Red blood cell indices

Definition

Red blood cell (RBC) indices are calculations derived from the complete blood count that aid in the diagnosis and classification of anemia. Measurements needed to calculate indices are the red blood cell count, hemoglobin, and hematocrit. The hematocrit is the percentage of blood by volume that is occupied by the red cells. The three RBC indices are:

• Mean corpuscular volume (MCV). The average size of the red blood cells expressed in femtoliters. MCV is calculated by dividing the hematocrit (as percent) by the RBC count in millions per microliter of blood, then multiplying by 10.
• Mean corpuscular hemoglobin (MCH). The average amount of hemoglobin inside an RBC expressed in picograms. The MCH is calculated by dividing the hemoglobin concentration in grams per deciliter by the RBC count in millions per microliter, then multiplying by 10.
• Mean corpuscular hemoglobin concentration (MCHC). The average concentration of hemoglobin in the RBCs expressed as a percent. It is calculated by dividing the hemoglobin in grams per deciliter by the hematocrit, then multiplying by 100.

Purpose

Red blood cell indices help classify types of anemia, a decrease in the oxygen carrying capacity of the blood. Healthy people have an adequate number of correctly sized red blood cells containing enough hemoglobin to carry sufficient oxygen to all the body's tissues. Anemia is diagnosed when either the hemoglobin or hematocrit of a blood sample is too low.

The mechanisms by which anemia occurs will alter the RBC indices in a predictable manner. Therefore, the RBC indices permit the physician to narrow down the possible causes of an anemia. The MCV is an index of the size of the RBCs. When the MCV is below normal, the RBCs will be smaller than normal and are described as microcytic. When the MCV is elevated, the RBCs will be larger than normal and are termed macrocytic. RBCs of normal size are termed normocytic. Failure to produce hemoglobin results in smaller than normal cells. This occurs in many diseases, including iron deficiency anemia , thalassemia (an inherited disease in which globin chain production is deficient), and anemias associated with chronic infection or disease. Macrocytic cells occur when division of RBC precursor cells in the bone marrow is impaired. The most common causes of macrocytic anemia are vitamin B ₁₂ deficiency, folate deficiency, and liver disease. Normocytic anemia may be caused by decreased production (e.g. malignancy and other causes of bone marrow failure), increased destruction (hemolytic anemia), or blood loss. The RBC count is low, but the size and amount of hemoglobin in the cells are normal.

A low MCH indicates that cells have too little hemoglobin. This is caused by deficient hemoglobin production. Such cells will be pale when examined under the microscope and are termed hypochromic. Iron deficiency is the most common cause of a hypochromic anemia. The MCH is usually elevated in macrocytic anemias associated with vitamin B ₁₂ and folate deficiency.

The MCHC is the ratio of hemoglobin mass in the RBC to cell volume. Cells with too little hemoglobin are lighter in color and have a low MCHC. The MCHC is low in microcytic, hypochromic anemias such as iron deficiency, but is usually normal in macrocytic anemias. The MCHC is elevated in hereditary spherocytosis, a condition with decreased RBC survival caused by a structural protein defect in the RBC membrane.

Description

Cell indices are usually calculated from tests performed on an automated electronic cell counter. However, these counters measure the MCV, which is directly proportional to the voltage pulse produced as each cell passes through the counting aperture. Electronic cell counters calculate the MCH, MCHC, hematocrit, and an additional parameter called the red cell distribution width (RDW). The RDW is a measure of the variance in red blood cell size. It is calculated by dividing the standard deviation of RBC volume by the MCV and multiplying by 100. A large RDW indicates abnormal variation in cell size, termed anisocytosis. The RDW aids in differentiating anemias that have similar indices. For example, thalassemia minor and iron deficiency anemia are both microcytic and hypochromic anemias, and overlap in MCV and MCH. However, iron deficiency anemia has an abnormally wide RDW, but thalassemia minor does not.

Precautions

Certain prescription medications may affect the test results. These drugs include zidovudine (Retrovir), phenytoin (Dilantin), and azathioprine (Imuran). When the hematocrit is determined by centrifugation, the MCV and MCHC may differ from those derived by an electronic cell counter, especially in anemia. Plasma trapped between the RBCs tends to cause an increase in the hematocrit, giving rise to a somewhat higher MCV and lower MCHC.

RBC indices require 3–5 mL of blood collected by venipuncture. A nurse or phlebotomist usually collects the sample following standard precautions for the prevention of transmission of bloodborne pathogens.

Aftercare

Discomfort or bruising may occur at the puncture site. Pressure to the puncture site until the bleeding stops reduces bruising; warm packs relieve discomfort. Some people feel dizzy or faint after blood has been drawn and should be treated accordingly.

Risks

The risks are potential bruising at the puncture site, and mild dizziness . Rarely excess bleeding, or infection of the puncture site occurs.

Normal results

Normal results for red blood cell indices are as follows:

• MCV: 78–102 fl (femtoliters) for ages 12–18 years, 77–95 fl for ages six to 12 years, 75–87 fl for ages two to six years, 70–86 fl for ages six months to two years, 85–123 fl for age one month
• MCH: 25–35 pg (picograms) for ages 12–18 years, 25–33 pg for ages six to 12 years, 24–30 pg for ages two to six years, 23–31 pg for ages six months to two years, 28–40 pg for age one month
• MCHC: 31–37 g/dL for ages two to 18 years, 30–36 g/dL for ages six months to two years, 29–37 pg for age one month
• RDW: 12–15 percent

Parental concerns

The pain from the needle puncture only lasts a moment. The parent should comfort a child as needed. Older children can be prepared for the test ahead of time, and the reason why the test is being given should also be explained if the child is old enough to understand.

When to call a doctor

If the bleeding does not stop at the needle puncture site, or if hours to days later, there appears to be infection (redness and swelling), then parents should contact a doctor.

Resources

BOOKS

Chernecky, Cynthia C., and Barbara J. Berger. Laboratory Tests and Diagnostic Procedures, 3rd ed. Philadelphia, PA: W. B. Saunders Company, 2001.

Kee, Joyce LeFever. Handbook of Laboratory and Diagnostic Tests, 4th ed. Upper Saddle River, NJ: Prentice Hall, 2001.

Kjeldsberg, Carl, et al. Practical Diagnosis of Hematologic Disorders, 3rd Ed. Chicago: ASCP Press, 2000.

Mark A. Best