Get Permission Sardar, Adhane, Chettiankandy, Sachdev, and Tupkari: Reference intervals and gender variation in establishing blood parameters in dental institution: A retrospective study


Introduction

Complete blood count (CBC) has been extensively used by general physicians to assess the status of sick and healthy people. CBC is routinely employed owing to its simplicity, low cost and easy availability, which enables an appropriate approach to investigate, diagnose and determine the prognosis of the conditions such as anemia, risk of infection and/or hematologic malignancies, coagulation disorders and screening of blood donors.1

Observed values from laboratory tests of a person or patient are compared with a reference interval for determination of accurate diagnosis, therapeutic management or other physiological assessment.2 In general, nearly all the investigations in a clinical laboratory have a pre-determined reference interval.3 The decision-making process of a clinician is guided by the difference between observed values and reference intervals.

Several studies has investigated hematologic parameters in different populations, racial, ethnic and gender subgroups, even in different seasons.4, 5 In most of these studies gender difference in hematological parameters were significant and therefore it is essential to establish this difference and also to estimate reference range for population. The present study was conducted to appraise the hematological changes in different blood parameters amongst males and females and also to set a reference range for general population.

Materials and Methods

Sample size and sample collection

The study was conducted on a total of 361 patients comprising of 163 males (45.2%) and 198 females (54.8%) in the institutional hematology laboratory. Patients of age 18 to 50 years reporting for dental treatment and did not have any systemic illness were included in the study by means of convenience sampling method. The study was conducted over a period of six months from May to December, 2019. 20 µl sample of capillary blood obtained through skin puncture over a finger which was added to 100 µl diluent containing sodium chloride, sodium sulfate, a phosphate buffer agent, ethylene diamine tetra-acetic acid (EDTA), 1-pyridone-2-sulphur and formaldehyde with pH value of the solution 6.5-7.4.

Haematology analyser

CBC, including a white blood cell (WBC) differential and a reticulocyte count, were performed using fully automatic blood cell counter PCE 210 [ERMA INC, Japan] by small volume of sample suction. Measurements of parameters and histograms were quickly processed within 60 sec. The main principle involved for counting cells is by electrical impedance, also known as the Coulter principle.6 Whole blood is passed between two electrodes through an aperture where the area is so small that only one cell can pass at a time. Using hydrodynamic focusing, the cells are sent through an aperture one cell at a time. During this, a laser is directed at them, and the scattered light is measured at multiple angles. The absorbance is also recorded. The cell can be identified based on the intensity of the scattered light and the level of absorbance and haemoglobin measurement is done by colorimetric method.6, 7

Observational parameters

The components of the CBC consisting of hemogram and differential WBC count. The hemogram includes enumeration of WBCs, red blood cells (RBCs), and platelets. It also allows evaluation of hemoglobin, hematocrit, and RBC indices. The differential WBC count enumerates the different WBC types. Together, hemogram and differential WBC count aid in determining diagnosis, treatment and prognosis of haematological disorders.8

Following parameters were assessed: (Table 1)9, 10

Table 1

S. No.

Parameters

Description

Normal value

Male

Female

2.

White Blood Cell (WBC)

Immune system

4,000-11,000 cells/ul

3.

Lymphocytes

Cell mediated and humoral immunity

1,500-4,000 cells/ul

4.

Granulocyte

Neutrophils

Phagocytosis

2,000-7, 500 cells/ul

Eosinophils

Ag-Ab reaction

40-400 cells/ul

Basophils

Histamine release

10-100 cells/ul

5.

Red Blood Cell (RBC)

Oxygen transport

4.5-6.5 million/mm3

4-5.5 million/mm3

6.

Haemoglobin (Hb)

Oxygen transport

13.5-18 g/dl

11.5-16 g/dl

7.

Haematocrit (HCT)

Ratio of the volume of RBC to the total volume of the blood

40-52%

37-47%

8.

Mean Corpuscular Volume (MCV)

Average volume of red blood corpuscles

77-93 femtoliter

9.

Mean Corpuscular Haemoglobin (MCH)

Average mass of Hb per RBC

27-32 picogram

10.

Mean Corpuscular Haemoglobin Concentration (MCHC)

Average concentration of Hb in given volume of blood

30-35 g/dl

11.

Red cell Distribution Width (RDW)

Amount of RBC variation in volume and size

11.8-14.5%

12.2-16.1%

12.

Platelet (PLT)

Primary haemostasis

1,50,000-4,00,000 cells/ul

13.

Plateletcrit (PCT)

Volume occupied by PLT in a blood as a percentage

25-27%

14.

Mean platelet volume (MPV)

Average size of PLT

8-12 femtoliter

Statistical analysis

Descriptive and inferential statistical analyses were carried out in the present study. Results on continuous measurements were presented on Mean ± SD and results on categorical measurement were presented in number (%). Level of significance was fixed at p=0.05 and any value less than or equal to 0.05 was considered to be statistically significant.

All the variables from the study were statistically analyzed using the statistical software IBM SPSS statistics 20.0 (IBM Corporation, Armonk, NY, USA).

Results

The mean values of haematological parameters obtain are enlisted in Table 2. The mean values of haematological parameters between males and females were compared, and it revealed statistically significant results with certain parameters using unpaired t test (Table 3). The reference range of parameters were established using median and SD (Table 4).

Table 2

Mean values of haematological parameters

Variable

WBC

LYM

GRA

RBC

Hb

HCT

MCV

MCH

MCHC

RDW

PLT

PCT

MPV

Mean

7.6632

2.7136

4.0468

4.3355

11.318

32.827

76.745

26.974

34.499

15.922

251.47

0.2472

9.442

SD

2.6109

0.9822

1.7467

1.9620

2.920

7.707

11.386

4.335

2.986

2.129

93.553

0.1132

0.7362

Table 3

Comparison of different parameters amongst males and females

Variables

Gender

n (%)

Mean

SD

P value

WBC

Male

163(45.2)

7.5693

2.41623

0.536

Female

198(54.8)

7.7404

2.76464

LYM

Male

163(45.2)

2.6871

0.97513

0.643

Female

198(54.8)

2.7354

0.98998

GRA

Male

163(45.2)

3.9571

1.71702

0.376

Female

198(54.8)

4.1207

1.77178

RBC

Male

163(45.2)

4.7306

2.68114

<0.001**

Female

198(54.8)

4.0103

0.94242

Hb

Male

163(45.2)

12.3933

2.62328

<0.001**

Female

198(54.8)

10.4334

2.86172

HCT

Male

163(45.2)

36.2049

7.45234

<0.001**

Female

198(54.8)

30.0465

6.75814

MCV

Male

163(45.2)

79.2301

11.98352

<0.001**

Female

198(54.8)

74.7005

10.46623

MCH

Male

163(45.2)

28.2442

4.04556

<0.001**

Female

198(54.8)

25.9293

4.29646

MCHC

Male

163(45.2)

34.9920

3.31046

0.004*

Female

198(54.8)

34.0939

2.63112

RDW

Male

163(45.2)

15.8362

2.33869

0.486

Female

198(54.8)

15.9935

1.94334

PLT

Male

163(45.2)

236.87

94.308

0.007*

Female

198(54.8)

263.49

91.424

PCT

Male

163(45.2)

.22834

0.105365

0.004*

Female

198(54.8)

.26273

0.117285

MPV

Male

163(45.2)

9.4663

0.73612

0.605

Female

198(54.8)

9.4260

0.73776

[i] p < 0.05 - Significant*, p < 0.001 - Highly significant**

Table 4

Reference range of haematological parameters

Variables

Median

SD

Reference range

WBC

7.4000

2.61094

4.79-10.01

LYM

2.6000

.98224

1.62-3.58

GRA

3.8000

1.74676

2.06-5.54

RBC

4.1300

1.96207

2.17-6.09

Hb

10.9000

2.92096

7.98—13.82

HCT

31.3000

7.70736

23.6-39.0

MCV

78.0000

11.38688

66.62-89.38

MCH

27.2000

4.33557

22.87-31.53

MCHC

34.5000

2.98667

31.52-37.48

RDW

15.4000

2.12933

13.28-17.52

PLT

245.00

93.553

151.45-338.55

PCT

.22900

.113212

0.11-0.33

MPV

9.4000

.73627

8.67-10.13

The mean values of the RBC, Hb, HCT, MCV, MCH between males and females showed statistically highly significant reduction with p < 0.001, while MCHC was significantly reduced with p < 0.05 in females compared to males (Figure 1). Haematological parameters such as PLT, PCT were slightly higher in females compared to males showing statistically significant results with p < 0.05 (Figure 2).

Figure 1

Mean values of haematological parameters in males & females

https://s3-us-west-2.amazonaws.com/typeset-prod-media-server/47879e0b-c3e2-450e-812d-f9b4cdf4caf5image1.png

Figure 2

Mean values of PLT, PCT in males & females

https://s3-us-west-2.amazonaws.com/typeset-prod-media-server/47879e0b-c3e2-450e-812d-f9b4cdf4caf5image2.png

Discussion

Having thorough knowledge of the reference values of RBCs and WBCs variables amongst males and females is profoundly important for proper interpretation of the results of CBC.11 The gender differences seen in haematological profile is a well-documented fact that has been similarly reported in other studies, males having a higher RBC profile compared to females.12, 13 Females had a higher platelet count compared to males, comparable to a study which looked at cultural and sex differences in WBCs and PLTs counts.14

The sex differences in Hb level in adults are well known, and the underlying mechanisms is probably a direct effect of sex hormones, both estrogen and androgens on erythropoiesis.15 There is no evidence showing reduced cellular mechanisms for heme synthesis in females, and there is no difference in the iron absorption between females and males.16 In pre-pubertal humans, no major differences can be found between the genders in RBC count or Hb and serum ferritin concentrations. The difference in haematological variables between genders emerges after onset of menstruation and persist until 10 year after the menopause.17 The two main reasons for lower values of Hb, iron and RBC count of females compared to males are menstruation and nutritional intake.18 The reduced level of RBC and Hb in females are responsible for subsequent reduction in HCT, MCV, MCH and MCHC as these parameters are dependent on the values of RBC and Hb.

The results in our study coincided with studies conducted by Pekelharing et al,19 Wakeman et al,20 in which they showed statistically significant reduction of reference intervals of Hb, RBC, HCT, MCH, MCHC while increase in PLT and PCT in females compared to males. No significant difference in WBC parameters were observed amongst males and females. Study by Rui Qiao21 in 1259 Han individuals from North China also confirmed the mean values of RBC, Hb, HCT, MCV, MCH, and MCHC are higher in males; whereas, the PLTs are higher in females. According to Ginevra Biino et al.,22 PLT count was similar in males and females until the age of 14 years, but as age advances females had steadily more PLT than males.

Greater understanding about normal and altered levels of blood parameters is essential as different parameters can be used as independent biomarker to investigate the prognosis of patient with various pathologic conditions. Elevated levels of RBC and HCT are associated with increased risk of coronary heart disease. MPV is an independent predictor of peripheral arterial disease, and could be used as a marker of inflammation in patients with peripheral arterial disease.23 RDW, PLT count have diagnostic value in distinguishing patients with gastric carcinoma from those with intestinal metaplasia.24 MCV and RDW are bio-markers that can be used as the predictive marker in patients with endometrial carcinoma.25

In literature, not many studies have been done on relation between blood parameters and oral lesions. Study by Ramesh el al, in 40 samples of OSMF patients showed significantly lower levels of Hb, RBC and PLT and increased levels of erythrocyte sedimentation rate (ESR) and WBC than in controls.26 So, it is put forward to subject the patients to hematological investigations as it may aid in early diagnosis and prognosis of the diseases.

To the best of our knowledge, less information is available on alteration of blood parameters in oral lesions, it is necessary to carry out such investigations, so that clinician will be updated regarding geographic, ethnic, gender, age wise variation of blood parameters in different oral lesions. Present study was done to analyze the complete hemogram amongst males and females and also to set a reference interval for the same. To employ the results the test should be performed on larger sample to allow a more precise estimate of the test so that it will be easier to assess the representativeness of the sample and to generalize the results.

Conclusion

The CBC is a rich collection of information about each blood cell rather than mere cell counts. Now a days, with new diagnostic tests and prognostic tools based on molecular analysis, it is important to not overlook the value of the tests clinicians have been ordering for generations. These blood parameters will not likely provide confirmative diagnostic or prognostic information, but when understood and used properly, they provide readily available, cost-effective, and useful data that can supplement and guide clinical decision making. It is important to periodically update reference intervals for better correlation with health and disease conditions. Our findings would serve to update present data available data pertaining to blood parameters, their reference range and gender variation on a regional level.

Source of Funding

None.

Conflict of Interest

The authors declare no conflict of interest.

References

1 

JL Anderson BS Ronnow BD Horne JF Carlquist HT May TL Bair Usefulness of a complete blood count-derived risk score to predict incident mortality in patients with suspected cardiovascular diseaseAm J Cardiol200799216974

2 

GL Horowitz Reference intervals: Practical aspectsElectron J Int Fed Clin Chem Lab Med200819295

3 

KK Sehgal D Tina U Choksey RJ Dalal KJ Shanaz Reference range evaluation of complete blood count parameters with emphasis on newer research parameters on the complete blood count analyzer Sysmex XE-2100Indian J Pathol Microbiol20135621204

4 

MR Taylor CV Holland R Spencer JF Jackson GI O'connor Haematological reference ranges for school childrenClin Lab Haematol199719115

5 

L Kaestner A Bogdanova Regulation of red cell life-span, erythropoiesis, senescence, and clearanceFront Physiol20145269

6 

LV Rao D Moiles M Snyder Finger-stick complete blood counts: Comparison between venous and capillary bloodPoint Care20111031202

7 

X Zhang Y Ding Y Zhang J Xing Y Dai E Yuan Age-and sex-specific reference intervals for hematologic analytes in Chinese childrenInt J Lab Hematol20194133317

8 

B George-Gay K Parker Understanding the complete blood count with differentialJ Perianesth Nurs200318296117

9 

CL Ghai A textbook of practical physiology8th EdJP Medical LtdIndia2012

10 

J Greer J Forester G Rodgers F Paraskevas B Glader D Arber Wintrobe's clinical hematology12th EdLippincott Williams & WilkinsPhiladelphia2008

11 

JP Gligoroska S Gontarev B Dejanova L Todorovska DS Stojmanova S Manchevska Red blood cell variables in children and adolescents regarding the age and sexIran J Public Health201948470412

12 

KA Koram MM Addae JC Ocran S Adu-Amankwah WO Rogers FK Nkrumah Ghana Med J Population based reference intervals for common blood haematological and biochemical parameters in the Akuapem north districtGhana Med J20074141606

13 

D Menard MJ Mandeng MB Tothy EK Kelembho G Gresenguet A Talarmin Immunohematological reference ranges for adults from the Central African RepublicClin Vaccine Immunol20031034435

14 

JB Segal AR Moliterno Platelet counts differ by sex, ethnicity, and age in the United StatesAnn Epidemiol200616212330

15 

WG Murphy The sex difference in haemoglobin levels in adults-mechanisms, causes, and consequencesBlood Rev2014282417

16 

L Hallberg L Hulten E Gramatkovski Iron absorption from the whole diet in men: how effective is the regulation of iron absorption?Am J Clin Nutr199766234756

17 

JB Wish Assessing iron status: beyond serum ferritin and transferrin saturationClinical J Am Soc Nephrol200611S48

18 

DH Rushton R Dover AW Sainsbury MJ Norris JJ Gilkes ID Ramsay Why should women have lower reference limits for haemoglobin and ferritin concentrations than men?Br Med J2001322729813557

19 

JM Pekelharing O Hauss R DeJonge J Lokhoff J Sodikromo M Spaans Haematology reference intervals for established and novel parameters in healthy adultsSysmex J Int201020119

20 

L Wakeman Al-Ismail S Benton A Beddall A Gibbs A Hartnell Robust, routine haematology reference ranges for healthy adultsInt J Lab Hematol200729427983

21 

R Qiao S Yang B Yao H Wang J Zhang H Shang Complete blood count reference intervals and age-and sex-related trends of North China Han populationClin Chem Lab Med2014527102532

22 

G Biino I Santimone C Minelli R Sorice B Frongia M Traglia Age-and sex-related variations in platelet count in Italy: a proposal of reference ranges based on 40987 subjects' dataPloS One201381e54289

23 

Y Velioglu A Yuksel Complete blood count parameters in peripheral arterial diseaseAging Male201922318791

24 

EK Aksoy S Kantarcı M Torgutalp MY Akpınar FP Sapmaz GŞ Yalçın The importance of complete blood count parameters in the screening of gastric cancerPrz Gastroenterol20191431837

25 

CY Abide EB Ergen E Cogendez C Kilicci F Uzun E Ozkaya Evaluation of complete blood count parameters to predict endometrial cancerJ Clin Lab Anal2018326e22438

26 

S Ramesh P Govindaraju B Pachipalusu Evaluation of serum lipid profile and complete hemogram in patients with oral submucous fibrosis: A case control studyJ Int Oral Health2020125427427



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Received : 01-11-2021

Accepted : 29-12-2021


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https://doi.org/ 10.18231/j.ijcap.2022.005


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