SJ Jenks

35
Laboratory reference ranges
Notes on the international system of units (SI units) 1358
Laboratory reference ranges in adults 1358
Urea and electrolytes in venous blood 1358
Analytes in arterial blood 1358
Hormones in venous blood 1359
Other common analytes in venous blood 1360
Common analytes in urine 1361
Analytes in cerebrospinal fluid 1361
Analytes in faeces 1361
Haematological values 1362
Laboratory reference ranges in childhood and adolescence 1363
Laboratory reference ranges in pregnancy 1364
1358 • LABORATORY REFERENCE RANGES

Notes on the international system of Laboratory reference ranges in adults

units (SI units)
Reference ranges are largely those used in the Departments
of Clinical Biochemistry and Haematology, Lothian Health
Système International (SI) units are a specific subset of the
University Hospitals Division, Edinburgh, UK. Values are shown
metre–kilogram–second system of units and were agreed on
in both SI units and, where appropriate, non-SI units. Many
as the everyday currency for commercial and scientific work in
reference ranges vary between laboratories, depending on
1960, following a series of international conferences organised
the assay method used and on other factors; this is especially
by the International Bureau of Weights and Measures. SI units
the case for enzyme assays. The origin of reference ranges
have been adopted widely in clinical laboratories but non-SI
and the interpretation of ‘abnormal’ results are discussed on
units are still used in many countries. For that reason, values
page 3. No details are given here of the collection requirements,
in both units are given for common measurements throughout
which may be critical to obtaining a meaningful result. Unless
this textbook and commonly used non-SI units are shown in
otherwise stated, reference ranges shown apply to adults; values
this chapter. The SI unit system is, however, recommended.
in children may be different.
Many analytes can be measured in either serum (the supernatant
Examples of basic SI units of clotted blood) or plasma (the supernatant of anticoagulated
blood). A specific requirement for one or the other may depend
Length metre (m)
on a kit manufacturer’s recommendations. In other instances, the
Mass kilogram (kg)
Amount of substance mole (mol) distinction is critical. An example is fibrinogen, where plasma is
Energy joule (J) required, since fibrinogen is largely absent from serum. In contrast,
Pressure pascal (Pa) serum is required for electrophoresis to detect paraproteins because
Volume The basic SI unit of volume is the fibrinogen migrates as a discrete band in the zone of interest.
cubic metre (1000 litres). For
convenience, however, the litre (L) is
used as the unit of volume in
laboratory work.
35.1 Urea and electrolytes in venous blood
Examples of decimal multiples and submultiples
of SI units Reference range
Factor Name Prefix Analysis SI units Non-SI units
106 mega- M Sodium 135–145 mmol/L 135–145 mEq/L
103 kilo- k
Potassium* 3.6–5.0 mmol/L 3.6–5.0 mEq/L
10−1 deci- d
10−2 centi- c Chloride 95–107 mmol/L 95–107 mEq/L
10−3 milli- m Urea 2.5–6.6 mmol/L 15–40 mg/dL
10−6 micro- μ
Creatinine
10−9 nano- n
Male 64–111 μmol/L 0.72–1.26 mg/dL
10−12 pico- p
Female 50–98 μmol/L 0.57–1.11 mg/dL
10−15 femto- f
*Serum values are, on average, 0.3 mmol/L higher than plasma values.
Exceptions to the use of SI units
By convention, blood pressure is excluded from the SI unit
system and is measured in mmHg (millimetres of mercury)
rather than pascals.
Mass concentrations such as g/L and μg/L are used in
35.2 Analytes in arterial blood
preference to molar concentrations for all protein measurements
and for substances that do not have a sufficiently well-defined Reference range
composition. Analysis SI units Non-SI units
Some enzymes and hormones are measured by ‘bioassay’,
Bicarbonate 21–29 mmol/L 21–29 mEq/L
in which the activity in the sample is compared with the activity
(rather than the mass) of a standard sample that is provided Hydrogen ion 37–45 nmol/L pH 7.35–7.43
from a central source. For these assays, results are given in PaCO2 4.5–6.0 kPa 34–45 mmHg
standardised ‘units’ (U/L), or ‘international units’ (IU/L), which PaO2 12–15 kPa 90–113 mmHg
depend on the activity in the standard sample and may not be
Oxygen saturation > 97%
readily converted to mass units.
 Laboratory reference ranges in adults • 1359

35.3 Hormones in venous blood

Reference range
Hormone SI units Non-SI units
Adrenocorticotrophic hormone 1.5–13.9 pmol/L (0700–1000 hrs) 63 ng/L
(ACTH) (plasma)
Aldosterone
Supine (at least 30 mins) 30–440 pmol/L 1.09–15.9 ng/dL
Erect (at least 1 hr) 110–860 pmol/L 3.97–31.0 ng/dL
Cortisol Dynamic tests are required – see Box 18.53, p. 680
Follicle-stimulating hormone (FSH)
Male 1.0–10.0 IU/L –
Female 3.0–10.0 IU/L (early follicular) –
> 30 IU/L (post-menopausal) –
Gastrin (plasma, fasting) < 40 pmol/L < 83 pg/mL
Growth hormone (GH) Dynamic tests are usually required – see Box 18.55, p. 682
< 0.5 μg/L excludes acromegaly (if insulin-like growth factor 1 < 2 mIU/L
(IGF-1) in reference range)
> 6 μg/L excludes GH deficiency > 18 mIU/L
Insulin Highly variable and interpretable only in relation to plasma glucose and body habitus
Luteinising hormone (LH)
Male 1.0–9.0 IU/L –
Female 2.0–9.0 IU/L (early follicular) –
> 20 IU/L (post-menopausal) –
17β-Oestradiol
Male < 160 pmol/L < 43 pg/mL
Female: early follicular 75–140 pmol/L 20–38 pg/mL
post-menopausal < 150 pmol/L < 41 pg/mL
Parathyroid hormone (PTH) 1.6–6.9 pmol/L 16–69 pg/mL
Progesterone (in luteal phase in
women)
Consistent with ovulation > 30 nmol/L > 9.3 ng/mL
Probable ovulatory cycle 15–30 nmol/L 4.7–9.3 ng/mL
Anovulatory cycle < 10 nmol/L < 3 ng/mL
Prolactin (PRL) 60–500 mIU/L 2.8–23.5 ng/mL
Renin concentration
Supine (at least 30 mins) 5–40 mIU/L –
Sitting (at least 15 mins) 5–45 mIU/L –
Erect (at least 1 hr) 16–63 mIU/L –
Testosterone
Male 10–38 nmol/L 290–1090 ng/dL
Female 0.3–1.9 nmol/L 10–90 ng/dL
Thyroid-stimulating hormone (TSH) 0.2–4.5 mIU/L –
Thyroxine (free), (free T4) 9–21 pmol/L 0.7–1.63 ng/dL
Triiodothyronine (free), (free T3) 2.6–6.2 pmol/L 0.16–0.4 ng/dL

Notes
1. A number of hormones are unstable and collection details are critical to obtaining a meaningful result. Refer to local laboratory handbook.
2. Values in the table are only a guideline; hormone levels can often be meaningfully understood only in relation to factors such as gender, age, time
of day, pubertal status, stage of the menstrual cycle, pregnancy and menopausal status.
3. Reference ranges are usually dependent on the method used for analysis and frequently differ between laboratories. Non-SI units also differ; those
shown here are amongst those most widely used. Readers are encouraged to consult their local laboratory for non-SI units for individual analytes
and their respective reference ranges.

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35.4 Other common analytes in venous blood

Reference range Reference range
Analyte SI units Non-SI units Analyte SI units Non-SI units
α1-antitrypsin 1.1–2.1 g/L 110–210 mg/dL γ-glutamyl Male 10–55 U/L –
Alanine 10–50 U/L – transferase (GGT) Female 5–35 U/L
aminotransferase Glucose (fasting) 3.6–5.8 mmol/L 65–104 mg/dL
(ALT) See page 722 for definitions of impaired glucose
Albumin 35–50 g/L 3.5–5.0 g/dL tolerance and diabetes mellitus, and page 738
for definition of hypoglycaemia
Alkaline 40–125 U/L –
phosphatase (ALP) Glycated 4.0–6.0% –
haemoglobin 20–42 mmol/mol Hb
Amylase < 100 U/L – (HbA1c) See page 722 for diagnosis of diabetes mellitus
Aspartate 10–45 U/L – Immunoglobulins (Ig)
aminotransferase IgA 0.8–4.5 g/L –
(AST) IgE 0–250 kU/L –
Bile acids (fasting) < 14 μmol/L – IgG 6.0–15.0 g/L –
IgM 0.35–2.90 g/L –
Bilirubin (total) 3–16 μmol/L 0.18–0.94 mg/dL
Lactate 0.6–2.4 mmol/L 5.4–21.6 mg/dL
Calcium (total) 2.1–2.6 mmol/L 4.2–5.2 mEq/L
or 8.5–10.5 mg/dL Lactate 125–220 U/L –
dehydrogenase
Carboxyhaemoglobin 0.1–3.0% –
(LDH; total)
Levels of up to 8% may
be found in heavy Lead < 0.5 μmol/L < 10 μg/dL
smokers Magnesium 0.75–1.0 mmol/L 1.5–2.0 mEq/L
Caeruloplasmin 0.16–0.47 g/L 16–47 mg/dL or 1.82–2.43 mg/dL
Cholesterol (total) Ideal level varies according to cardiovascular risk Osmolality 280–296 mOsmol/kg –
(see cardiovascular risk chart, p. 511) Osmolarity 280–296 mOsmol/L –
HDL-cholesterol Ideal level varies according to cardiovascular Phosphate (fasting) 0.8–1.4 mmol/L 2.48–4.34 mg/dL
risk, so reference ranges can be misleading.
According to the National Cholesterol Education Protein (total) 60–80 g/L 6–8 g/dL
Programme Adult Treatment Panel III (ATPIII), Triglycerides 0.6–1.7 mmol/L 53–150 mg/dL
a low HDL-cholesterol is < 1.0 mmol/L (fasting)
(< 40 mg/dL) Troponins Values consistent with myocardial infarction are
Complement crucially dependent on which troponin is
C3 0.81–1.57 g/L – measured (I or T) and on the method employed.
C4 0.13–1.39 g/L – Interpret in context of clinical presentation. See
Total haemolytic 0.086–0.410 g/L – page 450
complement Tryptase 0–135 mg/L –
Copper 10–22 μmol/L 64–140 μg/dL Urate
C-reactive protein < 5 mg/L Male 0.12–0.42 mmol/L 2.0–7.0 mg/dL
(CRP) Highly sensitive CRP assays also exist that Female 0.12–0.36 mmol/L 2.0–6.0 mg/dL
measure lower values and may be useful in Vitamin D (25(OH)D)
estimating cardiovascular risk Normal > 50 nmol/L > 20 ng/mL
Creatine kinase (CK; total) Insufficiency 25–50 nmol/L 10–20 ng/ml
Male 55–170 U/L – Deficiency < 25 nmol/L < 10 ng/mL
Female 30–135 U/L – Zinc 10–18 μmol/L 65–118 μg/dL
Creatine kinase MB < 6% of total CK –
isoenzyme
Ethanol Not normally detectable
Marked intoxication 65–87 mmol/L 300–400 mg/dL
Stupor 87–109 mmol/L 400–500 mg/dL
Coma > 109 mmol/L > 500 mg/dL
 Laboratory reference ranges in adults • 1361

35.5 Common analytes in urine

Reference range
Analyte SI units Non-SI units
Albumin Definitions of microalbuminuria are given on page 394
Proteinuria is defined below
Calcium (normal diet) Up to 7.5 mmol/24 hrs Up to 15 mEq/24 hrs
or 300 mg/24 hrs
Copper < 0.6 μmol/24 hrs < 38 μg/24 hrs
Cortisol 20–180 nmol/24 hrs 7.2–65 μg/24 hrs
Creatinine
Male 6.3–23 mmol/24 hrs 712–2600 mg/24 hrs
Female 4.1–15 mmol/24 hrs 463–1695 mg/24 hrs
5-Hydroxyindole-3-acetic acid (5-HIAA) 10–42 μmol/24 hrs 1.9–8.1 mg/24 hrs
Metadrenalines
Normetadrenaline 0.4–3.4 μmol/24 hrs 73–620 μg/24 hrs
Metadrenaline 0.3–1.7 μmol/24 hrs 59–335 μg/24 hrs
Oxalate 0.04–0.49 mmol/24 hrs 3.6–44 mg/24 hrs
Phosphate 15–50 mmol/24 hrs 465–1548 mg/24 hrs
Potassium* 25–100 mmol/24 hrs 25–100 mEq/24 hrs
Protein < 0.3 g/L < 0.03 g/dL
Sodium* 100–200 mmol/24 hrs 100–200 mEq/24 hrs
Urate 1.2–3.0 mmol/24 hrs 202–504 mg/24 hrs
Urea 170–600 mmol/24 hrs 10.2–36.0 g/24 hrs
Zinc 3–21 μmol/24 hrs 195–1365 μg/24 hrs

*The urinary output of electrolytes such as sodium and potassium is normally a reflection of dietary intake. This can vary widely. The values quoted are appropriate to a
‘Western’ diet.

35.6 Analytes in cerebrospinal fluid 35.7 Analytes in faeces

Reference range Reference range
Analysis SI units Non–SI units Analyte SI units Non-SI units
Cells < 5 × 106 cells/L < 5 cells/mm3 Calprotectin < 50 μg/g –
(all mononuclear) Elastase > 200 μg/g –
Glucose1 2.3–4.5 mmol/L 41–81 mg/dL
IgG index2 < 0.65 –
Total protein 0.14–0.45 g/L 0.014–0.045 g/dL
1
Interpret in relation to plasma glucose. Values in CSF are typically approximately
two-thirds of plasma levels. 2A crude index of increase in IgG attributable to
intrathecal synthesis.

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35.8 Haematological values

Reference range
Analysis SI units Non-SI units
Bleeding time (Ivy) < 8 mins –
Blood volume
Male 65–85 mL/kg –
Female 60–80 mL/kg –
Coagulation screen
Prothrombin time (PT) 10.5–13.5 secs –
Activated partial thromboplastin time (APTT) 26–36 secs –
D-dimers
Interpret in relation to clinical presentation < 200 ng/mL –
Erythrocyte sedimentation rate (ESR) Higher values in older patients are not necessarily abnormal
Adult male 0–10 mm/hr –
Adult female 3–15 mm/hr –
Ferritin
Male (and post-menopausal female) 20–300 μg/L 20–300 ng/mL
Female (pre-menopausal) 15–200 μg/L 15–200 ng/mL
Fibrinogen 1.5–4.0 g/L 0.15–0.4 g/dL
Folate
Serum 2.8–20 μg/L 2.8–20 ng/mL
Red cell 120–500 μg/L 120–500 ng/mL
Haemoglobin
Male 130–180 g/L 13–18 g/dL
Female 115–165 g/L 11.5–16.5 g/dL
Haptoglobin 0.4–2.4 g/L 0.04–0.24 g/dL
Iron
Male 14–32 μmol/L 78–178 μg/dL
Female 10–28 μmol/L 56–157 μg/dL
Leucocytes (adults) 4.0–11.0 × 109/L 4.0–11.0 × 103/mm3
Differential white cell count
Neutrophil granulocytes 2.0–7.5 × 109/L 2.0–7.5 × 103/mm3
Lymphocytes 1.5–4.0 × 109/L 1.5–4.0 × 103/mm3
Monocytes 0.2–0.8 × 109/L 0.2–0.8 × 103/mm3
Eosinophil granulocytes 0.04–0.4 × 109/L 0.04–0.4 × 103/mm3
Basophil granulocytes 0.01–0.1 × 109/L 0.01–0.1 × 103/mm3
Mean cell haemoglobin (MCH) 27–32 pg –
Mean cell volume (MCV) 78–98 fl –
Packed cell volume (PCV) or haematocrit
Male 0.40–0.54 –
Female 0.37–0.47 –
Platelets 150–350 × 109/L 150–350 × 103/mm3
Red cell count
Male 4.5–6.5 × 1012/L 4.5–6.5 × 106/mm3
Female 3.8–5.8 × 1012/L 3.8–5.8 × 106/mm3
Red cell lifespan
Mean 120 days –
Half-life (51Cr) 25–35 days –
Reticulocytes (adults) 25–85 × 109/L 25–85 × 103/mm3
Transferrin 2.0–4.0 g/L 0.2–0.4 g/dL
Transferrin saturation
Male 25–50% –
Female 14–50% –
Vitamin B12
Normal > 210 ng/L –
Intermediate 180–200 ng/L –
Low < 180 ng/L –
 Laboratory reference ranges in childhood and adolescence • 1363

Laboratory reference ranges in childhood and adolescence

The levels of many analytes in blood vary due to the physiological interpretation of the results. For example, a creatinine of 70 μmol/L
changes that occur during growth and adolescence. Hospital (0.79 mg/dL) is perfectly normal for the majority of adults but
laboratories may provide reference ranges that are age- may indicate significant renal impairment in a child. Reference
adjusted or based on pubertal stage but this is not always ranges for hormone results are described according to the
the case. It is therefore important for the doctor requesting Tanner stages of puberty (p. 1290).
these tests to understand the impact of age and puberty on

35.9 Analytes that may be significantly affected by growth and puberty*

Age/Pubertal Age/Pubertal
Analyte stage Gender Reference range Analyte stage Gender Reference range
Alkaline < 1 year M, F 80–580 U/L Luteinising Prepubertal M < 1.0 IU/L
phosphatase 1–16 years M, F 100–400 U/L hormone (LH) (< 0.1 μg/L)
(ALP) 16–20 years M 50–250 U/L Pubertal stage 2 M < 3.0 IU/L
F 40–200 U/L (< 0.3 μg/L)
Creatinine < 1 year M, F 12–39 μmol/L Prepubertal and F < 1.0 IU/L
(0.14–0.44 mg/dL) pubertal stage 2 (< 0.1 μg/L)
1–4 years M, F 13–42 μmol/L Pubertal stage 3 M 1.0–4.0 IU/L
(0.15–0.48 mg/dL) (0.1–0.4 μg/L)
4–12 years M, F 20–57 μmol/L Pubertal stages M 1.0–5.0 IU/L
(0.23–0.64 mg/dL) 4–5 (0.1–0.6 μg/L)
12–15 years M, F 31–67 μmol/L Pubertal stages F 1.0–8.0 IU/L
(0.35–0.76 mg/dL) 3–5 (0.1–0.9 μg/L)
15–18 years M 39–92 μmol/L 17β-Oestradiol Prepubertal and M < 75 pmol/L
(0.44–1.04 mg/dL) pubertal stages (< 20 pg/mL)
F 34–72 μmol/L 2–3
(0.38–0.81 mg/dL) Prepubertal and F < 100 pmol/L
Follicle- Prepubertal M < 3.0 IU/L pubertal stage 2 (< 27 pg/mL)
stimulating (< 0.6 μg/L) Pubertal stages M < 130 pmol/L
hormone F < 3.2 IU/L 4–5 (< 35 pg/mL)
(FSH) (< 0.64 μg/L) Pubertal stages F < 150 pmol/L
Pubertal stage 2 M < 6.6 IU/L 3–5 (< 41 pg/mL)
(< 1.32 μg/L) Testosterone Prepubertal M < 0.5 nmol/L
F < 4.1 IU/L (< 10 ng/dL)
(< 0.82 μg/L) F < 0.6 nmol/L
Pubertal stage 3 M 0.7–5.0 IU/L (< 20 ng/dL)
(0.14–1 μg/L) Pubertal stage 2 M < 10.6 nmol/L
Pubertal stages M 1.5–6.0 IU/L (< 310 ng/dL)
4–5 (0.3–1.2 μg/L) F < 1.4 nmol/L
Pubertal stages F 2.5–13.5 IU/L (< 40 ng/dL)
3–5 (0.5–2.7 μg/L) Pubertal stage 3 M 0.4–30 nmol/L
Insulin-like < 7 years M 15–349 μg/L (10–870 ng/dL)
growth F 17–272 μg/L Pubertal stage 4 M 5.6–30 nmol/L
factor 1 8–16 years M 67–510 μg/L (160–870 ng/dL)
F 59–502 μg/L Pubertal stage 5 M 10–30 nmol/L
(290–870 ng/dL)
Pubertal stages F 0.4–1.9 nmol/L
3–5 (10–50 ng/dL)

*Non-SI equivalents are given in brackets where appropriate.

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1364 • LABORATORY REFERENCE RANGES

Laboratory reference ranges in pregnancy

The levels of many analytes in blood vary during pregnancy, and it is important for the clinician reviewing the results to be
when many hormonal and metabolic changes occur. The aware of this to enable appropriate interpretation and patient
standard adult reference ranges may therefore not be appropriate management.

35.10 Analytes that may be significantly affected by pregnancy*

Reference range
Analyte First trimester Second trimester Third trimester
Alkaline phosphatase (ALP) 17–88 U/L 25–126 U/L 38–229 U/L
Packed cell volume (PCV) or haematocrit 0.31–0.41 0.30–0.39 0.28–0.40
Haemoglobin 116–139 g/L 97–148 g/L 95–150 g/L
Human chorionic gonadotrophin 4 weeks: 16–156 IU/L 4270–103 000 IU/L 2700–78 300 IU/L
4–9 weeks: 101–233 000 IU/L
9–13 weeks: 20 900–291 000 IU/L
17β-Oestradiol 690–9166 pmol/L 4691–26 401 pmol/L 12 701–22 528 pmol/L
(188–2497 pg/mL) (1278–7192 pg/mL) (3460–6137 pg/mL)
Progesterone 25–153 nmol/L Not available 314–1088 nmol/L
(8–48 ng/mL) (99–342 ng/mL)
Prolactin 765–4532 mIU/L 2340–7021 mIU/L 2914–7914 mIU/L
(36–213 ng/mL) (110–330 ng/mL) (137–372 ng/mL)
Thyroid-stimulating hormone (TSH) 0.60–3.40 mIU/L 0.37–3.60 mIU/L 0.38–4.04 mIU/L
Thyroxine (free), (free T4) 10–18 pmol/L 9–16 pmol/L 8–14 pmol/L
0.77–1.40 ng/dL 0.70–1.24 ng/dL 0.62–1.09 ng/dL

*Non-SI equivalents are given in brackets where appropriate.

Further information
Abbassi-Ghanavati M, Greer LG, Cunningham FG. Pregnancy and Tanner JM, Whitehouse RH. Clinical longitudinal standards for height,
laboratory studies: a reference table for clinicians. Obstet Gynecol weight, height velocity, weight velocity, and stages of puberty. Arch
2009; 114:1326–1331. Dis Child 1976; 51:170–179.