International Journal of Laboratory Hematology

The Ofcial journal of the International Society for Laboratory Hematology

ORIGINAL ARTICLE

INTERNATIONAL JOURNAL OF LABORATO RY HEMATO LOGY

Analysis of reticulocyte parameters on the Sysmex XE 5000 and LH 750 analyzers in the diagnosis of inefcient erythropoiesis
E. URRECHAGA*, L. BORQUE , J. F. ESCANERO

*Hematology Laboratory, Hospital Galdakao Usansolo, Galdakao, Vizcaya, Spain Department of Pharmacology and Physiology, Faculty of Medicine, University of Zaragoza, Zaragoza, Spain Correspondence: Dra Elosa Urrechaga, Hematology Laboratory, Hospital Galdakao Usansolo, 48960 Galdakao, Vizcaya, Spain. Tel.: +34 94 400 7102; Fax: +34 94 400 7128; E-mail: eloisa.urrechagaigartua@ osakidetza.net
doi:10.1111/j.1751-553X.2010.01238.x

SUMMARY

Received 26 November 2009; accepted for publication 18 March 2010 Keywords Erythropoiesis, reticulocyte hemoglobin equivalent (Ret He), red blood cell size factor (RSf), anemia

The reticulocyte hemoglobin equivalent (Ret He) represents an indirect measure of the functional iron available for erythropoiesis over the previous 23 days. Only the analyzers of a single manufacturer, Sysmex (Sysmex Corporation, Kobe, Japan), include Ret He. Red blood cell size factor (RSf) is a new parameter provided by Beckman Coulter, which joins together the volume of the erythrocytes and the volume of p reticulocytes. RSf MCV MRV The aims of the study were to investigate the clinical usefulness of RSf in the study of erythropoiesis status and to assess its concordance with Ret He values. Samples from 417 patients were run on both LH 780 (Beckman Coulter) and Sysmex XE 5000 analyzers. Independent samples t-test, Pearson correlation, receiver operating characteristic (ROC) analysis and inter-rater reliability (j index) were applied. Good correlation between RSf and Ret He was observed, r = 0.8184. Signicant differences (P < 0.001) were detected when groups with inefcient erythropoiesis were compared with patients undergoing therapy and healthy subjects. ROC analysis for RSf in the diagnosis of inefcient erythropoiesis, cutoff 91.1 , area under curve 0.963, sensitivity 91.7%, specicity 88.5%. Concordance between RSf and Ret He j = 0.68. RSf and Ret He are suitable parameters for the assessment of erythropoiesis status.

INTRODUCTION
Automated blood cell counters have changed deeply over the last 20 years. Reliable and accurate counts of red cell indices including the reticulocyte count are now standard. Reticulocytes are immature erythrocytes (RBC) representing the output of erythroid proliferation;
2010 Blackwell Publishing Ltd, Int. Jnl. Lab. Hem. 2011, 33, 3744

they are only for a few days (11.5) recognizable in peripheral blood before developing into mature RBC. Reticulocytes have acquired great interest and importance following the introduction of instruments that use dyes specic for RNA. This has resulted in precise and accurate counts even at low concentrations. The latest generation of automated analyzers provides additional information, such as the mean
37

38

E. URRECHAGA, L. BORQUE AND J. F. ESCANERO

RSF IN DIAGNOSIS OF RESTRICTED ERYTHROPOIESIS

reticulocyte volume (MRV) and reticulocyte hemoglobin content (CHr, Ret He). The blood concentration of reticulocytes represents a quantitative measure of erythropoiesis, while the reticulocyte parameters provide real-time information about the quality of the erythropoiesis (Brugnara, 2000). There has been much interest in the potential use of new reticulocyte parameters in the diagnosis of anemias and in monitoring the erythropoiesis status (Macdougall et al., 1992; Fishbane et al., 1997; Mast et al., 2002; Canals et al., 2005; Thomas et al., 2005; David et al., 2006; Garzia et al., 2007). The measurement of reticulocyte hemoglobin content (CHr) is a direct assessment of the incorporation of iron into erythrocyte hemoglobin (Hb) and thus is an estimate of the recent functional availability of iron into the erythron (Brugnara, 2003). CHr has been used as a diagnostic tool, together with biochemical markers, to distinguish iron-deciency anemia (IDA) from anemia of the chronic diseases, and it is incorporated to National Kidney Foundation, Kidney Disease Outcomes Quality Initiative (NKF-K/DOQI) guidelines for the monitoring of recombinant human erythropoietin (rHuEPO) therapy (NKF-K/DOQI, 2006). To date, the measurement of CHr has been restricted to the analyzers of a single manufacturer, Siemens (Siemens Medical Solutions Diagnostics, Tarrytown, NY, USA). A second manufacturer has produced a comparable index, the so-called reticulocyte hemoglobin equivalent (Ret He) generated by the Sysmex analyzers (Sysmex Corporation, Kobe, Japan). Measurements of Ret He provide useful information in diagnosing anemia, iron-restricted erythropiesis and functional iron deciency and response to iron therapy during r-HuEPO. Twenty-nine picograms is the cutoff value that denes decient erythropoiesis (Buttarello et al., 2004; Canals et al., 2005; Brugnara, Schiller & Moran, 2006; Thomas et al., 2006). Ret He correlates with CHr with the same clinical meaning (Mast, Blinder & Dietzen, 2008). Modern hematological counters, based on principles of impedance, report the volume of the reticulocytes (MRV) (Abbott Laboratories, Abbott Park, IL, USA; Beckman Coulter; Beckman Coulter Inc., Miami, FL, USA; Horiba-ABX Inc., Irvine, CA, USA). The measurement of MRV could provide real-time data

regarding certain aspects of erythropoiesis that can inuence the dimensions of red cells, i.e. the effective iron availability. Few studies have been carried out concerning the clinical usefulness of MRV. In subjects with depleted iron stores, this parameter increases rapidly when iron supplements are administered and decreases quickly during iron-decient erythropoiesis (dOnofrio et al., 1995; Brugnara, 1998). MRV has been also used to establish the success of a marrow transplant, as a marker of bone marrow normalization (Torres et al., 2001). Beckman Coulter has recently introduced a new parameter on the LH series analyzers. Red blood cell size factor (RSf) joins together the volume of mature red cells (MCV) and the volume of reticulocytes (MRV), both related to erythropoietic activity and hemoglobinization. p MCV MRV

RSf

When MCV is measured what is measured is the average size or volume of the red blood cells produced in a period of 120 days before the sample is drawn; on the other hand, when MRV is measured what is measured is the size or volume of the more recently produced red cells, within a period of <3 days before the analysis is performed: Because in both mature red cells and reticulocytes above 90% cellular contents are Hb, the size of these cells directly correlates with the Hb content of the cells. RSf, as a product function of MCV and MRV, reects indirectly the cellular Hb content of both reticulocyte and red blood cells; adding the square root averages both volumes and the units in which RSf is expressed in femtoliters. Examining both precursors and mature cells provides an opportunity to detect and monitor acute and chronic changes in the cell volume, related to cellular hemoglobin and the amount of the iron supply. The reference range (91.1106.9 ) and the mean values of RSf in different clinical situations have been previously described (Urrechaga, 2009). The aims of the study were to establish the correlation between RSf and Ret He in normal population and in different types of anemia and to assess the optimal cutoff for the detection of restricted erythropoiesis, in terms of concordance with Ret He.
2010 Blackwell Publishing Ltd, Int. Jnl. Lab. Hem. 2011, 33, 3744

E. URRECHAGA, L. BORQUE AND J. F. ESCANERO

RSF IN DIAGNOSIS OF RESTRICTED ERYTHROPOIESIS 39

MATERIALS AND METHODS

Patients A previous work on RSf has been published; the present study has been conducted independently, during a 4-month period (October 2009January 2010); the patients are different from those included in the previous study. Samples from 90 healthy individuals, 124 patients with IDA, 105 patients with chronic kidney disease (CKD) and 98 b thalassemia carriers, collected in K3 EDTA anti-coagulant tubes (Vacutainer BectonDickinson, Rutherford, NJ, USA), were extracted from the routine workload and prospectively analyzed on the two automated counters Sysmex SE 5000 (Sysmex Corporation) and LH 780 (Beckman Coulter Inc.), within 6 h of collection. Members of the staff of the Hematology Laboratory processed the samples in batch on the LH 780 analyzer and later, within 90 min, on the Sysmex XE 5000; the amount of sample required is 300 ll (LH 780), while Sysmex XE 5000 employs 200 ll. The healthy group included 45 male and 45 female healthy adult subjects, with no clinical symptoms of disease and results within reference ranges in the complete blood count and biochemical iron metabolism markers. Patients with IDA who fullled the traditional diagnostic criteria for IDA diagnosis, serum iron <7.5 lM, transferrin saturation <20%, ferritin <50 lg/l, hemoglobin (Hb) <110 g/l and C reactive protein <5 mg/l, were included before iron treatment. Patients with CKD were managed according to the recommendations of the NKF-K/DOQI guidelines (6). All patients were treated with a variety of rHuEPO doses given three times a week, at the time of hemodialysis treatment. In addition, the majority of patients were treated with a maintenance dose of intravenous iron (100200 mg of iron gluconate) weekly or every other week to maintain Hb at the recommended level 110120 g/l. Thalassemia group consisted of 98 patients with a previous diagnosis of b thalassemia trait. b Thalassemia screening is routinely performed in our Laboratory by means of the measure of their red blood cell indices and the level of HbA2. Molecular characterization of mutations is performed with allele 2010 Blackwell Publishing Ltd, Int. Jnl. Lab. Hem. 2011, 33, 3744

specic oligonucleotide polymerase chain reaction (ASO-PCR) techniques (Thein & Wallace, 1986; Kazazin & Boehm, 1988). Samples with erythrocytosis (RBC > 5.5 1012/l) and microcytosis (MCV < 70 ) are selected for HbA2 quantication (HPLC HA 8160; Menarini Diagnostics, Firenze, Italy). Increased HbA2 (>3.5%) is considered to be conrmatory for b thalassemia trait. Molecular analysis is performed if genetic counsel is required. Only b thalassemia carriers with ferrokinetic parameters within reference range were included. Biochemical and hematological data of patients included in the study are summarized in Table 1. Analytical methods The Sysmex XE 5000 is a recently introduced fully automated blood cell counter: this analyzer employs uorescent ow cytometry technology. In the reticulocyte channel, blood cells are stained by a polymethine dye, specic for RNA/DNA, and analyzed by ow cytometry using a semiconductor laser. A bidimensional distribution of forward scattered light and uorescence is presented as a scattergram, indicating mature red cells and reticulocytes. Forward scatter correlates with erythrocyte and reticulocyte hemoglobin equivalent (RBC He, Ret He). Beckman Coulter applies impedance principles and the Volume, Conductivity, Scatter (VCS) technology to the LH 780 analyzer. Cells are identied and classied by simultaneous three-dimensional analysis using volume, conductivity and light scatter. Volume, as measured by direct current, is used to identify the size of the cell. Conductivity, or radio frequency measurements, provides information about the internal characteristics of the cell. Light scatter measurements, obtained as cells pass through the heliumneon laser beam, provide information about cell surface characteristics and cell granularity. The Beckman Coulter procedure of reticulocyte analysis uses new methylene blue stain, a nonuorochrome dye, to precipitate the residual RNA within the reticulocytes. Blood is mixed with the new methylene blue stain and allowed to incubate for a short period of time. An acidic, hypo-osmotic, ghosting solution is then introduced, clearing the hemoglobin while preserving the stained RNA within the reticulocytes.

40

E. URRECHAGA, L. BORQUE AND J. F. ESCANERO

RSF IN DIAGNOSIS OF RESTRICTED ERYTHROPOIESIS

SD, standard deviation; RBC, red blood cells; Hb, hemoglobin; MCV, mean cell volume; MCH, mean cell hemoglobin; MCHC, mean cell hemoglobin concentration; Ret He, reticulocyte hemoglobin equivalent; Transf, transferrin; % Sat, % transferrin saturation.

(7.5) (4.3) (12) (15)

Table 1. Hematological and biochemical data in 90 healthy individuals and in three groups of patients, including 124 patients with iron-deciency anemia (IDA), 98 b thalassemia carriers and 105 patients with chronic kidney disease (CKD)

Ferritin (lg/l)

103 25 109 286

(54) (34) (99) (188)

The reliability of the results is guaranteed with the quality control: The Sysmex analyzer uses CHECK XE provided by the manufacturer. LH 780 analyzer employs Coulter 5C Cell Control and Coulter Retic C Cell Control provided by the manufacturer. Statistical evaluation of analytical results Statistical software package SPSS version 17.0 for windows was applied for statistical analysis of the results (SPSS, Chicago, IL 60606, USA). KolmogorovSmirnoff test was applied to verify the Gaussian distribution of RSf values on normal population. Correlation coefcients were calculated by Pearson method. Independent samples t-test was performed to detect statistical deviations between the groups of patients; P values <0.05 were considered to be statistically signicant. Receiver operating characteristic (ROC) curve analysis was utilized to illustrate the diagnostic performance of RSf and Ret He in the assessment of erythropoietic function. Cohens Kappa index of interrater reliability (j index) was assessed to determine the concordance between both parameters. j index has a range from 0 to 1.0, with larger values indicating better reliability; j > 0.7 is considered satisfactory.

Sat (%) Transf (g/l) Iron (lmol/l) Rsf () RetHe (pg) MCHC (g/l) MCH (pg)

30.5 23.2 20.9 29.8

(0.9) (3.1) (1.2) (2.3)

335 304 321 322

(9) (15) (66) (15)

33.8 25.2 22.6 32.4

(1.4) (4.8) (1.9) (3.6)

100.9 82.1 76.9 101.1

(4.8) (9.1) (4.1) (8.2)

17.1 4.8 16.5 10.7

(2.3) (2.8) (6.1) (5.7)

2.46 3.00 2.36 1.92

(0.3) (0.7) (0.4) (0.47)

28 7 27 24

MCV ()

(2.9) (7.6) (3.5) (5.9)

RESULTS
CHECK XE on the Sysmex XE 5000 reported Ret He mean 24.9 pg, CV 1.1% (assigned Ret He value 24.0 pg); mean 27.9 pg, CV 1.4% (assigned Ret He value 28.0 pg). Coulter 5C Cell Control on the LH 780 reported MCV mean 78.3 , CV 0.77% (assigned MCV value 78.0 ); mean 88.1 , CV 0.7% (assigned MCV value of 88.0 ). Coulter Retic C Cell Control reported MRV mean 92.3 , CV 2.5% (assigned MRV value 92.0 ); mean 108.0 , CV 1.9% (assigned MCV value 108.2 ). The values obtained for RSf in the healthy subjects ranged 91.1105 , within the reference range previously published, and normally distributed (P = 0.314). Figure 1 shows correlation between Ret He and RSf and Pearson regression coefcient 0.8184 (P < 0.001, 95% CI 0.780.85). Mean values and SD obtained for the different groups are summarized in
2010 Blackwell Publishing Ltd, Int. Jnl. Lab. Hem. 2011, 33, 3744

Hb (g/l) RBC (1012/l)

Healthy mean (SD) IDA mean (SD) b Thal mean (SD) CKD mean (SD)

4.95 4.12 6.2 3.65

(0.37) (0.74) (1.3) (0.5)

151 97 117 108

(9) (17) (11) (8)

90.9 74.2 65.1 91.8

E. URRECHAGA, L. BORQUE AND J. F. ESCANERO

RSF IN DIAGNOSIS OF RESTRICTED ERYTHROPOIESIS 41

130 120 110 RSf (fL) 100 90 80 70 60 15 20 25 30 35 Ret He (pg) 40 45

Figure 2. Box and whisker plot showing reticulocyte hemoglobin equivalent (Ret He) distribution in the three groups of patients with anemia, iron-deciency anemia, thalassemia carriers, chronic kidney disease and in the healthy group. The horizontal line in the center of the box shows the median value, the upper and lower limits of the box show the interquartile range, and the whiskers show the minimum and maximum values for each group.

Figure 1. Relationship between reticulocyte hemoglobin equivalent (Ret He) and red blood cell size factor (RSf) values, n = 417. Correlation coefcient calculated by Pearson method, r = 0.8184y = 42.9 + 1.67x.

Table 2, Figure 2 (Ret He) and Figure 3 (RSf). IDA and b thalassemia groups presented inefcient erythropoiesis, because of lack of iron or globin, as is stated by Ret He values: mean value 25.2 pg for IDA and 22.6 pg for b thalassemia carriers. b Thalassemia carriers had signicantly lower RSf values (mean 76.9 ) than the patients with IDA (82.1 , P < 0.0001). Six normocytic patients in the IDA group had RSf values 9193.5 .

Table 2. Reticulocyte hemoglobin equivalent (Ret He) and red blood cell size factor (RSf) values, mean (standard deviation), in a group of 90 healthy individuals and in the group of patients, which included 124 patients with iron-deciency anemia (IDA), 98 b thalassemia carriers and 105 patients with chronic kidney disease (CKD) Ret He (pg) mean (SD) Healthy IDA b Thalassemia CKD 33.8 25.2 22.6 32.4 (1.4) (4.8) (1.9) (3.6) (RSf ) mean (SD) 100.9 82.1 76.9 101.1 (4.8) (9.1) (4.1) (8.2)

Figure 3. Box and whisker plot showing red blood cell size factor (RSf) distribution in the three groups of patients with anemia, iron-deciency anemia, thalassemia carriers, chronic kidney disease and in the healthy group. The horizontal line in the center of the box shows the median value, the upper and lower limits of the box show the interquartile range and the whiskers show the minimum and maximum values for each group.

2010 Blackwell Publishing Ltd, Int. Jnl. Lab. Hem. 2011, 33, 3744

42

E. URRECHAGA, L. BORQUE AND J. F. ESCANERO

RSF IN DIAGNOSIS OF RESTRICTED ERYTHROPOIESIS

Patients with CKD receiving therapy maintained Ret He levels higher (mean 32.4 pg) than the cutoff value of 29 pg, which denes inefcient erythropoiesis (Buttarello et al., 2004; Canals et al., 2005; Brugnara, Schiller & Moran, 2006; Thomas et al., 2006). RSf values were high, and the mean in this group showed no statistical difference compared to the healthy group (P = 0.8210). Eight percent of the patients with CKD displayed macrocytosis with RSf values higher than that of the reference range. Signicant differences in RSf values (P < 0.001) were detected when groups with inefcient erythropoiesis (IDA and b thalassemia) were compared with patients with CKD under therapy and healthy subjects. The ROC curve analysis for RSf in the diagnosis of restricted erythropoiesis proved that the optimal cutoff point for RSf was 91.1 , which provided sensitivity 91.7%, specicity 88.5% and area under curve (AUC) 0.963 (95%, CI 0.9380.98). Ret He obtained AUC 0.930 (95%, CI 0.9020.953), P = 0.027 (Figure 4). An overall agreement of 85% between the results of

RSf and Ret He was observed, j index 0.68 (95%, CI 0.5850.775).

DISCUSSION
Hematological tests are widely used to screen for anemia. Hb, MCV, mean cell hemoglobin (MCH) and mean cell hemoglobin concentration (MCHC) are the most commonly used hematological screening test, but they are derived from the entire population of red blood cells, with a life span of about 120 days, and therefore takes some time to be altered by a state of iron deciency, absolute or functional. Consequently, relying on mature red cell parameters for screening will delay the detection of inefcient erythropoiesis. With the life span of reticulocytes in the circulation being only 2448 h, reticulocyte-dependent parameters provide a more real-time view of bone marrow activity. Measurement of reticulocyte cellular characteristics may provide useful information about marrow erythropoietic activity in a variety of anemias (Brugnara et al., 1997). In the initial phases of iron deciency and restricted erythropoiesis, uctuations in the iron supply to the bone marrow yield decreased Hb production in reticulocytes, resulting in low Hb content and also low MRV (Mast et al., 2002). Ret He generated by all Sysmex XE analyzers has been recognized as a direct assessment of the incorporation of iron into erythrocyte Hb and an estimate of the recent functional availability of iron into the erythron, thus providing the same information as CHr (Thomas et al., 2005; David et al., 2006). Beckman Coulter applies the VCS technology, and a new parameter, RSf, could be useful to investigate the bone marrow erythropoietic activity. The goal of the present study was to determine the diagnostic performance of RSf against the existing test Ret He for inefcient erythropoiesis diagnosis. The reference range for RSf was calculated with 90 apparently healthy adult subjects. A previous work on RSf has been published (Urrechaga, 2009) and the reference range in that work (91.1114.4 ) was wider than the values obtained in this study (91.3110.5 ). The reason for the different upper value obtained may be because of the limited sample size and the wide
2010 Blackwell Publishing Ltd, Int. Jnl. Lab. Hem. 2011, 33, 3744

Figure 4. Receiver operating characteristic analysis results for reticulocyte hemoglobin equivalent (Ret He) and red blood cell size factor (RSf) in the diagnosis of iron-decient erythropoiesis area under curve, RSf, 0.963 0.014; Ret He, 0.930 0.019, P = 0.027.

E. URRECHAGA, L. BORQUE AND J. F. ESCANERO

RSF IN DIAGNOSIS OF RESTRICTED ERYTHROPOIESIS 43

reference range for MCV and MRV. More studies are necessary including greater number of subjects with the purpose of verifying these results. A good correlation between RSf and Ret He has been stated. Table 2 displays the average values for RSf and Ret He; although both follow the same tendency in the four groups of patients, it is interesting to review the ampler values of SD obtained in case of RSf. The explanation could be that RSf is a calculation and the dispersion of values logically is wider than in the case of a single parameter. In the IDA group, a certain overlapping between the values obtained in healthy subjects is observed; consecutive patients were recruited, and eight normocytic patients (6.3%) were included in this group, and six of them had RSf values higher than 91.1 . Patients with inefcient erythropoiesis, because of lack of iron (IDA) or globin (thalassemia), exhibited RSf values lower than those of the healthy subjects. Because of impaired globin synthesis, microcytes in case of b thalassemia have a small volume and an abnormally low Ret He (Noronha & Grotto, 2005). b Thalassemia is characterized by an increase in the percentage of RBC with volume <60 and both the mature red cells and the reticulocytes are microcytic; RSf unites both volumes, and the values were the lowest ones of the four groups. Although Ret He and RSf resulted to be signicantly lower in b thalassemia carriers than in patients with IDA, a great overlap of individual values was observed in both groups of microcytic anemias; we conclude that these parameters may be used with caution, as indicative of iron deciency, in populations where b thalassemia minor is frequent. But, on the other hand, RSf could be helpful in the identication of b thalassemia carriers, when a patient presents low RSf value, erythrocytosis, microcytosis and normal serum ferritin. Ret He has proven to be a suitable marker of functional iron deciency and an indicator of reduced iron availability in CKDs during erythropoietin therapy (Briggs et al., 2001; Garzia et al., 2007). Patients with CKD selected for this study were receiving treatment to maintain the iron supply adequate to erythropoiesis requirements; all of them were stable, with Hb levels near the desirable value 110 g/l and normal
2010 Blackwell Publishing Ltd, Int. Jnl. Lab. Hem. 2011, 33, 3744

erythropoiesis, as Ret He values reects (mean 32.4 pg), but some hemodialyzed patients present macrocytosis with MCV and MRV values higher than the reference range, independently of rHuEPO therapy and unrelated to folate and vitamin B12 deciency. Eight percent of the patients with CKD displayed macrocytosis and, as RSf averages both volumes, the extreme values affect this parameter, and the values obtained were higher than the reference range. In the previous study (Urrechaga, 2009), the values of RSf in the CKD group were higher (mean value 110.8 ); the different percentages of patients with macrocytosis 16% in the rst studied group but only 8% in the present group can explain the discrepancy. Signicant differences in Ret He and RSf values (P < 0.001) were detected when groups with inefcient erythropoiesis (IDA and thalassemia) were compared with those with normal erythropoiesis (healthy subjects and patients with CKD undergoing therapy). Figure 4 shows the diagnostic performance of RSf and Ret He in the detection of inefcient erythropoiesis dened by iron status. The optimal cutoff point for RSf was set on 91.1 , the lower value of the reference range, which provided a sensitivity of 91.7%, a specicity of 88.5% and AUC of 0.963. This study shows that both Ret He and RSf are suitable parameters for the study of bone marrow erythropoietic activity. Ret He is an early measure of the state of erythropoiesis and describes the amount of iron contained in red cell precursors. RSf refers to the red cells volume both mature and immature. As iron availability can inuence the dimensions of red cells, this new parameter can also provide real-time data about the effective iron supply for erythropoiesis. The new parameter derived from Beckman Coulter technology seems to be an acceptable alternative to Ret He in the routine practice, with the same clinical meaning. The analysis of this new parameter can be performed simultaneously in the course of routine blood counts, with no incremental costs and no additional needs of more blood sampling. RSf, in conjunction with standard blood cell counts and iron parameters, enables the diagnosis to be made rapid and accurately.

44

E. URRECHAGA, L. BORQUE AND J. F. ESCANERO

RSF IN DIAGNOSIS OF RESTRICTED ERYTHROPOIESIS

REFERENCES
Briggs C., Rogers R., Thompson B. & Machin S.J. (2001) New red cell parameters on the Sysmex XE 2100 as potential markers of functional iron deciency. Infusion Therapy Transfusion Medicine 28, 256262. Brugnara C. (1998) Use of reticulocyte cellular indices in the diagnosis and treatment of hematological disorders. International Journal of Clinical and Laboratory Research 28, 111. Brugnara C. (2000) Reticulocyte cellular indices: a new approach in the diagnosis of anemias and monitoring of erythropoietic function. Critical Reviews in Clinical Laboratory Sciences 37, 93 130. Brugnara C. (2003) Iron deciency and erythropoiesis: new diagnostic approaches. Clinical Chemistry 49, 15731578. Brugnara C., Schiller B. & Moran J. (2006) Ret He and assessment of iron decient states. Clinical and Laboratory Haematology 28, 303308. Brugnara C., Zelmanovic D., Sorette M., Ballas S.K. & Platt O. (1997) Reticulocyte Hemoglobin: an integrated parameter for evaluation of erythropoietic activity. American Journal of Clinical Pathology 108, 133142. Buttarello M., Temporin V., Ceravolo R., Farina G. & Burian P. (2004) The new reticulocyte parameter RET Y of the Sysmex XE 2100. Its use in the diagnosis and monitoring of post treatment sideropenic anemia. American Journal of Clinical Pathology 121, 489495. Canals C., Remacha A.F., Sarda M.P., Piazuelo J.M., Royo M.T. & Romero M.A. (2005) Clinical utility of the new Sysmex XE 2100 parameter reticulocyte hemoglobin equivalent in the diagnosis of anemia. Haematologica 90, 1133 1134.

David O., Grillo A., Ceoloni B., Cavallo F., Podda G., Biancotti P.P., Bergamo D. & Canavese C. (2006) Analysis of red cell parameters on the Sysmex XE 2100 and Advia 120 in iron deciency and in uraemic chronic disease. Scandinavian Journal of Clinical and Laboratory Investigation 66, 113 120. Fishbane S., Galgano C., Langley R.C., Jr, Caneld W. & Maesaka J.K. (1997) Reticulocyte hemoglobin content in the evaluation of iron status of hemodialysis patients. Kidney International 52, 217222. Garzia M., Di Mario A., Ferraro E., Tazza L., Rossi E., Luciani G. & Zini G. (2007) Reticulocyte Hemoglobin Equivalent: an indicator of reduced iron availability in chronic kidney diseases during erythropoietin therapy. Laboratory Haematology 13, 611. Kazazin H. & Boehm C. (1988) Molecular basis and prenatal diagnosis of b thalassemia. Blood 72, 11701176. Macdougall I.C., Cavill I., Hulme B., Bain B., Mcgregor E., Mckay P., Sanders E., Coles G.A. & Williams J.D. (1992) Detection of functional iron-deciency during erythropoietin treatment a new approach. British Medical Journal 304, 225226. Mast A.E., Blinder M.A. & Dietzen D.J. (2008) Reticulocyte haemoglobin content. American Journal of Hematology 83, 307310. Mast A.E., Blinder M.A., Lu Q., Flax S. & Dietzen D.J. (2002) Clinical utility of the reticulocyte hemoglobin content in the diagnosis of iron deciency. Blood 99, 14891491. National Kidney Foundation, Kidney Disease Outcomes Quality Initiative (NKF-K/DOQI) (2006) NKF-K/DOQI clinical practice guideline and clinical practice recommendations for anemia in chronic kidney disease. American

Journal of Kidney Disease 47(Suppl 3), S11S145. Noronha J.F.A. & Grotto H.Z.W. (2005) Measurement of reticulocyte and red blood cell indices in patients with iron deciency anemia and b thalassemia minor. Clinical Chemistry and Laboratory Medicine 43, 195197. dOnofrio G., Chirillo R., Zini G., Caenaro G., Tommasi M. & Micciulli G. (1995) Simultaneous measurement of reticulocyte and red cell indices in healthy subjects and patients with microcytic and macrocytic anemia. Blood 85, 818823. Thein S.L. & Wallace R.S. (1986) The use of synthetic oligonucleotides as specic hybridation probes in the diagnosis of genetic disorders. In: Human genetic diseases, a practical approach (ed. KE Davis), pp. 3350. IRL press, OxfordWashington DC. Thomas L., Franck S., Messinger M., Linssen J., Thome M. & Thomas C. (2005) Reticulocyte hemoglobin measurement comparison of two methods in the diagnosis of iron-restricted erythropoiesis. Clinical Chemistry and Laboratory Medicine 43, 11931202. Thomas C., Kirschbaum A., Boehm D. & Thomas L. (2006) The diagnostic plot. Medical Oncology 23, 2336. Torres A., Sanchez J., Lakomsky D., Serrano J., Alvarez M.A., Martin C., Valls C., Nevado L., Rodriguez A., Casano J., Martinez F. & Gomez P. (2001) Assessment of hematologic progenitor engraftment by complete reticulocyte maturation parameters after autologous and allogeneic hematopoietic stem cell transplantation. Haematologica 86, 2429. Urrechaga E. (2009) Clinical utility of the new Beckman Coulter parameter red blood cell size factor in the study erythropoiesis. International Journal of Laboratory Hematology 31, 623629.

2010 Blackwell Publishing Ltd, Int. Jnl. Lab. Hem. 2011, 33, 3744