Laboratory test

RBC (Red Blood Cell) count

The RBC count is most useful as raw data for calculation of the erythrocyte
indices MCV and MCH [see below]. Decreased RBC is usually seen in anemia of
any cause with the possible exception of thalassemia minor, where a mild or
borderline anemia is seen with a high or borderline-high RBC. Increased RBC is
seen in erythrocytotic states, whether absolute (polycythemia vera, erythrocytosis
of chronic hypoxia) or relative (dehydration, stress polycthemia), and in
thalassemia minor

HEMOGLOBIN, HEMATOCRIT, MCV (mean corpuscular volume), MCH (mean

corpuscular hemoglobin), MCHC (mean corpuscular hemoglobin concentration)

Strictly speaking, anemia is defined as a decrease in total body red cell mass. For
practical purposes, however, anemia is typically defined as hemoglobin <12.0 g/dL and
direct determination of total body RBC mass is almost never used to establish this
diagnosis. Anemias are then classed by MCV and MCHC (MCH is usually not helpful)
into one of the following categories:

• Microcytic/hypochromic anemia (decreased MCV, decreased MCHC)

o Iron deficiency (common)
o Thalassemia (common, except in people of Germanic, Slavonic, Baltic,
Native American, Han Chinese, Japanese descent)
o Anemia of chronic disease (uncommonly microcytic)
o Sideroblastic anemia (uncommon; acquired forms more often macrocytic)
o Lead poisoning (uncommon)
o Hemoglobin E trait or disease (common in Thai, Khmer, Burmese,Malay,
Vietnamese, and Bengali groups)
• Macrocytic/normochromic anemia (increased MCV, normal MCHC)
o Folate deficiency (common)
o B deficiency (common)
12

o Myelodysplastic syndromes (not uncommon, especially in older

individuals)
o Hypothyroidism (rare)
• Normochromic/normocytic anemia (normal MCV, normal MCHC) The first
step in laboratory workup of this broad class of anemias is a reticulocyte count.
Elevated reticulocytes implies a normo-regenerative anemia, while a low or
"normal" count implies a hyporegenerative anemia:
o Normoregenerative normocytic anemias (appropriate reticulocyte
response)
 Immunohemolytic anemia
 Glucose-6-phosphate dehydrogenase (G6PD) deficiency (common)
 Hemoglobin S or C
 Hereditary spherocytosis
 Microangiopathic hemolytic anemia
  Paroxysmal hemoglobinuria
o Hyporegenerative normocytic anemias (inadequate reticulocyte response)
 Anemia of chronic disease
 Anemia of chronic renal failure
 Aplastic anemia*

WBC (White Blood Cell) count

The WBC is really a nonparameter, since it simply represents the sum of the
counts of granulocytes, lymphocytes, and monocytes per unit volume of whole
blood. Automated counters do not distinguish bands from segs; however, it has
been shown that if all other hematologic parameters are within normal limits, such
a distinction is rarely important. Also, even in the best hands, trying to reliably
distinguish bands from segs under the microscope is fraught with reproducibility
problems. Discussion concerning a patient's band count probably carries no more
scientific weight than a medieval theological argument.

Eosinophils

Eosinophilia is seen in allergic disorders and invasive parasitoses. Other causes

include pemphigus, dermatitis herpetiformis, scarlet fever, acute rheumatic fever,
various myeloproliferative neoplasms, irradiation, polyarteritis nodosa,
rheumatoid arthritis, sarcoidosis, smoking, tuberculosis, coccidioidomycosis,
idiopathicallly as an inherited trait, and in the resolution phase of many acute
infections.

Eosinopenia is seen in the early phase of acute insults, such as shock, major
pyogenic infections, trauma, surgery, etc. Drugs producing eosinopenia include
corticosteroids, epinephrine, methysergide, niacin, niacinamide, and
procainamide.

Lymphocytes

Lymphocytosis is seen in infectious mononucleosis, viral hepatitis,

cytomegalovirus infection, other viral infections, pertussis, toxoplasmosis,
brucellosis, TB, syphilis, lymphocytic leukemias, and lead, carbon disulfide,
tetrachloroethane, and arsenical poisonings. A mature lymphocyte count
>7,000/µL is an individual over 50 years of age is highly suggestive of chronic
lymphocytic leukemia (CLL). Drugs increasing the lymphocyte count include
aminosalicyclic acid, griseofulvin, haloperidol, levodopa, niacinamide, phenytoin,
and mephenytoin.

Lymphopenia is characteristic of AIDS. It is also seen in acute infections,

Hodgkin's disease, systemic lupus, renal failure, carcinomatosis, and with
administration of corticosteroids, lithium, mechlorethamine, methysergide, niacin,
and ionizing irradiation. Of all hematopoietic cells lymphocytes are the most
 sensitive to whole-body irradiation, and their count is the first to fall in radiation
sickness.

Monocytes

Monocytosis is seen in the recovery phase of many acute infections. It is also seen
in diseases characterized by chronic granulomatous inflammation (TB, syphilis,
brucellosis, Crohn's disease, and sarcoidosis), ulcerative colitis, systemic lupus,
rheumatoid arthritis, polyarteritis nodosa, and many hematologic neoplasms.
Poisoning by carbon disulfide, phosphorus, and tetrachloroethane, as well as
administration of griseofulvin, haloperidol, and methsuximide, may cause
monocytosis.

Monocytopenia is generally not a clinical problem.

Components of the CBC

Test Name Increased/decreased
WBC White Blood Cell May be increased with infections, inflammation,
cancer, leukemia; decreased with some
medications (such as methotrexate), some
autoimmune conditions, some severe infections,
bone marrow failure, and congenital marrow
aplasia (marrow doesn't develop normally)
%
Neutrophil/Band/Seg/Gran
Neutrophil
This is a dynamic population that varies
Lymphs Lymphocyte somewhat from day to day depending on what is
% Mono Monocyte going on in the body. Significant increases in
% Eos Eosinophil particular types are associated with different
% Baso Basophil temporary/acute and/or chronic conditions. An
Neutrophil Neutrophil/Ban/Seg/Gran example of this is the increased number of
Lymphs Lymphocyte lymphocytes seen with lymphocytic leukemia.
Mono Monocyte For more information, see Blood Smear and
Eos Eosinophil WBC.
Baso Basophil
Decreased with anemia; increased when too
RBC Red Blood Cell many made and with fluid loss due to diarrhea,
dehydration, burns
Hgb Hemoglobin Mirrors RBC results
Hct Hematocrit Mirrors RBC results
Increased with B12 and Folate deficiency;
MCV Mean Corpuscular Volume
decreased with iron deficiency and thalassemia
Mean Corpuscular
MCH Mirrors MCV results
Hemoglobin
MCHC Mean Corpuscular May be decreased when MCV is decreased;
 Test Name Increased/decreased
increases limited to amount of Hgb that will fit
Hemoglobin Concentration
inside a RBC
Increased RDW indicates mixed population of
RDW RBC Distribution Width
RBCs; immature RBCs tend to be larger
Decreased or increased with conditions that
affect platelet production; decreased when
greater numbers used, as with bleeding;
decreased with some inherited disorders (such as
Platelet Platelet
Wiskott-Aldrich, Bernard-Soulier), with
Systemic lupus erythematosus, pernicious
anemia, hypersplenism (spleen takes too many
out of circulation), leukemia, and chemotherapy
Vary with platelet production; younger platelets
MPV Mean Platelet Volume
are larger than older ones

The CBC is a very common test. Many patients will have baseline CBC tests to help
determine their general health status. If they are healthy and they have cell populations
that are within normal limits, then they may not require another CBC until their health
status changes or until their doctor feels that it is necessary.

If a patient is having symptoms such as fatigue or weakness or has an infection,

inflammation, bruising, or bleeding, then the doctor may order a CBC to help diagnose
the cause. Significant increases in WBCs may help confirm that an infection is present
and suggest the need for further testing to identify its cause. Decreases in the number of
RBCs (anemia) can be further evaluated by changes in size or shape of the RBCs to help
determine if the cause might be decreased production, increased loss, or increased
destruction of RBCs. A platelet count that is low or extremely high may confirm the
cause of excessive bleeding or clotting and can also be associated with diseases of the
bone marrow such as leukemia.

How is it used?

The CBC is used as a broad screening test to check for such disorders as anemia,
infection, and many other diseases. It is actually a panel of tests that examines different
parts of the blood and includes the following:

• White blood cell (WBC) count is a count of the actual number of white blood
cells per volume of blood. Both increases and decreases can be significant.
• White blood cell differential looks at the types of white blood cells present. There
are five different types of white blood cells, each with its own function in
protecting us from infection. The differential classifies a person's white blood
cells into each type: neutrophils (also known as segs, PMNs, granulocytes, grans),
lymphocytes, monocytes, eosinophils, and basophils.
• Red blood cell (RBC) count is a count of the actual number of red blood cells per
volume of blood. Both increases and decreases can point to abnormal conditions.
 • Hemoglobin measures the amount of oxygen-carrying protein in the blood.
• Hematocrit measures the percentage of red blood cells in a given volume of whole
blood.
• The platelet count is the number of platelets in a given volume of blood. Both
increases and decreases can point to abnormal conditions of excess bleeding or
clotting. Mean platelet volume (MPV) is a machine-calculated measurement of
the average size of your platelets. New platelets are larger, and an increased MPV
occurs when increased numbers of platelets are being produced. MPV gives your
doctor information about platelet production in your bone marrow.
• Mean corpuscular volume (MCV) is a measurement of the average size of your
RBCs. The MCV is elevated when your RBCs are larger than normal
(macrocytic), for example in anemia caused by vitamin B12 deficiency. When the
MCV is decreased, your RBCs are smaller than normal (microcytic) as is seen in
iron deficiency anemia or thalassemias.
• Mean corpuscular hemoglobin (MCH) is a calculation of the average amount of
oxygen-carrying hemoglobin inside a red blood cell. Macrocytic RBCs are large
so tend to have a higher MCH, while microcytic red cells would have a lower
value.
• Mean corpuscular hemoglobin concentration (MCHC) is a calculation of the
average concentration of hemoglobin inside a red cell. Decreased MCHC values
(hypochromia) are seen in conditions where the hemoglobin is abnormally diluted
inside the red cells, such as in iron deficiency anemia and in thalassemia.
Increased MCHC values (hyperchromia) are seen in conditions where the
hemoglobin is abnormally concentrated inside the red cells, such as in burn
patients and hereditary spherocytosis, a relatively rare congenital disorder.
• Red cell distribution width (RDW) is a calculation of the variation in the size of
your RBCs. In some anemias, such as pernicious anemia, the amount of variation
(anisocytosis) in RBC size (along with variation in shape – poikilocytosis) causes
an increase in the RDW.

Urine tests are typically evaluated with a reagent strip that is briefly dipped into your urine
sample. The technician reads the colors of each test and compares them with a reference
chart. These tests are semi-quantitative; there can be some variation from one sample to
another on how the tests are scored.

pH: This is a measure of acidity for your urine.

Specific Gravity (SG): This measures how dilute your urine is. Water would have a SG of
1.000 . Most urine is around 1.010, but it can vary greatly depending on when you drank
fluids last, or if you are dehydrated.

Glucose: Normally there is no glucose in urine. A positive glucose occurs in diabetes. There
are a small number of people that have glucose in their urine with normal blood glucose
levels, however any glucose in the urine would raise the possibility of diabetes or glucose
intolerance.

Protein: Normally there is no protein detectable on a urinalysis strip. Protein can indicate
kidney damage, blood in the urine, or an infection. Up to 10% of children can have protein
in their urine. Certain diseases require the use of a special, more sensitive (and more
expensive) test for protein called a microalbumin test. A microalbumin test is very useful in
screening for early damage to the kidneys from diabetes, for instance.

Blood: Normally there is no blood in the urine. Blood can indicate an infection, kidney
stones, trauma, or bleeding from a bladder or kidney tumor. The technician may indicate
whether it is hemolyzed (dissolved blood) or non-hemolyzed (intact red blood cells).
Rarely, muscle injury can cause myoglobin to appear in the urine which also causes the
reagent pad to falsely indicate blood.

Bilirubin: Normally there is no bilirubin or urobilinogen in the urine. These are pigments
that are cleared by the liver. In liver or gallbladder disease they may appear in the urine as
well.

Nitrate: Normally negative, this usually indicates a urinary tract infection.

Leukocyte esterase: Normally negative. Leukocytes are the white blood cells (or pus cells).
This looks for white blood cells by reacting with an enzyme in the white cells. White blood
cells in the urine suggests a urinary tract infection.

Nitrite

A positive nitrite test indicates that bacteria may be present in significant numbers in
urine. Gram negative rods such as E. coli are more likely to give a positive test.

bilirubin- The fixed phagocytic cells of the spleen and bone marrow destroy old
red blood cells and convert the heme groups of hemoglobin to the pigment
bilirubin. The bilirubin is secreted into the blood and carried to the liver where it
is bonded to (conjugated with) glucuronic acid, a derivative of glucose. Some of
the conjugated bilirubin is secreted into the blood and the rest is excreted in the
bile as bile pigment that passes into the small intestine. The blood normally
contains a small amount of free and conjugated bilirubin. An abnormally high
level of blood bilirubin may result from: an increased rate of red blood cell
destruction, liver damage, as in hepatitis and cirrhosis, and obstruction of the
common bile duct as with gallstones. An increase in blood bilirubin results in
jaundice, a condition characterized by a brownish yellow pigmentation of the skin
and of the sclera of the eye.

Urobilinogen is a colourless product of bilirubin reduction. It is formed in the intestines

by bacterial action. Some urobilinogen is reabsorbed, taken up into the circulation and
excreted by the kidney. This constitutes the normal "enterohepatic urobilinogen cycle".

Increased amounts of bilirubin are formed in haemolysis, which generates increased

urobilinogen in the gut. In liver disease (such as hepatitis), the intrahepatic urobilinogen
cycle is inhibited also increasing urobilinogen levels. Urobilinogen is converted to the
yellow pigmented urobilin apparent in urine.
low urine urobilinogen levels may result from congenital enzymatic jaundice
(hyperbilirubinemia syndromes) or from treatment with drugs that acidify urine, such as
ammonium chloride or ascorbic acid.

COLOR. Normal urine is straw yellow to amber in color. Abnormal colors include bright
yellow, brown, black (gray), red, and green. These pigments may result from
medications, dietary sources, or diseases. For example, red urine may be caused by blood
or hemoglobin, beets, medications, and some porphyrias. Black-gray urine may result
from melanin (melanoma) or homogentisic acid (alkaptonuria, a result of a metabolic
disorder). Bright yellow urine may be caused by bilirubin (a bile pigment). Green urine
may be caused by biliverdin or certain medications. Orange urine may be caused by some
medications or excessive urobilinogen (chemical relatives of urobilinogen). Brown urine
may be caused by excessive amounts of prophobilin or urobilin (a chemical produced in
the intestines).

TRANSPARENCY. Normal urine is transparent. Turbid (cloudy) urine may be caused by

either normal or abnormal processes. Normal conditions giving rise to turbid urine
include precipitation of crystals, mucus, or vaginal discharge. Abnormal causes of
turbidity include the presence of blood cells, yeast, and bacteria.

SPECIFIC GRAVITY. The specific gravity of urine is a measure of the concentration of

dissolved solutes (substances in a solution), and it reflects the ability of the kidneys to
concentrate the urine (conserve water). Specific gravity is usually measured by
determining the refractive index of a urine sample (refractometry) or by chemical
analysis. Specific gravity varies with fluid and solute intake. It will be increased (above
1.035) in persons with diabetes mellitus and persons taking large amounts of medication.
It will also be increased after radiologic studies of the kidney owing to the excretion of x
ray contrast dye. Consistently low specific gravity (1.003 or less) is seen in persons with
diabetes insipidus. In renal (kidney) failure, the specific gravity remains equal to that of
blood plasma (1.008–1.010) regardless of changes in the patient's salt and water intake.
Urine volume below 400 mL per day is considered oliguria (low urine production), and
may occur in persons who are dehydrated and those with some kidney diseases. A
volume in excess of 2 liters (slightly more than 2 quarts) per day is considered polyuria
(excessive urine production); it is common in persons with diabetes mellitus and diabetes
insipidus.

pH: A combination of pH indicators (methyl red and bromthymol blue) react with
hydrogen ions (H + ) to produce a color change over a pH range of 5.0 to 8.5. pH
measurements are useful in determining metabolic or respiratory disturbances in acid-
base balance. For example, kidney disease often results in retention of H + (reduced acid
excretion). pH varies with a person's diet, tending to be acidic in people who eat meat but
more alkaline in vegetarians. pH testing is also useful for the classification of urine
crystals.

pH: the relative acidity or alkalinity; ranges from 4.6 to 8.0; average pH of urine
is 6.0
Protein: Based upon a phenomenon called the "protein error of indicators," this test uses a
pH indicator, such as tetrabromphenol blue, that changes color (at constant pH) when
albumin is present in the urine. Albumin is important in determining the presence of
glomerular damage. The glomerulus is the network of capillaries in the kidneys that
filters low molecular weight solutes such as urea, glucose, and salts, but normally
prevents passage of protein or cells from blood into filtrate. Albuminuria occurs when the
glomerular membrane is damaged, a condition called glomerulonephritis.

Glucose (sugar): The glucose test is used to monitor persons with diabetes. When blood
glucose levels rise above 160 mg/dL, the glucose will be detected in urine. Consequently,
glycosuria (glucose in the urine) may be the first indicator that diabetes or another
hyperglycemic condition is present. The glucose test may be used to screen newborns for
galactosuria and other disorders of carbohydrate metabolism that cause urinary excretion
of a sugar other than glucose.

Ketones: Ketones are compounds resulting from the breakdown of fatty acids in the body.
These ketones are produced in excess in disorders of carbohydrate metabolism, especially
Type 1 diabetes mellitus. In diabetes, excess ketoacids in the blood may cause life-
threatening acidosis and coma. These ketoacids and their salts spill into the urine, causing
ketonuria. Ketones are also found in the urine in several other conditions, including fever;
pregnancy; glycogen storage diseases; and weight loss produced by a carbohydrate-
restricted diet.
any present could indicate diabetes, starvation, or alcohol intoxication

Blood: Red cells and hemoglobin may enter the urine from the kidney or lower urinary
tract. Testing for blood in the urine detects abnormal levels of either red cells or
hemoglobin, which may be caused by excessive red cell destruction, glomerular disease,
kidney or urinary tract infection, malignancy, or urinary tract injury.

Bilirubin: Bilirubin is a breakdown product of hemoglobin. Most of the bilirubin

produced in humans is conjugated by the liver and excreted into the bile, but a very small
amount of conjugated bilirubin is reabsorbed and reaches the general circulation to be
excreted in the urine. The normal level of urinary bilirubin is below the detection limit of
the test. Bilirubin in the urine is derived from the liver, and a positive test indicates
hepatic disease or hepatobiliary obstruction.

Specific gravity: Specific gravity is a measure of the ability of the kidneys to concentrate
urine by conserving water.

Nitrite: Some disease bacteria, including the lactose-positive Enterobactericeae,

Staphylococcus, Proteus, Salmonella, and Pseudomonas are able to reduce nitrate in
urine to nitrite. A positive test for nitrite indicates bacteruria, or the presence of bacteria
in the urine.

Urobilinogen: Urobilinogen is a substance formed in the gastrointestinal tract by the

bacterial reduction of conjugated bilirubin. Increased urinary urobilinogen occurs in
prehepatic jaundice (hemolytic anemia), hepatitis, and other forms of hepatic necrosis
that impair the circulation of blood in the liver and surrounding organs. The urobilinogen
test is helpful in differentiating these conditions from obstructive jaundice, which results
in decreased production of urobilinogen.

Leukocytes: The presence of white blood cells in the urine usually signifies a urinary
tract infection, such as cystitis, or renal disease, such as pyelonephritis or
glomerulonephritis.

Normal results
Normal urine is a clear straw-colored liquid, but may also be slightly hazy. It has a slight
odor, and some laboratories will note strong or atypical odors on the urinalysis report. A
normal urine specimen may contain some normal crystals as well as squamous or
transitional epithelial cells from the bladder, lower urinary tract, or vagina. Urine may
contain transparent (hyaline) casts, especially if it was collected after vigorous exercise .
The presence of hyaline casts may be a sign of kidney disease, however, when the cause
cannot be attributed to exercise, running, or medications. Normal urine contains a small
amount of urobilinogen, and may contain a few RBCs and WBCs. Normal urine does not
contain detectable amounts of glucose or other sugars, protein, ketones, bilirubin,
bacteria, yeast cells, or trichomonads. Normal values used in many laboratories are given
below:

• Glucose: negative (quantitative less than 130 mg/day or 30 mg/dL).

• Bilirubin: negative (quantitative less than 0.02 mg/dL).
• Ketones: negative (quantitative 0.5–3.0 mg/dL).
• pH: 5.0–8.0.
• Protein: negative (quantitative 15–150 mg/day, less than 10 mg/dL).
• Blood: negative.
• Nitrite: negative.
• Specific gravity: 1.015–1.025.
• Urobilinogen: 0–2 Ehrlich units (quantitative 0.3–1.0 Ehrlich units).
• Leukocyte esterase: negative.
• Red blood cells: 0–2 per high power field.
• White blood cells: 0–5 per high power field (0–10 per high power field for some
standardized systems).

Resources
BOOKS

Chernecky, Cynthia C, and Barbara J. Berger. Laboratory Tests and Diagnostic

Procedures , 3rd ed. Philadelphia, PA: W. B. Saunders Company, 2001.