New red blood cell and reticulocyte parameters and reference values for
               healthy individuals and in chronic kidney disease

Scherer, Patrícia S.; Moraes, Daniela; Munhoz, Terezinha P.; Sgnaolin, Vanessa

doi:10.5935/1676-2444.20150014

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Laboratory Medicine • J. Bras. Patol. Med. Lab. 51 (2) • Mar-Apr 2015 • https://doi.org/10.5935/1676-2444.20150014 copy

New red blood cell and reticulocyte parameters and reference values for healthy individuals and in chronic kidney disease

Novos parâmetros e valores de referência eritrocitários e reticulocitários normais e na doença renal crônica

Authorship SCIMAGO INSTITUTIONS RANKINGS

Introduction:

The importance of local references values has been well described in the literature; this is because the characteristics of the population may influence the laboratory tests.

Objective:

To establish the reference range for traditional and extended red blood cell parameters and reticulocyte indices in order to investigate its application in patients with chronic kidney disease (CKD).

Materials and methods:

249 blood donors (125 males and 124 females) were selected to establish the reference values. The hemodialysis sample consisted of 62 patients with terminal CKD (48 male and 14 female). All analyzes were performed using the Sysmex XE-5000 automated hematology analyzer.

Results:

Differences between reference values was observed in relation to gender: red blood cells (RBC), hemoglobin (HGB), hematocrit (HCT), mean corpuscular hemoglobin concentration (MCHC), percentage of hyperchromic red blood cells (%HYPER), percentage of microcytosis (%MICRO), percentage of macrocytosis (%MACRO), absolute reticulocyte count (RET), reticulocyte hemoglobin content (RET-He), immature reticulocyte fraction (IFR), low fluorescence reticulocytes (LFR), medium fluorescence reticulocytes (MFR), and high fluorescence reticulocytes (HFR). Individuals with CKD presented RBC, HGB, HCT, MCHC, red cell distribution width expressed as coefficient of variation (RDW-CV), percentage of hypochromic red blood cells (%HYPO), percentage of reticulocytes (RET%), RET (female group), IFR, LFR, MFR, and HFR results compatible with the anemic state, which can be observed in 91.8% of patients. All studied parameters were in the area under the curve (AUC) > 0.4. In male group, %HYPO (AUC: 0.806) and IFR (AUC: 0.762) presented higher AUC values, while female group presented %HYPO (AUC: 0.806), %HYPER (AUC: 0.815), and IFR (AUC: 0.660).

Conclusion:

The medical advancement, the development of new techniques and hematological parameters have revealed important information about functional integrity of bone marrow, diagnosis of anemia and recombinant human erythropoietin monitoring therapy used in hemodialysis patients.

reference values; red blood cell indices; reticulocytes; chronic renal failure

Variable	Healthy individuals				P
	Male (n = 125)		Female (n= 124)
	Mean (SD)	RV 95%	Mean (SD)	RV 95%
RBC (10⁶/μl)	4.83 (0.39)	3.92-5.37^* * Kolmogorov-Smirnov test (p < 0.05);	4.26 (0.30)	3.66-4.85	< 0.001^# # Student’s t-test;
HGB (g/dl)	14.38 (1.05)	12.32-16.45	12.59 (0.77)	11.09-14.09	< 0.001^# # Student’s t-test;
HCT (%)	41.50 (3.80)	34.55-46.69^* * Kolmogorov-Smirnov test (p < 0.05);	37.24 (2.26)	32.81-41.66	< 0.001^# # Student’s t-test;
MCV (fl)	86.66 (3.47)	79.85-93.46	87.57 (3.94)	79.84-95.29	0.055^# # Student’s t-test;
MCH (pg)	29.97 (1.47)	27.08-32.85	29.55 (1.78)	26.00-32.95^* * Kolmogorov-Smirnov test (p < 0.05);	0.088^# # Student’s t-test;
MCHC (g/dl)	34.70 (1.30)	32.51-36.38^* * Kolmogorov-Smirnov test (p < 0.05);	33.85 (0.89)	32.10-35.60	< 0.001^# # Student’s t-test;
RDW-CV (%)	12.80 (0.90)	11.91-14.27^* * Kolmogorov-Smirnov test (p < 0.05);	12.80 (0.78)	11.90-14.66^* * Kolmogorov-Smirnov test (p < 0.05);	0.892^§ § Mann-Whitney U-test.
RBC-He (pg)	30.35 (1.29)	27.81-32.88	30.26 (1.34)	27.64-32.89	0.609^# # Student’s t-test;
%HYPO	0.20 (0.10)	0.10-0.78^* * Kolmogorov-Smirnov test (p < 0.05);	0.20 (0.10)	0.10-1.09^* * Kolmogorov-Smirnov test (p < 0.05);	0.520^§ § Mann-Whitney U-test.
%HYPER	1.00 (0.20)	0.80-1.30^* * Kolmogorov-Smirnov test (p < 0.05);	0.90 (0.20)	0.70-1.10^* * Kolmogorov-Smirnov test (p < 0.05);	< 0.001^§ § Mann-Whitney U-test.
%MICRO	1.40 (1.15)	0.51-4.39^* * Kolmogorov-Smirnov test (p < 0.05);	1.30 (0.98)	0.31-6.55^* * Kolmogorov-Smirnov test (p < 0.05);	0.027^§ § Mann-Whitney U-test.
%MACRO	5.90 (0.95)	4.71-9.54^* * Kolmogorov-Smirnov test (p < 0.05);	5.45 (0.98)	4.21-9.15^* * Kolmogorov-Smirnov test (p < 0.05);	< 0.001^§ § Mann-Whitney U-test.
RET (%)	1.32 (0.64)	0.68-2.71^* * Kolmogorov-Smirnov test (p < 0.05);	1.36 (0.45)	0.48-2.25	0.794^# # Student’s t-test;
RET (μl)	0.07 (0.02)	0.02-0.11	0.06 (0.02)	0.02-0.09	0.003^# # Student’s t-test;
RET-He (pg)	33.63 (1.70)	30.30-36.96	33.18 (1.71)	29.81-36.54	0.038^# # Student’s t-test;
IFR (%)	6.62 (3.22)	2.11-14.14^* * Kolmogorov-Smirnov test (p < 0.05);	5.10 (2.78)	1.59-12.30^* * Kolmogorov-Smirnov test (p < 0.05);	0.010^§ § Mann-Whitney U-test.
LFR (%)	93.90 (4.45)	85.86-97.88^* * Kolmogorov-Smirnov test (p < 0.05);	94.90 (2.77)	87.70-98.41^* * Kolmogorov-Smirnov test (p < 0.05);	0.010^§ § Mann-Whitney U-test.
MFR (%)	5.70 (3.55)	1.91-12.41^* * Kolmogorov-Smirnov test (p < 0.05);	4.80 (2.60)	1.56-11.25^* * Kolmogorov-Smirnov test (p < 0.05);	0.008^§ § Mann-Whitney U-test.
HFR (%)	0.50 (0.70)	0.00-1.90^* * Kolmogorov-Smirnov test (p < 0.05);	0.30 (0.40)	0.00-1.60^* * Kolmogorov-Smirnov test (p < 0.05);	0.029^§ § Mann-Whitney U-test.

Variable	Sex	Healthy individuals - Mean (SD)	CKD patients - Mean (SD)	P
RBC (10⁶/pl)	M	4.80 (0.34)	3.65 (0.55)	< 0.001^# # Student’s t-test;
RBC (10⁶/pl)	F	4.26 (0.30)	3.21 (0.76)	< 0.001^# # Student’s t-test;
HGB (g/dl)	M	14.38 (1.05)	11.03 (1.47)	< 0.001^# # Student’s t-test;
HGB (g/dl)	F	12.59 (0.77)	9.59 (2.05)	< 0.001^# # Student’s t-test;
HCT (%)^* * Kolmogorov-Smirnov test (p < 0.05);	M	41.09 (4.77)	33.39 (4.59)	< 0.001^§ § Mann-Whitney U-test.
HCT (%)^* * Kolmogorov-Smirnov test (p < 0.05);	F	37.24 (2.26)	28.91 (6.46)	< 0.001^§ § Mann-Whitney U-test.
MCV (fl)	M/F	87.11 (3.73)	91.42 (5.65)	< 0.001^# # Student’s t-test;
MCH (pg)	M/F	29.81 (1.48)	30.24 (2.07)	0.058^# # Student’s t-test;
MCHC (g/dl)	M	34.51 (1.25)	33.04 (1.05)	< 0.001^# # Student’s t-test;
MCHC (g/dl)	F	33.85 (0.89)	33.17 (1.07)	0.009^# # Student’s t-test;
RDW-CV (%)^* * Kolmogorov-Smirnov test (p < 0.05);	M/F	12.80 (0.90)	14.70 (2.00)	<0.001^§ § Mann-Whitney U-test.
RBC-He (pg)	M/F	30.31 (1.31)	30.37 (2.22)	0.781^# # Student’s t-test;
%HYPO^* * Kolmogorov-Smirnov test (p < 0.05);	M/F	0.20 (0.10)	0.80 (1.25)	<0.001^§ § Mann-Whitney U-test.
%HYPER^* * Kolmogorov-Smirnov test (p < 0.05);	M	1.03 (0.12)	1.27 (1.56)	0.169^§ § Mann-Whitney U-test.
%HYPER^* * Kolmogorov-Smirnov test (p < 0.05);	F	0.90 (0.11)	0.83 (0.27)	0.040^§ § Mann-Whitney U-test.
%MICRO^* * Kolmogorov-Smirnov test (p < 0.05);	M	1.67 (0.99)	2.32 (2.62)	0.519^§ § Mann-Whitney U-test.
%MICRO^* * Kolmogorov-Smirnov test (p < 0.05);	F	1.56 (1.60)	2.11 (1.74)	0.198^§ § Mann-Whitney U-test.
%MACRO^* * Kolmogorov-Smirnov test (p < 0.05);	M	6.13 (1.08)	9.21 (5.70)	< 0.001^§ § Mann-Whitney U-test.
%MACRO^* * Kolmogorov-Smirnov test (p < 0.05);	F	5.67 (1.10)	6.84 (2.56)	0.149^§ § Mann-Whitney U-test.
RET (%)^* * Kolmogorov-Smirnov test (p < 0.05);	M/F	1.31 (0.61)	1.86 (1.40)	< 0.001^§ § Mann-Whitney U-test.
RET (μl)	M	0.066 (0.025)	0.071 (0.033)	0.310^# # Student’s t-test;
RET (μl)	F	0.058 (0.019)	0.080 (0.043)	< 0.001^# # Student’s t-test;
RET-He (pg)	M	33.63 (1.70)	32.95 (3.24)	0.077^# # Student’s t-test;
RET-He (pg)	F	33.18 (1.71)	33.32 (2.01)	0.768^# # Student’s t-test;
IFR (%)^* * Kolmogorov-Smirnov test (p < 0.05);	M	6.62 (3.22)	14.13 (7.27)	< 0.001^§ § Mann-Whitney U-test.
IFR (%)^* * Kolmogorov-Smirnov test (p < 0.05);	F	5.58 (2.44)	16.34 (9.15)	< 0.001^§ § Mann-Whitney U-test.
LFR (%)^* * Kolmogorov-Smirnov test (p < 0.05);	M	93.37 (3.22)	85.34 (7.34)	< 0.001^§ § Mann-Whitney U-test.
LFR (%)^* * Kolmogorov-Smirnov test (p < 0.05);	F	94.41 (2.46)	83.66 (9.15)	< 0.001^§ § Mann-Whitney U-test.
MFR (%)^* * Kolmogorov-Smirnov test (p < 0.05);	M	6.02 (2.78)	11.64 (4.59)	< 0.001^§ § Mann-Whitney U-test.
MFR (%)^* * Kolmogorov-Smirnov test (p < 0.05);	F	5.14 (2.22)	12.02 (4.55)	< 0.001^§ § Mann-Whitney U-test.
HFR (%)^* * Kolmogorov-Smirnov test (p < 0.05);	M	0.60 (0.54)	3.01 (3.22)	< 0.001^§ § Mann-Whitney U-test.
HFR (%)^* * Kolmogorov-Smirnov test (p < 0.05);	F	0.45 (0.43)	4.32 (5.22)	0.001^§ § Mann-Whitney U-test.

Variable	Sex	AUC	Cut-off (Youden's index)	Sensitivity	Specificity
%HYPO	M/F	0.806	0.350	67.8	84.5
%HYPER	M	0.626	0.950	54.4	78.3
%HYPER	F	0.815	0.850	75.8	79.0
%MICRO	M	0.466	4.45	12.3	98.3
%MICRO	F	0.604	0.850	87.9	30.5
%MACRO	M	0.626	7.15	47.4	87.0
%MACRO	F	0.657	5.05	48.5	81.0
RET (%)	M/F	0.611	1.69	41.1	78.2
RET (μl)	M	0.474	0.094	19.3	90.4
RET (μl)	F	0.418	0.082	15.2	88.6
RET-He (pg)	M	0.534	31.65	26.3	88.7
RET-He (pg)	F	0.608	33.95	84.8	42.9
IFR (%)	M	0.762	9.85	63.2	87.0
IFR (%)	F	0.660	7.40	48.5	84.8
LFR (%)	M	0.778	90.15	64.9	87.0
LFR (%)	F	0.660	92.60	48.5	84.8
MFR (%)	M	0.779	7.60	75.4	77.4
MFR (%)	F	0.673	7.25	45.5	87.6
HFR (%)	M	0.767	0.95	71.9	78.3
HFR (%)	F	0.529	2.70	15.2	99.0

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[1] MAILING ADDRESS Vanessa Sgnaolin:, Laboratório de Bioquímica, Genética Molecular e Parasitologia; Instituto de Geriatria e Gerontologia; Pontifícia Universidade Católica do Rio Grande do Sul (PUCRS); Avenida Ipiranga, 6690, 3º andar; CEP: 90610-000; Porto Alegre-RS, Brazil; Phone: +55 (51) 3320-3000, ramal 2660; e-mail: vanessasgnaolin@yahoo.com.br.