Table of Contents

Complete Blood Count (CBC)...........................................................3

Folate................................................................................................4
Haptoglobin.......................................................................................6
HbA1c (Glycosylated hemoglobin)....................................................7
Hematocrit (Hct)................................................................................9
Hemoglobin (Hgb)............................................................................10
Hemoglobin in plasma......................................................................11
Mean Cell Hemoglobin Concentration (MCHC)...............................12
Mean Cell Volume (MCV).................................................................13
Methylmalonic Acid (MMA)...............................................................14
Platelet Count (Thrombocytes).........................................................15
Red Blood Cell Count (RBC)............................................................17
Reticulocytes....................................................................................18
Complete Blood Count (CBC)

The CBC is used as a screening tool to confirm a hematologic disorder, to establish or rule
out a diagnosis, to detect an unsuspected hematologic disorder, or to monitoreffects of
radiation or chemotherapy. These counts are used as clinical guides in the diagnosis and/or
monitoring of many diseases.

Clinical Information
A complete blood count (CBC) test measures the following:
- The number of red blood cells (RBCs).
- The number of white blood cells (WBCs).
- The total amount of hemoglobin in the blood.
- The fraction of the blood composed of red blood cells (hematocrit).
- The size of the red blood cells (mean corpuscular volume, or MCV).

Interpretation
The CBC test also provides specific information the size and hemoglobin content of individual
red blood cells. This is determined from the additional following measurements:
- Mean corpuscular hemoglobin (MCH).
- Mean corpuscular hemoglobin concentration (MCHC).
- The platelet count is also usually included in the CBC.
Folate

Investigation of suspected folate deficiency.

Reference Range
≥ 3.5 μg/L or ≥ 6 nmol/L

Clinical Information
The term folate refers to all derivatives of folic acid.
Approximately 20% of the folate absorbed daily is derived from dietary sources; the
remainder is synthesized by intestinal microorganisms. Serum folate levels typically fall within
a few days after dietary folate intake is reduced and may be low in the presence of normal
tissue stores. Red blood cell folate levels are less subject to short-term dietary changes.
Significant folate deficiency is characteristically associated with macrocytosis and
megaloblastic anemia. Lower than normal serum folate also has been reported in patients
with neuropsychiatric disorders, in pregnant women whose fetuses have neural tube defects,
and in women who have recently had spontaneous abortions. Folate deficiency is most
commonly due to insufficient dietary intake and is most frequently encountered in pregnant
women or in alcoholics. Other causes of low serum folate concentration include: Excessive
utilization (e.g., liver disease, hemolytic disorders, and malignancies), Rare inborn errors of
metabolism (e.g., dihydrofolate reductase deficiency, forminotransferase deficiency, 5,10-
methylenetetra-hydrofolate reductase deficiency, and tetrahydrofolate methyltransferase
deficiency).

Interpretation
Serum folate is a relatively nonspecific test. Low serum folate levels may be seen in the
absence of deficiency and normal levels may be seen in patients with macrocytic anemia
dementia, neuropsychiatric disorders, and pregnancy disorders. Evaluation of macrocytic
anemias commonly requires measurement of the serum concentration of both vitamin B12
and folate; ideally they should be measured at the same point in time. Additional testing with
homocysteine and methylmalonic acid determinations may help distinguish between vitamin
B12 and folate deficiency states. In folate deficiency, homocysteine levels are elevated and
methylmalonic acid levels are normal. In vitamin B12 deficiency, both homocysteine levels
and methylmalonic acid levels are elevated.
Haptoglobin

Confirmation of intravascular hemolysis.

Reference Range
30 - 200 mg/dL or 3 - 20 μmol/L

Clinical Information
Haptoglobin is an immunoglobulin-like plasma protein that binds hemoglobin. The
haptoglobin-hemoglobin complex is removed from plasma by macrophages and the
hemoglobin is catabolyzed. When the hemoglobin-binding capacity of haptoglobin is
exceeded, hemoglobin passes through the renal glomeruli, resulting in hemoglobinuria. If all
the plasma haptoglobin is removed fllowing an episode of intravascular hemolysis, and if
hemolysis ceases, the haptoglobin concentration should return to normal in a week. Absence
of plasma haptoglobin may therefore indicate intravascular hemolysis. However, congenital
anhaptoglobinemia is common, particularly in African-Americans. For this reason, it may be
difficult or impossible to interpret a single measurement of plasma haptoglobin. If the assay
value is low, the test should be repeated after one to two weeks following an acute episode of
hemolysis. Chronic intravascular hemolysis causes persistently low haptoglobin
concentration. Regular strenuous exercise may cause sustained low haptoglobin, presumably
from low-grade hemolysis. Low serum haptoglobin may also be due to severe liver disease.
Neonatal plasma or serum specimens usually do not contain measurable haptoglobin. Adult
levels are achieved by six months. Increase in plasma haptoglobin concentration occurs as
an acute-phase reaction. Levels may appear to be increased in conditions such as burns and
nephrotic syndrome. An acute-phase response may be confirmed and monitored by assay of
other acute-phase reactants such as alpha-1-antitrypsin and C-reactive protein.

Interpretation
Low levels of serum haptoglobin may indicate intravascular hemolysis.
Glycosylated Hemoglobin (HbA1c)

Used for evaluating the long-term control of blood glucose concentrations in diabetic patients.
The American Diabetes Association recommends measurement of HbA1c (typically 3 - 4
times per year for type 1 and poorly controlled type 2 diabetic patients, and 2 times per year
for well controlled type 2 diabetic patients) to determine whether a patient's metabolic control
has remained continuously within the target range.

Reference Range
4.7 - 5.8 %

Clinical Information
Diabetes mellitus is a chronic disorder associated with disturbances in carbohydrate, fat, and
protein metabolism and characterized by hyperglycemia. It is one of the most prevalent
diseases, affecting 1 - 5 % of the total population. Long-term treatment of the disease
emphasizes control of blood glucose levels in preventing the acute complications of ketosis
and hyperglycemia. In addition, long-term complications such as retinopathy, neuropathy,
nephropathy,and cardiovascular disease can be minimized if blood glucose levels are
effectively controlled. Hemoglobin A1c (HbA1c) is a result of the nonenzymatic attachment of
a hexose molecule to the N-terminal amino acid of the hemoglobin molecule. The attachment
of the hexose molecule occurs continually over the entire life span of the erythrocyte and is
dependent on blood glucose concentration and the duration of exposure of the erythrocyte to
blood glucose. Therefore, the HbA1c level reflects the mean glucose concentration over the
previous period (approximately 6 - 8 weeks) and provides a much better indication of long-
term glycemic control than blood and urinary glucose determinations. Diabetic patients with
very high blood concentrations of glucose have from 2 to 3 times more HbA1c than do normal
individuals.
Interpretation
Goal of therapy: < 7.0 % HbA1c
Action suggested: > 8.0 % HbA1c
Since the HbA1c assay reflects long-term fluctuations in the blood glucose concentration, a
diabetic patient who has in recent weeks come under good control may still have a high
concentration of HbA1c. The converse is true for a diabetic previously under good control
who is now poorly controlled.
Hematocrit (Hct)

Hematocrit is a blood test that measures the number of red blood cells and the size of red
blood cells. It gives a percentage of red blood cells found in whole blood.

Reference Range
Male: 40.7 - 50.3 %
Female: 36.1 - 44.3 %

Clinical Information
This test is almost always ordered as part of a complete blood count (CBC). May be ordered
if there are signs of anemia, leukemia and diet deficiency.

Interpretation
Low hematocrit: Anemia, blood loss (hemorrhage), bone marrow failure, destruction of red
blood cells, leukemia, malnutrition or specific diet deficiencies, multiple myeloma or
rheumatoid arthritis.
High hematocrit: Dehydration, burns, diarrhea, erythrocytosis or polycythemia vera.
Hemoglobin (Hgb)

Hemoglobin is a protein in red blood cells that carries oxygen. The hemoglobin test is almost
always done as part of a complete blood count (CBC) and most often to test for anemia and
bleeding.

Reference Range
Male: 13.8 - 17.2 g/dL or 8 - 10.5 mmol/L
Female: 12.1 - 15.1 g/dL or 7 - 9.5 mmol/L

Clinical Information
Lower-than-normal hemoglobin may be due to: Anemia (various types), bleeding,
erythropoietin deficiency (from kidney disease), nutritional deficiencies of iron, folate, vitamin
B12 and vitamin B6. More uncommon conditions include lead poisoning, malnutrition,
overhydration and red blood cell destruction associated with transfusion reaction.
Higher-than-normal hemoglobin may be due to: Congenital heart disease, Cor pulmonale,
Increased red blood cells due to too much erythropoietin, Pulmonary fibrosis and
Polycythemia vera.
Additional conditions under which the test may be performed: Anemia of chronic disease,
Clinical hemoglobin C, Diabetes, Drug-induced immune hemolytic anemia, Giant cell
(temporal, cranial) arteritis, Hemolytic anemia due to G6PD deficiency, Idiopathic aplastic
anemia, Idiopathic autoimmune hemolytic anemia, Immune hemolytic anemia, Iron deficiency
anemia, Paroxysmal cold hemoglobinuria (PCH), Paroxysmal nocturnal hemoglobinuria
(PNH), Pernicious anemia, Placenta abruptio, Polymyalgia rheumatica, Rhabdomyolysis,
Secondary aplastic anemia and many more.

Interpretation
The hemoglobin level should allways be evaluated in combination with the complete blood
count (CBC).
Hgb in plasma

Determining whether hemolysis is occurring such as from: Transfusion reaction and

mechanical fragmentation of red blood cells.

Reference Range
≥ 18 years: 0 - 15 mg/dL or 0 - 2.3 μmol/L

Clinical Information
Plasma normally contains no free hemoglobin (no hemoglobin that is not contained in
erythrocytes).

Interpretation
Significant amounts of hemoglobin occur in plasma following hemolysis such as might result
from a transfusion reaction or mechanical fragmentation of red blood cells during cardiac
surgery.
Mean Cell Hemoglobin Concentration (MCHC)

The mean corpuscular hemoglobin concentration, or MCHC, is a measure of the

concentration of hemoglobin in a given volume of packed red blood cell.

Reference Range
32 - 36 g/dL or 320 - 360 g/L

Clinical Information
It is reported as part of a standard complete blood count (CBC). It is calculated by dividing the
hemoglobin by the hematocrit.

Interpretation
It is diminished (hypochromic) in microcytic anemias, and normal (normochromic) in
macrocytic anemias (due to larger cell size, though the hemoglobin amount or MCH is high,
the concentration remains normal). MCHC is elevated in hereditary spherocytosis. This count
is used to give a rough guide to what shade of red, RBC will be (paler equals lower than the
standard).
Mean Cell Volume (MCV)

The mean corpuscular volume, or MCV, is a measure of the average red blood cell volume
(i.e. size) that is reported as part of a standard complete blood count (CBC).

Reference Range
80 - 100 fL

Clinical Information
In patients with anemia, it is the MCV measurement that allows classification as either a
microcytic anemia (MCV below normal range) or macrocytic anemia (MCV above normal
range). It can be calculated (in litres) by dividing the hematocrit by the red blood cell count
(number of red blood cells per litre). The result is typically reported in femtolitres.

Interpretation
High levels: Common in presence of hemolytic anaemia, presence of reticulocytes can
increase MCV. In pernicious anemia (macrocytic), MCV can range up to 150 femtolitres. An
elevated MCV is also associated with alcoholism (as are an elevated GGT and a ratio of
AST : ALT of 2 : 1). Vitamin B12 and/or Folic Acid deficiency has also been associated with
macrocytic anemia (high MCV numbers).
Low levels: The most common causes of microcytic anemia are iron deficiency (due to
inadequate dietary intake, gastrointestinal blood loss, or menstrual blood loss), thalassemia,
or chronic disease. A low MCV number in a patient with a positive stool guaiac test (bloody
stool) is highly suggestive of GI cancer. In iron deficiency anemia (microcytic anemia), it can
be as low as 60 to 70 femtolitres. In cases of thalassemia, the MCV may be low even though
the patient is not iron deficient.
Methylmalonic Acid (MMA)

Screening for the differential diagnosis of signs and symptoms associated with a variety of
causes of cobalamin deficiency. Serum MMA may be a more reliable marker of cobalamin
deficiency than direct cobalamin determination. Evaluating children with signs and symptoms
of methylmalonic acidemia.

Reference Range
≤ 0.40 μmol/L or 400 nmol/L

Clinical Information
Methylmalonic acid (MMA) is a specific diagnostic marker for a group of inherited disorders
collectively known as methylmalonic acidemias, which includes at least 8 different entities
identified according to biochemical phenotype and somatic cell complementation analysis.
Their collective incidence is approximately 1 : 48,000 live births. Acquired causes of
methylmalonic acidemia are much more common. Elevated MMA levels in plasma and urine
are found in patients with cobalamin (vitamin B12) deficiency as a consequence of intestinal
malabsorption, impaired digestion, or poor diet. Other conditions such as renal insufficiency,
hypovolemia, and bacterial overgrowth of the small intestine also contribute to the possible
causes of mild methylmalonic acidemia/-uria. Elderly patients with cobalamin deficiency may
present with peripheral neuropathy, ataxia, loss of position and vibration senses, memory
impairment, depression, and dementia in the absence of anemia.

Interpretation
In pediatric patients, markedly elevated MMA values are consistent with a diagnosis of
methylmalonic acidemia. In adults, moderately time elevated values are indicative of
cobalamin deficiency.
Platelet Count (Thrombocytes)

Platelets, or thrombocytes, are small, irregularly shaped anuclear cells, 2 - 4 μm in diameter,

which are derived from fragmentation of precursor megakaryocytes. The average life span of
a platelet is between 8 and 12 days. Platelets play a fundamental role in hemostasis and are
a natural source of growth factors. They are involved in hemostasis leading to the formation
of blood clots.

Reference Range
A normal platelet count in a healthy person is between 150 - 400 x 10^9/L

Clinical Information
If the number of platelets istoo low, excessive bleeding can occur; however, if the number of
platelets is too high, blood clots can form (thrombosis), these can block blood vessels, and
may cause a stroke and/or a heart attack. An abnormality or disease of the platelets is called
a thrombocytopathy, which could be either a low number (thrombocytopenia), a decrease in
function (thrombasthenia) or an increase in number (thrombocytosis).

Interpretation
High and low counts: Both thrombocytopenia (thrombopenia) and thrombocytosis may
present with coagulation problems. In general, low platelet counts increase bleeding risks
(although there are exceptions, e.g., immune heparin-induced thrombocytopenia), and
thrombocytosis may lead to thrombosis (although this is mainly when the elevated count is
due to myeloproliferative disorder).
Low platelet counts are, in general, not corrected by transfusion unless the patient is bleeding
or the count has fallen below 5 x 10^9/L. It is contraindicated in thrombotic thrombocytopenic
purpura (TTP), as it fuels the coagulopathy. In patients having surgery, a level below 50 x
10^9/L) is associated with abnormal surgical bleeding, and regional anaesthetic procedures
such as epidurals are avoided for levels below 80 - 100.
Normal platelet counts are not a guarantee of adequate function. In some states, the
platelets, while being adequate in number, are dysfunctional. For instance, aspirin irreversibly
disrupts platelet function by inhibiting cyclooxygenase-1 (COX1), and hence normal
hemostasis. Normal platelet function will not return until the aspirin has ceased and enough of
the affected platelets have been replaced by new ones, which can take over a week. Uremia
(a consequence of renal failure) leads to platelet dysfunction that may be ameliorated by the
administration of desmopressin.
Red Blood Cell Count (RBC)

An RBC (Erythrocyte count; Red blood cell count) count is a blood test that tells how many
red blood cells (RBCs) there is.

Reference Range
Male: 4.7 - 6.1 million cells/μL
Female: 4.2 - 5.4 million cells/μL

Clinical Information
Normal results vary in diffrent laboratory settings.

Interpretation
RBCs contain hemoglobin, which carries oxygen. How much oxygen the tissues gets
depends on how many RBCs there are and how well they work. This test can help diagnose
anemia and other conditions affecting red blood cells. The RBC count is almost always part of
the CBC (complete blood count) test. Damaged RBCs do not live as long as normal. Injury
inside the blood vessels, such as that caused by artificial heart valves or peripheral blood
vessel disease, can damage RBCs.
Reticulocytes

Assessing erythropoietic bone marrow activity in anemia and other hematologic conditions.

Reference Range
% Reticulocytes: 0.60 - 1.83 %
Absolute reticulocytes: 29 - 87 x 10^9/L

Clinical Information
Reticulocytes are immature erythrocytes (RBCs) that have been released into the peripheral
blood from the bone marrow after extrusion of their nucleus. The reticulocyte contains
residual polyribosomes used in the formation of hemoglobin in the developing erythrocyte.
The reticulocyte count is a measure of the number of RBCs delivered by the bone marrow. It
is elevated with active erythropoiesis such as regeneration and is decreased in hypoplastic or
deficiency conditions such as vitamin B12 deficiency.

Interpretation
Reticulocyte counts must be carefully correlated with other clinical and laboratory findings.