Science

Assessment of the Reliability of the Sysmex

XE-5000 Analyzer to Detect Platelet Clumps
Jennifer Hawkins, DO,1,2 Gene Gulati, PhD,2* Guldeep Uppal, MD,2 Jerald Gong, MD2
Laboratory Medicine 47:3:189-194

DOI: 10.1093/labmed/lmw016

ABSTRACT
Objective: Platelet counts generated by automated analyzers on
blood specimens that contain platelet clumps are often inaccurate and
require verification by blood-smear review. In this study, we assessed
the reliability of the Sysmex XE-5000 instrument to detect platelet
clumps.
Method: We reviewed automated complete blood count (CBC)
results and the findings of the microscopic review of corresponding
blood smears of 600 blood specimens specifically selected from
the routine laboratory workload. The sensitivity, specificity,
efficiency, positive predictive value (PPV), and negative predictive
value (NPV) of its 2 platelet-associated flags (abnormal platelet-
size distribution [PAD] flag and platelet-clumps [CLP] flag) were
determined.
Results: The respective values for the sensitivity, specificity, efficiency,
and PPV were 42%, 83%, 63%, and 1% for the PAD flag and 57%, 99%,
78%, and 37% for the CLP flag. The NPV was 100%.
Conclusion: The overall reliability of the CLP flag is superior than that of
the PAD flag but there is room for further improvement.
Keywords: Sysmex XE-5000, platelet clumps, assessment, automated
platelet counts, reliability, CBC

Clinical laboratories worldwide use the XE-5000, an
automated hematology analyzer from Sysmex Corporation,
to perform complete blood counts (CBCs) and differential
leukocyte counts (DIFFs) on ethylenediamineteraacetic acid
(EDTA)–anticoagulated blood specimens. The overall
reliability of the results generated by this analyzer has been
assessed and found to be acceptable for clinical use.1
However, the CBC results generated on some of the blood
specimens are flagged by the analyzer for verification of the
Abbreviations
CBCs, complete blood counts; DIFFs, differential leukocyte counts; EDTA,
ethylenediamineteraacetic acid; PPV, positive predictive value; NPV,
negative predictive value; PAD, platelet size distribution flag; CLP, plate-
let clumps; IMI, immature cell information; NRBC, nucleated red blood
cells; NA, not applicable, VPA, vortexed prior to analysis; PCIC, platelet
count inaccurate due to clumps; NPLT, platelet count not obtainable due
to clumps; NWC, normal with clumps; IWC, increased with clumps; DWC,
decreased with clumps; RBT, if clinically indicated, a reliable platelet
count may be obtained from a specimen collected in a blue-top (citrated)
tube
1
Department of Pathology, Marshall University, 2Department of
Pathology, Anatomy, and Cell Biology, Sydney Kimmel Medical College,
Thomas Jefferson University, Philadelphia, Pennsylvania
*To whom correspondence should be addressed.
gene.gulati@jefferson.edu
result of the flagged parameter by other means. One such
parameter of clinical significance is the automated platelet
count, which is often unreliable and consequently
unreportable if the blood specimen contains platelet clumps.
We have assessed the reliability of the Sysmex XE-5000
analyzer to detect platelet clumps by determining the
sensitivity, specificity, efficiency, positive predictive value
(PPV), and negative predictive value (NPV) of its 2 relatively
frequently generated platelet-associated flags, namely, the
abnormal platelet size distribution (PAD) flag and the platelet
clumps (CLP) flag. The PAD flag is generated by the analyzer
based on automated analysis of the platelet histogram-
associated parameters. The CLP flag is generated based on
automated analysis of the specific area (upper right area of
the ghost population) in the DIFF, immature cell information
(IMI), and nucleated red blood cell (NRBC) scattergrams.2
These flags may be generated by the analyzer individually or
together, with or without accompanying white blood cell and/
or red blood cell-associated flags.
Our study focused on the selected platelet-associated flags
and their variant combinations. The latter category included 2
scenarios, one represented by PAD and/or CLP and the other

C American Society for Clinical Pathology, 2016. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com
V 189
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by PAD and CLP together. In our laboratory, which processes,
on average, 634 specimens for CBC per day (based on 1
week of data), the number of specimens flagged in either or
both flag categories averages 48 (7.6%) per day. Among these
flags, the PAD is the most prevalent, accounting for 5.7% of
total specimens; the CLP flag accounts for 1.4%. The
remaining 0.5% account for generation of the 2 flags (PAD and
CLP) together by the analyzer.
Materials and Methods
In this study, we included automated CBC results generated
by the analyzer and morphologic findings of microscopic
review of the corresponding blood smears of a total of 600
EDTA-anticoagulated blood specimens, specifically selected
as described later herein, from the routine workload of our
laboratory during a 5-month period. The analyzer-generated
acceptable platelet counts of these specimens spanned a
range of 5  103 per lL to 1102  103 per lL. The
categorical distribution of the platelet counts among the
entire group of specimens included 35.5% decreased (ie,
<140  103/lL, of which 72.4% were <100  103/lL), 6.2%
increased (ie, >440  103/lL), and 58.3% normal (ie, within
the range of 140-440  103/lL).
Our laboratory routinely performs CBCs on 2 Sysmex XE-
5000 analyzers, which are calibrated and quality controlled
per manufacturer instructions.2 The platelet count is routinely
performed via the impedance method by this analyzer. The
optical method for platelet count is also available on this
analyzer, but we did not consider it to be appropriate or
necessary for our study. Blood smears are routinely prepared
and stained with a Romanowsky stain (Wright stain) on the
Sysmex SP-1000 instrument. One of the coauthors (G.G.)
reviewed all smears microscopically for the presence of
platelet clumps, fibrin strands, and large/giant platelets. The
smear review process was unbiased, despite the fact that
the reviewer was aware of the flagging status of each
specimen included in the determination of PPV and NPV by
virtue of the specimen-selection process.
Sensitivity, Specificity, and Efficiency
For determination of sensitivity, we retrospectively reviewed
the CBC results of 100 blood specimens, for which smears
revealed significant platelet clumping and/or the presence of
190 Lab Medicine 2016;47:3;189–194
190 DOI: 10.1093/labmed/lmw016
fibrin strands by microscopic review, for the presence of
PAD and CLP flags. We defined significant clumping and the
presence of fibrin strands as the degree of clumping and/or
the presence of fibrin strands that rendered the automated
platelet count unreliable and consequently unreportable.
Similarly, for determination of specificity, we retrospectively
reviewed the CBC results of an equal number of blood
specimens (ie, 100), for which smears did not reveal any
platelet clumps and/or fibrin strands via microscopic review,
for the presence of PAD and CLP flags. The sensitivity was
defined as the percentage of specimens, among the
morphologically positive cases, for which test results
revealed either or both of the analyzer-generated flags. The
specificity was defined as the percentage of specimens
revealing neither of the 2 flags among the morphologically
negative cases. The efficiency was defined as the
percentage of specimens among this group of 200
specimens that were correctly identified by the analyzer as
having true positive or true negative results.
Positive Predictive Value (PPV)
To determine the PPV, blood smears of 300 additional
specimens flagged by the analyzer for PAD (n ¼ 100) or CLP
(n ¼ 100), or both flags together (n ¼100) were reviewed for
the presence of platelet clumps and fibrin strands. PPV was
defined as the percentage of flagged specimens that, via
microscopic review, revealed significant platelet clumping
and/or the presence of fibrin strands.
Negative Predictive Value (NPV)
The NPV was defined as the percentage of specimens not
revealing significant clumping or any fibrin strands by
microscopic review. To determine the NPV, we reviewed
blood smears of an additional 100 specimens, which had not
been flagged by the analyzer for any of the platelet-associated
flags, for the presence of platelet clumps and fibrin strands.
Results
Sensitivity
Among the specimens that tested morphologically positive,
the analyzer flagged 42 for the PAD and 57 for the CLP,
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Table 1. Sensitivity of Sysmex XE- 5000 in Table 2. Specificity of Sysmex XE- 5000 in
Detecting Platelet Clumpsa Detecting Platelet Clumpsa
Variable Specimens, No. Sensitivity Variable Specimens, No. Specificity

Platelet-Associated Flagged Not Flagged Platelet-Associated Flagged Not Flagged

Flag(s) by Analyzer by Analyzer Flag(s) by Analyzer by Analyzer
Platelet abnormal 42 58 42.0% Platelet abnormal 17 83 83.0%
distribution (PAD) distribution (PAD)
Platelet clump (CLP) 57 43 57.0% Platelet clump (CLP) 1 99 99.0%
PAD and/or CLP 73 27 73.0% PAD or CLP 18 82 82.0%
PAD and CLP 26 74 26.0% PAD and CLP 18 82 82.0%
a a
Data from specimens that tested positive for platelet clumps and/or fibrin strands Data from specimens that tested negative for platelet clumps and fibrin strands via
via blood smear (n ¼ 100). The Sysmex XE-5000 instrument is manufactured by blood smear (n ¼ 100). The Sysmex XE-5000 instrument is manufactured by
Sysmex Corporation. Sysmex Corporation.

yielding sensitivities of 42.0% and 57.0%, respectively

(Table 1). The sensitivity increased to 73.0% when a Table 3. Efficiency of the Sysmex XE 5000 in
specimen was considered flagged for platelet clumps if the
Detecting Platelet Clumpsa
PAD flag and/or the CLP flag was/were generated by the Platelet-Associated No. of Specimens Efficiency
Flag(s) Correctly Flagged By
analyzer. It decreased, however, to 26.0% when a specimen
Analyzer
was considered flagged for platelet clumps if the PAD and
Platelet abnormal distribution 125 62.5%
CLP flags were generated together by the analyzer. The
(PAD)
reported platelet estimates of this group of 100 specimens Platelet clump (CLP) 156 78.0%
ranged from 10 (10.0%) that were decreased with clumps to PAD and/or CLP 155 77.5%
76 (76.0%) that were normal with clumps to 14 (14.0%) that PAD and CLP 108 54.0%
a
were increased with clumps. n ¼ 200. The Sysmex XE-5000 instrument is manufactured by Sysmex Corporation.

Specificity
Among the specimens that tested morphologically negative,
the analyzer flagged 17 for PAD and 1 for CLP, yielding
specificities of 83.0% and 99.0%, respectively (Table 2). The
specificity dropped a bit, to 82.0%, when a specimen was
considered flagged for platelet clumps, if either of the 2 flags
or both flags were generated by the analyzer. The analyzer-
generated platelet counts of this group of 100 specimens
ranged from 41  103 per lL to 1102  103 per lL. Based on
our laboratory’s reference range of 140 to 440  103 per lL,
the categorical distribution of the platelet counts among this
group included the following: decreased (ie, <140  103/lL),
36 (36.0%; 28 of 36 [77.8%] were <100  103/lL); increased
(ie, >440  103/lL), 9 (9.0%); and normal (ie, within the range
of 140-440 103/lL), 55 (55.0%) .
Efficiency
The respective efficiencies for the PAD and CLP flags, as
determined from this data set from 200 specimens, were
63.0% and 78.0% (Table 3). The efficiency decreased to 54%
when a specimen was considered flagged for platelet clumps
if both flags were generated together by the analyzer.
However, this value remained relatively unchanged at 77.5%
when a specimen was considered flagged for platelet clumps
if either of the 2 flags or both flags was/were generated by
the analyzer. The categorical distribution of the platelet
counts among this group of 200 specimens included the
following: decreased, 46 (23.0%); increased, 23 (11.5%); and
normal, 131 (65.5%).
Positive Predictive Value
The respective PPVs for the PAD and CLP flags for detecting
platelet clumps were 1.0% and 37.0% (Table 4). The PPV
increased minimally to 39.0% when a specimen was
considered flagged for platelet clumps if both flags were
generated together by the analyzer. The analyzer-generated
platelet counts of this group of 300 specimens ranged from
5  103 per lL to 780  103 per lL. The categorical
distribution of the platelet counts among this group included

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DOI: 10.1093/labmed/lmw016
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Table 4. Positive Predictive Value (PPV) for
Platelet-Associated Flags Generated by Sysmex
XE- 5000 in Detecting Platelet Clumps
Variable No. of Specimens, Result
for Clumps and Fibrin
Platelet-Associated Flag(s) Positive Negative
a
Platelet abnormal distribution (PAD) 1 99
Platelet clump (CLP)a 37 63
PAD and CLPa 39 61
a
n ¼ 100. The Sysmex XE-5000 instrument is manufactured by Sysmex Corporation.
the following: decreased, 142 (47.3%; with 108 of the 142
[76.0%] having values of < 100  103/lL); increased, 10
(3.3%); and normal, 148 (49.3%).
Negative Predictive Value
The NPV for the blood specimens not flagged by the
analyzer for any of the platelet-associated flags was 100%.
The analyzer-generated platelet counts of this group of 100
specimens ranged from 18  103 per lL to 771  103 per lL.
The categorical distribution of the platelet counts among this
group included the following: decreased, 25 (25.0%; with 14
of the 25 [56.0%] having a value of less than 100  103/lL);
increased, 4 (4.0%); and normal, 71 (71.0%).
A summary of all data, including the sensitivity, specificity,
efficiency, PPV, and NPV, is presented in Table 5.
Discussion
Among the 2 platelet-associated flags and their variant
combinations, which we assessed for their ability to detect
platelet clumps, we found the CLP to be relatively more
reliable, with sensitivity of 57.0%, specificity of 99.0%, PPV of
37.0%, and overall efficiency of 78.0%; the NPV was 100%.
The PAD flag, compared with the CLP flag, had much lower
values: sensitivity, 42.0%; specificity, 83.0%; efficiency,
62.5%; and PPV, 1.0%. When a specimen was considered
correctly identified by the analyzer for the presence of
platelet clumps because it generated a PAD flag, a CLP flag,
or both (ie, the PAD and/or CLP combination), the sensitivity
increased to 73.0%, but the specificity decreased to 82.0%,
and efficiency remained relatively unchanged at 77.5%,
compared with the corresponding values for the CLP flag.
192 Lab Medicine 2016;47:3;189–194
192 DOI: 10.1093/labmed/lmw016
The variant combination of PAD and CLP flags together
minimally increased the PPV to 39.0%, at the expense of a
reduction in sensitivity to 26.0% and efficiency to 54.0%, with
specificity remaining unchanged at 82.0%, compared with
PPV
the corresponding values for the CLP flag.
These low levels of sensitivity and efficiency for the
1.0% combination of PAD and CLP point to its inferiority to the
37.0% CLP flag in detecting platelet clumps. Among the 3
39.0%
categories of platelet counts (decreased, increased, and
normal), the flagging rate was fairly similar between the
decreased (47.3%) and normal categories (49.3%), with the
remaining 3.3% representing the increased category.
However, among the flags, the PAD was the most prevalent
(50.0%) in the decreased platelet count category, and the
CLP flag was the most prevalent in the increased (70.0%)
and normal (50.0%) platelet-count categories. The
incidence of combined flagging (PAD and CLP together)
was also fairly similar between the decreased (36.6%) and
normal (31.1%) platelet count categories and a bit lower
(20.0%) in the increased platelet count category. From these
findings, one might infer that the analyzer generates
platelet-associated flags at all levels of platelet counts but
the type of generated flag varies somewhat with the level of
the platelet count. The PAD flag, which has the lowest PPV
of 1.0%, was more often associated with decreased platelet
counts. In contrast, the CLP flag and the combination of the
2 flags (PAD and CLP together), which yield the relatively
higher PPVs of 37.0% and 39.0%, respectively, were more
often associated with the normal and decreased platelet
counts.
To our knowledge, there are no published study results on
the Sysmex XE-5000 with which we can compare our
findings. However, comparable study results on other
automated hematology analyzers have been published
during the past several years. The most comparable
observations are from a study on the evaluation of
automated platelet counts generated by the XE-2100, an
earlier model of automated hematology analyzer from
Sysmex Corporation, the same manufacturer as the XE-
5000.3 For detection of platelet clumps, this study reported
a sensitivity of 1% for the PAD flag, 22.5% for the CLP flag,
and 35.4% for the CLP þ PAD flag when the blood
specimens collected in lavender-top tubes were used to
perform the CBCs. The sensitivity for the CLP flag was
higher (57.1%) when blood specimens collected in
Microtainer tubes (Becton, Dickinson and Company) were
used to perform CBCs.3
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Table 5. Summary of Data on Sensitivity, Specificity, Efficiency, PPV, and NPV for Platelet-Associated
Flags Generated by the Sysmex XE-5000 in Detecting Platelet Clumpsa
Platelet-Associated Flags Sensitivityb Specificityb Efficiencyc PPVd NPVb
Platelet abnormal distribution flag (PAD) 42.0% 83.0% 62.5% 1.0% NA
Platelet clump flag (CLP) 57.0% 99.0% 78.0% 37.0% NA
PAD and/or CLP 73.0% 82.0% 77.5% NA NA
PAD and CLP 26.0% 82.0% 54.0% 39.0% NA
Neither PAD nor CLP NA NA NA NA 100%
NA, not applicable, PPV, positive predictive value, NPV, negative predictive value.
a
The Sysmex XE-5000 instrument is manufactured by Sysmex Corporation.
b
n ¼ 100.
c
n ¼ 200.
d
n ¼ 100/flag(s).

Table 6. Platelet-Associated Smear Review Findings and Suggested Course of Action

Platelet-Associated Smear Review Finding Suggested Course of Action
Significant platelet clumping, and automated platelet count Vortex the specimen to break up the clumps and rerun the specimen to determine
appears unreliable the CBC. If clumps break up, as judged by the smear review, report the platelet
count from the vortexed specimen and append to it the comment “VPA”
or
If clumps do not break on vortex or if vortex is not feasible, modify the platelet count
to “PCIC” (if already released) or “NPLT” (if not already released), report a platelet
estimate as “NWC,” “IWC,” or “DWC” from the smear, and attach a comment “RBT”.
Many fibrin strands Cancel the CBC (reason: unsuitable specimen) and ask for an appropriately
collected new specimen.
Rare platelet clumps and/or rare fibrin strands and automated Report automated platelet count and attach the comment “with rare
platelet count appears reliable clumps/fibrin strands”.
No platelet clumps and no fibrin strands; automated platelet count Report the automated platelet count and attach to it the comment
appears reliable “verified by smear review”.
Few giant platelets, and automated platelet count appears reliable Report the automated platelet count and attach to it the comment
“with few giant platelets”.
Many giant platelets, and automated platelet count appears falsely lowDo not report automated platelet count but report an estimated platelet
count from the smear; attach the comment “estimated”.
Platelet satellitosis, and automated platelet count appears unreliable Do not report automated platelet count but report an estimated platelet
count from the smear if feasible; attach the comment “platelet
satellitosis present”.
Platelet satellitosis, and automated platelet count appears reliable Report automated platelet count and attach to it the comment
“platelet satellitosis present, result may be affected”.
VPA, vortexed prior to analysis; PCIC, platelet count inaccurate due to clumps; NPLT, platelet count not obtainable due to clumps; NWC, normal with clumps; IWC, increased with
clumps; DWC, decreased with clumps; RBT, if clinically indicated, a reliable platelet count may be obtained from a specimen collected in a blue-top (citrated) tube; CBC, complete
blood count

Our findings regarding the XE-5000, based on the CBCs
performed on specimens collected primarily (98.0%) in
lavender-top tubes, show an improvement in the reliability
of its automated platelet flagging system compared with
that of the XE-2100, but the degree of improvement does
not approach the desirable level of at or close to 100% for
each analyzed statistical parameter. The overall efficiency
of 78.0%, which we observed for the CLP flag generated
by the XE-5000, also compares favorably with the
previously reported efficiency in the range of 33.0% to
67.0% for platelet-clump flagging by 3 different
hematology analyzers (Beckman Coulter LH750 [Beckman
Coulter, Inc.], Sysmex XE-2100 [Sysmex Corporation], and
Siemens ADVIA 120 [Siemens Healthcare GmbH]). 4 A
study on evaluation of the automated flagging system of
an older hematology analyzer (GenS) from a different
manufacturer (Beckman Coulter, Inc) reported a sensitivity
of 12.0% to 44.0%, and specificity, efficiency, NPV, and

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DOI: 10.1093/labmed/lmw016
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PPV of more than 95.0% each for the CLP flag.5 Our
findings on the XE-5000 reveal better sensitivity and
similar or slightly lower NPV, PPV, and specificity
compared with that of the GenS.
Another relatively recently published study reported
sensitivity in the range of 40.4% to 82.8% for the detection of
platelet clumps/fibrin strands in blood smears by the
CellaVision DM96 (Siemens Healthcare GmbH), which is an
automated image analysis system.6 These 2 systems may
not be considered completely comparable because one (the
CellaVision DM96) is semiautomated and uses stained blood
smears for performing DIFFs and platelet scans, and the
other (the Sysmex XE-5000) is fully automated and uses
whole blood to perform the same analyses.
All of these previously published reports and our findings
point towards the continued need for improvement in the
reliability of the automated flagging system to detect platelet
clumps. To maximize the sensitivity while maintaining the
specificity, it is highly desirable that users of the XE-5000
analyzer include 1 or more additional criteria along with the
CLP flag to verify the automated platelet count by smear
review and that the manufacturer of the analyzer continue its
efforts to enhance the automatic detectability of platelet
clumps to the desirable level of at or close to 100%. The
manufacturer of the analyzer recommends verification of the
flagged results by other means before reporting; the
verification method generally used by the clinical laboratories
is blood-smear review. The clinical laboratory at our
institution routinely verifies automated platelet counts by
smear review if they are accompanied by the CLP flag, less
than 100,000 per lL on initial encounter, and/or reveal delta
failure with a 50% or greater drop compared with the most
194 Lab Medicine 2016;47:3;189–194
194 DOI: 10.1093/labmed/lmw016
recent past count. We chose these criteria to ensure patient
safety in a cost-effective way, with the premise that the
likelihood of the patient being subjected to unnecessary
platelet transfusion, additional diagnostic work-up, and/or
other undue measures is low in such circumstances. Our
laboratory’s policy on reporting the results of the platelet
count based on the findings of the blood smear review, as
outlined in Table 6, may be used as a guide by others for
potential implementation in their laboratories.LM
Acknowledgments
We thank Nandita Patel, B.Sc., and Vikas Patel, B.Sc., for
their help in obtaining the slides and the data from the ana-
lyzer that we needed for the study.
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