tests for the
diagnosis of
blood
disorders
learning objectives
Describe various laboratory
tests in assessment and
monitoring of disease
condition
CBC
Complete blood count
• With or without differential
Peripheralvenous blood is collected in a
lavender tube (contains the anticoagulant
EDTA) and should be thoroughly mixed
Unacceptable specimen:
• Clotted or greater than 48 hours old
What is measured?
Red blood cell data
• Total red blood cell count (RBC)
• Hemoglobin (Hb)
• Hematocrit (Hct)
• Mean corpuscular volume (MCV)
• Red blood cell distribution width (RDW)
White blood cell data
• Total white blood cell (leukocyte) count (WBC)
• A white blood cell count differential may also be ordered
Platelet Count (PLT)
Total Red Blood Cell Count
Count of the number of circulating red blood
cells in 1mm3 of peripheral venous blood
Hemoglobin
Thehemoglobin concentration is a measure of the
amount of Hb in the peripheral blood, which reflects
the number of red blood cells in the blood
• Hb constitutes over 90% of the red blood cells
Decrease in Hb concentration = anemia
Increase in Hb concentration = polycythemia
Hematocrit
Hematocrit is a measure of the percentage of the
total blood volume that is made up by the red blood
cells
Thehematocrit can be determined directly by
centrifugation (“spun hematocrit”)
• The height of the red blood cell column is measured and
compared to the column of the whole blood
Mean Corpuscular Volume
The MCV is a measure of the average volume, or size, of an
RBC
It is determined by the distribution of the red blood cell
histogram
• The mean of the red blood cell distribution histogram is the MCV
The MCV is important in classifying anemias
• Normal MCV = normocytic anemia
• Decreased MCV = microcytic anemia
• Increased MCV = macrocytic anemia
Red Blood Cell Distribution
Width
RDW is an indication of the variation in the RBC size
(referred to anisocytosis)
Itis derived from the red blood cell histogram and
represents the coefficient of variation of the curve
Ingeneral, an elevated RDW (indicating more
variation in the size of RBCs) has been associated
with anemias with various deficiencies, such as iron,
B12, or folate
Thalassemia is a microcytic anemia that
White Blood Cell Count
A count of the total WBC, or leukocyte, count in 1mm3 of
peripheral blood
A decrease in the number of WBCs =
• Leukopenia
An increase in the number of WBCs =
• Leukocytosis
WBCs with shift to the left …
• Increased immature and very immature neutrophils – elevated total WBCs
Sign of acute infection!
WBC Differential
When a differential is ordered, the percentage of each type of
leukocyte present in a specimen is measured.
Name the types of leukocytes
• Neutrophils (includes bands)
• Lymphocytes
• Monocytes
• Eosinophils
• Basophils
WBC differentials are either performed manually or by an automated
instrument
Manual Differentials
“Manual” WBC differentials are performed by trained medical technologists who
count and categorize typically 100 white blood cells via microscopic examination
of a Romanowsky-stained peripheral blood smear
In addition to the differential count, evaluation of the smear provides the
opportunity to morphologically evaluate all components of the peripheral blood,
including red blood cells, white blood cells and platelets
The manual differential allows for the detection of disorders that might
otherwise be lost in a totally automated system
This applies to < 20% of specimens
Theinstrument is programmed with criteria to flag an operator when a
manual differential should be performed
Platelet Count (PLT)
A count of the number of platelets
(thrombocytes) per cubic milliliter of blood
• A decreased number of platelets = Thrombocytopenia
• An increased number of platelets = Thrombocytosis
MCH and MCHC
Both MCH and MCHC are of little clinical
diagnostic use in the vast majority of patients
(so we did not talk about them in any detail)
• MCH is the hemoglobin concentration per cell
• MCHC is the average hemoglobin concentration per
total red blood cell volume
Interpret this CBC
CBC
WBC 19.5 [4.0-10.0] k/ul
RBC 3.49 [3.60-5.50] m/ul
Hgb 10.4 [12.0-16.0] gm/dl
Hct 31.2 [34.0-51.0] %
MCV 82 [85-95] fl
MCH 28.3 [28.0-32.0] pg
MCHC 33.3 [32.0-36.0] gm/dl
RDW 6.6 [11.0-15.0] %
Plt Count 98 [150-400] k/ul
One final CBC pearl
Clinicians have a short-hand way to report CBC values:
HgB
PLT
WBC
HCT
Basic Metabolic Profile
BMP
• Blood test that measures glucose levels, electrolytes, acid/base balance and kidney
function.
BMP Components
• Sodium – normal 135 – 145 mEq/L
• Potassium – normal 3.7 – 5.2 mEq/L
• Calcium - normal 8.5 - 10.4
• Chloride – normal 101 – 111 mmol/L
• Carbon Dioxide (CO2) – normal 20 -29 mmol/L
• Glucose – normal 64 - 128 mg/dL
• Blood Urea Nitrogen (BUN) – normal 7– 20 mg/dL
• Creatinine – normal 0.8 to 1.4 mg/dL
Sodium
Sodiumis the major cation in the extracellular space
where serum levels of approximately 140mmol/L
exist
• Sodium salts are major determinants of extracellular
osmolality.
Increased serum sodium level = Hypernatremia
Decreased serum sodium level = Hyponatremia
Potassium
Potassium is the major intracellular cation with levels of ~ 4 mmol/L found
in serum
Elevated serum potassium level =
• Hyperkalemia
Decreased serum potassium level =
• Hypokalemia
If a specimen is hemolyzed (such as by traumatic venipuncture or drawing blood
with a needle that is too small) potassium levels may be “falsely” elevated. Why?
• There are high concentrations of K in red blood cells. If RBCs are lysed during
phlebotomy, K is released into the serum resulting in elevated measured levels
Chloride
Chloride
is the major extracellular anion with serum
concentration of ~ 100 mmol/L
Hyperchloremiaand hypochloremia are rarely
isolated phenomena.
• Usually they are part of shifts in sodium or bicarbonate to
maintain electrical neutrality.
Carbon Dioxide Content
Thecarbon dioxide content (CO2) measures the H2CO3,
dissolved CO2 and bicarbonate ion (HCO3) that exists in
the serum
Becausethe amounts of H2CO3 and dissolved CO2 in the
serum are so small, the CO2 content is an indirect
measure of the HCO3 anion
• Therefore, clinicians most often refer to the CO2 measurement
in the BMP as the “bicarbonate level” or “bicarb level”
Blood Urea Nitrogen
TheBUN measures the amount of urea nitrogen in
the blood
• Urea is formed in the liver as the end product of protein metabolism
and is transported to the kidneys for excretion.
• Nearly all renal diseases can cause an inadequate excretion
of urea, which causes the blood concentration to rise above
normal.
• The BUN is interpreted in conjunction with the creatinine
test – these tests are referred to as “renal function studies”
Creatinine
Thecreatinine test measures the amount of
creatinine in the blood.
• Creatinine is a catabolic product of creatinine
phosphate used in skeletal muscle contraction
• Creatinine, as with blood urea nitrogen, is excreted
entirely by the kidneys and blood levels are
therefore proportional to renal excretory function
GLOMERULAR FILTRATION RATE
(GFR)
The GFR estimates how much blood passes through the tiny filters in
the kidneys, called glomeruli, each minute. Rate decreases with age
Normal results range from 90 - 120 mL/min
High GFR occurs with normal to higher blood pressures
Decreased GFR and increased fluid retention occurs during hypotension
Levels below 60 mL/min for 3 or more months are a sign of chronic
kidney disease
Those with GFR results below 15 mL/min are a sign of kidney failure
Glucose
Plasma glucose levels should be evaluated in
relation to a patient’s meal
• i.e., postprandial vs fasting
• Elevated glucose levels may also be indicative of
diabetes mellitus
Glucoseis the most commonly measured test in
the laboratory
Diagnosing Diabetes
The criteria for the diagnosis of diabetes:
• Fasting Plasma Glucose ≥126 mg/dL
• 2 hour Post-Prandial Glucose ≥200 mg/dl
• Random Plasma Glucose >200 mg/dL in the
presence of symptoms
• Any one of these criteria must be repeated on
subsequent testing of a new specimen
Total Calcium
The total serum calcium is a measure of both
• Free (ionized) calcium
• Protein bound (usually to albumin) calcium
Therefore,the total serum calcium level is
affected by changes in serum albumin
• As a rule of thumb, the total serum calcium level
decreases by approximately 0.8mg for every
1gram decrease in the serum albumin level
Interpret the BMp
Component Value Flag Low High Units
SODIUM 142 136 144 MM/L
POTASSIUM 3.9 3.3 5.1 MM/L
CHLORIDE 107 98 108 MM/L
CO2 27 20 32 MM/L
BUN 10 7 22 MG/DL
CREATININE 0.80 0.7 1.5 MG/DL
GLUCOSE 100 70 100 MG/DL
CALCIUM 8.5 L 8.9 10.3 MG/DL
FRACTIONAL EXCRETION OF NA (FENA)
Fractionof Na+ filtered at the glomerulus that
is then excreted in the urine
TheFENa is helpful when the provider is trying
to decide what the cause is of the renal failure
Nota lab, but a mathematical equation from
the labs.
Ionized Calcium Levels
Normal levels for adults: 4.4 - 5.3 mg/dL
Ionized calcium is calcium that is freely flowing
in your blood and not attached to proteins
Complete Metabolic Panel
The CMP provides a more extensive laboratory evaluation of organ dysfunction and includes:
• Sodium
• Potassium
• Chloride
• Carbon Dioxide Content
• Albumin
• Total Bilirubin
• Total Calcium
• Glucose
• Alkaline Phosphatase
• Total Protein
• Aspartate Aminotransferase
• Blood Urea Nitrogen
• Creatinine
Total Protein
Albumin and globulin constitute most of
the protein within the body and are
measured in the total protein test
Albumin
Albumin comprises ~ 60% of the total protein within the
extracellular portion of the blood (Hgb is the most
abundant protein in whole blood and is intracellular)
Albumin’s major effect within the blood is to maintain
colloid osmotic pressure
• Transports many important blood constituents
drugs, hormones, enzymes
Albumin
is synthesized in the liver and therefore is a
measure of hepatic function
Alkaline Phosphatase
(Alk Phos or ALP)
Alkaline phosphatase is an enzyme present in a number of
tissues, including liver, bone, kidney, intestine, and placenta,
each of which contains distinct isoenzyme forms
Isoenzymes are forms of an enzyme that catalyze the same
reaction, but are slightly different in structure
The two major circulating alkaline phosphatase isoenzymes
are bone and liver.
• Therefore elevation in serum alkaline phosphatase is most commonly a
reflection of liver or bone disorders.
Levels of alk phos are increased in both extrahepatic and intrahepatic
obstructive biliary disease
Bilirubin, Total
The total serum bilirubin level is the sum of the
conjugated (direct) and unconjugated (indirect)
bilirubin.
• Normally the unconjugated bilirubin makes up 70-85% of the
total bilirubin
Remember that bilirubin metabolism begins with the
breakdown of red blood cells in the reticuloendothelial
system and bilirubin metabolism continues in the liver
• Elevation in total bilirubin may therefore be a reflection of
any aberrations in bilirubin metabolism or increased levels of
bilirubin production (such as hemolysis)
Aspartate Aminotransferase
(AST)
AST is an enzyme that is present in
hepatocytes and myocytes (both
skeletal muscle and cardiac)
• Elevations in AST are most commonly
a reflection of hepatocellular injury
Butthey may also be elevated in
myocardial or skeletal muscle injury
CMP Case
The following CMP is from a patient who presented with systolic
congestive heart failure exacerbation
Complete Metabolic Panel
Glucose 112 H [70 – 100]mg/dl
Blood Urea Nitrogen 39 H [7 - 22] mg/dl
Creatinine 1.6 H [0.7 - 1.5] mg/dl
Calcium 8.9 [8.5 - 10.5] mg/dl
Sodium 32 L [136 - 146] mmol/L
Potassium 4.0 [3.5 - 5.3] mmol/L
Chloride 93 L [98 - 108]mmol/L
Carbon Dioxide 3 [20 - 32] mmol/L
Albumin 3.1 L [3.6 - 5.0] gm/dl
Protein, Total 5.8 L [6.2 - 8.0] gm/dl
Alkaline Phosphatase 200 [25 - 215]IU/L
AST 35 [5 - 40] IU/L
Bilirubin, Total 1.9 H [0.2 - 1.4] mg/dl
Interpretation?
BUN and creatinine are elevated with a BUN:Creat
ratio greater than 20:1 consistent with pre-renal
azotemia, the result of inadequate renal perfusion
and resulting reduced urea clearance
Hepatic congestion leads to hypoxia and altered
function of the liver cells
• Bilirubin, especially the indirect fraction, and enzymes,
like alkaline phosphatase, may be elevated. Total
protein may decline at the expense of the decreased
albumin produced in the liver.
The electrolyte changes, especially hyponatremia,
reflect a dilutional effect with water retention and
decreased glomerular filtration rate (poor perfusion)
Hyperglycemia is present but it is not known whether
CPKs – CREATININE
PHOSPHOKINASE
Increases within 4-6 hours, peaks at 12-24 hrs and
returns to normal within 3 days
Normal range = 30 -170 u/L
Lacks specificity
Grosslyhemolyzed samples may elevate and
increases with exercise (skeletal muscle release),
trauma, alcoholism
Not cardiac specific
CK ISOENZYMES – (CK-MB)
CK-MB trumps the CK. It is looking at the cardiac
isoenzymes, so more reliable.
CK-MB < 5% of total CK is normal
> 5% implication for MI
Limitation
is the lack of early elevation in an acute MI
in some patients
TROPONIN I
Preferred test, highly specific marker of myocardial injury.
Normal < 0.4 ng/L (>1.4 suggests MI)
Elevated 3-6 hours post MI.
Peaks in 24 hours (and this is what drives the protocol for
labs over 24 hours) and continues to be released over the
next several days
Stays elevated for 14 days so can be a clue to a recent MI as
well
BNP - B-Type Natriuretic Peptide
Aidesin the diagnosis and assessment of severity
of heart failure.
Normal < 100 ng/L
Elevated signs –
• 400 - 800 or > points to CHF
• 100 - 400 may support findings of an MI
• 150-400 may point to need to test for PE
PRO-BNP
PRO-BNP
• The precursor to the BNP – so more commonly used with
chronic failure.
Normal ≤ 300 pg/ml
CHF very likely if > 450 pg/mlThe precursor to the
BNP – so more commonly used with chronic failure.
Normal ≤ 300 pg/ml
CHF very likely if > 450 pg/ml
C Reactive Protein
C-reactive protein (CRP) test is a blood test that measures
the amount of a protein called C-reactive protein in your
blood
C-reactive protein measures general levels of inflammation in
your body
Use the CRP to evaluate risk of heart disease
Current risk levels used:
• Low risk: a CRP level of less than 1.0 milligram per liter (mg/L).
• Average risk: a CRP level between 1.0 and 3.0 mg/L.
• High risk: a CRP level greater than 3.0 mg/L
CRPlevel greater than 10 mg/L is a sign of serious infection, trauma or chronic
disease
ABG
Preferred when determining the relationship between
ventilation and perfusion – respiratory status!
An ABG is an important reflection of overall pulmonary
function.
It also determines acid base interpretation
MIXED VENOUS BLOOD GAS
Drawn from the pulmonary artery using a Swan-Ganz catheter
Drawn from the pulmonary artery, assures the venous
return from the body
organs are thoroughly “mixed.”
Is preferred to reflect the oxygenation and acid base at the
tissue level in the settings of circulatory failure or when the
cardiac output is markedly reduced
Mixed venous blood gas values are usually close to those of an
ABG, except for the PaO2 and SaO2. They will both run lower.
Normal findings for a PaO2 is 35-40 (instead of > 60)
Normal findings for a SaO2 is 65-75% (instead of 93-
98%)
VENOUS BLOOD GAS
A venous blood gas is sufficient if the
focus is acid base interpretation
instead of pulmonary function
When is a venous blood gas OK instead of
an ABG?
When we don’t need to determine oxygenation status
Can be helpful determining acid/base status
ABG components
pH (percent Hydrogen): Numeric value associated with the
hydrogen ions (H+) in the blood.
The greater the number of H+ ion concentration, the more
acidic the blood
Acidosis: pH < 7.35
Alkalosis: pH > 7.45
PaO2: is the circulating oxygen in the arterial blood sample –
normal > 60
SaO2: Percentage of oxygenation – should correlate with O2
sat reading from the finger probe
VENOUS BLOOD GAS
Easier to draw & less painful for patients!
Decreased risk to patient – less chance of hematoma, arterial
laceration/thrombosis
When is a venous blood gas OK instead of an ABG?
• When we don’t need to determine oxygenation status. Can be helpful
determining acid/base status
Reference Range Critical Range
• pH 7.32-7.43 <7.20 or >7.65
• pCO2 40-60 mm Hg <20 or >65 mm Hg
• pO2 30-55 mm Hg (at RA)
• HCO3- 22-27 mmol/L
• O2 Sat 40%-85%
Lactate
Serum Lactate Levels:
Used to detect and evaluate the severity of hypoxia and
lactic acidosis occurring at the organ level
Lactate > 2 mEq/L are abnormal
Perthe Surviving Sepsis Campaign website, if
> 4 mEq/L supports septic shock
PROCALCITONIN LEVELS (PCT)
Helps differentiate sepsis from nonbacterial infections
(viral/fungal)
It’s a precursor to calcitonin
< 0.5 ng/ml – low risk of
Progressing to severe sepsis
0.5 to 2 ng/ml – moderate risk or progressing
> 2 ng/ml – high risk
GRAM STAIN
How to read it?
After processing a slide with the sample on it, then
looking under the microscope
• Gram + bacteria are stained purple and Gram –
ones red or pink
Gram stains are quicker than cultures and can guide
us in which antibiotics will be most beneficial to the
patient.
Ifwe had to wait for cultures to return, we would not
have as many good outcomes and would have to use
the big guns (broad spectrum) antibiotics on all!
Gram Stain
Focusing on which drugs will be most effective
Gram positive bacteria have a thick waxy layer
Gram negative bacteria have an extra fat layer
that can act as a barrier to some antibiotics
NORMAL RESULTS FOR CSF/LP
Gross appearance: Normal CSF is clear and colorless.
CSF opening pressure: 50 – 175 mm H2O
Specific gravity: 1.006 – 1.009
Glucose: 40 – 80 mg/dL
Total protein: 15 – 45 mg/dL
Lactate: less than 35 mg/dL
Leukocytes (WBCs) 0 – 5/microL (adults and children); up to 30/microL (newborns)
Differential: 60% – 80% lymphocytes; up to 30% monocytes and macrophages; other
cells 2% or less
Gram stain: negative
Culture: sterile
Syphilis serology: negative
Red blood cell count: None
Thyroid Function Tests (TFTs)
Used to determine how well the thyroid gland is
functioning. The thyroid affects virtually all
metabolic processes in the body.
Itcontrols how quickly the body uses energy,
makes proteins and how sensitive the body is to
other hormones that regulate the growth and rate
of function of many other systems.
The thyroid also produces calcitonin, which plays a
role in calcium homeostasis
TSH
Normal Range TSH: 0.4 – 4.0 MIU/L
The American Association of Clinical Endocrinologists has
proposed a range of 0.3 to 3.0 for normal TSH levels
Using these cutoff values would lead to more people being
diagnosed with an underactive thyroid (hypothyroidism).
Medications can impact TSH levels
Steroids, levodopa, lithium, heparin
If TSH is abnormal, then we start looking for more clues like
running a T4 and possibly a T3.
T3 LEVELS = 100 – 200 MCG/DL
HIGH LOW
Rises in pregnancy or use Hypothyroidism
of birth control Acute or chronic illness,
pills/estrogen including
replacement
kidney or liver disease
Hyperthroidism
Severe malnutrition
Thyroiditis
Medications as listed in
T3 thyroid toxicosis manual
Toxic Adenoma
T4 LEVELS – TOTAL OR FREE?
TotalT4 levels = T4 bound to proteins + floating in
blood available for conversion to T3
Normal range 4.8 – 10.4 mcg/dl
Free
T4 level = Just what is floating in the blood not
bound to proteins
Normal range 0.9 – 2.0 mcg/dl
T4
HIGH
LOW
Acute thyroiditis Hypothryoidism
Birth
control or Drugs:
estrogen
Steroids, antithyroid
IVP contrast with iodine medications, lithium,
Pregnancy phenytoin, propanolol
Drugs:Heparin and Kidney failure
heroine Myxedema
Thyrotoxicosis
or toxic and Cretinism
thyroid adenoma
APTT (OR PTT)
APTT (Activated Partial Thromboplastin Time) –
measures one part of the clotting pathway known as
the “intrinsic pathway.” It is compared against a
sample of normal blood, the “control” value.
Itis increased by therapy with heparin, hemophilia,
severe liver disease (cirrhosis) or DIC
Normal levels are 25-50 seconds
PROTHROMBIN TIME (PT)
PT – Elevated in patients taking warfarin (Coumadin)
or in those who are vitamin K deficient.
Normal is 11-12.5 seconds.
INR
INR (International Normalized Ratio) – measures one
part of the clotting pathway known as the “extrinsic
pathway.”
It is increased by warfarin (Coumadin) therapy, liver
dysfunction or DIC
Measured as a ratio – normal 1-1.5. Re-expression of
the PT
PLATELETS
Platelets – the number of platelets in the bloodstream
Platelets are important for clot formation.
Reminder – normal findings are 150,000 to 400,000/cmm
What can cause platelet dysfunction?
• End-Stage Renal Disease (ESRD)
• Viral infections
• Platelet inhibitor medications, like clopidogrel (Plavix), Brilinta, or ASA
• NSAIDs
FIBRINOGEN
Fibrinogen– this protein is a precursor to fibrin,
which is an essential part of a blood clot.
May be consumed by conditions such as DIC.
Decreased fibrinogen results in an increased bleeding
tendency
Normal levels are about 1.5-3 g/L
Antithrombin III (ATIII)
Antithrombin III (ATIII) is a nonvitamin K-dependent
protease
Inhibits coagulation by neutralizing the enzymatic
activity of thrombin (factors IIa, IXa, Xa)
Antithrombin III activity is markedly potentiated by
heparin
Antithrombin III activity is the principal mechanism by
which both heparin and low–molecular-weight heparin
result in anticoagulation
Nonvitamin K-dependent protease that inhibits coagulation
by neutralizing the enzymatic activity of thrombin (factors
D-DIMER
A product of clot breakdown (fibrinolysis)nand is increased in
conditions of increased clotting activity in the body.
Relatively nonspecific
D-dimer levels normally 2 mg/L
When do we see it commonly ordered?
Pulmonary Emboli
DIC
False Positives can occur
D-dimer concentrations may rise in the elderly, patients with
rheumatoid arthritis or high triglycerides, or if a sample is hemolyzed
LAB VALUES – DIC PANEL
Decreased platelets (<100,000)
Increased PTT (>60-90 sec)
Increased PT (>15 sec)
Decreased fibrinogen (<200 mg/100ml)
Increased FDP/FSP (>10 g/ml)
Increased D-dimer (>2 mg/L)
Decreased antithrombin III (<70%)
CRYOPRECIPITATE
Indicated for specific factor replacement
Factor VIII and Factor XIII
Fibrinogen
Prevents and controls bleeding
Complications: viral infection
Use immediately after thawing.
Cangive it fast. Each unit raises fibrinogen levels by
75 mg/dL.
Urinalysis (UA)
A routine urinalysis usually includes the
following tests:
Color, transparency, specific gravity, pH,
protein, glucose, ketones, blood, bilirubin,
nitrite, urobilinogen and leukocyte esterase
Microscopicevaluation – will see bacteria,
RBCs, WBCs and strands of protein through the
microscope
UA NORMAL VALUES
Color Pale yellow to amber
Turbidity Clear to slightly hazy
Specific gravity 1.015-1.025
pH 4.5-8.0
Glucose Negative
Ketones Negative
Blood Negative
Protein Negative
Bilirubin Negative
Urobilinogen 0.1-1.0
Nitrate Negative
Leukocyte esterase Negative
Casts Occasional hyaline casts
Red blood cells Negative or rare
Crystals Negative
White blood cells Negative or rare
Epithelial cells Few
UA Components
Nitrites are byproducts of bacterial metabolism
Protein is detected because the bacteria are made
of it
Bloodis present in the urine as a result of the
inflammation caused by the bacteria
Positive
leukocyte esterase results from the
presence of WBCs either as whole cells or as lysed
cells
• If negative, an infection is unlikely!
