CHAPTER
INTERPRETING LABORATORY RESULTS
KEY POINTS
 There are basically four types of anemia:
1. Iron deficiency
2. Anemia of chronic disease
3. Hemolytic anemia, and
4. Macrocytic/nutritionally deficient anemia.
 By examining the urinary sodium, potassium,
and osmolarity, the causes of hyponatremia and
hypernatremia can be readily determined.
 Liver function tests can distinguish among six
different diseases of the liver:
 hepatitis,
 cirrhosis,
 biliary disease,
 space-occupying lesions of the liver,
 passive congestion, and
 fulminant hepatic failure.
 Renal failure can be readily diagnosed by
observing elevated BUN (urea) and creatinine; it
is possible to pinpoint the site of renal failure—that
is, glomerular or tubular—from the ratio of serum
to urine osmolality.
 Blood gas results allow determination of the
causes of metabolic versus respiratory acidosis or
alkalosis; there is a critical relationship between
the partial pressure of oxygen and carbon dioxide
such that, in respiratory diseases, high levels of
carbon dioxide block oxygenation of venous blood,
leading to respiratory crisis.
 Elevation of cardiac troponin in serum, is
diagnostic of myocardial infarction.
 Elevations of serum C-reactive protein
indicate inflammatory disease.
 Elevations of serum amylase and lipase point
to acute pancreatitis.
 Two types of endocrine disease are discussed:
thyroid and adrenal.
 Serum levels of T4 (or, better, free T4) and
thyroid-stimulating hormone (TSH) can be used
to diagnose primary or secondary hypothyroidism
or hyperthyroidism
 Serum levels of cortisol and
adrenocorticotropic hormone (ACTH) can be
used to diagnose primary or secondary
hypoadrenalism or hyperadrenalism.
INTERPRETING AND CORRELATING
ABNORMAL LABORATORY VALUES
GENERAL CONSIDERATIONS
 The major purpose of performing analyte
determinations in the clinical laboratory is to
aid in the diagnosis and management of
disease and in this regard,
 Clinical pathologist is often called upon as a
consultant to explain abnormal laboratory
values, especially those that do not seem to
correlate with one another, and to recommend
or even to order laboratory tests that may lead to
the correct diagnosis in the workup of patients
for particular medical problems.
 For evaluation of test results, the laboratory
computer is an invaluable aid.
 Virtually all such systems perform daily checks
for patient values that lie significantly outside
of their established reference intervals or that
have undergone large changes over a 24-hour
period.
 These are often reported as “failed delta
checks.” Thus patients with significant
laboratory findings can be identified
FUNDAMENTAL PRINCIPLES IN
INTERPRETATION OF VALUES
Before embarking on a discussion of specific
conditions giving rise to abnormal values, certain
precepts should always be followed:
1. Never rely on a single out-of-reference
range value to make a diagnosis. It is
vital to establish a trend in values.
Ex: A single sodium value of, for example, 130
mEq/L does not necessarily indicate
hyponatremia. This single abnormal value
may be spurious and may reflect such
factors as improper phlebotomy technique,
laboratory variability, and so on.
Rather, a series of low sodium values in
successive serum samples from a given
patient does indicate this condition. Thus it is
vital to follow trends in particular values.
2. Osler’s rule. Especially if the patient is
under the age of 60 years, try to
attribute all abnormal laboratory findings
to a single cause. Only if there is no
possible way to correlate all abnormal
 findings should the possibility of multiple
diagnoses be entertained
ABNORMALITIES IN THE HEMATOLOGY
PROFILE
ANEMIA
- A common hematologic disorder, is
defined pathophysiologically as a decrease
in the oxygen-carrying capacity of the
blood.
- Red blood cell counts below the lower limit
of
the reference range suggest this presence
o All oxygen carrying capacity of the blood is due to
the binding of oxygen to hemoglobin contained
uniquely in red blood cells.
o Because anemia can cause tissue hypoxia, it often
produces such symptoms as fainting, fatigue,
pallor,and difficulty in breathing.
o Practically, the best indicator for this condition is a
low red blood cell count or number of red blood
cells per volume of whole blood.
o Although the reference range for the red cell count
varies with age, sex, and population,
it encompasses values from around 4 to 6×106 red
blood cells per cubic millimeter (cu mm) or
microliter.
o Red blood cells occupy a well-defined range in
terms of the percent of the volume that they
occupy of whole blood or the hematocrit.
Generally, normal adult hematocrit values range
from about 36% to 45% (normal values for
females are generally slightly lower than those for
males).
Concentration of hemoglobin in whole blood is
about 12 to 15 g/dL or approx. 33 to 36 g/dL in
red blood cells—that is, the mean corpuscular
hemoglobin concentration.
Normal values are also dependent on patient age
and altitude of residence. Normally, the hematocrit
is about three times the value of the hemoglobin
concentration, which, in turn, is
about three times the value of the red blood cell
count.
 An excellent history and physical examination are
required for appropriate test selection, diagnosis,
and the best possible patient care and treatment.
 In addition, a review of the peripheral blood
film with respect to red and white cell morphology is
often helpful.
Common red cell indices:
A. Mean corpuscular volume (MCV)
- measured in femtoliters (fL), or
1 × 10−15 L, in conjunction with the red
cell distribution width (RDW) and the
reticulocyte count (percent
reticulocytosis) or reticulocyte
production index (RPI).
B. Mean Corpuscular Hemoglobin
Concentration (MCHC)
- measures the chromicity of red cells
quantitatively—that is, the intensity of
the red color of the cells due to
intracellular hemoglobin.
 Taken together, these indices help to form a
working hypothesis for the underlying cause of the
anemia.
 Electronic determination of MCV directly from red
cell distribution data allows for classification on the
basis of red blood cell size as:
 macrocytic (MCV generally >100 fL),
 microcytic (MCV generally <80 fL), or
 normocytic (MCV generally between 80 and
100 fL).
The sizes (volumes) of red cells vary within a certain
range in which the number of cells of particular
volumes form a bell-shaped or Gaussian distribution.
C. Red cell distribution width (RDW)
- the standard deviation of the cell volumes
divided by the mean cell volume
- measured as a percent
- is a parameter that helps to further classify
an anemia because it reflects the variation
of red blood cell size.
- generally varies between about 12 and 17
and is dependent on the patient’s age, sex,
and ethnic subgroup.
- it can be helpful in differentiating causes of
 microcytosis, because:

o Moderate to severe iron deficiency anemia is

associated with an increased RDW, whereas
o Thalassemia and anemia of chronic disease
(ACD) are associated with a normal RDW.

Peripheral blood reticulocytosis is

o a measure of bone marrow response in the face
of anemia.

Reticulocyte proliferation index (RPI)

o corrects the reticulocyte count with respect to
the proportion of reticulocytes present in a patient
without anemia and the premature release of
reticulocytes into the peripheral circulation.

Hyperproliferative Hypoproliferative
Bone marrow Anemia may be due
response to anemia to defective red blood
may be appropriate cell production or
marrow failure
Increased reticulocyte Decreased
count reticulocyte count
with an RPI over 3 generally indicated
generally indicating by an RPI less than 2
marrow red cell
hyperproliferation
Ex: Hemolytic anemia Ex: Renal disease
Acute blood loss ACD
Bone marrow
aplasia/hypoplasia

Thus, although these red cell indices are not

pathognomonic of the cause of a particular type of
anemia, the combination of MCV, RDW, and
RPI examined together will often significantly narrow
the differential diagnosis and facilitate further test
selection.
 Anemia Disease
there is a primary appears to be due to
deficiency of iron defective iron
available to the red utilization/metabolism
cell (usually due to
blood loss, but other
causes include
dietary deficiency,
malabsorption, and
pregnancy)
chronic blood loss associated with chronic
should always lead to non
further investigation hematologic disorders
such as chronic
because it is
infections, connective
commonly associated tissue disorders,
with malignancy. malignancy, and renal,
thyroid, and
pituitary disorders
Serum iron: Low Serum iron: Low or N
Iron store: Depleted Iron store: Abundant
Serum ferritin: low Serum ferritin: N to Low
TIBC: High RDW: Low
RDW: High
Iron levels in red cells: Low
Hemoglobin levels: Low
MCHC: Low
Termed: Hypochromic (low red color in red cells
or low MCHC), Microcytic (low MCV) anemia
LAB DIAGNOSIS
 Typically made using additional serum or
whole blood laboratory tests.
 However, because IDA is always
accompanied by loss of iron that is stored
bound to the protein ferritin in bone
marrow macrophages, the diagnosis can
always in principle be made with a bone
marrow biopsy with an iron stain—that is,
nitroprusside—that shows the absence
Microcytic Anemia of marrow iron.
 This procedure is, of course, invasive and
Common microcytic anemias include: should only be performed as a last
 Iron deficiency anemia (IDA) resort.
 Thalassemias
 Hemoglobinopathies
A. Serum Ferritin Levels
 Anemia of chronic disease (ACD) o Lower stored iron → lower intracellular ferritin
→ lower extracellular ferritin
Iron deficiency anemia and the anemia of o Extracellular ferritin level is directly measured
chronic disease, a common differential by serum ferritin level (performed on serum
diagnosis for patients with microcytic anemia. aliquots using ELISA)
Both anemias appear to be disorders involving o Give an excellent measure of available iron
iron metabolism. stores, noninvasively.
o assay that can be used in differentiating
IDA from ACD
Iron Deficiency Anemia of Chronic
o An acute phase reactant ( proteins that rise in
response to an acute process – an acute
inflammatory condition)
 So if a patient has an acute infection,
the serum ferritin level may be
spuriously elevated
B. Serum Iron and Iron-Binding Capacity
o TIBC - a direct measure of the protein
transferrin, which transports iron from the gut
to iron storage sites in bone marrow.
 transferrin is a beta-protein—that is, it
migrates in the beta-region in serum
protein electrophoresis—and is an
acute-phase reactant—that is, its
serum levels change (usually
decrease, as a so-called “negative
acute phase reactant”) in inflammatory an increased reticulocyte count, include:
conditions.
C. Red Blood Cell Distribution Width
o In iron deficiency anemia, there is a marked
dispersion in cell volumes (sizes) so that the
red cell distribution width (RDW) increases,
whereas it generally remains within normal
limits in the anemia of chronic disease.
Normocytic Anemia
Red cells show normal MCVs and MCHCs —that
is, they are normocytic and normochromic
Common causes of normocytic anemia include:
 Acute hemorrhage
 Hemolytic anemia
 Marrow hypoplasia
 Renal disease
 ACD
Acute hemorrhage presents as normocytic
anemia because it involves major blood loss that
is associated with loss of iron stores. However,
iron depletion requires time to develop; acutely,
major blood loss presents as normocytic
anemia.
 Reticulocyte count – very useful measurement
in determining the cause of normocytic anemia
 Reticulocytes are newly formed red
blood cells that have recently lost their
nuclei but retain high levels of
cytosolic mRNA dedicated to the
synthesis of hemoglobin.
 This RNA reacts with the dye,
methylene blue, to give a bright
green color, making it possible
to perform reticulocyte counts.
In cases, prominently in hemolytic anemia,
where there is a loss of red blood cells due to
peripheral destruction of these cells, there is an
increased synthesis in bone marrow of red blood
cells and an early release of red blood cell
precursors, especially reticulocytes.
Hyperproliferative Normocytic Anemia
Hyperproliferative normocytic anemias, associated with
 Hemolytic anemia
 Anemia associated with acute blood loss
Hypoproliferative anemias, associated with a decreased
reticulocyte count, include:
 Renal disease
 ACD
 Bone marrow aplasia/hypoplasia.
o Renal disease can affect juxtaglomerular cells
that are involved in the synthesis of
erythropoietin, the growth factor that induces
differentiation of bone marrow hematopoietic
stem cells into the red cell line.
o Bone marrow aplasia/hypoplasia give rise to
low reticulocyte counts if caused by agents,
such as chemotherapeutic agents, that kill
bone marrow hematopoietic stem cells.
o In such conditions as myelofibrosis, clonal
expansion of cancer cells such as occurs in
leukemia, lymphoma, myeloma, and metastatic
cancer, there may be a release of early red
and white blood cell precursors from bone
marrow leading to increased nucleated red
blood cell and reticulocyte counts.
MOST COMMON CAUSES OF NORMOCYTIC
ANEMIA
A. Hemolytic Anemia
 Hemolysis – destruction of red cell
membrane causing hemoglobin release
 May occur slowly as a normal physiological
process or may be accelerated in pathologic
states
 Different underlying causes for the decrease
in survival/increase in destruction of RBCs:
 Membrane defects (hereditary
spherocytosis)
 Enzyme defects (glucose-6-phosphate
dehydrogenase [G6PD] deficiency)
 Hemoglobinopathies (sickle cell disease
or beta-thalassemia)
 Immune destruction (autoimmune
hemolytic or anemia or hemolytic
transfusion reaction)
 Nonimmune destruction
Immune and nonimmune destruction include:
 destruction due to infectious agents
 toxic agents/drugs, physical agents
 hypersplenism
 microangiopathic hemolytic anemias
Microangiopathic hemolytic anemias
o are caused by mechanical destruction of
RBCs, mainly in bone marrow where
they are synthesized, from such factors
as fibrin deposition in the blood vessels
of bone marrow microvasculature,
fibrosis or malignancies such as
leukemia, lymphoma and metastatic
cancer
o mechanical destruction can result from
extramedullary causes such as
prosthetic heart valves
 After erythrocyte membrane breakdown,
hemoglobin is extruded
 Plasma and urine may contain free
hemoglobin or its degradation products
 Free hemoglobin may be present
acutely in the plasma (hemoglobinemia)
or urine (hemoglobinuria), while
 hemosiderin may be present in the urine
(hemosiderinuria) in more chronic
episodes of hemolysis.
 Because of the often-marked changes in size
 Extruded hemoglobin becomes bound to
alpha-20 fraction protein, haptoglobin
 Hemoglobin-haptoglobin complex becomes
catabolized by macrophages that engulf these 
complexes by receptor-mediated endocytosis
 Low haptoglobin value – an excellent indicator
for hemolytic anemia
Because the red cell contents are extruded into the
plasma, besides hemoglobin, there are other
indicators of red cell damage:
o high serum potassium (because intracellular
potassium concentration is much higher in red
cells than in the extracellular fluid)
o serum elevations of the enzyme lactate
dehydrogenase (LD).
 LD-1 the predominant isoenzyme of LD in
red cells that occurs predominantly in
cardiac tissue
 Carbon monoxide and unconjugated bilirubin
become elevated in blood in hemolytic anemia
 When hemoglobin is extruded, large amounts
become oxidized → methemoglobin. Heme
portion dissociates and then becomes oxidized →
bilirubin
 1st step: Oxidative opening of the porphyrin
ring of heme with the liberation of carbon
monoxide (CO).
 Elevated CO levels in normochromic,
normocytic anemias are an excellent
indicator of hemolytic anemia.
Because there is an increased production of bilirubin,
which is unconjugated there will be at least a transient
elevation of serum indirect bilirubin.
 Hemolytic anemia is almost always accompanied
by an increased reticulocyte count and by evidence
of red cell damage.
 reticulocyte count will be elevated
(increase in polychromasia on the blood
film),
 with erythroid hyperplasia present in the
bone marrow, indicative of increased red
cell production.
 Peripheral blood film may show evidence of the
particular type of red cell damage associated with
the particular type of hemolytic anemia (e.g., sickle
cells in sickle cell disease or schistocytes/helmet
cells in microangiopathic hemolytic anemia).
 There is also a noticeable difference in red cell size
(anisocytosis) and shape (poikilocytosis) due to the
presence of damaged and/or young cells.
and/or shape, the RDW is usually elevated. A
number of nucleated red blood cells may also be
identified.
Direct antiglobulin test (DAT)/direct Coombs test
can be used to detect immunoglobulin attached to
the red cell surface that identifies immune
hemolytic anemia as the cause of red cell
destruction
 Red cells are incubates with antihuman
immunoglobulin
  If red cells are coated with antibody:
agglutination
 If red cells are not coated with antibody: no
agglutination
 Positive test: suggest an autoantibody or
alloantibody – may be responsible for
anemia
B. Microangiopathic Hemolytic Anemia
 Results from traumatic destruction of newly
formed red blood cells in the microvasculature
where both red and white blood cell
precursors are being formed
 Red cell fragments (schistocytes) may be
present on peripheral blood films due to
mechanical (e.g., prosthetic heart valve) or
thermal (severe burns) destruction.
 Mechanical rupture of red cells within the
microvasculature may also occur by physical
damage to red cells in the microvasculature of
bone marrow
 This may be due to space occupying
lesions, such as metastatic tumors or
leukemia or lymphoma, to myelofibrosis, or
to the intravascular deposition of fibrin
strands upon endothelial cell surfaces
 Disseminated intravascular coagulopathy
(DIC) – there is an abnormal activation of
the coagulation process in which fibrin-
platelet clots form intravascularly and
embolize to virtually any tissue. These
clots block the microvasculature of tissues,
including that of bone marrow, resulting in
the destruction of newly synthesized red
cells.
Fibrin is deposited on endothelial surfaces,
also resulting in the shearing and
fragmentation of newly synthesized red
blood cells
Hypoproliferative Normocytic Anemia
A. Bone Marrow Hypoplasia/Aplastic Anemia
 MCV and RDW usually within normal –
typically affects all peripheral blood elements
(red cells, white cells, and platelets)
 Immature white cells and red cells are not
usually present on peripheral blood films
 Bone marrow biopsy is commonly performed
to obtain the diagnosis and typically shows
severely hypoplastic/aplastic marrow with
severe depletion of all hematopoietic marrow
precursors
 Aplastic anemia may be primary/inherited or
secondary/acquired, with the latter due to
chemotherapy, chemical toxins, infection,
radiation, or immune dysfunction.
 Serum iron may be elevated due to lack of
erythropoiesis
None of the quantitative serum diagnostic tests for
hemolytic anemia, such as haptoglobin,
carboxyhemoglobin, and indirect bilirubin elevation,
are positive in this condition
B. Myelodysplatic Syndrome
 Often presents a normocytic anemia
 Can also on occasion present as a mildly
macrocytic or microcytic anemia, is refractory to
treatment such as transfusion of packed RBCs
 May present simply as a refractory anemia in its
early stages
 Thought to progress then to refractory anemia with
ringed sideroblast and eventually to so-called
preleukemic stages with an excess of blasts in
bone marrow (in myeloid or lymphoid lines) and
excess blasts in transformation
 Condition may also present initially as a refractory
cytopenia that involves all three (erythroid,
granulocytic, megakaryocytic) hematopoietic cell
lines.
 Appears to be a clonal stem cell disorder that is
characterized by ineffective hematopoiesis
C. Anemia of Renal Failure
 Loss of the kidneys’ excretory function produces
an increase in BUN and creatinine, as well as a
buildup of metabolic by products.
 The resulting uremia appears to be responsible for
changes in red cell shape, with burr cells
(echinocytes) and ellipsoidal cells commonly
present on peripheral blood films.
 ID of Burr cells on PBS during course of
illness may signal the development of
renal dysfunction
 There is a decrease in the kidney’s ability to
produce EPO resulting to impaired erythropoiesis
 White cell and platelet counts remain within normal
limits
None of the quantitative serum diagnostic tests for
hemolytic anemia, such as haptoglobin,
carboxyhemoglobin, and indirect bilirubin elevation,
are positive in this condition
 Other possible causes of macrocytic anemia
Macrocytic Anemia include:
 Posthemorrhagic states
Low red blood cell count and a high MCV often  Alcoholism (assoc. w/ folate deficiency)
exceeding 100 fL  Liver disease
 Myelodysplasia
Most common cause of macrocytic anemia is:
 Vitamin B12 deficiency
 Folate deficiency

 Lack of factor is thought to disrupt DNA

synthesis but not RNA synthesis, such that the
nucleus and cytoplasm of the cell no longer
mature in synchrony
 Morphologically, the cell cytoplasm matures,
while the nucleus remains immature, and the
cell appears megaloblastic
 This lack of synchrony produces
hypersegmented neutrophils (five-lobed nuclei
in more than 5% of the neutrophils or any
neutrophil with six or more lobes)
 Large, oval-shaped red cells termed
macroovalocytes, both of which are present on
blood films of patients with megaloblastic
anemia
 RDW is increased
 Reticulocyte count is decreased

If macrocytic anemia is diagnosed, the first serum

analytes whose concentrations should be
determined are B12 and folate, for which rapid and
accurate ELISA tests are performed. If these
analytes are both found to be within the reference
range, assays for thyroid function should be
performed because hypothyroidism is a cause of
macrocytosis

In this era of the automated complete blood count

(CBC), it is possible also that red cell precursor
forms, such as nucleated red blood cells, may be
counted as mature erythrocytes. Therefore, in a
patient with a “macrocytic” anemia with normal
B12, folate, and thyroid hormone levels, it is
important to check the reticulocyte and nucleated
red blood cell count to determine if these are
significantly elevated. If so, the possibility of a
hemolytic anemia should be considered.