©UFS Understanding Complete Blood Counts The ABCs of CBCs Robert Miceli, MD MetLife The Good, The Bad, and The Ugly Common Abnormal but • Mild iron deficiency anemia in pre-menopausal women Benign CBCs • Beta thalassemia minor (CBC may be accepted without • Chronic benign neutropenia repeat CBC or clinical evaluation) • Reactive thrombocytosis • Iron deficiency anemia in men or post-menopausal women Abnormal / Worrisome CBCs • Mild or moderate anemia, not fully evaluated (may require additional follow-up • Unexplained thrombocytopenia or thrombocytosis or clinical evaluation) • Mild abnormalities involving all 3 cell lines (red cells, white cells, and platelets), mild pancytopenia • Leukemia Markedly Abnormal CBCs • Severe anemia • Severe leukopenia or severe pancytopenia For Financial Professional Use Only 2 What Are the Major Components of Blood? • Red Blood Cells (also called erythrocytes) • White Blood Cells (also called leukocytes) • Platelets (also called thrombocytes) • Plasma For Financial Professional Use Only 3 Fancy Words for High and Low Cell Type Too High Too Low Erythrocytosis or Red Blood Cells (Erythrocytes) Anemia Polycythemia Thrombocytosis or Platelets (Thrombocytes) Thrombocytopenia Thrombocythemia White Blood Cells (Leukocytes) Leukocytosis Leukopenia Neutrophils Neutrophilia Neutropenia Lymphocytes Lymphocytosis Lymphopenia Eosinophils Eosinophilia --- Monocytes Monocytosis --- Basophils Basophilia --- For Financial Professional Use Only 4 Symptoms Factor Too Much Too Little Shortness of breath RBCs Clots, strokes (dyspnea), hypoxia, fatigue, pallor WBCs Clots, strokes Infections Platelets Clots, strokes Bleeding For Financial Professional Use Only 5 Hematology Tests • Specialized tests – Bone Marrow aspiration and biopsy • All of the formed elements of the blood are produced primarily in the bone marrow • They are produced by progenitor cells – cells which grow and differentiate into mature formed elements • This test can detect the lack or overabundance of these progenitor cells, and can find other problems such as cancer For Financial Professional Use Only 6 How Are Blood Cells Formed? For Financial Professional Use Only 7 Red Blood Cells (RBCs) • Largest cellular component of blood, about 40-45% of blood volume • Comprised mostly of hemoglobin • Transport oxygen • Red blood cells normally last about 120 days before they are removed by the spleen For Financial Professional Use Only 8 Hemoglobin • Red pigment molecule which gives RBCs (and blood) its color • Contains 4 molecules of heme and 4 of globin (2 alpha chains and 2 beta chains) • Each molecule of heme contains one iron ion For Financial Professional Use Only 9 White Blood Cells • There are several types of White Blood Cells • They are all involved in immunity but in somewhat different ways – Granulocytes (neutrophils, PMNs, polymorphonuclear leukocytes, or “polys”) – involved in acute infections with bacteria. Immature form is called a “band” – Lymphocytes – involved in many types of infection, especially viruses -Produce antibodies and “memory cells” - Are further divided into T-cells and B-cells – Eosinophils – involved in parasitic infections and allergies – Basophils – involved in parasitic infections and allergies – Monocytes – involved in bacterial and parasitic infections For Financial Professional Use Only 10 White Blood Cells (WBCs) • Neutrophils – also called a variety of other names on CBC reports, including: – polys – PMNs – segs – grans • Lymphocytes • Monocytes • Eosinophils • Basophils For Financial Professional Use Only 11 Platelets • Really more of a fragment of a cell – They are broken off from a very large cell in the bone marrow called a megakaryocyte – Primary function is to aid in blood clotting – Lifetime in the blood is 7-10 days after which they are destroyed in the spleen – Their clotting function is permanently inhibited by aspirin For Financial Professional Use Only 12 Plasma • Plasma is the liquid component of blood • Comprised mostly of water, but also includes: – Protein (albumin, globulin, fibrinogen) – Lipids (cholesterol, triglycerides) – Dissolved salts and minerals (sodium, calcium, potassium) – Glucose For Financial Professional Use Only 13 Case # 1 • 32 yo female applying for $1 million whole life • Insurance labs show elevations of total cholesterol at 240 and alkaline phosphatase at 170, other labs are normal • Medical records include CBC from 1 month prior to application, done during routine office visit. TEST RESULT UNITS REF RANGE WBC 10.8 x 1000/mm3 3.9 - 11.1 RBC 3.73 L x 106/mm3 4.00 - 5.20 HGB 10.8 L g/dL 12.0 - 16.0 HCT 32.4 L % 38.5 - 49.0 MCV 84 fl 80 - 97 MCH 31.0 pg 27.5 - 33.5 MCHC 33.3 % 32.0 - 36.0 PLT 310 x 1000/mm3 150 - 350 • Paramedical exam: currently pregnant For Financial Professional Use Only 14 “Anemia” of Pregnancy • During pregnancy, the volume of red blood cells increases by about 20%, but the plasma volume increases by 45%. • Net result is ≈ 15% decrease in hemoglobin and hematocrit. For Financial Professional Use Only 15 Complete Blood Count (CBC) TEST RESULT UNITS REF RANGE WBC 5.2 x 1000/mm3 3.9 - 11.1 RBC 3.81 L x 106/mm3 4.20 - 5.70 HGB 14.5 g/dL 13.2 - 16.9 HCT 41.2 % 38.5 - 49.0 MCV 98 H fl 80 - 97 MCH 33.7 H pg 27.5 - 33.5 MCHC 35.3 % 32.0 - 36.0 RDW 11.8 % 11.0 - 15.0 PLT 172 x 1000/mm3 140 - 390 MPV 7.6 fl 7.5 - 11.5 NEUT % 40.1 % 38.0 - 80.0 LYMPH % 46.1 % 15.0 - 49.0 MONO % 12.9 % 0.0 - 13.0 EOS % 0.6 % 0.0 - 8.0 BASO % 0.3 % 0.0 - 2.0 NEUT, ABS 2085 cells/mm3 1650 - 8000 LYMPH, ABS 2397 cells/mm3 1000 - 3500 MONO, ABS 671 cells/mm3 40 - 900 EOS, ABS 31 cells/mm3 30 - 600 BASO, ABS 16 cells/mm3 0 - 125 For Financial Professional Use Only 16 Red Blood Count and RBC Indices TEST RESULT UNITS REF RANGE WBC 5.2 x 1000/mm3 3.9 - 11.1 RBC 3.81 L x 106/mm3 4.20 - 5.70 HGB 14.5 g/dL 13.2 - 16.9 HCT 41.2 % 38.5 - 49.0 MCV 98 H fl 80 - 97 MCH 33.7 H pg 27.5 - 33.5 MCHC 35.3 % 32.0 - 36.0 RDW 11.8 % 11.0 - 15.0 PLT 172 x 1000/mm3 140 - 390 MPV 7.6 fl 7.5 - 11.5 NEUT % 40.1 % 38.0 - 80.0 LYMPH % 46.1 % 15.0 - 49.0 MONO % 12.9 % 0.0 - 13.0 EOS % 0.6 % 0.0 - 8.0 BASO % 0.3 % 0.0 - 2.0 NEUT, ABS 2085 cells/mm3 1650 - 8000 LYMPH, ABS 2397 cells/mm3 1000 - 3500 MONO, ABS 671 cells/mm3 40 - 900 EOS, ABS 31 cells/mm3 30 - 600 BASO, ABS 16 cells/mm3 0 - 125 For Financial Professional Use Only 17 Measuring RBCs (and the “Rule of Threes”) • Hematocrit (HCT) is the percent of a volume of whole blood occupied by intact red blood cells. Measured in percent. – Normal range for women: 36 - 46% – Normal range for men: 41 - 53% • Hemoglobin (HGB) measures the concentration of hemoglobin expressed as grams of hemoglobin per deciliter (100 ml) of whole blood. – Normal range for women: 12 - 16 g/dL – Normal range for men: 13.5 - 17.5 g/dL • RBC count is the number of red blood cells per microliter of whole blood. Measured in millions of RBCs per microliter of whole blood. – Normal range for women: 4.0 - 5.2 x106/mm3 – Normal range for men: 4.5 - 5.9 x106/mm3 For Financial Professional Use Only 18 Red Blood Cell Indices • Mean Corpuscular Volume (MCV) is the average size of red blood cells. – Normal range: 80-100 fL – Low = “microcytic” (“too small”) High = “macrocytic” (“too big”) Normal = “normocytic” (“just right”) • Red Cell Distribution Width (RDW) measures the variability in the size of red blood cells. – Normal range: 11.5-14.5% – On a peripheral blood smear, high RDW is described as “anisocytosis” • Mean Corpuscular Hemoglobin (MCH) is the amount of hemoglobin in an average red blood cell. – Normal range: 26-34 pg/cell • Mean Corpuscular Hemoglobin Concentration (MCHC) is the average concentration of hemoglobin in an average RBC. – Normal range: 31-37 g/dL – “Hypochromic” = “too pale” “Normochromic” = “just right” For Financial Professional Use Only 19 Red Blood Cell Indices • Mean Corpuscular Volume (MCV) is the average size of red blood cells. – Normal range: 80-100 fL – Low = “microcytic” (“too small”) High = “macrocytic” (“too big”) Normal = “normocytic” (“just right”) • Red Cell Distribution Width (RDW) measures the variability in the size of red blood cells. – Normal range: 11.5-14.5% – On a peripheral blood smear, high RDW is described as “anisocytosis” • Mean Corpuscular Hemoglobin (MCH) is the amount of hemoglobin in an average red blood cell. – Normal range: 26-34 pg/cell • Mean Corpuscular Hemoglobin Concentration (MCHC) is the average concentration of hemoglobin in an average RBC. – Normal range: 31-37 g/dL – “Hypochromic” = “too pale” “Normochromic” = “just right” For Financial Professional Use Only 20 Red Blood Cell Indices • Mean Corpuscular Volume (MCV) is the average size of red blood cells. – If anemia is present, MCV is a useful tool to guide further testing – If anemia is not present, MCV is of little value: • Low MCV without anemia suggests thalassemia minor (trait) • High MCV without anemia can be caused by certain medications (Dilantin, oral contraceptives, methotrexate) and is a “soft” marker of possible alcohol overuse • Red Cell Distribution Width (RDW) measures the variability in the size of red blood cells. – Not useful in the absence of anemia For Financial Professional Use Only 21 Classification of Anemias Using MCV and RDW Low MCV Normal MCV High MCV (Microcytic) (Normocytic) (Macrocytic) Low RDW Thalassemia minor (low variability) Anemia of chronic Thalassemia minor Aplastic anemia disease Normal RDW Anemia of chronic Myelodysplastic Hereditary disease syndrome spherocytosis Early deficiency of B12 or folate High RDW Iron deficiency iron, B12, or folate