1. Utility of new mature erythrocyte and reticulocyte indices in
screening for iron-deficiency anemia in a pediatric population
V. OSTA*, M. S. CALDIROLA*, M. FERNANDEZ†
, M. I. MARCONE*, G. TISSERA*, S. PENNESI†
,
C. AYUSO*
*Central Laboratory, Ricardo
Gutierrez Children’s Hospital,
Buenos Aires, Argentina
†
Hematology Service, Ricardo
Gutierrez Children’s Hospital,
Buenos Aires, Argentina
Correspondence:
Dr Viviana A. Osta, Zapata
31 - 2˚ “A”, Ciudad Autonoma
de Buenos Aires (1426),
Argentina. Tel./Fax: 54 11
49626770;
E-mail: viviosta@yahoo.com.ar
doi:10.1111/ijlh.12030
Received 8 September 2012;
accepted for publication 11
October 2012
Keywords
Reticulocytes, iron deficiency
anemia, microcytic anemia
SUMMARY
Introduction: Iron-deficient erythropoiesis attributable to nutritional
deficiency is the most common cause of anemia in early childhood.
Beckman Coulter has proposed new parameters: red blood cell size
factor (RSf) and low hemoglobin density (LHD%).
RSf ¼
ffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffi
MCV Â MRV
p
LHD% ¼ 100
ffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffi
1 À 1= 1 þ e 1:8 30ÀMCHCð Þð Þ½ Š
q
The aims of the present communication were to establish reference
ranges (RR) for RSf and LHD% in a healthy pediatric population;
to evaluate clinical utility of these parameters in the diagnosis of
iron-deficiency anemia (IDA); and to compare RSf and LHD% with
RET-He.
Methods: Two hundred healthy infants and 51 with IDA were
analyzed on Coulter LH750 and Sysmex XT2000i analyzers.
Results: RR for RSf in children aged 0.5–6 years, 82.2–102.0 and
83.7–103.1 fl in the group aged 6-18 years. RR for LHD% was
1.1–9.0%. ROC analysis for RSf and LHD% in the diagnosis of IDA
showed an AUC 0.8460 and 0.8654, respectively. The best RSf
value to detect a restricted erythropoiesis was 89fl, sensitivity 92%,
specificity 81%. LHD% optimal cutoff point was 6.0%, sensitivity
80%, and specificity 88%. Good correlation was observed between
these parameters with Ret-He, r = 0.888 and r = À0.790, respectively.
Conclusion: RSf and LHD% could be useful tools in the screening of
IDA. These parameters can be obtained in the course of routine blood
counts, with no additional cost or need for more blood sampling.
INTRODUCTION
The two main causes of microcytic anemia are iron
deficiency and thalassemia. Iron deficiency attribut-
able to malnutrition is the most common cause of
anemia in children.
Detection and treatment of iron deficiency, before
it progresses to anemia, play a key role in the preven-
tion of neurocognitive impairments [1–3].
Iron balance is fundamentally regulated by the rate
of erythropoiesis and the size of the iron stores [4].
Iron deficiency is usually diagnosed using biochemical
© 2012 Blackwell Publishing Ltd, Int. Jnl. Lab. Hem. 1
ORIGINAL ARTICLE INTERNATIONAL JOURNAL OF LABORATORY HEMATOLOGY
International Journal of Laboratory Hematology
The Official journal of the International Society for Laboratory Hematology

2. markers such as serum iron, ferritin, and transferrin
saturation. However, these parameters are subject to
biological variability, for example, diurnal variation,
fluctuation with dietary intake and in infection/
inflammatory states (acute-phase reactants).
In recent years, new hematological parameters
have been developed for the early detection of iron
deficiency. These indices, which in some cases
combine more than one of the classic red cell parame-
ters, can be used as a preliminary screening tool in
the differential diagnosis of anemia [5].
The latest generation hematology analyzers provide
some reticulocyte indices equivalent to the RBC indi-
ces. The study of specific characteristics of the reticu-
locyte, such as mean reticulocyte volume (MRV),
RNA content, reticulocyte hemoglobin content (CHr)
and reticulocyte hemoglobin equivalent (Ret-He), can
give useful information about the iron availability for
erythropoiesis and the erythropoietic activity of the
bone marrow [6–9]. Currently, the main limitation in
the use of these indices is the fact that not all instru-
ments can perform them.
These reticulocyte parameters provide information
that could allow the differential diagnosis of anemia,
the early (latent) detection of iron deficiency, and the
real-time monitoring of bone marrow erythropoietic
activity. Besides aiding the diagnosis of iron-deficiency
anemia, reticulocyte parameters could potentially be
helpful in monitoring the response of erythropoiesis
to iron supplementation [10].
The CHr reflects the synthesis of hemoglobin in
bone marrow precursors and is a measure of the ade-
quacy of iron availability [11]. This parameter has
been incorporated to National Kidney Foundation
Kidney Disease Outcomes Quality Initiative (NKF-K/
DOQI) Guidelines for the monitoring of recombinant
human erythropoietin (rHuEPO) therapy [12]. Excep-
tions are heterozygotes for b-thalassemia whose CHr
is always reduced independently of iron stores [13].
The use of this parameter is limited to the analyzers
of a single manufacturer, Siemens (Siemens Medical
Solutions Diagnostics, NY, USA).
A comparable index called RET-Y has been devel-
oped by Sysmex Corporation (Japan) [14]. This param-
eter is measured based on automated fluorescent flow
cytometry, which in the reticulocyte channel, using a
polymethine dye specific for RNA/DNA, measures the
mean value of the forward light scatter intensity of
reticulocytes, expressed in arbitrary units. A mathe-
matical transformation applied to RET-Y gives a reticulo-
cyte hemoglobin equivalent (RETHe = 5.5569e0.001RET-Y
)
expressed in picograms [15, 16]. This parameter is
dependent on the hemoglobin content of reticulocytes
and shows a high correlation witch CHr and the same
clinical meaning [9, 17].
Compared to the mature erythrocyte population,
each with a lifespan of about 120 days, reticulocytes
have a greater mean volume and circulate for about
1–1.5 days in the blood stream, so reticulocyte-
dependent parameters provide a more real-time view
of certain aspects of erythropoiesis that can influence
the dimensions of red cells, such as iron availability.
The Beckman Coulter analyzers (Beckman Coulter
Inc., Miami, Fl, USA) identified and classified cells by
three-dimensional analysis: volume, conductivity, and
light scatter (VCS) technology. Using these technol-
ogy, the Beckman Coulter LH750 has recently pro-
posed two new parameters in the LH series: the red
blood cell size factor (RSf) and the low hemoglobin
density (LHD%) [18, 19].
The RSf combines the mean volume of mature red
cells (MCV) and the mean reticulocyte volume, both
related to erythropoietic activity and hemoglobiniza-
tion, because in both stages of erythrocyte maturation,
above 90% of cellular content are represented by
hemoglobin [20].
RSf ¼
ffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffi
MCV Â MRV
p
The LHD% derived from the mean cell hemoglobin
concentration (MCHC) uses the mathematical sigmoid
transformation:
LHD% ¼ 100
ffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffi
1 À 1= 1 þ e 1:8 30ÀMCHCð Þð Þ½ Š
q
The MCHC is a measure of both the availability of
iron over the preceding 90–120 days and the introduc-
tion of iron into erythrocyte hemoglobin. In the same
way, LHD% is related to iron availability and the
hemoglobinization of the mature red cells [19, 21].
Unlike biochemical studies such as ferritin, these
parameters require no extratubes of blood to be
drawn and are calculated without any additional cost.
These indices could be used as a preliminary screening
tool to allow confirmatory analysis.
The aims of this study were to establish the refer-
ence range for RSf and LHD% in a healthy children
© 2012 Blackwell Publishing Ltd, Int. Jnl. Lab. Hem.
2 V. OSTA ET AL. | NEW MATURE ERYTHROCYTE AND RETICULOCYTE INDICES

3. population; to determine the utility of RSf and LHD%
in the diagnosis of iron-deficiency anemia; and to
compare RSf and LHD% with RET-He that has been
clinically validated.
MATERIALS AND METHODS
Study population
Two patient groups were analyzed during a 1-year
period (March 2010–February 2011). Peripheral blood
samples from 251 patients collected in K3-EDTA anti-
coagulant tubes, 1.3 mL final volume, were randomly
selected from the routine workload and prospectively
analyzed.
Control group
Two hundred healthy children who were undergoing
minor surgery, with no clinical symptoms of disease,
exhibited no abnormal hematologic findings in their
complete blood cell count.
Iron-deficiency anemia (IDA) group
This group consisted of 51 children with diagnosis of
IDA according to their hemoglobin (Hb) and mean cor-
puscular volume (MCV) values less than the lower
limit of reference range for age, serum iron (50 lg/dL),
serum ferritin (10 lg/L), and transferrin saturation
(12%).
All specimens were run on the LH 750 (Beckman
Coulter Inc) and on the Sysmex XT 2000i analyzer
(Sysmex Corporation of America, Long Grove, Illinois,
USA) within 3 h of collection for a complete blood
cell count (CBC) including reticulocytes. Biochemical
iron metabolism markers such as serum iron, serum
transferrin (Tf), serum ferritin (Ft), and percentage of
transferrin saturation (% Sat) were also analyzed.
Serum iron and serum transferrin were assayed with
the Vitros 5.1 (Johnson Johnson), and serum ferri-
tin was determined by MEIA (Axsym Abbott).
Statistical analysis
Data were evaluated using STATISTIX for Windows
software package version 8.0 (Analytical Software,
Tallahassee, FL, USA). To assess the normality of the
variables, the Shapiro–Wilk normality test was used.
A P value 0.05 implies that the data were sampled
from a non-Gaussian distribution. When the parame-
ters under study presented a Gaussian distribution,
correlation coefficients were calculated by Pearson’s
method; independent samples t-test was performed to
detect statistical deviations between the groups of
patients. When the parameters under study presented
a non-Gaussian distribution, correlation coefficients
were calculated by Spearman’s method and indepen-
dent samples Mann–Whitney U-test was performed.
The top 97.5 and bottom 2.5 percentiles were used as
the limits of the reference range obtained in the group
of healthy children (95 central percentiles of the
distribution of the recorded values).
Box and whisker plots were created to display the
distributions of RSf and LHD% levels of control and IDA
groups. Statistical significance was defined as P 0.05.
Receiver operating characteristic (ROC) curve analysis
was used to evaluate the diagnostic performance of
ferritin, serum iron, transferrin,%Sat, Ret-He, RSf and
LHD% for differential diagnosis of iron-deficiency
anemia. Cutoff values were established based on the
optimal combination of sensitivity and specificity.
RESULTS
The study population included children and adoles-
cents between 6 months and 18 years of age (mean
age 9.1 Æ 4.6 years). Hematological data and mean
values obtained for RSf and LHD% for both patient
groups are shown in Table 1.
RSf showed a normal distribution (P = 0.058)
(Figure 1a). We found statistically significant correla-
tion of RSf with age (r = 0.384, P 0.01); thereby to
establish reference ranges, we considered two age-
groups. In the healthy group between 6 months and
6 years (n = 75), the reference range for RSf was 82.2–
102.0 fl (95 central percentiles of the distribution of
the recorded values) and in the healthy group between
6 and 18 years (n = 125), the reference range for RSf
was 83.7–103.1 fl, being the mean difference between
both groups statistically significant (P 0.05).
Low hemoglobin density (LHD %) values showed a
non-Gaussian distribution (P 0.001) (Figure 1b). Refer-
ence range was 1.1–9.0% (95 central percentiles of the
distribution of the recorded values). No correlation was
found between ages and LHD% (r = 0.1069, P = 0.1463).
© 2012 Blackwell Publishing Ltd, Int. Jnl. Lab. Hem.
V. OSTA ET AL. | NEW MATURE ERYTHROCYTE AND RETICULOCYTE INDICES 3

4. The values of RSf and LHD% for control and IDA
groups are shown in Table 1. RSf values were signifi-
cantly lower in patients with IDA compared with
healthy children (79.0 vs. 91.9 fl, P 0.01), and LHD
% values were higher in IDA than in the control
group (15.0 vs. 4.0%, P 0.01) (Figure 2a,b).
Good correlation was found between RSf and RET-He
(r = 0.888 P 0.001) in the entire population (n = 251).
On the other hand, LHD% showed a significant inverse
correlation with Ret-He (r = À0.790, P 0.001).
To evaluate clinical usefulness of RSf and LHD% to
diagnose restricted erythropoiesis due to iron defi-
ciency, the ROC curves were analyzed (Figure 3). The
best RSf value to detect a restricted erythropoiesis
state was 89 fl, showing a sensitivity of 92% and a
specificity of 81%. The AUC was 0.8460 (CI 95%
0.7963–0.8956, P 0.0001). For LHD%, the optimal
cutoff point was 6% and provided a sensitivity of
80% and a specificity of 88% and an AUC of 0.8654
(CI 95% 0.8157–0.9151, P 0.0001). Ret-He showed
the best AUC 0.9489 (CI 95% 0.9144–0.9833,
P 0.0001) among considered indices. The AUC for
serum iron was 0.8910 (CI 95% 0.8276–0.9545,
P 0.0001) and for Sat% 0.8988 (CI 95% 0.8393–
0.9584, P 0.0001). Serum ferritin showed the lowest
AUC 0.6504 (CI 95% 0.5516–0.7493, P = 0.009).
DISCUSSION
Although transferrin saturation and ferritin are the
most widely used markers of iron status, both have
significant limitations.
In the last years, there has been much interest in
the potential use of new reticulocyte parameters in
the diagnosis of anemia and the monitoring of the
erythropoiesis activity of bone marrow [14, 22, 23].
The CHr is a direct measure of iron incorporated
into nascent red blood cells. Its reduction indicates
iron-deficiency erythropoiesis, even in conditions in
Table 1. Hematological parameters in 200 healthy
children and adolescents, and 51 iron deficiency
anemia (IDA) patients
Healthy
controls IDA
Age (years) 7.9 (4.8) 6.1 (3.2)
Hb (g/L) 129 (9) 107 (17)*
Hct (%) 38.5 (2.7) 30.6 (4.6)*
MCV (fl) 84.1 (4.9) 67.9 (8.3)*
MRV (fl) 99.0 (0.6) 98.1 (1.1)
RSf (fl) 91.9 (5.0) 79.0 (7.7)*
LHD% 4.0 (0.9–10.5) 15.0 (2.3–73.8)*
RET-He (pg) 32.0 (1.7) 25.5 (4.1)*
Values of LHD% are median (range); the remaining
parameters are reported as mean (standard deviation).
MCV, mean corpuscular volume; MRV, mean reticulo-
cyte volume; RSf, red blood cell size factor; LHD%, low
hemoglobin density%; Ret-He, reticulocyte hemoglobin
equivalent; IDA, Iron deficiency anemia.
*0.01 vs. controls.
(a) (b)
Figure 1. Panel (a): Red blood
cell size factor (RSf) distribution
values in a population of 200
healthy children. Panel (b): low
hemoglobin density (LHD%)
distribution values in a
population of 200 healthy
children.
(a) (b)
Figure 2. Box and whisker plot showing red blood cell
size factor (RSf) (panel a) and low hemoglobin
density (LHD%) (panel b) distribution in the control
and iron deficiency anemia (IDA) groups.
© 2012 Blackwell Publishing Ltd, Int. Jnl. Lab. Hem.
4 V. OSTA ET AL. | NEW MATURE ERYTHROCYTE AND RETICULOCYTE INDICES

5. which traditional biochemical markers such as ferritin
are inadequate.
In a group of 210 pediatric patients, mean age
2.9 years, undergoing routine office visits, CHr
emerged as the strongest predictor of iron deficiency
and iron-deficiency anemia [24]. Another test that
has been used for the study of anemia is the percent-
age of hypochromic red cells, which is a test of
hemoglobin concentration, reflects iron availability
and is a sensitive method for quantitating the hemo-
globinization of mature red blood cells [25].
Some studies have shown the utility of measuring
the mean corpuscular volume of reticulocytes (MCVr).
MCVr increases rapidly following iron therapy and
decreases equally as rapidly with the development of
iron-deficient erythropoiesis [26]. It has also been
noted that a sudden increase in MCVr/MCV ratio was
one of the earliest signs of erythropoietic response
after bone marrow transplantation [27].
RSf could allow the detection of those patients with
inefficient or restricted erythropoiesis due to iron defi-
ciency or alterations in globin chain synthesis and differen-
tiate them from those with chronic disease anemia [18].
RSf showed a very acceptable correlation with
another reticulocyte parameter previously validated
such as the CHr and Ret-He [18, 20].
The reference range found for RSf was slightly
lower than the previously reported in adults [18, 20].
These differences may be attributable to the transient
physiologic decrease in MCV and MCH observed
during the first 2 years of life.
RSf values obtained in the IDA group were statisti-
cally lower than the control group. The optimal cutoff
point for the detection of iron deficiency was 89 fl,
which provided and AUC of 0.8460.
Although MCV and RSf have similar behaviors and
showed to be significantly lower in patients with iron
deficiency than in healthy controls, the advantage of
RSf is that this parameter includes the reticulocyte
mean volume. These cells have a lifespan of 24–48 h
compared to mature red cells (120 days), providing a
‘snapshot’ of the bone marrow erythropoietic activity.
In the same way, LHD% reference range also was
slightly higher than the previously reported [19].
Low hemoglobin density % values obtained in the
IDA group were statistically higher than the control
group. The optimal cutoff point for the detection of
iron deficiency was 6%, which provided and AUC of
0.8654.
Although cutoff values for RSf and LHD% defined
in this study are included within the normal range, it
shows high sensitivity and specificity to be considered
useful markers for the screening of IDA.
These results raised the possibility to meet diagnosis
of iron deficiency in early childhood from the analysis
of hematimetric indices, without the need for bio-
chemical studies.
RSf and LHD% could be useful tools in the screen-
ing of iron-deficiency anemia, and samples with RSf
less than 89 fl or LHD% 6% could be chosen for
further analysis to confirm the diagnosis of iron
deficiency.
These new parameters can be obtained in the
course of routine blood counts, with no additional
cost or needs of more blood sampling. This is a funda-
mental aspect in pediatric population.
Further considerations are necessary regarding the
possible clinical use of these new parameters that
have not yet reached their full potential.
CONFLICT OF INTEREST
The authors declare that there is no conflict of
interest.
Figure 3. Receiver operating characteristic (ROC)
curve analysis for red blood cell size factor (RSf), low
hemoglobin density (LHD%), reticulocyte
hemoglobin equivalent (Ret-He), serum iron, serum
ferritin and percentage of transferring saturation
(Sat%) for the detection of iron deficiency anemia.
© 2012 Blackwell Publishing Ltd, Int. Jnl. Lab. Hem.
V. OSTA ET AL. | NEW MATURE ERYTHROCYTE AND RETICULOCYTE INDICES 5

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