 72 h (Fig. 1b). Samples stored for 12 h at RT
PLT-I, × 109/l 2–29 1.00 0.1 1.00 and 4–8 °C showed significant EDTA change and discrepant DIFF counts
(low)
for monocytes, eosinophils and basophils.
WBC, white blood cell; RBC, red blood cell; Hb, hemoglobin; Hct, hematocrit; PLT-I,
platelet (impedance). 3.3. Carryover

Table 3 The percentage carryover for the WBC was 0.06%, 0% for the Hb,
Comparison between ADVIA (2)120 (reference method) and the Sysmex XN 9000 (vali- 0.56% for RBC and 0.82% for the PLT-I (Supplementary data). This was
dation method) for full blood count and reticulocyte count. not clinically significant and within the manufacturer's limit of 1%.
Parameter N Correlation Intercept Slope Bias (95% limit of
coefficient (r) agreement) 3.4. Linearity
9
WBC, × 10 / 120 0.98 0.1 1.07 0.49 (0.36–0.62) All parameters showed excellent linearity for high and low ranges
l
RBC, × 1012/ 120 0.99 −0.1 1.05 0.07 (0.05–0.09)
(Table 2).
l
Hb, g/l 120 0.99 −0.3 1.04 0.11 (0.04–0.18) 3.5. Throughput
Hct, l/l 120 0.99 0 1.05 0.004 (0.002–0.007)
PLT-I, 120 0.98 11.2 1.03 17.76 (14.07–21.44)
The throughput achieved for 40 samples was 17 min for FBC and
× 109/l
PLT-F, 120 0.97 −15.3 1.09 3.40(−20.99 to DIFF analysis.
× 109/la 27.79)
Ret, % 120 0.96 0.5 0.64 − 0.18 (− 0.34 to 3.6. Comparison study
− 0.02)

WBC, white blood cell; RBC, red blood cell; Hb, hemoglobin; Hct, hematocrit; PLT-I,
platelet (impedance); PLT-F, platelet (fluorescent); Ret, reticulocyte count.
a
PLT-F compared to PLT-I on the Sysmex XN 9000.
criteria were used to define an abnormal (positive) peripheral blood
smear (PBS) result [9]. Blinded-review of the study PBS was in-
dependently performed by two competent observers. In the event of
discrepant counts, the PBS were reviewed by a third observer. True
positive rates (%), false positive rates (%), true negative rates (%), false
negative rates (%) and review rates (%) were calculated and evaluated.
The quality of the PBS prepared by the SP-10's was evaluated by two
competent observers [5].
3. Results
The results of the XN-20 analytical module capable of processing up
to 100 samples per hour are presented.
3.1. Precision
The XN-9000 showed good imprecision for the measurement of
normal and abnormal high and low controls for all parameters
The correlations between the XN-9000 and the Advia (2)120 were
excellent (Tables 3 and 4). Further, the bias was small with few outliers
for the WBC, RBC, Hb, Hct and Ret (Fig. 2). On investigation, the
outliers included micro tubes for pediatric patients owing to low sample
volume. The PLT-I measured on the XN 9000 was higher in comparison
to the ADVIA (2)120 with a % bias of 17.76% (14.07 to 21.44%).
However, the 95% limits of agreement were very wide. The PLT-F was
reflexed in 84 samples and compared with the optical platelet count
with a small % bias observed. All PBS prepared by the SP 10 were of
acceptable quality with no artifacts or stain precipitate observed. The
correlations for the manual differential were excellent with the excep-
tion of the basophil comparison owing to the low numbers (r = 0.56)
[7]. Samples with abnormal low WBC counts analyzed on the low WBC
mode also showed good correlation with the manual DIFF (r = 0.93).
Table 5. shows the sensitivity, specificity and efficiency of the mor-
phology flags as compared to manual PBS review on 275 samples. There
were 39 (14%) false negative results of which 16 (6%) were RBC flags,
11 (4%) were PLT flags and 12 (4%) were WBC flags. There were 74
blast/abnormal lymphocyte flags from the WDF channel which trig-
gered a reflex measurement in the WPC channel. WPC reflex analysis
generated 31 ‘blast?’ and 17 ‘abnormal lymphocyte?’ flags. Analysis of
these results is shown in Table 5. The WPC channel increased the
specificity and efficiency of the abnormal WBC flags and correctly

Table 4
Comparison between manual method (reference method) and the Sysmex XN-9000 (validation method) for the differential count.

Parameter Units N Correlation coefficient (r) Intercept Slope Bias (95% limit of agreement)

NEUT % 60 0.98 − 0.5 0.94 −2.1 (− 4.57 to 0.36)

LYMPH % 60 0.98 2.1 0.94 1.38 (−0.87 to 3.63)
MONO % 60 0.98 0.4 1.17 2.19 (−4.17 to 8.55)
EOS % 60 0.97 0.2 0.97 0.17 (−1.12 to 1.47)
BASO % 60 0.56 0.3 0.47 0.27 (−0.63 to 1.17)
NRBC % 60 0.99 0.3 0.82 0.08 (−0.23 to 0.39)

NEUT, neutrophil; LYMPH, lymphocyte; MONO, monocyte; EOS, eosinophil; BASO, basophil; NRBC, nucleated red blood cell.

135
E. Schapkaitz, S. Raburabu Clinical Biochemistry 53 (2018) 132–138

Fig. 2. Bland - Altman Difference Plots.

136
E. Schapkaitz, S. Raburabu Clinical Biochemistry 53 (2018) 132–138

Table 5
Performance of the Sysmex XN morphology flags as compared to manual peripheral blood smear review.

Flag N True positive False negative False positive True negative Sensitivity (%) Specificity (%) Efficiency (%)

Red cell fragments 209 17 10 4 178 63 89 77

Dimorphic red cells 203 6 6 2 189 50 88 71
NRBC 208 22 0 3 183 100 89 94
Platelet clumping 212 9 8 13 179 53 71 66
Large platelets 118 8 3 9 197 73 70 71
Immature granuloctyes 211 17 4 6 184 81 82 81
Blasts/Abnormal lymphocytes 218 20 0 53 145 100 73 76
Atypical lymphocytes 209 23 8 18 160 74 73 74
Blasts (WPC flag) 196 12 0 19 165 100 90 95
Abnormal lymphocyte (WPC flag) 182 6 0 11 165 100 94 94

NRBC, nucleated red blood cell; WPC, white cell precursor channel.

suppressed the initial WDF blast/abnormal lymphocyte flag in 25 (34%)
of the reflexed samples.
4. Discussion
In this study, the performance of the Sysmex XN-9000 automated
system and the new measurement channels were evaluated and com-
pared with the ADVIA (2)120 and the manual method. Adult and pe-
diatric samples with abnormal WBC populations and counts at the
upper and lower limit of the analytical range were included.
The XN-9000 showed acceptable imprecision, good linearity for
high and low ranges and < 0.82% carryover which is comparable with
other hematology analyzers [10–14]. Although the manufacturer's
claims are higher than the throughput achieved on the XN-9000, the
performance was adequate to meet the laboratory's requirements. The
new PLT-F also showed acceptable imprecision of < 4% in particular in
the low range. This, however, was not significantly lower when com-
pared to the PLT-I. The PLT-F channel has been designed to specifically
optimize the management of patients with thrombocytopenia. Several
studies have demonstrated the improved precision as well as accuracy
of the new PLT-F channel [13,15]. Similarly, in this study the PLT-F
compared with the optical platelet count on thrombocytopenic samples
(r = 0.99). Comparison to the ICSH reference flow cytometric method
was however not possible, which is a limitation of this study.
A further limitation of this study is that PLT-F was not reflexed on
assessment of stability. A recent study demonstrated reduced PLT-F
stability in samples stored at RT beyond 48 h [13]. In this study, the Hct
(and MCV) were stable until 12 h in samples stored at RT. As such it is
necessary to process samples stored at RT for FBC analysis on the XN-
9000 within 12 h. Other studies, however, have employed different
statistical methods and have demonstrated a longer stability of up to
24 h at RT [16–18]. The Ret however was stable at RT for at least 72 h
after collection. This concurs with the findings of other hematology
analyzers such as the Coulter LH 750, Sysmex XE-2100 and Cell-DYN
Sapphire [18–19]. Storage of samples at 4–8 °C for 72 h increased the
stability of the FBC and Ret parameters. However, the stability of some
DIFF parameters, namely % eosinophils, % basophils and % monocytes,
did not improve.
The XN-9000 showed comparable performance with the ADVIA (2)
120 for the FBC and Ret, despite the use of different technologies. There
was no significant difference observed in the Ret between the two
analyzers using different fluorescent nucleic acid dyes. Similarly,
Ciepiela et al. found concordant Ret performance with the Mindray BC-
6800 (Mindray, Shenzhen, China) which uses cyanine, the Beckman
Coulter LH 750 (Beckman Coulter, Miami, USA) which uses methylene
blue and the XN 2000 which uses polymethine dye [20]. In addition,
the smear and staining of slides prepared by the SP-10 was excellent.
The six-part DIFF showed excellent correlation with the manual re-
ference method. Basophils, however, as described by others, showed a
poor correlation [20–21]. The NRBC count from the WNR channel also
showed an excellent correlation with the manual method. This will
assist in reducing the number of slides requiring manual DIFF.
Lastly, we evaluated the performance of the instrument generated
morphology flags from the WDF channel. The overall sensitivity, spe-
cificity and efficiency were excellent which confirms the results of
previous investigators [12,14]. Use of the WPC channel improved the
abnormal WBC flagging efficiency. In the dedicated WPC channel, the
fluorescent dye (Fluorocell WPC, Sysmex Diagnostics) binds to the in-
tracellular nucleic acid content after cell lysis (Lysercell WPC, Sysmex
diagnostics). Blasts, abnormal lymphocytes and atypical lymphocytes
are separated from mature and reactive cells according to the lipid and
nucleic acid composition. The abnormal WBC populations are identified
according to the adaptive cluster analysis which takes into account
differences in scattered light and fluorescence signal with a proprietary
algorithm [2]. With the addition of the WPC analysis to the WDF
channel, we observed a 34% reduction in the manual PBS review rate.
The WPC showed an excellent sensitivity for the detection of blasts and
abnormal lymphocytes of 100% as well as a higher specificity which
concurs with other studies [12–13,22]. In the presence of leucopenia,
however, a higher false positive rate for abnormal WBC flags was ob-
served. This study adds to the evidence that WPC reflex channel has an
enhanced analytical capability for the differentiation of abnormal WBC
populations [12,14].
In conclusion, the new measurement channels, WPC, WDF, WNR
and PLT-F show enhanced analytical performance. The WPC channel
improved the abnormal WBC flagging efficiency from the WDF channel
and reduced the number of PBS requiring manual review. The NRBC
count from the WNR channel showed an excellent correlation with the
manual differential. The PLT-F channel provided accurate and precise
results on thrombocytopenic samples. The Sysmex XN-9000 is suitable
for academic laboratories with a large volume of abnormal samples.
Acknowledgements
We would like to thank the staff members of hematology.
Declaration of conflict of interests
The author(s) declare no conflicts of interest with respect to the
authorship and/or publication of this article.
Appendix A. Supplementary data
Supplementary data to this article can be found online at https://
doi.org/10.1016/j.clinbiochem.2018.01.014.
References
[1] J. Hotton, et al., Performance and abnormal cell flagging comparisons of three
automated blood cell counters: Cell-Dyn Sapphire, DxH-800, and XN-2000, Am. J.
Clin. Pathol. 140 (6) (2013) 845–852.

137
E. Schapkaitz, S. Raburabu
[2] Sysmex Corporation, Instruction for Use XN-series (for XN-9000 system), 2nd edn,
Sysmex Corporation, Kobe, Japan, 2011.
[3] International Council for Standardization in Haematology, G. W., et al., ICSH
guidelines for the evaluation of blood cell analysers including those used for dif-
ferential leucocyte and reticulocyte counting, Int. J. Lab. Hematol. 36 (6) (2014)
613–627.
[4] ISO, Medical Laboratories - Particular Requirements for Quality and Competence.
ISO 15189, ISO, Geneva, 2012.
[5] P.A. Wayne, Reference Leukocyte (WBC) Differential Count (Proportional) and
Evaluation of Instrumental Methods; Approved Standard, Second Edition, Clinical
and Laboratory Standards Institute, 2007 H26 - A2.
[6] P.A. Wayne, Validation, Verification, and Quality Assurance of Automated
Hematology Analyzer, Approved Standard-Second Edition, Clinical and Laboratory
Standards Institute, 2010.
[7] J.Y. Vis, A. Huisman, Verification and quality control of routine hematology ana-
lyzers, Int. J. Lab. Hematol. 38 (Suppl. 1) (2016) 100–109.
[8] A. Rabinovitch, et al., Validation, Verification, and Quality Assurance of Automated
Hematology Analyzers; H26-A2, Clinical and Laboratory Standards Institute, 2010
ISSN 0273-3099, ISBN 1-56238-728-6.
[9] P.W. Barnes, et al., The international consensus group for hematology review:
suggested criteria for action following automated CBC and WBC differential ana-
lysis, Lab. Hematol. 11 (2) (2005) 83–90.
[10] T. Ghys, R. Malfait, V.A.N.D.B. J., Performance evaluation of the Sysmex XS-1000i
automated haematology analyser, Int. J. Lab. Hematol. 31 (5) (2009) 560–566.
[11] S.Y. Jo, et al., Performance evaluation of recently launched Sysmex XN-550
Automatic Hematology Analyzer, Int. J. Lab. Hematol. 39 (1) (2017) e4-e9.
[12] I. Perez, et al., Local verification between the hematological analyzers Sysmex XN-
series and XE-5000, Int. J. Lab. Hematol. 38 (3) (2016) 256–264.
[13] J.Y. Seo, S.T. Lee, S.H. Kim, Performance evaluation of the new hematology
138
Clinical Biochemistry 53 (2018) 132–138
analyzer Sysmex XN-series, Int. J. Lab. Hematol. 37 (2) (2015) 155–164.
[14] M.A. van Dievoet, H. Louagie, T. Ghys, Performance evaluation of the Sysmex((R))
XP-300 in an oncology setting: evaluation and comparison of hematological para-
meters with the Sysmex((R)) XN-3000, Int. J. Lab. Hematol. 38 (5) (2016) 490–496.
[15] M. Schoorl, et al., Multicenter verification of the Sysmex XN-Series, Int. J. Lab.
Hematol. 39 (5) (2017) 489–496.
[16] G. Bourner, J. Dhaliwal, J. Sumner, Performance evaluation of the latest fully au-
tomated hematology analyzers in a large, commercial laboratory setting: a 4-way,
side-by-side study, Lab. Hematol. 11 (4) (2005) 285–297.
[17] G.L. Gulati, et al., Changes in automated complete blood cell count and differential
leukocyte count results induced by storage of blood at room temperature, Arch.
Pathol. Lab. Med. 126 (3) (2002) 336–342.
[18] P. Hedberg, T. Lehto, Aging stability of complete blood count and white blood cell
differential parameters analyzed by Abbott CELL-DYN Sapphire hematology ana-
lyzer, Int. J. Lab. Hematol. 31 (1) (2009) 87–96.
[19] F. Imeri, et al., Stability of hematological analytes depends on the hematology
analyser used: a stability study with Bayer Advia 120, Beckman Coulter LH 750 and
Sysmex XE 2100, Clin. Chim. Acta 397 (1–2) (2008) 68–71.
[20] O. Ciepiela, et al., A comparison of Mindray BC-6800, Sysmex XN-2000, and
Beckman Coulter LH750 automated hematology analyzers: a pediatric study, J.
Clin. Lab. Anal. 30 (6) (2016) 1128–1134.
[21] B.T. Tan, A.J. Nava, T.I. George, Evaluation of the Beckman Coulter UniCel DxH
800 and Abbott Diagnostics Cell-Dyn Sapphire hematology analyzers on pediatric
and neonatal specimens in a tertiary care hospital, Am. J. Clin. Pathol. 135 (6)
(2011) 929–938.
[22] A.S. Jones, et al., The value of the white precursor cell channel (WPC) on the
Sysmex XN-1000 analyser in a specialist paediatric hospital, J. Clin. Pathol. 68 (2)
(2015) 161–165.