Patients & Visitors Find & Contact us Working for us About us For GPs

Pathology Handbook

Pathology User Handbook

Section 3: Department of Haematology & Immunology

Table of Contents

3.1  Useful Phone Numbers

You may dial directly through to the extension you require by prefixing the extension number with the numbers (01225) 82.

Urgent Requests

01225 824740


01225 824700

Haematology Laboratory Enquiries

01225 824728

Haematology Clinical Enquiries/Referrals

Lab Registrar  01225 824463 or
01225 428331 bleep:
7559 or 7702

Haematology Inpatient Enquiries

Ward Registrar 01225 828331 or
01225 428331 and bleep 7702

Senior Staff of the Haematology Department

Dr Christopher Knechtli

Consultant Haematologist

01225 824654

Dr Charles Singer

Consultant Haematologist

01225 824488

Dr Sarah Wexler

Consultant Haematologist         

01225 824487

Dr Josephine Crowe

Consultant Haematologist

01225 821799

Mr Nigel Roberts

Laboratory Manager Haematology

01225 824727

Mr Richard Gardiner

Chief BMS Blood Bank

01225 824739

Mrs Christine Williams

Chief BMS Haematology

01225 824728

back to top

3.2  Advice and Information

Haematology Department staff are always available to give advice on technical matters.  During "office hours" please contact extension 4728.  For clinical advice please contact the  Haematology Registrar through the switchboard on bleep 7559 or on extension 4463.  Outside normal working hours the on-call BMS (Bleep 7555) and on-call member of the Medical Staff are available for advice through the RUH switchboard.   A senior Haematologist is available to give advice on weekdays between 3 and 5 pm via a dedicated mobile number 07789 928466.

back to top

3.3  Urgent Requests during Normal Working Hours

The Haematology Department needs prior notification to process requests urgently.  If you require an urgent analysis please telephone the Laboratory Specimen Reception on 01225 824740.

The laboratory may need to discuss with you the validity of the urgent test; please indicate on the request form how you may be contacted. The results of urgent requests will be telephoned to the ward or Practice and made available on Ultra and ICE, providing the instructions above are followed. The Haematology Department cannot guarantee that specimen request forms labelled "urgent" will be fast-tracked service unless prior notification is received by telephone.

back to top

3.4  General Haematology Laboratory Tests

Full Blood count

Peripheral blood EDTA  (Mauve capped Vacutainer)

back to top

Differential Leucocyte Count

Films are examined on all samples with any result significantly outside the normal range, samples on which morphological abnormalities are flagged by the machine analysis. This test can be performed on the FBC sample.

Plasma Viscosity

This investigation is performed at the clinician's request.  It is a sensitive index of plasma protein changes resulting from inflammation and tissue damage.  It is a more reliable test than the ESR  as it is unchanged by variation of the haematocrit and delay in analysis up to 24 hours.  This test can be performed on the FBC sample.

Reticulocyte Count

This test for circulating immature red cells is a useful confirmatory investigation in patients in whom haemolysis recent blood loss or a response to haematinics is suspected.  This test can be performed on the FBC.

Infectious Mononucleosis Screen

The test can be negative in the early stage of EBV infection but the presence of atypical mononuclears and a negative IM screen is more likely to be due to other viral infections most notably CMV or to infection by Toxoplasma gondii.  This test can be performed on an SST sample.

Malaria Screen

 Please indicate the countries visited by any patient who has been abroad.  Symptoms can develop more than a year after a visit to a malarial area and it is important to remember that a negative screening test does not exclude malaria.  If symptoms persist the screen must be repeated.   This test can be performed on the FBC sample.

If you require clinical advice on the management of a patient with malaria, 24 hours advice is available from the Department of Clinical Parasitology at the Hospital for Tropical Diseases on 0171-387-4411.

back to top

Coagulation Laboratory Tests

4.5 mL citrated blood (Light-blue capped Vacutainer)

Blood samples for coagulation tests should preferably reach the laboratory within 4 hours.  All INR and APTT requests will be carried out on the day of sampling. Sample tubes for coagulation tests must always be filled with the correct amount of blood. Four citrate samples are required for coagulation factor assays, lupus screen and acquired or inherited thrombophilia screens

Coagulation Screen

The one stage prothrombin time (PT) allows calculation of the INR result (International Normalised Ratio) and in combination with the activated partial thromboplastin time (APTT) provides a basic screen of the clotting mechanism.  It is the first step of any investigation of coagulation and should always be requested prior to the initiation of anticoagulant therapy.

Control of Anticoagulant Therapy

Warfarin and heparin therapy are monitored using the INR and APTT respectively.  Baseline evaluation of these tests is recommended prior to commencement of therapy.

Disseminated Intravscular Coagulation (DIC) Screen

If this condition is suspected a coagulation screen should be performed with a full blood count to exclude any fall in the haemoglobin or platelet count, a blood film to evaluate red cell fragmentation and  a fibrinogen assay. If there is any abnormality in the coagulation screen or fibrinogen level, a D-dimer assay should be performed and this will provide evidence of intravascular coagulation.
Note: D-dimer result is commonly elevated in sick patients.

4.5 mL citrated blood (Light-blue capped Vacutainer)
Peripheral blood EDTA (Mauve capped Vacutainer)

back to top

Thrombophilia Investigations

Referrals should be addressed to Dr Jo Crowe, Consultant Haematologist.

4x4.5 mL citrated blood             (Light-blue capped Vacutainer)
Four citrate specimens required.

Consultations and referrals to the clinic are welcomed for:

Blood specimens are best to be processed within four hours of collection. 

PCR tests

As part of the thrombophilia screen PCR analysis for the factor 5 Leiden and prothrombin 20210 gene mutations are undertaken.

No extra specimens are required as analysis can be undertaken on the citrate specimens sent for thrombophilia testing.

Prothrombotic tests are best performed when the patient:

A patient may still be referred when these conditions are not met for limited investigations and planned future investigations.

back to top

Coagulation Screening

Specific assay of coagulation factors will be undertaken by the laboratory for the investigation of patients with suspected inherited or acquired deficiencies.  In addition factor assays may be required prior to surgery and to monitor therapy in patients with known deficiencies.  These investigations require fresh samples and may involve several tests to fully identify the abnormality.  It is recommended that outpatients are referred to a Haematology Clinic (see below) and inpatients are referred for a Haematology consultation.

Other assays are available please contact the laboratory for further advice 4728

back to top

3.5  Special Haematology Laboratory Tests

Haematinic Assays

These should be performed to establish the cause of macrocytic (serum vitamin B12 & Serum Folate ) or microcytic anaemia (serum ferritin).  The serum ferritin may be elevated as an acute phase protein in patients with underlying neoplasia inflammatory disease e.g. rheumatoid arthritis and this may give an apparently normal result in an iron deficient patient.

6 mL clotted blood  (Yellow capped Vacutainer)
Peripheral blood EDTA  for FBC (Mauve capped Vacutainer)

back to top

Sickle cell Anaemia and Haemoglobinopathy Screen

A screening test for sickle cell anaemia and trait is available on a 24 hour basis.  Full diagnosis of sickle cell disease and other haemoglobinopathies requires HPLC analysis.

Peripheral blood EDTA              (Mauve capped Vacutainer)

back to top

Thalassaemia/Haemoglobinopathy Screen

This should be suspected in any individual with hypochromic microcytic red cell indices and normal iron stores.  Diagnosis will require HPLC analysis and may involve other studies.

Peripheral blood EDTA (Mauve capped Vacutainer)

back to top

Haemolysis Screen

Patients suspected of having haemolytic anaemia should have haemolysis confirmed prior to proceeding to complex investigations designed to establish the cause.  All such patients should have a blood film, direct Coombs test, reticulocyte count, unconjugated serum bilirubin, urinalysis and if intravascular haemolysis is suspected, haptoglobin quantitation, methaemalbumin and urinary haemosiderin.

Subsequent appropriate investigations may be discussed with Haematoloty medical staff.

back to top


PCR gene analysis is available for Haemochromatosis. An EDTA specimen should be sent along with a SST specimen, for iron studies.

6 mL clotted blood (Yellow capped Vacutainer)
Peripheral blood EDTA (Mauve capped Vacutainer)

back to top

Blood Group and Antibody Screen

Patients for whom elective surgery is planned should have a blood group and antibody screen at pre-admission. A repeat blood group & antibody screen will need to be taken on admission so that the laboratory has a valid sample if blood or blood products are required (sample viability, see below).

back to top

Crossmatch and Electronic Issue

Electronic issue means that blood can be issued instantly if the patient has been grouped twice and the antibody screen is negative as long as there is a valid sample in the laboratory. In the majority of cases there is no need to reserve blood for surgery as it can be provided immediately there is a need, as long as the above conditions are met.

If irregular antibodies to red cell antigens are identified the blood will need to be crossmatched. Compatible donor blood can usually then be arranged in advance to cover surgery and allow the procedure to go ahead without delay. Where possible a sample should be submitted for the crossmatch 24 hours before blood is required for an elective procedure. If irregular antibodies in the patient serum make provision of the requested blood difficult the Blood Bank will liaise with the requesting clinician.

Crossmatch or electronic issue samples can only be held for 7 days. This period is reduced to 3 days if the patient has been transfused within 28 days.


The neonate's blood group must be known before blood can be issued. No crossmatch is required for neonates up to 4 months old, unless the serum of the mother contains an antibody.

5 mL EDTA blood (Pink capped Vacutainer)

Coombs Direct Anti-human Globulin Test (DAGT)

This test should be performed on all patients in whom an acquired haemolytic anaemia is suspected.  All samples for group and save or crossmatch have a Coombs' DAGT performed.

5 mL EDTA blood (Pink capped Vacutainer)

back to top

Antenatal Serology

Blood group and antibody screen samples should be submitted for all pregnant women during the first trimester and at 28 weeks.  If irregular antibodies are detected the sample will be sent to the Regional Blood Transfusion Centre for confirmation and antibody quantitation.  Follow-up samples will be requested as required.

5 mL EDTA blood (Pink capped Vacutainer)

All rhesus D negative women must be offered anti-D prophylaxis. A 1500 IU dose should be given at 28 weeks. No further testing is required until delivery (see below).

back to top

Cord Blood Samples and Kleihauer Test at Delivery

Cord blood samples should be examined on all babies born to Rh(D) negative women and women found to have irregular antibodies during pregnancy.  The Kleihauer test for circulating foetal red cells should be performed on all Rh(D) negative women who deliver a Rh(D) positive baby.

Kleihauer kit Cord blood EDTA (Mauve capped Vacutainer)
Maternal blood EDTA (Mauve capped Vacutainer)

back to top

Anti Rh(D) Prophylaxis

Prophylaxis with anti-Rh(D) immunoglobulin should be administered within 72 hours of the event to Rh(D) negative women without detectable circulating anti-Rh(D) antibodies as follows:

1500 IU

All Rh D negative women must be offered anti-D prophylaxis.  A 1500 IU dose should be given at 28 weeks. No further testing is required until delivery.

250 IU

Miscarriage before 20 weeks gestation
Trauma in pregnancy before 20 weeks
Termination of pregnancy

500 IU

All patients delivered after 20 weeks
Women with an intrauterine foetal death
Trauma in pregnancy after 20 weeks
Amniocentesis Rh(D) negative women transfused with Rh(D) positive platelets

back to top

Blood Components and Products

The following are available through the RUH Blood Transfusion Department:

Red cells  (leucodepleted)

CMV negative products

Platelets (leucodepleted)

Irradiated products

Beriplex CMV

Paediatric red cell packs

HLA-matched platelets  

Anti-Rh(D) immunoglobulin

Paediatric platelet packs


Fresh frozen plasma

Human albumin 20%

Human albumin 4.5%

Factor IX concentrates

Factor VIII concentrates


back to top

3.6  Immunology Laboratory Tests

Immunology is supported by a Consultant Immunologist, Dr Sarah Johnston based at the RUH most Wednesdays. Tel 01225 821406, email: or tel. 0117 959 6307 (not Wednesdays).

A 5mL clotted sample is required for immunology tests, in addition to samples required for any Biochemistry tests requested at the same time.

Auto-immune Profile

Patients in whom an organ-specific or organ-non-specific auto-immune condition is suspected may have an auto-immune profile performed which will screen for auto-antibodies to nuclear protein, mitochondria, gastric parietal cells, reticulin and smooth muscle.


Quantitation of IgG, IgM and IgA : see Clinical Biochemistry. This investigation is of value in patients suspected of having inherited or acquired immunodeficiency, hypergammaglobulinaemia, lymphoid neoplasia and myeloma.

It may be appropriate in some circumstances to assay in addition the serum levels of IgD and IgE or IgG subclasses. This should be discussed with the laboratory.


The surface antigens of leucocytes in the peripheral blood or bone marrow can be identified by fluorescent antibody studies and the lineage of abnormal cell populations determined. This investigation is of value in the diagnosis of acute and chronic leukaemias and atypical leukocytoses.

This investigation should be arranged in advance with the Immunology Laboratory and the panel of markers used in the analysis will be determined by the clinical information.


This tissue type which is associated with ankylosing spondylitis can be quickly identified on fluorescent antibody analysis of peripheral blood lymphocytes.

A PCR test is used for confirmation.

Anticardiolipin Antibodies

This antibody is associated with the presence of an anti-phospholipid antibody and the condition known as "lupus anticoagulant syndrome". In combination with a coagulation screen, it is a useful screening test for patients with recurrent miscarriage or thrombosis in whom this condition should be excluded. However it is neither diagnostic nor specific for this condition and has many other clinical associations. Full lupus anticoagulant screening coagulation assays should be performed in any patient in whom there is a strong suspicion of this diagnosis.

Rheumatoid Factor

This test is important in the diagnosis of polyarthropathy. The result should be assessed in the context of clinical and other laboratory findings. Low levels of rheumatoid factor do not necessarily exclude the diagnosis of rheumatoid arthritis, nor are high levels restricted to this condition.

Further advice and information

If a clinician wishes investigations which are not in the RUH Laboratory Test Index to be carried out, advice will be given about where these can be obtained, please contact the laboratory for advice Telephone 01225 824730 (Lab) or 01225 821406 (Lead BMS).

The following table provides all details of sample requirements, special instructions, reference range, etc.

Immunology Sample Requirements

back to top

3.7  Clinical Haematology Service

Outpatient Clinics

Three primarily general haematology clinics are held weekly (Tuesday a.m., Wednesday a.m., Friday a.m.) for the investigation and treatment of patients with primarily non-malignant haematological diseases.  Two primarily haematological-oncology clinics are held weekly (Tuesday a.m., Thursday a.m.) for the treatment of patients with leukaemia, lymphoma, myeloma and related disorders at which outpatient intravenous chemotherapy can be administered. 

Referrals may be faxed to the department on 01225-461044.  Under normal circumstances urgent referrals are seen within 2 weeks and routine referrals are seen within 12 weeks.  Emergency referrals will be admitted through MAU if they cannot be admitted directly to the Clinical Haematology Unit.

There is a weekly (Friday a.m.) clinic for the investigation of patients with haematinic and thrombotic disorders

There is a weekly anticoagulant clinic in the RUH for monitoring the warfarin treatment of patients for whom their general practitioners would prefer hospital follow-up.  Twice monthly an anticoagulant clinic is held in Devizes for patients for whom hospital follow-up is required.

A weekly immunodeficiency clinic takes place in the RUH and there is a bimonthly joint Haematology-Paediatric clinic for the investigation and treatment of children with haematological disorders.

An outpatient INR service, compliant with NPSA guidance on anticoagulation is run from the RUH. This service is provided in two formats.

  1. Staff attend GP surgeries where a one stop service is offered, testing and dosing patients at the same appointment.
  2. A blood sample is taken and sent to the laboratory where testing, and dosing takes place. The laboratory communicates to the patient the next appointment time and the dosage.

As part of the service initiation of patients on warfarin is undertaken by the department.

Contact Anticoagulation Administrator Mandy Budds on 5504.

back to top

Inpatient Services

Patients with serious haematological disease are investigated and treated in single rooms in the William Budd Unit by an experienced team of nursing and medical staff.  Patients who require short term admission or less intensive nursing care (i.e. do not require reverse barrier nursing) are treated in the 6 patient bays in William Budd Ward.

Patients with leukaemia, lymphoma and myeloma receive therapy as part of (if the patient consents) or based on current national, international, MRC and multicentre clinical trials including, if appropriate, high dose chemotherapy and chemo-irradiation  with autologous bone marrow or peripheral blood progenitor cell transplantation. Patients requiring allogenic (sibling or unrelated  donor) BMT are referred to centres in Bristol, Royal Free or UCH.

back to top

Bone Marrow Analysis

Outpatients will generally  undergo bone marrow sampling  on William Budd Day Care Unit with sedation if a trephine biopsy is also required.  New outpatient referrals for whom it is clear that a bone marrow is required may have this arranged prior to the first outpatient consultation.  Please refer patients to a Consultant Haematologist.

A bone marrow/trephine will only be performed at the discretion of the haematology medical staff and a request for a haematology consultation.

back to top

Telephone Advice

A member of the Haematology medical staff is always available to discuss Haematology problems.  During office hours please contact the Haematology Registrar on bleep 7559 or 7702.  Out of hours please contact the Hospital Switchboard (01225 428331) who will put you in touch with the on-call medical Haematologist.

back to top

3.8 Main Laboratory

back to top

Full Blood Count



4.0 – 11.0 x 10 /l



4.5 – 6.5 x 1012  /l


3.5 – 5.5 x 1012  /l



13.5 – 18.0 g/dl


11.5 –16.5 g/dl



0.35 – 0.540 l/l


0.370 – 0.470 l/l



78.0 – 100.0 fl



27.0 – 32.0 pg



31.5 – 36.0 g/dl



11.5 – 15.5



150 - 400 x 109 /l



8 – 12 fl



2.0 –7.5 x 109  /l



1.5 – 4.5 x 109  /l



0.2 – 1.0 x 109  /l



0.04 – 0.4 x 109  /l



0.0 – 0.01 x 109  /l

Plasma Viscosity


Adult Normal Range

1.50 – 1.72 mPa

Normal Range    10 - 100 x 109 /l

Children (under 3 years)

1.25 – 1.47 mPa

Serum Ferritin

Serum B12


24 – 336 ng/ml

Normal Range 150 – 914 ng/ml

Female <50 years

11 – 307 ng/ml

Female >50 years

20 – 307 ng/ml


Serum Folate

Normal Range


back to top


Clotting Screen

INR Normal Range

0.89 – 1.11 Ratio

Prothrombin time PT

10.4 – 12.6 seconds

APTT Normal Range

23 – 32 seconds

Therapeutic Range

41.3 – 68.8 seconds

Clauss Fibrinogen

1.8 – 3.8 g/l

Factor Assays 

Factor II:C

70 – 150 % (IU/dl)

Factor V:C

70 – 150 % (IU/dl)

Factor VII:C

70 – 150 % (IU/dl)

Factor VIII:C

70 – 150 % (IU/dl)

Factor IX:C

70 – 150 % (IU/dl)

Factor X:C

70 – 150 % (IU/dl)

Factor XI:C

70 – 150 % (IU/dl)

Factor XII:C

70 – 150 % (IU/dl)

D-Dimer Assays

Normal Range

<550 mg/ml FEU

? DVT or PE

<500 mg/ml FEU

D-dimer test does not have a 100%  Negative Predictive Value for DVT or PE.

Free Protein S

Normal Range


70 – 148 %


50 – 134 %

Age and hormonal status may affect the normal range for females

VWF Antigen (vWF:Ag) -  Ristocetin Cofactor Activity (vWF:Rco)

Normal Range

50 – 150 IU/dl

Normal Range based on blood groups:

Group O

Group O  49 – 142%

Groups A+B+AB

Group A + B + AB 66 – 183%

VWF Ristocetin Cofactor Activity (vWF:RCo)

Normal Range

Group O  49 – 142%    Group A + B + AB 66 – 183%

Antithrombin (AT) Activity

Normal Range

75 – 125 IU/dl

Protein C Activity

Normal Range
(Substrate Factor Xa)

70 – 140 IU/dl

Activated Protein C Resistance (PCA Test)

Normal Range

0.86 – 1.10 Ratio

Heterozygous F5L

0.7 Ratio

Inhibitor Screen

Kaolin Clotting Time (KCT)

1:1 Mix

Normal (Test/Normal)       <1.2 Ratio

Normal Range    0.8 – 1.2 Ratio

Lupus Anticoagulant Screens




Normal Range

0.8 – 1.2 Ratio

0.8 – 1.2 Ratio


>1.2 Ratio


Normalised LAC Ratio

Normal Range

0.8 – 1.2 Ratio

Normalise APTT

Normal range <1.2 Ratio

Normalise DRVTT ratio

Normal range <1.2 ratio

back to top

Special Haematology

Haemoglobin F (HbF)  

Haemoblobin A2 (Hb A2)

Normal Range   <1.0%  

Normal Range 1.9 – 3.2 %

HbF forms >50% of total  Hb of newborn but falls to adult level within 6 months.



Normal Range   4.6 – 13.5 U/gHb

Normal Male & Female 0.3 – 2g/l

back to top




<30 IU/ml


>30 IU/ml

RF(IgM) (Grifols)


<6 IU/ml


>6 IU/ml




Normal Range:

1.1 – 2.6 mg/l

<81 kU/l

Anticardiolipin (IgG)(Grifols)


Negative  <20gpl/ml

Negative <100 IU/ml
Positive  >100 IU/ml

Positive  >17gpl/ml


Tissue Transglutaminase (TTG)

Rast Allergen


<10 IU/ml

0 = negative
1= weak positive


>10 IU/ml

2 = weak positive
3 = positive
4= positive
5 = strong positive
6 = strong positive

ENA screen (Orgentec)

IFA (Inova)


Negative           <25 iu/ml

Positive. Positives referred for ENA typing

Positive            >25 iu/ml

back to top

Paediatric Reference Ranges

Full Blood Count























2 weeks











2 months











6 months











1 year











2-6 years











6-12 years











12-18 years











12-18 years




78 - 95







* Data given as approximate ranges, compiled from various sources. Hinchliffe RF, reference values. Paediatric Haematology (1992)

Reference ranges in childhood based on literature quoted values.

Literature quoted values are generated using a specific reagent/FBC analyser combination and must therefore only be used as a guide alongside all other available clinical information.

Clotting Screen

For healthy full term infant during first 6 months of life:


Not significantly different from adult values


Day 1 – 30 Prolonged
Not significantly different from adult values from day 90.


Not significantly different from adult values


Not significantly different from adult values

Factor Assays


30 – 50% of adult levels: normal by 1 – 3 months

Factor V

Not significantly different from adult values

Factor VII

30 – 50% of adult values: normal by 1 month

Factor VIII

Variable: 50 – 200% of adult levels

Factor IX

20 – 50% of adult levels: normal by 1 month

Factor X

30 – 50% of adult levels: normal by 1 month

Factor XI

20 – 50% of adult levels: normal by 1 year

Factor XII

20 – 50% of adult levels: normal by 3 months

Factor XIII

50 – 100% of adult levels: normal by 1 month

Thrombophilia Tests


50 – 80% of adult levels: normal by 6 – 12 months

Protein C

30 – 50% of adult levels: normal by 3 month

Protein S

30 – 50% of adult levels: normal by 3 month

Von Willebrand Screen


Usually raised (up to 3 x adult levels)



Range (%)

3 days

1.0 - 4.5

1 month

0.3 - 1.0

6 months

0.4 - 1.4

6+ months

0.2 - 2.0

Serum B12 / Red Cell Folate

Not significantly different from adult values

Serum Ferritin

Similar mean values as adults
No distinction between males and females between 6 months and 12 years.

back to top