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Quick Reference
  • Normal Range (Men): 13.0-18.0 g/dL (or 130-180 g/L)
  • Normal Range (Women): 12.0-16.0 g/dL (or 120-160 g/L)
  • Anemia Definition: Hgb <13.0 g/dL (men), <12.0 g/dL (women)
  • Severe Anemia: Hgb <7.0 g/dL (transfusion often needed)
  • Primary Use: Diagnose and classify anemia, monitor oxygen-carrying capacity, guide transfusion decisions
  • Sample Type: Whole blood (EDTA tube - purple top)
  • Key Point: Hemoglobin is the gold standard for anemia diagnosis; more clinically important than RBC count or hematocrit

Test Description

What is Hemoglobin?

Hemoglobin (Hgb or Hb) is the iron-containing protein in red blood cells that binds and transports oxygen from the lungs to tissues and carries carbon dioxide back to the lungs. It gives blood its red color and is essential for aerobic metabolism.

Structure of Hemoglobin

Each hemoglobin molecule consists of:

  • Four globin chains: Two alpha and two beta chains in normal adult hemoglobin (HbA)
  • Four heme groups: Each containing an iron atom that binds one oxygen molecule
  • Oxygen capacity: One hemoglobin molecule can carry up to four oxygen molecules
  • Cooperative binding: Binding of oxygen increases affinity for additional oxygen molecules (sigmoidal dissociation curve)

Types of Hemoglobin

  • HbA (Adult Hemoglobin): Comprises ~95-98% of adult hemoglobin; two alpha and two beta chains (α2β2)
  • HbA2: Comprises ~2-3% of adult hemoglobin; two alpha and two delta chains (α2δ2); elevated in beta-thalassemia
  • HbF (Fetal Hemoglobin): Comprises <1% in adults; two alpha and two gamma chains (α2γ2); higher oxygen affinity than HbA; elevated in some hemoglobinopathies
  • HbS (Sickle Hemoglobin): Abnormal hemoglobin causing sickle cell disease; glutamic acid replaced by valine in beta chain
  • HbC, HbE: Other variant hemoglobins causing hemolytic anemias

How Does Hemoglobin Work?

Hemoglobin's function depends on its ability to reversibly bind oxygen:

  • In the lungs: High oxygen concentration causes hemoglobin to bind oxygen (oxyhemoglobin)
  • In tissues: Low oxygen and high CO2 cause hemoglobin to release oxygen (deoxyhemoglobin)
  • Bohr effect: Acidic pH and high CO2 promote oxygen release in metabolically active tissues
  • 2,3-DPG regulation: 2,3-diphosphoglycerate shifts oxygen dissociation curve right, facilitating oxygen delivery
Why Hemoglobin Matters Most: While RBC count and hematocrit are useful, hemoglobin concentration is the gold standard for diagnosing anemia because it directly measures oxygen-carrying capacity. A patient with low hemoglobin has reduced tissue oxygenation regardless of RBC count.
Normal Ranges

Hemoglobin normal ranges vary by age, sex, pregnancy status, and altitude. Men have higher hemoglobin than women due to testosterone's stimulatory effect on erythropoiesis and lack of menstrual blood loss.

Swipe to see more
Population Normal Range (g/dL) SI Units (g/L)
Adult Men 13.0-18.0 130-180
Adult Women (non-pregnant) 12.0-16.0 120-160
Pregnant Women 11.0-14.0 110-140
Newborns (0-2 weeks) 14.0-24.0 140-240
Infants (2-6 months) 9.5-14.0 95-140
Children (6 months-12 years) 11.0-16.0 110-160
Adolescents (13-18 years) 12.0-17.0 120-170
Important Considerations:
  • WHO Anemia Definitions: Men <13.0 g/dL, non-pregnant women <12.0 g/dL, pregnant women <11.0 g/dL
  • Altitude adjustment: Hemoglobin increases ~0.5 g/dL per 1000 meters above sea level
  • Hydration status: Dehydration falsely elevates hemoglobin (hemoconcentration); overhydration lowers it
  • Pregnancy: Physiologic anemia occurs due to plasma volume expansion exceeding RBC mass increase
  • Smoking: Chronic smokers have higher hemoglobin (compensation for carbon monoxide binding)
Clinical Significance

Low Hemoglobin (Anemia)

Anemia is defined as hemoglobin below normal limits for age and sex. Causes are categorized by mechanism and MCV (mean corpuscular volume).

Microcytic Anemia (MCV <80 fL)

  • Iron deficiency anemia: Most common worldwide; due to blood loss, inadequate intake, or malabsorption
  • Thalassemia: Genetic disorder of globin chain production; common in Mediterranean, Asian, African populations
  • Anemia of chronic disease: Can be microcytic or normocytic; iron sequestration by hepcidin
  • Lead poisoning: Inhibits heme synthesis
  • Sideroblastic anemia: Defective heme synthesis despite adequate iron

Normocytic Anemia (MCV 80-100 fL)

  • Acute blood loss: Trauma, GI bleeding, postpartum hemorrhage
  • Hemolytic anemia: Increased RBC destruction (autoimmune, hereditary spherocytosis, G6PD deficiency, sickle cell)
  • Anemia of chronic disease: Chronic infections, inflammatory disorders, malignancy
  • Chronic kidney disease: Decreased erythropoietin production
  • Bone marrow failure: Aplastic anemia, myelodysplasia, leukemia infiltration

Macrocytic Anemia (MCV >100 fL)

  • Vitamin B12 deficiency: Pernicious anemia, malabsorption, strict veganism
  • Folate deficiency: Inadequate intake, malabsorption, increased demand (pregnancy, hemolysis)
  • Alcohol use: Direct toxic effect on bone marrow and often folate deficiency
  • Hypothyroidism: Decreased metabolic demand
  • Liver disease: Impaired folate metabolism and lipid abnormalities affecting RBC membranes
  • Medications: Methotrexate, hydroxyurea, azathioprine, antiretrovirals

Elevated Hemoglobin (Polycythemia)

Elevated hemoglobin increases blood viscosity and thrombosis risk. Classified as primary or secondary.

Primary Polycythemia

  • Polycythemia vera: Myeloproliferative neoplasm with JAK2 mutation; autonomous RBC overproduction

Secondary Polycythemia

  • Chronic hypoxia: COPD, sleep apnea, high altitude living, cyanotic heart disease
  • Renal disease: Renal cell carcinoma, polycystic kidney disease (excess EPO production)
  • EPO-secreting tumors: Hepatocellular carcinoma, cerebellar hemangioblastoma
  • Exogenous EPO: Erythropoietin therapy, athletic doping
  • Testosterone therapy: Stimulates erythropoiesis

Relative Polycythemia

  • Dehydration: Hemoconcentration from volume depletion
  • Gaisböck syndrome: Apparent polycythemia in obese, hypertensive individuals
Interpretation Guidelines

Anemia Severity Classification

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Severity Hemoglobin (g/dL) Clinical Features
Mild Anemia 10.0-12.0 (women)
10.0-13.0 (men)		 Often asymptomatic or mild fatigue
Moderate Anemia 8.0-10.0 Fatigue, dyspnea on exertion, tachycardia
Severe Anemia 6.5-8.0 Marked symptoms, possible angina in CAD patients
Life-Threatening <6.5 High-output heart failure, shock risk; urgent transfusion often needed

Approach to Low Hemoglobin

Step 1: Confirm anemia and assess severity

Step 2: Classify by MCV (microcytic, normocytic, macrocytic)

Step 3: Check reticulocyte count:

  • Elevated reticulocytes: Suggests appropriate bone marrow response (blood loss or hemolysis)
  • Low reticulocytes: Suggests production problem (nutritional deficiency, bone marrow failure, renal disease)

Step 4: Order targeted testing based on MCV:

  • Microcytic: Iron studies (ferritin, TIBC, serum iron), hemoglobin electrophoresis for thalassemia
  • Normocytic: Hemolysis labs (LDH, haptoglobin, indirect bilirubin), renal function, bone marrow biopsy if indicated
  • Macrocytic: B12, folate, TSH, liver function tests

Transfusion Guidelines

Restrictive Transfusion Strategy (Most Patients):
  • Threshold: Transfuse if Hgb <7.0 g/dL in hemodynamically stable patients
  • Target: Hgb 7.0-9.0 g/dL post-transfusion
Liberal Transfusion Strategy (Higher Risk Patients):
  • Acute coronary syndrome: Transfuse if Hgb <8.0 g/dL
  • Symptomatic anemia: Consider transfusion if Hgb <8.0 g/dL with symptoms (dyspnea, chest pain, tachycardia)
  • Massive hemorrhage: Transfuse to maintain Hgb >7.0-8.0 g/dL during active bleeding
Interfering Factors

Factors That Increase Hemoglobin

  • Dehydration: Hemoconcentration from volume depletion (most common cause of falsely elevated Hgb)
  • Altitude: Chronic high altitude causes true elevation (physiologic adaptation)
  • Smoking: Carbon monoxide binding reduces oxygen delivery, stimulating EPO
  • Medications: Erythropoietin (EPO), testosterone, anabolic steroids
  • COPD: Chronic hypoxia stimulates RBC production

Factors That Decrease Hemoglobin

  • Overhydration: IV fluids, SIADH (hemodilution)
  • Pregnancy: Physiologic hemodilution (plasma volume increases 40-50%)
  • Recent transfusion: May mask underlying anemia
  • Blood donation: Temporary decrease post-donation
  • Supine position: Hemoglobin ~0.5 g/dL lower when supine versus standing

Pre-analytical Errors

  • Clotted sample: Falsely low hemoglobin; redraw required
  • Lipemia: Severe hypertriglyceridemia can falsely elevate hemoglobin
  • Leukocytosis: Extreme WBC elevation (>100,000) can falsely elevate hemoglobin
  • Prolonged tourniquet time: Hemoconcentration causes falsely high hemoglobin

Hemoglobin Variants

  • Carboxyhemoglobin: CO poisoning; hemoglobin bound to carbon monoxide
  • Methemoglobin: Oxidized hemoglobin unable to carry oxygen; caused by certain drugs or toxins
  • Sulfhemoglobin: Rare; caused by certain drugs (sulfonamides, phenacetin)
Clinical Pearls
Clinical Pearl
"Hemoglobin is king": While RBC count and hematocrit provide useful information, hemoglobin is the gold standard for diagnosing anemia because it directly measures oxygen-carrying capacity. Use hemoglobin to guide transfusion decisions and treatment.
Clinical Pearl
Rule of Three: In normal individuals, hemoglobin (g/dL) × 3 ≈ hematocrit (%). For example, Hgb 15 g/dL × 3 = Hct ~45%. If this relationship doesn't hold, consider lab error or abnormal RBC morphology.
Acute hemorrhage doesn't immediately lower hemoglobin: In acute bleeding, both plasma and RBCs are lost proportionally, so initial hemoglobin may appear normal. Only after hemodilution (fluid shifts or IV resuscitation) will hemoglobin fall. Serial measurements over 12-24 hours reveal true degree of blood loss.
Clinical Pearl
Symptoms correlate poorly with hemoglobin level: Chronic anemia (developing over weeks-months) is often asymptomatic even at Hgb 7-8 g/dL due to physiologic compensation. Acute anemia causes symptoms at higher hemoglobin levels. Consider rate of decline, not just absolute value.
Don't transfuse based on hemoglobin alone: Transfusion decisions should consider hemoglobin, symptoms, comorbidities (especially cardiac disease), and ongoing bleeding. Most stable patients tolerate Hgb 7-8 g/dL without transfusion. Overtransfusion carries risks (volume overload, transfusion reactions, infections).
Clinical Pearl
MCV guides anemia workup: Microcytic anemia → iron studies. Normocytic anemia → reticulocyte count and hemolysis labs. Macrocytic anemia → B12, folate, TSH. This systematic approach narrows differential diagnosis efficiently.
Clinical Pearl
Pregnancy anemia threshold is lower: Pregnant women have physiologic hemodilution with hemoglobin nadir at 28-32 weeks. WHO defines anemia in pregnancy as Hgb <11.0 g/dL. Most pregnant women need iron supplementation to maintain adequate stores.
Ferritin is key for iron deficiency: In microcytic anemia, ferritin <15 ng/mL confirms iron deficiency. Ferritin 15-50 ng/mL suggests possible iron deficiency (ferritin is an acute phase reactant, may be falsely normal in inflammation). Transferrin saturation <20% also supports iron deficiency.
References
  1. Kratz, A., Ferraro, M., Sluss, P. M., & Lewandrowski, K. B. (2004). Laboratory reference values. New England Journal of Medicine, 351, 1548-1564.
  2. Lee, M. (Ed.). (2009). Basic skills in interpreting laboratory data. Ashp.
  3. Farinde, A. (2021). Lab values, normal adult: Laboratory reference ranges in healthy adults. Medscape. https://emedicine.medscape.com/article/2172316-overview?form=fpf
  4. Nickson, C. (n.d.). Critical Care Compendium. Life in the Fast Lane • LITFL. https://litfl.com/ccc-critical-care-compendium/
  5. Farkas, Josh MD. (2015). Table of Contents - EMCrit Project. EMCrit Project. https://emcrit.org/ibcc/toc/
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