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Abnormal red blood cell size: Macrocytic anemia: Symptoms, causes, and types


Macrocytic anemia: Symptoms, causes, and types

Macrocytic anemia is a type of anemia that causes unusually large red blood cells. Like other types of anemia, macrocytic anemia means that the red blood cells also have low hemoglobin.

Hemoglobin is an iron-containing protein that transports oxygen around the body. Deficiencies in vitamin B-12 or folate often cause macrocytic anemia, so it is sometimes called vitamin deficiency anemia.

In this article, we look at the causes and symptoms of macrocytic anemia, the treatment options, and how to prevent complications.

Macrocytic anemia occurs if the red blood cells are unusually large. A unit called femtoliters (fL) is used to measure the size of blood cells. Usually, red blood cells are between 80–100 fL.

Red blood cells larger than 100 fL are considered macrocytic. When the cells grow too large, there are fewer of them than there needs to be and they carry less hemoglobin. This means the blood is not as oxygen-rich as it should be. Low blood oxygen can cause a range of symptoms and health problems.

Macrocytic anemia is not a single disease, but a symptom of several medical conditions and nutritional problems.

One of the most common types of macrocytic anemia is megaloblastic macrocytic anemia. This happens when red blood cells produce DNA too slowly to divide.

Anemia develops gradually, so a person may not notice any symptoms until it is severe. When symptoms appear, they may include:

Macrocytic anemia is just one type of anemia. The symptoms of anemia are similar across all types, so it is important to use blood tests to diagnose the specific anemia a person has.

When people develop macrocytic anemia due to B-12 deficiency, they may have other symptoms. These include:

  • weakness, pain, numbness, or tingling in the hands or feet
  • instability when walking
  • memory loss

These symptoms may resolve after treatment, but they can become permanent if left untreated.

Share on PinterestMacrocytic anemia is usually caused by a deficiency of folate or vitamin B-12, which is abundant in animal products.

Macrocytic anemia is almost always due to a deficiency of folate or vitamin B-12. A person may have a deficiency of one of these if their body cannot absorb vitamins due to an underlying disease, or because they do not eat enough foods with these vitamins.

B-12 is abundant in animal products, so vegans and vegetarians are more at risk of a B-12 deficiency. In some cases, people may eat enough foods with B-12 but are unable to absorb the vitamin due to autoimmune disorders, cancer, alcohol addiction, or inflammatory bowel disease.

A folate deficiency, sometimes known as vitamin B-9 deficiency, can also cause macrocytic anemia. Pregnant and breast-feeding women use more folate and have a higher risk of becoming deficient.

People who do not eat enough folate-rich foods can also become deficient. Diseases that interfere with the body’s ability to absorb nutrition, such as celiac disease, can lead to a folate deficiency.

Other causes of macrocytic anemia may include:

  • medications, including HIV drugs, cancer drugs, and others that suppress the immune system
  • liver disease
  • hypothyroidism
  • rare metabolic disorders

Each of these factors can make it more difficult for the body to absorb and metabolize essential nutrients.

In very rare cases, macrocytic anemia can be caused by a bone marrow disorder that prevents the body from producing enough healthy blood cells.

Doctors classify macrocytosis into two broad categories:

  • Megaloblastic macrocytosis is the most common form. It occurs when DNA cannot be produced because of a vitamin deficiency.
  • Nonmegaloblastic macrocytosis, which can happen when there is a problem with the liver, spleen, or bone marrow.

When a person shows signs of macrocytic anemia, a doctor will take several blood tests to find the underlying cause. They may also ask questions about a person’s diet, lifestyle, and other symptoms.

In most cases, vitamin injections are the first line of treatment. Injecting vitamins ensures the body can absorb these even if an underlying condition, such as celiac disease, prevents vitamin absorption.

Eating more foods containing vitamin B-12 may improve symptoms if a person is deficient in this vitamin because of their diet.

Other treatment options include:

  • changing medications when a drug interferes with vitamin absorption
  • taking medication for certain autoimmune or liver diseases
  • taking medication for thyroid disorders
  • making lifestyle changes, such as avoiding alcohol
  • having blood transfusions or bone marrow transplants for bone marrow disorders

Share on PinterestWhen left untreated, macrocytic anemia can cause heart failure, an enlarged heart, and circulatory problems.

When the blood does not have enough hemoglobin, it will not have enough oxygen. The body may try to fix this by increasing the heart rate or blood pressure. Left untreated, anemia can cause heart failure, an enlarged heart, and circulatory problems.

When macrocytic anemia is due to a problem with the bone marrow or an organ, this underlying cause can trigger further complications. For example, people with untreated bone marrow disorders may develop leukemia.

Most cases of macrocytic anemia are due to vitamin deficiencies, which can cause different complications depending on the vitamin:

Vitamin B-12 deficiencies

A vitamin B-12 deficiency can cause:

  • neural tube defects in babies born to women with a B-12 deficiency
  • infertility
  • stomach cancer
  • mobility problems and tingling in the hands and feet
  • memory loss

Folate deficiencies

A folate deficiency can cause:

  • neural tube defects in babies born to women with a folate deficiency
  • infertility
  • an increased risk of some cancers, including colon cancer
  • cardiovascular health problems
  • an increased risk of premature labor in pregnant women
  • an increased risk of a placenta rupture before or during childbirth

Most cases of macrocytic anemia can be managed with vitamin injections. A doctor will continue to monitor a person’s B-12 or folate levels and use blood tests to determine whether red blood cells have returned to their normal size.

While most people recover with prompt treatment, they may need periodic checks for anemia.

When macrocytic anemia is due to an underlying disease, the outlook depends on what disease is causing the deficiency, and how it is treated.

Macrocytic anemia often goes undiagnosed until it becomes severe. People who have symptoms of anemia, a family history of anemia, or who have or are at risk of a condition linked to macrocytic anemia should see a doctor for a blood test.

Regular blood tests can help detect all forms of anemia before they undermine a person’s health. Most cases of anemia can be easily diagnosed and treated.

Macrocytosis: What causes it? – Mayo Clinic

What causes enlarged red blood cells (macrocytosis)?

Answer From Rajiv K. Pruthi, M.B.B.S.

Macrocytosis is a term used to describe red blood cells that are larger than normal. Also known as megalocytosis or macrocythemia, this condition typically causes no signs or symptoms and is usually detected incidentally on routine blood tests.

Macrocytosis isn’t a specific disease, but it may indicate an underlying problem that requires medical evaluation. Common causes of macrocytosis include:

  • Vitamin B-12 deficiency
  • Folate deficiency
  • Liver disease
  • Alcoholism
  • Hypothyroidism
  • A side effect of certain medications, such as those used to treat cancer, seizures and autoimmune disorders
  • Increased red blood cell production by the bone marrow to correct anemia, for example, after blood loss
  • An underlying bone marrow cancer called myelodysplastic syndrome

If you have macrocytosis, blood tests can help determine its cause. In some cases, it may be necessary to remove a sample of your bone marrow — the spongy tissue inside your bones — for testing.

Management of macrocytosis consists of finding and treating the underlying cause. In the case of vitamin B-12 or folate deficiency, treatment may include diet modification and dietary supplements or injections. If the underlying cause is resulting in severe anemia, you might need a blood transfusion.


Rajiv K. Pruthi, M.B.B.S.

May 06, 2021

Show references

  1. Kaferle J, et al. Evaluation of macrocytosis. American Family Physician. 2009;79:203.
  2. Schrier SL. Macrocytosis/macrocytic anemia. http://www.uptodate.com/home. Accessed April 17, 2019.
  3. Pruthi RK (expert opinion). Mayo Clinic, Rochester, Minn. April 17, 2019.

See more Expert Answers


Size changes | eClinpath

Changes in red blood cell (RBC) size on a blood smear correspond to changes in diameter of the cell and not necessarily to changes in red blood cell volume, as assessed by the hematologic analyzer. Cells can appear smaller but be of normal volume (e.g. spherocytes) whereas other cells actually appear bigger because they are thinner and spread more in a blood smear (hypochromic red blood cells). Variation in red blood cell size on a blood smear is called anisocytosis and this can be due to increased proportions of larger red blood cells than normal, smaller red blood cells than normal or a combination of both. Thus, anisocytosis has no more specific meaning other than increased variation in red blood cell size (diameter). Note that low numbers of larger or smaller red blood cells may not increase or decrease the mean cell volume (MCV) above or below reference  limits. There needs to be sufficient numbers of cells of higher or lower volume to shift the mean volume. Modern hematology analyzers also measure the variation in red blood cell volume and report this value out as a red blood cell distribution width (RDW). This does correlate somewhat to the smear examination assessment of anisocytosis. At Cornell University, we only report macrocytes, when they are distinctly visualized in a blood smear. These may or may not be associated with a macrocytosis (MCV higher than the upper reference limit), depending on the numbers in blood. We do not report microcytes, because they are of uncertain diagnostic relevance. However, microcytosis (MCV below the lower reference limit) can be a physiologic or pathologic finding in animals. Thus, only macrocytes will be discussed here.


These are larger red blood cells than normal. Macrocytes have a normal content of hemoglobin and very little RNA. In fact, there is insufficient RNA (blue) to offset the red of hemoglobin, so macrocytes are red in color. This differs from polychromatophilic RBC which are usually larger and purple because they contain more RNA. Detection of macrocytes requires the presence of cells of normal size in the blood. If all the cells are macrocytic, it is difficult to recognize that they are larger than normal (i.e. there is nothing to compare them to).

Macrocytes form through several mechanisms:

Macrocytes in a camelid

  • Regeneration: Macrocytes can be (but are not always) younger RBC than normal. They can be seen in all mammalian species that are mounting a regenerative response. Indeed, these are the cells we look for in an anemic horse to assess whether the horse is responding to the anemia (or not). This is because equine release only low numbers of reticulocytes in response to an anemia. These can be counted by modern hematology analyzers (using fluorescent dyes) but are not usually detectable as polychromatophilic RBC in blood.  Immature macrocytic RBC will probably contain small amounts of RNA, which is precipitated by vital dyes, such as new methylene blue, or binds fluorescent dyes, such as oxazine, i.e. they are usually punctate reticulocytes. Punctate reticulocytes have a 3 day half life in cats (they can persist in blood for 7-10 days). Cats that have recovered from an anemia may be macrocytic due to persistence of this punctate reticulocytes (post-regenerative macrocytosis). Premature release of RBC may underly macrocytosis seen in some animals with hyperthyroidism.
  • Abnormal DNA synthesis: Since RBC becomes successively smaller with each cell division during erythropoiesis, larger RBC are formed if DNA synthesis is retarded or abnormal. This occurs under the following situations:
    • Feline leukemia virus (FeLV) infection: The virus integrates into the feline host cell genome and retards DNA metabolism. The virus also causes neoplastic transformation of feline erythroid cells, called primary myelodysplasia. Macrocytosis is a characteristic feature of myelodysplastic syndrome in the cat and is frequently seen in the presence of a severe non-regenerative anemia.
    • Myelodysplasia: Abnormal production of red blood cells can result in macrocytosis. This is most frequently seen in cats with FeLV infection and rarely in other species.
    • Congenital dyserythropoiesis: Congenital dyserythropoietic anemia (CDA) is an inherited defect in humans that results in macrocytosis. This has been reported in Poll Hereford cattle and is likely the cause of macrocytosis in Poodles (despite the lack of anemia).
    • Mineral/nutrient deficiencies: Vitamin B12, cobalt and folate are required for DNA synthesis (purine and pyrimidine metabolism or synthesis of nucleic acids). Deficiencies in these vitamins and minerals can result in macrocytosis, with or without anemia. Molybdenum excess in pastures or feed can result in a secondary cobalt deficiency in ruminants.
    • Drugs: Drugs which interfere with vitamin B12 metabolism or folate absorption can result in macrocytosis (with or without anemia), e.g. hydroxyurea, sulfur drugs.
  • Red blood cell swelling: This can occur due to membrane defects (e.g. hereditary stomatocytosis), hyperosmolality (e.g. diabetes mellitus) or a storage-associated artifact. Since this affects all RBC, macrocytes are usually not identified readily on the blood smears, although the MCV may be above the upper reference limit for that species.

Red Blood Cell Count – Understand Your Tests & Results

Sources Used in Current Review

Wintrobe’s Clinical Hematology. 12th ed. Greer J, Foerster J, Rodgers G, Paraskevas F, Glader B, Arber D, Means R, eds. Philadelphia, PA: Lippincott Williams & Wilkins: 2009, Section 2: The Erythrocyte.

Harmening, D. Clinical Hematology and Fundamentals of Hemostasis, Fifth Edition, F.A. Davis Company, Philadelphia, 2009, Chapter 3.

Sources Used in Previous Reviews

Thomas, Clayton L., Editor (1997). Taber’s Cyclopedic Medical Dictionary. F.A. Davis Company, Philadelphia, PA [18th Edition].

Pagana, Kathleen D. & Pagana, Timothy J. (2001). Mosby’s Diagnostic and Laboratory Test Reference 5th Edition: Mosby, Inc., Saint Louis, MO.

Hillman RS and Finch CA. Red Cell Manual (1974). FA Davis, Philadelphia. Pp. 23-51.

Pagana, Kathleen D. & Pagana, Timothy J. (© 2007). Mosby’s Diagnostic and Laboratory Test Reference 8th Edition: Mosby, Inc., Saint Louis, MO. Pp. 797-799.

Henry’s Clinical Diagnosis and Management by Laboratory Methods. 21st ed. McPherson R, Pincus M, eds. Philadelphia, PA: Saunders Elsevier: 2007, Chap 31.

(March 1, 2011) National Heart, Lung and Blood Institute. What is Polycythemia vera? Available online at http://www.nhlbi.nih.gov/health/public/blood/index.htm. Accessed Sep 2011.

(Aug 1, 2010) National Heart, Lung and Blood Institute. Anemia. Available online at http://www.nhlbi.nih.gov/health/health-topics/topics/anemia/. Accessed Sep 2011.

(June 17, 2011) Conrad M. Anemia. Medscape Reference article. Available online at http://emedicine.medscape.com/article/198475-overview. Accessed Sep 2011.

(August 26, 2011) Harper J. Pediatric Megaloblastic Anemia. eMedicine article. Available online at http://emedicine.medscape.com/article/959918-overview. Accessed Sep 2011.

(June 8, 2011) Artz A. Anemia in Elderly Persons. eMedicine article. Available online at http://emedicine.medscape.com/article/1339998-overview. Accessed Sep 2011.

(February 9, 2010) Dugdale D. RBC Count. MedlinePlus Medical Encyclopedia. Available online at http://www.nlm.nih.gov/medlineplus/ency/article/003644.htm. Accessed Sep 2011.

Riley R, et.al. Automated Hematologic Evaluation. Medical College of Virginia, Virginia Commonwealth University. Available online at http://www.pathology.vcu.edu/education/PathLab/pages/hematopath/pbs.html#Anchor-Automated-47857. Accessed Sep 2011.

Kasper DL, Braunwald E, Fauci AS, Hauser SL, Longo DL, Jameson JL eds, (2005). Harrison’s Principles of Internal Medicine, 16th Edition, McGraw Hill, Pp 329-336.

Pagana K, Pagana T. Mosby’s Manual of Diagnostic and Laboratory Tests. 3rd Edition, St. Louis: Mosby Elsevier; 2006, Pp 447-448.

Harmening D. Clinical Hematology and Fundamentals of Hemostasis. Fifth Edition, F.A. Davis Company, Piladelphia, Chapter 3.

Maakaron, J. et. al. (Updated 2014 October 29). Anemia. Medscape Drugs & Diseases [On-line information]. Available online at http://emedicine.medscape.com/article/198475-overview. Accessed November 2014

Lehman, C. and Straseski, J. (Updated 2014 February). Anemia. ARUP Consult [On-line information]. Available online at http://www.arupconsult.com/Topics/Anemia.html?client_ID=LTD#tabs=0. Accessed November 2014

Gersten, T. (Updated 2014 February 24). RBC count. MedlinePlus Medical Encyclopedia [On-line information]. Available online at http://www.nlm.nih.gov/medlineplus/ency/article/003644.htm. Accessed November 2014

(2012 May 18). Anemia. National Heart Lung and Blood Institute [On-line information]. Available online at http://www.nhlbi.nih.gov/health/health-topics/topics/anemia/. Accessed November 2014

Kahsai, D. (Updated 2013 August 2). Acute Anemia. Medscape Drugs & Diseases [On-line information]. Available online at http://emedicine.medscape.com/article/780334-overview. Accessed November 2014

Curry, C. (Updated 2012 February 3). Erythrocyte Count (RBC). Medscape Drugs & Diseases [On-line information]. Available online at http://emedicine.medscape.com/article/2054474-overview. Accessed November 2014

Pagana, K. D., Pagana, T. J., and Pagana, T. N. (© 2015). Mosby’s Diagnostic & Laboratory Test Reference 12th Edition: Mosby, Inc., Saint Louis, MO. Pp 785-791.

Understanding the Red Blood Cell (RBC) Count

The red blood cell (RBC) count is used to measure the number of oxygen-carrying blood cells in a volume of blood. It is one of the key measures we use to determine how much oxygen is being transported to cells of the body.

An abnormal RBC count is often the first sign of an illness that may either be undiagnosed or without symptoms. At other times, the test can point the doctor in the direction of a diagnosis if there are symptoms, such as shortness of breath or fatigue, which cannot be readily explained.


Complete Blood Count

Typically speaking, an RBC count is less useful on its own to diagnose a medical condition. Instead, it is most often performed as part of a more comprehensive test called a complete blood cell (CBC) count which measures the composition cells in a blood sample. They include:

  • Red blood cells (RBC) which transport oxygen to cells of the body
  • White blood cells (WBC), which are a part of the immune system
  • Hemoglobin (Hb), a protein which carries oxygen and carbon dioxide molecules
  • Platelets (PLT), the cells responsible for blood clotting
  • Hematocrit (Hct), the ratio of RBC to the total volume of blood

Based on the composition of blood cells, doctors can better know where to focus their investigation and which areas they can probably avoid.

An RBC count may also be used to monitor treatment for blood disorders or medications that affect your RBC. This is especially true for cancer and cancer chemotherapy, both of which can have a detrimental cause-and-effect impact on blood counts.

Normal Ranges

An RBC count is the number of red blood cell per a particular volume of blood. It may be reported in millions of cells per microliter (mcL) of blood or in millions of cells per liter (L) of blood.

The “normal” range can sometimes vary by population. Many reference values will be far higher in high-altitude cities like Denver and far lower in low-altitude areas like the Gulf Coast. As such, the ranges cannot be considered hard-and-fast values but rather, as the name suggests, a reference point.

The RBC count reference range varies by sex and age:

  • Women: 4.2 to 5.4 million/mcL
  • Men: 4.7 to 6.1 million/mcL
  • Children: 4.1 to 5.5 million/mcL

High or Low RBC Counts

When the RBC count is higher or lower than the reference range, it alerts the physician that there could be an underlying condition. The other values from the CBC will be considered, as well as other diagnostic tests.

High RBC Count Causes

A high RBC count tells us that there has been an increase in oxygen-carrying cells in blood. In some cases, this may indicate that the body is compensating for some condition that is depriving the body of oxygen, in others, the cause may be related to diseases or drugs that alter the production of RBCs.

Low RBC Count Causes

A low RBC count indicates a decrease in oxygen-carrying cells in the blood, otherwise known as anemia. The causes can be numerous, ranging from infections and deficiencies to malnutrition to malignancies, including:

  • Kidney failure
  • Thyroid problems
  • Bleeding, internal or external
  • Leukemia, a type of blood cancer
  • Drug side effects, including chemotherapy
  • Multiple myeloma, a type of cancer affecting plasma cells
  • Erythropoietin deficiency, a kidney hormone that promotes RBC growth
  • Deficiencies in iron, folate, vitamin B12, or vitamin B6
  • Hemolysis, the abnormal breakdown of red blood cells
  • Pregnancy


Treatment of an abnormal RBC count is typically focused on treating the underlying condition, whether it be an infection, injury, cancer, or a genetic disorder.

If, on the other hand, the cause is related to a nutritional deficiency, medication use, or a chronic condition, there may be things you can do to not only improve your blood count but your overall health, as well.

High RBC Count Treatment

If you have a high RBC count:

  • Exercise to improve heart and lung function.
  • Eat less red meat and iron-rich foods.
  • Avoid iron supplements.
  • Keep yourself well hydrated.
  • Avoid diuretics, including coffee and caffeinated drinks.
  • Stop smoking, especially if you have COPD or pulmonary fibrosis.
  • Avoid the use of steroids, erythropoietin, and other performance-enhancing drugs.

Low RBC Count Treatment

If you have a low RBC count (including anemia):

  • Maintain a healthy, balanced diet.
  • Take a daily vitamin and iron supplement, if needed.
  • Exercise regularly to improve heart and lung function.
  • Stop smoking.
  • Avoid aspirin, which reduces clotting and can cause slow chronic blood loss.
  • Take your thyroid medications as prescribed if you have thyroid problems.

Red Cell Indices – Clinical Methods


Mean corpuscular volume (MCV), mean corpuscular hemoglobin (MCH), and mean corpuscular hemoglobin concentration (MCHC) were first introduced by Wintrobe in 1929 to define the size (MCV) and hemoglobin content (MCH, MCHC) of red blood cells. Termed red cell indices, these values are useful in elucidating the etiology of anemias. Red cell indices can be calculated if the values of hemoglobin, hematocrit (packed cell volume), and red blood cell count are known. With the general availability of electronic cell counters, red cell indices are now automatically measured in all blood count determinations.

Variation in the size of red cells (anisocytosis) can be quantified and expressed as red cell distribution width (RDW) or as red cell morphology index. The RDW is more widely available and is discussed in this chapter. The size distribution of a population of cells is graphically represented by the red cell histograms (Price–Jones curves) (see ). Similar histograms are also available for white blood cells and platelets.

Figure 152.1

Red cell histograms in various conditions. (A) Heterozygous beta thalassemia. (B) Poor iron utilization (R-E block, chronic disease). (C) Iron deficiency anemia. (D) Dimorphic anemia—iron deficiency, recent transfusion. (E) Macrocytic anemia (liver (more…)

MCV defines the size of the red blood cells and is expressed as femtoliters (10−15; fl) or as cubic microns (μm3). The normal values for MCV are 87 ± 7 fl.

MCH quantifies the amount of hemoglobin per red blood cell. The normal values for MCH are 29 ± 2 picograms (pg) per cell.

MCHC indicates the amount of hemoglobin per unit volume. In contrast to MCH, MCHC correlates the hemoglobin content with the volume of the cell. It is expressed as g/dl of red blood cells or as a percentage value. The normal values for MCHC are 34 ± 2 g/dl.

RDW represents the coefficient of variation of the red blood cell volume distribution (size) and is expressed as a percentage. The normal value for RDW is 13 ± 1.5%.


Red cell indices MCV, MCH and MCHC are calculated from hemoglobin, hematocrit, and red blood cell count as follows:

Most clinical laboratories now use automated machines to perform blood counts (commonly called CBC) that include red cell indices as part of the profile. Two types of automated machines are generally used. Instruments like the Coulter S model employ the principle of electric impedance; others, like the Hemalog System Analyzer, use optical methods in performing cell counts. Most of the automated machines give the following values: white cell count, red cell count, platelet count, hemoglobin, hematocrit, MCV, MCH, and MCHC. Newer machines, capable of calculating RDW or red cell morphology index, mean platelet volume, absolute lymphocyte count, and differential white cell count ate now being used in many clinical laboratories. These instruments are also capable of producing histograms.

While the automated cell counters are fast, convenient, and precise, certain conditions can interfere with machine calculations and result in spurious values. It is important that clinicians become familiar with the more common causes of spurious results with electronic counters ():

Table 152.1

Spurious Results with Automated Cell Counters.

  • In red cell agglutination, doublet erythrocytes are counted as one, and larger clumps are not counted as red blood cells at all. This leads to a “decrease” in red cell count and a falsely elevated MCV. Determination of the hemoglobin value is not affected. Prewarming the sample eliminates these spurious values.

  • In hyperglycemia, red cells are transiently hypertonic in relation to the isotonic diluting fluid, resulting in swollen cells and an elevated MCV. This can be avoided if some time is allowed for equilibration after dilution.

  • Hemoglobin is quantified based on its absorption characteristics. Conditions such as hyperlipidemias, hyperbilirubinemia, a very high white blood cell count, and high serum protein can interfere with this measurement and result in falsely elevated hemoglobin values.

  • Presence of immunoglobulins or fibrinogen precipitated by low temperatures in the blood sample leads to interference with cell counts, resulting in spuriously increased white blood cell count and sometimes small elevations in hemoglobin, hematocrit, red blood cell count, and a slight decrease in MCV. Prewarming the sample to 37°C will correct the artificial values.

  • When the values of hemoglobin, red cell count, and MCV are affected, MCH and MCHC also become abnormal, since these indices are calculated and are not directly measured.

Sometimes a set of spurious values may be the first clue to an otherwise unsuspected clinical condition (e.g., the combination of low hematocrit, normal hemoglobin, and high MCV and MCHC is characteristic of cold agglutinins). The MCV, since it is an average value, can be normal in the presence of two different cell populations (e.g., dimorphic anemias, red cell fragmentation with reticulocyte response). It is, therefore, important to examine the peripheral smear in the evaluation of anemias. When available, RDW is a good indicator of the degree of anisocytosis. Similarly, the red cell histogram, which offers a graphic depiction of red cell size distribution, will reveal anisocytosis even when the MCV is normal.

Basic Science

During erythropoiesis, the process of erythroid maturation involves a progressive condensation of nuclear chromatin (termed nuclear maturation) and finally its extrusion from the cell, the synthesis of hemoglobin in the cytoplasm (termed cytoplasmic maturation), and a concomitant reduction in cell size due to division and water loss.

Defects in nuclear maturation, as seen in megaloblastic anemias due to folate or B12 deficiency, result in large oval erythrocytes (macroovalocytes) with a normal hemoglobin content. The MCV and MCH are increased, while the MCHC remains normal. There is anisocytosis, and RDW is often increased. In the macrocytosis of liver disease, where there is no defect in nuclear maturation, the cells are large due to an excess red cell membrane. These cells are round, rather than oval, and the RDW is normal.

Defective hemoglobin synthesis results in small cells (low MCV) with or without anisocytosis. In heterozygous β-thalassemias, the cells are uniformly small (low MCV; RDW tends to be normal), whereas in iron deficiency, anisocytosis (increased RDW) may be the first laboratory abnormality, even before anemia and microcytosis are seen.

In abnormalities involving nuclear maturation, hemoglobin production proceeds normally, while cell division lags behind, ultimately leading to a larger than normal cell. In contrast, when there is defective and delayed synthesis of hemoglobin, the continued cell division leads to microcytosis.

Clinical Significance

Anemias may be classified based on their etiology (e.g., hemolytic, hemorrhagic, etc.), erythropoietic response (e.g., hypoproliferative, ineffective), or cell morphology (e.g., macrocytic, microcytic-hypochromic).

Red cell indices are valuable in the morphologic classification of anemias. Since different etiologic factors result in characteristically different red cell morphology, the clinician can properly plan the management of a patient with an anemia if he can interpret the blood counts and peripheral blood smear well.

Anemias are classified, according to the size of the red cell, as being normocytic (normal MCV), macrocytic (increased MCV), or microcytic (decreased MCV). Microcytic anemias were also often described as being hypochromic based on peripheral smear examination and MCHC when this value was determined manually. MCHC as measured by the electronic machines is mostly normal in microcytic anemias, however, and the value of MCH closely parallels the value of MCV. The optical properties of the small, thin microcytes make them appear hypochromic on the blood smear, while the hemoglobin concentration remains in the normal range (microcytic, normochromic anemias).

There are no hyperchromic anemias. In spherocytosis, the MCHC is increased due to loss of membrane and the consequent spherical shape assumed by the cell.

The general availability of RDW as a measure of anisocytosis helps further in the evaluation of anemias based on morphology (see ). Significant anisocytosis often leads to an increased RDW, whereas in its absence the RDW remains normal.

It should be pointed out again that an evaluation of anemias is not complete without the careful examination of a well-prepared peripheral blood smear. Red cell indices, RDW, and red blood cell histograms will not help identify conditions such as red cell inclusions (e.g., malarial parasites) or membrane abnormalities such as spherocytosis that might be responsible for the anemia.


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  2. Bessman JD, Gilmer PR, Gardner FH. Too early to put down RDW for discriminating iron deficiency and thalassemia. Am J Clin Pathol. 1986;86:693–5. [PubMed: 3776927]
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  4. Gottfried EL. Erythrocyte indexes with the electronic counter. N Engl J Med. 1979;300:1277. [PubMed: 431694]
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  8. Williams WJ. Examination of the blood. In: Williams WJ, Beutler E, Erslev AJ, Lichtman MA, eds. Hematology, 3d ed. New York: McGraw-Hill, 1983;9–14.

  9. Wintrobe MM. Principles of hematologic examination. In: Wintrobe MM, ed. Clinical hematology, 8th ed. Philadelphia: Lea & Febiger, 1981;7–19.

Hemolytic Anemia | Johns Hopkins Medicine

What is hemolytic anemia?

Hemolytic anemia is a disorder in which red blood cells are destroyed faster than they can be made. The destruction of red blood cells is called hemolysis.

Red blood cells carry oxygen to all parts of your body. If you have a lower than normal amount of red blood cells, you have anemia. When you have anemia, your blood can’t bring enough oxygen to all your tissues and organs. Without enough oxygen, your body can’t work as well as it should.

Hemolytic anemia can be inherited or acquired:

  • Inherited hemolytic anemia happens when parents pass the gene for the condition on to their children.
  • Acquired hemolytic anemia is not something you are born with. You develop the condition later.

What causes hemolytic anemia?

There are 2 main types of hemolytic anemia: inherited and acquired. Different diseases, conditions, or factors can cause each type:


With the inherited type, parents pass the genes for the condition on to their children. Two common causes of this type of anemia are sickle cell anemia and thalassemia. These conditions produce red blood cells that don’t live as long as normal red blood cells.


With this type of anemia, you are not born with a certain condition. Your body makes normal red blood cells, but they are later destroyed. This may happen because of:

  • Certain infections, which may be viral or bacterial
  • Medicines, such as penicillin, antimalarial medicines, sulfa medicines, or acetaminophen
  • Blood cancers 
  • Autoimmune disorders, such as lupus, rheumatoid arthritis, or ulcerative colitis
  • Certain tumors
  • An overactive spleen (hypersplenism)
  • Mechanical heart valves that may damage red blood cells as they leave the heart
  • A severe reaction to a blood transfusion

Some types of acquired hemolytic anemia are short-term (temporary) and go away over several months. Other types can become lifelong (chronic). They may go away and come back again over time.

What are the symptoms of hemolytic anemia?

Each person’s symptoms may vary. Symptoms may include:

  • Abnormal paleness or lack of color of the skin
  • Yellowish skin, eyes, and mouth (jaundice)
  • Dark-colored urine
  • Fever
  • Weakness
  • Dizziness
  • Confusion
  • Can’t handle physical activity
  • Enlarged spleen and liver
  • Increased heart rate (tachycardia)
  • Heart murmur

The symptoms of hemolytic anemia may look like other blood conditions or health problems. Always see your healthcare provider for a diagnosis.

How is hemolytic anemia diagnosed?

Your healthcare provider may think you have hemolytic anemia based on your symptoms, your medical history, and a physical exam. Your provider may also order the following tests:

  • Complete blood count (CBC). This test measures many different parts of your blood.  
  • Other blood tests. If the CBC test shows that you have anemia, you may have other blood tests. These can find out what type of anemia you have and how serious it is.  
  • Urine test. This can check for hemoglobin (a protein in red blood cells) and iron.
  • Bone marrow aspiration or biopsy. This involves taking a small sample of bone marrow fluid (aspiration) or solid bone marrow tissue (called a core biopsy). The sample is usually taken from the hip bones. It is checked for the number, size, and maturity of blood cells or abnormal cells.

How is hemolytic anemia treated?

Your healthcare provider will create a treatment plan based on:

  • Your age, overall health, and medical history
  • How sick you are
  • The cause of the disease
  • How well you handle certain medicines, treatments, or therapies
  • If your condition is expected to get worse
  • Your opinion or preference

The treatment for hemolytic anemia will vary depending on the cause of the illness. Treatment may include:

  • Blood transfusions
  • Corticosteroid medicines
  • Treatment to strengthen your immune system (using intravenous immune globulin)
  • Rituximab

In more severe cases, the following treatments may be needed:

  • Surgery to remove the spleen
  • Medicine to reduce the strength of your immune system (immunosuppressive therapy)

Living with hemolytic anemia

Work with your healthcare provider to reduce your risk of red blood cell breakdown, and your risk of infections. For example, cold weather can often trigger the breakdown of red blood cells. To protect yourself, avoid the cold, wear warm clothes, and keep your home warmer.

You can also reduce your risk of infections by:

  • Staying away from people who are sick
  • Avoiding large crowds
  • Washing your hands often
  • Avoiding undercooked foods
  • Brushing your teeth regularly
  • Getting a flu shot each year

Key points about hemolytic anemia

  • Hemolytic anemia is a disorder in which the red blood cells are destroyed faster than they are made.
  • Inherited hemolytic anemia means that parents pass the gene for the condition on to their children.
  • Acquired hemolytic anemia is not something you are born with. You develop the condition later.
  • Symptoms include weakness, paleness, jaundice, dark-colored urine, fever, inability to do physical activity, and heart murmur.
  • Treatment includes blood transfusions, corticosteroids, and other medicines

Next steps

Tips to help you get the most from a visit to your healthcare provider:

  • Know the reason for your visit and what you want to happen.
  • Before your visit, write down questions you want answered.
  • Bring someone with you to help you ask questions and remember what your provider tells you.
  • At the visit, write down the name of a new diagnosis, and any new medicines, treatments, or tests. Also write down any new instructions your provider gives you.
  • Know why a new medicine or treatment is prescribed, and how it will help you. Also know what the side effects are.
  • Ask if your condition can be treated in other ways.
  • Know why a test or procedure is recommended and what the results could mean.
  • Know what to expect if you do not take the medicine or have the test or procedure.
  • If you have a follow-up appointment, write down the date, time, and purpose for that visit.
  • Know how you can contact your provider if you have questions.

Erythrocyte indices

Erythrocyte indices determine the size and hemoglobin content of an erythrocyte and include the mean erythrocyte volume (MCV), the mean erythrocyte hemoglobin content (MCHC), the mean erythrocyte hemoglobin concentration (MCHC), and the red blood cell size distribution (RDW).

Determination of the above indicators is an integral part of the general blood test and is not performed separately.

Synonyms Russian

Average erythrocyte volume, average hemoglobin content in erythrocytes, average hemoglobin concentration in erythrocytes, erythrocyte size distribution, erythrocyte morphology index.

Synonyms English

Red Cell Indicies, Red Blood Indicies, Red Blood Cell Indices, Blood indicies MCV, MCH, MCHC, Mean cell hemoglobin, Mean Cell Volume, Mean cell hemoglobin concentration, Mean corpuscular volume, Mean corpuscular hemoglobin concentration, Mean corpuscular hemoglobin, RDW, RDW-CS, RDW-SD, Red cell distribution of width.

General information about the study

Erythrocytes are red blood cells, which are the main blood cells.They contain hemoglobin – a protein that carries oxygen from the lungs to tissues and organs. It consists of a protein called globin and a gem-complex containing iron that can bind to oxygen. In some people, the process of “assembly” of hemoglobin can be disrupted, which affects the appearance and size of red blood cells.

A change in the number of red blood cells is usually associated with changes in the level of hemoglobin. When the number of red blood cells and the level of hemoglobin are reduced, the patient has anemia, when they are increased, polycythemia.

Erythrocyte indices allow to estimate the size of erythrocytes and the content of hemoglobin in them. They characterize the cells themselves, and not their number, as a result of which they are relatively stable parameters.

Average erythrocyte volume (MCV)

MCV – the average volume of one erythrocyte. It can be measured by the analyzer directly by evaluating many thousands of red blood cells or calculated using the formula as the ratio of hematocrit to the number of red blood cells.

This indicator is measured in femtoliters (10 -15 / l).One femtoliter is equal to one cubic micrometer (one millionth of a meter).

With a large number of abnormal red blood cells (eg, sickle cell disease), the MCV count is unreliable.

Average content of hemoglobin in erythrocyte (MCH)

MCH reflects how much hemoglobin is on average contained in one red blood cell. It is measured in picograms (one trillionth of a gram, 10 -12 ) per red blood cell and is calculated as the ratio of hemoglobin to red blood cell count.It corresponds to the color indicator that was previously used to reflect the hemoglobin content in erythrocytes. Usually MCH in the erythrocyte is the basis for the differential diagnosis of anemia.

Average concentration of hemoglobin in erythrocytes (MCHC)

MCHC is an indicator of saturation of the erythrocyte with hemoglobin, unlike MCH, it does not characterize the amount of hemoglobin in the cell, but the “density” of filling the cell with hemoglobin. It is calculated as the ratio of total hemoglobin to hematocrit – the volume occupied by red blood cells in the bloodstream.It is measured in grams per liter and is the most sensitive indicator for hemoglobin formation disorders. In addition, it is one of the most stable hematological parameters, so the MCHC is used as an indicator of analyzer errors.

Distribution of erythrocytes by volume (RDW)

RDW – the degree of dispersion of erythrocytes in volume. There are different options for calculating this indicator. RDW-CV is measured as a percentage and shows how much the volume of red blood cells deviates from the average.RDW-SD is measured in femtoliters, just like the average red blood cell volume (MCV), and shows the difference between the smallest red blood cell and the largest.

In general, RDW corresponds to anisocytosis, which is determined on the basis of blood smear microscopy, but is a much more accurate parameter.

What is the research used for?

Evaluation of erythrocyte indices allows you to get an idea of ​​the characteristics of erythrocytes, which is very important in determining the type of anemia.Erythrocyte indices often respond quickly to treatment for anemia and can be used to assess the effectiveness of therapy.

When is the study scheduled?

As a rule, erythrocyte indices are included in the routine general blood test, which is prescribed both as a planned and for various diseases, before surgical interventions. Repeatedly, this test is prescribed to patients undergoing treatment for anemia.

What do the results mean?

Mean erythrocyte volume (MCV)



Reference values ​​

Less than 1 year

71 – 112 fl

1-5 years

73 – 85 fl

5-10 years

75 – 87 fl.

10-12 years

76 – 94 fl


12-15 years

73 – 95 fl

15-18 years

78 – 98 fl

18-45 years old

81 – 100 fl.

45-65 years

81 – 101 fl

Over 65 years

81 – 102 fl


12-15 years

77 – 94 fl

15-18 years

79 – 95 fl

18-45 years old

80 – 99 fl

45-65 years

81 – 101 fl

Over 65 years

81 – 102 fl

Based on MCV, erythrocyte size, anemias are classified into the following types:

  • Microcytic – when MCV is less than normal, small red blood cells predominate in the blood.The most common cause of microcytic anemia is iron deficiency. It can occur due to prolonged blood loss, impaired absorption of iron, insufficient consumption of meat products, as well as due to some disorders of the “assembly” of hemoglobin, for example, with thalassemia or with various chronic diseases (long-term infections, oncology).
  • Normocytic – when the red blood cells are of normal size. This happens when the bone marrow is suppressed – with aplastic anemia, recent bleeding, chronic liver and kidney diseases.
  • Macrocytic, when large red blood cells predominate in the blood. Most often this occurs with a deficiency of vitamin B 12 or folic acid. MCV can also increase with a normal hemoglobin level – due to alcohol abuse, long-term smoking, decreased thyroid function

The average volume of erythrocytes normally changes throughout life: it is maximum in newborns, and then gradually decreases.

What can influence the result?

A large number of reticulocytes, pronounced leukocytosis, as well as a significant increase in glucose levels overestimate the average volume of erythrocytes.

With a simultaneous increase in the number of large (macrocytic) and small (microcytic) erythrocytes in the blood, MCV will be normal. In this case, microscopic examination of a blood smear allows detecting violations.

Average erythrocyte hemoglobin (MCH)



Reference values ​​

30 – 37 pg

14 days – 1 month

29 – 36 pg

1 – 2 months

27 – 34 pg

2 – 4 months

25 – 32 pg

4 – 6 months

24 – 30 pg

6 – 9 months

25 – 30 pg

9 – 12 months

24 – 30 pg

1 – 3 years

22 – 30 pg

3 – 6 years

25 – 31 pg

6 – 9 years

25 – 31 pg

9-15 years

26 – 32 pg

15-18 years

26 – 34 pg

18-45 years old

27 – 34 pg

45-65 years

27 – 34 pg

> 65 years


27 – 35 pg

> 65 years


27 – 34 pg

According to MCH, anemias are divided into normochromic (when the average hemoglobin content in the erythrocyte is within the reference range), hypochromic (when the MCH is reduced) and hyperchromic (if the average hemoglobin content in the erythrocyte is increased).

Normochromia is inherent in healthy people, but also occurs in hemolytic, aplastic anemias, as well as after recent bleeding.

Hypochromia, as a rule, is associated with a decrease in the volume of red blood cells (microcytosis), but it can also occur in normal red blood cells.

Thus, a decrease in MCH usually occurs in micro- and normocytic anemias. An increase is noted in macrocytic anemia and in newborns.

What can influence the result?

Elevated blood lipids and significant leukocytosis, multiple myeloma, and heparin administration overestimate MCH results.

Mean erythrocyte hemoglobin concentration (MCHC)


Reference values ​​

Less than 1 year

290 – 370 g / l

1-3 years

280 – 380 g / l

3-12 years

280 – 360 g / l

12-19 years

330 – 340 g / l

Over 19 years

300 – 380 g / l

An increase in MCHC is observed in an inherited disease, when red blood cells have a rounded shape – hereditary spherocytosis, as well as in newborns.

A decrease in MCHC usually occurs with microcytic anemias.

What can influence the result?

Elevated blood lipids, multiple myeloma, and heparin saturation lead to falsely elevated MCHC results.

RDW-SD (distribution of erythrocytes by volume, standard deviation): 37 – 54.

RDW-CV (distribution of erythrocytes by volume, coefficient of variation):



14.9 – 18.7

> 6 months

11.6 – 14.8

An increase in RDW is noted with a significant variation in the size of red blood cells, which can be with iron deficiency anemia, when the number of small red blood cells (microcytes) increases, or with a deficiency of vitamin B 12 or folic acid, when the number of increased red blood cells increases – megaloblasts.

An increase in RDW is one of the earliest signs of iron deficiency anemia.A decrease in mean erythrocyte volume with normal RDW suggests thalassemia.

If the majority of red blood cells are reduced or enlarged, the RDW result may remain normal.

The pathological causes of decreased RDW are unknown.

What can influence the result?

A significant increase in the number of reticulocytes or leukocytes overestimates the RDW result.

Important notes

  • A complete picture of the appearance and size of red blood cells can be obtained if the calculation of red blood cell indices is carried out in conjunction with the assessment of red blood cells by microscopy of a blood smear.

Also recommended

Who orders the study?

General practitioner, therapist, hematologist, nephrologist, surgeon.

Features of the study of the morphology of abnormal forms of erythrocytes by atomic force microscopy



UDC 612.Selimov M. A. [Selimov M. A.],

111.45 [53-57] Demchenkov E. J1. [Demchenkov E. I__],

Nagdalian A. A. [Nagdalian A. A.], Gatina Y.S. [Gatina Y.S.]


Features morphology abnormal forms of erythrocytes by atomic force microscopy

The possibility of using atomic force microscopy (ACM) for the qualitative assessment of the morphology and visualization of abnormal forms of red blood cells (erythrocytes), in comparison with traditional methods of optical microscopy, was studied.A comparison of the methods of sample preparation proposed by other authors in previous studies was carried out; the optimal method was chosen, which does not significantly affect the change in the morphological characteristics of the cell. By acting on erythrocytes with salts of heavy metals, erythrocyte forms that differ from physiologically normal have been obtained. It was found that atomic force microscopy is an important tool for visualizing the morphology of abnormal forms of blood cells, and when using software tools (Nova PX), it is possible to obtain a more complete picture of the dimensional characteristics and parameters of erythrocytes.The possibility of using atomic force microscopy in studies of morphology and visualization of abnormal forms of erythrocytes is shown.

Keywords: atomic force microscopy, red blood cells, size and morphology of erythrocytes, heavy metal salts.

Annotation The possibility of using atomic force microscopy (AFM) to qualitatively assess the morphology and the visualization of abnormal forms of red blood cells (RBCs), in comparison with traditional methods of optical microscopy, was studied in this article.The analysis of sample preparation methods of another authors showed what kind of methods are better and more useful. Based on that analysis, the authors chose optimal method without significant effect on morphological features of cells. The authors identified abnormal forms of the red blood cells under heavy metals salts effect. It was established that atomic force microscopy is an important tool for visualization the morphology of abnormal forms of red blood cells. The authors concluded that usage of software tools (Nova FX) provides researches by complete pictures of the dimensional characteristics and parameters of red blood cells.

Keywords: atomic force microscopy, red blood cells, the size and morphology of the red blood cells, salts of heavy metals.

* The research was partially carried out with the financial support of the Ministry of Education and Science of Russia, as part of the implementation of the basic part of the state assignment (2014/216).


Atomic force microscopy is a type of probe microscopy, which is based on the force interaction between the probe and the surface, for the registration of which special probe sensors are used, which are an elastic console with a sharp probe at the end.The force acting on the probe from the surface leads to bending of the console, which, moving relative to the surface and reacting to the force interaction, registers its relief [8].

At present, atomic force microscopy is actively used to study the structural features of biological macromolecules (proteins, DNA), since it allows obtaining images with a resolution of several nanometers. Along with the study of dry samples, AFM allows the study of molecules in buffer solutions.To obtain images by the AFM method, the objects under study must be fixed on some surface. When studying biological objects, the following is usually used as a substrate: crystalline mica, glass, sapphire plates, etc. In most cases, mica is used because it has an atomically smooth surface [7].

Today, AFM is becoming one of the most promising methods for studying the structural features of macromolecules, since it allows one to obtain images of objects with a high resolution comparable to the level of X-ray structural analysis, under conditions under which macromolecules are not subjected to harsh processing and exhibit their natural activity.In addition, atomic force microscopy makes it possible not only to visualize objects at the molecular level, but also to study the properties of individual macromolecules: the distribution of surface charges, the mobility of individual regions, conformational changes depending on conditions, the strength of specific interactions between molecules. Atomic force microscopy can be used to observe in real time the assembly of macromolecular complexes, the distribution of proteins on the cell surface, and the peculiarities of intracellular transport of macromolecules [4].

So, recently the most interesting and complete experimental data on the structure of the erythrocyte and the structure of the cytoskeleton were obtained by atomic force microscopy (AFM). [3, 12]

In the work of Nagornov Yu.S. [9] also associated with atomic force microscopy, the volume of the erythrocyte was calculated from the measurement data of the obtained scan of the membrane surface, and then the scan of the erythrocyte was cut diagonally to measure its height geometric characteristics.

AFM visualizes micro-objects with high spatial resolution and allows performing local micromechanical tests. In works [11, 13], the authors showed that AFM, being a modern nanotechnological tool for measuring the local elasticity of cell membranes, can be used to determine Young’s modulus and surface potential of erythrocytes, erythrocyte-containing media and other blood components. Another study revealed a statistically significant conjugate increase in the values ​​of Young’s modulus and surface potential of red blood cells, accompanied by a change in their shape to echinocytes and spheroechinocytes after long-term storage of erythrocyte-containing media for 35 days at standard temperature conditions of +4 ° C [5].

In [6], three methods of preparing erythrocytes for research by AFM methods were considered: without fixation of cells and with fixation in solutions of glutaric aldehyde with concentrations of 0.5 and 2.5%, in order to identify the most suitable for obtaining high-quality AFM. images of blood cells.

Use of such methods of visualization of biological objects as optical and electronic

microscopy, which makes it possible to construct a 2-dimensional image of an object, to estimate its length and width, cannot adequately provide reliable information about the parameters of the sample under study, including its dimensional characteristics, including features of the relief and surface topography.Another disadvantage of such microscopy methods can be considered the process of sample preparation, which sometimes requires a whole series of manipulations, treatment of samples with contrasting agents or the deposition of metal particles on the surface of the sample under study, which ultimately can affect the reliability of the research results.

The purpose of this work was to consider the possibility of studying the features of morphology, as well as visualization of the dimensional characteristics of abnormal forms of erythrocytes using atomic force microscopy, which, on the one hand, allows to minimize the procedure for sample preparation of the sample itself, and on the other hand, to obtain a more clear picture of the features of the relief and topography surface.The objectives of this study included:

– to simulate the object of research, namely the abnormal shape of the erythrocyte, by processing a suspension of red blood cells with heavy metal salts;

– visualize the received erythrocytes;

– compare scans with images obtained with an optical microscope;

– to measure the morphological features of abnormal cell shapes.

Material and methods.

For the experiment, erythrocytes of rats of the W $ & / g line were used. Of the many options for applying erythrocytes to a substrate – a simple smear, blowing off a drop of erythrocyte suspension with an air stream, creating a monolayer by centrifugation, various options for precipitating erythrocytes from the suspension, the latter was chosen. Since this method of sample preparation does not significantly affect the change in the shape of erythrocytes [2].Samples were prepared –

Lena by sedimentation from a suspension onto coverslips, which were pretreated with 1% glutaraldehyde. In the studies carried out to create a solution for fixing erythrocytes, it was optimal to use 2.5% glutaraldehyde prepared in 20 mM Hepes buffer and Ringer-Locke’s solution. Glutaraldehyde lowers pH and has a significant effect on red blood cells. The action of aldehydes is reduced to the formation of bonds between the molecules of cell membranes and membranes of organelles, into a strong unified network due to the “stitching”, mainly of cellular proteins [10].With this method of fixation, the cell does not spread over the substrate and the values ​​of its macro-morphometric parameters are as close as possible to the values ​​of native erythrocytes (cell height, depth of the central depression). However, when obtaining images with a higher resolution, the surface relief of the membrane is smoothed and it is not possible to evaluate membrane nanostructures with this method of fixation [1].

Preparation of preparations for AFM scanning.

Dry preparations of erythrocytes were prepared from 50 μl of erythrocytes with 1950 μl of a solution of 10 μg / l CdCl2, Then the samples were kept in a shaker thermostat for 1 hour at a speed of 300 rpm and a temperature of 37 ° C, after which the samples were centrifuged. At the end of centrifugation, the incubation medium was discarded, and 1 ml of fixing solution was added to the samples. The resulting composition was applied to a cover glass and evenly distributed over the surface.The preparation was dried in air for 20 min. at room temperature, after which it was scanned with AFM. A control sample was prepared according to the same principle, but without the use of CdCl2.

Atomic force microscopy.

Scanning was performed using an atomic force microscope from NT-MDT (Zelenograd, Russia), model Ntegra Life. Cantilevers model HA_NC (Etalon), side B were used for work.Radius of curvature <10 nm, beam length 124 µm. Data processing and counting were carried out using specialized software "Nova". Scanning was carried out in a semicontact mode with a generated frequency of 153 kHz. The scanned area of ​​the control sample was 6.2 x 6.2 µm, and that of the treated CdCl2 sample was 8.6 x 8.6 µm.

On the preparation, from objects evenly distributed over the surface, an erythrocyte was randomly selected, on the surface of which the formation unusual for physiologically normal forms of formation was clearly distinguished.The data obtained were processed using the NovaPX computer program attached to the microscope to construct the horizontal and vertical profile of the erythrocyte surface.

Results and discussion.

As a result of AFM scanning of the cover glass surface of the test sample with fixed erythrocytes, images of red blood cells were obtained, the shape, morphological features and sizes of which had a form unusual for erythrocytes. Physiological abnormalities in the samples under study are most likely due to the interaction of heavy metal salts with cell membranes.For comparison with the normal form, the test samples under optical and atomic force microscopy were compared with the control samples.

The image obtained using an optical microscope (Fig. 1 a) shows a group of red blood cells, which have obvious deviations in shape from physiologically normal cells. On the cell surface, “contrasting” areas are clearly visible, which are places with abnormal morphology.In another part of the figure (Fig. 16), one can observe erythrocytes with physiology –

Fig. 1. Red blood cells (erythrocytes) under optical

microscope. a) damaged cell forms; b) control sample.

are in normal shape, which are also obtained using optical microscopy. These red blood cells were identified in the control images.Using optical microscopy, it is not possible to reliably visualize the dimensional parameters of places with abnormal morphology. Figure 1 shows the same sample that was subsequently scanned using atomic force microscopy.

rs ~ isvg = ‘• “- • oaiva

a) 3c1 image of single cells of normal and abnormal form of erythrocyte;

b) 2D image of normal and abnormal cells;

c) a graph of the section of normal and abnormal cells;


AFM image of an abnormal erythrocyte cell (scanned in air).

During AFM scanning of samples for comparison, a three-dimensional image of a single erythrocyte of normal and abnormal shape was obtained (Fig. 2a). The image of the damaged erythrocyte in the region of the depression clearly shows the presence of “accrete outgrowths” of a hilly shape, sharply contrasting with respect to the surface of the sample.The possibility of constructing a 3-dimensional picture of the image allows you to clearly observe the shape and parameters of formations unusual for the normal form of erythrocytes. At

2-dimensional image of erythrocytes (Fig. 26) can reveal a slight difference in the diameter of the presented single cells, which is most likely also due to the damaging effect of heavy metal salts.

Application package (NovaPX), allows you to evaluate the size, shape and nature of changes occurring with the cell under the influence of heavy metal salts.Figure 2c shows a cross-sectional graph characterizing the features of changes in cell morphology.

As part of the study of a single abnormal cell shape, vertical and horizontal cross-sectional profiles of the studied object were built, which clearly display the shape, size and height of the abnormal blood cell (Fig. 3-4).

According to the data of atomic force microscopy (Fig.

3-4), it is possible to determine not only the dimensions of the object, but also the dimensions of the components included in the composition or interacting with the sample under study.So, the width (diameter) of the erythrocyte sample under study is in the range of 6-6.5 microns, and the height of this abnormal form of the blood cell is about 1.5 microns. The outlines of the volume of the cell itself are clearly visible, as well as

Fig. 3. AFM image of an erythrocyte: a) 2D image from pro

section of the vertical profile of the section; b) a graphic representation of the vertical profile of the section.


AFM image of an erythrocyte: a) 2D image with a projection of the horizontal profile of the section; b) a graphic representation of the horizontal profile of the section.

is the shape and location of the “outgrowth” in the central part of the erythrocyte cavity.

Since the traditionally used methods of visualization of the studied objects in the micrometer range (mainly optical microscopy) cannot accurately characterize its morphological and parametric characteristics, it can be assumed that the use of atomic force microscopy methods in studies of small biological objects is promising.


Thus, according to the results of the work, it was shown that, based on simple methods of sample preparation, it is possible to obtain AFM images of individual objects with detailed morphological parameters and use them for a qualitative assessment of the morphofunctional activity of these cells. The study of the features of changes in the surface morphology of erythrocytes was carried out using AFM, and the results were contrasted with the data obtained on the basis of optical microscopy.This work is the first to study and compare the features of the morphology of the surface of red blood cells (erythrocytes) physiologically normal and deformed by interaction with cadmium salts.

As part of the work, damaged (abnormal) red blood cells were obtained by treating washed erythrocytes with heavy metal salts (CdCL). A comparison of images obtained with an optical microscope with AFM scans has been carried out.When examining damaged erythrocytes using an atomic force microscope, a parallel measurement of the control sample was carried out in order to compare them

morphometric features, both in the 3c1 version and when plotting along the profile of the section.

It should be borne in mind that some dimensional characteristics may differ from the reference values, both upward and downward, both due to the fact that the test sample was exposed to salts of heavy metals and has an abnormal shape, and because of possible errors associated with sample preparation.But the very fact that it is possible to study an object and visualize unusual changes in shape and volume, in comparison with optical microscopy methods, cannot cause any doubts.


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13. Ebner A., ​​Schillers H., Hinterdorfer P Normal and pathological erythrocytes studied by atomic force microscopy // Methods Mol Biol. Vol. 736 2011. P. 223-241.

14. Sawateev M.N., Kozlovskaya N.V., Moisenovich M.M. et al II AIP Conference Proceedings, V. 696, 2003 P. 428.

The research was partially carried out with the financial support of the Ministry of Education and Science of Russia, as part of the implementation of the basic part of the state assignment (2014/216).


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Preliminary differentiation (division) of leukocytes into three subpopulations. The main advantages of automatic cell differentiation are speed and high accuracy: compared to counting 100 cells with manual microscopy, the automatic analyzer counts 15,000 cells on average in one sample.

Sysmex separates lymphocytes, neutrophils and a mixed cell population of monocytes, basophils and eosinophils. Analysis using other technologies separates leukocytes into lymphocytes, monocytes and a mixed population of granulocytes. Isolation of a separate fraction of neutrophils gives an advantage in the diagnostic significance of the result, since neutrophils are an early marker of inflammation and infectious diseases, rather than monocytes.

Complete differentiation of leukocytes into five main subpopulations, which are normally contained in peripheral blood at certain concentrations, is a division of cells into lymphocytes, monocytes, eosinophils, basophils and neutrophils.The ability of 5-diff analyzers to perform separate counts of small cell types (monocytes, eosinophils and basophils) is a significant advantage.

The results are presented as a percentage of the total number of leukocytes and in absolute value, since it is more informative: in various diseases, the ratio of cell subpopulations is disturbed, which is why the use of the percentage of cells without absolute values ​​is impractical.

The fundamental difference from 3-diff analysis technologies is that the identification of each cell is carried out on the basis of three-dimensional analysis, and not only the cell size.This allows the identification of immature and abnormal cells, which helps in determining the possible causes of the patient’s illness.

The latest modern hematology analyzers are able to separately classify immature granulocytes (IG) as the sixth subpopulation and provide values ​​as a percentage of total leukocyte count and in absolute numbers.

The term “6-diff analysis” refers to the classic 5-diff analysis with an additional count of immature granulocytes (IG) as the sixth leukocyte subpopulation.The Sysmex XN and XN-L series analyzers count immature granulocytes as diagnostic parameters as a percentage of the total leukocyte count and as an absolute value as part of a standard assay.


Sysmex analyzers use a special principle for counting blood cells: the cells are counted by the number of pulses generated in a certain volume of blood. The advantage of this approach is that there is no need to perform calibration while using the analyzer.

Sysmex method for evaluating the signals of individual cells during the measurement and determining their belonging to certain population clusters. Since the method provides high flexibility, taking into account the biological variation between patients, it allows for more accurate differentiation results, especially for pathological samples in which the cell morphology may be altered due to disease.

Albumin is a low molecular weight soluble protein that is synthesized in the liver and found in the blood.In terms of quantity, albumin prevails in the blood in comparison with other proteins and performs binding and transport functions. If the kidneys work properly, they preserve all the most important elements in the blood, including albumin. In healthy people, only a small amount of protein is excreted daily. In contrast, albuminuria is a pathological condition of the body in which a large amount of protein is detected in the urine over a long period of time (> 30 mg / 24 h).This allows early recognition of nephropathy. Early diagnosis of (micro-) albuminuria prevents or slows down the process of severe kidney damage.

Anemia is usually defined as a decrease in hemoglobin (HGB) levels below the minimum range of normal values. The values ​​that determine the presence or absence of anemia depend on the sex and age of the patient. Hematocrit (HCT) is a concomitant indicator as it also decreases with anemia. Anemia is a symptom rather than a disease in its own right, with many reasons that need to be identified for successful treatment.


There may be some bacteria in the urine of healthy patients. Large numbers of bacteria are caused by poor hygiene or urinary tract infections. Bacteria can be classified into gram-positive and gram-negative in terms of cell wall composition. Depending on the type of cell wall, they are sensitive to different antibiotics.

Basophils belong to the group of granulocytes and are the least common type of leukocytes in the peripheral blood.Despite their similarity to eosinophils, an increase in the concentration of basophils does not always indicate an allergy or the presence of a parasitic infection. Together with mast cells, they act as effector cells in complex processes such as chemotaxis or nonspecific cell adhesion, and act as immune modulators during allergic reactions.

Most proteins normally remain in the blood because they are too large to pass through the glomerular membrane. However, if these filters are damaged, proteinuria – the presence of protein in the urine – can develop.Protein in urine is a common symptom of kidney disease, but not very specific. A temporary increase in the amount of protein in the urine is possible during exercise, fever, or stress.

Bilirubin is formed during the breakdown of hemoglobin, which is released mainly during the destruction of old erythrocytes in the reticuloendothelial system. It then binds to albumin and is carried in the blood to the liver.

Pathological processes that increase the concentration of conjugated bilirubin in plasma, such as fibrosis and swelling or necrosis of liver cells, also lead to an increase in the content of bilirubin in the urine.

A type of body fluid sample, typically in the veterinary field.


Optional software application built into the Extended IPU that is activated when interference is detected in the analysis of red blood cells or related parameters (eg MCHC). These can be cases of cold agglutination, hemolysis or hypoosmolarity, and others. The CBC-O algorithm provides reliable information about the causes of interference, suggests replacing erroneous values ​​of the affected parameters with the results of their analogs from the RET channel, and automatically recalculates erythrocyte indices.This feature relieves the laboratory from the need for additional processing of a number of problematic samples, contributing to more automation of the workflow.

A technology (method) used to differentiate stained cells in a blood smear or on a cytocentrifuge slide by capturing images and recognizing them using artificial neural network technology. High-resolution images of cells are displayed on the screen for validation (confirmation) or subsequent reclassification, and can also be further transmitted online, including for consultation with other experts.

Urinary casts usually consist of Tamm-Horsfall protein (mucoprotein) (BTX). Approximately 50 mg of liquid BTX is excreted daily, so detection of BTX in urine is normal.

Hyaline casts (Hy. CAST) are the most common type of casts in urine. They are cylindrical in shape and appear almost transparent. The cylinders are formed as a result of the coagulation of mucoprotein in the lumen of the renal tubules. The presence of hyaline casts in the urine may be due to dehydration, fever, or intense exercise.

Pathological casts (Path. CAST) contain inclusions. They are formed if particles such as erythrocytes or renal epithelial cells are present during BTX coagulation. The particles stick to the fibrillar protein network and remain trapped in it. Such cylinders appear in the urine if pathological processes take place in the kidneys. Examples: granular cylinders, cell cylinders, waxy cylinders.


Parameters containing diagnostically significant information about the patient, which is transmitted to clinicians and hospital departments.

Scatter plots (chart type) are generated by placing two different captured signals for each cell opposite each other in a 2D analysis. Signals can be derived from volumetric impedance, high frequency electromagnetic energy, optical (direct scattered light and side scattered light signals), and cytochemical indication (side fluorescent light).
More than one cell population can be evaluated and displayed.These two or more separate cell populations are differentiated using the ACAS method (not used in all devices and channels), which is superior in quality (for differential leukocyte counts) to fixed synchronization.
More than two captured signals per cell can be recorded, so more than one scatterplot can be generated to isolate and display different cell populations.

Software component for monitoring the entire XN analysis system: this is an application that protects the operating environment, as well as monitors maintenance and performance issues.

Abbreviation for digital morphology, ie digital morphology; also refers to the CellaVision AB DM Series analyzers.

Automatic re-measurement of a sample to obtain reliable analysis results, based on a set of rules, with a profile identical to the original order (measurement).

Yeast cells are smooth, colorless and usually ovoid. Their walls are birefringent, cells are of different sizes and often bud.The most common type of yeast found in urine is Candida albicans . Yeast cells in the urine may be due to contamination from the skin or vagina, or it may indicate a fungal infection of the urinary tract.


Basophils belong to the group of granulocytes and are the least common type of leukocytes in the peripheral blood. Despite their similarity to eosinophils, an increase in the concentration of basophils does not always indicate an allergy or the presence of a parasitic infection.Together with mast cells, they act as effector cells in such complex processes as chemotaxis or nonspecific cell adhesion, and act as immune modulators during allergic reactions. Eosinophils belong to the group of granulocytes, as they are filled with granules containing various enzymes. They can move and phagocytose (i.e. absorb) particles. Since they kill parasites by secreting certain cytotoxic enzymes and are involved in allergic reactions, the increased concentration of eosinophils is most likely associated with parasitic invasion or allergy.Eosinophilia can also indicate the development of malignant diseases, as in some types of neoplasia.

“Epithelium” is a general term for the cellular tissue that covers certain surfaces. Different types of epithelial cells are present in the urinary tract: squamous (SEC) and non-planar (Non SEC) epithelium. Non-squamous epithelial cells are also subdivided into transitional epithelial cells (Tran. EC) and renal epithelial cells (RTEC).

Squamous epithelial cells are large, flat cells of irregular shape. They contain a small central nucleus and a large volume of cytoplasm. The edges are often curled up and the cage can be rolled up to form a cylinder. The presence of squamous epithelium in the urine is normal. These cells get there from the lower part of the urethra or from the skin that comes in contact with urine during collection. Thus, their presence may be due to contamination typical of improper collection of urine samples in the middle of urination.

Transitional epithelial (urothelium) cells vary in size and shape depending on their origin. They can be sourced from the upper part of the urethra, ureters, or the renal hilum (scar). A small amount of transitional epithelium in the urine is normal.

The epithelial cells of the renal tubules are slightly larger than leukocytes and contain a large, round nucleus. They can appear flat, cubic, or columnar. They enter the urine from the nephron tubule system.The presence of renal tubular epithelium in the urine indicates kidney problems.

Red blood cells deliver oxygen to the tissues of the body, moving through the circulatory system. These are round smooth red cells. If red blood cells are unchanged in shape, they are called isomorphic or eumorphic, and they do not come from the glomeruli. If red blood cells have been damaged, they are called dysmorphic. Deformation (damage) occurs when passing through the glomerular structures of the kidneys, however, in addition, its appearance is possible with prolonged contact with urine.Abnormal dysmorphic red blood cells are also called “acanthocytes”. Their presence may indicate a glomerular disorder such as glomerulonephritis.

The appearance of a small amount of red blood cells in the urine can be considered normal. However, a large number of red blood cells can indicate damage, the presence of crystals, stones, or a urinary tract infection.

A set of haematological inflammation parameters that quantify and characterize particular lymphocytes (RE-LYMP, AS-LYMP) and the activation status of neutrophils (NEUT-GI, NEUT-RI).These diagnostic parameters provide additional information about the activation of the patients’ immune response and help clinicians monitor inflammatory conditions in more detail. They become available with license activation on XN systems via XN-DIFF measurement. The use of WPC is of extra value here as it excludes malignancies reliably.

Software utility for standardization and control of workflow, as well as synchronization of processing of samples, orders and data streams (for example, extended technical validation based on a set of rules).In the XN Series analyzers, the extended information processing system – Extended IPU – allows you to perform a wide range of standard and optional functions at all stages of the analysis: “before”, “during” and “after”. In addition, the software solution’s “workspace management” capabilities include a set of customizable rules to ensure standardization of technical and biomedical validation, as well as tools to optimize workflow.


Sysmex technology used in X and XN hematology analyzers for differential cell counting to detect and differentiate blood cells from all three major cell lines after intravital labeling with proprietary fluorescent labels and laser irradiation in a flow cell.

A chemical compound that can bond with other structures and exhibit the phenomenon of fluorescence: after excitation with light of a certain wavelength, a molecule emits light with a slightly longer wavelength. The electrons inside the molecule absorb the energy of the exciting light (for example, laser radiation), rise to a higher energy level, and return to their original level within a short period of time. At this point, they emit most of the excess energy in the form of light.Less energy is released as thermal energy, so the wavelength of the emitted light is longer (at less energy) than the wavelength of the exciting light. Which wavelengths are suitable for excitation and which are emitted depends on the properties of the fluorochrome.

Fluorochromes are used to label individual cell components (eg nucleic acids) because the fluorescent light emitted can be measured. A photomultiplier tube is usually used as a detector. This means that fluorochromes can serve as markers for these cell components, allowing their quantitative and qualitative analysis, since the fluorescence intensity is proportional to the amount of an individual component, for example, intracellular RNA and / or DNA.

Thanks to the use of an original reagent system, the Sysmex XN and XN-L hematology analyzers allow differentiation of cells by their functionality, especially in cases where it is difficult to make a decision based on morphology. Determination of cell functionality is based on the analysis of the individual lipid composition of cell membranes and allows differentiation of mature and immature cells, as well as reactive and malignant cells.

Unique Sysmex reagents allow making a conclusion about:

1.cell maturity,

2. cell malignancy,

3. cell activation state.


Hemoglobin is an iron-containing red blood pigment that is found in red blood cells and provides oxygen transport in the body. The detection of hemoglobin in urine may be due to its increased content, or the presence of red blood cells in the sample. Elevated values ​​of this indicator are an important symptom in trauma, the presence of crystals, glomerulonephritis, kidney stones, or urinary tract infections.

Sysmex technology used in hematology and urine analyzers to optimize cell / particle counting. The sustained flow separates cells or particles from each other and aligns themselves in a straight line before entering the flow cell, preventing them from passing through the aperture together and recirculating after the initial readout.

In particular, red blood cells change their shape under the influence of rapid acceleration in suspension. When using hydrodynamic focusing, the level of acceleration is significantly reduced, due to which the native characteristics of the cells are preserved to a greater extent.

Histograms are of the type of diagrams and are built on the basis of measuring the size (volume) of each individual cell, which is determined by the height of the pulse generated when the cell passes through the impedance aperture. Also, histograms can be built on the basis of other signals generated by the recorded cells, for example, the signal of forward light scattering, lateral light scattering or fluorescence, which reflect such properties of the cell as the cross-sectional area (size), the complexity of the intracellular structure and the content of nucleic acids, respectively.

It is possible to evaluate and display more than one cell population, for example, on erythrocyte and platelet histograms, as well as a curve with three peaks of distribution of leukocytes in 3-diff analyzers. These two or more separate populations of cells are distinguished by so-called “discriminators”, expressed in a certain cell size.

The urine of a healthy person contains only traces of sugar, that is, glucose. Glucose appears in urine when its concentration in the blood increases as a result of glucose metabolism disorders.Determination of glucose in urine has a high diagnostic value for the early detection of disorders such as diabetes mellitus.

Granulocytes belong to the group of myeloid leukocytes, which are characterized by the presence of granules in the cytoplasm. They are divided into neutrophils, eosinophils, and basophils. Granulocytes constitute a group of polymorphonuclear leukocytes, in contrast to mononuclear leukocytes (lymphocytes and monocytes).

In biological fluid analysis mode on the Sysmex XN and XN-L series analyzers, as well as in some X-class analyzers, the number of granulocytes is displayed by the PMN parameter.When combined with the MN parameter, which indicates the number of mononuclear cells, the test results can help in determining the cause of an existing infection or inflammation, for example, in CSF (cerebrospinal fluid) samples.


A long-term monitoring parameter used to control diabetics’ medical status. It has become a frequently ordered test in medical labs nowadays because of the increase in lifestyle diseases such as diabetes.Automated HbA 1c testing is facilitated with the Tosoh HLC-723 G11 Analyzer, which can also be integrated into XN-9000/9100 configurations ‘Sorting & Archiving’ or ‘Maximum Workload’ including the tube-sorting process.


Using the Aged Sample Identifier (software application that must be activated if required) on the XN and XN-L Series analyzers reliably differentiates samples with abnormal distribution on the WDF scatterogram into true abnormal samples and old or improperly stored samples …This application is effective in detecting false positive flagging, especially the “Blasts / Abnormal lymphocytes?” (Blasts / Abn Lympho?), Which results in fewer smears performed for this type of specimen. This reduces the effort to process samples that have changed due to the influence of time or external factors such as temperature, so that the main focus of attention will be focused on truly pathological samples that require more careful analysis.Sysmex recommends using the Old Sample ID in laboratories where the workflow is complicated by the high proportion of old samples.

Flow cytometry using monoclonal antibodies by differentiating the surface characteristics of cells. This term has a broader meaning than “immunophenotyping” and can be used to describe, for example, a reference platelet counting method (using antibodies to CD41 / 61), with which platelet counting in the PLT-F channel on Sysmex XN analyzers demonstrates excellent correlation of results.

Flow cytometry using monoclonal antibodies by differentiating the surface characteristics of cells. This term is commonly used to refer to the precise differentiation of leukocytes in the differential diagnosis of leukocyte abnormalities such as leukemia and lymphoma. If this term is used in relation to platelet counting, it implies an extended analysis that includes examination of the activation status of cells, etc.

The impedance (direct current) method is based on the possibility of using an electric field created between two oppositely charged electrodes to counting and determining the size of cells.Blood cells conduct electricity poorly. The diluent (reagent), in which the cells are suspended in a diluted state during counting, is an isotonic solution that is a good conductor. Thus, as cells in the diluent pass through the aperture (narrow opening) between the electrodes, each individual cell momentarily increases the impedance (resistance) of the electrical circuit between the electrodes. The electrical impulse generated by each cell is proportional to the size (volume) of the given cell.

Dedicated measuring channel in the XE-2100 and XE-5000 analyzers for the detection of immature myeloid cells. Analysis in this channel improves flagging for immature myeloid cells, such as blast cells, which are considered abnormal in peripheral blood.

Sysmex laboratory analysis solutions are intelligently managed through an embedded software concept. This allows you to harmonize and standardize the relationship between the sample itself and the data flow, regardless of the type of system, whether it is a single analytical module or several work areas connected into a single network located in different places.
However, Sysmex offers more than software to take your laboratory analysis to the next level. These are Sysmex Academy Training services, distance learning and offsite educational seminars, as well as consulting services and assistance.

Software utility (including required hardware) through which the Sysmex analyzers are started and controlled. In the XN-Series, the IPU has a number of standard functions for different stages of the analysis.In particular, they can be linked to the capabilities of the Extended IPU to extend the functionality of the system.


Ketones in urine indicate an increased breakdown of fat in the body. This may be due to insufficient energy intake in the form of carbohydrates. When fatty acids are broken down in the liver, intermediates are formed called “ketone bodies” (acetoacetic acid, β-hydroxybutyric acid and acetone). The presence of ketones in urine is possible with increased breakdown of fat, which is especially important when studying metabolic decompensation in diabetes mellitus.

Sysmex Automated Hematology Analyzer Group of XE, XT and XS Series. The X-Class analyzers use fluorescence flow cytometry technology to analyze blood samples by separating leukocytes into 5 subpopulations and provide the laboratory with a set of various advanced parameters that enhance diagnostic capabilities.

Implies increasing the value of parameters or their combinations for diagnostics and therapy / monitoring – only based on verified data.

Glomerular filtration is the first stage of urine production. Through this process, the kidneys filter excess fluid and metabolic waste from the blood to remove them from the body.

The renal corpuscles filter about 1 liter of blood per minute due to the pressure gradient on the capillary walls. The filtrate formed in the glomerular capsule, containing water, glucose, amino acids, uric acid, urea, electrolytes, etc., is known as “glomerular filtrate” or “primary urine”.

Modular and scalable software system, which consists of various embedded components (information processing unit (IPU), extended software system Extended IPU, remote / web components) and has a single user interface. The system includes functions for workflow control, validation based on a set of predetermined rules, system maintenance and networking of individual analyzers or complex solutions, both analyzing in different laboratory directions, and located in different places.The system integrates equipment or work areas in the fields of hematology, hemostasis and urinalysis.

Creatinine is a breakdown product of creatine phosphate in muscle, and its amount depends on muscle mass. Normally, creatinine is formed at a fairly constant rate (about 1 g of creatinine is excreted per day). Thus, creatinine concentration can be used to interpret the results of urine samples taken during natural voiding to account for differences in urine concentration and obtain more consistent results.

Crystals in urine can take many different forms. They are formed by the precipitation of substances dissolved in the urine, such as inorganic salts or organic compounds. Crystals are usually not clinically significant unless the patient has metabolic disorders, stones (urolithiasis), or the drug needs to be adjusted. The most significant crystals in this context are cystine, tyrosine, leucine and cholesterol.

Sysmex method for measuring hematocrit (HCT). Hematocrit is a measure of the ratio of the total (cumulative) volume of red blood cells to the total volume of whole blood. Expressed as an index in SI (l / l) or as a percentage (%) value.

In Sysmex analyzers, the hematocrit value is determined using the impedance of the accumulation of RBC volume based on the pulse height of each individual cell. Thus, the hematocrit value is measured directly, rather than calculated, as is the case with analysis using other technologies.


Leukocyte esterase is an enzyme produced by leukocytes, or rather granulocytes. Detection of leukocyte esterase activity indicates the presence of granulocytic leukocytes. An increase in this indicator is an important symptom of inflammatory diseases of the urinary tract and kidneys.

Leukocytes are a vital part of the immune system. They help protect the body from infections and foreign organisms. As a rule, leukocytes are round in shape and, being a granulocyte type, also have granularity.Their diameter is approximately 1.5-2 times the diameter of erythrocytes. The most common type of leukocyte in urine is neutrophils (i.e., neutrophilic granulocytes), while lymphocytes or eosinophils (eosinophilic granulocytes) are rare in urine. In healthy people, a small number of white blood cells may be present in the urine, but high levels may indicate inflammation or infection of the urinary tract.

Lymphocytes originate from the lymphoid lineage (as opposed to the myeloid lineage).Lymphoid cell development is not restricted to the bone marrow and takes place in primary and secondary lymphoid organs.

Lymphocytes defend the organism against infection by distinguishing the body’s own cells from foreign ones. Molecules recognized by the body as foreign are known as antigens. Each lymphocyte is only stimulated by one specific antigen. When lymphocytes recognize this antigen, they produce chemicals to fight it.

There are three main types of lymphocytes: B lymphocytes, T lymphocytes and natural killer (NK) cells.Lymphocytes belong to the mononuclear white blood cells. Although compared to other white blood cells all lymphocytes are small and round without granules, there is a large variety of different subtypes, and distinguishing between them morphologically is tricky.

Reasons for an increased lymphocyte count include infection or inflammation, as well as certain types of malignancies, especially haematological malignancies. Despite giving an absolute and relative lymphocyte count, several flags on Sysmex analyzers can point to suspicious lymphocytes for which, if present, a follow-up test should be performed.


A function that allows for the on-line analysis of individual samples.

The scalability of the XN concept allows for system upgrades to adapt the solution to the needs of the laboratory. This concept includes the ability to select performance indicators, clinical indicators and professional services.

Brand name for methanol-free staining reagents manufactured by RAL Diagnostics and used in the RAL Stainer and RAL semi-automatic blood smear staining device.

The average hemoglobin content in a red blood cell is calculated based on the values ​​of the total red blood cell count (RBC) and hemoglobin (HGB). MCH [pg] = HGB / RBC. The normal range of MCH values ​​depends on age. The MCH value is usually proportional to the mean erythrocyte volume (MCV), since cell size is largely determined by the hemoglobin content.

Cells that have normal MCH levels are called normochromic, while cells with low and high values ​​are hypochromic and hyperchromic, respectively.A low MCH level indicates that the cells contain too little hemoglobin due to insufficient production. These cells are called hypochromic because they appear pale when examined under a microscope.

The average concentration of hemoglobin in the erythrocyte is calculated on the basis of the hematocrit (HCT) and hemoglobin (HGB) values ​​and reflects the quantitative ratio of the hemoglobin content in the erythrocyte to the cell volume. MCHC [g / dl] = HGB / HCT. The normal range of MCHC values ​​is extremely stable throughout life and generally has a very narrow range with minimal coefficient of variation.

MCHC is also used to determine normo-, hypo- and hyperchromic erythrocyte populations. Cells with a low hemoglobin content are lighter in color and have a low MCHC level. An increase in the MCHC level for any clinical reason is extremely rare, practically only in the case of a change in the shape of the cells to spherical (due to the loss of the membrane) or if the cells are largely dehydrogenated. Hyperchromic red blood cells have an unusually high concentration of hemoglobin due to loss of cell volume.

MCHC is typically used to monitor the analyzer’s correct operation.

Average cell volume is calculated based on total red blood cell count (RBC) and hematocrit (HCT) values. MCV [fl] = HCT / RBC. The normal range of MCV values ​​depends on age. The terms “normocytic”, “microcytic” and “macrocytic” are used to describe populations of red blood cells with normal, low and high MCV values.

Since the size of red blood cells depends on the hemoglobin content, the inability to produce hemoglobin leads to a decrease in red blood cells – microcytosis.Macrocytic cells are found when the division of red blood cell precursor cells in the bone marrow is impaired.

The urethra (urethra) originates from the base of the bladder and drains urine out of the body. This is the only structure of the urinary system, the structure of which differs significantly between men and women, due to the dual role of the male urethra, which serves to transport both urine and semen.

The ureter is the tube that carries urine from the kidney to the bladder.There are two ureters, one for each kidney.

The bladder is a hollow muscular organ that collects and stores urine coming from the kidneys through the ureters before it is excreted (urinating). It is a very stretchable (elastic) organ. Typically, an adult’s bladder stores 300 to 500 ml of urine before the urge to urinate occurs, but it can hold much more.

Monocytes, like lymphocytes, belong to the group of mononuclear cells, but their formation occurs in the myeloid lineage, the cells of which are produced in the bone marrow.

Monocytes play a key role in the immune response. They can quickly move to the areas of infection and differentiate into macrophages and dendritic cells, causing an immune response. The cells of the monocyte-macrophage system can absorb foreign particles and break them down into antigens, which they can then present on their surface.

Automatic counting of monocytes is possible both as the ratio of the number of monocytes to the total number of leukocytes, and as their absolute content in the sample.An increased concentration of monocytes can be a sign of various diseases, for example, chronic inflammation or infection, but it can also occur in malignant diseases such as chronic myelomonocytic leukemia.


Nephron is a microscopic structural and functional filtering unit of the kidney. Each kidney is made up of over one million nephrons that purify the blood and balance the circulatory components.The nephron consists of the renal corpuscle, a complex system of renal tubules and an associated capillary network.

Nephrons process the blood flowing through the bringing arterioles by glomerular filtration, tubular reabsorption and secretion. In different parts of the nephron, many processes take place before the filtrate (primary urine) turns into a final product called “urine”.

Neutrophils belong to the group of granulocytes. They play an important role in immune defense and are the first immune cells to arrive at the site of infection – usually within an hour.This is due to a process called chemotaxis. Neutrophils can phagocytose other cells, such as bacteria, which are recognized as harmful to the body. However, in this process, the neutrophils themselves do not survive. The pus is made up mostly of dead neutrophils and processed bacteria. The absolute and relative count of neutrophils provides certain information for the diagnosis and monitoring of the development of infectious diseases, and is also taken into account when conducting chemotherapy.An increased concentration of neutrophils can also be observed in non-pathological conditions, for example, after suffering stress or in smokers.

Fluorescence flow cytometry detects immature cells based on their higher nucleic acid content compared to mature cells. Consequently, immature granulocytes (IG) are included in differential leukocyte counts as a separate subpopulation. Immature granulocyte counts include promyelocytes, myelocytes, and metamyelocytes, but not stab granulocytes.

The presence of immature granulocytes is always a pathology, with the exception of the period immediately after childbirth and in newborns less than 3 days old. The accuracy of automatic counting of immature granulocytes is significantly higher than with manual microscopy, which is ideal for continuous monitoring of patients’ condition and allows you to replace more time-consuming manual cell counting with a standardized method.

Nitrite is formed as a result of nitrate reduction. Various bacteria that cause urinary tract infections (UTIs) produce enzymes that convert nitrates to nitrites.The presence of nitrites in urine indirectly confirms a bacterial infection (bacteriuria). Common microorganisms that can cause urinary tract infections, such as Escherichia coli and Enterobacter, Citrobacter, Klebsiella and Proteus, form enzymes that reduce nitrate in urine to nitrite.

A negative nitrite test strip does not rule out urinary tract infection, as there are bacteria that do not produce nitrite.Thus, nitrite is a specific but not sensitive indicator of UTI. In addition, with vigorous bacterial growth, nitrite may eventually be degraded to nitrogen, causing the residual amount of nitrite in the sample to fall below the detection limit.

Normocytic anemia may result from decreased production of red blood cells, increased destruction of red blood cells, or blood loss. In normocytic anemia, the value of the total content of red blood cells is low, but the size of the cells and the content of hemoglobin in them remain normal.


Special articles on clinical and diagnostic topics with a scientific and educational bias. Articles are devoted, for example, to topics such as coagulation, hematology, urinalysis and body fluids, etc.

The classic 8-parameter hematological analysis includes the counting of erythrocytes, leukocytes and platelets, as well as the determination of the hemoglobin level (HGB), hematocrit number (HCT), the average red blood cell volume (MCV), the average hemoglobin content in the erythrocyte (MCH) and the average hemoglobin concentration in erythrocyte (MCHC).

The TWO application improves and simplifies the entire platelet analysis workflow by optimizing the use of repeat (reflex) tests in the PLT-F channel and intelligent software support in the differential diagnosis and monitoring of thrombocytopenic patients.

The new TWO algorithm is built into the Extended IPU and can be used in conjunction with the PLT-F application.

The MWO application embedded in the Extended IPU is a special solution for differentiating reactive and malignant monocytosis.The MWO concept helps to reduce unnecessary blood smear microscopy while optimizing the detection mechanism for CML, thereby improving laboratory workflow.

Parameters containing personalized diagnostic information that is shared with physicians and hospital departments or relevant physicians outside the laboratory / hospital.

Analyzers, which use the relative principle of cell counting, determine the number of blood cells based on the number of pulses generated in a fixed period of time.These systems are prone to aperture clogging errors that require regular calibrations to resolve.


Parameters that, in addition to and in combination with diagnostic / recorded parameters, contain diagnostically relevant information for exclusive use in the laboratory for the purpose of validating results and reporting diagnostic data. These results are not directly communicated to, for example, hospital departments or doctors, but diagnostic results can be communicated based on diagnostic / logged parameters.Parameters that, in addition to and in conjunction with basic parameters, provide diagnostically relevant information for exclusive use in the laboratory for the purpose of confirming results and reporting diagnostic data. These parameter results are not transmitted directly to, for example, hospital departments or doctors, however, diagnostic results in relation to the main diagnostic parameters can be transmitted in this way.Pathological changes in leukocytes can occur from the myeloid or lymphoid lineage. They can be caused by both reactive and non-reactive diseases (neoplasm or malignant tumor). Reactive changes can be observed with the development of infectious or inflammatory diseases, while malignant changes indicate the development of leukemia, lymphoma and other malignant hematological neoplasms.To differentiate between the various diseases associated with white blood cells, it is critical to determine their exact number, type and degree of maturity. Automated hematology analysis is a very important component of the diagnostic process and helps to determine the presence of disease, as it provides accurate cell counts and reveals prominent cell populations. In diseases associated with white blood cells, making the correct diagnosis is a difficult task and requires studying all the information obtained from the results of general and differential blood tests, morphology, immune phenotyping and other analyzes.

Primary urine is a fraction of blood plasma filtered by renal corpuscles. Due to the abundant blood supply to the kidneys and a large number of filtering units – glomeruli, the body produces about 150 liters of primary urine daily. Approximately 99% of the primary urine is reabsorbed through the epithelium of the glomeruli, so only 1.8 liters should be excreted from the body every day. The components of the primary urine correspond to the composition of the blood plasma without protein.

pH is an indicator that characterizes the degree of acidity or alkalinity of a medium based on the concentration of hydrogen ions.Persistently acidic or alkaline urine may indicate an acid-base imbalance. Permanently alkaline urine pH values ​​indicate a urinary tract infection. With microscopy, it is important to take into account that at a pH above 7, cells can lyse faster than under normal (weakly acidic to almost neutral) conditions.

Clinical units are optionally available for XN Series analyzers for platelet measurement due to special fluorescent markings and are highly accurate in the thrombocytopenic range.Demonstrates very good correlation with the reference method (CD41 / 61).
Platelet fluorescence also allows the determination of the immature platelet fraction (IPF), which reflects the thrombopoietic activity of the bone marrow, which is especially useful in detecting thrombocytopenia and its possible causes.

The renal corpuscle is the site of filtration of blood plasma. It consists of a glomerulus and a capsule of the renal glomerulus, or “Bowman’s capsule”. The supplying arterioles form a network of high-pressure capillaries called the “glomerulus”.The glomerular capillary bundle filters the blood based on particle size and the filtrate is collected in the surrounding bowl-shaped chamber, Bowman’s capsule (glomerulus capsule).

The renal tubule is a long convoluted structure emerging from the glomerulus and functionally subdivided into three main parts: the proximal convoluted tubule, the loop of Henle (with descending and ascending knees), and the distal convoluted tubule. After passing through the renal tubule, the filtrate enters the collecting duct system.

The kidneys are the two bean-shaped organs of the renal system. They perform a number of important functions, including regulating the balance of water and electrolytes, as well as filtering and removing metabolic waste (such as urea, uric acid and ammonia), drugs and toxic substances. In addition, the kidneys secrete hormones that promote the formation of red blood cells (erythropoietin, EPO), regulate blood pressure (renin) and strengthen bones (absorption of calcium by converting calcidiol to calcitriol).

A test parameter indicating the presence of lymphocytes with high fluorescence, which are activated cells (secretion of antibodies of B-lymphocytes / plasma cells), if systemic hematological diseases are excluded.

CBC parameters such as mean erythrocyte volume (MCV), mean erythrocyte hemoglobin (MCH), and mean erythrocyte hemoglobin concentration (MCHC) are collectively referred to as erythrocyte counts.Combined with the red blood cell volume distribution (RDW), these indicators are used to narrow down the number of possible causes of anemia in a patient. The mean erythrocyte hemoglobin concentration (MCHC) is an early sensitive marker as the mean erythrocyte hemoglobin (MCH) and mean erythrocyte hemoglobin concentration (MCHC) fall before the red blood cells become microcytic.

A group of compounds that are used (in addition to being widely used in industry) as fluorochrome markers for supravital cell staining using a semiconductor laser as a light source in Sysmex equipment for blood and urine analysis (patented by Sysmex).

These compounds have several advantages: their maximum absorption can be precisely adapted to the laser wavelength, their permeability into cells and nuclei can be individually adjusted, and their sensitivity (affinity) to certain cell components, for example, nucleic acids, can be created out of necessity – through changes in the molecular structure. Polymethines have excellent signal-to-noise ratios, are readily degraded in aqueous waste and are considered mutagenically safe compared to other nucleic acid-binding fluorochromes.

The Sysmex X-Class and XN Series analyzers (including the XN-L) use several different polymethine reagents to allow differential analysis of mature and immature cells in all three cell lines.

A type of laser, also called a “diode laser”, which is used in the latest generation of Sysmex flow cytometers for the analysis of blood and urine. Unlike previous gas lasers, these lasers consume less power (typically in the red part of the spectrum), take less time to wake up (allow the system to start up quickly), and have a longer life.

Characteristic of the convergence (closeness to each other) of the results: repeated serial studies under identical conditions.

Automatic re-measurement of the sample to obtain reliable analysis results in the event that certain errors occurred in the analyzer during the first measurement (related, for example, to pressure, temperature, etc.).

Optimization and harmonization of all integrated laboratory processes with an emphasis on total cost, while considering their contribution to ensuring fast and high quality results.

The UX and UF series urine analyzers use Sysmex technology, thanks to which the determination and differentiation of urine particles and cells is carried out by their supravital staining using special fluorescent markers and subsequent exposure to laser light when passing through the flow cell.


When an object passes through a beam of light, the light changes direction. This phenomenon is called light scattering and occurs at all angles between 0 and 360 degrees.The direction of the scattered light gives information about the size and quality of the object.
Forward scattered light (light scattered at a low angle) allows you to determine the size of an object. In addition to size, forward scattered light is influenced by the shape of the object and the refractive index. The detection of this light signal is usually done with a fast photodiode.
Side scatter light (light scattered at a wide angle) provides information about the intrinsic quality of an object.In cells, the side scattered light is affected by the presence or absence of granules. This light signal requires a sensitive photomultiplier tube as a detector, since its intensity – in comparison with the light scattered in the forward direction – is several times weaker.

The immature platelet fraction (IPF) is determined by PLT-F analysis. Immature platelets are analogous to reticulocytes and reflect the thrombopoietic activity of the bone marrow. Determination of the fraction of immature platelets is carried out both in relative and in absolute terms, and is especially useful for tracking the dynamics of thrombocytopenia and determining its possible causes.

Automatically calculated parameter that provides information on the level of variability of red blood cells (RBC) by volume. RDW is a quantitative measure of the variability in the size of individual red blood cells. Displayed as standard deviation (RDW-SD) and coefficient of variation (RDW-CV).

A high RDW value indicates an abnormal inhomogeneity in the size of individual erythrocytes (anisocytosis), which is well observed on microscopy of a blood smear. RDW is used to differentiate anemias with other identical erythrocyte indices.

Reexamining a sample based on a predefined rule system with a different or extended analysis profile for more reliable results.

The value obtained from the RET scatterogram to determine the RET-H parameter e , which reflects the level of hemoglobin saturation of the reticulocyte population.

The RET application, optionally available on the XN and XN-L series analyzers, has a high clinical value and is used to count and differentiate reticulocytes according to their stages of maturity (high fluorescence reticulocytes (HFR), medium fluorescent reticulocytes (MFR), reticulocytes with low fluorescence (LFR)) due to special fluorescent staining.Additionally, the analysis in the RET channel allows you to obtain the results of an optical platelet count (PLT-O).

RET analysis also allows to determine the fraction of immature reticulocytes (IRF = HFR + MFR) and the equivalent of hemoglobin in reticulocyte (RET-H e ), which allow to judge the quantity (erythropoietic activity) and quality (synthesis and content of hemoglobin) newly formed erythrocytes. This is important in the differential diagnosis of anemia. In addition, RET-H e is an early indicator of changes in the saturation of erythrocytes with hemoglobin, which is useful, for example, in monitoring the effectiveness of therapy.

The XT-4000i and XT-2000i Analyzers and the XE-Series Analyzers use the term “RET” to refer to the reticulocyte channel that provides data on the above parameters, partly included in the standard configuration and partly optional.

The reticulocyte production index (RPI) reflects the erythropoietic activity of the bone marrow in patients with anemia. This index, in contrast to a simple reticulocyte count, is used to assess the adequacy of the bone marrow response in anemic patients.In the absence of anemia, the index has no practical value.

RPI is determined by the following formula: RPI = (RET% × HCT) ÷ (0.45 × maturation period of red blood cells in the blood (in days)). 0.45 is the ideal hematocrit value where the RPI is identical to the percentage of reticulocytes, ideally around 1% for a healthy person. In anemic patients with adequate bone marrow response, the RPI is> 2.0. At the same time, the opposite statement (if RPI <2.0, then the bone marrow response is considered inadequate) is not always true.

A qualitative marker of a proper bone marrow response to anemia is an increase in absolute reticulocyte count along with a clear increase in immature reticulocyte fraction (IRF).


A Sysmex design solution that makes working with equipment more pleasant: the developers put user convenience first and optimized the interaction between the operator and the system that he uses on a daily basis.

SILENT DESIGN ® was designed around five core principles to continuously improve the user experience with the device: Human – Space – Appearance – Seriality – Durability. All five principles are taken into account in the manufacture of our products based on SILENT DESIGN ® to create an extremely positive experience.

The flag system messages are the result of a comprehensive analysis system (complete differentiation), which allows for the qualitative identification of immature and abnormal cells.
The flag system helps reduce laboratory uptime and cost-effectiveness by significantly reducing manual differential counting and directing the test sample for further pathology analysis through generated flags. In the future, manual microscopic analysis plays an essential role in fixing any remarkable elements of the morphological structure and confirming the presence of abnormal populations of cells, which during the automatic analysis were identified as suspicious and flagged with flags to attract the operator’s attention.
Flags are also used in pre-parsers. Here, they generally indicate excessively low or high counts and unreliable results, for example due to interference.

“Glomerular filtration rate” (GFR) is the volume of fluid filtered by the capillaries of the renal glomeruli into Bowman’s capsule per minute. In healthy adults, the GFR is approximately 125 ml / min (i.e., approximately 150 liters of primary urine are produced per day) and is an important indicator of kidney function.

A common traditional test that serves as a sensitive but not specific marker of inflammation. It can be used in the diagnosis and monitoring and control of various autoimmune diseases, acute and chronic infections, and neoplastic diseases. ESR is also used as a marker of “general physical condition”, which is assessed in conjunction with the patient’s medical history and physical examination.

The cyanide-free sodium lauryl sulfate hemoglobin measurement method used in the Sysmex analyzers provides reliable results through efficient lysis of erythrocytes, leukocytes and lipids, which reduces potential interferences.

Sysmex XTRA Online is a special section of the Sysmex library on the official website, containing many articles about both the company’s products and other related topics. This section is based on the Sysmex XTRA printed edition, produced by Sysmex in some countries, including Russia.


Unique WPC measurement option for hematopoietic progenitor cell counting (HSC, HPC). XN Stem Cells shows a high correlation with CD34 counts by flow cytometry in mobilized peripheral blood samples.

Optionally available on the XN and XN-L Series analyzers, the XN-BF application is of high clinical value and is used for automatic and standardized analysis of body fluids. The application allows analysis without pretreatment of samples at any time with excellent reproducibility of results, which reduces the number of time-consuming manual counting in the counting chamber.

In addition to the quantitative analysis of leukocytes and erythrocytes, a total count of nucleated cells is carried out, and leukocytes are divided into mononuclear cells and polymorphonuclear cells, which guarantees rapid recognition of infectious diseases and other disorders.

A functional application included in the standard configuration of the XN Series analyzers and of high clinical relevance in the field of CBC.

An additional advantage over standard CBC is achieved by counting normoblasts (nucleated red blood cells, NRBC) as a separate population. This can be important for the detection of critical disorders in patients of the intensive care unit, and is also necessary for accurate counting of the number of leukocytes in the presence of normoblasts, for example, in newborns, when their concentration is high enough.Thanks to the automatic counting of normoblasts, the need for manual counting is eliminated, the time of the result is accelerated and the workflow is standardized.

A functional application included in the standard configuration of the XN Series analyzers and of high clinical value in the area of ​​differential leukocyte counting in whole blood samples.

An additional advantage over the standard division of leukocytes into 5 subpopulations is achieved by counting immature granulocytes (IG) as a separate population, a three-dimensional flag system with high sensitivity and special messages that provide the doctor with additional diagnostic information.The special L-WBC mode, which is automatically activated when needed, allows for deeper and more accurate processing of low white blood cell samples by means of an expanded sample volume.

Difference between anisocytosis and poikilocytosis (Health)

Key difference – anisocytosis

versus poikilocytosis

Anisocytosis and poikilocytosis refer to abnormalities in red blood cells. The key difference between anisocytosis and poikilocytosis is that Anisocytosis refers to a condition in which red blood cells are uneven in size, while Poikilocytosis refers to a condition in which red blood cells are abnormal.

With anisocytosis, erythrocytes are unequal in size. It looks like they are smaller or larger than the standard size. With poikilocytosis, erythrocytes have an abnormal shape. They do not have a standard biconvex shape.


1. Overview and main differences
2. What is anisocytosis
3. What is poikilocytosis
4. Similarities between anisocytosis and poikilocytosis
5. Side-by-side comparison – anisocytosis versus poikilocytosis in table form

What is anisocytosis?

Anisocytosis is a disorder in which red blood cells develop an abnormal difference in their cell size.Red blood cells appear to be uneven in size. Red blood cells typically have a disc diameter of approximately 6.2-8.2 microns. The size of the red blood cell cells is larger or smaller than these parameters when it is said that a person has anisocytosis.

Anemia is the main cause of anisocytosis. There are different types of anemia that cause anisocytosis. These include iron deficiency anemia, sickle cell anemia, megaloblastic anemia, pernicious anemia, and thalassemia.

Figure 01: Anisocytosis

Diagnosis Anisocytosis simply involves microscopic analysis of a blood smear obtained from the person concerned.During microscopic observation, red blood cells appear to be either larger than normal ( macrocytosis ) less than normal ( microcytosis ) or both (some larger and some smaller than normal). Other symptoms: weakness, fatigue, pale skin and shortness of breath, etc.

What is poikilocytosis?

Poikilocytosis occurs when red blood cells take on different shapes, resulting in an abnormal shape of red blood cells. These various abnormal shapes include sickle shape, burr shape, teardrop shape, and elliptical shape.These red blood cells are more flattened and may contain pointed projections on the cell surface, thereby altering the cell’s normal shape.

In addition to anemia, poikilocytosis is also caused by liver disease, hereditary blood cell diseases and alcoholism. Poikilocytosis is diagnosed by microscopic observation of red blood cells. If abnormal forms are identified, they are additionally referred for treatment. Poikilocytosis can also be caused by a lack of vitamin B12 and folate, which are essential for red blood cells.

Figure 02: Poikilocytosis

There are different types of poikilocytosis depending on the shape of the erythrocyte; Spherocytes, stromatocytes – elliptical or slit-like, condocytes – specialized cells, leptocytes, sickle cells, etc.

What are the similarities between anisocytosis and poikilocytosis?

  • Both Anisocytosis and Poikilocytosis are associated with abnormalities in red blood cells.
  • Both can be caused by different types of anemia.
  • Both are mostly diagnosed by microscopic observation.

What is the difference between anisocytosis and poikilocytosis?

Anisocytosis versus Poikilocytosis

In anisocytosis, erythrocytes are uneven in size and appear to be either smaller or larger than the standard size. In poikilocytosis, erythrocytes are abnormal. They do not have a standard form.
Differentiation factor
The size of erythrocytes is controlled by anisocytosis. The shape of erythrocytes is controlled in poikilocytosis.
Types of anisocytosis: anisocytosis with microcytosis and anisocytosis with macrocytosis. Types of poikilocytosis: spherocytes, stromatocytes, condocytes, leptocytes, sickle cell, etc.

Summary – Anisocytosis

against poikilocytosis

states.During anisocytosis, erythrocytes are uneven in size, while in poikilocytosis, red blood cells are abnormal. Diagnosis is made primarily by microscopy. Treatment mainly includes vitamin B12 and folate supplementation. This is the difference between anisocytosis and poikilocytosis.


1. Poikilocytosis: Symptoms, Treatment, Prospects and More. Healthline, Healthline Media. Available here
2. Anisocytosis: Causes, Diagnosis and Treatment.Healthline, Healthline Media. Available here

Image Credit:

1. ‘Anisocytosis’ by Dr. Graham Birds – Own work, (CC BY-SA 3.0) via Commons Wikimedia
2. Poikilocytes by Dr. Graham Birds – Own work, (CC BY-SA 3.0) via Commons Wikimedia

Radionuclide diagnostics with labeled erythrocytes


  • Suspected pathological vascular formations (arteriovenous malformations (AVM) of the brain)
  • Cavernous hemangiomas of the liver, bones of the extremities
  • Vascular pathology of the extremities (endarteritis, diabetic foot)
  • Disturbances of central hemodynamics and contractile function of the heart
  • Gastrointestinal (GI) bleeding
  • Pathology of development and trauma of the spleen, conditions after splenectomy.


Detection of vascular formations (AVM of the brain, cavernous hemangiomas of the liver, bones of the extremities), vascular pathology of the extremities (endarteritis, diabetic foot), carrying out radionuclide equilibrium ventriculography to measure the volumetric parameters of central hemodynamics and assess the contractile function of the heart, diagnostics of GI bleeding, verification of asplenia or polysplenia , determination of residual tissue after splenectomy.


Erythrocytes labeled with Tc99m – erythrocytes after the formation of a complex with Pirfotech (temporary damaging effect of tin dichloride on the cell membrane) are labeled in vivo with Tc99m-pertechnetate. With the sequential introduction of lyophilisate and sodium pertechnetate Tc99m with an interval of 20 minutes, erythrocytes are labeled for a period of up to 3-4 hours. This allows visualization of the vascular pool of erythrocytes, their extravasation and abnormal vascular structures.


To assess the main blood flow through the vessels of the extremities, to determine the nature of the filling of the pathological formation in hemangiomas, a dynamic study is carried out after the bolus administration of Tc99m pertechnetate for 1-3 minutes.

Planar images, at least in front and rear projections, and if necessary, in lateral and oblique projections, are obtained for 15 minutes and 30 minutes.

Next, a delayed scan is performed 60-120 minutes after the injection in the same mode and projections as before.


No special training is required.

Image interpretation

Analysis and interpretation of research results consists of:

a) detection of focal RP hyperfixation in comparison with the surrounding tissue or with contralateral areas on delayed images, is a scintigraphic sign of AVM or cavernous hemangioma

b) determining the level of interruption of the main blood flow and reducing the accumulation of RP in the equilibrium phase in the presence of vascular pathology of the extremities

c) visualization of the location, structure and shape of the spleen, the presence and characteristics of aberrant tissue

d) determining the place of focal and / or diffuse accumulation of RP in the abdominal cavity outside the vascular bed in case of GI bleeding


It is carried out after receiving questionable data from planar studies (incl.h. with ectopia). Necessarily carried out when examining small focal formations (less than 2 cm).

© V.Yu. Sukhov, V.A. Pospelov “Methods of radionuclide diagnostics”, St. Petersburg, 2015


Essence of the disease

Thalassemias – a group of hereditary diseases of the hematopoietic system, which are characterized by a violation of hemoglobin synthesis. Therefore, the main manifestation of the disease is anemia.

As you know, normal human hemoglobin HbA consists of four protein chains of two different types: two α-chains and two β-chains.Accordingly, if the synthesis of α-chains is impaired (in this case, abnormal hemoglobin consisting of four β-chains appears in the blood), then they say about alpha-thalassemia . If the synthesis of β-chains is disturbed, then we are talking about beta-thalassemia ; in this case, other variants of hemoglobin are formed that do not contain β-chains. Beta thalassemia is more common. There are also other variants of the disease, but their clinical significance is small.

The listed varieties of the disease are subdivided into several more subtypes, depending on the number and type of genetic defects.So, in beta-thalassemia, large, intermediate and small forms are distinguished; the most severe disease is thalassemia major , while beta thalassemia minor is almost normal.

Frequency of occurrence, risk factors

Thalassemias are hereditary diseases. Severe forms of thalassemia are inherited by an autosomal recessive mechanism, that is, sick children can be born in families where both the father and mother are carriers of the defective gene – however, the corresponding blood anomalies in the parents are weakly expressed, since they also have “healthy” copies the required gene.For example, two parents with beta thalassemia minor may have a baby with thalassemia major.

The disease occurs in both boys and girls. Its frequency is about 1 per 100 thousand on average throughout the world, but depends primarily on the region. The majority of patients with thalassemia are residents of southern countries (Mediterranean, Central and South Asia). This is because carriage of the “defective” gene leads to better resistance to malaria disease. Therefore, in regions with widespread malaria, the number of carriers and, accordingly, the number of patients with thalassemia can be quite large.In Russia, there are relatively few patients with large beta-thalassemia, and many of them are descendants of residents of the Volga region, the Caucasus or Central Asia.

Families who have already had cases of the birth of children with severe forms of thalassemia are advised to consult a geneticist. Since the carriage of the “defective” gene in beta-thalassemia is easily determined by simple and inexpensive blood tests, prevention programs for the disease are being developed in countries with high prevalence of thalassemia.

Signs and symptoms

With thalassemia, the usual symptoms of anemia are observed: pallor, shortness of breath, poor exercise tolerance, decreased appetite.In large beta-thalassemia, anemia usually begins to manifest itself at the age of several months.

Growth retardation is not uncommon in children. Abdominal pain may occur due to an enlarged spleen and gallstones. Often there is an increase in the liver, yellowness of the skin and mucous membranes, bone deformities (due to dysfunction of the bone marrow), malocclusion, heart failure and / or arrhythmias, etc.


With thalassemia, characteristic changes in the clinical analysis of blood are observed.The number of erythrocytes, the level of hemoglobin (in severe forms – sometimes up to 20-30 g / l) and the color index are sharply reduced. Red blood cells of a reduced size, often of an unusual appearance – the so-called “target-shaped”. For diagnosis, it is also useful to use the results of a biochemical blood test and, possibly, analysis of a bone marrow sample.

Analysis of hemoglobin by electrophoresis, as well as biochemical determination of fetal hemoglobin can confirm the diagnosis. In thalassemias, the amount of “normal” hemoglobin is reduced, but the amount of abnormal hemoglobin is increased.

A family history is useful to establish the hereditary nature of anemia. In some cases, genetic analysis may be performed to identify a specific genetic defect.


RBC transfusions are used to treat anemia in large thalassemia – for example, once a month or two months. They allow you to maintain an acceptable level of hemoglobin. However, regular transfusions lead to the accumulation of excess iron in the body – that is, iron overload.Gradually, this excess becomes life-threatening, and patients must take special chelating medications to remove iron from the body.

If the spleen is severely enlarged (splenomegaly), surgical removal may be recommended. The enlargement of the spleen in thalassemia is associated both with its increased participation in the destruction of abnormal erythrocytes, and with the processes of ineffective hematopoiesis occurring in it. Removing the spleen leads to some improvement in the condition, but increases the risk of infections and other complications.In recent years, information has appeared that therapy with the drug Jakavi (ruxolitinib) can help some patients: studies show that such therapy, if successful, leads to a decrease in the size of the spleen and a decrease in the need for transfusions, and also, in combination with immunosuppressive drugs, increases chances of success for subsequent transplantation.

Since we are talking about a genetically determined disease, no conservative therapy can lead to a complete cure.The only chance to normalize hematopoiesis is given by allogeneic bone marrow transplantation. However, this is a complex and life-threatening procedure. If there is a compatible, healthy donor among the siblings of the patient, the transplant is usually successful. Transplantations from other donors are now being carried out more and more often, but they are fraught with serious difficulties, primarily with an increased risk of rejection. Therefore, doctors are constantly developing new protocols for preparing for transplantation.


In the past, severe thalassemia (such as large beta thalassemia) usually caused death in early childhood. The situation has changed in recent decades. Nowadays, periodic blood transfusions, combined with therapy aimed at removing excess iron, often allow patients to live to middle and even old age. However, it should be remembered that this therapy does not lead to a complete cure and should be lifelong.

Bone marrow transplantation, if successful, leads to the normalization of hematopoiesis, but its implementation is associated with certain risks, especially if the patient does not have a compatible related donor.

Indicators of erythrocytes – Red blood cell indices

Details of red blood cells as part of a routine blood test

Erythrocyte indices
Target information on hemoglobin content and erythrocyte size

Red Blood Cell Index are blood tests that provide information about the hemoglobin content and size of red blood cells.Abnormal values ​​indicate the presence and type of anemia.

Average corpuscular volume

The average corpuscular volume (MCV) is the average red blood cell volume calculated by dividing the hematocrit (Hct) by the concentration of the red blood cell count.

  • MCV = Hct [RBC] {\ displaystyle {\ textit {MCV}} = {\ frac {\ textit {Hct}} {[{\ textit {RBC}}}}}}
  • Normal range: 80-100 fl (femtoliter)

Average corpuscular hemoglobin

Average corpuscular hemoglobin (MCH) is the average amount of hemoglobin (Hb) per red blood cell and is calculated by dividing hemoglobin by the number of red blood cells.

  • MCHR = HOURBC {\ displaystyle MCH = {\ frac {Hb} {RBC}}}
  • Normal Range: 27-31 pg / cell

Average concentration of corpuscular hemoglobin

Mean Corpuscular Hemoglobin Concentration (MCHC) is the mean hemoglobin concentration per unit volume of red blood cells, calculated by dividing hemoglobin by hematocrit.

  • MCHR = HURCHC = {\ displaystyle MCHC = {\ frac {Hb} {Hct}}}
  • Normal range: 32-36 g / dL

Erythrocyte distribution width

Red Blood Cell Distribution Width (RDW or RDW-CV or RCDW and RDW-SD) is a measure of the range of change in red blood cell volume (RBC) to understand morphology.

Indexes of erythropoietic precursors

The reticulocyte production index (RPI) or corrected reticulocyte count (CRC) is the true value of the absolute reticulocyte count to provide some reflection of erythropoietic supply and demand. The immature reticulocyte fraction (IRF) goes further to shed more light on the same issue.

Example of work

Measurement Units Conventional units Conversion
Hct 40%
Hb 100 grams / liter 10 grams / deciliter (decite 10 −1 )
RBK 5E + 12 cells / liter 5E + 6 cells / μl (micro – 10 −6 )
MCV = (Hct / 100) / RBC 8E-14 liters / cell 80 femtoliters / cell (femto- 10 −15 )
MCH = Hb / RBC 2E-11 grams / cell 20 picograms / cell (pico-10 −12 )
MCHC = Hb / (Hct / 100) 250 grams / liter 25 grams / deciliter (deci 10 −1 )