[The ways of harmonization of clinical laboratory measurement techniques].

The results of implementation of different clinical laboratory techniques are to be equal in clinically significant limits to be optimally applied in diagnostics of diseases and treatment of patients. When the results of laboratory tests are not standardized and harmonized for the very same clinical assay the results can be expressed by unmatched numbers. Unfortunately, in some handbooks the values are presented based on the results of application of specific laboratory techniques without considering possibility or likelihood of differences between various techniques. When this is a case, accumulation of data of diferent clinical research studies and working out of clinical handbooks on this basis will be inconsistent. Inadequate understanding of issue that the results of laboratory tests are not standardized and harmonized can lead to incorrect clinical, financial, managerial or technical decisions. The standardization of clinical laboratory techniques was applied to many measurands related to primary referent techniques (standard specimen of pure substance) or/and developed referent measurement techniques. However, harmonization of clinical laboratory techniques for those measurands which are not related any developed measurement techniques is quite problematic due to inadequate determination of measurand, its inadequate analytical specificity, insufficient attention to commutability of referent materials and poor systematic approach to harmonization. To overcome these issues an infrastructure is to be developed to support systematic approach to identification and prioritization of measurands which are to be harmonized on the basis of clinical importance and technical applicability. The management of technical implementation harmonization process for specific measurands.

Validation of 5 routine assays for serum free testosterone with a candidate reference measurement procedure based on ultrafiltration and isotope dilution-gas chromatography-mass spectrometry.

BACKGROUND/METHOD: The analytical validity of free testosterone (FTe) analog immunoassays is subject to much controversy. We revisited the validation of 4 analog assays and 1 FTe calculation procedure with a metrologically traceable reference measurement procedure (RMP) based on ultrafiltration and isotope dilution-mass spectrometry for direct measurement of Te in the ultrafiltrate. To this end, we performed split-sample measurements of 40 male sera. RESULTS: Deming regression showed that 3 of the immunoassays had moderate to good correlation (0.8474 < or = r < or = 0.9241) with the RMP; however, the slope was markedly below 1. The FTe calculation procedure was in good agreement with this result. The Sy/x values for all assays were higher than the combined imprecision values, which indicate their susceptibility to matrix-related effects. CONCLUSIONS: The study demonstrated substantial differences in analytical quality of FTe assays; however, the results suggested that after extending the validation with a larger variety of samples, recalibration of some analog assays might be worth further investigation.

Novel perfluoroacyl derivatives of corticosteroids and related substances for potential use in quantitative gas chromatography mass spectrometry.

We investigated the potential of perfluoroacylation for gas chromatographic mass spectrometric determination of corticosteroids and related substances. Structure elucidation of the reaction products was performed with high and low resolution mass spectrometry and with proton and carbon nuclear magnetic resonance spectrometry. Besides the well known 3-enol ester formation, 17ß-methyl-18-nor-13(14)-ene steroids were formed via loss of the 17-α hydroxyl group followed by a Wagner-Meerwein rearrangement. Compounds that bear an 11ß-hydroxy group formed additionally a 9(11) double bond when acetone was used as solvent, whereas acetonitrile or cyclohexane led to formation of 11ß-perfluoroacyl esters. In particular, perfluoroacylation of cortisol led to a clearly defined product instead of complex mixtures observed before, which thus makes it a valuable alternative to methoxime formation-silylation of cortisol for quantitative gas chromatographic mass spectrometric analyses.

A reference system for cortisol.

OBJECTIVES: The International Federation of Clinical Chemistry (IFCC) initiated a pilot study, with cortisol as an example, that aims to implement the concept of standardization of hapten immunoprocedures on the basis of metrological traceability. In fact, this standardization concept comes down to correct calibration of measurement procedures, so that measurement results for patient samples can be traced back to the metrologically highest reference of a result, i.e., an SI unit as embodied in the primary reference material. In consequence, demonstration of standardization of a test system on the basis of traceability requires evaluation of measurement results pertaining to patient samples for accuracy. Such an evaluation shall be done by a correlation study of the routine test system with an accuracy-based reference measurement procedure. DESIGN AND METHODS: The IFCC project will select a panel of single donation human serum samples, and assign them with values for cortisol by measurement with at least two isotope dilution-gas chromatography/mass spectrometry reference methods. Limited amounts of the panel will be distributed to manufacturers, with the object to measure the samples with their calibrated immunoprocedures. The patient correlation studies between the routine and the reference methods will then be interpreted in terms of specificity and accuracy. It will also be investigated whether the performed comparison can be used as a basis for re-calibration. From the experience gained through this pilot study for cortisol, IFCC will formulate recommendations and guidance to manufacturers on how to perform and reliably interpret patient correlation studies. In this way, it is to be expected that the project might form a basis for general implementation of the concept of standardization of hapten immunoassays on the basis of metrological traceability.

Validation of candidate reference methods based on ion chromatography for determination of total sodium, potassium, calcium and magnesium in serum through comparison with flame atomic emission and absorption spectrometry.

OBJECTIVES: We report on the validation of candidate reference methods based on ion chromatography for the determination of total sodium, potassium, calcium, and magnesium in serum. The current study is a continuation of previous investigations in which we were able to show the potential of ion chromatography to serve as a reference method principle. The validation consisted of comparison of the ion chromatographic methods with generally recognized reference methods based on flame atomic emission (for sodium/ potassium) and absorption (for calcium/magnesium) spectrometry. METHODS: Sample preparation consisted of acidic dilution and pre-purification with reversed phase cartridges. Ion chromatography with suppressed conductivity was performed with polymeric stationary phases chemically modified with carboxylate and sulfonate functional groups for sodium/potassium and calcium/magnesium, respectively. Single-point calibration was used in combination with individual adaptation of serum sampling and diluting to give similar responses in samples and standards. In the study, more than 25 control sera were analyzed in parallel with the ion chromatographic methods and the traditional reference methods. The measurement protocol consisted of quadruplicate analysis of each sample per run, in 3 different runs. In each measurement series, internal quality control with certified reference materials from the National Institute of Standards and Technology and the Bureau Communautaire de Référence was applied. The performance criteria to fulfill were pre-defined (i.e., the maximum within-day and overall coefficient of variation, the confidence interval, the daily and overall deviation from the certified value and the maximum total analytical error). RESULTS: The comparison is presented as difference plot (i.e., % deviation of the results obtained with ion chromatography from those obtained with the respective traditional reference methods). The mean deviations were +0.9% for sodium, +1.0% for potassium, +/- 0.0% for calcium, and +0.1% for magnesium. With the exception of 2 values each for sodium and potassium, all deviations were within the limit of 2 times the allowed total analytical error. From the data obtained for internal quality control during the different measurement campaigns, we further estimated the long-term precision and accuracy of our methods. The overall coefficient of variation (respectively the bias) amounted to 0.7% (+0.1%) for sodium, 0.9% (-0.3%) for potassium, 1.3% (-0.1%) for calcium, and 1.0% (+/- 0.0%) for magnesium. CONCLUSION: From the precision and accuracy reached by our ion chromatographic methods, we conclude that they can be proposed as candidate reference methods for the determination of total sodium, potassium, calcium, and magnesium in serum.

External quality assessment of laboratory performance in haematology in Belgium: analysis of two and a half years' experience.

In Belgium, external quality assessment of health laboratories is organised according to the directives of the government. The programme in the discipline haematology, as conceived by our laboratory, has now been carried out for about two and a half years. The results obtained in the different surveys are reported. A few general conclusions on the state of the art of laboratory performance in routine haematological tests are drawn from these experimental data.

A modified statistical approach for the detection of outlying values in external quality control: comparison with other techniques.

Laboratory results submitted to External Quality Assessment Schemes (EQAS) are evaluated against the arithmetic mean (m) and standard deviation (SD) of the result from other participants assuming a normal distribution of individual results. The sample statistics m and SD can only be reliable estimates of the theoretical mean (mu) and standard deviation (sigma), if they are not distorted by outlying values. Outliers are commonly detected by defining a confidence interval m +/- k SD, typically with k-values fixed at 3.0 or 3.2. The objective of our study was to prove the deficiency of the use of these fixed limits in large-scale EQAS, because it results in an unacceptable increase of outlier rate and hence in a serious distortion of the estimate of sigma. We have proposed a modified approach using a variable k-value which is dependent upon sample size and keeping the significance level constant at 5%. The influence of different decision limits on the number of outliers and on the sample statistics m and SD was compared using data from the Belgian National EQAS obtained in 6 consecutive surveys.

Evaluation of intrinsic and routine quality of serum total magnesium measurement.

We investigated the intrinsic (as delivered by the manufacturer) and routine quality of four systems for measurement of serum total magnesium (t-Mg(2+)) by method comparison with an ion chromatography reference method. The results of the study were interpreted on the basis of analytical quality specifications derived from the biological variation of t-Mg(2+), expanded by the analytical uncertainty of the reference measurements. This resulted in limits for systematic error of 2.1% and for total error of 4.3%. The study demonstrated that those limits were challenging for all routine systems. Most of them met the total error criterium just borderline and one showed a considerable systematic error (-5.2%). Concerning the measurement quality in the routine laboratories, the study showed that many were unable to preserve the intrinsic quality of the respective manufacturer. Consequently, loss of system performance in the routine laboratory mostly led to violation of the analytical specifications. Most strikingly, the study revealed enormous quality differences between routine laboratories. This indicates that, still, many routine laboratories do not make adequate use of currently available internal and external quality control tools. Moreover, some laboratories considerably expanded the high end of the reference interval, thereby reducing the diagnostic potential of t-Mg(2+).

External quality control of clinical chemistry laboratories in Belgium.

A description is given of one of the existing National External Quality Assessment Schemes as organised in Belgium. The results of the six surveys held in 1981 in the disciplines Clinical Chemistry and Hormonology are reported. A few general conclusions are drawn from experimental data.

Ion chromatography as potential reference methodology for the determination of total sodium and potassium in human serum.

The potential of ion chromatography to serve as a new reference method principle for the determination of total sodium and potassium in human serum was investigated. Sample pretreatment consisted of acidic dilution and filtration and detection was based on conductivity. Methods for the separate and simultaneous determination of both analytes were investigated. Further, the influence of calibration (using either a single-point calibration or a standard curve) on method imprecision, inaccuracy and analysis time was examined. The best method performance was achieved by separate analysis using single-point calibration with bracketing analysis scheme. For this variant, the mean total coefficient of variation for sodium and potassium was 1.0% and the mean method bias was -0.2% for sodium and 2% for potassium, as determined with three control materials from the National Institute of Standards and Technology. Our results are comparable to those of reference methods based on flame atomic emission spectrometry. Therefore, we consider ion chromatography as a valuable reference methodology for the determination of total sodium potassium in human serum.

Practical aspects of suppressed ion chromatography for cations in human serum.

In spite of the good accuracy and precision of ion chromatographic methods for the determination of mono- and divalent cations in human serum, the major drawback with these methods were problems with the membrane suppressor's performance. Here, we describe experiments undertaken to solve these problems. We address in particular the use of histidine-sulfuric acid eluents, sample purification with OnGuard-A cartridges and chromatographic "front-cut" for divalent cations. The latter two adaptations, resulting in removal of the anionic species from the sample, were successful in solving the observed suppressor problems. The eluent substitution, moreover, allowed us to switch from the chemical to the electric suppression mode. We believe that these adaptations will allow secure and robust determination of cations in human serum samples with ion chromatography.

Quantitative analysis of urinary C-peptide by liquid chromatography-tandem mass spectrometry with a stable isotopically labelled internal standard.

We describe the first results of a quantitative LC-tandem mass spectrometry method for urinary C-peptide with the use of [2H14]C-peptide as internal standard. LC was based on gradient elution of a Hypersil PEP C18 column. Mass spectrometry was performed in the negative electrospray ionization mode and by monitoring of the transitions at m/z 1514/1334 ([2H14]C-peptide) and 1507/1320 (C-peptide). For sample preparation, we applied ultrafiltration. The analytical performance of the method in terms of measurement precision gave an RSD of <2% (n=10). The overall imprecision was investigated from independent analysis of two urine samples in six-fold and resulted in an RSD<5%. The limit of detection, expressed as signal-to-noise ratio 3, was approximately 0.15 ng C-peptide injected. Analysis of 10 random urine samples from laboratory volunteers showed interference-free ion chromatograms at a signal-to-noise ratio of approximately 75 on average. The C-peptide concentrations calculated from quantification by the bracketing calibration technique ranged from 32 to 165 ng/ml.

Electron-capture GLC determination of bromhexine in human plasma.

A specific and sensitive GLC analysis of bromhexine in human plasma is described. After addition of the internal standard and an aqueous triethanolamine solution, bromhexine is extracted at alkaline pH into n-hexane, transferred to an acidic aqueous solution, and back-extracted into n-hexane after alkalinization. Both compounds are derivatized with trifluoroacetic anhydride and quantified by GLC using , 63Ni-electron-capture detector. The method has a sensitivity of approximately 1.0 ng/ml of plasma. Linearity of plasma working curves was good. The extraction recovery from spiked plasma was 90.1 +/- 5.68% (SD). The within-run and within-day precisions (CV) were 6.0% (4.3 ng/ml, n = 8) and 8.6% (11.0 ng/ml, n = 13), respectively. The procedure was applied successfully to measurement of the plasma concentration-time profile in a human volunteer after oral drug administration.

Survey of serum potassium reference measurements.

We compared the quality of reference measurements for serum potassium in four reference laboratories from three different European countries, using a panel of 60 native patients' samples. The reference methods were based on either ion chromatography (one laboratory) or flame atomic emission spectrometry (three laboratories). Performance specifications for serum potassium measurements were defined as a maximum overall coefficient of variation (CV) of 1.5%, a maximum bias of 0.65% and a maximum total error of 3.0%. The overall imprecision for all laboratories was in the range of 0.7 to 1.3%, and was thus below the proposed specification of 1.5%. However, two laboratories reported 12 and 13 quadruplicates with CVs exceeding this limit. The mean bias (expressed as deviation from the overall mean of all laboratories) for all reference laboratories was < 0.65%. In the lower concentration range, however, one laboratory exceeded this limit. No laboratory measured samples with a total error above 3.0%. From these results, it can be concluded that the reference measurements, and, thus, also the reference methodologies, based on ion chromatography and flame atomic emission spectrometry were equivalent, and able to satisfy current analytical specifications for serum potassium measurements.

The ionized fraction of serum total magnesium in hemodialysis patients: is it really lower than in healthy subjects?

AIM OF THE STUDY: Based on data in the literature, it remains unclear whether the ionized fraction of serum total magnesium (Mg) is lower in chronic hemodialysis (HD) patients compared to healthy subjects. PATIENTS AND METHODS: The ionized fraction of serum total Mg was investigated in 49 HD patients, pre- and post-dialysis, and compared to 30 healthy controls. The quality of the analytical performance of the Mg measurements has been emphasized by applying a reference method and/or rigorous internal quality control (IQC). In addition, the ionized fraction of serum total calcium (Ca) was measured in both populations, because the results for Mg should be related to those of Ca. RESULTS: In HD patients, the ionized fraction of serum total Mg was on average 65% (pre-dialysis 64.2% and post-dialysis 66.2%). In healthy controls, the ionized fraction was 64.9%. When the analytical variability was taken into account, no significant differences (p > 0.05) were observed between pre- and post-dialysis samples and controls. For Ca, an ionized fraction of 55.3% was found in HD patients, which was not significantly different from the fraction obtained in the control group (55.7%). CONCLUSION: The present study demonstrates that, compared to healthy controls, the ionized fraction of serum total Mg is not different in hemodialysis patients.

Bioanalytical mass spectrometry as applied to organic acid profiling and steroid reference methodology.

Gas chromatography-mass spectrometry (GC-MS) is a versatile and powerful diagnostic tool in clinical chemistry. Instrumental aspects of the technique are considered. The use of GC-MS for identification purposes is exemplified by the metabolic profiling of organic acids for the diagnosis of inborn errors of metabolism. Quantitative GC-MS is discussed with particular emphasis on the choice of the internal standard. For highest precision and accuracy, isotope dilution GC-MS is the most suitable technique; the application of ID-GC-MS to reference methods and reference materials is discussed in relation to the analysis of steroid hormones. The principles involved in devising calibration procedures and measurement protocols in quantitative GC-MS are outlined.

Determination of creatinine in human serum using isocratic HPLC with an aluminum oxide stationary phase.

An isocratic high-performance liquid chromatographic method that uses aluminum oxide as the stationary phase is developed for the quantitation of creatinine in human serum. Sample pretreatment includes ultrafiltration, and ultraviolet detection is performed at 240 nm. The within-day precision, expressed as a mean coefficient of variation (CV), is 0.8%; the total method CV is 1.2%. The inaccuracy of the method is +1.5, -0.3, and +0.5%, respectively, as determined with the National Institute of Standards and Technology standard reference materials 909, 909 a1, and 909 a2. The detection limit of the method is 1.6 pmol (180 pg). The absence of interferences is confirmed by chromatographically analyzing patient serums again after enzymatic breakdown of creatinine.