High anion gap metabolic acidosis induced by cumulation of ketones, L- and D-lactate, 5-oxoproline and acute renal failure.

INTRODUCTION: Frequent causes of high anion gap metabolic acidosis (HAGMA) are lactic acidosis, ketoacidosis and impaired renal function. In this case report, a HAGMA caused by ketones, L- and D-lactate, acute renal failure as well as 5-oxoproline is discussed. CASE PRESENTATION: A 69-year-old woman was admitted to the emergency department with lowered consciousness, hyperventilation, diarrhoea and vomiting. The patient had suffered uncontrolled type 2 diabetes mellitus, underwent gastric bypass surgery in the past and was chronically treated with high doses of paracetamol and fosfomycin. Urosepsis was diagnosed, whilst laboratory analysis of serum bicarbonate concentration and calculation of the anion gap indicated a  HAGMA. L-lactate, D-lactate, ß-hydroxybutyric acid, acetone and 5-oxoproline serum levels were markedly elevated and renal function was impaired. DISCUSSION: We concluded that this case of HAGMA was induced by a variety of underlying conditions: sepsis, hyperglycaemia, prior gastric bypass surgery, decreased renal perfusion and paracetamol intake. Risk factors for 5-oxoproline intoxication present in this case are female gender, sepsis, impaired renal function and uncontrolled type 2 diabetes mellitus. Furthermore, chronic antibiotic treatment with fosfomycin might have played a role in the increased production of 5-oxoproline. CONCLUSION: Paracetamol-induced 5-oxoproline intoxication should be considered as a cause of HAGMA in patients with female gender, sepsis, impaired renal function or uncontrolled type 2 diabetes mellitus, even when other more obvious causes of HAGMA such as lactate, ketones or renal failure can be identified.

Analytical performance of the VITROS® Immunodiagnostic Products total PSA II and free PSA assays.

OBJECTIVES: To assess the precision and the performance of the VITROS(®) total PSA II (tPSA) and free PSA (fPSA) assays on the VITROS(®) ECi/ECiQ Immunodiagnostic system. DESIGN AND METHODS: The precision of the tPSA and fPSA assays was evaluated following the Clinical and Laboratory Standards Institute (CLSI)-guideline EP5-A2. During a 20-day period, 2 runs of 5 quality control (QC) samples were performed daily. Results of tPSA (n=292) and fPSA (n=289) were compared between VITROS(®) ECi/ECiQ Immunodiagnostic system and Roche Cobas 8000 e602 system (Cobas tPSA and fPSA assays). A modified CLSI-guideline EP9-A2 was used to correlate the results based on a Deming regression correlation study. RESULTS: A within-run and within-calibration imprecision of ≤2% was obtained for all 5 QC concentration levels for both tPSA and fPSA. Method comparison revealed a constant bias of 17% for tPSA and 6% for fPSA. These values are within the desirable bias of 18.7% suggested by the Westgard Biological Variation Database Specifications. A high agreement was found between the two methods, with correlation coefficients of 0.997 and 0.993 for tPSA and fPSA respectively. CONCLUSION: The VITROS(®) tPSA and fPSA assays showed an excellent precision and bias and a good correlation with the Roche method.

Laboratory detection of macro-aspartate aminotransferase: case report and evaluation of the PEG-precipitation method.

BACKGROUND: Chronic elevated AST without other signs of liver disease, cardiac or skeletal abnormalities, is suggestive for macro-AST. Laboratory detection can be performed by gel filtration chromatography, ultrafiltration or precipitation with polyethylene glycol (PEG). PATIENT AND METHODS: A healthy 27 year-old female was referred because of chronic elevated AST (116-704U/L) without other abnormalities. Macro-AST positivity was suspected since AST was no longer measurable in the supernatant of a serum sample (<3U/L) after PEG precipitation. Optimization of this method included analysis of proteins and lipids precipitated, testing the effect of different PEG concentrations and centrifugation times. 25% (m/v) PEG solution gave the most reliable results. No significant difference was seen between 10 and 30 min centrifugation time. A reference range was obtained by analysis of 31 normal patient samples (mean % PEG precipitation activity 35.1% with 95% confidence limits of 14.5-62.5%). Retrospective analysis of 1371 patient samples with elevated AST revealed one other positive patient sample. CONCLUSION: Early recognition of macro-AST, proven by simple PEG precipitation, can avoid time-consuming and invasive investigations.

Improvement of a real-time RT-PCR assay for the detection of enterovirus RNA.

We describe an improvement of an earlier reported real-time RT-PCR assay for the detection of enterovirus RNA, based on the 5' exonuclease digestion of a dual-labeled fluorogenic probe by Taq DNA polymerase. A different extraction method, real-time RT-PCR instrument and primer set were evaluated. Our data show that the optimized assay yields a higher sensitivity and reproducibility and resulted in a significant reduced hands-on time per sample.