Association between serum sodium trajectory and mortality in patients with acute kidney injury: a retrospective cohort study.

INTRODUCTION: Dysnatremia is strongly associated with poor prognosis in acute kidney injury (AKI); however, the impact of sodium trajectories on the prognosis of patients with AKI has not yet been well elucidated. This study aimed to assess the association between sodium trajectories in patients with AKI and mortality at 30-day and 1-year follow-up. METHODS: This retrospective cohort study used data from Medical Information Mart for Intensive Care (MIMIC)-IV database, and patients diagnosed with AKI within 48 h after admission were enrolled. Group-based trajectory models (GBTM) were applied to map the developmental course of the serum sodium fluctuations. Kaplan-Meier survival curve was used to compare differences in mortality in AKI patients with distinct serum sodium trajectories. Hazard ratios (HRs) were calculated to determine the association between trajectories and prognosis using Cox proportional hazard models. RESULTS: A total of 9,314 AKI patients were enrolled. Three distinct sodium trajectories were identified including: (i) stable group (ST, in which the serum sodium levels remained relatively stable, n = 4,935; 53.0%), (ii) descending group (DS, in which the serum sodium levels declined, n = 2,994; 32.15%) and (iii) ascending group (AS, in which the serum sodium levels were elevated, n = 1,383; 14.85%). There was no significant difference in age and gender distribution among the groups. The 30-day mortality rates were 7.9% in ST, 9.5% in DS and 16.6% in AS (p < 0.001). The results of 1-year mortality rates were similar (p < 0.001). In adjusted analysis, patients in the DS (HR = 1.22, 95% confidence interval [CI], 1.04-1.43, p = 0.015) and AS (HR = 1.68, 95% CI, 1.42-2.01, p = 0.013) groups had higher risks of 30-day mortality compared to those in the ST group. CONCLUSION: In patients with AKI, the serum sodium trajectories were independently associated with 30-day and 1-year mortality. Association between serum sodium level trajectories and prognosis in patients with AKI deserve further study.

Characteristics of casein phosphopeptides in Chinese human milk and its correlation with infant growth: A cross-sectional study.

This research aimed to investigate the characteristics of casein phosphopeptides in Chinese human milk, and their potential relationship to infant growth. Using the liquid chromatography-Orbitrap-mass spectrometry technique, a total of 15 casein phosphopeptides were identified from 200 human milk samples. Also, our results indicate that casein phosphopeptides were phosphorylated with only one phosphate. The relative concentrations of casein phosphopeptides at 6 months postpartum were increased compared with milk at 2 months (FDR < 0.05). Significantly positive correlations were observed between casein phosphopeptides and infant growth, as shown by four casein phosphopeptides were positively correlated with the infants' weight-for-age Z-scores (rs range from 0.20 to 0.29), and three casein phosphopeptides were positively correlated with the infants' length-for-age Z-scores (rs range from 0.19 to 0.27). This study is the first to reveal the phosphorylated level and composition of casein phosphopeptides in Chinese human milk, and their potential relationship with infant growth.

Effects of endogenous DHA milk and exogenous DHA milk on oxidative stress and cognition in SAMP8 mice.

In this study, Senescence Accelerated Mice (SAMP8) were supplemented with exogenous DHA milk, endogenous DHA milk, normal milk, or 0.9 % saline solution. Enzyme-linked immunosorbent assay (ELISA), gas chromatography (GC), ultra-performance liquid chromatography-electrospray ionization-tandem mass spectrometry (UPLC-ESI MS/MS), and Morris water maze were used to characterize the effects of diet on oxidative stress and cognition in SAMP8 mice. Supplementation endogenous DHA milk or exogenous DHA milk can enhance the antioxidant capacity of mice organs. Endogenous DHA milk increased the superoxide dismutase (SOD) activity of mice brain and serum than normal milk and 0.9 % saline solution (P ≤ 0.05), as well as increased SOD activity of mice liver and glutathione peroxidase (GSH-Px) activity of mice brain than normal milk (P ≤ 0.05). Exogenous DHA milk increased SOD activity of mice brain than normal milk and 0.9 % saline solution, as well as increased SOD activity of mice serum than 0.9 % saline solution (P ≤ 0.05). Several polar lipid relative content, such as 18:0/18:2 PS, 17:0 Ceramide, and 20:4 LPC in mice brain was affected by dietary supplementation with DHA-containing milk. Lipid oxidation metabolites in mice brain were not affected by DHA-containing milk. Endogenous DHA milk increased the number of platform location crossing times of mice in the Morris water maze test, compared with Exogenous DHA milk, normal milk, and 0.9 % saline solution (P ≤ 0.05).

A LC-MS/MS method for the simultaneous quantitative determination of aldosterone, its precursor 18-hydroxycorticosterone and its metabolite tetrahydroaldosterone in human urine.

Aldosterone (ALD), its precursor 18-hydroxycorticosterone (18-OHB) and its metabolite tetrahydroaldosterone (TH-ALD) are important biomarkers for the diagnosis of primary aldosteronism (PA). Liquid chromatography-tandem mass spectrometry (LC-MS/MS) is increasingly utilized in the detection of small molecules of hormones because it has advantages in terms of specificity and sensitivity. The objective of this study is to develop a new LC-MS/MS method for the simultaneous quantification of ALD (free), 18-OHB, and TH-ALD in human urine and attempt to diagnose primary aldosteronism using different indicators. The urine samples were treated with a solid-phase extraction pretreatment technique and the three analytes were separated on a reversed-phase column and detected on a triple quadrupole mass spectrometer. The established method was validated according to CLSI C62-A standard guidelines. The calibration ranges from 25 pg/mL to 5000 pg/mL for aldosterone (free), 18-hydroxycorticosterone and tetrahydroaldosterone, and the lower limit of quantification for these three analytes was 25 pg/mL. The matrix effects and recoveries of these three analytes ranged from 85.1 % to 115 % and from 86.3 % to 114 %, respectively. The intra-day and inter-day precision ranged from 1.29 % to 6.78 % and from 1.77 % to 8.64 %, respectively. The performance of the method met the requirements of the guidelines. 40 clinical urine samples including 22 PA patients and 18 non-PA patients were detected, and the ROC curves of three diagnostic indicators were established. The area under the curve (AUC) of ALD (free) is the biggest, so ALD (free) was the best compound to be used as a diagnostic indicator in this study. When the cut-off point was taken as 141 ng/24-h, the sensitivity was 72.7 % and the specificity was 88.9 %. We developed and validated an LC-MS/MS method for the simultaneous quantification of ALD (free), 18-OHB and TH-ALD in human urine. Our study provides a reference for the use of new biomarkers for the diagnosis of primary aldosteronism.

Identification of molecular subgroups and establishment of risk model based on the response to oxidative stress to predict overall survival of patients with lung adenocarcinoma.

OBJECTIVE: Oxidative stress is associated with the occurrence and development of lung cancer. However, the specific association between lung cancer and oxidative stress is unclear. This study aimed to investigate the role of oxidative stress in the progression and prognosis of lung adenocarcinoma (LUAD). METHODS: The gene expression profiles and corresponding clinical information were collected from GEO and TCGA databases. Differentially expressed oxidative stress-related genes (OSRGs) were identified between normal and tumor samples. Consensus clustering was applied to identify oxidative stress-related molecular subgroups. Functional enrichment analysis, GSEA, and GSVA were performed to investigate the potential mechanisms. xCell was used to assess the immune status of the subgroups. A risk model was developed by the LASSO algorithm and validated using TCGA-LUAD, GSE13213, and GSE30219 datasets. RESULTS: A total of 40 differentially expressed OSRGs and two oxidative stress-associated subgroups were identified. Enrichment analysis revealed that cell cycle-, inflammation- and oxidative stress-related pathways varied significantly in the two subgroups. Furthermore, a risk model was developed and validated based on the OSRGs, and findings indicated that the risk model exhibits good prediction and diagnosis values for LUAD patients. CONCLUSION: The risk model based on the oxidative stress could act as an effective prognostic tool for LUAD patients. Our findings provided novel genetic biomarkers for prognosis prediction and personalized clinical treatment for LUAD patients.

Comparison of Whey Proteome and Glycoproteome in Bovine Colostrum and Mature Milk.

Milk samples were collected from 10 cows, in the colostrum (3-4 days) and mature (90 days) lactation stage, to assess the differential expression of all whey proteins and N-glycoproteins. In total, 240 whey proteins and 315 N-glycosylation sites on 214 glycoproteins were quantified. GO annotations, KEGG pathway analysis, and protein classification were performed to understand the similarities and differences of the biological functions of whey proteins and N-glycoproteins among different lactation stages in bovine milk. Furthermore, differential expression of whey proteins and whey N-glycosylated proteins was found between different lactation stages. The related changes of biological functions in differentially expressed proteins were discussed. For example, the increased frequency of glycosylation on lactoferrin and folate receptor alpha occurring in bovine colostrum may provide protection and stimulate development of the newborn calf. Our study thereby improves understanding of variations of glycosylation sites on milk glycoproteins among lactation stages.

Determination and Risk Assessment of Flavor Components in Flavored Milk.

This study aimed to determine chemical composition and assess exposure in flavored milk among Chinese residents, based on risk assessment methodologies of acceptable daily intake (ADI) and toxicological concern threshold (TTC). Esters (32.17%), alcohols (11.19%), olefins (9.09%), aldehydes (8.39%), and ketones (7.34%) comprised the majority of the flavoring samples. Methyl palmitate (90.91%), ethyl butyrate (81.82%), and dipentene (81.82%) had the highest detection rates in flavor samples. This study screened fifteen flavor components of concern and discovered that 2,3,5-trimethylpyrazine, furfural, benzaldehyde, and benzenemethanol were detected in 100% of flavored milk samples. Benzenemethanol was found in the highest concentration (14,995.44 µg kg-1). The risk assessment results revealed that there was no risk for Chinese residents in consuming flavored milk, and the maximum per capita daily consumption of 2,3,5-trimethylpyrazine, furfural, and benzenemethanol were 226.208 g, 140.610 g, and 120.036 g, respectively. This study could provide guidelines for amounts of flavor additive ingredients in milk.

Simultaneous measurement of 19 steroid hormones in dried blood spots using ultra-performance liquid chromatography-tandem mass spectrometry.

A rapid and accurate ultra-performance liquid chromatography-tandem-mass spectrometry (UPLC-MS/MS) method was developed for the measurement of 19 steroid hormones in dried blood spots and to achieve the highly traceable analysis of steroid hormones in dried blood samples. In this method, a BEH C8 column and UPLC-MS/MS were used for the separation of the steroid hormones. The extraction process was simple and accurate. The distribution ranges of 19 steroid hormones in four healthy individuals (2 males and 2 females) were determined simultaneously by positive ionization mode (ESI+) and negative ionization mode (ESI-) analysis, which were recorded by multiple reaction monitoring (MRM) modes. The linearity of the standard curves of 19 steroid hormones in dried blood spots was good, and the linear correlation coefficients R2 were all ≥0.997. Meanwhile, the matrix effect of the method ranged from 87.1% to 131.3%. Across the analytical range, the inter-assay coefficient of variation (CV) was <12.07% and the intra-assay CV was <18.16%. The spiked recovery was >67.33%. The distribution ranges of 19 steroid hormones in four healthy individuals were in agreement with those in previous reports. A UPLC-MS/MS method for the simultaneous measurement of 19 steroid hormones in dried blood spots was developed to achieve traceable analysis of steroid hormones in dried blood samples.

Upregulation of NUAK2: A novel prognostic marker in breast cancer.

BACKGROUND: Breast cancer is the most commonly diagnosed neoplasm in women worldwide. New molecular biomarkers and effective prognostic models are being developed. This study aimed to investigate the clinical and prognostic significance of NUAK2 expression in patients with breast cancer. METHODS: The expression of NUAK 2 was examined in breast cancer cells and tissues by real-time PCR, western blotting, and immunohistochemical staining. CCK-8 and colony formation assays were performed to verify the effect of NUAK2 on the proliferation and tumor progression of breast cancer cells. A tumor formation assay in nude mice was performed to analyze the effect of NUAK2 on the tumorigenicity of breast cancer cells. RESULTS: The expression of NUAK2 in breast cancer tissues was higher than that in paracarcinoma and normal breast tissues. The overall survival of patients with high NUAK2 expression was significantly lower than that of patients with low NUAK2 expression. Multivariate analyses indicated that NUAK2 was an independent prognostic indicator of survival in breast cancer. In vitro experiments demonstrated that knocking down NUAK2 in breast cancer cells inhibited cell proliferation and tumor-forming ability, and overexpression of NUAK2 showed the opposite effects. NUAK2 overexpression promoted the tumorigenicity of breast cancer cells in vivo. CONCLUSION: These findings suggest that NUAK2 is involved in breast cancer development and progression. NUAK2 may be a valuable prognostic indicator in patients with breast cancer.

Comparison of twelve human milk oligosaccharides in mature milk from different areas in China in the Chinese Human Milk Project (CHMP) study.

Human milk oligosaccharides (HMOs) act as a vital role in the development of infant's gut microbiome and immune function. This study aimed to measure 12 oligosaccharides in milk from Chinese donors (n = 203), and evaluated the influences of multiple factors on the HMOs profiles. The results indicated that concentrations of 6'-sialyllactose were the highest among 12 oligosaccharides (2.31 ± 0.81 g/L). HMOs concentrations varied depending on geographical location. Latitude was observed to be related to concentrations of Lacto-N-neohexaose, lacto-N-fucopentaose III, 3'-sialyllactose (r = -0.67, r = +0.63 and r = +0.50, respectively). Environmental factors like seasons correlated with lacto-N-difucohexaose Ⅱ, Lacto-N-neohexaose and 2'-fucosyllactose (r = -0.47, r = -0.4, r = -0.35, respectively). Several HMOs concentrations were correlated with maternal diet. As a consequence, the HMOs profiles measured were influenced by geographical, environmental, maternal anthropometric as well as dietary factors.

[Clinical and genetic analysis of a patient with isolated 17,20 lyase deficiency presenting with pubertal gynecomastia].

OBJECTIVE: To explore the clinical and genetic basis for a patient with isolated 17,20 lyase deficiency presenting with pubertal gynecomastia. METHODS: Clinical manifestation, steroid analysis as well as genetic testing were carried out for a 14-year-old boy featuring puberty gynecomastia. RESULTS: The patient was admitted due to puberty gynecomastia for 2 years. Physical examination showed Tanner B5, G2 and normal blood pressure. Laboratory examination showed normal range of serum potassium and blood gas. Steroid analysis revealed extremely high pregnenolone, progesterone, 17-hydropregnenolone and 17-hydroprogesterone, Correspondingly, the DHEA, androstenedione, testosterone and dihydrotestosterone were low. He was found to harbor compound heterozygous variants of CYP17A1 gene (c.1304T>C/p.F435S and c.1346G>A/p.R449H), among which the R449H variant may result in isolated 17,20 lyase deficiency by altering the structure of redox-partner binding site. CONCLUSION: Isolated 17,20 lyase is a rare cause for puberty gynecomastia. The p.R449H variant of the CYP17A1 gene can result in isolated 17,20 lyase deficiency.

A Case of a Rare Parathyroid Hormone (PTH)-Producing Neuroendocrine Tumor.

BACKGROUND Neuroendocrine neoplasms are commonly seen in association with hormone production, and clinical signs that arise from these hormonal effects often manifest as the first presentation of malignancy. The excess production of parathyroid hormone (PTH) in particular, however, is primarily sporadic (80-85%) in clinical settings. In the context of malignancy, hyperparathyroidism manifestations arise most frequently from non-neuroendocrine pulmonary tumors through a ligand mimicker, parathyroid hormone-related peptide (PHrP). Excess PTH or PTHrP production has been very rarely described in association with gastrointestinal tumors and almost never described as a primary paraneoplastic syndrome from a neuroendocrine tumor (NET) alone. CASE REPORT We present a patient with a prior surgically resected carcinoid tumor who later presented with an elevated parathyroid hormone level, hypercalcemia, and clinical manifestations of primary hyperparathyroidism. She was found to have a low-grade, recurrent neuroendocrine tumor on resection of a parathyroid mass suspected to be a productive adenoma. Despite no longer having parathyroid glands given the extent of resection, her PTH level remained elevated and was rising. Further investigation via repeat sestamibi nuclear scan excluded the possibility of exogenous parathyroid tissue, and subsequent dotatate positron emission tomography/computed tomography (PET/CT) revealed the source of the PTH production: multiple sites of metastatic neuroendocrine tumors producing native PTH. CONCLUSIONS This case highlights the rare possibility of NETs to secrete PTH and the importance of considering early staging with dotatate PET/CT to evaluate the extent of disease. Additionally, our case reveals the importance of considering NET as an alternative etiology for refractory hypercalcemia.

Utilization of cinnamaldehyde and zinc oxide nanoparticles in a carboxymethylcellulose-based composite coating to improve the postharvest quality of cherry tomatoes.

Carboxymethylcellulose (CMC)-based film packaging enriched with plant-sourced cinnamaldehyde (CIN) and zinc oxide nanoparticles (ZnONPs) of simple synthesis were prepared in this work. Then, the physico-mechanical and barrier properties and antifungal activities of CMC-based films, including pristine CMC, CIN/CMC, ZnONPs/CMC, ZnONPs/CIN/CMC were investigated. The results indicated that the ZnONPs incorporation produced a nanocomposite film with low transparency, good flexibility and high mechanical resistance. Furthermore, the water barrier capacity and antifungal performance of CMC-based films were significantly improved with the addition of CIN. CMC-based composite film incorporating with both CIN and ZnONPs, in turn, exhibited satisfactory mechanical characterizations, excellent barrier capacities against water and oxygen molecules and anti-Aspergillus niger activity. Moreover, ZnO/CIN/CMC nanocomposite film was significantly effective at inhibiting the weight loss and firmness of cherry tomatoes and in decreasing the total acidity content of these fruits after storage. Our results suggested that the ZnO/CIN/CMC nanocomposite film packaging can improve the cherry tomatoes quality by suppressing physiological the metabolic activities of the fruits during postharvest storage period.

Standardization of clinical enzyme analysis using frozen human serum pools with values assigned by the International Federation of Clinical Chemistry and Laboratory Medicine reference measurement procedures.

Variation in clinical enzyme analysis, particularly across different measuring systems and laboratories, represents a critical but long-lasting problem in diagnosis. Calibrators with traceability and commutability are imminently needed to harmonize analysis in laboratory medicine. Fresh frozen human serum pools were assigned values for alanine aminotransferase (ALT), aspartate aminotransferase (AST), gamma-glutamyltransferase (GGT), creatine kinase (CK) and lactate dehydrogenase (LDH) by six laboratories with established International Federation of Clinical Chemistry and Laboratory Medicine reference measurement procedures. These serum pools were then used across 76 laboratories as a calibrator in the analysis of five enzymes. Bias and imprecision in the measurement of the five enzymes tested were significantly reduced by using the value-assigned serum in analytical systems with open and single-point calibration. The median (interquartile range) of the relative biases of ALT, AST, GGT, CK and LDH were 2.0% (0.6-3.4%), 0.8% (-0.8-2.3%), 1.0% (-0.5-2.0%), 0.2% (-0.3-1.0%) and 0.2% (-0.9-1.1%), respectively. Before calibration, the interlaboratory coefficients of variation (CVs) in the analysis of patient serum samples were 8.0-8.2%, 7.3-8.5%, 8.1-8.7%, 5.1-5.9% and 5.8-6.4% for ALT, AST, GGT, CK and LDH, respectively; after calibration, the CVs decreased to 2.7-3.3%, 3.0-3.6%, 1.6-2.1%, 1.8-1.9% and 3.3-3.5%, respectively. The results suggest that the use of fresh frozen serum pools significantly improved the comparability of test results in analytical systems with open and single-point calibration.

Development of a matrix-based candidate reference material of total homocysteine in human serum.

We developed and evaluated a candidate serum reference material to help improve clinical routine measurement, and to provide traceability of the measurement results. D8-Homocystine, dithiothreitol, and acetonitrile were used as an internal standard, the reducing agent, and the protein precipitating agent, respectively. A triple quadrupole mass spectrometer with an electrospray ionization source was used for monitoring the transitions (m/z 140.0 → 94.0, 136.0 → 90.0) in multiple-reaction-monitoring mode. We used a calibration model relying on bracketing and gravimetric measurements to give SI-traceability and higher accuracy to serum value assignments. The method was evaluated for accuracy using NIST Standard Reference Material SRM1955. The results of the three concentrations (1, 2, and 3) of total homocysteine in human serum samples were determined by an isotope-dilution liquid chromatography-tandem mass spectrometry method; tHcy 1 is 28.8 ± 1.1 µmol/L, tHcy 2 is 17.93 ± 0.57 µmol/L, and tHcy 3 is 14.38 ± 0.46 µmol/L. Graphical abstract The workflow diagram.

Extramedullary hematopoiesis: A report of two cases.

Extramedullary hematopoiesis (EMH) is defined as hematopoiesis occurring in organs outside of the bone marrow. The present report describes two cases of thalassemic patients with paraspinal medullary hematopoiesis and analyzes the clinical manifestations, imaging, pathology, diagnosis and treatment of EMH. In addition, a supplementary review of previously published cases is provided along with a review of the related literature. Computed tomography (CT) of the first case revealed multiple paraspinal masses, and the largest was 6.2×8.0 cm in diameter. Likewise, CT of the second patient revealed multiple paraspinal masses in the bottom of the left thoracic cavity, and the largest was measured 10.1×10.5 cm. The two cases underwent surgical biopsy and the findings were compatible with a diagnosis of EMH. In conclusion, EMH is a compatible and rare disease, and should be distinguished from other neoplasms. EMH must considered when masses with characteristic radiologic appearance are detected in patients with thalassemia intermedia.

Measurement of unconjugated estriol in serum by liquid chromatography-tandem mass spectrometry and assessment of the accuracy of chemiluminescent immunoassays.

BACKGROUND: Unconjugated estriol (uE3) is routinely analyzed in clinical laboratories as risk assessment for Down syndrome. Immunoassays of various types are the most commonly used methods. The accuracies of RIAs and ELISAs for uE3 have been questioned, and to date there have been no independent studies investigating the accuracy of the relatively new chemiluminescent immunoassays. We developed and validated a liquid chromatography-tandem mass spectrometry (LC-MS/MS) method for uE3 measurements in serum. METHODS: Serum samples from patients in the second trimester of pregnancy were used, and uE3 concentrations were measured by LC-MS/MS and the Beckman Coulter Access® 2 and Siemens IMMULITE 2000 automatic chemiluminescent immunoassay analyzers. RESULTS: The LC-MS/MS method was validated and showed limit of detection 0.05 ng/mL; limit of quantification 0.2 ng/mL; linearity of response to 32 ng/mL; total imprecision of 16.2%, 10.4%, and 8.2% for uE3 at 1.10, 4.18, and 8.32 ng/mL, respectively; and analytical recoveries of 95.9%-104.2%. ANOVA of the correlation for LC-MS/MS results vs chemiluminescent immunoassays results showed R(2) = 0.9678 (Access 2 = 0.9305 LC-MS/MS + 0.2177, Sy|x = 0.1786, P < 0.0001), and R(2) = 0.9663 (IMMULITE 2000 = 0.8849 LC-MS/MS - 0.0403, Sy|x = 0.1738, P < 0.0001). Bland-Altman plots of uE3 results revealed concentration-dependent immunoassay biases. Mock risk analysis for Down syndrome showed no apparent difference in the risk assessment outcomes if the adjusted method-specific multiples of the median were used, and the assay imprecision was <10% CV. CONCLUSIONS: Standardization of immunoassay methods for uE3 analysis is needed to improve the accuracy of the measurements.

Common reference intervals for aspartate aminotransferase (AST), alanine aminotransferase (ALT) and γ-glutamyl transferase (GGT) in serum: results from an IFCC multicenter study.

BACKGROUND: Aspartate aminotransferase (AST), alanine aminotransferase (ALT) and γ-glutamyl transferase (GGT) measurements are important for the assessment of liver damage. The aim of this study was to define the reference intervals (RIs) for these enzymes in adults, paying attention to standardization of the methods used and careful selection of the reference population. METHODS: AST, ALT and GGT were measured with commercial analytical systems standardized to the IFCC-recommended reference measurement systems. Three centers (two in Italy and one in China) measured their own freshly collected samples; one of these centers also measured frozen samples from the Nordic Countries RI Project and from a Turkish center. RIs were generated using non-parametric techniques from the results of 765 individuals (411 females and 354 males, 18-85 years old) selected on the basis of the results of other laboratory tests and a specific questionnaire. RESULTS: AST results from the four regions (Milan, Beijing, Bursa and Nordic Countries) were statistically different, but these differences were too small to be clinically relevant. Likewise, differences between the upper reference limits for genders was only 1.7 U/L (0.03 µkat/L), allowing a single RI of 11-34 U/L (0.18-0.57 µkat/L) to be defined. Interregional differences were not statistically significant for ALT, but partitioning was required due to significant gender differences. RIs for ALT were 8-41 U/L (0.13-0.68 µkat/L) for females and 9-59 U/L (0.15-0.99 µkat/L) for males, respectively. The upper reference limits for GGT from the Nordic Country population were higher than those from the other three regions and results from this group were excluded from final calculations. The GGT RIs were 6-40 U/L (0.11-0.66 µkat/L) for females and 12-68 U/L (0.20- 1.13 µkat/L) for males, respectively. CONCLUSIONS: For AST and ALT, the implementation of common RIs appears to be possible, because no differences between regions were observed. However, a common RI for GGT that is applicable worldwide appears unlikely due to differences among populations.