Reticulocyte analysis by flow cytometry and other techniques

Marked hemoglobin mass expansion and plasma volume contraction in Sherpas acclimatizing to 5,400 m altitude

In lowlanders, high altitude (HA) acclimatization induces hemoconcentration by reducing plasma volume (PV) and increasing total hemoglobin mass (Hbmass). Conversely, Tibetan highlanders living at HA are reported to have a similar hemoglobin concentration ([Hb]) as lowlanders near sea level, and we investigated whether this reflects alterations in the PV or the Hbmass response to HA. Baseline assessment of PV and Hbmass was performed by carbon monoxide rebreathing at low altitudes (∼1,400 m) in Sherpas (an ethnic group of Tibetans living in Nepal) and native lowlanders. Participants then ascended to the Everest Base Camp (EBC) (5,400 m), where further measurements were performed after ∼2 days (EBC 1) and ∼6 wk (EBC 2). While on EBC 1 an increase in [Hb] was observed in lowlanders (P = 0.004) but not in Sherpas (P = 0.179), marked increases in [Hb] were observed in both groups on EBC 2 (P < 0.001). On EBC 1, Hbmass (Sherpas, P = 0.393; lowlanders, P = 0.123) and PV (Sherpas, P = 0.348; lowlanders, P = 0.172) were not different from baseline in either group, while circulating erythropoietin was increased in both groups (P < 0.001). On EBC 2, large increases in Hbmass and reductions in PV were observed along with elevated circulating erythropoietin in both groups (all P < 0.002). Neither the increases in erythropoietin on EBC 1 (P = 0.846) or EBC 2 (P = 0.564) nor the expansion of Hbmass (P = 0.771) or reduction in PV (P = 0.099) on EBC 2 differed between the groups. We conclude that the hematological response of Sherpas to extended exposure to very high altitudes does not fundamentally differ from that of native lowlanders.NEW & NOTEWORTHY We measured the hematological response to ∼6 wk exposure to an altitude of 5,400 m in Sherpa highland natives and Nepalese lowlanders. While the increase in hemoglobin concentration at high altitudes tended to be smaller in Sherpas than in lowlanders, the two groups experienced a similar reduction in plasma volume and increase in hemoglobin mass. We conclude that the hematological response of Sherpas to high-altitude exposure does not fundamentally differ from that of lowlanders.

Reticulocyte Antioxidant Enzymes mRNA Levels versus Reticulocyte Maturity Indices in Hereditary Spherocytosis, β-Thalassemia and Sickle Cell Disease

The antioxidant enzymes superoxide dismutase (SOD), catalase (CAT), glutathione peroxidase (GPx) and peroxiredoxin 2 (Prx2) are particularly important in erythroid cells. Reticulocytes and other erythroid precursors may adapt their biosynthetic mechanisms to cell defects or to changes in the bone marrow environment. Our aim was to perform a comparative study of the mRNA levels of CAT, GPX1, PRDX2 and SOD1 in reticulocytes from healthy individuals and from patients with hereditary spherocytosis (HS), sickle cell disease (SCD) and β-thalassemia (β-thal), and to study the association between their transcript levels and the reticulocyte maturity indices. In controls, the enzyme mRNA levels were significantly correlated with reticulocyte maturity indices for all genes except for SOD1. HS, SCD and β-thal patients showed younger reticulocytes, with higher transcript levels of all enzymes, although with different patterns. β-thal and HS showed similar reticulocyte maturity, with different enzyme mRNA levels; SCD and HS, with different reticulocyte maturity, presented similar enzyme mRNA levels. Our data suggest that the transcript profile for these antioxidant enzymes is not entirely related to reticulocyte maturity; it appears to also reflect adaptive mechanisms to abnormal erythropoiesis and/or to altered erythropoietic environments, leading to reticulocytes with distinct antioxidant potential according to each anemia.

Hematological parameters: is there a difference between those released by the hematological analyzer and to the customer?

OBJECTIVE

This study aimed to compare the hematological parameters released by hematological analyzers with those released in customer reports.

METHODS

We conducted a descriptive study in the laboratories of a medium-sized municipality in the state of Minas Gerais registered in the National Register of Health Establishments. Interviews were conducted using a questionnaire to obtain information regarding the parameters released by the analyzers and those available in the customer's report.

RESULTS

Sixteen laboratories were evaluated, and none of them released all the parameters obtained from the hematological analyzers to customers. The red blood cell distribution width was released in 88% of the laboratories, atypical lymphocytes in 70%, mean platelet volume in 50%, platelet distribution width and platelet count in 20%. No laboratory released information on reticulocytes, fraction of immature reticulocytes and immature granulocytes, nucleated erythrocyte count, immature platelet fraction and reticulocyte hemoglobin, and large platelet rate.

CONCLUSION

All evaluated clinical analysis laboratories had at least one parameter that was not released in the customer's report despite being released by the hematological analyzers. The lack of knowledge on the part of professionals about the clinical importance of each parameter of the complete blood count results in a loss in patient assessment, and it is important to include these parameters in the complete blood count report.

Pre-analytical and analytical variability of reticulocyte counts in dogs

BACKGROUND

Automated fluorescence-based haematology analysers are now available for reticulocyte enumeration in veterinary medicine, but manual counting is still largely used. This study aimed to evaluate potential sources of analytical and pre-analytical errors when performing automated and manual counts.

METHODS

Automated and two-operator double-blind manual reticulocyte counts were performed on 15 blood samples. The intra-assay variation of the automated and manual counts and the interoperator variation in the manual counts were then calculated. In addition, the effects of storage were evaluated using samples refrigerated at 4°C or stored at room temperature for 2, 4, 12, 24, 48 or 72 hours after sampling.

RESULTS

Intra-assay coefficients of variation were lower for automated counts than for manual counts. Comparison between automated and mean total manual reticulocyte count showed no significant differences. In both refrigerated samples and those stored at room temperature, an increase in reticulocyte count was recorded only after 72 hours. Staining artefacts occurred only in one stored sample counted manually.

LIMITATIONS

The presence of cytoplasmic particles other than RNA can cause misinterpretation of cells, leading to an erroneous reticulocyte count.

CONCLUSION

The use of an automated analyser is preferable for reticulocyte enumeration in dogs. Common storage conditions seem to minimally affect reticulocyte evaluation; however, it is recommended to perform the analysis as soon as possible after sampling.

Not all red cells sickle the same: Contributions of the reticulocyte to disease pathology in sickle cell anemia

Sickle cell anemia (SCA) is associated with morbidity and early death. While the switch from fetal to sickle hemoglobin during the first months of life results in hemolytic anemia with reticulocytosis, the role of the reticulocyte in the pathophysiology and prognosis of SCA is not well-defined. Reticulocytes have unique cytoskeletal and membrane components that allow them to be distinguished from mature sickle erythrocytes in the circulation. Reticulocytes in patients with SCA are less dense than more mature and 'sickled' erythrocytes, and have increased adhesive properties. The circulating reticulocyte number in peripheral blood may assist in predicting disease severity in SCA; characterization of patient-specific reticulocyte properties during infancy and childhood may assist in predicting therapeutic response to therapies. Here, we review the biological and clinical data regarding reticulocytes and their potential impact on SCA pathophysiology and disease severity.

Determination of reference ranges for immature platelet and reticulocyte fractions and reticulocyte hemoglobin equivalent

Introduction

The immature platelet and immature reticulocyte fractions represent the ratios of platelets and reticulocytes recently released into the circulation and thus with higher RNA content. They are considered early indicators of bone marrow recovery.

Objective

The aim of this study was to determine the reference ranges for the immature platelet and reticulocyte fractions of hematologically normal individuals in a university hospital.

Methods

Venous blood samples collected in ethylenediaminetetraacetic acid K3 were analyzed using a Sysmex XE-5000™ analyzer. Individuals with platelet and reticulocyte counts within the reference ranges, and a blood count within the laboratory's screening criteria were included. Individuals with clinical conditions that could affect hematological results were excluded. The immature platelet fraction, high, medium and low fluorescence reticulocyte fractions and reticulocyte hemoglobin equivalent were evaluated. The reference ranges were determined according to the recommendations of the International Federation of Clinical Chemistry.

Results

One hundred and thirty-two outpatients were evaluated. The mean age was 44 years (range: 13–80 years), 72 (54.5%) were women treated in a university hospital. The mean platelet count was 250.8 × 10⁹/L and the mean reticulocyte count was 0.052 × 10⁹/L. The following reference ranges were obtained: immature reticulocyte fraction 1.6–12.1%, the high, medium and low fluorescence reticulocyte fractions were 0.0–1.7%, 1.6–11.0% and 87.9–98.4%, respectively, the reticulocyte hemoglobin equivalent was 30.0–37.6% and immature platelet fraction was 0.8–5.6%. There was a statistically significant difference (p-value = 0.006) between genders in respect to the immature platelet fraction with 0.8–4.7% for females and 0.7–6.1% for males. The immature reticulocyte fraction was directly correlated with the reticulocyte count.

Conclusion

Determining the reference range is critical to the introduction of a new parameter. The reference ranges obtained herein corroborate those reported in previous publications and will contribute to the clinical and laboratory application of the indices.

Comparative Characterization of Hepatic Distribution and mRNA Reduction of Antisense Oligonucleotides Conjugated with Triantennary N-Acetyl Galactosamine and Lipophilic Ligands Targeting Apolipoprotein B

TriantennaryN-acetyl galactosamine (GalNAc, GN3) and lipophilic ligands such as cholesterol andα-tocopherol conjugations dramatically improve the distribution and efficacy of second-generation antisense oligonucleotides (ASOs) in the whole liver. To characterize ligands for delivery to liver cells based on pharmacokinetics and efficacy, we used a locked nucleic acid gapmer of ASO targeting apolipoprotein B as a model compound and evaluated the amount of ASO and apolipoprotein B mRNA in the whole liver, hepatocytes, and nonparenchymal (NP) cells as well as plasma total cholesterol after administration of ASO conjugated with these ligands to mice. Compared with unconjugated ASO, GN3 conjugation increased the amount (7-fold) and efficacy (more than 10-fold) of ASO in hepatocytes only and showed higher efficacy than the increased rate of the amount of ASO. On the other hand, lipophilic ligand conjugations led to increased delivery (3- to 5-fold) and efficacy (5-fold) of ASO to both hepatocytes and NP cells. GN3 and lipophilic ligand conjugations increased the area under the curve of ASOs and the pharmacodynamic duration but did not change the half-life in hepatocytes and NP cells compared with unconjugated ASO. In the liver, the phosphodiester bond between ASO and these ligands was promptly cleaved to liberate unconjugated ASO. These ligand conjugations reduced plasma total cholesterol compared with unconjugated ASO, although these ASOs were well tolerated with no elevation in plasma transaminases. These findings could facilitate ligand selection tailored to liver cells expressed in disease-related genes and could contribute to the discovery and development of RNA interference-based therapy.

Manual and automated reticulocyte counts

Manual reticulocyte counts were examined under light microscopy, using the property whereby supravital stain precipitates residual ribosomal RNA versus the automated flow methods, with the suggestion that in the latter there is greater precision and an ability to determine both mature and immature reticulocyte fractions. Three hundred and forty-one venous blood samples of patients were analyzed of whom 224 newborn and the rest adults; 51 males and 66 females, with ages between 0 and 89 years, as part of the laboratory routine for hematological examinations at the Clinical Laboratory of the Hospital Universitário do Oeste do Paraná. This work aimed to compare manual and automated methodologies for reticulocyte countings and evaluate random and systematic errors. The results obtained showed that the difference between the two methods was very small, with an estimated 0·4% systematic error and 3·9% random error. Thus, it has been confirmed that both methods, when well conducted, can reflect precisely the reticulocyte counts for adequate clinical use.

Feature on erythropoiesis in dietary restricted rats

We attempted to characterize the influence of undernutrition on erythropoiesis in toxicity studies. Male rats were divided into the following 5 groups: dietary restriction groups in which feeding was restricted by 33% or 66% for 14 days (R33 and R66); phlebotomy groups in which 1% or 4% of total blood volume was removed by serial phlebotomy for 14 days (PB01 and PB04); and a nontreated group (NT). Toxicological parameters such as hematology and blood chemistry were evaluated. The body weight gains in the R33 and phlebotomy groups (PB01 and PB04) were similar and were less than that observed in the NT group. Decreases in peripheral blood reticulocytes, bone marrow erythroids and the unsaturated iron binding capacity (UIBC) were observed as changes that suppressed erythropoiesis in the R33 and R66 groups. However, increases in reticulocytes and UIBC were observed as opposite changes in the phlebotomy groups. In addition, an increase in the blood urea nitrogen level and a decrease in the serum alkaline phosphatase level were observed as changes reflecting poor nutrition in the phlebotomy groups. Decreased reticulocytes which are related to poor nutrition were not observed. However, increases in those cells as reflected by a loss of blood were observed in the phlebotomy groups. Even if undernutrition suppresses erythropoiesis, the ability of erythropoiesis to respond to a demand appears to be retained. In repeated dose toxicity studies, decreased food consumption is often observed in the drug administration groups. Our study results provide useful information for hematological evaluations in toxicity studies.

Morphological definition of CD71 positive reticulocytes by various staining techniques and electron microscopy compared to reticulocytes detected by an automated hematology analyzer

BACKGROUND

The enumeration of peripheral blood reticulocytes plays an important part in clinical hematology. Although reticulocyte enumeration is currently performed with visible dyes such as New Methylene Blue (NMB), fluorescent dyes, or anti-CD71 (transferrin receptor) antibody, it has not been demonstrated whether the reticulocytes detected in each method are the same or not.

METHODS

We prepared the reticulocyte rich fraction with density gradient centrifugation, stained with both anti-CD71 and Sysmex's fluorescent stain RET SEARCH (II), and detected the cells by both confocal laser scanning microscopy and flow cytometry. We also stained the reticulocyte rich fraction and the CD71+ reticulocytes with NMB and compared them by microscopy. We also observed the CD71+ reticulocytes by electron microscopy.

RESULTS

Almost all CD71+ reticulocytes were intensely stained with both NMB and RET SEARCH (II). These cells were therefore classified as highly immature reticulocytes. During the stages of reticulocyte maturation, the expression of CD71 antigen decreased prior to the reduction of the reticular structures. The electron microscopic observation showed that CD71+ reticulocytes had some typical morphological characteristics found in highly immature reticulocytes.

CONCLUSIONS

The CD71+ reticulocytes consisted of highly immature reticulocytes and were not equal to the reticulocytes defined with NMB or RET SEARCH (II).

Erythropoietin pharmacokinetic/pharmacodynamic analysis suggests higher doses in treating neonatal anemia

BACKGROUND

The establishment of effective treatment of neonatal anemia using recombinant human erythropoietin (r-HuEPO) requires a thorough understanding of the physiology and mechanism of EPO's pharmacologic effect. The purpose of the present preclinical study in sheep was to elucidate the stimulatory effect of EPO on erythroid progenitors and their differentiation into reticulocytes useful in predicting optimal r-HuEPO dosing.

METHODS

Five young adult sheep each underwent two phlebotomies spaced 4-6 weeks apart in which their hemoglobin levels were reduced from 12 g/dL to 3-4 g/dL. Endogenous EPO levels and reticulocyte counts produced in response to anemia were sampled throughout the study and analyzed using a pharmacokinetic/pharmacodynamic (PK/PD) model.

RESULTS

The phlebotomy-induced drop in hemoglobin resulted in a increase in EPO levels, which reached a maximum of 764 +/- 55 mU/mL (mean +/- %CV) in 0.5-2.6 days. The reticulocyte counts increased from baseline values of 76.9 x 10(3) +/- 67/microL to 619 x 10(3) +/- 30/microL in 8 days. The PK/PD analysis indicated an increased maturation time for the reticulocytes (4.88 +/- 35 days) and demonstrated that the E(max) model for EPO's activation of the progenitors did not show significant effect saturation at the endogenous EPO levels reached.

CONCLUSIONS

In extrapolating from the animal pilot experiment, the present study provides a case for the use of higher r-HuEPO doses in human studies to determine if higher doses are more effective in treatment of neonatal anemia to reduce, and in some less severe cases, eliminate, the need for blood transfusions.

A biparametric flow cytometry analysis for the study of reticulocyte patterns of maturation

Automated haematological analysers still represent the gold standard for the study of reticulocyte maturation even if this technique is based on structural properties and staining affinity rather than on functional aspects. On the contrary, flow cytometry allows the simultaneous analysis of multiple cellular characteristics including functional features. Aim was to investigate whether simultaneous analysis of different reticulocyte parameters using flow cytometry may add functional information when considering their pattern of maturation. Thirty-nine healthy donors (H) and 31 haemodialysed patients on treatment with rHuEpo (HDT) were analysed. Reticulocyte counts and their stages of maturation were studied both with ADVIA 2120 and by flow cytometry. TO/CD71 scattergraph reticulocyte analysis designed a peculiar distribution which was similar among the same group of subjects (H or HDT), but different between H and HDT. distribution of the percentage of reticulocytes in low, medium and high boxes calculated by ADVIA 2120 did not show any difference between H and HDT groups, while the analysis using flow cytometry pointed out statistically significant differences between H and HDT groups in the three boxes where the TO+/CD71+ reticulocytes were localized. The present study suggests that TO/CD71 analysis was reproducible and could detect different pattern of maturation of a particular clinical setting.

Podocalyxin selectively marks erythroid-committed progenitors during anemic stress but is dispensable for efficient recovery

OBJECTIVE

Podocalyxin expression on Ter119(+) erythroblasts is induced following administration of erythropoietin (Epo) or phenylhydrazine treatment, but is notably absent on committed erythroid progenitors during homeostatic red cell turnover. Following high-dose Epo administration in vivo, podocalyxin surface expression is upregulated, in part, via a signal transducers and activators of transcription 5-dependent pathway and this expression has been postulated to play a role in the release of reticulocytes from hematopoietic organs into the periphery under conditions of increased erythropoietic rate. Here we have thoroughly addressed this hypothesis and further examined the expression profile of podocalyxin during Epo-induced erythroblast expansion and stress erythropoiesis.

MATERIALS AND METHODS

Following Epo induction, progenitor cells were sorted to characterize podocalyxin expression during stress. In addition, as podocalyxin-deficient mice die perinatally, we used chimeric mice reconstituted with wild-type or podocalyxin-deficient hematopoietic cells to analyze differences in response to high dose Epo administration and chemically induced anemia.

RESULTS

Podocalyxin surface expression is rapidly upregulated in response to stress and marks early erythroid progenitors and erythroblasts. Despite loss of podocalyxin, chimeras exhibit normal basal erythropoiesis and no differences in erythroid progenitor proportions in the spleen and marrow in response to Epo. Further, podocalyxin is dispensable for efficient recovery from models of anemia.

CONCLUSIONS

We demonstrate that podocalyxin is a highly specific marker of stress-induced blast-forming unit erythroid and colony-forming unit erythroid progenitors in mouse bone marrow and spleen. In addition, our findings suggest that podocalyxin is not necessary for efficient erythroblast expansion, erythroid differentiation, or reticulocyte release in response to Epo stimulation in vivo.

Determination of red cells, nucleic acid-containing cells and platelets (RNP Determination) by a crossover analysis of emission DNA/RNA light

We developed a new flow cytometry analysis method using a crossover analysis of emission light from intracellular DNA/RNA. Both the RNA and the DNA content in each cell were new parameters obtained by fluorescence analysis using acridine orange supravital stain. With this method, two-dimensional diagrams produced by cellular RNA concentration (CRc) and cellular DNA concentration (CDc) enabled clear separation of red cells and platelets, and the diagram (RNP Diagram) also distinguished fluorescently stained blood cells and small particles derived from background dust of the reagent. This study assessed the capability of RNP Determination concerning reticulocyte count and accurate platelet count obtained by the ratio of red cells and platelets. The distance of each event between red cell distribution and platelet distribution was sufficiently large on the diagram, and the two regions did not overlap. Both reticulocyte count and platelet count showed excellent correlation with those obtained by their respective reference methods. In conclusion, this new assay, using RNP Determination, demonstrated great potential for detecting abnormalities of red cells and platelets.

Contagem de reticulócitos de cães saudáveis ou anêmicos pela citometria de fluxo

Compararam-se os resultados da contagem de reticulócitos pela microscopia de luz e pelo método da citometria de fluxo em 25 cães saudáveis (controle), 60 cães com anemia regenerativa e 40 com anemia arregenerativa. Houve diferença nas contagens absolutas obtidas pela microscopia de luz e pela citometria de fluxo nos três grupos estudados. A contagem de reticulócitos foi mais alta pela citometria de fluxo que a contagem pela microscopia de luz, mostrando ser um método mais sensível, simples e seguro para a quantificação de reticulócitos.

Pharmacodynamic analysis of time-variant cellular disposition: reticulocyte disposition changes in phlebotomized sheep

Most pharmacodynamic (PD) models of cellular response assume a time-invariant (i.e., constant) cellular disposition despite known changes in the disposition with time, such as the reticulocyte residence time in the systemic circulation during stress erythropoiesis. To account for changes in cellular disposition, a comprehensive PD model that involves endogenous erythropoietin (Epo), reticulocytes, and hemoglobin responses was developed in phlebotomized sheep that considers a time-variant reticulocyte residence time and allows for the simultaneous determination of changes in the cellular disposition and cellular production. Five sheep were phlebotomized to hemoglobin concentrations of approximately 4 g/dl. Epo concentrations, reticulocytes, and hemoglobin concentrations were frequently sampled for 5-7 days prior to and 25-30 days following the phlebotomy. Initial steady-state conditions were assumed and the time-variant reticulocyte residence time in the systemic circulation was semiparametrically represented using a constrained spline function. Hemoglobin production was modeled using a Hill function via an effect site compartment. The initial steady state reticulocyte residence time in the systemic circulation was estimated as 0.477 (0.100) (mean (SD)) days, which maximally increased 2.01- to 2.64-fold higher than the initial steady-state residence time 5.95 (0.899) days post-phlebotomy (P < 0.01). On average, the residence time returned to steady-state values 15.4 (2.36) days post-phlebotomy, which was not significantly different from the initial steady-state value (P > 0.05). The baseline hemoglobin production rate was estimated at 0.0929 (0.0472) g/kg/day and the maximum production rate under stress phlebotomy was estimated at 0.504 (0.0422) g/kg/day. These data indicate that endogenously released Epo under acute anemic conditions can increase hemoglobin production approximately 5-fold. The determined increase in reticulocyte residence time produced under stress erythropoiesis is similar to the commonly reported 2- to 3-fold increase observed in human patients.

Erroneously elevated immature reticulocyte counts in leukemic patients determined using a Sysmex XE-2100 hematology analyzer

The immature reticulocyte fraction (IRF) in peripheral blood, as determined by automated reticulocyte analysis, is calculated using the sum of medium and highly fluorescent reticulocyte numbers and provides information about erythropoietic activity in bone marrow. The purpose of this study was to investigate erroneously elevated IRF in leukemic patients, as determined using a Sysmex XE-2100 hematology analyzer (Sysmex, Kobe, Japan). Normal reticulocyte scattergram patterns show regions corresponding to reticulocytes located between matured RBCs and an upper particle (UPP) region, which show a continuum of non-separated fraction. The UPP represents erythroblasts and some immature reticulocytes. As a control group, peripheral blood was taken from patients with benign hematologic diseases, and their reticulocyte scattergrams all showed a normal pattern; UPP values were all less than 100. However, the reticulocyte scattergrams of 5 of 11 leukemia patients showed abnormal patterns and displayed a gap between RBC and reticulocyte regions. Three patients showed a flag with a message such as "RET Abn Scattergram". IRF results were elevated in these five patients, and their UPP values were above 100. For the remaining six leukemia patients with a normal reticulocyte scattergram pattern, immature reticulocytes were not markedly increased, and UPP values were less than 100. The findings of the present study demonstrate that IRF results may be erroneously elevated in leukemia patients and indicate that hematologists should examine reticulocyte scattergrams and UPP values carefully.

Spurious counts and spurious results on haematology analysers: a review. Part II: white blood cells, red blood cells, haemoglobin, red cell indices and reticulocytes

Haematology analysers provide quick and accurate results in most situations. However, spurious results, related either to platelets (part I of this report) or to other parameters from the cell blood count (CBC) may be observed in several instances. Spuriously low white blood cell (WBC) counts may be observed because of agglutination in the presence of ethylenediamine tetra-acetic acid (EDTA). Cryoglobulins, lipids, insufficiently lysed red blood cells (RBC), erythroblasts and platelet aggregates are common situations increasing WBC counts. In most of these instances flagging and/or an abnormal WBC differential scattergram will alert the operator. Several situations lead to abnormal haemoglobin measurement or to abnormal RBC count, including lipids, agglutinins, cryoglobulins and elevated WBC counts. Mean (red) cell volume (MCV) may be also subject to spurious determination, because of agglutinins, excess of glucose or salts and technological considerations. In turn, abnormality related to one measured parameter will lead to abnormal calculated RBC indices: mean cell haemoglobin content (MCHC) is certainly the most important RBC indices to consider, as it is as important as flags generated by the haematology analysers (HA) in alerting the user to a spurious result. In many circumstances, several of the measured parameters from CBC may be altered, and the discovery of a spurious change on one parameter frequently means that the validity of other parameters should be considered. Sensitive flags now allow the identification of several spurious counts, but only the most sophisticated HA have optimal flagging and more simple HA, especially those without a WBC differential scattergram, do not possess the same sensitivity for detecting anomalous results. Reticulocytes are integrated now into the CBC in many HA, and several situations may lead to abnormal counts.

Reticulocyte Maturation Parameters Are Reliable Early Predictors of Hematopoietic Engraftment after Allogeneic Stem Cell Transplantation

Early detection of donor-derived hematopoietic restoration after allogeneic stem cell transplantation (allo-SCT) is a crucial issue in the management of heavily immunocompromised patients. The aim of this prospective study was to validate our previously defined cutoff values for reticulocyte maturation parameters as early predictors of hematopoietic engraftment. Importantly, the effect of clinical variables in reticulocyte engraftment was also sought. For this purpose, we prospectively studied 136 consecutive patients undergoing allo-SCT from related (n = 89) or unrelated (n = 47) donors. High fluorescence reticulocytes (RETH), immature reticulocyte fraction (IRF), mean fluorescence index (MFI), and mean reticulocyte volume (MRV) were automatically measured in peripheral blood samples drawn on a daily basis. We previously defined reticulocyte engraftment when MFI > or =10, RETH > or =3%, IRF > or =10%, and MRV > or =110 fL. Median neutrophil engraftment was 18 days (range, 10-35 days); for reticulocyte parameters, the values were 14 days for IRF (range, 7-45 days), 14 days for MFI (range, 7-43 days), 15 days for RETH (range, 7-43 days), and 21 days for MRV (range, 9-74 days). These differences reached statistical significance for MFI and IRF when compared with standard neutrophil recovery, even when analyzing siblings or unrelated donors separately. In univariate analysis, donor-recipient ABO disparity adversely influenced erythroid engraftment (P = .04 for IRF, P = .03 for MFI), but the infusion of >2.9 x 10(6)/kg of CD34+ cells was associated with a shorter time to reach erythroid engraftment (P = .02 for IRF and MFI). In Cox regression analysis, > or =100/microL neutrophils and IRF > or =10% were predictive parameters for standard neutrophil engraftment. Based on these findings, we suggest that serial measurement of IRF or MFI should be routinely used to trace hematopoietic restoration after allo-SCT because these preceded standard neutrophil recovery by a median of 4 days and are therefore very useful to make clinical decisions.

Murine extramedullary erythropoiesis induced by tick infestation

Tick saliva contains molecules that modulate the haemostasis, pain/itch responses, wound healing and immune defences of the host. Using BALB/c mice that were each infested with 10 nymphs of Dermacentor andersoni Stiles (Acari: Ixodidae), an attempt has now been made to determine the influence of tick infestation on the expression of leucocyte adhesion molecules in the host. The ticks became fully engorged by the fourth to sixth day of infestation. On the fourth day of infestation, the results of flow cytometry indicated that 2% of the host's splenocytes were expressing high levels of CD49 (alpha4 integrin of VLA-4) and low levels of CD11a (alphaL subunit of the integrin LFA-1). By the eighth day of infestation, 30% of the hosts' splenocytes had this phenotype and were negative for the lineage markers CD3e (T-lymphocytes), DX5 (natural-killer cells of a BALB/c lineage), B220 (B-lymphocytes), CD11b (monocytes/macrophages, granulocytes, natural-killer cells, activated T-lymphocytes, and B-1 cells) and CD11c (myeloid and splenic dendritic cells). Histological examination of the spleens from infested mice revealed disruption of the white-pulp/red-pulp demarcations and the presence of a large number of basophilic normoblasts. The CD11a(lo) population of splenocytes from the tick-infested mice was positive for TER-119 but negative for CD3, B220, CD11b and Gr, confirming that the splenocytes were members of the erythroid lineage. These results indicate that, within 8 days of their initiation, the tick infestations induced extramedullary erythropoiesis in the spleens of their murine hosts.

Pharmacodynamic Analysis of Changes in Reticulocyte Subtype Distribution in Phlebotomy-Induced Stress Erythropoiesis

Changes in the reticulocyte subtype distribution (high, medium and low reticulocytes count (HR, MR, LR)) measured by flow cytometry following phlebotomy-induced stress erythropoiesis (abruptly dropping hemoglobin to 3-4 g/dl over 4-5 hr) and the pharmacodynamic (PD) relationship to the stimulated erythropoietin (EPO) was investigated in sheep. A PD model was developed that describes the relationship between EPO and the reticulocyte maturity distribution fractions (r=0.95+/-0.02, mean +/- SD). The lag-time between EPO activation of erythroid progenitor cells and the subsequent increase in the least mature HR fraction in the peripheral circulation was 0.72 +/- 0.08 days. The mean transition times (in days) for all three reticulocyte fractions changed at baseline from, T(HR) : 0.09 +/- 0.06, T(MR) : 0.06 +/- 0.04, and T(LR) : 0.46 +/- 0.24 to T(HR) : 0.13 +/- 0.08, T(MR) : 0.29 +/- 0.15, and T(LR) : 2.3 +/- 0.24 under stress erythropoiesis. The total mean residence time for a reticulocyte in the peripheral circulation, T(total) (T(HR) + T(MR) + T(LR)), increased from 0.60 +/- 0.33 days under basal to 2.8 +/- 0.09 days during stress erythropoiesis. The statistically significant increase observed for T(LR) and T(total) supports the hypothesis that stress erythropoiesis perturbs the mean reticulocyte transition times. A correlation analysis between various new, proposed metrics involving the HR, MR and LR fractions and the total reticulocyte count, with the latter indicative of stress erythropoiesis at higher total counts, revealed a highly significant correlation indicating these new metrics may be a valuable adjunct to the reticulocyte maturation index (RMI) and the immature reticulocyte fractions index (IRF) previously used in assessing erythropoietic activity in response to anemia.

Recommendations on haematological criteria for the diagnosis of epoetin-induced pure red cell aplasia

Pure red cell aplasia (PRCA) is a rare condition characterised by an arrest in red blood cell production, which may be congenital or acquired. Recombinant human erythropoietin (epoetin) was introduced in 1989 for the treatment of anaemia of chronic kidney disease patients and has maintained an excellent therapeutic and safety record while treating hundreds of thousands of patients. A very rare, but serious adverse event associated with epoetin administration is a condition in which patients develop neutralising anti-erythropoietin antibodies and, consequently, PRCA. This condition is referred to as epoetin-induced PRCA (epo-PRCA). Since it is a rare condition, many haematologists and nephrologists around the world see the condition infrequently and may be uncertain about the diagnosis. For this reason, an ad hoc international working group of expert haematologists and nephrologists met together to derive new recommendations for the haematological diagnosis of epo-PRCA. These recommendations, which represent the consensus opinions of the working group, address haematological approaches to monitor and investigate suspected epo-PRCA and should help physicians differentiate between PRCA and other bone marrow diseases, as well as, between PRCA and epo-PRCA.

Proficiency testing of reticulocyte counting in Ontario

The reticulocyte count reflects the erythropoietic activity of the bone marrow and is thus useful in both the approach to the diagnosis of anemia and in monitoring bone marrow response to therapy. Traditionally, reticulocyte quantitation relied upon microscopic techniques; recently automated reticulocyte quantitation has become widely available. External quality assessment (EQA) of reticulocyte quantitation has not been widely reported; this paper presents data from reticulocyte EQA surveys conducted in Ontario between November 2000 and October 2004. Samples with normal and increased reticulocyte levels were obtained from adult donors and analyzed within 48 hours. We found that despite improved accuracy and precision, automated reticulocyte counting techniques do not translate into markedly improved inter-laboratory accuracy and precision. Further, we found that both microscopic and automated techniques can effectively differentiate between patients with normal and those with increased reticulocyte counts. Finally, we ascertained that reference intervals submitted with the initial surveys revealed that laboratories could have made erroneous clinical interpretations of their normal or elevated reticulocyte counts. The reestablishment of reference intervals by participants resulted in a marked improvement of the reference intervals submitted on subsequent surveys.

Clinical application of reticulocyte counts in dogs and cats

Reticulocytes are anucleate immature red blood cells that contain a network of RNA, organelles, and mitochondria, which stain with supravital dyes. Both aggregate and punctate reticulocytes are present in domestic cats, and aggregate reticulocytes are used to assess the degree of regeneration in anemic dogs and cats. Multiple factors influence the degree of regenerative response to anemia. These factors include time of reticulocyte measurement, concurrent diseases, species, and ongoing therapy. Although many automated systems for reticulocyte enumeration exist, manual counts remain the gold standard in veterinary medicine.