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Quick Reference
  • Normal Range (Men): 4.6-6.2 million cells/μL (or 4.6-6.2 × 10¹²/L)
  • Normal Range (Women): 4.2-5.4 million cells/μL (or 4.2-5.4 × 10¹²/L)
  • Primary Use: Evaluate anemia, polycythemia, and overall oxygen-carrying capacity
  • Sample Type: Whole blood (EDTA tube - purple top)
  • Key Point: RBC count should always be interpreted alongside hemoglobin, hematocrit, and RBC indices (MCV, MCH, MCHC)

Test Description

What are Red Blood Cells?

Red blood cells (RBCs), also called erythrocytes, are the most abundant cells in blood. Their primary function is to transport oxygen from the lungs to tissues and carry carbon dioxide back to the lungs for elimination. The RBC count measures how many red cells are present per microliter of blood.

Structure and Function

  • Shape: Biconcave disc shape maximizes surface area for gas exchange
  • Hemoglobin: Each RBC contains approximately 270 million hemoglobin molecules that bind oxygen
  • Lifespan: Average RBC survives 120 days in circulation before being removed by the spleen
  • Production: RBCs are produced in bone marrow through erythropoiesis, stimulated by erythropoietin (EPO) from the kidneys
  • No nucleus: Mature RBCs lack a nucleus, providing more space for hemoglobin

Why is RBC Count Important?

The RBC count provides crucial information about blood disorders and systemic conditions:

  • Anemia detection: Low RBC count indicates anemia, reducing oxygen delivery to tissues
  • Polycythemia screening: Elevated RBC count increases blood viscosity and clotting risk
  • Classification of anemia: Combined with MCV (mean corpuscular volume), helps categorize anemia types (microcytic, normocytic, macrocytic)
  • Monitoring treatment: Tracks response to iron supplementation, EPO therapy, or chemotherapy
RBC vs Hemoglobin vs Hematocrit: These three measurements assess oxygen-carrying capacity from different angles:
  • RBC count: Number of red cells (how many cells)
  • Hemoglobin: Amount of oxygen-carrying protein (most clinically important)
  • Hematocrit: Percentage of blood volume occupied by RBCs (volume percentage)
All three typically rise or fall together, but discrepancies can reveal important conditions (e.g., microcytic anemia has low hemoglobin but relatively preserved RBC count).
Normal Ranges

RBC counts vary significantly by age, sex, and altitude. Men have higher RBC counts than women due to testosterone's stimulatory effect on erythropoiesis. Values also increase at high altitudes as a physiologic adaptation to lower oxygen levels.

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Population Normal Range (million/μL) SI Units (× 10¹²/L)
Adult Men 4.6-6.2 4.6-6.2
Adult Women (non-pregnant) 4.2-5.4 4.2-5.4
Pregnant Women (varies by trimester) 3.4-4.5 3.4-4.5
Newborns (0-2 weeks) 4.1-6.1 4.1-6.1
Infants (2-6 months) 2.7-4.9 2.7-4.9
Children (6 months-12 years) 3.9-5.3 3.9-5.3
Adolescents (13-18 years) 4.1-5.7 4.1-5.7
Important Considerations:
  • Sex difference: Men have ~10-15% higher RBC counts than women due to testosterone
  • Pregnancy: Physiologic anemia of pregnancy causes lower RBC count (plasma volume expands more than RBC mass)
  • Altitude: People living at high altitudes have higher baseline RBC counts (adaptation to hypoxia)
  • Hydration status: Dehydration falsely elevates RBC count (hemoconcentration); overhydration lowers it (hemodilution)
  • Aging: RBC count may decline slightly with advanced age
Clinical Significance

Decreased RBC Count (Associated with Anemia)

Low RBC count typically indicates anemia, though hemoglobin is the primary diagnostic criterion. Causes are categorized by mechanism: decreased production, increased destruction, or blood loss.

Decreased RBC Production

  • Iron deficiency: Most common cause of anemia worldwide; microcytic RBCs
  • Vitamin B12 or folate deficiency: Impairs DNA synthesis; macrocytic RBCs
  • Chronic kidney disease: Decreased erythropoietin production
  • Bone marrow disorders: Aplastic anemia, myelodysplastic syndrome, leukemia, marrow infiltration
  • Chronic disease/inflammation: Cytokines suppress erythropoiesis
  • Hypothyroidism: Decreased metabolic demand reduces RBC production

Increased RBC Destruction (Hemolysis)

  • Autoimmune hemolytic anemia: Antibodies destroy RBCs
  • Hereditary spherocytosis: Membrane defect causes premature destruction
  • G6PD deficiency: Oxidative stress triggers hemolysis
  • Sickle cell disease: Abnormal hemoglobin causes RBC sickling and hemolysis
  • Mechanical hemolysis: Prosthetic heart valves, microangiopathic hemolytic anemia (MAHA)
  • Hypersplenism: Enlarged spleen sequesters and destroys RBCs

Blood Loss

  • Acute hemorrhage: Trauma, GI bleeding, surgical blood loss
  • Chronic blood loss: GI bleeding (ulcers, malignancy), heavy menstruation, occult bleeding

Elevated RBC Count (Polycythemia)

Elevated RBC count increases blood viscosity, raising risks of thrombosis and cardiovascular events. Polycythemia is classified as primary (intrinsic bone marrow disorder) or secondary (reactive to hypoxia or other stimuli).

Primary Polycythemia

  • Polycythemia vera: Myeloproliferative neoplasm with uncontrolled RBC production; often JAK2 mutation positive

Secondary Polycythemia

  • Chronic hypoxia: COPD, sleep apnea, high altitude, right-to-left cardiac shunts
  • Renal disease: Kidney tumors, renal artery stenosis, polycystic kidney disease (all cause excess EPO)
  • Tumors producing EPO: Hepatocellular carcinoma, renal cell carcinoma, cerebellar hemangioblastoma
  • Exogenous EPO: Athletes using EPO for doping; patients on EPO therapy
  • Testosterone therapy: Stimulates erythropoiesis

Relative Polycythemia (Pseudopolycythemia)

  • Dehydration: Hemoconcentration from fluid loss (vomiting, diarrhea, diuretics, burns)
  • Gaisböck syndrome: Apparent polycythemia in obese, hypertensive men due to reduced plasma volume
Interpretation Guidelines

Approach to Low RBC Count

Step 1: Confirm anemia by checking hemoglobin and hematocrit

Step 2: Classify anemia by MCV (mean corpuscular volume):

  • Microcytic (MCV <80 fL): Iron deficiency, thalassemia, anemia of chronic disease, lead poisoning
  • Normocytic (MCV 80-100 fL): Acute blood loss, hemolysis, chronic disease, bone marrow failure, renal failure
  • Macrocytic (MCV >100 fL): B12/folate deficiency, hypothyroidism, liver disease, myelodysplasia, alcohol use

Step 3: Assess reticulocyte count to determine if bone marrow is responding appropriately

Step 4: Additional testing based on MCV classification (iron studies, B12/folate, hemolysis labs, bone marrow biopsy if indicated)

Approach to High RBC Count

Step 1: Rule out hemoconcentration (dehydration) by checking hydration status and repeating test when euvolemic

Step 2: Measure erythropoietin (EPO) level:

  • Low EPO: Suggests polycythemia vera (primary polycythemia)
  • High EPO: Suggests secondary polycythemia (hypoxia, tumor, renal disease)

Step 3: If EPO high, evaluate for causes of hypoxia or EPO-secreting tumors:

  • Pulse oximetry and arterial blood gas
  • Sleep study if sleep apnea suspected
  • Imaging for renal or hepatic tumors

Step 4: If EPO low, consider hematology referral for JAK2 mutation testing and evaluation for polycythemia vera

Hyperviscosity Syndrome: Severe polycythemia (hematocrit >60%) can cause:
  • Neurologic symptoms: Headache, dizziness, visual disturbances, stroke
  • Cardiovascular: Thrombosis (DVT, PE, MI), paradoxical bleeding
  • Treatment: Phlebotomy to reduce hematocrit to <45% (target <42% in polycythemia vera)
Interfering Factors

Factors That Increase RBC

  • Dehydration: Most common cause of falsely elevated RBC (hemoconcentration)
  • Altitude: Chronic high altitude causes true elevation (physiologic adaptation)
  • Smoking: Chronic hypoxia stimulates EPO production
  • Medications: Testosterone, anabolic steroids, erythropoietin (EPO)
  • Time of day: RBC count slightly lower in morning, higher in evening

Factors That Decrease RBC

  • Overhydration: IV fluids, excessive fluid intake (hemodilution)
  • Pregnancy: Physiologic hemodilution (plasma volume increases more than RBC mass)
  • Medications: Chemotherapy, immunosuppressants, chronic NSAID use (GI bleeding)
  • Blood donation: Temporary decrease following donation

Pre-analytical Errors

  • Clotted sample: Falsely low RBC; redraw required
  • Prolonged tourniquet time: Hemoconcentration causes falsely high RBC
  • EDTA-induced RBC agglutination: Rare; causes falsely low count
  • Sample storage: RBCs swell over time; analyze within 6 hours for accurate MCV
Clinical Pearls
Clinical Pearl
"Hemoglobin is king": While RBC count is useful, hemoglobin is the gold standard for diagnosing and monitoring anemia. A patient with low hemoglobin is anemic regardless of RBC count.
Clinical Pearl
Rule of Three: In patients without anemia or polycythemia, hemoglobin (g/dL) × 3 ≈ hematocrit (%). If this relationship doesn't hold, consider lab error, abnormal RBC morphology, or interfering substances.
Clinical Pearl
Microcytic anemia with normal RBC count: Think thalassemia. In thalassemia, there are many small RBCs (low MCV, normal or high RBC count) versus iron deficiency (low MCV, low RBC count). The Mentzer index (MCV/RBC) helps distinguish: <13 suggests thalassemia, >13 suggests iron deficiency.
Acute blood loss doesn't immediately lower RBC count: In acute hemorrhage, both plasma and RBCs are lost proportionally, so initial hemoglobin/RBC may be normal. Only after hemodilution (fluid shifts into vascular space or IV fluids given) do the values drop. Serial measurements over 24-48 hours reveal true degree of anemia.
Polycythemia increases thrombosis risk: Hematocrit >45-50% significantly increases blood viscosity. In polycythemia vera, target hematocrit <45% with phlebotomy to reduce cardiovascular events. Don't forget aspirin for thrombosis prophylaxis unless contraindicated.
Clinical Pearl
Erythropoietin (EPO) levels guide polycythemia workup: Low EPO with high RBC suggests polycythemia vera (autonomous RBC production). High EPO with high RBC suggests secondary polycythemia (appropriate response to hypoxia or inappropriate secretion by tumor).
Clinical Pearl
Always check reticulocyte count in anemia: Reticulocytes are young RBCs released from bone marrow. High reticulocyte count indicates appropriate bone marrow response (blood loss, hemolysis). Low reticulocyte count suggests production problem (iron deficiency, bone marrow failure, renal disease).
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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