Hematopathology / PLATELET COUNTING

Platelet Counting by the Coulter LH 750, Sysmex XE 2100, and Advia 120 A Comparative Analysis Using the RBC/Platelet Ratio Reference Method
Linda M. Sandhaus, MD,1 Ebenezer S. Osei, MS,2 Neeta N. Agrawal, MD,1 Christine A. Dillman, MT(ASCP),2 and Howard J. Meyerson, MD1
Key Words: Platelet counting; Optical platelet counts; Impedance platelet counts; Flow cytometry; Reference method; Automated hematology analyzers

Abstract
We compared the accuracy and precision of the impedance platelet counts generated by the Beckman Coulter LH 750 and the Sysmex XE 2100 and the optical platelet counts produced by the Advia 120 and the Sysmex XE 2100 with flow cytometric reference platelet counts. Samples analyzed had platelet counts less than 150 103/L (150 109/L) with a platelet flag or less than 75 103/L (75 109/L) on the Sysmex SE 9500. The 105 samples were run sequentially through each analyzer. Anti-CD41 and anti-CD61 monoclonal antibodies were used for flow cytometric determination of the reference platelet count by the RBC/platelet ratio method. The Beckman Coulter and the Sysmex impedance platelet counts showed better correlation with the reference method than the optical platelet counts by the Advia and the Sysmex. At platelet transfusion thresholds of 10 and 20 103/L (10 and 20 109/L), the precision of the impedance methods was somewhat better than that of the optical methods. Current methods of optical platelet counting may not be superior to impedance platelet counts for all patient populations.

Despite tremendous advancements in automated hematology analyzers, the reporting of accurate platelet counts continues to pose difficulties for the hematology laboratory. Factors that contribute to problems with platelet count accuracy and precision include the following: (1) limitations of instrument technologies for eliminating cellular and particulate interference; (2) unsatisfactory reproducibility of manual platelet counting methods; and (3) preanalytic interference, such as platelet clumping, that precludes accurate platelet counts by automated or manual methods. The need for automated hematology analyzers that produce accurate platelet counts, particularly for thrombocytopenic patients, is accentuated by the increasing use of intensive chemotherapeutic regimens that produce profound and sustained thrombocytopenia and the clinical imperative to optimize platelet transfusions. Clinical outcomes analyses have led to the development of practice guidelines that recommend that the threshold for prophylactic platelet transfusion can be lowered from 20 103/L (20 109/L) to 10 103/L (10 109/L) or less for most clinical conditions.1-4 Recently, an immunoplatelet count by flow cytometry (the RBC/platelet ratio method) has been advanced by the International Council for Standardization in Haematology (ICSH) and the International Society of Laboratory Hematology (ISLH) as the new reference method for platelet counting.5,6 Automated platelet counts are being evaluated against this new gold standard to validate the accuracy and precision of automated hematology analyzers at the lower platelet count transfusion threshold.7-12 The impedance principle, patented by Coulter in 1953, was the first automated method for platelet counting.13 The limitations of the impedance method are well known and include inability to distinguish platelets from other particles
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that overlap the size range of platelets, notably, microcytic and fragmented erythrocytes on the higher end and noncellular particulate interference and electronic noise on the lower end of the size spectrum. Curve fitting and moving threshold are computerized algorithms that have been applied to impedance methods to correct for interference and improve the accuracy of impedance-derived platelet counts. In recent years, instrument manufacturers have taken diverse approaches to solve the remaining problems with platelet count accuracy. Bayer Diagnostics, Tarrytown, NY (Advia 120), and Abbott Diagnostics, Santa Clara, CA (Cell-Dyn 4000), have developed optical platelet counting methods, which use laser light scatter to identify platelets.12,14-17 Sysmex has introduced a fluorescence light scatter technique to identify platelets.18 These methods take advantage of the distinctive optical properties of platelets to distinguish them from nonplatelet cellular elements or particles. Beckman Coulter, on the other hand, has adapted new data extraction techniques and computer algorithms to reduce interference with the impedance platelet count.8,10,11 Some recent studies seem to indicate that optical platelet counting methods may be more accurate than impedance methods.7,15-18 The purpose of the present study was to compare the accuracy and precision of platelet counts produced by 3 state-of-the art hematology analyzers on the patient population of the University Hospitals of Cleveland (UHC; Cleveland, OH), a tertiary care hospital with a comprehensive cancer center. The study was undertaken as part of a multiparameter hematology analyzer evaluation. The analyzers evaluated were the Beckman Coulter LH 750 (Miami, FL; hereafter referred to as Coulter LH 750), Bayer Advia 120, and the Sysmex XE 2100 (Sysmex, Kobe, Japan). The Abbott Cell-Dyn 4000 was not evaluated. The immunoplatelet RBC/platelet ratio method was used as the reference method.

were hand carried to the flow cytometry laboratory where they were stained and analyzed within 90 minutes. Peripheral blood smears were reviewed on all study samples for the presence of erythrocyte or leukocyte fragments, marked microcytosis, giant platelets, and the presence of platelet clumps or fibrin strands. Patients A total of 105 specimens were obtained from 61 adult and pediatric patients during a 5-day period, October 13 to October 17, 2001. Twenty-five patients were included in the study more than once. Seventeen patients received platelet transfusions during the study period. Diagnoses in this patient population included hematologic malignant neoplasm, 18 cases; solid organ malignant neoplasm, 9 cases; solid organ transplantation, 6 cases; liver disease or end-stage renal disease, 7 cases; cardiovascular disease, 6 cases; and other diagnoses, 15 cases. Instruments The Sysmex XE 2100 has the capability to produce both an impedance platelet count and a fluorescence-based optical platelet count when the sample is run in the reticulocyte mode.18 The Coulter LH 750 uses impedance technology with enhanced data extraction techniques and algorithms to eliminate interference.8,10,11 The Advia 120 uses an optical method in which the volume and refractive index of platelets are determined simultaneously by measuring 2 angles of laser light scatter.15,16 All of these instruments use software-generated flagging algorithms for identifying abnormal platelet distributions that may indicate the presence of plateletspecific interference or the presence of platelet clumping. In the present study, we evaluated the flagging efficiency of the platelet clumps flag only, because this is the most frequently generated instrument-defined flag that results in smear reviews for verification of platelet counts in our laboratory. The Sysmex XE 2100, Coulter LH 750, and the Advia 120 were calibrated according to manufacturers specifications by field service representatives, and precision studies were done. Three medical technologists from the UHC Core Laboratory were trained to operate the instruments by the field service representatives. Three levels of quality control and required maintenance procedures were performed daily, according to manufacturers instructions. Calibrators were run at the conclusion of the study to verify that the instrument had maintained calibration, and all stored quality control and maintenance data were reviewed and verified by field service representatives. Study samples were run by UHC technical personnel only. Immunoplatelet Counting by the ICSH/ISLH Reference Method Platelet counting by the RBC/platelet ratio method was performed by flow cytometry as previously described.5,6
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Materials and Methods

Blood Specimens All blood samples were drawn in K3EDTA-anticoagulated blood and run on a Sysmex SE 9500 within 8 hours of phlebotomy. The criteria for inclusion in the study were a platelet count of 150 103/L (150 109/L) or less with an instrumentgenerated platelet flag, and all samples with a platelet count of 75 103/L (75 109/L) or less. Samples were run successively through each analyzer in the auto-sampling mode within 1 hour of the initial CBC count. The sequence of the analyzers was randomized for each batch of 5 samples. Four samples contained insufficient volume to obtain results in the auto-sampling mode by all 3 analyzers (no results were given for 3 samples on the Advia 120 and for 1 on the Coulter LH 750). The samples then
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Briefly, 5 L of well-mixed blood, 5 L of anti-CD41 fluorescein isothiocyanate (Beckman Coulter, Brea, CA), and 5 L of anti-CD61 fluorescein isothiocyanate (Becton Dickinson, San Jose, CA) were pipetted into diluent to reach a final dilution of 1:1,000. The preparation was incubated in the dark for 15 minutes and was mixed by gentle inversion to ensure proper and equal distribution of RBCs and platelets before flow cytometric analysis on a flow cytometer (FACSCalibur, Becton Dickinson). The flow rate, discriminator, and photomultiplier settings were as specified elsewhere.6 At least 50,000 total events were acquired. If a minimum of 1,000 events within the platelet gate was not reached after 50,000 total events, acquisition was continued until either 1,000 events were obtained in the platelet gate or 500,000 total events were acquired. Platelet and RBC counts were determined based on bitmap analysis using Cellquest software (Becton Dickinson). RBC-platelet coincident events also were determined as previously described.5,6 The platelet count was calculated by using the following formula: Reference Platelet Count = RBC* Platelets/RBC where RBC* is the mean RBC count of the 3 analyzers; platelets, the number of events in the platelet gate; and RBC, the number of events in the RBC gate by flow cytometry. We calculated the reference platelet count both with and without correction for RBC-platelet coincidence events, using each instruments RBC count and the mean RBC count of the 3 analyzers. As there was no significant difference between any of these methods for calculating the platelet count (data not shown), we used the platelet count calculated from the simple ratio and the mean RBC count for all statistical analyses. Precision studies done on 3 to 6 replicates of 7 samples with platelet counts ranging from 26 to 90 103/L (26-90 109/L) demonstrated a mean coefficient of variation of 4%. Statistical Analysis All statistical analyses were performed in EP Evaluator (David G. Rhoads Associates, Kennett Square, PA). The platelet counts generated by each instrument were correlated with the reference platelet count. For the Sysmex XE 2100,

the impedance and optical platelet counts were analyzed independently. Regression statistics were determined by using Deming linear regression, with an assumption of equal variance between the methods.

Results
The regression results for the entire range of data are shown in Table 1 and Figure 1. The regression results for platelet counts of 50 103/L (50 109/L) or less are shown in Table 2 and Figure 2. The results indicate that the correlation coefficients for the Coulter LH 750 and the Sysmex XE 2100 impedance counts were comparable and were higher than the correlation coefficients for either of the optical platelet counts. The differences between the impedance and optical methods became more apparent when the analysis was limited to very low platelet counts. An analysis of 17 samples that contained many RBC fragments and/or large platelets also was done. The correlation coefficients for this subset analysis Table 3 also fail to demonstrate superior performance of the optical platelet counts. To examine the precision of platelet counts near the platelet transfusion thresholds of 10 and 20 103/L (10 and 20 109/L), we compared the 95% confidence intervals of platelet counts at these decision points Table 4. Although there were no major differences among the instruments, the confidence intervals were slightly wider for the optical methods than for the impedance methods. Six samples were excluded from the correlation study owing to the presence of marked platelet clumping observed on the peripheral blood smear, resulting in pseudothrombocytopenia in 4 samples. The platelet counts for these 6 specimens are shown in Table 5. An interesting observation is that the platelet counts generated by the Advia 120 tended to be higher than the platelet counts produced by the other instruments. We evaluated the flagging efficiency of the different analyzers for detecting marked platelet clumping Table 6. All of the analyzers had deficiencies in this discrimination, with the Coulter LH 750 seeming to have the poorest sensitivity and the Sysmex XE 2100 the poorest specificity.

Table 1 Regression Results for Analyzer vs Reference Platelet Counts*

Analyzer Coulter LH 750 Advia 120 Sysmex XE 2100 Impedance Optical
*

N 98 96 99 99

Slope 1.06 (1.03 to 1.10) 1.08 (1.03 to 1.12) 1.00 (0.97 to 1.04) 1.01 (0.96 to 1.05)

Intercept ( 109/L) 1.5 (4.2 to 1.2) 2.4 (5.5 to 0.8) 3.3 (5.8 to 0.8) 1.8 (4.9 to 0.4)

Bias ( 109/L) 2.4 2.4 3.3 1.4

R2 0.968 0.958 0.970 0.951

The conversion from Systme International units ( 109/L) to conventional units ( 103/L) is 1 to 1 (ie, divide by 1). For proprietary information, see the text. The 95% confidence intervals are shown in parentheses.

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A
180

B
200 Sysmex XE ( 109/L) 150 100 50 0

A
60 Sysmex XE ( 109/L)

B
60 Sysmex XE ( 109/L) 0 15 30 45 60 RBC Ratio ( 109/L) 45 30 15 0 0 15 30 45 60 RBC Ratio ( 109/L)

Sysmex XE ( 109/L)

135 90 45 0

45 30 15 0

45

90

135 180
9

RBC Ratio ( 10 /L)

45 90 135 180 RBC Ratio ( 109/L)

C
220 Coulter LH ( 109/L)

D
200

C
60 Coulter LH ( 109/L)

D
60 Advia ( 109/L) 45 30 15 0 0 15 30 45 60 RBC Ratio ( 109/L)

165 110 55 0 0

Advia ( 109/L)

150 100 50 0

45 30 15 0

45 90 135 180 RBC Ratio ( 109/L)

45 90 135 180 RBC Ratio ( 109/L)

15 30 45 60 RBC Ratio ( 109/L)

Figure 1 Regression results for platelet counts of 150 109/L or less. Comparison of the immunoplatelet reference count (derived from the RBC/platelet ratio) with the platelet counts from the Sysmex XE 2100 (A, impedance, Y = X 3.3, R2 = 0.970; B, optical, Y = 1.01X 1.8, R 2 = 0.951), Beckman Coulter LH 750 (C, Y = 1.06X 1.5, R 2 = 0.968), and Advia 120 (D, Y = 1.08X 2.4, R 2 = 0.958) over the entire range of data. Short dashes, 95% confidence intervals; long dashes, line of equality; solid line, regression line. The conversion factor to conventional units ( 103/L) is 1. For proprietary information, see the text.

Figure 2 Regression results for platelet counts of 50 109/L or less. Comparison of the immunoplatelet reference count (derived from the RBC/platelet ratio) with the platelet counts from the Sysmex XE 2100 (A, impedance, Y = 0.96X , 1.1, R 2 = 0.92; B, optical, Y = 0.95X + 1.7 R 2 = 0.72), Beckman Coulter LH 750 (C, Y = 0.99X + 1.3, R 2 = 0.88), and Advia 120 (D, Y = 0.96X + 2.0, R 2 = 0.81). Short dashes, 95% confidence intervals; long dashes, line of equality; solid line, regression line. The conversion factor to conventional units ( 103/L) is 1. For proprietary information, see the text.

Table 2 Regression Results for Analyzer vs Reference Platelet Counts for Platelet Counts 50 109/L*
Analyzer Coulter LH 750 Advia 120 Sysmex XE 2100 Impedance Optical
*

N 48 46 49 49

Slope 0.99 (0.89 to 1.09) 0.96 (0.83 to 1.09) 0.96 (0.88 to 1.04) 0.95 (0.79 to 1.1)

Intercept ( 109/L) 1.3 (1.9 to 4.5) 2.0 (2.1 to 6.1) 1.1 (3.6 to 1.4) 1.7 (3.1 to 6.5)

Bias ( 109/L) 0.9 0.8 2.3 0.2

R2 0.88 0.81 0.92 0.72

The conversion from Systme International units ( 109/L) to conventional units ( 103/L) is 1 to 1 (ie, divide by 1). For proprietary information, see the text. The 95% confidence intervals are shown in parentheses.

Discussion
We used the ICSH/ISLH immunoplatelet reference method to evaluate the platelet count accuracy of the Sysmex XE 2100, the Coulter LH 750, and the Advia 120 on blood samples from patients with thrombocytopenia. We challenged
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the reference method for potential sources of error and found the method to be robust. We used the simple RBC/platelet ratio for calculating the reference immunoplatelet count after demonstrating that platelet counts obtained using the correction for platelet-RBC coincidence events did not significantly alter the results. A potential source of error of the immunoplatelet
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method could be that prolonged acquisition times for specimens with very low platelet counts would affect the RBC/platelet ratio owing to cell settling. However, we observed no differences between continuous, uninterrupted collections and interrupted, remixed sample collections (data not shown). We observed some limitations of the reference method that were related to the presence of large platelets or platelet clumps. In a few samples, large platelets may not have been included in the initial platelet gate, because their high fluorescence and forward scatter placed them outside the bitmap gate. Regating those samples so that all highly fluorescent events were included resulted in up to a 9% increase in the platelet counts in 3 samples. These adjusted platelet counts resulted in a slight but insignificant improvement in the correlation results for the 2 optical platelet methods. This limitation can be surmounted by adjusting the photomultiplier settings on the flow cytometer, using quadrant statistics, or visually adjusting the bit map gates. A limitation that could not be corrected for, however, was the presence of marked platelet clumping that was observed in 6 samples. When there is marked platelet clumping in the sample, the flow cytometric determination of the RBC/platelet ratio cannot be considered reliable, because the platelet events may be falsely lowered. The major finding is that the impedance methods of platelet counting evaluated in the present study seemed to be more accurate than the optical methods of platelet counting for platelet counts of 150 103/L (150 109/L) or less.
Table 4 Precision of Platelet Counts at Transfusion Thresholds*
Sysmex XE 2100 Platelet Count ( 109/L) 10 20
*

Table 3 Analyzer vs Reference Platelet Counts for Specimens With RBC Fragments or Giant Platelets (N = 17)
Analyzer* Coulter LH 750 Advia 120 Sysmex XE 2100 Impedance Optical
*

R 0.98 0.96 0.97 0.95

R2 0.96 0.92 0.94 0.90

For proprietary information, see the text.

Both the Coulter LH 750 and the Sysmex XE 2100 impedance counts showed slightly better correlation with the reference platelet counts than did the Advia 120 or the Sysmex XE 2100 optical counts. These differences became even more apparent at very low platelet counts. Furthermore, the 2 impedance methods correlated as well with each other (R2 = 0.969) as they did with the reference method. The optical methods, on the other hand, correlated better with each other (R2 = 0.971) than they did with the reference method. These results suggest that the sources of error for the 2 optical methods may be similar and that they differ from those of the impedance methods. Our results are in contrast with those of recently published studies that suggest the superior accuracy of optical platelet counting methods for thrombocytopenic specimens.7,15-18 Harrison et al7 demonstrated an R2 of 0.96

Impedance 4.5-8.9 (4.4) 14.7-18.7 (4.0)

Optical 5.4-11.2 (5.8) 15.8-20.9 (5.1)

Coulter LH 750 6.7-11.6 (4.9) 17 .6-21.9 (4.3)

Advia 120 5.5-11.3 (5.8) 16.7-21.7 (5.0)

Data are given 109/L. Numbers in parentheses represent width of 95% confidence intervals ( 109/L). The conversion from Systme International units ( 109/L) to conventional units ( 103/L) is 1 to 1 (ie, divide by 1). For proprietary information, see the text.

Table 5 Platelet Counts on Six Specimens With Platelet Clumping*

Sysmex XE 2100 Specimen No. 23 30 38 41 58 89
*

Impedance 10 159 167 150 79 19

Optical 19 150 229 145 140 23

Coulter LH 750 6 125 162 174 87 19

Advia 120 15 231 285 200 121 44

Reference Method 3 104 176 159 54 21

Data are given 109/L. The conversion from Systme International units ( 109/L) to conventional units ( 103/L) is 1 to 1 (ie, divide by 1). For proprietary information, see the text. When there is marked platelet clumping in the sample, the flow cytometric determination of the RBC/platelet ratio cannot be considered reliable, because the platelet events may be falsely lowered.

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Table 6 Analyzer Flagging of Platelet Clumps*

Platelet Clumps Flag Total No. of flags True-positive False-positive False-negative
*

Sysmex XE 2100 20 4 16 2

Coulter LH 750 3 2 1 4

Advia 120 4 3 1 3

See the Discussion section for comments on the reliability of flagging platelet clumps. For proprietary information, see the text. A true-positive flag was defined as the presence of marked platelet clumping on the peripheral blood smear that precluded quantitative platelet estimation. See text for comments on false-negative rate.

for the Advia 120 with the RBC/platelet reference method for platelet counts less than 100 103/L (<100 109L), which is consistent with our own results. In their multiinstrument comparison, the impedance counts from the 3 other instruments evaluated yielded poorer correlation results. However, the sample size for thrombocytopenic samples in that study7 was less than in the present study, and the Coulter LH 750 was not among the instruments compared. Other published studies that seem to demonstrate superior performance of the Advia optical platelet count over impedance platelet counts have used manual platelet counting methods as the reference methods.15-17 It also is important to note that the blood samples included in these studies were highly selected for potential platelet interfering substances. Similarly, an evaluation of the Sysmex XE 2100 platelet counts using the immunoplatelet reference method demonstrated significantly better performance of the optical platelet count when the samples were selected specifically for known platelet disorders or potential interfering substances.18 Sample selection may partially explain the results of our study. The patient samples were selected primarily on the basis of low platelet count. Platelet flags, which might indicate the presence of interfering particles, such as RBC or leukocyte fragments, were used to select only samples with platelet counts between 75 and 150 103/L (75-150 109/L; 21.0% [22/105] of the total samples). Forty-four percent (27/61) of the patients in the study had oncology diagnoses, and the majority of them were thrombocytopenic owing to bone marrow suppression. Several of these patients underwent sampling more than once. Therefore, oncology patients may be overrepresented in the present study in comparison with some other published studies. In addition, 17 patients had received platelet transfusions. Evaluation of platelet morphologic features by peripheral smear review suggested that the high frequency of patients with hypoproliferative bone marrow states might have created a sampling bias for small platelets, which would tend to minimize any advantage of optical methods for discriminating large
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platelets. Nevertheless, a subset analysis of 17 samples with RBC fragmentation and/or giant platelets identified on peripheral blood smears failed to demonstrate improved accuracy of the optical methods. For very low platelet counts at or near a prophylactic platelet transfusion threshold of 20 103/L (20 109/L), all instruments showed comparable reliability, with confidence intervals ranging from 4.0 to 5.1 103/L (4.0-5.1 109/L). Slightly wider confidence intervals were obtained for the optical methods than for the impedance methods, which might reflect the lower numbers of total events that are enumerated by optical methods. Based on the combined performance of these analyzers, the results indicate that a true platelet count of 20 103/L (20 109/L) could range from 14.7 to 21.7 103/L (14.7-21.7 109/L). If 10 103/L (10 109/L) is used as the platelet transfusion threshold, the reported platelet counts could range from 4.5 to 11.6 103/L (4.5-11.6 109/L). Clinicians should be aware of the limits of the analytic method for platelet counting in determining the appropriateness of recommended platelet transfusion thresholds for different clinical conditions.19 Platelet clumping in EDTA anticoagulants continues to pose procedural problems for the clinical hematology laboratory.20 In our laboratory, when a platelet clumps flag is generated, the automated platelet count is removed from the CBC count results in the laboratory information system, a smear is reviewed for platelet count verification, and the final platelet count is entered manually and verified in the laboratory information system. Each of these steps influences the turnaround time for CBC counts and introduces the potential for laboratory error. In our evaluation of the analyzers flagging efficiency for platelet clumps, we defined a true-positive flag as the presence of marked platelet clumping on the peripheral blood smear that precluded determination of a numeric platelet estimate. At the factory settings, the Sysmex XE 2100 had the highest sensitivity (67%) and the poorest specificity (84%). The platelet clumps flag on this analyzer is an adjustable flag, but adjustments to improve specificity might further reduce the sensitivity. The Coulter LH 750 demonstrated the poorest sensitivity for platelet clumps, with 4 of 6 clumped specimens not flagged. Failure to flag platelet clumps could lead to erroneous reporting of low platelet counts if laboratory algorithms for confirming low platelet counts are inadequate or not followed carefully. It is difficult to be conclusive about the flagging efficiency of the analyzers based on these limited data, because the possibility that the degree of platelet clumping varied during the performance of the sequential CBC counts and flow cytometric analysis cannot be excluded. In this regard, it is interesting that the platelet counts generated by the Advia 120 on the specimens with platelet clumping tended to be higher than the counts
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obtained from the other 2 instruments. One possible explanation for this observation is that mechanical dispersion of platelet clumps occurs in the optical counting chamber. Mechanical dispersion of platelet clumps also might explain the lower flagging rate for platelet clumps by the Advia 120. This multi-instrument comparison did not demonstrate any advantages of optical platelet counting methods over current impedance methods when the RBC/platelet reference method was used as the gold standard. We suggest that patient population, sample selection, and reference method should be considered possible explanations for discordant results of evaluations of platelet count methods. However, it is important to recognize that the accuracy of automated platelet counts is a function not only of the underlying technology that is used to detect platelets but also of the computerized algorithms that are designed to evaluate the platelet data. The improved performance of the Coulter LH 750 over that of the Coulter GenS (Beckman Coulter, Miami, FL) has been attributed largely to improvements in the analyzers data extraction process.10,11 The Sysmex XE 2100 determines which platelet count is reported, optical or impedance, based on a predefined algorithm. Optimally, the performance of the reported platelet count by the Sysmex XE 2100 actually might exceed the performance of either the optical platelet count or the impedance count. The present study, however, was not designed to evaluate the switching algorithm. Finally, improvements in the ability to reliably detect (or overcome) EDTA-induced platelet clumping would contribute greatly to rapid and accurate platelet count reporting by clinical laboratories.
From the Departments of Pathology, 1Case Western Reserve University School of Medicine and 2University Hospitals of Cleveland, Cleveland, OH. Address reprint requests to Dr Sandhaus: Dept of Pathology, University Hospitals of Cleveland, 11100 Euclid Ave, Cleveland OH 44106.

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