usergroup ypsilanti 2015 no notes [read-only]€¦ · describe novel hematology parameters and...

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© 2015 Sysmex America, Inc. All rights reserved.

Advanced Parameters that go Beyond the Routine CBC

Tiffany Ivers, MS, MLS(ASCP)CM

Scientific Marketing Specialist

© 2015 Sysmex America, Inc. All rights reserved.© 2015 Sysmex America, Inc. All rights reserved.

OBJECTIVES

Describe novel hematology parameters and their derivation

Investigate the evidence for their clinical utility

Discuss how new information can be applied to patient care


UNIQUE CLINICAL UTILITY

Basic ChannelsRBC & PLT Impedance

HGB Channel

WNR Channel (WBC / BASO / NRBC)

WDF Channel (6-part DIFF including IG)

Body Fluid Channel (Including 2-part DIFF)

Advanced ChannelsPlatelet (PLT-F / IPF)

Complete Reticulocyte Analysis (Retic / IRF / RET-He)

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FOUNDATIONAL TECHNOLOGY

RBC & PlateletDC Detection / Hydrodynamic Focusing

HemoglobinAbsorbance / Sulfolyser


FLUORESCENT FLOW CYTOMETRY

Side Fluorescent LightDNA/RNA information

Side Scattered LightCell inside structure information

Forward Scattered LightCell size information

Dichroic Mirror

Laser Beam wavelength=633nm


REVIEW HEMATOPOIESIS

Erythropoiesis (Retic, NRBC)

Red Cell Hemoglobinization (RET‐He)

Leukopoiesis (IG)

Thrombopoiesis (IPF)

Immature cell count data can be used in conjunction with mature cell counts to assess pathophysiological mechanisms

(© 2001 Terese Winslow, Lydia Kibiuk)

http://stemcells.nih.gov/info/scireport/pages/chapter4.aspx

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SYSMEX ADVANCED CLINICAL PARAMETERS

ACP

IG, RET-He, IPF


OVERVIEW OF ADVANCED CLINICAL PARAMETERS (ACPS)

IG (Immature Granulocytes) A direct cellular measure of leukopoiesis; an increased IG count indicates the presence of immature cells in peripheral blood

With other clinical information, it may aid physicians in identification of patients with infection sooner

RET-He (Reticulocyte Hemoglobin Content) A direct cellular measurement of iron availability in the bone marrow

Utilizing RET-He, retic count and IRF (Immature Reticulocyte Fraction) may assist clinicians with the diagnosis and management of anemia

IPF (Immature Platelet Fraction)A direct cellular measurement of thrombopoietic activity

The IPF may be used in conjunction with other patient information to assist physicians in identifying the cause of thrombocytopenia in a patient


WDF CHANNEL Scattergram - Normal Pattern

LYMPH NEUT+BASO

EO

MONO

Debris

IG

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SIGNIFICANCE OF LEFT SHIFT


MANUAL WBC DIFFERENTIAL IMPRECISION

Rumke CL: The statistically expected variability in differential leukocyte counting. p. 39. In Koepke JA (ed): Differential Leukocyte Counting. College of American Pathologists, Skokie, IL 1978, with permission.


IG CORRELATION STUDIES

Fernandes and Hamaguchi (2007). Am J Clin Pathol;128:454-463

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IG: ELEVATED WHEN OTHER MARKERS ARE NOT

Doc. No. 1116-CFL, Rev 1, June 2014

IG can elevate in infection even when WBC, ANC, and other markers are normal

Briggs, C. et al (2003). Laboratory Hematology;117 - 123


SUMMARY

IG (Immature Granulocytes)

A direct cellular measure of leukopoiesis; an increased IG count indicates the presence of immature cells in peripheral blood

With other clinical information, it may aid physicians in identification of patients with infection sooner


ERYTHROPOIESIS MANAGEMENT

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ANEMIA PREVALENCE AND IRON DEFICIENCY

3.4 million people in US, 2 billion people globally (1/3 of population)

Iron deficiency (ID) is the most common cause of anemia (> 600 million people)

Leading causes:

• Gastrointestinal blood loss

• Dietary iron deficiency (poor nutrition, malabsorption)

• Infectious disease, Cancer treatment

• Increased iron demand

Rapid diagnosis and treatment of iron deficiency can prevent anemia

National Anemia Action Council, 2006


DIAGNOSIS OF IRON DEFICIENCY

Biochemical parameters

Transferrin, transferrin saturation (Tfsat)

Ferritin

Serum iron

Hematological parameters

Hb, MCV, RDW

Reticulocyte count

Reticulocyte Hb content (RET-He /CHr)


IRON METABOLISM

If we want to know about iron metabolism at the cellular level. . .

Shouldn’t we directly measure changes to developing RBC?

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RET CHANNEL Scattergram on Normal Pattern

PLT

RET

HFRRBC

MFRLFR

IRF


RETICULOCYTE PARAMETERS

Reticulocytes # and % of immature RBC’s

Immature Reticulocyte FractionNewly released from the marrow, a direct cellular measurement of erythropoiesis

Reticulocyte HemoglobinDirect cellular measure of iron availability


CLINICAL APPLICATIONS OF RETICULOCYTE HEMOGLOBIN

WellnessPediatrics - Iron deficiency and Iron Deficiency Anemia

PreventionSurgical patients – pre and post surgical assessments

Chronic Disease ManagementEnd Stage Renal Disease - anemia management

Monitoring response to therapy with ESA and/or iron

Cancer- anemia status

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IRON DEFICIENCY PREVALENCE IN INFANTS AND TODDLERS

Adverse consequences in pediatric patients:

Increased lead absorption

Impaired immunity

Anemia

Impaired neurocognitive development

Centers for Disease Control and Prevention (CDC). National Center for Health Statistics (NCHS). National Health and NutritionExamination Survey Data. Hyattsville, MD: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention.

2.1 – 4.1% of infants and toddlers in the US have iron deficiency anemia;10% have iron deficiency without anemia.


WELLNESS - INFANT SCREENING

JAMA. 2005, 294:924-930. Screening healthy infants for iron deficiency using reticulocyte hemoglobin content. Ulrich, C., et al.


RECOMMENDATIONS FOR WELLNESS SCREENING

“A low CHr concentration has been shown to be the strongest predictor of ID in children.”

“For infants with Hb <11.0 mg/dL or with significant risk of ID or IDA, SF and CRP or CHr levels should also be measured to increase the sensitivity and specificity of the diagnosis.”

Baker, R., Greer, F. and The Committee on Nutrition. Diagnosis and Prevention of Iron Deficiency and Iron-Deficiency Anemia in and Infants and Young Children (0 - 3 Years of Age). Pediatrics 2010;126;1040-1050.

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ANEMIA MANAGEMENT IN PRE-SURGICAL PATIENTS

Increased morbidity after surgeryIncreased rates of post-operative complications

Increased length of stay

Anemia screening 4 – 6 weeks prior to surgery

Identify presence of anemia

Determine etiology/type of anemia

Therapy to correct anemia before surgeryI.V. iron (less expensive than ESA, effective even in inflammation, fewer adverse events)


PREVENTION - EARLY IDENTIFICATION FOR APPROPRIATE INTERVENTION

Sysmex Journal International. 2009; 19:1, 1-8. Protocol for Transfusion Free Major Orthopaedic Operations Using RET-He. Muusze, R. et al. adapted from the original in Dutch Kwaliteitsingtituut voor de gezondheidszorg CBO. Richtlijn Bloedtransfusie. Utrecth/Alphen a/d Rinin, 2004 with kind permission from the publisher.

“The course of 2 clinical parameters during preoperative epoetintreatment. . . There is a clear difference between responders and non-responders. The haemoglobinisation level of reticulocytes is an early detector of functional iron deficiency due to epoetin injections.”


CHRONIC DISEASE MANAGEMENT OF ANEMIA

Chronic Kidney Disease patients on dialysis

Anemia (i.e. hemoglobin levels < 11–12 g/dL) is almost a universal feature of patients with end-stage renal disease on dialysis.

Largely the result of insufficient production of Erythropoietin by non-functioning kidney.

IDA is especially a problem in hemodialysis, due to the coupling of accelerated erythropoiesis (ESA) and dialysis-related blood loss.

Serum iron studies are unreliable.

Challenges with EPO and Iron treatment.

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FINDING BALANCE IN ANEMIA MANAGEMENT

DECISIONS: IRON OR EPO?

Challenges

How do you balance dosage and timing of iron therapy?

What is the best assessment to balance ESA and Iron therapy?

What is the best assessment of iron stores?

Shouldn’t we measure changes on the cellular level?


CHr< 26pg 100% 80%

Serum Ferritin < 100 ng/mL 71.4% 60%

Transferrin Sat < 20% 57.1% 80%

Kidney International. 1997; 52:217 - 222. Reticulocyte Hemoglobin content in the evaluation of iron status of hemodialysis patients. Fishbane, S., et al.

CHr TO DETECT FUNCTIONAL IRON DEFICIENCY


RETICULOCYTE HEMOGLOBIN IN THE DIAGNOSIS OF IDA

27.2 pg

93.3%

83.2%

<40

<20

<11

<100

*

* For patients on maintenance hemodialysis

Clinical Laboratory Hematology. 2006 Oct; 28(5):303 - 308. Reticulocyte Hemoglobin Equivalent (Ret He) and Assessment of Iron-deficient States. Brugnara, C., Schiller, B., Moran, J.

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UTILITY OF RET-He for ID

“The presence of inflammation and uremia makes this diagnosis particularly challenging for dialysis patients.”

“By directly measuring the RET-He, early stages of iron deficiency may be identified, at a time that other traditional biochemical parameters are non-informative.”

Clinical Laboratory Hematology. 2006 Oct; 28(5):303 - 308. Reticulocyte Hemoglobin Equivalent (Ret He) and Assessment of Iron-deficient States. Brugnara, C., Schiller, B., Moran, J.


KDOQI GUIDELINES FOR EVALUATIONOF ANEMIA

Cellular AssessmentHgb < 12 g/dL

RBC indices

Absolute Retic

WBC & Diff

Platelet

Iron AssessmentSerum ferritin

Serum TSAT or CHr

Initial Anemia Evaluation Iron Assessment Indices

HD-CKD Target Ferritin > 200 ng/ml and

Tsat > 20% or CHr > 29 pg

National Kidney Foundation. KDOQI Clinical Practice Guidelines and Clinical Practice Recommendations for Anemia in Chronic Kidney Disease. Am J Kidney Dis 47:S1-S146, 2006 (suppl 3).


HEMOGLOBIN CONTENT OF RETICULOCYTES TO EVALUATE ANEMIA IN PATIENTS WITH CANCER

Background

This study examined using the hemoglobin content of reticulocytes (RET-He) to rule out ID, as defined by serum iron studies

Anemia was defined by transferrin saturation <20%, serum iron <40 µg/dL, and ferritin <100 ng/mL), in an unselected cancer patient population.

Patient Population

Cancer patients with anemia were entered into the study based on the existence of concurrent laboratory test requests for CBC and serum iron studies.

Peerschke EI, Pessin MS, Maslak P. Using the Hemoglobin Content of Reticulocytes (RET-He) to Evaluate Anemia in Patients With Cancer. Am J Clin Pathol 2014 Oct;142(4):506-12.

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HEMOGLOBIN CONTENT OF RETICULOCYTES TO EVALUATE ANEMIA IN PATIENTS WITH CANCER

Results

Using a threshold of 32 pg/cell, RET-He ruled out ID with a negative predictive value (NPV) of 98.5% and 100%, respectively, in the study population (n = 209) and subpopulation of patients with low reticulocyte counts (n = 19).

In comparison, the NPV of traditional CBC parameters (hemoglobin, <11 g/dL; mean corpuscular volume, <80 fL) was only 88.5%.

Summary

These results support the use of RET-He in the evaluation of ID in a cancer care setting.

In addition, the laboratory reduced unnecessary iron studies by 66% if RET-He was used alone for anemia diagnosis.

If a combination approach was used RET-He(<32 pg) and HGB (<11 g/dL) a reduction of 80% of iron studies would be realized by the laboratory.

Peerschke EI, Pessin MS, Maslak P. Using the Hemoglobin Content of Reticulocytes (RET-He) to Evaluate Anemia in Patients With Cancer. Am J Clin Pathol 2014 Oct;142(4):506-12.


SUMMARY

RET-He (Reticulocyte Hemoglobin Content)

A direct cellular measurement of iron availability in the bone marrow

Utilizing RET-He, retic count and IRF (Immature Reticulocyte Fraction) may assist clinicians with the diagnosis and management of anemia


THROMBOCYTOPENIA MANAGEMENT

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PLT-F CHANNEL

Impedance platelet analysis (size) has limitations in the identification and discrimination of platelets from interfering particles with the same size.

Possible interferences

RBC fragments counted as platelets: falsely high

Microcytic RBCs counted as platelets: falsely high

Large platelets counted as RBC: falsely low


MEAN PLATELET VOLUME (MPV)

Measures the average size of the platelet (similar to MCV for RBCs)

Calculated or derived parameter

May be used as an indicator of thrombopoiesis

Limitations

Not all large platelets are young platelets

MPV is derived or calculated from the platelet histogram

Copyright © 2014 Sysmex America, Inc. All rights reserved.

What do you do if you don’t havea good histogram?


BINDING SITES OF FLUOROCELL PLT

Fluorocell PLT stains nucleic acid rich organelle

Rough-surfaced endoplasmic reticulum (ribosomal RNA)

Mitochondria (MtDNA)open tubule

α granule

←glycogen granule

microtubule

deep dyeing granule

rough-surfaced endoplasmic reticulum

mitochondria

RBCRBC

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PLT-F CHANNEL Scattergram - Normal Pattern

RBC

PLT‐F

IPF


COMPREHENSIVE PLATELET COUNT

Immature Platelet Fraction (IPF) (Reticulated Platelets)

% of platelets newly released from the bone marrow

Reference Range is 1.1 – 6.1%

IPF is a direct cellular measurement of thrombopoiesis.

↓ Plts, ↓/Normal IPF = ↓ Production

↓ Plts, ↑ IPF = ↑ Destruction


CLINICAL CHALLENGE IN THROMBOCYTOPENIA

What is the cause of the thrombocytopenia?

Is this a disorder of decreased production?

Aplastic Anemia, Leukemia, BM suppression, drugs…

Is platelet destruction increased? ITP, TTP, DIC, drugs…..

Is patient’s bone marrow recovering adequately without intervention?

What other diagnostic tests do we need to use to characterize the pathophysiology?

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POSSIBLE MECHANISMS OF THROMBOCYTOPENIA

Production Disorders

Myeloablative Therapy

Bone Marrow Transplant

Acute Myeloid Leukemia (AML)

Destruction DisordersImmune Thrombocytopenic Purpura (ITP)Thrombotic Thrombocytopenic Purpura (TTP)Infections (HIV, Hepatitis C, CMV)Disseminated Intravascular Hemolysis (DIC)Autoimmune DiseaseBacteremiaHeparin Induced Thrombocytopenia (HIT)SepsisPregnancyDrug-Induced Thrombocytopenia (DIT)

Stasi, R. How to approach thrombocytopenia. Hematology 2012 2012:191; 10.1182/asheducation-2012.1.191


Low PLT + Low/Normal IPFConsistent with production

disorder

Normal Low PLT+ High IPF Consistent with destructionmechanism (ITP, TTP, DIC,

autoimmune)

DIFFERENTIATE PHYSIOLOGICAL MECHANISMS


IPF% IN DIFFERENT POPULATIONS OF THROMBOCYTOPENIC PATIENTS

Kickler TS, Oguni S, Borowitz MJ. A Clinical Evaluation of High Fluorescent Platelet Fraction Percentage in Thrombocytopenia. Am. J. Clin. Pathol. 2006; 25(2):282-287.

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PLATELET PARAMETERS IN ITP AND AML/MDS

Psaila B, Bussel JB, Frelinger AL, Babula B, Linden MD, Li Y. et al. Differences in Platelet Function in Patients with Acute Myeloid Leukemia and Myelodysplasia compared to equally Thrombocytopenic Patients with Immune Thrombocytopenia. J ThrombHaemost 2011; 9(11):2302-2310.


IMMATURE PLATELET FRACTION TO ASSESS BONE MARROW RECOVERY

Study objective: How well can IPF help the clinician predict bone marrow recovery following peripheral blood HPC transplantation?

“A persistently low IPF in this setting would suggest failure of thrombopoieticrecovery.”

Zucker M., Murphy CA, Rachel JM, Martinez GA, Abhyankar S, McGuirk JP. Immature Platelet Fraction as a Predictor of Platelet Recovery following Hematopoietic Progenitor Cell Transplantation. Laboratory Hematology, 2006 12:125 – 130.


SUMMARY

IPF (Immature Platelet Fraction)

A direct cellular measurement of thrombopoietic activity

The IPF may be used in conjunction with other patient information to assist physicians in identifying the cause of thrombocytopenia in a patient

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MORE INFO

Customer Resource Center (CRC)

https://www.sysmex.com/us


THANK YOU!

Questions?

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