Artifactual elevation of serum creatinine level due to fasting.

Abnormal serum creatinine (1.6 mg/dL) and creatinine clearance (33 mL/min) levels found in a 50-year-old woman during fasting were corrected with refeeding. Five healthy subjects who fasted for 96 hours demonstrated an increase in their mean serum creatinine level from 1.0 +/- 0.08 to 1.7 +/- 0.11 mg/dL as determined by Jaffé's method. This increase was probably an artifact caused by the rise in the serum acetoacetate level during fasting. The serum creatinine level determined by an enzymatic method and serum urea nitrogen level did not change substantially during the fast. We conclude that fasting may cause an artifactual increase in the serum creatinine level determined by Jaffé's method, the method used by most clinical laboratories.

Long-term, ambulatory, subcutaneous insulin infusion versus multiple daily injections in brittle diabetic patients.

We compared the blood glucose control of four intact and eight kidney recipient, metabolically unstable, ketosis-prone, insulin-dependent diabetic patients under two different regimens: (a) intensive conventional treatment with two to four insulin injections daily (48 patient-months) and (B) subcutaneous, portable insulin delivery system (IDS) (54 patient-months). Both regimens included frequent home blood glucose and 24-h urine glucose determinations and daily telephone follow-up to maximize compliance with treatment. Analyzed as a group the fasting blood glucose for intact patients (A: 172 +/- 13 mg/dl; B: 141 +/- 12, P less than 0.02) and the nonfasting blood glucose for kidney recipient patients (A: 165 +/- 10; B: 138 +/- 5, P less than 0.01) were significantly lower during treatment with the IDS than with multiple injections. Six out of 12 patients (2/4 intact and 4/8 kidney recipient patients) showed significant and consistent improvement of blood glucose concentrations. Four showed marginal and inconsistent improvement. Two patients (one intact and one kidney recipient) improved on the IDS but maintained the improvement when changed back to conventional treatment. The 24-h urine glucose, maximal glucose excursions, number of blood glucoses less than or equal to 40 mg/dl, and glycosylated hemoglobin decreased significantly in some patients on the pump. We conclude that subcutaneous, portable insulin delivery devices can significantly improve the metabolic control of some ambulatory, unstable diabetic patients during long-term treatment beyond that obtained with intensive, multiple-injection, conventional treatment. Normalization of the metabolic control, however, is not obtained. These infusion systems still pose several problems during ambulatory use, which could have serious consequences in patients less compliant and/or followed less closely than ours.

A comparison of the Murphy-Pattee and the Seligson methods for serum thyroxine.

We compared two methods for serum thyroxine measurement by competitive protein binding - the Murphy and Pattee and the Seligson and Seligson methods. We found the Seligson and Seligson method, which requires less sample volume and analysis time, to be the method of choice on the basis of sensitivity, extraction efficiency, precision, and accuracy. Standard plots of time/10,000 counts versus thyroxine concentration are linear to 20 ug/dl, extraction efficiency is 99.6 per cent, within-day S.D. plus or minus 0.28 ug/dl, and 98.3 per cent of added thyroxine is recovered in the Seligson and Seligson method. The Seligson and Seligson method is superior to the Murphy and Pattee method with respect to all these parameters. The methods were also compared with correlation and normal value studies.

Improved method for identifying alpha 1-antitrypsin Pi M subtypes by isoelectric focusing in agarose.

We describe an improved method for the classification of alpha 1-antitrypsin variants by isoelectric focusing in agarose. Identification of the three Pi M subtypes can now be made by using a narrow-range carrier ampholyte (pH 4.2-4.9) and pretreating serum with dithioerythritol-iodoacetic acid to enhance band resolution. Phenotype results for two groups of Pi M homo- and heterozygotes are compared to illustrate the improved accuracy of the new method.

Nephelometric assay of apolipoprotein A-I with a centrifugal analyzer.

We developed an automated immunonephelometric assay for quantification of human apolipoprotein A-I (apo A-I) with a fluorescence light-scattering microcentrifugal analyzer. The presence of polyethylene glycol and Tween 20 in the reaction mixture ensures maximum exposure of the antigenic sites of the apoprotein so that immune complex formation occurs more rapidly (reaction is complete within 2 min) and to a greater extent. Lipemia and hemolysis do not interfere with the measurement of apo A-I. The method requires only 10 microL of specimen and is fast and easy to perform. Results vary linearly with apo A-I concentrations to 2.5 g/L. Assay precision (CV) was 3.1% for a specimen with an apo A-I concentration of 1.45 g/L, and the lower limit of detection was 0.15 g/L. Values for a candidate Reference Material agree well with those reported in an international survey (Clin Chem 1985;30:223-8).

A simple and precise method of determining true sodium, potassium, and chloride concentrations in hyperlipemia.

Sodium, potassium, and chloride levels are artifactually depressed in hyperlipemic sera. Accurate electrolyte levels are needed for management of patients with hyperlipemia, but present methods for correcting the values (serum water and/or osmolality determinations) either are technically cumbersome or fail to provide accurate data to correct the falsely low levels. Alternatively, to determine true sodium, potassium, and chloride concentrations in hyperlipemic sera, only the required electrolyte values and the triglycerides are measured. The percentage by which the measured electrolyte levels in the hyperlipemic sample must be increased to approximate the true values is given by the following equation: per cent increase = 2.1 X triglycerides (Gm./dl.) - 0.6.

Determination of inorganic phosphorus using a centrifugal analyzer.

A method involving the molybdenum blue reaction for measurement of serum phosphorus using a centrifugal analyzer is described. The need to measure a separate serum blank is eliminated by measuring the rate of color development compared to that of a known standard. The procedure which uses o-phenylenediamine as a reductant is precise and compares well with a continuous flow automated procedure.

Enzyme inactivation in serum before determination of total bile acids.

Endogenous NADH-generating enzymes must be inactivated before total serum bile acids can be measured accurately by the direct enzymic method. To do this, we pretreat the sera with NaOH, in a final concentration of 0.1 mol/L. Consequently, lactate dehydrogenase activity at least as high as 30 000 U/L is destroyed, obviating blank determinations. Values for bile acid in serum, so obtained, agree with values obtained after pretreatment with heat, an alkali-methanol solution, or sodium pyruvate, but our pretreatment has the advantages of ease, speed, economy, and negligible blank values.

Effect of protein on the determination of total bile acids in serum.

We measured total serum bile acids on a fluorescence-light-scattering micro centrifugal analyzer by the direct enzymatic method with 3 alpha-hydroxysteroid dehydrogenase (EC 1.1.1.50) and with resazurin as a fluorogenic electron acceptor. We found that serum protein has an inhibitory effect on the measurement of bile acids, but this effect was eliminated by adding bovine serum albumin to the reaction mixture in a final protein concentration (12.2 g/L) that was high compared with that contributed by a normal serum specimen. The assay is a sensitive method that reaches equilibrium in 5 min. The method is microscale (5 microL of sample, 150 microL of working reagent), is easy to perform, and is accurate (analytical recovery = 104.1%) and precise (CV = 11.1 and 5.7% on specimens with bile acid concentrations of 7.6 and 35.4 mumol/L, respectively). Normal values are 1-12 and less than 9 mumol/L on nonfasting and fasting individuals, respectively. Pure 3 alpha-hydroxysteroid dehydrogenase must be used: we found several enzyme preparations that gave falsely high values for bile acid.

Improved simultaneous gas-chromatographic analysis for homovanillic acid and vanillylmandelic acid in urine.

We describe an improved gas-chromatographic method for the simultaneous quantitation of the catecholamine metabolites, homovanillic acid (3-methoxy-4-hydroxyphenylacetic acid) and vanillylmandelic acid (3-methoxy-4-hydroxymandelic acid). Our improvements in the method of Muskiet et al. (Clin. Chem. 23: 863, 1977) include a shorter program time and a longer silylation interval. Recovery and precision data obtained by this improved technique are similar to those of Muskiet et al. Vanillylmandelic acid results (y) were compared with those by the method of Pisano et al. (Clin. Chim. Acta 7: 285, 1962). The relation is expressed by the equation y = 0.52 + 1.05x (Sy . x = 2.33 mg/24 h and r = 0.997). Results for homovanillic acid (y) were compared with those by the method of Knight and Haymond (Clin. Chem. 23: 2007, 1977); the equation was y = 0.84 + 0.90x (Sy . x = 2.04 and r = 0.97). Retention times are also reported for several phenolic acids and other related compounds found in urine.

Direct assays of lactate, pyruvate, beta-hydroxybutyrate, and acetoacetate with a centrifugal analyzer.

Methods are described for direct assays of lactate, pyruvate, beta-hydroxybutyrate, and acetoacetate in plasma with the GEMSAEC centrifugal analyzer. The methods for lactate, beta-hydroxybutyrate, and acetoacetate are kinetic and ratiometric, eliminating the need for specimen-blank assays. The pyruvate method is an end-point assay, because endogenous lactate dehydrogenase interferes in a kinetic pyruvate assay. The methods are precise and accurate and 1-min of analysis time is adequate for each assay. Rapid assessment and monitoring of metabolic acidosis is possible with these methods, as is illustrated by examples.

Immunonephelometry of apolipoprotein B with a centrifugal analyzer.

We developed an automated immunonephelometric assay for the measurement of apolipoprotein B (apo B) with a light-scattering microcentrifugal analyzer. Pretreating specimens with a dilute solution of Tween 20 or triglyceride lipase decreased the nephelometric response of apo B. Polyethylene glycol is included in the reaction mixture, and the reaction is complete within 4 min. The method is precise (CV = 6.5%, mean = 0.68 g/L) and the standard curve is linear to an apo B concentration of 2.8 g/L. Lipemia does not interfere with the method if grossly lipemic specimens are centrifuged to remove chylomicrons.

Two-point determination of plasma ammonia with the centrifugal analyzer.

A simple, convenient, and rapid method for determining ammonia in plasma by the glutamate dehydrogenase reaction is described for the centrifugal analyzer. The measuring principle is fixed-time, with NADH as the coenzyme. ADP is added to stabilize glutamate dehydrogenase and prevent interference from endogenous plasma ADP. The reaction is linear to 400 mumol of ammonia per liter. The plasma sample volume is 100 microliter and the whole procedure takes only 25 min, including the 15-min preincubation. The normal range for venous plasma was 44 +/- 13.5 (SD) mumol of ammonia per liter.

Response of serine antiproteases to growth hormone therapy in growth hormone deficient children.

Growth hormone regulates the hepatic mRNA levels of alpha 1-antitrypsin and two contrapsin-like mRNAs in the rat. To determine whether growth hormone regulates similar serine protease inhibitors in humans, we measured serum alpha 1-antitrypsin, alpha 1-antichymotrypsin, and antithrombin III by radioimmunodiffusion in 16 growth hormone deficient children before and after growth therapy. Of the 19 determinations made, 17/19 showed an increase in alpha 1-antitrypsin after administration of growth hormone, 198.6 +/- 39.1 mg/dl before growth hormone and 239.4 +/- 44 mg/dl after growth hormone (p = 0.005). Specificity of the response for alpha 1-antitrypsin was indicated by the fact that neither alpha 1-antichymotrypsin or antithrombin III values changed after growth hormone (p = 0.6 and 0.5, respectively). These data are compatible with the hypothesis that growth hormone regulates serine protease inhibitors in humans and suggests that investigation of other members of the serpin gene family might prove fruitful in defining additional growth hormone target genes.

Value of alkaline phosphatase, 5'-nucleotidase, gamma-glutamyltransferase, and glutamate dehydrogenase activity measurements (single and combined) in serum in diagnosis of metastasis to the liver.

We assessed, in 98 patients with cancer, the diagnostic value of measuring serum alkaline phosphatase, 5'-nucleotidase, gamma-glutamyltransferase, and glutamate dehydrogenase activities as an aid to detection of liver metastases. All four enzymes showed diagnostic value, but 5'-nucleotidase appeared to have the greatest. It showed the lowest false-positive results (7.4%) with the highest predictive value of a positive test (85.7%) and agreement (81.3%).. gamma-Glutamyltransferase showed the lowest proportion of false-negative results (2.8%), but was the least specific 35% false-positive results). Analysis of various test combinations showed that the best agreement (77.5%) was obtained when the patients were divided into those who had no or only one abnormal test result, and those who had two or more abnormal test results. However, this was not better than the agreement for 5' nucleotidase alone (81.3%). The agreement of 5'-nucleotidase and gamma-glutamyltransferase (i.e., both tests were positive or negative) was excellent (91.4%), but such agreement included only 67% of the patients with liver metastases.

Factitious hypophosphatemia related to mannitol therapy.

We observed factitious hypophosphatemia in a patient who was receiving large amounts of intravenous mannitol. Mannitol concentrations as low as 25 mmol/L inhibited phosphorus measurement by the Dupont aca endpoint method; a kinetic method was unaffected. The mechanism of the mannitol interference was binding to molybdate in the reaction, decreasing both the rate of color development and the endpoint measurement. We conclude that the molybdate concentration in the DuPont method is suboptimal for measuring phosphorus in specimens containing mannitol.

Discrepancies between sodium concentrations measured by the Kodak Ektachem 700 and by dilutional and direct ion-selective electrode analyzers.

We have identified rare (approximately 0.2% of all samples), but clinically significant, discrepancies between serum or plasma sodium concentrations measured with the Kodak Ektachem 700's direct ion-selective electrode (ISE) method and concentrations measured with two other analyzers: the Beckman Synchron CX3's dilutional ISE instrument and the Radiometer KNA2 instrument for sodium-potassium analysis by the direct ISE method. The differences do not appear to be related to any previously identified sources of discrepancy, such as variations in triglycerides, bicarbonate, total protein, albumin, or gamma-globulin, the presence of paraproteins, or interference by benzalkonium chloride from heparinized catheters. They occurred despite the use of Gen 04 reference fluid on the Ektachem. We could not identify any drug or family of drugs that the patients had taken in common and that might influence the results. Until this problem is resolved, Ektachem users should be aware of the potential for discrepancies of > 6 mmol/L in measurements of sodium concentrations.