**3. Results**

From total patient in our study, a minority of patients, 36 patients (40%) had normal results for all hematological tests under monitoring treatment of specialty. In type of anemia from kidney chronic diseases, an additional 16 (18%) patients had normal HGB and HCT, but low MCV or MCH ((mean value 72 fL, SD= 2.1) or MCH (mean value 24.3pg, SD= 1.6). Other 28 patients (31%) had mild anemia (HGB decreased but > 106 g/L), while only 10 patients (11%) have had severe anemia. All individuals in the group with severe anemia had low RET (mean value 1.2%, range 0.5-1.5%), and RPI in mean value of <1.4, indicating a hyporegenerative type of anemia.

cytoplasm and release small particles. This may lead to the erroneous detection of platelets

Recognizing erroneous results of platelet counts is especially critical for a consistent decision in the diagnosis of disseminated intravascular coagulation (DIC) and for clinical decision

The platelet count is an indispensable parameter in the DIC scoring system proposed by the International Society on Thrombosis and Hemostasis Sub-Committee of the Scientific and Standardization Committee on DIC, in which platelet counts of less than 100 × 103/μL (100 × 109/L) and less than 50 × 103/μL (50 × 109/L) would score 1 and 2 points, respectively. [15, 16] The samples were assessed for platelet count by statistical parameters: [SD = (Xi- Xm )2 /n – 1; accuracy: (%Diff = X average – X target/ X mean x 100, with normal value until + − 25) and Z score( Z = X average-X target/SD, with normal value until +-2,

From total patient in our study, a minority of patients, 36 patients (40%) had normal results for all hematological tests under monitoring treatment of specialty. In type of anemia from kidney chronic diseases, an additional 16 (18%) patients had normal HGB and HCT, but low MCV or MCH ((mean value 72 fL, SD= 2.1) or MCH (mean value 24.3pg, SD= 1.6). Other 28 patients (31%) had mild anemia (HGB decreased but > 106 g/L), while only 10 patients (11%) have had severe anemia. All individuals in the group with severe anemia had low RET (mean value 1.2%, range 0.5-1.5%), and RPI in mean value of <1.4, indicating a hypo-

when using the microscopy owing to their deformed morphology.

Fig. 1.

**3. Results** 

making regarding transfusion.

regenerative type of anemia.

R>0.95%), for average platelets 150-400 x10³/μl, 95% CI.].

To the 54 patients with anemia of chronic kidney diseases (ACKD) and chronic renal failure( CRF) were registered in 30.90% of cases normal TIBC values (mean value 282 microgram/ d L, SD=2.5), low RPI in mean value of 1.33, low IST in mean value of 7.62%, with middle ineffective erythropoiesis and moderate iron deficiency anemia (IDA) and to 19.10 % of patients with ACKD and CRF associated with renal inflammations, were calculated low RPI, in mean value of 1.21, high TIBC value (mean value 468 microgram/d L, SD =2.4) and low IST in mean value of 6.5%, with severe ineffective erythropoiesis and severe IDA.

In biochemical field, in this study on this cohort of hemodialysis patients, was obtained the variability of plasma osmolality past normal individual values (310 Osm/l), in the samples taken from the patients with chronic renal failure because of high values of Urea nitrogen (mean value 112 mg%; 40 mmol/L; SD = 2.40); Creatinine (mean value 5.5 mg/%; 4.85 mmol/L); SD=0.15); Sodium (mean value 170 mmol/L; SD=0.14); Potassium (mean value 14.5 mmol/l; SD=2.88); E CO2 (mean value 11 mmol/L; SD=0.26). Prevalence of anemia to patients admitted in hospital for undergoing schedules of hemodialysiss have been registered in percents: 60% of cases, with normochromic-normocytic anemia, 30% of cases with microcytic-hypochomic anemia and nutritional iron deficiency, 7% of cases with aplastic anemia and 3% with macrocytic and vitamin B12 deficiency.

In cases with microcytic-hypochomic anemia and nutritional iron deficiency were registered by this study that mean corpuscular volume (MCV) of red cells decreases below normal value before that the hemoglobin to be decreased under normal value. Iron deficiency anemia associated with ACKD was presented in three forms:


In the two cases of study were registered suspect flags on Coulter HMX: neutropenia, lymphopenia and increased MCV erythrocyte index (109 f L). On blood smear from peripheral blood, in optic microscopy the reticulocyte count was decreased (0.4%), and neutrophil granulocytes showed multi-segmented nuclei, macrocytes (larger than normal RBCs) presence of ovalocytes (oval-shaped RBC) but Howell-Jolly bodies(chromosomal remnant) was absented. An elevated MCV should not be ignored because the patient is especially suspected of alcohol abuse. Blood chemistries will also showed: an increased lactic acid dehydrogenase (LDH) values of .increased of homocysteine, folic and vitamin B12 deficiency.

Bone marrow (checked in a patient suspected of megaloblastic anemia on hematological analyzer, in 3% from cases) showed megaloblastic hyperplasia~ 45%, ploycromathopil and acidophil erythroblasts with megaloblastic character, large metamielocytes and giant band forms. Biopsy results from gastric mucosa showed lesions of chronic gastritis, non-atrophic epithelium and the patient was receiving the recommendation from clinician doctor to assess B12 vitamin.

Variability of Biological Parameters in Blood Samples

Graphic 1. Levels of HGB, RBC and HTC in chromic renal failure

with respect to morphological aspects of platelets.

The performance of devices used was assessed by **Z score = < 1 = optic performance; 1 < Z < 2 = good performance; 2 < Z < 3 = satisfactory performance and Z > 3 =unsatisfactory performance.** In parallel, we assessed platelet count using the peripheral blood smear and found that it provided information that was complentary to the other methods, especially

Counting thrombocytes on slide from peripheral blood smear is necessary in quantitative platelet disorders, as isolated thrombocytopenia: immune versus nonimmune, thrombocytopenia associated with other hematological abnormalities or in differential diagnosis with platelet clump, thrombocytosis and qualitative disorders, as giant platelets (megathrombocytes), platelet inclusion or granule abnormalities, bizarre in shape and size.

mmol/L; SD=0.26). (Table3. Graphic 2)

Between Two Consecutive Schedules of Hemodialysis 111

SD=0.15); Sodium (170 mmol/L; SD=0.14); Potassium (14.5 mmol/l; SD=2.88); E CO2 (11

Diagnosis in all these patients has been established in collaboration with clinician doctors from department of hospitals in the system of evidence based medicine, on data encompassed in observation daily sheet of patients.

The suspect cases with hemolytic anemia were verified on biochemistry panel (unconjugated bilirubin, LDH) and in hematological field by Coombs test direct (DET ) and indirect,reticulocytes presented in elevated number, haptoglobin levels decreased, also increased urobilinogen in urine analysis.

The bone marrow aspiration was performed by sternum bone puncture, to 7 patients with suspect chronic refractory anemia from myelodisplastic syndrome on evidence of aspect of peripheral smear with neutropenia, anemia and thrombocytopenia, (low cell counts of white and red blood cells, and platelets, respectively) with blast count <5% in the peripheral blood, beside macrocytosis and microcytosis. The morphological abnormality was observed in the granulocytes. These included bi-lobed or un-segmented nuclei (pseudo–Pelger-Huet abnormality) and granulation abnormalities in vary from.

After this aspect the clinician doctors recommended bone morrow puncture to National Institute of Reference Hematological Diseases, City Bucharest, (Romania). Was excluded the diagnosis of acute myeloid leukemia when < 20% blasts was observed on blood smear of bone morrow. In severe cases, red blood cells in eliptocytes forms accompanied microcytic and hypochromic cells on blood film. Low SI, IST%, and SF combined with elevated RDW, TIBC suggest IDA and this type of anemia must be differentiated from uncomplicated anemia from ACKD. An association between, HCT, HGB and RBC (Graphic 1) or HCT, TIBC, RPI and IST (Table 1) can be applied and in assessment of anemia from chronic diseases taken in this study.


Table 1. Correlation between Hematocrit (HTC), Reticulocytes Production Index (RPI) Total Iron Binding Capacity (TIBC) and Index Saturation Transferrin (IST) in Anemia of Chronic Renal Failure

The platelet count determined on the peripheral blood smear was used to complement data from the quantitative methods and provided morphological information.

The comparison between the platelet counts on the Coulter HMX (mean value X⎯ = 233 x 10³μl; p=0.028; SD=2; % Diff=0.90; Z score = - 0.30) and by optical microscopy (X⎯ = 250 x 10³μl; p=0.029; SD= 2.6; %Diff = -3.6; Z score =0.40) yielded similar values in a control group (120 male and female healthy subjects, ages 25-55 years( mean age 40).

For the dialysis patients, we found that results for platelet counts with the Coulter HMX, before and after hemodialysis were similar: (pre-dialysis mean X⎯= 230 10³ μl; p=0.024; SD=3.45; % Diff = -4.53; Z score =2.5; post dialysis mean X⎯= 245 x 10³μl; p=0.034; SD=2.1; %Diff = 6.34; Z score = 0.10) but differences appeared if counting was done using optical microscopy (pre-dialysis mean X⎯=261 x 10³μl; p = 0.020; SD=7.1; %Diff= 5.90; Z score=3.90); post-dialysis mean X⎯ = 167 x 10 ³μl; p = 0.6; SD=4.2; %Diff= -7.10; Z score= -2.90). Table 2

The latter results may be attributable to the variability of plasma osmolality in the samples taken from the patients with chronic renal failure: Glucose (98mg%; 5.44mmol/L; SD=2.80); Urea nitrogen (112 mg%; 40 mmol/L; SD = 2.40); Creatinine (5.5 mg/%; 4.85 mmol/L);

Diagnosis in all these patients has been established in collaboration with clinician doctors from department of hospitals in the system of evidence based medicine, on data

The suspect cases with hemolytic anemia were verified on biochemistry panel (unconjugated bilirubin, LDH) and in hematological field by Coombs test direct (DET ) and indirect,reticulocytes presented in elevated number, haptoglobin levels decreased, also

The bone marrow aspiration was performed by sternum bone puncture, to 7 patients with suspect chronic refractory anemia from myelodisplastic syndrome on evidence of aspect of peripheral smear with neutropenia, anemia and thrombocytopenia, (low cell counts of white and red blood cells, and platelets, respectively) with blast count <5% in the peripheral blood, beside macrocytosis and microcytosis. The morphological abnormality was observed in the granulocytes. These included bi-lobed or un-segmented nuclei (pseudo–Pelger-Huet

After this aspect the clinician doctors recommended bone morrow puncture to National Institute of Reference Hematological Diseases, City Bucharest, (Romania). Was excluded the diagnosis of acute myeloid leukemia when < 20% blasts was observed on blood smear of bone morrow. In severe cases, red blood cells in eliptocytes forms accompanied microcytic and hypochromic cells on blood film. Low SI, IST%, and SF combined with elevated RDW, TIBC suggest IDA and this type of anemia must be differentiated from uncomplicated anemia from ACKD. An association between, HCT, HGB and RBC (Graphic 1) or HCT, TIBC, RPI and IST (Table 1) can be applied and in assessment of anemia from chronic diseases taken in this study.

**HTC % RPI TIBC microgram/d L IST %**  35 - 30 1.52 225 29.1 29 - 25 1.33 282 7.62 24 - 18 1.21 468 6.5 Table 1. Correlation between Hematocrit (HTC), Reticulocytes Production Index (RPI) Total Iron Binding Capacity (TIBC) and Index Saturation Transferrin (IST) in Anemia of Chronic

The platelet count determined on the peripheral blood smear was used to complement data

The comparison between the platelet counts on the Coulter HMX (mean value X⎯ = 233 x 10³μl; p=0.028; SD=2; % Diff=0.90; Z score = - 0.30) and by optical microscopy (X⎯ = 250 x 10³μl; p=0.029; SD= 2.6; %Diff = -3.6; Z score =0.40) yielded similar values in a control group

For the dialysis patients, we found that results for platelet counts with the Coulter HMX, before and after hemodialysis were similar: (pre-dialysis mean X⎯= 230 10³ μl; p=0.024; SD=3.45; % Diff = -4.53; Z score =2.5; post dialysis mean X⎯= 245 x 10³μl; p=0.034; SD=2.1; %Diff = 6.34; Z score = 0.10) but differences appeared if counting was done using optical microscopy (pre-dialysis mean X⎯=261 x 10³μl; p = 0.020; SD=7.1; %Diff= 5.90; Z score=3.90); post-dialysis mean X⎯ = 167 x 10 ³μl; p = 0.6; SD=4.2; %Diff= -7.10; Z score= -2.90). Table 2 The latter results may be attributable to the variability of plasma osmolality in the samples taken from the patients with chronic renal failure: Glucose (98mg%; 5.44mmol/L; SD=2.80); Urea nitrogen (112 mg%; 40 mmol/L; SD = 2.40); Creatinine (5.5 mg/%; 4.85 mmol/L);

from the quantitative methods and provided morphological information.

(120 male and female healthy subjects, ages 25-55 years( mean age 40).

encompassed in observation daily sheet of patients.

abnormality) and granulation abnormalities in vary from.

increased urobilinogen in urine analysis.

Renal Failure

SD=0.15); Sodium (170 mmol/L; SD=0.14); Potassium (14.5 mmol/l; SD=2.88); E CO2 (11 mmol/L; SD=0.26). (Table3. Graphic 2)

Graphic 1. Levels of HGB, RBC and HTC in chromic renal failure

The performance of devices used was assessed by **Z score = < 1 = optic performance; 1 < Z < 2 = good performance; 2 < Z < 3 = satisfactory performance and Z > 3 =unsatisfactory performance.** In parallel, we assessed platelet count using the peripheral blood smear and found that it provided information that was complentary to the other methods, especially with respect to morphological aspects of platelets.

Counting thrombocytes on slide from peripheral blood smear is necessary in quantitative platelet disorders, as isolated thrombocytopenia: immune versus nonimmune, thrombocytopenia associated with other hematological abnormalities or in differential diagnosis with platelet clump, thrombocytosis and qualitative disorders, as giant platelets (megathrombocytes), platelet inclusion or granule abnormalities, bizarre in shape and size.

Variability of Biological Parameters in Blood Samples

Between Two Consecutive Schedules of Hemodialysis 113

Graphic 2. Biochemical parameters of chronic renal failure which are frequently increased in

Chronic Kidney Diseases (CKD)

The control group to 40 potential health persons (20 adult men and 20 adult females), on hematological analyzer Coulter HMX, was next results (mean value), form men: WBC=9700/dL, RBC=4500 000/dLHGB=13,9g/dL, MCV= 90 f L, RDW=13.5%, MCV = 29 f L, MCHC = 34%) and for women WBC=95/dL, RBC=4200 000/dL, HGB=12,5g/dL, MCV= 80 f L, RDW=14.5%, MCV = 27 f L, MCHC = 30%) [Sensitivity = (35/ 40) x 100 = 87.50%].

In biochemistry field, normal results of the same group control were registered next results: Creatinine, 1.2 mg/dl, with SD=0.15,CV%=29, accuracy [Z] =-1.36; Iron, 100 microgram/dl, SD=2.88, CV%=1.8, Z=-0.56; Phosphate, 27.mEq/dl, SD=0.14.CV%=2.2, Z=-0.8; Urea, 40mg/dl, SD=2.40, CV=2.2, Z=-0.13; Uric acid, 8mg/dl, SD=0.26; CV=3.2, Z=-0.79; [Normal Z = ±2 in Control of Levey Jennings Chart.].

The precision to our cohort in study was registered as next results: CV < 2% for RBC, CV < 1% for HGB and CV < 2% for HCT, (Accuracy: r > 0.95 for HGB and HCT, 95% CI), mean SD=2.2 and p=0.04 for HGB, mean SD = ± 2.5 and p < 0.05 for MCV in CBC, MCHC with CV =2%, MCH with CV=1.5%, RDW with CV = 3%. [Specificity = (124/140) x 100 = 88%]. Positive predictive value (107/124) = 86%.


Table 2. Assessment of performances for methods used in platelets count to patients with Chronic Renal Failure, undergoing dialysis

Functional ID was closely related to the production of hypochromic red cells, and measurement of red cells hemoglobinization provides a sensitive method for determining the quantity of circulating iron incorporated into the red blood cells which, reflect recent changes in erythropoiesis.

The control group to 40 potential health persons (20 adult men and 20 adult females), on hematological analyzer Coulter HMX, was next results (mean value), form men: WBC=9700/dL, RBC=4500 000/dLHGB=13,9g/dL, MCV= 90 f L, RDW=13.5%, MCV = 29 f L, MCHC = 34%) and for women WBC=95/dL, RBC=4200 000/dL, HGB=12,5g/dL, MCV= 80 f L, RDW=14.5%, MCV = 27 f L, MCHC = 30%) [Sensitivity = (35/ 40) x 100 =

In biochemistry field, normal results of the same group control were registered next results: Creatinine, 1.2 mg/dl, with SD=0.15,CV%=29, accuracy [Z] =-1.36; Iron, 100 microgram/dl, SD=2.88, CV%=1.8, Z=-0.56; Phosphate, 27.mEq/dl, SD=0.14.CV%=2.2, Z=-0.8; Urea, 40mg/dl, SD=2.40, CV=2.2, Z=-0.13; Uric acid, 8mg/dl, SD=0.26; CV=3.2, Z=-0.79; [Normal

The precision to our cohort in study was registered as next results: CV < 2% for RBC, CV < 1% for HGB and CV < 2% for HCT, (Accuracy: r > 0.95 for HGB and HCT, 95% CI), mean SD=2.2 and p=0.04 for HGB, mean SD = ± 2.5 and p < 0.05 for MCV in CBC, MCHC with CV =2%, MCH with CV=1.5%, RDW with CV = 3%. [Specificity = (124/140) x 100 = 88%].

> **Microscopy Normal Patients**  ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,, X⎯ = 250 x 10³µl; p=0.029; SD= 2.6; %; Diff = -3.6; Z score =0.40.

**Optic Microscopy Patients with CRF before connected to dialysis devices**  ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,, X⎯=261 x 10³µl; p = 0.020; SD=7.1; %; Diff= 5.90; Z score=3.90

**Optic Microscopy Patients disconnected from dialysis devices** ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,, X⎯ 167 x 10 ³ µl; p = 0.6; SD=4.2; %; Diff= -7.10; Z score= -2.90

Table 2. Assessment of performances for methods used in platelets count to patients with

Functional ID was closely related to the production of hypochromic red cells, and measurement of red cells hemoglobinization provides a sensitive method for determining the quantity of circulating iron incorporated into the red blood cells which, reflect recent

**Microscopy Normal slide blood** ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,, X⎯ = 240 x 10³ µl;CV=5.3%, SD= 12.7; %; Diff= 8.30; Z score= 3.33;

**Microscopy slides Patients with CRF before connected to dialysis devices**  ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,, X⎯ = 275 x 10³ µl; CV=5%; SD= 13.75; %; Dif= 15.75; Z score = -3.46,

**Microscopy slides Patients disconnected from dialysis devices** ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,, X⎯ =190 x10³ µl;CV=4.6%; SD= 8.74; %Diff =18; Z score =7.60;

87.50%].

Z = ±2 in Control of Levey Jennings Chart.].

Positive predictive value (107/124) = 86%.

**Coulter HMX Normal Patients;**  ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,, X⎯ = 233 x 10³µl; p=0.028; SD=2; %; Diff=0.90; Z score = - 0.30;

**Coulter HMX Patients with CRF before connected to dialysis devices**  ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,, X⎯=230 x10³ µl; p=0.024; SD=3.45; % Diff = -4.53; Z score =2.5),

**Coulter HMX Patients disconnected from dialysis devices** ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,, X⎯= 245 x 10³ µl; p=0.034; SD=2.1; %; Diff = 6.34; Z score = 0.10),

changes in erythropoiesis.

Chronic Renal Failure, undergoing dialysis

Graphic 2. Biochemical parameters of chronic renal failure which are frequently increased in Chronic Kidney Diseases (CKD)

Variability of Biological Parameters in Blood Samples

precede the onset of microcytosis.

concentration.

span of erythrocytes.

carrier. (Graphic 3)

reserves are depleted and not.

Between Two Consecutive Schedules of Hemodialysis 115

significant deposition of tissue iron. TS levels increase as additional iron is accumulated. A

Current guidelines from the American College of Physicians include a normal level of TSI encompassed between 20-40%, a cut off level of TSI >55% identifying iron overload and TSI < 15% meaning IDA. Red distribution width (RDW) is a mathematical expression of size variation used to quantify anisocytosis. The higher the RDW means the greater the anisocytosis. Increased RDW may be an early indication of iron deficiency, where it may

These measurements, known as erythrocyte or red blood cell indices, provide an important information about various types of anemia. If the MCV is low, the cells are microcytic or smaller than normal. Microcytic red blood cells have been seen in iron deficiency anemia and thalassemia minor. If the MCV is high, the cells are macrocytic, or larger than normal. Macrocytic red blood cells were associated with pernicious anemia or folic acid deficiencies. If the MCV is within the normal range, the cells are referred to as normocytic and nomocytic anemia was met with more frequency in chronic diseases/inflammation, small MCH under 27% show hypocromic erythrocytes, frequently encountered in IDA. In the same correlation with MCHC less than 32% indicates that the red blood cells are deficient in hemoglobin

This situation is most often seen with iron deficiency anemia. RDW is a measurement of anisocytosis. IDA and thalassemia are both microcytic-hypochromic anemia. As screening tests for discovery of anemia to elderly we used, beside additional tests, erythrocytes indexes such as MCV, MCH, and RBC number to distinguish this anemia types. MCH is just the equivalent of Retyculocites –Hemoglobin (Ret-He) that indicates the long term of life

Both serum transferrin receptor and erythrocyte zinc protoporphyrin have been demonstrated to be useful in a variety of clinical situations. Serum transferrin receptor can be best used in diagnosing iron disorders, especially for patients with pathologies that may affect iron metabolism. Erythrocyte zinc protoporphyrin can be best used as a primary screening test for assessing iron status, especially in patients likely to have uncomplicated

Other anemia, most notably thalassemia, are also characterized by low MCV, MCH, MCHC and additional tests are needed for confirmation of thalassemia Patient with a ratio target cells/normal cells > 1% in low power field and with >20% microcytic red cells on blood film ( magnification x 400), were suspicious for beta-thalssemia. RBC count result higher in thalassemia minor group in comparison with IDA. Microcytic, hypochromic and polyglobulia are more evident in thalassemia minor compared with IDA and hemoglobin and hematocrit can be normally but only MCV and MCH decreased in thalassemia silent

The bone morrow hemosiderrin and microscopic bone marrow examination have been recommended in clinical management in most elderly patients with anemia in Mielodysplastic Syndrome (MDS) The problems in diagnostic anemia occurs when the iron

The peptide hormone Hepcidin appears to play a central role in the pathogenesis of the anemia of chronic disease, but is extremely difficult to measure in the serum. Thus the "anemia of chronic disease" may include patients with a variety of patho-physiological mechanisms. The peptide hormone Hepcidin, secreted by the liver, controls plasma iron concentration by inhibiting iron export from macrophages cells(cut off, 15 ng/d L, Elisa

iron deficiency hemoglobin status and life span of erythrocytes [18].

drawback to using the TS is that it is dependent on performing both the SI and TIBC.


Table 3.Values of biochemical and hematological parameters in blood samples from patients with Chronic Renal Failure, undergoing the schedules of dialysis
