Original article
Performance evaluation of the Sysmex haematology
1
Department of Haematology,
University College London
Hospital, London, UK
2
Department of Haematology,
The Doctors Laboratory,
London, UK
Correspondence to
Carol Briggs, Department of
Haematology, University College
London Hospital, Haematology
Evaluations, 5th Floor, 60
Whitfield Street, London W1T
4EU, UK;
carolbriggs@hotmail.com
Accepted 18 June 2012
Published Online First
31 July 2012
1024
XN modular system
Carol Briggs,1 Ian Longair,1 Punamar Kumar,1 Deepak Singh,2 Samuel J Machin1
ABSTRACT
Background The Sysmex XN haematology instrument
performs automatic reflex testing, depending on sample
results. A nucleated red blood cell (NRBC) count is
provided on all samples. The instrument has a smaller
footprint (34%) than previous Sysmex XE analysers.
Methods An evaluation comparing all results to the
Sysmex XE-2100 and manual microscopic differential and
morphology (n=390) was performed followed by a
workflow study of 1000 samples to compare speed of
operation and number of blood films reviews required
from both systems.
Results The new features on the instrument are: (1)
white cell and NRBC channel, all samples include the
NRBC count; (2) white cell precursor channel: false
positive flags for blasts, abnormal lymphocytes and
atypical lymphocytes are reduced significantly without a
statistical increase of false negatives; (3) low white cell
count mode: suggested setting of <0.5×109/l. An
extended count is more precise and provides an accurate
differential. Fluorescent platelet count is performed in a
dedicated channel. If the red cell or platelet size
histograms are abnormal or if the platelet count is low,
then a fluorescent platelet count is automatically
performed. Good correlation with the XE-2100 and
manual differential was found and the improved results
compared to the reference flow cytometric analysis for
platelet counts, especially below 30×109/l (XE-2100,
R2=0.500; XN, R2=0.875).
Conclusion The XN showed reduced sample
turnaround time of 10% and reduced number of blood
films for examination, 49% less than the XE-2100
without loss of sensitivity with more precise and
accurate results on low cell counts.
INTRODUCTION
There is an increasing demand for haematology
tests with reduced turnaround times, along with
cuts in budgets for pathology laboratory. There
have been advances in haematology instrumenta-
tion which have resulted in faster throughput.
Abnormal cells that were previously only indicated
by an abnormal cell flags, such as immature granu-
locytes and nucleated red blood cells (NRBC), can
now be reliably enumerated on several top of the
range analysers,1–3 leading to a reduction in the
number of microscopic counts. All haematology
analysers generate suspect flags in the presence of
abnormal cells, but false positive rates are high,
leading to unnecessary blood film reviews. The
aim of any manufacturer is to increase specificity
without losing sensitivity.
The Sysmex XE-2100 (SYSMEX, Kobe, Japan)
was introduced in 1999.1 It is an automated
haematology analyser using direct current sheath
J Clin Pathol 2012;65:1024–1030. doi:10.1136/jclinpath-2012-200930
J Clin Pathol: first published as 10.1136/jclinpath-2012-200930 on 31 July 2012. Downloaded from http://jcp.bmj.com/ on 9 April 2019 by guest. Protected by copyright.
flow for red cell count, haematocrit and impedance
platelet count. Fluorescence flow cytometry is
used for leucocyte differential, NRBC, reticulocytes
and fluorescence platelet count. Information on
immature cells is derived from the immature
myeloid information (IMI) channel.
Over recent years software upgrades have been
introduced; the first allowed reliable automated
counting of immature granulocytes ( promyelo-
cytes, myelocytes and metamyelocytes) in the dif-
ferential channel.2
Later a new automated method to quantitate
reticulated platelets, expressed as the immature
platelet fraction (IPF), was introduced.4 5 The IPF is
identified by flow cytometry with the use of a
nucleic acid specific dye in the reticulocyte/optical
platelet channel. The clinical utility of this param-
eter has been established in the laboratory diagnosis
of thrombocytopenia due to increased peripheral
platelet destruction, particularly autoimmune
thrombocytopenic purpura and thrombotic throm-
bocytopenic purpura, and as a predictor of platelet
recovery following haematopoietic progenitor
cell transplantation.6 The latest software to be
introduced was for the measurement of Ret-He,
reticulocyte haemoglobin concentration. Ret-He is
a measure of the forward scatter of stained reticulo-
cytes and provides an indirect measure of the iron
available for new red blood cell production over the
previous 3–4 days. It also provides an early measure
of the response to iron therapy, increasing within
2–4 days of the initiation of intravenous iron
therapy.7
The Sysmex XE-5000 was launched in 2007.This
analyser performs with blood cells and leucocytes
in the same way as the XE-2100 but with added
parameters. The instrument measures the haemo-
globin content of individual red cells, calculates the
percentage of hypochromic red cells (%Hypo He)
and the percentage of hyperchromic red cells
(%Hyper He) and quantifies the proportion of
microcytic and macrocytic erythrocytes (%Micro
R) and (%Macro R). The availability of extended
red cell parameters should allow earlier diagnosis of
abnormal iron metabolism and the response to iron
or folate supplementation.8
The XN Modular analyser was introduced in
2011. The instrument used in this evaluation was
a prototype and there has been a software upgrade
for the instrument after this evaluation before
release to the market. The red cell parameters and
impedance platelets are measured in the same way
as previous XE series instruments, but several new
channels have been introduced: white cell
nucleated channel (WNR); white cell differential
channel (WDF); white cell precursor channel

(WPC); and fluorescent platelet channel (PLT-F). The reticulo-
cyte (RET) channel with related immature RET parameters
remains the same as on the XE series of instruments, including
an optical platelet count if desired.
Using the WNR, a NRBC count is performed on all samples;
there is no longer a need to repeat the count in the NRBC
channel as before.
The WDF includes the basophil count; there is no longer a
separate basophil channel and the separation of lymphocytes
and monocytes has been optimised. All NRBC are measured by
light scattering and fluorescence; impedance is no longer used
for white blood cells (WBC).
The WPC channel is only used for reflex testing when a
sample shows a blast/abnormal lymphocyte flag. The flags will
be separated into the specific flags of blast or abnormal
lymphocyte or not shown at all if found to be false positive
from the WDF channel; this reflex is automatic.
The PLT-F channel can be selected for testing on any sample
or only used as a reflex test if there are abnormal red cell or
platelet size histograms or if the platelet count is below a
pre-set limit, determined by the user, when an extended plate-
let count is performed to increase accuracy and precision. The
PLT-F is in a new dedicated channel using a RNA dye; it also
quantitates the IPF, which is no longer performed in the RET
channel as on the XE-2100.
There is also a low WBC mode where samples with a WBC
of 0.5×109/l or less are reflexed for an extended count and a
leucocyte differential is reported; a differential is not reported
on WBC <0.5×109/l on the XE-2100.
The aim of this study was to evaluate the performance char-
acteristics of the new methods, carryover, linearity and sample
stability as well as compare the results for all parameters to
the XE-2100 and abnormal cell flagging with a manual diff-
erential and morphological examination and comparison of
platelet counts to the International Society for Heamatology/
International Council for Standardization in Haematology
(ISLH/ICSH) reference flow cytometric method 9 with particular
regard to counts <20×109/l.
A further study was performed to evaluate the time for ana-
lysis, number of repeats on the XE-2100 and reflex tests on the
XN. The number of abnormal cell flags on both instruments
were also compared which would result in an examination of a
blood film in the routine laboratory. One thousand samples,
selected to mimic the samples seen in our laboratory on a daily
basis, were analysed.
The ideal result would be faster throughput and an increase
in specificity of the flags without loss of sensitivity, and more
accurate and precise results on low WBC and platelet counts.
PATIENTS AND METHODS
Patients
For the comparative study, 390 residual K2EDTA anticoagulated
(Beckton Dickinson, San Jose, California, USA) samples were
selected from the routine haematology laboratory at University
College London Hospital (UCLH) Haematology after all routine
testing had been completed. Samples included 131 normal
samples; the rest comprised various haematological diseases,
such as leukaemias, lymphoma, myeloma, haemoglobinopa-
thies, idopathic thrombocytopenic purpura, thrombotic throm-
bocytopenic purpura and interfering substances such as lipids
and bilirubin. Due to small sample volumes no paediatric
samples were included in the study; although the XN only
requires 150 ml after testing in the routine laboratory,
J Clin Pathol 2012;65:1024–1030. doi:10.1136/jclinpath-2012-200930
Original article
frequently there was insufficient sample for further testing for
J Clin Pathol: first published as 10.1136/jclinpath-2012-200930 on 31 July 2012. Downloaded from http://jcp.bmj.com/ on 9 April 2019 by guest. Protected by copyright.
this evaluation.
For the workflow study samples, 1000 were selected at differ-
ent times of the day and on different days of the week to try
to mimic 1 day’s workload. UCLH receives a high proportion
of abnormal samples as a tertiary reference centre.
Samples were analysed on the XE-2100 and the XN modular
system in Complete Blood Count and DIFF mode, with auto-
matic reflex testing on the XN as required.
Principle of leucocyte differential on the XE-2100
The optical system on the XE-2100 employs a stable red diode
laser producing a light beam of 633 nm wavelength and a poly-
methine based fluorescent dye. Three signals are produced:
forward scattered (FSC) light, providing information on cell size;
side scattered light (SSc), providing information on internal cell
structure; and side fluorescence (SFL), providing information on
DNA/RNA content. The basophil count is derived in the WBC/
BASO channel, where basophils are resistant to the reagent
system and retain their size and shape, forming a cluster of larger
cells distinct from other non-basophil nucleated cells whose
membranes are perforated and cytoplasm is lost.
In the IMI channel a combination of radio frequency and
impedance, direct current resistance methods are used in conjunc-
tion with special reagents. Immature WBC contain less lipid
then mature cells. The effect of the lysing reagent differs with
each type of immature cell, allowing quantitative differentiation.
NRBC are measured in a dedicated channel. This is per-
formed by flow cytometry and a polymethine dye, which
stains the intracytoplasmic organelles and the nucleus of WBC
quite strongly while the staining of NRBCs is weak. This
allows clear discrimination between the counts.
Principle of measurements on the XN
Fluorescent labelling of cells takes place after perforation of the
cell membrane caused by specific lysing reagents. After this a
polymethine dye enters the cell and binds to nucleic acid and
bioreactive proteins in the cytoplasmic organelles.
Platelet and IPF are stained by a fluorescent dye based on
oxadine: SFL light which gives information on DNA/RNA
content of the cell; side scattered light which gives information
on intracellular structure of the cell; and FSC light which gives
information on cell size. All three methods are used in the four
new channels which are the WNR, WDF, WPC and PLT-F
(figure 1) as well as the RET channel which is the same as on
the XE series of instruments.
Abnormal cell flags
Abnormal cells have differing characteristics, such as cell size,
nuclear size and granule content, from normal cells. In the
presence of abnormal cells most instruments will generate an
abnormal or suspect flag. The instrument detects the cloud for
a particular cell population as having an abnormal size or shape
by cluster analysis. The instrument will also detect events
outside the normal cell population areas. The flags are gener-
ated by pattern abnormalities from the DIFF channel and the
IMI channel on the XE-2100, and from four different channels
on the XN. WNR flags for platelet clumps, abnormal NRBC
and abnormal WBC.
The WDF channel flags for atypical lymphocytes and blast/
abnormal lymphocytes.
PLT-F flags the presence of platelet clumps and abnormal
platelets.
1025
 Original article

J Clin Pathol: first published as 10.1136/jclinpath-2012-200930 on 31 July 2012. Downloaded from http://jcp.bmj.com/ on 9 April 2019 by guest. Protected by copyright.
Figure 1 (A) The white cell nucleated channel (WNR) scatterplot showing the position of white blood cells (WBC), basophils (BASO), nucleated
red blood cells (NRBC), platelet clumps and ghosts. Side fluorescence (SFL) on the x-axis and forward scatter (FSC) on the y-axis. (B) The white cell
differential channel (WDF) scatterplot showing the position of neutrophils with basophils (NEUT+BASO), lymphocytes (LYMPH), monocytes (MONO),
eosinophils (EO), BASO, immature granulocytes (IG) and NRBC. The positions of atypical lymphocytes, blasts or abnormal lymphocytes are also
shown. Side scatter (SSC) on the x-axis and SFL on the y-axis. (C) The WPC scatterplot showing the position of abnormal lymphocytes, atypical
lymphocytes, NRBC, granulocytes, lymphocytes monocytes and blast cells. SSC on the x-axis and SFL on the y-axis. (D) The white cell precursor
channel (WPC) scatterplot showing the position of abnormal lymphocytes, atypical lymphocytes, granulocytes, lymphocytes, monocytes and blast or
basophils cells. SSC on the x-axis and FSC on the y-axis. (E) The fluorescent platelet channel (PLT-F) scatterplot showing the position of platelets
(PLT-F) IPF, WBC and RBC. SFL (SSC) on the x-axis and FSC on the y-axis. This figure is only reproduced in colour in the online version.

The WPC channel is only used when a reflex test is triggered
in the presence of the abnormal lymphocytes/blasts. These
two abnormal cells are separated into separate flags or no
longer shown if it was a false positive flag from the WDF
channel.
Calibration and quality control
The XE-2100 and XN analysers were calibrated by their respect-
ive engineers before the study started. Manufacturer’s quality
control material was run on both instruments on a daily basis.
For the XE 2100 this was normal level of e-CHECK and for the
XN normal level of XN check.
Comparative study
All results were compared to the XE-2100.
Blood films were examined for every sample in accordance
with the recommended manual 400-cell differential from the
Clinical and Laboratory Standards Institute (CLSI) protocol
H20-A2, 2007,10 including NRBC, and results compared with
those from the XE-2100 and the XN. The absolute differential
counts for each class of leucocyte were obtained by multiplying
their relative microscopic percentages by the total XE-2100
WBC. Instrument generated abnormal cell flags were compared
with the morphological findings of the blood films.
Platelet counts were compared to the ISLH/ICSH9 reference
flow cytometic method on samples, range 1–1728×109/l
(n=185); 67 samples were at, or below, the platelet transfusion
threshold used at our hospital of 20×109/l (selected by the
impedance count on the XE-2100).
Low WBC mode
Thirty samples were selected and analysed on the XN and by
manual differential. The samples were then diluted to a WBC
value less than 0.5×109/l. The samples were then re-run on the
XN; the low WBC mode was automatically activated. The dif-
ferentials from these results were compared to the manual dif-
ferentials and the automated counts on the whole blood and
diluted blood.
Workflow study
This was undertaken to evaluate the time saving possibilities
of using the XN in the routine laboratory. For the purpose of
this study any sample with an abnormal cell flag, or incom-
plete differential results, was considered to need a manual

1026 J Clin Pathol 2012;65:1024–1030. doi:10.1136/jclinpath-2012-200930

 Original article

blood film review. Quantitative flags alone, or numerical results Table 1 Correlation statistics of complete blood count results,

J Clin Pathol: first published as 10.1136/jclinpath-2012-200930 on 31 July 2012. Downloaded from http://jcp.bmj.com/ on 9 April 2019 by guest. Protected by copyright.
outside the normal range, were not considered to need a including nucleated red blood cell (NRBC), reticulocytes, immature
manual review. This allowed the assessment of the changes in granulocytes and immature platelet fraction (IPF%); XN compared to
flagging on the total number of blood films made in the labora- XE-2100
tory on a typical working day. The number of repeat tests Parameter R2 value Slope Intercept
needed on the XE-2100 and the automatic reflex tests on the WBC 0.99 1.07 −0.76
XN were recorded as well as the time taken for analysis on RBC 0.99 1.05 −0.24
each instrument. Hb 0.99 0.99 −0.05
HcT 0.99 1.04 −1.90
Carryover MCV 0.99 0.99 +0.08
Carryover was estimated following the method of Broughton MPV 0.87 0.99 +0.34
et al11 as recommended by ICSH. This was performed for PLT-I vs PLT-F 0.98 1.06 −13.70
PLT-O vs PLT-F 0.99 1.06 −1.50
WBC, NRBC, PLT-F and IPF, which are the methods changed
Neutrophils 0.99 1.00 −0.02
on the XN, by measuring a patient sample with high values in
Lymphocytes 0.99 1.14 −0.3
triplicate followed by a sample with low values in triplicate.
Monocytes 0.91 0.90 +0.09
Eosinophils 0.99 0.98 0.00
Precision Basophils 0.76 1.15 +0.01
Precision was performed on WBC, NRBC, PLT-F and IPF, the NRBC 0.99 1.04 0.00
changed methods on the XN. Low and normal values were Immature granulocytes 0.94 1.14 +0.02
used where possible for WBC, PLT-F and IPF and varying levels Reticulocytes 0.98 1.00 +1.32
for NRBC. Samples were tested 10 times according to the Ret-He 0.94 0.99 +0.71
ICSH guidelines.12 IPF 0.60 0.58 +1.0.
IPF, immature platelet fraction; PLT-F, fluorescent platelet channel; Ret-He, reticulocyte
Linearity haemoglobin; WBC, white blood cells.
This was performed on WBC, NRBC, PLT-F and IPF; both high
counts and low counts were examined. Linearity in the low
For platelet counting results for all samples, results were
range is very important for all parameters. Samples were
similar between instruments for the impedance method com-
diluted and analysed twice; the mean of these results were
pared to the reference method (XE-2100, R2=0.986; XN,
plotted against the calculated expected value for the dilution.
R2=0.972). The PLT-F method was superior to the XE-2100
optical method when compared to the flow cytometric refer-
Stability ence method on samples with a platelet count of ≤30×109/l
Stability was performed on all new measured parameters, as (XE-2100, R2=0.500; XN, R2=0.875); results are shown in
above. Samples were stored at room temperature and 4°C. figure 3.
Samples were tested immediately and 24, 48 and 72 h. All
samples were aliquoted and those stored at 4°C were warmed
for 15 min before testing. Workflow study
One thousand samples analysed on both analysers resulted in
a reduction of 49% of blood films for review when using the
RESULTS
results from the XN. This is due to a reduction in the blast,
Comparative study
abnormal lymphocyte flag and atypical lymphocyte flag.
Results for parameters compared to the XE-2100 are shown in
Results are shown in table 4. More re-runs/reflex tests were
table 1. All results were excellent apart from the IPF%. This
needed on the XN (3.7% more than the XE-2100) but this is
was caused by eight outlying samples. These had very high
preferable because of the 49% reduction in the number of blood
results on the XE-2100 but less than 2% on the XN.
films that would be reviewed on a daily basis compared to
Six samples were from patients on chemotherapy and the
results from the XE-2100. Turnaround time was shorter on the
other two had aplastic anaemia.
XN by 10% and if the time is included for the making of blood
Although there is no reference method for IPF it could be
films on the Sysmex SP 1000 (automated blood film and
assumed, using the clinical details from the patients, that the
stainer), this is reduced further.
XN results from the PLT-F channel are more correct. Apoptopic
WBC are sometimes stained by the RET stain on the XE-2100,
giving falsely high results for IPF%; an example is given in Low WBC mode
figure 2. This was from a patient with acute promyelocytic leu- Differentials on the diluted samples with a WBC count of
kaemia on chemotherapy with a WBC of 1.6×109/l. The <0.5×109/l showed no difference compared to the undiluted
optical platelet count from the RETIC channel on the XE-2100, samples when compared to the manual 400 cell differential;
where the IPF is also measured, is also falsely high compared to results are shown in table 5.
the flow cytometric reference counting method.
Results compared to the reference differential method are
Carryover
shown in table 2.
Results for all parameters tested were in the range 0.00–0.07%.
The flagging performance compared to microscopic morph-
No carryover was detected for any parameters tested.
ology comments, of the XN was greatly improved. For atypical
lymphocytes this was seen even when no reflex test was per-
formed to the instrument with the WPC channel. Results are Precision
shown in table 3.There is a 20% reduction in the blast/abnor- All results for all parameters within the normal values were
mal lymphocyte flag and 20% for the atypical lymphocyte flag. below manufacturer’s specifications.

J Clin Pathol 2012;65:1024–1030. doi:10.1136/jclinpath-2012-200930 1027

 Original article

J Clin Pathol: first published as 10.1136/jclinpath-2012-200930 on 31 July 2012. Downloaded from http://jcp.bmj.com/ on 9 April 2019 by guest. Protected by copyright.
Figure 2 (A) Fluorescent platelet channel (PLT-F) scattergram from the XN of a patient with acute promyelocytic leukaemia. The impedance platelet
count and PLT-F agree with the reference flow cytometric method and the immature platelet fraction (IPF%) is 1.1. (B) The optical platelet
scattergram from the same patient. The impedance platelet count agrees with the reference flow cytometric method, but the optical count is falsely
high due to apoptotic/fragmented white blood cells (WBC). This has also caused a falsely high IPF%. This figure is only reproduced in colour in the
online version.

For low WBC counts, n=9 (range 0.66–1.21×109/l), the coef-
ficient of variation (CV%) was on average 8.6%.
For low platelet counts, PLT-F, n=16 (range 9–39×109/l), the
CV% average was 4.0%.
For IPF normal counts, n=7 (range 1.25–5.88%), CV% was
6.8%, for high IPF% values; n=4 (range 12.6–34.29%), the CV
% was 4.5%.
For NRBC counts samples were tested on low (range 1–5/
100 WBC), medium (range 5–20/100 WBC) and high counts
(greater than 20/100 WBC).
For the low range the average CV% was 32%, medium range
7.4% and above 20/100 WBC, 8.7%.
Linearity
Results for linearity for both high and low counts for WBC
and PLT-F, IPF% and NRBC can be seen in table 6.
Stability
Results for the parameters tested, WBC, leucocyte differential,
NRBC, PLT-F and IPF% were all within precision limits over
72 h at both room temperature and 4°C.
as necessary, WPC and PLT-F and reticulocytes can be included,
or excluded, on any analyser as necessary, thereby saving
reagents when not required.
With needs for faster turnaround times it is necessary to
reduce the number of blood film reviews performed in the
laboratory, the challenge is to reduce them without missing
important diagnostic information. Using current haematology
analysers, 80% of blood film reviews are triggered by abnormal
cell flags from the haematology analyser13 and 62% are due to
false positive flags.14
Comparative results against the Sysmex XE-2100 were all
good apart from the IPF%. There is no current reference
method for the IPF, but due to the diagnosis of the eight
patients showing discrepant results compared to the XE-2100
(low on the XN and high on the XE-2100) it may be that the
results were more correct on the XN. Six patients were under-
going chemotherapy and two had aplastic anaemia. It has been
previously documented that apoptotic WBC or WBC fragments
interfere with optical platelet counts.15 Figure 2 clearly demon-
strates a falsely high optical platelet count and calculated IPF%
on the XE-2100 compared to the XN and reference flow platelet
flow cytometric method. This patient was on chemotherapy

DISCUSSION
The XN is a user defined platform from a single instrument to
Table 3 Efficiency of abnormal white blood cells flags on the XE-2100
a line up of up to nine modules, so laboratories can adapt the
and XN in 390 patient samples
system to their needs. Analytical requirements can be adopted
Blast True False True False
cell flag positive positive negative negative Sensitivity Specificity
XE-2100 20 68 302 0 100% 82%
Table 2 Correlation statistics of differential results, including nucleated XN 19 20* 350 1 95% 99.7%
red blood cells (NRBC) and immature granulocytes; XN compared to Abnormal lymphocytes
the reference 400-cell differential XE-2100 4 30 352 4 50% 99%
Parameter R2 value Slope Intercept XN 3 8* 374 5 37.5% 98.7%
Neutrophils 0.98 0.97 −0.06 Atypical lymphocytes
Lymphocytes 0.99 1.10 −0.24 XE-2100 8 82 285 15 34.8% 95%
Monocytes 0.66 1.29 +0.05 XN 5 9* 358 18 78.3% 95.2%
Eosinophils 0.94 1.06 +0.02 XN 5 9* 358 18 78.3% 95.2%
Basophils 0.70 1.54 +0.03 without
WPC
Immature granulocytes 0.69 1.75 +0.08
NRBC 0.97 0.97 −0.13 *p<0.001.
WPC, white cell precursor channel.

1028 J Clin Pathol 2012;65:1024–1030. doi:10.1136/jclinpath-2012-200930


Figure 3 Results for the optical and
fluorescent platelet channel (PLT-F) on
samples selected with a platelet count
of 20×109/l using the impedance
count on the XE-2100. (A) Correlation
graph of the XE-2100 optical platelet
count compared to the reference flow
cytometric method. (B) Correlation
graph of the XN PLT-F count compared
to the reference flow cytometric
method.
for acute promyelocytic leukaemia. A reference method for reti-
culated platelets/IPF is clearly needed.
Results for the differential compared to the reference method
were good. Monocytes and immature granulocytes show
slightly less good correlation (R2=0.66 and 0.69, respectively;
table 2); this was due to eight samples with thalassaemia
major or intermedia with high numbers of NRBCs, 621.13 per
100/WBC–69.2 NRBC per 100 WBC. All outliers were rejected
differentials on the XE-2100; no results reported. If the outliers
are removed, correlation for monocytes is 0.74, and for imma-
ture granulocytes is 0.89. On this prototype analyser the sup-
pressed differential was not activated and on future versions
these types of samples will not have the differential reported;
however this would mean a manual differential will have to be
performed. These are highly unusual samples not often
encountered in most laboratories.
The XN NRBC counts are reported on every sample form
the WNR channel with corrected WBC and lymphocyte
counts. The reporting of the NRBC saves repeat testing in the
presence of the flag. The NRBC count has been shown to be
both accurate and precise.
The flagging efficiency of the XE-2100 has been published
previously.16 17
The flagging performance for the two analysers was assessed
by comparing microscopic morphological appearance of cells.
Only the blast cell flag, and abnormal lymphocyte/lymphoblast
and atypical lymphocyte flags have been optimised on the XN
and these were the ones evaluated in the comparative study.
There were too few samples with abnormal lymphocytes
present to give meaningful information but all three flags
showed fewer false positives on the XN without a loss of sensi-
tivity; the specificity was approximately the same on both ana-
lysers. Even without reflex testing to the WPC channel there
was a reduction of false positives for the atypical lymphocyte
Table 4 The total number of blood films from 1000 samples that
would have been made using flagging results from the XE-2100 and XN
n=100 XE-2100 XN with WPC-ch
Blood films 199 101
Reflex analysis 75 112
TAT (min) analysis 611 553
TAT (min) analysis+SP 710 604
Table shows number of samples needing to be re-run and the time taken for analysis.
TAT, turnaround time; SP, SP1000 automated film maker and stainer; WPC, white cell
precursor channel.
J Clin Pathol 2012;65:1024–1030. doi:10.1136/jclinpath-2012-200930
Original article
J Clin Pathol: first published as 10.1136/jclinpath-2012-200930 on 31 July 2012. Downloaded from http://jcp.bmj.com/ on 9 April 2019 by guest. Protected by copyright.
flag from 82 on the XE-2100 to nine on the XN without a stat-
istical increase in false negatives.
For the workflow study abnormal cell flags for all cells, WBC,
RBC and platelets, were used and the number of blood films
that would need to be examined using the rules previously
described on 1000 samples were compared. Our findings show
that the number of blood films would be reduced from 199 on
the XE-2100 to 101 using the XN the WPC channel (49% fewer)
but with an increase in reflex testing of 37 samples on the XN
compared to repeat tests needed on the XE-2100 (table 4) in the
1000-sample set analysed. In the laboratory this automatic
reflex testing is preferable to the number of blood films exam-
ined microscopically. Nearly all the reduction in blood films is
due to the increased specificity of the blast and abnormal
lymphocyte/lymphoblast flag achieved using the WPC channel
without any loss of sensitivity.
Impedance platelet counting results are similar on both ana-
lysers. This is to be expected as it is the same technology;
however flags suggesting an optical platelet count is needed on
the XE-2100 were seen on 27% of samples but only 9% of
samples on the XN (figure 3) requiring a PLT-F. This is a reduc-
tion of repeat sampling.
The PLT-F method was superior to the XE-2100 optical
method when compared to the flow cytometric reference
method on samples with a platelet count of 30×109/l or less
(XE-2100, R2=0.500; XN, R2=0.875). These results are very
important as this is the most common threshold for platelet
transfusion and accuracy is needed to ensure patients receive, or
do not receive, transfusions where indicated.
The precision of platelet counts on the XN is also impressive
due to the extended platelet counts. PLT-F precision showed a
CV% of only 4% on platelet counts of between 9×109/l and
39×109/l. This is far superior precision than previously docu-
mented on the impedance platelet counts from the Sysmex
XE-2100 with an average CV of 13.6% on counts in this range
of counts.18
Table 5 Results for neutrophils
Neutrophils R2 Lymphocytes R2 Monocytes R2
Undiluted sample 0.914 0.917 0.808
Diluted sample 0.968 0.948 0.878
Lymphocytes and monocytes were compared to the reference 400-cell differential.
Samples were then diluted to <0.5×109/l and re-run on the XN using the low WBC mode
(extended count) and differential results compared to the original undiluted manual
differential.
1029
 Original article
Table 6 Linearity results; both high and low levels were examined
WBC×109/l High (range 385.65–38.5)
R2=0.998
PLT-F×109/l High (range 2561–256)
R2=0.998
IPF×109/l High (range 65–6.5)
R2=0.988
NRBC Range 48.94–4.89
R2=0.999
IPF, immature platelet fraction; NRBC, nucleated red blood cell; PLT-F, fluorescent platelet
channel; WBC, white blood cells.
The low WBC mode allows more precise counts below
0.5×109/l with proven accurate differentials. The XE-2100
automatically suppresses the differential at counts below
0.5×109/l. The XN differential information may be useful for
patients recovering from chemotherapy or stem cell/bone
marrow transplants and will be certainly more accurate and
less time consuming than performing a manual differential.
Results for all performance characteristics, such as carryover,
precision and linearity were excellent.
Stability was performed on the new parameters, WBC, differ-
ential, NRBC, PLT-F and IPF; they were found to be stable up to
72 h both at room temperature and at 4°C. Stability for other
parameters will be the same for the XE-2100, as technology has
not been changed, and these have been published previously.19
With continuing pressure on laboratory resources and the
need for faster turnaround times, the challenge is to reduce the
number of blood films examined without missing important
diagnostic information. Any analyser that decreases the
number of false positive flags without losing sensitivity will
increase laboratory efficiency and this has been clearly demon-
strated for the blast cell, blast/abnormal lymphocyte and atyp-
ical lymphocyte flag. With an NRBC count reported on every
sample this has further reduced the number of manual differen-
tials or repeat tests required. More accurate and precise results
are available for both platelets and low WBC counts from the
PLT-F and WPC channels, and in addition a leucocyte differen-
tial is reported on WBC counts of <0.5×109/l.
The use of the XN system improves workflow efficiency and
confidence of results in abnormal samples in the routine
haematology laboratory.
Take-home messag
The Sysmex haematology XN modular system improves
workflow in a routine haematology laboratory.
Acknowledgements The assistance of Dr Jo Linssen, Sysmex Europe, is
acknowledged.
1030
Contributors All authors contributed to either the practical work or writing of the
paper.
J Clin Pathol: first published as 10.1136/jclinpath-2012-200930 on 31 July 2012. Downloaded from http://jcp.bmj.com/ on 9 April 2019 by guest. Protected by copyright.
Low (range 1.03–0.12)
R2=0.998 Competing interests None.
Low (range 60–6) Provenance and peer review Not commissioned; externally peer reviewed.
R2=0.998
Low (range 6–0)
R2=0.972 REFERENCES
1. Briggs C, Harrison P, Grant , et al. New quantities parameters on a recently
introduced automated blood cell counter—the XE-2100. Clin Lab Haem
2000;22:345–50.
2. Fernandez B, Hamachi Y. Automated enumeration of immature granulocytes. Am J
Clan Pathol 2007;128:454–63.
3. Jean A, Boutet C, Lenormand B, et al. The new haematology analyzer DxH 800: an
evaluation of the analytical performances and leucocyte flags, comparison with the
LH 755. Int J Lab Hematol 2011;33:138–45.
4. Briggs C, Hart , Kunka S, et al. Assessment of an immature platelet fraction (IPF)
in peripheral thrombocytopenia. Br J Haematol 2004;126:93–9.
5. Pons I, Monteagudo M, Lucchetti G, et al. Correlation between immature platelet
fraction and reticulated platelets. Usefulness in the etiology diagnosis of
thrombocytopenia. Eur J Haematol 2010;2:158–63.
6. Zucker ML, Murphy CA, Rachel JM, et al. Immature platelet fraction as a predictor
of platelet recovery following hematopoietic progenitor cell transplantation. Lab Hem
2006;12:125–30.
7. Miwa N, Akiba T, Kimata N, et al. Usefulness of measuring reticulocyte hemoglobin
equivalent in the management of haemodialysis patients with iron deficiency. Int J
Lab Hematol 2010;32:248–55.
8. Urrechaga E, Borque L, Escanero JF. Potential utility of the new Sysmex XE 5000
red blood cell extended parameters in the study of disorders of iron metabolism.
Clin Chem Lab Med 2009;47:411–16.
9. International Council for Standardization in Haematology Expert Panel on
Cytometry; International Society of Laboratory Hematology Task force on
platelet counting. Platelet counting by the RBC/platelet ratio method. A reference
method. Am J Clin Pathol 2001;115:460–4.
10. Clinical and Laboratory Standards Institute. Reference leukocyte differential
count ( proportional) and evaluation of instrument methods. 2007: Approved
standard. CLSI document H20-A2. CLSI, Wayne, PA.
11. Broughton PM, Gowenlock AN, McCormack JJ, et al. Revised scheme for the
evaluation of instruments for use in clinical chemistry. Ann Clin Biochem
1974;11:207–18.
12. International Council for Standarization in Haematology Expert Panel on
Cytometry. Guidelines for the evaluation of blood cell analysers including those
used for differential leucocyte and reticulocyte counting and cell marker applications.
Clin Lab Haemat 1994;16:157–74.
13. Novis DA, Walsh M, Wilkinson D, et al. Laboratory productivity and the rate of
manual peripheral blood smear review: a College of American patholgists Q-Probes
study of 95, 141 complete blood count determinations performed in 263
institutions. Arch Pathol Lab Med 2006;130:596–601.
14. Barnes PW, McFadden SL, Machin SJ, et al. The International Consensus Group for
Hematology Review suggested criteria for action following automated CBC and WBC
differential analysis. Lab Heamatol 2005;11:83–92.
15. Zandecki M, Genevieve F, Gerard J, et al. Spurious counts and spurious results on
haematology analysers: a review. Part I: platelets. Int J Lab Hematol 2007;29:4–20.
16. Ruzicka K, Veitl M, Thalhammer-Scherrer R, et al. The new hematology analyser
Sysmex XE-2100: performance evaluation of a novel white blood cell differential
technology. Arch Pathol Lab Med 2001;125:391–6.
17. Stamminger G, Auch D, Diem H, et al. performance of the XE-2100 leucocyte
differential. Clin lab Haematol 2002;24:271–80.
18. De la Salle BJ, McTaggart PN, Briggs C, et al. The accuracy of platelet
counting in thrombocytopenic blood samples distributed by the UK National
External Quality Assessment Scheme for general haematology. Am J Clin Pathol
2012;137:65–74.
19. Imeri F, Herklotz R, Risch L, et al. Stability of hematological analytes depends on
the hematology analyser used: a stability study with Bayer Advia 120, Beckman
Coulter LH 750 and Sysmex XE-2100. Clin Chem Acta 2008;397:68–71.
J Clin Pathol 2012;65:1024–1030. doi:10.1136/jclinpath-2012-200930