Dr. Camila Masias

“5% of the population will have what the lab will describe as abnormal labs, but that's normal for them. So, 5% of the population may have a slightly lower white blood count than what the laboratory says it's normal, but it's normal for that specific patient. So really looking at that trend is going to be very important.”

Narrator

Welcome to the PDSA podcast, Bruised but Not Broken: Living with ITP. The diagnosis of a bleeding disorder like immune thrombocytopenia may leave you wondering, how can I really live my life with ITP? PDSA's podcast, Bruised but Not Broken: Living with ITP, brings empowering stories, the latest research and treatment updates, lifestyle tips, and answers to the real life questions the ITP community is asking. Here’s your host for this episode, Barbara Pruitt.

Barbara Pruitt

Hello. Today I'm joined by Dr. Camilla Messias. She is a hematologist and a clinical investigator at the Miami Cancer Institute, which is part of Baptist Health of South Florida.

She is also an assistant professor at Florida International University. Her work focuses on platelet disorders like ITP, and she brings both a clinical and a research perspective to patient care. Today, we're going to really look at something that every ITP patient sees over and over again. That is the CBC. I'm really looking forward to having her walk us through what all those results actually mean, and to find out what we need to pay attention to and maybe just as importantly, what we don't need to worry about.

Barbara Pruitt

Thank you, Dr. Masais, for joining us today. We've got a lot of information to cover, and we're going to talk about the lab work that we have drawn as an ITP patient. And we want to get your end input as to what needs to be drawn, why it's important, and what do all these abbreviations mean?

Dr. Camila Masias

Yes, of course. Thank you for having me. And I think I'm hopeful that this will help patients ease their anxiety because I can definitely relate to getting all these results. And you see a lot of ah numbers that are in red, right? And we understandably so start panicking as to what they all mean.

Barbara Pruitt

Right. Well, as we know, ITP is a diagnosis of exclusion. And one of the things when you go to see your hematology, once you've been diagnosed, when you go to your hematologist, they're going to get a CBC, which is a complete blood count, and usually a chemistry profile or a CP. Is that right?

Dr. Camila Masias

Yes, that's correct.

Barbara Pruitt

Okay. Okay. And why are those the two things that we always get drawn?

Dr. Camila Masias

Yes, so as you said, a complete blood count is going to be like a snapshot of your blood's health. So, we're going to get information on your plate account, of course, but also we want to see a normal red blood cell, and not only count, but shape, size, and white blood cell count. And that is gun on the CBC. And how you're going to see it is when you go to your doctor, he's going to draw at least two tubes. One is a purple top tube, and that is the one we use to count your cells accurately in your blood. And the red top tube, and this one has no additives and is used for chemistry tests, like liver that you mentioned, and kidney function.

Barbara Pruitt

Okay. One thing that I don't quite understand, I mean, i the machine that's used to do all of this, they take the blood, they spin it, they put it in the machine. And how does that work exactly? I mean, or in a snapshot, how does that machine work to determine all these different values? Yeah.

Dr. Camila Masias

Yeah, absolutely. So, modern laboratory machines are incredibly sophisticated, and they work by passing your blood cells through a tiny opening one at a time. And they use a light, light beams and electrical signals to count and measure each cell. So, they're literally counting by numbers how many, for example, red blood cells you have, but also are these cells the adequate size and shape that they should be. And then the machine can tell the difference between red cells, white cells, and platelets based on their size and other characteristics. So, for example, an Ana Bettencourt- platelet is much smaller so smaller than a white blood cell in a number of three or four so smaller size, so the machine can detect that Bettencourt. Of course, machines are imperfect sometimes they can mistake one type of cell for another, for example very large platelets that we tend to see in patients with ITP might be counted as white blood cells or red cell fragments might be counted as platelets and that is where looking at the b blood smear comes into place as something very important

Barbara Pruitt

That's interesting. I know my doctor has told me, because I do have large platelets, that they're probably being counted as white blood cells, and that could contribute to why my white count is usually up a little bit. So, well, let's go through, if you don't mind, let's go through a CBC and differential. What does differential mean?

Dr. Camila Masias

Differential is; it pertains or speaks specifically to the white blood cells differential. So, the white blood cells, and you're going to see that as WPC on the CBC report, and these are your infection fighters. The caveat with white blood cells is that there are six different types of white blood cells. So, that's why we call it a differential, because then you're going to see Neutrophils, which are the ones that is the most common type and help us fight bacterial infection. Lymphocytes, and these fight typically viral infections, but also coordinate in immune responses. Monocytes, which are really going to clean up debris and fight c certain infections. Eosinophils help us find fight parasites and are also involved in allergies. Basophils are also involved in allergic reactions. The caveat here is that you may also see immature cells which are young white cells that normally stay in the bone marrow and seeing them in the blood can indicate stress or bone marrow problems so going back to our patients that have ITP they should have what we call a benign differential meaning the white blood cell differential should be completely normal.

Barbara Pruitt

Okay. Should be normal. Okay. That makes sense. And one thing I know that I've been told three years is, you know, when you get the results back and now, you know, the patients, we usually get the results back pretty quickly. And I know that a lot of people, they look at that results and they see what the normals are and they see that, oh no, I'm just right outside the normal of this or that. And it freaks them out. But isn’t it true that a doctor is actually looking for, if there's an elevation or a decrease, you want to see if there's a pattern. So, if consecutive tests is continuing to show that, you don't freak out if it's just one time.

Dr. Camila Masias

Absolutely, and I think we should start by saying these numbers, the normal numbers, the numbers that will show very nicely in black or blue, correspond to 95% of the population.

5% of the population will have what the lab will describe as abnormal labs, but that's normal for them. So, 5% of the population may have a slightly lower white blood count than what the laboratory says it's normal, but it's normal for that specific patient. So really looking at that trend is going to be very important. I would say that, you know, if your doctor is not worried, hopefully you trust your doctor. And if your doctor is not worried, you know, you shouldn't worry about it. Sometimes we're going to see values that are just slightly outside normal range. Sometimes we may see values that are outside normal range because of the treatment we are giving to you. Sometimes we get an abnormal laboratory test and then that next time is normal. But certainly, values that are persistently significantly abnormal warrant more attention. If the results are getting worse, it's something that we want to pay attention to. Of course, if you have symptoms associated with these abnormal lumps, we can't and shouldn't ignore this. So, this; that's where the doctor should repeat tests and make adjustments.

Barbara Pruitt

And another thing I was just thinking about is people sometimes they want to compare their lab values to a friend's lab values. And isn't it true that different machines might have different parameters? So, it's not necessarily comparing apples to apples.

Dr. Camila Masias

Absolutely. You know, every laboratory has its own calibration and will give us slightly different normal lab values, as you said. So maybe for the lab where I work, a normal platelet count is more than 130,000. And then for another laboratory, it may be more than 150. So, that's hard to compare amongst patients. And the other thing I wanted to bring up is that when you get a CBC, when you specifically looked at the white blood cell differential, you will get two sets of numbers. The first one corresponds to percentages, your percentage of neutrophils, percentage of lymphocytes. And you may see some percentage that is abnormal, but then when you go down and look at the absolute numbers, though those tend to fall within range, and those are the ones we care the most.

Barbara Pruitt

Okay. So, like the lymphocytes absolute value is a bit more important than the percentage?

Dr. Camila Masias

That's correct. Yes.

Barbara Pruitt

Okay. And the same, I'm assuming with the basophils, neutrophils, monocytes, all of those.

Let's talk a little bit about; I know we talked about the white blood cells because they're the ones that are fighting infection in your body. And hemoglobin, that's something that's always on your complete blood count on the CBC. Tell us what the hemoglobin is measuring.

Dr. Camila Masias

The hemoglobin is measuring how the red blood cells are carrying oxygen throughout your body. And you will see RBC, red blood cells, and then you will see a hemoglobin and a hematocrit. And the both hemoglobin and hematocrit corresponds to the way the red blood cells are carrying oxygen. So, sometimes, although it's rare, patients may have a high hemoglobin and that can happen with dehydration or with lung problems. Sometimes it may be normal for patients that live in high altitude geographic areas. When a patient has a low hemoglobin, it indicates anemia, meaning they're not carrying enough oxygen. And we may; we may see that with ITP when the patients have bleeding from the ITP, but otherwise it should be normal.

Barbara Pruitt

I know. And I know that for women, if they have very heavy, heavy menstrual periods, sometimes their hemoglobin can go down and hematocrit.

Dr. Camila Masias

Absolutely. Yeah. And that that will get worse with ITP, of course. Their periods will get heavier, hence their hemoglobin will go down. So, it's a two-way problem.

Barbara Pruitt

Right. And that's when your doctor recommends, usually it's like an iron supplement or is there something else that's usually recommended?

Dr. Camila Masias

If the hemoglobin is low, we will first obtain iron panel, which is the most important marker for iron is ferreting. And if it's low, then yes, we will suggest we will give the patient either oral iron or IV iron, depending on how bad it is.

Barbara Pruitt

Okay. All right. Now, when it comes to part of the complete blood count, you've got all these abbreviations, MCV, MCH, MCHC, all of these things. Can you kind of go through those and explain what those mean and why they're important to see?

Dr. Camila Masias

Yeah, I think they're there to pretend that our job is very complicated when it's not. Because there's a lot of letters that are, of course, very confusing. But let's start with the MCV, MCH, and MCHC. So, the V speaks to the volume, and the H speaks to the color of the red blood cells. So, these three acronyms pertain to red blood cells. None of these pertain to platelets and therefore it should be normal in patients with ITP. But they're going to speak about the red blood cells size color and shape so red blood cells are sort of like a donut that has like a not a complete hole but it's certainly ah an area of power in the middle and these numbers are going to tell us hey, these red blood cells are too big or too small uh or they're too power or they're not there's not enough power in the middle. And this goes along with nutritional deficiencies. We talked about iron, for example, in women that have iron deficiency anemia, their red blood cells are going to be small and very pale. And that is going to be represented with a low MCV and MCH. But other nutritional deficiencies can actually have the opposite effect.

Barbara Pruitt

Okay. All right. So, then we get into the RDW.

Dr. Camila Masias

Yeah, so that stands for red cell distribution width. And that is going to tell us how much variability our is on the size of your red blood cells. So, if your RGW is high, that means that your red blood cells have many different sizes. You have some that are small, some that are normal, and some that are big. And that can happen with certain types of anemia. But again, this is something that usually should be normally patient with ITP.

Barbara Pruitt

Right, right. Okay. What about nucleated RBCs?

Dr. Camila Masias

So nucleated RBCs are sort of if you want call it immature or baby red blood cells that are seen on the peripheral, either the peripheral smear or reported as part of the CDC. They speak about bone marrow that is producing, your bone marrow is sort of working very hard and it's releasing this red blood cell sort of ahead of time, if you want to call it like that. It shouldn't normally be in your blood, but again, this is something that should not be seen with ITP. And it actually; it's very helpful in distinguishing from other blood disorders.

Barbara Pruitt

Okay, because actually all of these tests, if they're out of line, they're going to lead you to think that there's other things going on. I mean, but that's a hematologist. You know, that's what you're looking for all the time, looking at all those different blood cells. And then, of course, the platelet count is part of the CBC.

Dr. Camila Masias

The star our game. Yeah.

Barbara Pruitt

That's right. That's the star of our blood test. That's the one we're all focusing on. But as we also know, your treatment doesn't just depend on your platelet count. It depends also on how you present. I mean, if you're having a lot of symptoms, bleeding, petechiae, bruising and stuff, it's a like my doctor once told me, if we could come up with a wind sill a wind chill factor, that would be maybe a good way to describe how a patient is doing with their specific ITP.

Dr. Camila Masias

Yeah, that trend on every patient is so important. And this is something that it also, I wish we would do better as clinicians and as a laboratory reporting, because it's very unsettling to see a platelet count that's abnormal, right? It's red and it's say 100,000, certainly below the range. And you can say, hey, but it is really below the range, but And then your hematologist telling you, yeah, but we don't really do anything about it. You know, it's not what you were expecting to hear. Maybe we'll just watch it for now. We don't do anything until it drops even lower than that, much lower. So, I wish some numbers wouldn't be reported as sort of completely abnormal because clinically they're abnormal, but clinically we don't really make a difference.

Barbara Pruitt

Right. They're not significant. And patients will get very anxious in that interim between having that blood test drawn and then getting into their appointment with their hematologist. It's a very anxious period for them until they get the news that, well, it's low, but it's not really that bad. You know, you're not having symptoms. You're going to be safe. If you bump yourself, you'll be okay. So, I know there's a lot of anxiety related to an ITP diagnosis and also having your blood drawn. So, let's go over the comprehensive metabolic panel, or sometimes a CP or a CMP is what they call it. And I know a good part of it are what is called the electrolytes. Can you go over what the electrolytes are?

Dr. Camila Masias

Yes. So, the CMP or the chemistry profile, it looks at how well your organs are working and measures important chemicals, as the name implies, in your blood. So, electrolytes are minerals that are in your blood that carry electrical charges, and they're going to play an essential role in a number of things, including muscle function, mainly your heart, how your body signaling through nerves, the fluid balance, your acid-base balance. And you will see when you get a CMP reported, mainly sodium, which is gonna control the water balance and blood pressure, potassium, that is gonna really be critical for heart rhythm, muscle function, chloride, that is gonna work with sodium to control fluid balance, and CO2 or bicarbonate, which again is going to help maintain a proper acid-base balance.

Barbara Pruitt

Okay, and that's what the electrolytes are. Those are the things that get out of balance for athletes, that they're always drinking electrolyte replacement liquids, right?

Dr. Camila Masias

Yep, absolutely. Dehydration is a common cause of electrolyte imbalance. And that's why they, they are, so if they're truly, you know, athletes that are training long hours and several hours a week. Their recommendation is to for them to drink not only water, but with electrolytes to supplement.

Barbara Pruitt

Right, right. Now, the rest of the chemistry profile, we'll kind of go through it. There's a lot of different things that are measured. But as far as being an ITP patient, I think a lot of these are looked at from the aspect of wanting to make sure that maybe a treatment you're receiving is not causing any untoward values, correct?

Dr. Camila Masias

That's correct. So, for example, when patients have ITP and are on steroids, that can raise their blood sugar and that can affect electrolytes. And some medications for ITP may also stress the liver. Some treatments not necessarily ITP related can affect the kidney function. So, the electrolytes are one part of the chemistry profile. But the other part of the chemistry profile is going to pertain to the glucose, which is just a fancy name for sugar. BUN, creatinine, and EGFR are markers of your kidney function and how well your kidneys are filtering the fluids that you take. Calcium, it's important for your bones, your nerves, your muscles. We're going to see a total protein and albumin, and this is made by the liver, and it's going to be a marker of nutrition and liver function. And finally, the liver enzymes, and there's a number of letters again now, AST, ALT, alkaline phosphatase. These are liver enzymes that are going to tell us if your liver is inflamed or damaged. And this is very important for it to be normal when we're initially diagnosed with ITP, because if they're not normal, it's probably not ITP. It probably means that your platelet count is low because you have some liver inflammation.

Barbara Pruitt

Okay, so those are very important to look at. So, when you're getting your regular hematology test, you know, appointment and you get your blood testing, there is a reason to get the chemistry profile. It's making sure that all your other organs are working well, and it just means it's another vial that they draw. That's why you get the two vials done. This is great. Are there; anything else you want to mention about any of these tests in the chemistry profile?

Dr. Camila Masias

I would mention that don't be surprised your doctor, these are part of not only the initial diagnosis, but also a part of your treatment on your journey overall with ITP in which depending on the treatment that you're on, your doctor will most likely want to make sure that your electrolytes are on balance and your kidneys and your liver is working fine through treatment. So, it's not something that we just check once, but we repeat periodically to make sure that everything else is working fine, continues to work fine.

Barbara Pruitt

Which is great. That's constantly being monitored so that you, well, like I tell people, you really have to be an advocate for your own health. And you want to be proactive. You want to catch things before they become a problem. And when your hematologist is looking at these different values, if something looks a little out of whack, like let's say your kidney test that you would explain, if they weren't consecutively a little bit off, your hematologist might want to recommend that you see a nephrologist or a kidney specialist, especially if you know that it doesn't have anything to do with the treatment that you're getting. So, it's good to be proactive and know that your doctor is monitoring these things.

Dr. Camila Masias

I love it.

Barbara Pruitt

So, if anything does show up abnormal, you would be led in the right direction. So is there anything that would show up in either the CBC or the Chem; chemistry profile that might make you concerned about something totally different aside from ITP.

Dr. Camila Masias

So, yes, the chemistry profile should have a normal hepatic function panel for sure. And it, yes, yeah.

Barbara Pruitt

And that's for your liver. Hepatic function is for your liver, right?

Dr. Camila Masias

And then, that needs to be monitored through treatment, especially if patients are on a TPRA. Sometimes we want to make sure that the liver panel remains normal. Kidney problems are typically not associated with ITP, meaning some patients will have sort of some kind of kidney damage, maybe because they have diabetes, maybe because they have high blood pressure, but that shouldn't sort of cause a low plated count, but certainly that we want to make sure that we're on top of it, again, especially in patients that are taking steroids because prednisone affects, you know, so many different parts of our body that we want to make sure that our patients that have concomitant kidney damage have their electrolytes on balance and everything while they're on steroids.

Barbara Pruitt

Great, great. All right. Well, this has been very interesting. I mean, I've learned a lot from this. I think some of these things I knew before, but you know, when you don't visit it frequently, you kind of forget what they're all about. So, this has been very interesting. Is there anything else you want to share about the CBC and Chem Profile?

Dr. Camila Masias

Yeah, I would say i sometimes I wish we could only order a platelet count so that we don't get all these tests because sometimes I feel like, especially with a CBC, we don't need, that we know that the red blood cells are going to be and at a normal shape and size and sometimes we get the results. And what I wish for our patients to get from this is that don't be alarmed if some results are abnormal, follow a trend; you know. Find a doctor that you trust and he is keeping a close eye on your labs but also knows you know that some of the labs may be normal for you, but they're abnormal for the lab.

Barbara Pruitt

Well, thank you for your explanation of all of these values. I think, you know, when we go see our hematologist now, we're going to seem a lot more educated when we go over the test; when they show them to us.

Dr. Camila Masias

Yeah. Yeah.

Barbara Pruitt

So, we'll say, oh, I know what that's all about. That's for my kidney function or that's for my liver function. Everything looks good. That's great to know. So, well, thank you for spending the time with us, Dr. Masias. This has been terrific. And you've been very enlightening for all of us, not just me, but our listening audience. And we hope to have you on again if you're available in the future when we have lots more questions, as we always do.

Dr. Camila Masias

Thank you for having me. It's been a great conversation. Take care.

Narrator

How do you live your life with a bleeding disorder like ITP? From working in the kitchen with knives, to navigating sharp corners in your house, going out to eat in a restaurant, traveling on a plane, attending a sporting event, even dancing at a wedding. ITP patient, Barbara Pruitt, shares her tips and tricks for moving through life with ITP for more than 60 years. Here's her lifestyle lesson for the day.

Barbara Pruitt

Understanding our lab reports is important for anyone dealing with a chronic illness. Aside from your platelet count, sometimes another test result may come back a little out of the normal range. This is not a reason to freak out. Your doctor is going to review your results, and if there is a need for further testing, they'll let you know. As Dr. Masias mentioned in our podcast, a one-time out-of-range value is not that significant. But if that value has been out of range multiple times, it may have some significance. And at that time, they'll do further testing. Looking at your lab results is much easier when you understand what you're looking at. If there's something that concerns you, ask your doctor. Don't just sit there and worry. I know we all want to be normal, but what is normal? For us with ITP, our abnormal is our normal. Let that sink in. Well, that's it for today. I hope you'll join us next time. And until then, wishing you lots of happy, healthy platelets.

Narrator

Thanks for listening to the PDSA podcast, Bruised but Not Broken, Living with ITP. Made possible by our presenting sponsors, Amgen and Sanofi. Special thanks to Gus Mayorga for composing our theme music. To see what's coming up, visit our website at pdsa.org and subscribe wherever you get your podcasts. Please share this podcast through social media with anyone who you think might benefit from the information and stories we share with the ITP and other platelet disorders community. As always, please speak with a healthcare care professional before making any treatment decisions, but know that pdsa.org is a wealth of information and resources to help you navigate life with ITP and other platelet disorders. Remember, you are not alone.