Recommendations on the measurement and use of the alcohol consumption biomarker CDT. A position paper from the IFCC Working Group on CDT standardisation.

BACKGROUND: Carbohydrate deficient transferrin (CDT) is a biomarker for excessive alcohol consumption utilized in clinical and forensic medicine and workplace testing. Previously, many different analytical methods for CDT were used and the measurand varied considerably, making direct comparison of test results difficult. To end this confusion, the IFCC established a working group on CDT standardisation (WG-CDT) which completed its tasks in 2017. METHODS: This IFCC position paper by the WG-CDT summarizes state of the art information about the measurand and the analytical methods and gives concise recommendations for its utilization. RESULTS: The results achieved by the CDT standardisation process led to accuracy improvements in national external quality assessment schemes over the years. A brief review of ROC based comparison studies with the traditional biomarkers (GGT, MCV, ALT and AST) discusses the bias resulting from inadequate study populations. In large groups of the general population the superior diagnostic performance of CDT is confirmed. CONCLUSION: The relationship between alcohol intake versus resulting CDT is discussed as well as the cutoff and measurement uncertainty. Concerning the application in practice, potential pitfalls are considered and recommendations handling both analytical and preanalytical caveats are given. Finally, some examples of serious misunderstandings in publications about CDT are addressed.

A randomized trial on the effect of oral combined estradiol and drospirenone on glucose and insulin metabolism in healthy menopausal women with a normal oral glucose tolerance test.

BACKGROUND: Menopause is often associated with a central accumulation of body fat. This provokes insulin resistance. The resulting hyperinsulinemia may increase the risk of diabetes, cardiovascular disease and breast cancer. Long-term studies indicate that menopausal hormone therapy (MHT) reduces insulin resistance. To broaden knowledge of the mechanisms behind the influence of MHT on glucose homeostasis we focused on the direct short-term effects of MHT with oral combined estradiol and drospirenone on glucose and insulin metabolism in healthy postmenopausal women. METHODS: This randomized, placebo-controlled study recruited 80 healthy postmenopausal women. Women were randomized to treatment with estradiol 1 mg continuously combined with drospirenone 2 mg or placebo for 6-8 weeks. All participants underwent an oral glucose tolerance test (OGTT) before and after the treatment period. Glucose, insulin, fructosamine and C-peptide levels were measured in serum before and 30, 60, 90, 120 and 150 min after a 75-gram oral glucose challenge. RESULTS: After intervention, significantly higher glucose levels at 120 min (p < 0.024) and 150 min (p < 0.030) were observed in the MHT group compared with the placebo group. These glucose levels remained within the normal range. A significantly lower insulin peak serum level (p < 0.040) and a non-significantly smaller area under the curve (AUC) for insulin levels (p = 0.192) was observed in the MHT group at the end of the study period relative to baseline. No significant change in the insulin AUC in the placebo group was observed. There were no significant differences in fructosamine, HOMA-IR and C-peptide levels between the MHT group and the placebo group. CONCLUSION: This double-blind randomized study (EC/2008/694) indicates that treating healthy, postmenopausal women with 1 mg estradiol continuously combined with 2 mg drospirenone significantly decreases peak insulin levels and increases peak glucose levels during an OGTT compared to placebo. These glucose levels remained within the normal range.

Infrared spectroscopy as a novel tool to diagnose onychomycosis.

BACKGROUND: The determination of causative organisms of onychomycosis is still not optimal. There remains a need for a cheap, fast and easy-to-perform diagnostic tool with a high capacity to distinguish between organisms. OBJECTIVES: To determine whether attenuated total-reflectance Fourier transform infrared (ATR-FTIR) spectroscopy can detect and differentiate causative agents in culture-based, ex vivo nail and in vivo nail models. METHODS: A methodological study was conducted. Both the ex vivo nail model and in vivo pilot study were carried out in an academic university hospital. RESULTS: Analysis of cultured fungi revealed spectral differences for dermatophytes (1692-1606 and 1044-1004 cm-1 ) and nondermatophytes and yeasts (973-937 cm-1 ), confirmed by dendrograms showing an excellent separation between samples from different genera or species. Exploration of dermatophytes, nondermatophytes and yeasts growing on ex vivo nails exposed prominent differences from 1200 to 900 cm-1 . Prediction models resulted in a 96·9% accurate classification of uninfected nails and nails infected with dermatophytes, nondermatophytes and yeasts. Overall correct classification rates of 91·0%, 97·7% and 98·6% were obtained for discrimination between dermatophyte, nondermatophyte and yeast genera or species, respectively. Spectra of in vivo infected and uninfected nails also revealed distinct spectral differences (3000-2811 cm-1 , 1043-950 cm-1 and 1676-1553 cm-1 ), illustrated by two main clusters (uninfected vs. infected) on a dendrogram. CONCLUSIONS: Our data suggest that ATR-FTIR spectroscopy may be a promising, fast and accurate method to determine onychomycosis, including identification of the causative organism, bypassing the need for lengthy fungal cultures.

Bone morphogenetic protein 6 (BMP-6) modulates lung function, pulmonary iron levels and cigarette smoke-induced inflammation.

Chronic obstructive pulmonary disease (COPD) is associated with abnormal inflammatory responses and airway wall remodeling, leading to reduced lung function. An association between the bone morphogenetic protein (BMP-6) locus and forced vital capacity has been found in a genome-wide association study. However, the role of BMP-6 in the pathogenesis of COPD remains unknown. The pulmonary expression of BMP-6 was analyzed in patients with COPD and in cigarette smoke (CS)-exposed mice. We evaluated lung function and histology in BMP-6 KO mice at baseline. We exposed BMP-6 KO mice to CS for 4 weeks and measured pulmonary inflammation and iron levels. Pulmonary mRNA levels of BMP-6 were decreased in smokers with and without COPD and in CS-exposed mice. Importantly, BMP-6 expression was lowest in severe COPD. Accordingly, protein levels of BMP-6 were decreased in patients with COPD. Lung function measurements demonstrated a decreased compliance and total lung capacity in BMP-6 KO mice, whereas lung histology was normal. Furthermore, BMP-6 KO mice displayed elevated iron levels and an aggravated CS-induced inflammatory response. These results suggest that BMP-6 is important for normal lung function and that downregulation of BMP-6-as observed in patients with COPD-contributes to pulmonary inflammation after CS exposure.

Microscopic examination of urine sediment: Phase contrast versus bright field.

BACKGROUND: Today, phase contrast microscopy (PCM) is the recommended technique for manual urinary sediment (U-sed) examination. In fact, compared to bright field microscopy (BFM), it allows a better identification of most U-sed particles. METHODS: The main contributions, both as original papers in medical journals and as monographs on PCM applied to U-sed examination, published in the period 1950-1982 (which was chosen because it includes the results of the most important investigations on the subject) were identified and analysed. Moreover, a brief analysis on the use of PCM in U-sed examination today was carried out. RESULTS: After the discovery of PCM by the Dutch physicist Frits Zernike in the 1930s, several contributions were published, most of which are forgotten today. All of them demonstrated the advantages of PCM over BFM in identifying the U-sed particles, especially casts, renal tubular epithelial cells, atypical urothelial cells associated with urothelial carcinoma, and erythrocytes (which for the 1st time were classified as dysmorphic - of glomerular origin - and isomorphic - of non glomerular origin). The analysis of six recent monographs on U-sed or urinalysis, written in English and with an international distribution, demonstrated that only in two of them the U-sed particles were mostly shown by PCM. CONCLUSION: Several papers and monographs, published since the early 1950s, have demonstrated the advantages of PCM over BFM for U-sed examination. In spite of this, PCM is not as widely used as it should be.

Variability of serum concentrations of cystatin C and urinary retinol-binding protein, neutrophil gelatinase-associated lipocalin, immunoglobulin G, and C-reactive protein in dogs.

BACKGROUND: Markers of kidney dysfunction and damage have potential to detect chronic kidney disease (CKD) in early stages. However, data on long-term variation of these markers in healthy dogs is lacking and is crucial for the interpretation of results. HYPOTHESIS/OBJECTIVES: To determine temporal variations of serum cystatin C (sCysC) and urinary retinol-binding protein (uRBP), neutrophil gelatinase-associated lipocalin (uNGAL), immunoglobulin G (uIgG), and C-reactive protein (uCRP) in healthy dogs. ANIMALS: Eight clinically healthy adult Beagles were evaluated. METHODS: Longitudinal observational study. Serum cystatin C was determined by particle-enhanced nephelometric immunoassay. Urinary retinol-binding protein, uNGAL, uIgG and uCRP were determined by ELISA and concentrations were indexed to urinary creatinine. Within- and between-dog variance components (VC) and within-dog coefficients of variation (CV) were determined from blood and urine collected at eight time points over 1.5 years. RESULTS: Urinary C-reactive protein (uCRP) concentrations were consistently below the detection limit (5.28 ng/mL). Mean ± within-dog standard deviation for sCysC, uRBP/c, uNGAL/c and uIgG/c was 0.15 ± 0.01 mg/L, 0.09 ± 0.03 mg/g, 2.32 ± 2.03 µg/g and 12.47 ± 10.98 mg/g, respectively. Within-dog CV for sCysC, uRBP/c, uNGAL/c and uIgG/c was 8.1%, 33.7%, 87.2% and 88.1%, respectively. CONCLUSIONS AND CLINICAL IMPORTANCE: Serum cystatin C, uRBP/c, uNGAL/c and uIgG/c exhibit a wide range of long-term within-dog variability. Researchers and veterinarians might need to take this into account when interpreting their results. To assess their diagnostic and predictive ability, future studies need to establish reference ranges for healthy dogs and dogs with CKD.

The intriguing role of soluble urokinase receptor in inflammatory diseases.

Inflammation is a key player in the development of an increasing amount of diseases. The soluble urokinase plasminogen activator receptor (suPAR) is a highly flexible molecule with intrinsic chemotactic properties. This glycoprotein has been evaluated as a biomarker of inflammation, immune activation, organ damage and clinical outcome in several pathologies, including cardiovascular disease, hepatitis, renal disorders and rheumatic pathologies. The use of this early warning inflammatory biomarker could potentially improve the prediction of the severity of these diseases and mortality. In the present paper, we describe the general characteristics of suPAR and its intriguing role as a biomarker in different inflammatory diseases.

Evaluation of Cystatin C for the Detection of Chronic Kidney Disease in Cats.

BACKGROUND: Serum cystatin C (sCysC) and urinary cystatin C (uCysC) are potential biomarkers for early detection of chronic kidney disease (CKD) in cats. An in-depth clinical validation is required. OBJECTIVES: To evaluate CysC as a marker for CKD in cats and to compare assay performance of the turbidimetric assay (PETIA) with the previously validated nephelometric assay (PENIA). ANIMALS: Ninety cats were included: 49 CKD and 41 healthy cats. METHODS: Serum CysC and uCysC concentrations were prospectively evaluated in cats with CKD and healthy cats. Based on plasma exo-iohexol clearance test (PexICT), sCysC was evaluated to distinguish normal, borderline, and low GFR. Sensitivity and specificity to detect PexICT < 1.7 mL/min/kg were calculated. Serum CysC results of PENIA and PETIA were correlated with GFR. Statistical analysis was performed using general linear modeling. RESULTS: Cats with CKD had significantly higher mean ± SD sCysC (1.4 ± 0.5 mg/L) (P < .001) and uCysC/urinary creatinine (uCr) (291 ± 411 mg/mol) (P < .001) compared to healthy cats (sCysC 1.0 ± 0.3 and uCysC/uCr 0.32 ± 0.97). UCysC was detected in 35/49 CKD cats. R(2) values between GFR and sCysC or sCr were 0.39 and 0.71, respectively (sCysC or sCr = µ + GFR + Îµ). Sensitivity and specificity were 22 and 100% for sCysC and 83 and 93% for sCr. Serum CysC could not distinguish healthy from CKD cats, nor normal from borderline or low GFR, in contrast with sCr. CONCLUSION: Serum CysC is not a reliable marker of reduced GFR in cats and uCysC could not be detected in all CKD cats.

Secukinumab: IL-17A inhibition to treat psoriatic arthritis.

Interleukin-17A is an important cytokine in the pathogenesis of psoriatic arthritis. Secukinumab is a recombinant, high-affinity, fully human immunoglobulin G1kappa monoclonal antibody with a selective binding and neutralization of interleukin-17A. By providing an alternative mechanism of action to current treatments, secukinumab has shown efficacy in the key clinical domains of psoriatic arthritis. In the present paper, we discuss the role of interleukin-17A as a clinically relevant target in the treatment of psoriatic arthritis, based on preclinical findings, dose-ranging and regimen-finding, randomized, placebo-controlled clinical trials.

Elevated calprotectin levels reveal bowel inflammation in spondyloarthritis.

INTRODUCTION: Microscopic bowel inflammation is present in up to 50% of patients with spondyloarthritis (SpA) and is associated with more severe disease. Currently no reliable biomarkers exist to identify patients at risk. Calprotectin is a sensitive marker of neutrophilic inflammation, measurable in serum and stool. OBJECTIVES: To assess whether serum and faecal calprotectin in addition to C-reactive protein (CRP) can be used to identify patients with SpA at risk of microscopic bowel inflammation. METHODS: Serum calprotectin and CRP were measured in 125 patients with SpA. In 44 of these patients, faecal samples were available for calprotectin measurement. All 125 patients underwent an ileocolonoscopy to assess the presence of microscopic bowel inflammation. RESULTS: Microscopic bowel inflammation was present in 53 (42.4%) patients with SpA. Elevated serum calprotectin and CRP were independently associated with microscopic bowel inflammation. Faecal calprotectin was also significantly higher in patients with microscopic bowel inflammation. Patients with CRP and serum calprotectin elevated had a frequency of bowel inflammation of 64% vs 25% in patients with low levels of both. When either CRP or serum calprotectin was elevated, the risk was intermediate (40%) and measuring faecal calprotectin provided further differentiation. Hence we suggest a screening approach where initially serum calprotectin and CRP are assessed and, if necessary, faecal calprotectin. The model using this scenario provided an area under the ROC curve of 74.4% for detection of bowel inflammation. CONCLUSIONS: Calprotectin measurements in stool and serum, in addition to CRP, may provide a promising strategy to identify patients with SpA at risk of bowel inflammation and could play a role in overall patient stratification.

The effect of feeding, storage and anticoagulant on feline serum cystatin C.

Serum cystatin C (sCysC) is a possible marker for early detection of chronic kidney disease (CKD) in cats. In contrast with serum creatinine (sCr), feline sCysC is not affected by age, breed or sex. However, further biological and clinical validation is required. The objectives of this study were: (1) to investigate if food intake and circadian rhythm affect feline sCysC; (2) to determine the stability of sCysC under different storage conditions, and (3) to investigate if plasma concentrations of CysC (pCysC) differed from sCysC. A crossover study with 10 healthy laboratory cats fed the same commercial dry food was performed to study the influence of feeding and diurnal variation. Storage effects and comparison of pCysC with sCysC were determined using healthy cats (n = 3 and n = 10, respectively) and cats with CKD (n= 4 and n = 17, respectively). A significant daily sCysC variation was seen. Pre- and postprandial sCysC and sCr concentrations did not change significantly. Serum CysC significantly increased during storage at room temperature. After freezing, sCysC significantly decreased after 5 and 12 months at both -20 °C and -72 °C. Plasma CysC was significantly lower than sCysC. These findings suggest that it is not mandatory to fast cats before evaluation of sCysC and sCr. Samples were stable during routinely used storage conditions. Based on these findings, freezing for more than 5 months is not recommended, although additional studies are required to evaluate the clinical relevance of decreased sCysC after prolonged storage. Plasma and serum CysC cannot be compared directly.

Biological validation of feline serum cystatin C: The effect of breed, age and sex and establishment of a reference interval.

Chronic kidney disease (CKD) is common in cats, but the routine renal markers, serum creatinine (sCr) and urea, are not sensitive or specific enough to detect early CKD. Serum cystatin C (sCysC) has advantages over sCr, both in humans and dogs, and sCysC concentration is significantly higher in cats with CKD than in healthy cats. The objective of this study was to determine the effect of age, sex and breed on feline sCysC and to establish a reference interval for feline sCysC. In total, 130 healthy cats aged 1-16 years were included. sCysC was determined using a validated particle-enhanced nephelometric immunoassay. sCr, urea, urine specific gravity, urinary protein:creatinine ratio (UPC) and systolic blood pressure (SBP) were also measured. No significant differences in sCysC concentration were observed among young, middle-aged and geriatric cats, female intact, female neutered cats, male intact and male neutered cats, or among purebred and domestic short-or longhaired cats. The 95% reference interval for feline sCysC was determined to be 0.58-1.95 mg/L. sCr was significantly higher in geriatric cats than young cats. Serum urea in geriatric cats was significantly higher than in middle-aged and young cats (P = 0.004 and P <0.001, respectively). SBP in geriatric cats was significantly higher than in both middle-aged and young cats (P = 0.004 and P = 0.040, respectively). Male neutered and female neutered cats had significantly higher serum urea concentrations than female intact cats (P = 0.003 and P = 0.006, respectively). Male intact cats had a significantly higher UPC than female intact and female neutered cats (P = 0.02 for each comparison). There were no significant differences among sex groups for USG. It is of concern that sCysC in the majority of cats with CKD in previous studies falls within the reference interval calculated in this study. Further studies are warranted to evaluate the diagnostic value of sCysC as a renal marker in cats.

The serum estradiol concentration is the main determinant of the estradiol concentration in normal breast tissue.

BACKGROUND: The estrogen concentration has been determined in breast tissue, focusing largely on samples obtained from breast cancers. In this study, estradiol concentration was determined in normal breast tissue obtained from women undergoing esthetic, and oncoplastic surgery. METHODS: Normal breast tissue was obtained during 68 operations for esthetic or reconstructive indications in women with and without a history of breast cancer. Our study included six different groups of women. The first three groups were normal cycling women, women taking oral contraceptives, and normal postmenopausal women, all undergoing a bilateral esthetic breast reduction. The second three groups were premenopausal and postmenopausal women, with a history of breast cancer and currently taking tamoxifen treatment, or postmenopausal women currently taking an aromatase inhibitor, needing contra-lateral corrective esthetic surgery. FINDINGS: In the group of women without history of breast cancer, normal cycling women (n=24) presented a strong correlation (r=0.853; P<0.0001) between 17ß-estradiol concentration in serum (median: 29.7 pg/mL; IQR: 10.8-82.3 pg/mL) and in breast tissue (30.6 pg/g; IQR: 18.6-183.8 pg/g). Postmenopausal women had low 17ß-estradiol concentrations both in serum and breast tissue (r=0.813; P<0.0001, n=16). Women taking oral contraceptives (n=12) had low serum and breast tissue levels of estradiol (r=0.376; P=n.s.). Premenopausal women (n=6, mean age: 44.2 years) with a history of breast cancer and currently taking tamoxifen, had very high concentrations of 17ß-estradiol both in serum (277.9 pg/mL; IQR: 96.2-544.7 pg/mL) and in epithelial cells (251.9 pg/g; IQR: 115.0-426.5 pg/g) (r=0.803; P<0.001). Postmenopausal women taking tamoxifen (n=4, mean age: 48.3) had low concentrations of 17ß-estradiol in serum (7.0 pg/mL; IQR: 5.7-16.3 pg/mL) and in epithelial cells (14.6 pg/g IQR: 13.3-16.3 pg/g) (r=0.10; P=n.s.). The estradiol concentration in the breast of premenopausal women taking tamoxifen was 8.2 times higher that observed in the breast of normal cycling women, and 17.3 times higher that observed in postmenopausal women taking tamoxifen. Women taking adjuvant aromatase inhibitors had extremely low concentrations of 17ß-estradiol both in serum and in breast tissue. INTERPRETATION: This study shows that serum estradiol levels largely determine estrogen levels in normal breast tissue.

Subarachnoidal-pleural fistula (SAPF) as an unusual cause of persistent pleural effusion. Beta-trace protein as a marker for SAPF. Case report and review of the literature.

BACKGROUND: We describe a case of a 56-year-old woman who developed a recurrent pleural effusion after a thoracoscopic resection of an anterior bulging thoracic disc hernia (level D9-D10). Despite several evacuating pleural punctions, dyspnea reoccurred due to recurrent pleural effusion, the same side as the disc resection. Because of increasing headache after each punction, a subarachnoidal pleural fistula (SAPF) was suspected. Although magnetic resonance imaging (MRI) showed features suggestive of SAPF, there was not enough evidence to justify a new thorascopy. METHODS: Cerebrospinal fluid (CSF) leakage into the thoracic and abdominal cavity has been described as a result of trauma or surgery. Detection of beta-trace protein (BTP, a brain-specific protein) has been described to detect CSF fistulae causing rhino- and otoliquorrhea. Similarly, BTP determination could be used to identify the presence of CSF at other anatomical sites such as the thoracic cavity. Therefore, we decided to determine the concentration of BTP in the pleural effusion of this patient. BTP was assayed using immunonephelometry. RESULTS: The patient's BTP pleural fluid concentration was 14·0 mg/l, which was a 25-fold increase compared with the BTP serum concentration. After insertion of a subarachnoidal lumbal catheter, a video-assisted thorascopy was performed. Leakage of liquor through the parietal pleura into the thoracic cavity was observed. The SAPF was closed using a durasis patch and DuraSeal®. Postoperatively, there was no reoccurrence of pleural fluid. CONCLUSIONS: SAPF has to be included to the differential diagnosis of patients with persistent pleural effusion after spinal surgery. This case illustrates the importance of BTP in diagnosing SAPF, especially in cases where major therapeutic consequences may need to be drawn.

Cystatin C: a new renal marker and its potential use in small animal medicine.

The occurrence of chronic kidney disease is underestimated in both human and veterinary medicine. Glomerular filtration rate (GFR) is considered the gold standard for evaluating kidney function. However, GFR assessment is time-consuming and labor-intensive and therefore not routinely used in practice. The commonly used indirect GFR markers, serum creatinine (sCr) and urea, are not sufficiently sensitive or specific to detect early renal dysfunction. Serum cystatin C (sCysC), a proteinase inhibitor, has most of the properties required for an endogenous GFR marker. In human medicine, numerous studies have evaluated its potential use as a GFR marker in several populations. In veterinary medicine, this marker is gaining interest. The measurement is easy, which makes it an interesting parameter for clinical use. This review summarizes current knowledge about cystatin C (CysC) in humans, dogs, and cats, including its history, assays, relationship with GFR, and biological and clinical variations in both human and veterinary medicine.

Detecting doping use: more than an analytical problem.

The recent Armstrong case, where more than 250 negative doping tests are confronted with the athlete's confession of erythropoietin use, blood doping, steroid, and growth hormone abuse, illustrates the limitations of current laboratory tests in detecting doping in sport. Despite numerous doping controls and simultaneous indications of common doping abuse among professional athletes in the last two decades, the number of positive urine tests for recombinant human erythropoietin (rHuEPO) remains remarkably low. Athletes are using various masking strategies, among them protease inhibitors, intravenous injections of rHuEPO and alternative erythropoiesis stimulating agents. As one of the countermeasures, the Athlete's Biological Passport has been introduced. The sensitivity of the Athlete's Biological Passport is limited if the effect of a low-dose doping remains within the intra-individual reference range. A possible solution could be the use of a novel Epo test (MAIIA Diagnostics). Another performance-enhancing strategy is the return to 'old' doping techniques, such as autologous blood transfusions. Several indirect methods to detect autologous blood transfusions have been proposed with the majority relying on changes in erythropoiesis-sensitive blood markers. Currently, an algorithm based on the haemoglobin (Hb) level concentration and the percentage of reticulocytes (OFF-hr model; Hb(g/l)-60·âˆš%ret) is approved by the World Anti-Doping Agency. Genetic factors have been identified which may interfere with test interpretation. A large inter- and intra-ethnic variation in testosterone glucuronidation and excretion has been described. Consideration of genetic variation should improve performance of the testosterone doping test. Taking into account the pre-analytical care and better tailoring of the threshold values could increase test sensitivity. Anti-doping laboratories should routinely adjust for multiple testing as failure of doping control to detect cheaters could lead to more frequent controls. Finally, despite the huge technological progress, there is a need for increased collaboration between physiologists, analytical chemists, biostatisticians, and ethicists to reduce doping in sport.

Interpretation of hemolysis tests following administration of a second-generation hemoglobin-based oxygen carrier.

Hemoglobin released into the circulation during hemolysis or therapy with chemically modified hemoglobins, exert oxidative and NO-scavenging toxic effects. Pyridoxalated hemoglobin polyoxyethylene conjugate (PHP) is one of the second-generation hemoglobin-based oxygen carriers (HBOCs). We wanted to investigate the metabolism of PHP with a special focus on its consequences for interpreting hemolysis-related diagnostic parameters in PHP-treated patients. Clinical samples were analyzed from 3 patients, who received PHP (as part of the PHOENIX phase III trial) for treatment of catecholamine-resistant distributive shock. In contrast to expectations, clearance of PHP by hemopexin, instead of haptoglobin was documented by increased hemolysis indices, absence of decreased haptoglobin values, presence of free PHP-hemoglobin and exhausted hemopexin concentrations. The present case report is important for both clinicians and laboratorians since it nicely illustrates that a hemolytic aspect of plasma is not necessarely synonymous with hemolysis. A hemolytic aspect of plasma or serum (high hemolysis index) in combination with normal or increased haptoglobin values should draw the attention; additional determination of lactate dehydrogenase and hemopexin may then be useful to distinguish the condition from in vitro hemolysis and to monitor the in vivo elimination of the heme compounds.