Evidence Based Hematological Solutions

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Evidence Based Hematological Solutions

• John R. Hickman, Colonel, USAF, BSC
• 59th Laboratory Squadron
• Lackland AFB TX
• john.hickman_at_lackland.af.mil

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Todays Topics

• Sysmex XE-500 Principles/Technology
• Hematological challenges Solutions
• Infection Surveillance/Immature Granulocyte Count
  (IG)
• Anemia Management/Reticulocyte Hemoglobin
  (Retic-He) Immature Reticulocyte Fraction (IRF)
• Thombopoeisis Management/Immature Platelet
  Fraction (IPF)

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Red Cell/Platelet Counting Technology

• Direct current technology
• Hydrodynamic Focusing
• Floating Discriminators

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Hematocrit -Hemoglobin

• Hematocrit
• Cumulative Pulse Design Detection
• Direct Measurement/not calculated
• Cumulative sum all pulses in RBC histogram
• Total volume of RBCs
• Total volume of sample

• Hemoglobin
• Light AbsorbanceSulfolyser
• Sodium Laural Sulfate (lyse agent)
• Non-cyanide
• Environmentally safe

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Flow Cytometry- Measured Signals
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Diff Channel
Reagent Reaction?Stromatolyser-4DL 4DS
Same principle for Basophils (FB) NRBC (NR)
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Reticulocyte Channel
Reagent Reaction ? Ret Search II
High Fluorescence
Low Fluorescence
Reference Range 29 - 35 pg
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Immature Retic Fraction (IRF)
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Immature Platelet Fraction (IPF)

• Reference Range 0.9 - 11.2

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Hematological Challenges/Solutions

• Sysmex Advanced Hematological Parameters
• Infection Surveillance /Immature Granulocyte
  Count (IG)
• Anemia Management/Reticulocyte Hemoglobin
  (Retic-He) Immature Reticulocyte Fraction
• Thrombopoiesis Management/Immature Platelet
  Fraction (IPF)
• Simple to obtain
• Standardized
• Clinically relevant

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Infection Surveillance
70 of HAI Occur Outside the ICU
Klevens, R. M. et al, Public Health Reports,
Estimating Health Care-Associated Infections and
Deaths in U.S. Hospitals, 2002, March April,
2007 Vol. 122 160 166
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Pathogenesis of Sepsis

• Increased neutrophil migration and adhesion
• Increased coagulation
• Decreased fibrinolysis
• Increased inflammation
• Endothelial injury and loss of barrier integrity
• Microvascular injury results in altered
  microcirculatory perfusion

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Infection Surveillance Challenges

• How effectively can we identify present on
  admission infections?
• How early in the process can infections be
  identified?
• How do we work up febrile neutropenia?

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What about shift to left (?)

• Clinical significance of shift to left?
• Infection/inflammatory response
• Recovering bone morrow
• Bone marrow diseases (myleproliferative disorder,
  metastatic malignancy)
• Latrogenic (i.e. GF therapy)
• Detection of Shift to left (issues)
• No good definition
• Manual diffs not an accurate/precise indicator
• More accurate indicator needed

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IG (Immature Granulocyte) Count
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Flow Cytometry vs Manual diff
Fujmoto et al, Cytometry 2000, 42371-78
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IG Better than WBC
Ansari-lari, et al Am J of Clin Path
2003120795-799
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Clinical Utility IG

• More sensitive/specific for infection than WBC
  comparable to ANC
• IGs gt3 predicted positive blood cultures with
  92 specificity
• Improve predictive value of infection by adding
  the IG into an algorithm with other lab tests to
  target a careful workup on patients with a IG gt3
• IG count can ID potential acute infection or
  inflammatory response at early state when other
  parameters are within normal range and
  nonspecific indicator

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IG Infection Surveillance Tool
Briggs, C. et al Laboratory Hematology (2003)
IG can elevate in infection even when WBC, ANC,
and other markers are normal
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Solution Automated Immature Granulocyte Count
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Anemia challenges

• What is best assessment of Iron Deficiency
  Anemia (IDA)?
• Determine Fe stores before treatment?
• Determine efficacy of EPO and Fe therapy?

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IDA Testing

• Current Fe anemia testing

• Enhanced Fe anemia testing

• Retic
• Iron studies
• Serum Fe
• Ferritin
• T-Saturation
• H H

• Immature Retic Fraction (IRF)
• Retic-He
• Retic
• H H

Retic Count RBC Production Rate IRF Rate of
Change in RBC Production
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How RET-He Helps Diagnose IDA
Iron Deficiency Anemia diagnostic criteria for
patients on maintenance dialysis Fe lt40 Tsat lt20 F
erritin lt100 Hgb lt11
Brugnara, C., Schiller, B., Moran, J. (2006).
Clinical Laboratory Haematology, 18303 308
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Challenges AssessingFunctional Iron Deficiency
Functional Iron Deficiency diagnostic
criteria TSat lt20 Ferritin 100-800

• How does a direct cellular measure compare to
  traditional parameters for diagnosis of FID?
• Inflammation, uremia, and protein nutrition
  increases biological variation of chemistry
  parameters in these patients

Brugnara, C., Schiller, B., Moran, J. (2006).
Clinical Laboratory Haematology, 18303 308
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Clinical Utility Automated Ret-He

• Directly measuring the RET-He, early stages of
  iron deficiency may be identified, at a time that
  other traditional biochemical parameters are
  non-informative.
• Presence of inflammation and uremia makes this
  diagnosis particularly challenging for dialysis
  patients.

Brugnara, C., Schiller, B., Moran, J. (2006).
Clinical Laboratory Haematology, 18303 308
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Day-to-Day, Week-to-Week Variations in Tests of
Anemia and Iron Status

• Hgb, Hct, and RET-He, but not TSAT or Ferritin
  are useful analytes to guide dose adjustment for
  ESA or IV iron

David B. Van Wyck, MD, Harry Alcorn, PharmD1
Resmi Gupta,(2009) ASN poster
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Recognizing Functional Iron Deficiency Early for
Appropriate Intervention
Muusze, R. et al (2009). Protocol for
Transfusion Free Major Orthopaedic Operations
Using RET-He. Sysmex Journal International,
191, 1-8.
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Transfusion Assessment

• Low Retic Low IRF
• No Production
• Transfuse

• Low Retic High IRF
• Production
• Do Not Transfuse

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Decrease in Blood Transfusions
Muusze, R. et al (2009). Protocol for
Transfusion Free Major Orthopaedic Operations
Using RET-He. Sysmex Journal International,
191, 1-8.
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Solution Automated Reticulocyte Hemoglobin
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Thrombopoiesis Challenges

• Decreased Production?
• Aplastic anemia
• Leukemia
• Decreased Thrombopoietin production
• Liver and Kidney Disease
• Viral mediated

• Increased Destruction?
• Idiopathic/Immune Thrombocytopenia (ITP)
• Exclusionary Dx
• Thrombotic Thrombocytopenic Purpura (TTP)
• Idiopathic or secondary
• Heparin Induced Thrombocytopenia (HIT)

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Comprehensive Platelet Count

• Immature Platelet Fraction Reticulated Platelet
• of total platelets that are immature
• Measures platelets newly released from the bone
  marrow
• Indicates thrombopoiesis
• ? Plts ? IPF ? Production
• ? Plts ? IPF ? Destruction

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Immature Platelet Fraction for Differential
Diagnosis

• In thrombocytopenia does IPF diagnostically
  distinguish between consumptive and aplastic
  causes?
• In pregnancy, does IPF correlate with
  development of PIH?
• In thrombocytopenia, does regular monitoring of
  IPF provide valuable information for treatment
  decisions?

Briggs, C. (2004) British Journal of Haematology
126 93 - 99
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What about PLT Transfusions?

• 10 million platelet units to 2.2 million
  recipients each year
• 12,000 platelet units may be contaminated with
  bacteria

• 120,000 recipients dies from transfusion-transmit
  ted sepsis
• Platelets have second highest rate of transfusion
  related death
• Refractory to Platelets
• Alloimmunization
• Viral Transmission (particularly CMV)
• TPO T/2
• Product Availability?

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Transfusion Assessment

• Low PLT Low IPF
• No Production
• Transfuse

• Low PLT High IPF
• Production
• Do Not Transfuse

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Immature Platelet Fraction for Transfusion
Management

• When do patients need prophylactic platelet
  transfusions?
• When Plt is low and IPF is high Do we need to
  transfuse plts?

Briggs, C. (2003) Transfusion Management 16101 -
109
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CAP Transfusion Medicine Checklist

• TRM.42110 Phase I N/A YES NOIs the laboratory
  developing a plan to reduce the risk of
  transfusion-related acute lung injury(TRALI)?
• NOTE The laboratory should track the frequency
  of TRALI.

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Clinical Utility Transfusion Management

• IPF should allow a more controlled prophylactic
  platelet transfusion policy to be implemented at
  specified threshold count, particularly when
  platelet recovery is imminent.
• Predicting platelet recovery would permit more
  reasoned use of prophylactic platelet transfusion
  and provide the potential to reduce the use of
  platelet concentrates, minimizing possible
  transfusion-transmitted infections.

Briggs, C. (2003) Transfusion Management 16101 -
109
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Immature Platelet Fraction to Assess Bone Marrow
Recovery

• How well can IPF predict platelet recovery
  following peripheral blood HPC transplantation?

Zucker, M. Laboratory Hematology, 2006 12125 -
130
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Clinical UtilityBone Marrow Recovery

• Following HPC transplantation, IPF recovered
  significantly earlier than platelet count, ANC,
  and IRF.
• A persistently low IPF in this setting would
  suggest failure of thrombopoietic recovery.

Zucker, M. Laboratory Hematology, 12125 - 130
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Solution Immature Platelet Fraction
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Questions ??