Flagging XT Series

Product Specialist
PT. Saba Indomedika
Flagging
NEGATIVE No abnormality

POSITIVE One or more of the 39 IP messages is

generated

ERROR Classified as Func, functional

abnormality

ERROR Classified as Result, Low reliability

Positive and Error Alarm

POSITIVE
Diff Abnormality in Cell Differential

Morph Abnormality in Cell Morphology

Count Abnormality in Cell Count

ERROR

Func Analysis error other than ID Barcode

Result Low Reliability of Data

Delta Abnormalities with Delta Check

Positive and Error Alarm

Marks

+,- Data Exceeding Reference Interval

@ Data Outside Numerical Range

* Data is Doubtful

---- Analysis cant be done

++++ Data exceeds display capability

No order given

& Corrected Data

XT-1800i Principles
Parameter Channel Principles
WBC, BASO WBC/Baso Forward and Side Scatter
Neut, Lymph, Diff Side Scatter and Fluorescence
Mono, Eo

RBC, Hct, PLT RBC Hydrodyn. Focussing

Hgb HGB SLS-Hgb Method

SFL = Fluorescence intensity

SSC = Side Scatter Nucleus/Plasma , Granular

FSC = Forward Scatter Volume, Cell Size

Flagging
Erythrocytes Histogram Flagging

Thrombocyte Histogram Flagging

Erythrocytes Histogram Flagging
Histogram

RDW-SD / RDW-CV

Flagging

Abnormal Histogram
RU > 5%
RL >10% RU > 5%
+ RDW

Macro
MP
Micro

HGB
RBC Aggl. Other
Interf.
Erythrocyte Flagging
Abnormal Messages Category
RBC Abn Distribution Morph RL,RU,MP,DW
Dimorphic Population Morph MP
RET Abn Scattergram Morph RET-UPP
Reticulocytosis Count RET#,RET%
Anisocytosis Morph RDW-SD/CV
Microcytosis Morph MCV
Macrocytosis Morph MCV
Hypochromia Count MCHC
Anemia Count HGB
Erythrocytosis Count RBC#

Suspect Messages
RBC Agglutination? Count MCHC,MCH,RBC#,RU
Turbidity / HGB interf? Count MCHC
Iron Def? Morph MCHC,MCV,RDW-CV
HGB Defect? Morph RDW-CV,MCV
Fragments? Morph RDW-SD,PU,MCV,RET
Erythrocyte Histogram
The size distribution curve are separated by a moving
threshold.
RL RU RBC
100 %

The Erythrocytes do have a

size from 80-100 fl and are
20 % measured between 25 and
250 fl
100 200 250 fl
PLT
PL 12 fl PU
100 % The Platelets with a size
from 8-12 fl are counted
between 2 and 30 fl.
A fixed discriminator at
20 % 12 fl .

10 fl 20 fl 30 fl 40 fl
The volume distribution curve has to start at the base line
between the threshold lines.
Erythrocyte Histogram Distribution Width
RDW-CV

100 %
L2 - L1
RDW-CV (%) = X 100
L2 + L1

Range 11 - 16 %
200 250 fl
L1 L2
The Erythrocyte distribution
width is an indication for
RDW-SD
anisocytosis.
100 %

20 % Range 37 - 46 fl
200 250 fl
RBC Abnormal Distribution

1 RL abnormal height at lower discriminator

2 RU abnormal height at upper discriminator
3 Extreme RDW-SD Results
4 Dimorphic Population
RBC Abnormal Distribution (1)
1: Triggered by an abnormal height at lower
discriminator (> 10 %)
RL RU
100 %

10 %
100 200 250 fl

Possible causes:
Thrombocytosis
Fragments
Microcytes
RBC Abnormal Distribution (2)
2: Triggered by an abnormal height at upper
discriminator RU > 5%
RL RU RBC 0.53 * [ x 106/l]
100 % RBC HGB 10.2 * [g/dl]
HCT 5.6 * [%]
MCV 105.7 * [fl]
MCH 192.5 * [pg]
5%
MCHC 182.1 * [g/dl]
100 200 250 fl
Cave:
Curve does not start at the Please check all marked
baseline Parameters

Possible Causes:
RBC-Agglutination
Erythroblasts
Abnormal Distribution RBC Agglutination

RBC Agglutination
RBC Abnormal Distribution (3)
3. Triggered by an abnormal height at the
upper and/or lower discriminator > 20%
RL RU
100 %

20 %

100 200 250 fl

Possible causes:
Cold agglutinins (check MCHC)
Erythroblasts
RBC Abnormal Distribution (3)
4: Alarm Dimorphic Population
RL RU
100 %

Small-RBC/MCV
Large-RBC/MCV
in Service-Data

S L

100 200 250 fl

Possible causes:
Iron deficiency in therapy
Infect- or Tumor Anaemia
Transfusions
Leukocytosis (CLL)
Dimorphic Population treated Infect/Tumour Anemia
Dimorphic Population treated Infect/Tumour Anemia
Red Distribution Width Anisocytosis

RDW-SD = 74.8 fl (Anisocytosis)

Erythrocyte Histogram Macro/Microcytosis
Macrocytosis MCV > 110 fl
RL RU
100 %

20 %

100 200 250 fl

Microcytosis MCV < 70 fl

RL RU
100 %

20 %

100 200 250 fl

Morphological Flagging RBC
Turbidity Haemoglobin Interference
Triggered by MCHC > 22.8 mmol/l or 36.5 g/dL

Possible causes:

Haemolyse caused by a wrong blood

extraction
RBC/HCT falsely too low
New blood; Comparison to serum
Lipaemia: HGB wrongly high.
Sample dilution 1:5
Intravascular Hemolysis!
HGB falsely too high
RBC Cold agglutination
HCT minor falsely too low.
reheat sample to 37 C
Morphological Flagging RBC
Alarm RBC Agglutination
Triggered by MCHC > 40.0 g/dl or MCH > 40.0 pg
or RBC < 3,5 10^6/l and RU > 4 %.
RL RU
RBC 0.53 * [ x 106/l]
100 %
HGB 10.2 [g/dl]
HCT 5.6 * [%]
MCV 105.7 * [fl]
20 % MCH 192.5 * [pg]
MCHC 182.1 * [g/dl]
100 200 250 fl
Cave:
Please check all
marked Parameters
Possible causes:
Erythrocyte Agglutination
(reheat sample to 37 C)
RBC Abnormal Flagging
Abnormal Flagging
Hypochromasia MCHC < 29.0 g/dl

Anaemia Hgb < 10 g/dl

Erythrocytosis RBC > 6.5 x 106/l

Morphological Flagging
Fragments RDW-SD,
MCV and PU

Iron Deficiency MCHC < 31.0 g/dl and MCV < 75 fl

and RDW-CV > 15 %

Hgb Defect RDW-CV + MCV

Fragments .. RDW-SD

.. PLT Upper Discriminator

MCV

. RBC Lower Discriminator

MCHC

PLT_DC RBC_DC
Example Fragments
Thrombocyte Flagging
PLT- Flagging

Histogram

Histogram-Parameter

Abnormal Histogram

PL > 10% TYP (A) TYP (B)

TYP (C) P-LCR

Fonio- Method
Thrombocyte Flagging

Abnormal Messages Category

PLT Abn Distribution Morph PL, PU
PLT Abn Distribution Count P-LCR
Thrombocytopenia Count PLT#
Thrombocytosis Count PLT#

Suspect Messages
PLT Clumps? Morph/ Diff-Kanal
Count
Thrombocyte-Histogram

PL 12 fl PU
100 %

20 %

10 fl 20 fl 30 fl 40 fl

The Histogram should start and end on the baseline

PLT counted between 2 fl and 30 fl.

1 flexible Discriminator PL 2 to 6 fl.
1 flexible Discriminator PU 12-30 fl.
1 fixed Discriminator at 12 fl
Thrombocyte-Histogram Parameters
PLT Platelet Count

MPV Mean Platelet Volume

Normal Range: 8 - 12 fl

PL PU
100 %

PCT (%)
MPV (fl) =
PLT (x 103/l)

20 %

10 fl 20 fl 30 fl 40 fl
Thrombocyte Histogram Parameters
P-LCR Part of larger thrombocyte (Volume > 12 fl )

Normal range 15 - 35 %
Increase can be caused by:
PLT-Clumps, Micro erythrocytes, Giant Thrombocytes

PL 12 fl PU
100 %

P-LCR

20 %

10 fl 20 fl 30 fl 40 fl
Thrombocyte Histogram Parameters
PDW Distribution Curve of Thrombocytes

Normal range: 9 - 14 fl
Increase can be caused by:
Anisocytosis of thrombocytes

PL PU
100 %

PDW
20 %

10 fl 20 fl 30 fl 40 fl
Platelet Abnormal Distribution
1. Abnormal height at the lower or upper
discriminator

PDW, P-LCR, MPV marked with ----

PLT marked with *

2. P-LCR > 43%.

PLT, PDW, P-LCR, MPV marked with *
PL PU
100 %

20 %

10 fl 20 fl 30 fl 40 fl
Platelet Abnormal Distribution
Triggered by an abnormal height at the lower
discriminator PL > 10%
PL PU
100 %
PLT 211 * [ x 10/l]
PDW 12.5 * [fl]
MPV 9.3 * [fl]
P-LCR 22.5 * [%]
20 %

10 fl 20 fl 30 fl 40 fl Cave:
Check blank
Kurve beginnt nicht an der Basislinie

Possible causes: (very rare)

high Blank
cell Fragments or wreckage
bacteria
Case: Low PLT Count without flag PL PU
Low PLT Count 100 %
No Flag
Normal Curve

PLT Count is correct 20 %

Counting chamber is more imprecise. 10 fl 20 fl 30 fl 40 fl

Platelet Abnormal Distribution (1)
Triggered by PU > 20%

PL PU
100 %
PLT 125 [ x 10/l]
PDW ---.- [fl]
MPV ---.- [fl]
P-LCR---.- [fl]
20 %

10 fl 20 fl 30 fl 40 fl

Overlapping of the curves is the same on both sides

Platelet count is correct.

The counting chamber is
more imprecise.
Thrombocyte-Histogram PLT Abn Distr. (A)
Thrombocyte-Histogram PLT Abn Distr. (B)
Alarm Abn. Thrombocyte-Distribution (B)
Triggered by an abnormal height at the upper discriminator
PL > 20%

PL PU
100 %
PLT 91 * [ x 10/l]
PDW ---.- [fl]
MPV ---.- [fl]
P-LCR---.- [%]
20 %

10 fl 20 fl 30 fl 40 fl
Possible causes :
PLT Clumps Count PLT with
EDTA-incompatibility counting chamber or
coagulated sample check with Fonio
Giant Platelets
Mikroerythrocyts
fragments
Thrombocyte-Histogram PLT Abn Distr. (B)
Example Fragments.

PLT Switching Algorithmus is done

Thrombocyte-Histogram PLT Abn Distr. (C)
Alarm Abn. Thrombocyte-Distribution (C)
triggered byt PU > 20%

PL PU
PLT 125 [ x 10/l]
PDW ---.- [fl]
MPV ---.- [fl]
100 % P-LCR---.- [fl]
20 %
Cave:
10 fl 20 fl 30 fl 40 fl PLT-FL
Overlapping is not identical

Possible cause:
Giant platelets
extrem poikilocytosis
Thrombocyte-Histogram PLT Abn Distr. (C)
Example Giant PLT
Thrombocyte-Histogram
Alarm Abn. Thrombocyte-Distribution
P-LCR > 43%
PL 12 fl PU
100 %

PLT 155 [ x 10/l]

P-LCR 52,0 (%)

20 %

10 fl 20 fl 30 fl 40 fl

Possible causes:
Regeneration Bone marrow
Transfusion
PLT Clumps ?
PLT-Clumps ?
Triggered when:
PLT Clumps in Area in Diff -CH
DIFF
Q-Flag System

IP Message

BLASTS ? BLASTS ?
300 300

200 200

100 100
Red, if
above 100
Green, if 80 250
below 100
Numerical value of the bar height

Sysmex Q-Flag system gives the operator the full picture.

XT-1800i Scattergram
DIFF Channel WBC/BASO Channel

Forward scatter (Volume)

Fluorescence (RNA,
DNA)

Side Scatter (Internal Side Scatter

structure)
Abnormal and Suspect WBC Flags
DIFF WBC/BASO
Abnormal WBC Flag

DIFF WBC/BA

WBC Abn Scattergram

 ..
Abnormal WBC Flag
Neutropenia

.. Neutrophilia
Lymphopenia

.. Lymphocytosis
Monocytosis

.. Eosinophilia
Basophilia

. Leukocytopenia
Leukocytosis
 ..
Suspect WBC Flags
Blasts?

.. Immature Gran?
Left Shift?

.. Atypical Lympho?
Abn Lympho/L-Blasts?
RBC Lyse Resistance?
4 Diff Scattergram of abnormal cells
Fluorescence

Blasts/
Atypical
Lymph Immature Gran

Mono
Lymph Left Shift

NRBC Neut
Baso EO
Ghost PLT Clumps
Side Scatter
4 Diff Scattergram of abnormal cells

Atypical Promyelo
Lymph
Myelo

Metamyelo
Blast

Stab
Suspect WBC Flag: Blast?

DIFF

Blasts/Atypical Lymph Area in

Diff channel

Blasts?
Suspect WBC Flag: Immature Gran?

DIFF

Immature Gran Area in Diff-

Channel

Immature Gran?

Diff IG > 1% or
Suspect WBC Flag: Left Shift?

DIFF

Left Shift Area in Diff-Channel

Left Shift?

LS > 200
or > 4%
Suspect WBC Flag: Atypical Lymph?

DIFF

Blasts/Atypical Lymph Area in Diff-

Channel

Atypical Lymph?

150 Diskriminator > 1%

Suspect WBC Flag: Abn Lymph/L-Blast?

DIFF

Abn Lymph/L-Blast Area in Diff-

Channel

Abn Lympho/L-Blast?
RBC Lyse Resistance?
DIFF

RBC Lyse Resistance?

WBC/BASO
WBC 4000
WBC-Diff < 20% WBC-WBC/BASO

WBC < 4000

WBC-Diff < 50% WBC-WBC/BASO