Establishing a reference system in clinical enzymology.

The goal of standardization for measurements of catalytic concentrations of enzymes is to achieve comparable results in human samples, independent of the reagent kits, instruments and laboratory where the procedure is carried out. To pursue this objective, the International Federation of Clinical Chemistry and Laboratory Medicine (IFCC) has launched a project to establish a reference system in clinical enzymology. This system is based on three hinges: a) extensively evaluated and carefully described reference procedures, b) certified reference materials and c) a network of reference laboratories operating in a highly controlled manner. The original IFCC-recommended procedures for alanine aminotransferase, aspartate aminotransferase, creatine kinase, gamma-glutamyltransferase, lactate dehydrogenase and alpha-amylase have been slightly modified to optimize them at 37 degrees C, with the definition of detailed operating procedures. A group of laboratories perform these procedures manually, with self-made reagents on carefully calibrated instruments. Partially purified and stabilized materials, prepared in the past by the Community Bureau of Reference, have been re-certified by these laboratories for alanine aminotransferase, creatine kinase, gamma-glutamyltransferase and lactate dehydrogenase activities. Using these materials and the manufacturer's standing procedures, industry can assign traceable values to commercial calibrators. Thus, clinical laboratories, which will use routine procedures with these validated calibrators to measure human specimens, can finally obtain values which are traceable to reference procedures.

Standardized extracts from Chinese herbs induce IL-10 production in human monocyte-derived dendritic cells and alter their differentiation in vitro.

BACKGROUND: The efficacy of traditional Chinese medicine (TCM) as a treatment for atopic dermatitis has been evaluated in clinical trials. Until now, the underlying mechanism of this treatment has remained completely elusive; this is particularly true of its putative effects on dendritic cells (DCs), which might play a pivotal role in the disease. OBJECTIVE: We investigated the influence of a standardized extract from 10 Chinese herbs that was successfully used in clinical trials on the generation of monocyte-derived DCs from atopic donors. METHODS: Detailed phenotypic and functional exploration of DCs generated in the presence of IL-4 and GM-CSF and treated with different concentrations of TCM or a placebo control was performed. RESULTS: TCM profoundly affected the morphology and phenotype of the developing DCs. They lost their typical dendritic morphology and decreased their expression of CD1a as well as the low-affinity IgE receptor CD23. Most importantly, TCM-exposed DCs exhibited a diminished stimulatory activity toward autologous antigen-specific and allogeneic T cells while secreting high amounts of IL-10. CONCLUSION: TCM induces immunopharmacologic alterations on DCs from atopic donors in vitro. These alterations might account, at least in part, for the therapeutic effect of this treatment in AD in vivo.

Estimating the uncertainty of stability for matrix CRMs.

The new version of ISO Guide 34 requires producers of certified reference materials (CRMs) to include contributions of possible instability to the overall CRM uncertainty, to obtain a value for the uncertainty in compliance with the Guide to the Expression of the Uncertainty in Measurement (GUM). A pragmatic approach to estimating the uncertainty of stability is presented. It relies on regression analysis of stability data with subsequent testing of the slope of the regression line for significance. If the slope is found to be statistically insignificant, a shelf life is chosen and the uncertainty connected with this time is estimated via the standard deviation of the slope. This uncertainty is included in the overall uncertainty of the CRM. This approach is explained with examples showing its applicability to matrix CRMs.

Influence of oral dehydroepiandrosterone (DHEA) on urinary steroid metabolites in males and females.

Oral dehydroepiandrosterone (DHEA) replacement therapy may have a multitude of potential beneficial effects and exerts its action mainly via peripheral bioconversion to androgens (and estrogens). A daily dose of 50-mg DHEA has been shown by us and others to restore low endogenous serum DHEA concentrations to normal youthful levels followed by an increase in circulating androgens and estrogens. As the hepatic first-pass effect may lead to a non physiological metabolism of DHEA after oral ingestion we studied the influence of two single DHEA doses (50 and 100 mg) on the excretion of steroid metabolites in 14 elderly males [age 58.8+/-5.1 years (mean +/- SEM)] with endogenous DHEAS levels <1500 ng/ml and in 9 healthy females (age 23.3+/-4.1 years) with transient suppression of endogenous DHEA secretion induced by dexamethasone (dex) pretreatment (4x0.5 mg/day/4 days). Urinary steroid profiles in the elderly males were compared to the steroid patterns found in 15 healthy young men (age 28.9+/-5.1 years). In the females the results were compared to their individual baseline excretion without dex pretreatment. Urinary steroid determinations were carried out by semiautomatic capillary gas-liquid chromatography. In both genders DHEA administration induced significant increases in urinary DHEA (females: baseline vs. 50 mg vs. 100 mg: 361+/-131 vs. 510+/-264 vs. 1541+/-587 microg/day; males: placebo vs. 50 mg vs. 100 mg: 434+/-154 vs. 1174+/-309 vs. 4751+/-1059 microg/day) as well as in the major DHEA metabolites androsterone (A) and etiocholanolone (Et). Fifty mg DHEA led to an excretion of DHEA and its metabolites only slightly above baseline levels found in young females and in young men, respectively, whereas 100 mg induced clearly supraphysiological values. After 50 mg DHEA the ratios of urinary DHEA metabolites (A/DHEA, Et/DHEA) were not significantly different between elderly males vs. young male volunteers and young healthy females versus their individual baseline levels. In conclusion, an oral dose of 30 to 50 mg DHEA restores a physiological urinary steroid profile in subjects with DHEA deficiency without evidence for a relevant hepatic first-pass effect on urinary metabolites.

Estimation of the uncertainty of CRMs in accordance with GUM: application to the certification of four enzyme CRMs.

Uncertainties of four enzyme-CRMs that have recently been certified in a co-operation between the IRMM and the International Federation for Clinical Chemistry were estimated. Estimation was based on the sum of the uncertainties of characterization, homogeneity and stability. Data from the certification collaborative study were used to estimate laboratory uncertainties, which form the basis for the uncertainty of characterization. Estimations for the uncertainty of homogeneity were derived from classical homogeneity studies. The estimations of uncertainty of stability caused the most difficulties. Realistic uncertainties fitting the needs of customers while being derived from measurement data based on theoretical considerations were obtained.

Measurement of urea in human serum by isotope dilution mass spectrometry: a reference procedure.

BACKGROUND: A reference measurement procedure is needed to demonstrate the traceability of results of urea measurements in human serum. We developed a measurement procedure using the principle of isotope dilution gas chromatography/mass spectrometry. METHODS: [(13)C,(15)N(2)]Urea as internal standard was added to a serum sample and equilibrated with endogenous nonlabeled urea. For the preparation of calibrators, the same amount of labeled urea was mixed with known amounts of nonlabeled urea. The serum samples were treated with ethanol to remove proteins by precipitation. The labeled and nonlabeled urea of the samples was converted into a trimethylsilyl derivative of 2-hydroxypyrimidine. The gas chromatography/mass spectrometry system was adjusted to monitor m/z 153 and 168 for the nonlabeled urea derivative and m/z 156 and 171 for the isotopically labeled analogs. The results of the determination were calculated from peak ratios by a hyperbolic calculation function based on the theory of isotope dilution analysis. RESULTS: The procedure was applied to control samples and patient samples and evaluated with respect to its trueness and precision. The standard uncertainty of the results was 0.47-1.72%. CONCLUSIONS: This reference measurement procedure allows values to be assigned to controls and calibrators that are traceable to the primary urea reference material of NIST and, therefore, to the Système International unit "mole" with a low degree of uncertainty. This procedure provides a tool for the highly accurate determination of urea in control materials as well as in patient sera.

Characterization of 17beta-hydroxysteroid dehydrogenase activity in brain tissue: testosterone formation in the human temporal lobe.

Sex steroids exert important effects on the central nervous system (CNS). Although the formation of 17beta-hydroxysteroid dehydrogenase (17beta-HSD) metabolites in the CNS was discovered almost 30 years ago, conclusive studies concerning 17beta-HSD activity in the human brain are still lacking. Therefore, we investigated 17beta-HSD in vitro activity in human temporal lobe biopsies of 13 women and 13 men using radioactively labelled androstenedione, testosterone, oestrone and 17beta-oestradiol and compared it to that in human placenta, liver, testis and prostate. We could demonstrate androgenic and oestrogenic 17beta-HSD activities in all tissues under investigation. The reduction of androstenedione and oestrone in brain was NADPH dependent with a broad pH optimum between 6.5 and 9.0, whereas the oxidation of testosterone and 17beta-oestradiol was NAD dependent with a pH optimum of >/=9.0. Using optimum cofactors sex differences of brain 17beta-HSD activities were not observed. Conversion of androstenedione, testosterone, oestrone and 17beta-oestradiol was significantly higher in the subcortical white matter than in the cerebral cortex. We could demonstrate a significant formation of testosterone in the brain tissue of all patients under investigation. Substrate specificity and cofactor requirement patterns as well as pH optima and kinetic properties suggest the occurrence of 17beta-HSD type 3 and type 4 in the human temporal lobe.

Gestodene and desogestrel do not have a different influence on concentration profiles of ethinylestradiol in women taking oral contraceptives--results of isotope dilution mass spectrometry measurements.

OBJECTIVES: A new method for the quantitative determination of 17alpha-ethinylestradiol-17beta (EE2) in serum is presented here based on the principle of isotope dilution mass spectrometry (IDMS) with [13C]EE2 as internal standard. The technique was used to determine the concentration profiles of EE2 in the serum of female subjects who had taken oral contraceptives with different progestin components. The method has proved to be very reliable with respect to trueness, specificity, precision and detection sensitivity and offers considerable advantages compared with the immunological methods of measurement used to date. STUDY DESIGN: Forty-seven female volunteers took two different oral contraceptives containing EE2 combined with different progestins in accordance with a cross-over design. After the administration of 30 microg EE2 combined with 75 microg gestodene (EE2/GSD) or 150 microg desogestrel (EE2/DES), blood samples were taken from the subjects on certain days and in certain previously specified cycles in the course of 12 h after medication. RESULTS AND CONCLUSIONS: The biometric analysis of the results showed that the concentration profiles of EE2 were in their statistics, significantly equivalent after the administration of either of the two oral contraceptives. The sometimes contradictory results found in former studies after the administration of the different contraceptives were presumably due to the methodological shortcomings of the radioimmunological measurement technique. With the use of the highly accurate and specific technique of IDMS it can now be unequivocally established that the different progestins in the tested oral contraceptives have no influence on the bioavailability of EE2 (area under EE2 serum concentration curves, as usually defined in pharmacokinetics).

Analytical specifications of reference methods compilation and critical discussion (from the members of the European EQA-Organizers Working Group B).

We present a compilation of published data for accuracy, precision, and measurement design for analytes that, currently, are of major interest for European reference laboratories. These data are compared with recent recommendations for performance of reference methods to be used within networks of European reference laboratories. In addition, we review the literature on reference methods and related topics.

Analytical quality specifications for reference methods and operating specifications for networks of reference laboratories. discussion paper from the members of the external quality assessment (EQA) Working Group B1) on target values in EQAS.

The aim of the Working Group was to describe guidelines for the establishment of networks of reference laboratories. The need for such networks to achieve an accuracy-based uniform measurement system with traceability of results of analytical systems/test-kits to the true value is outlined. Criteria for analytical quality specifications, which are related to the ultimate purpose of the reference method and thereby to the objectives of the networks, are emphasized. The group recommends the use of two models: one based on specifications for routine methods, which are dictated by the biological variations of the respective analytes, the second respecting the analytical state-of-the-art of reference methodology. Further, the group presents operating specifications for networks that guarantee the continuous performance of reference method measurements whilst maintaining a uniform and stable level of quality.

Adrenocortical insufficiency in Rhodesian sleeping sickness is not attributable to suramin.

Suramin, a polysulphonated naphthylurea used in the treatment of human African trypanosomiasis (HAT), is known to cause adrenocortical insufficiency in doses exceeding the quantity used for treatment of HAT. We have previously reported that Trypanosoma brucei rhodesinese infection causes a combined central and peripheral adrenal insufficiency. To evaluate whether suramin therapy acts as an additional adrenotoxic factor, we assessed adrenocortical function in 72 patients suffering from HAT at different times during treatment with either suramin or melarsoprol by a rapid adrenocorticotropic hormone test. We found a significantly diminished peak cortisol response to stimulation in the acutely ill patients (P = 0.001), indicating impaired adrenocortical function, as well as a high incidence of partial adrenocortical insufficiency (27%). During and after trypanocidal therapy the incidence of partial adrenal insufficiency gradually declined (to 25% and 18% respectively). Stimulated peak cortisol levels did not differ significantly between patients receiving suramin and those given melarsoprol. No correlation was found between serum suramin concentration and the cortisol response to stimulation (r = 0.09, P = 0.47). Thus we conclude that suramin in trypanocidal doses neither causes nor worsens the adrenocortical dysfunction observed in Rhodesian HAT.

Suramin in adrenocortical cancer: limited efficacy and serious toxicity.

OBJECTIVE: No satisfactory treatment for adrenocortical carcinoma (ACC) is available. We investigated the efficacy and toxicity of suramin in the treatment of metastatic ACC since suramin has been recently reported to be active as a single agent therapy for patients with ACC and prostatic carcinoma. DESIGN: We collected data on 9 patients with metastatic ACC treated with suramin in four centres in Germany between 1987 and 1992. PATIENTS: Nine patients (5 women, 4 men; age range 32-67 years) were included. Biochemical evidence of steroid excess was found in 6/9, in three leading to clinical symptoms (hypertension, hyperglycaemia, hirsutism, gynaecomastia). MEASUREMENTS: Tumour responses were assessed by radiological and biochemical evaluation. Other investigations included regular measurements of blood cell counts, coagulation, hepatic and renal function parameters, and serum suramin concentrations. RESULTS: The patients received cumulative doses ranging from 8.2 to 30.2 g suramin over periods of 1-15 months. 3/9 achieved a partial response, 2/9 disease stabilization and 4/9 experienced progressive disease. Tumour responses were transient. Suramin treatment was without direct influence on steroid excess. Serious side-effects included coagulopathy (6/9), thrombocytopenia (6/9), polyneuropathy (2/9) and allergic skin reactions (4/9); the death of two patients was possibly related to suramin therapy. Both toxicity and tumour response were strongly associated with serum level or cumulative dose of suramin. CONCLUSIONS: (1) Suramin is of antineoplastic efficacy in the treatment of metastatic adrenocortical carcinoma. (2) The clinical use of suramin is limited by a narrow therapeutic window with the risk of serious and possibly lethal toxicity at one extreme, and loss of efficacy at the other. Strict monitoring of suramin serum levels is mandatory aiming at levels between 200 and 250 mg/l. Suramin should not be considered as first-line treatment for metastatic adrenocortical carcinoma. (3) To improve treatment options in adrenocortical carcinoma as well as for further investigation on the usefulness of suramin, controlled prospective trials are urgently needed.

Impairment of adrenocortical function associated with increased plasma tumor necrosis factor-alpha and interleukin-6 concentrations in African trypanosomiasis.

African sleeping sickness (SS) is a severe, potentially lethal parasitic disease. The treatments of choice are the antiparasitic agents suramin, which is adrenotoxic, and/or melarsoprol. We evaluated the functional integrity of the hypothalamic-pituitary-adrenal (HPA) axis of patients with SS before, during, and after therapy with suramin and/or melarsoprol, in two sequential stages. First, we employed the standard adrenocorticotropic hormone (ACTH) 1-24 stimulation test (250 micrograms i.v.) to assess the maximal adrenocortical responsiveness of 69 patients with SS and 38 normal controls. We demonstrated paradoxically subnormal cortisol responses before suramin therapy [net cortisol response 60 min after stimulation: 10.5 +/- 2.9 (mean +/- SE) vs. 17.5 +/- 1.0 micrograms/dl for controls, p = 0.004], with 27% of the patients falling within the adrenal insufficiency range (stimulated cortisol concentration < 20 micrograms/dl). These responses subsequently and unexpectedly improved with suramin and/or melarsoprol therapy. Second, we performed a human corticotropin-releasing hormone (hCRH) test (100 micrograms i.v.) in 68 additional patients with SS and 14 control subjects to examine whether the glucocorticoid deficiency observed was primary and/or secondary. Compared to controls, the ACTH and cortisol responses to hCRH were blunted (ACTH after 60 min: 29 +/- 7 vs. 58 +/- 8 pg/ml in controls, p = 0.014; cortisol: 15.2 +/- 1.5 vs. 19.6 +/- 0.7 micrograms/dl, p = 0.018), suggesting the presence of secondary adrenal insufficiency. There was improvement of both ACTH and cortisol responsiveness to hCRH with therapy, with cortisol recovery occurring before ACTH, suggesting an additional primary component of adrenal dysfunction in these patients.(ABSTRACT TRUNCATED AT 250 WORDS)

Standardization of hapten immunoprocedures: total cortisol.

The broad objectives of this report are to enhance the clinical utility of the results of hapten measurement immunoprocedures by encouraging standardization of the procedures. It was decided to restrict the subject of the report to one analyte, and cortisol was chosen because of its diagnostic importance, the need for improved comparability with routine procedures, and its relevance to many other analytes. Therefore, the immediate objectives are to improve the clinical utility of total serum cortisol concentrations measured on different occasions and in different laboratories, to make diagnostic reference intervals more reliable and widely applicable, and to improve diagnostic accuracy by: Improving the agreement between results from reference measurement procedures and the results obtained with normal routine immunoprocedures for the measurement of total serum cortisol, and hence the comparability of routine results; and Reducing the susceptibility of the immunoprocedures to crossreactivity and interference. It is recognized that good comparability of results depends on procedures which are specific, properly calibrated and validated, and that the most important factors are resistance to crossreactants and interferants. Analytical goals for cortisol immunoprocedures are zero bias for 'all' samples with respect to a reference procedures, with the total analytical standard deviation equal to, or less than, half the within-individual standard deviation for cortisol, or 7.6% according to a recent estimate. To these ends the group proposes the following measures: 1. An international network of reference laboratories for cortisol measurement should be established, and progressively developed to include other hapten analytes. The service of the participating laboratories would be necessary to make feasible other recommendations listed below. 2. Procedures should be comprehensively validated, including a thorough crossreactivity study with the results presented to indicate the possible significance of each crossreactivity, a direct comparison of results with those obtained by a reference procedure for an adequate number of varied fresh/frozen patient samples, and suitable clinical validation studies. 3. External quality assessment schemes should assess participating laboratory performance against reference procedure values, and not consensus values related to values determined by any group of participating procedures. They should also assess the ability to determine added standard and to resist common interferants. 4. Master calibrators for use in the production of calibrators included in commercial kits, and formulated identically to these, should be certified with at least one reference measurement procedure, so that the concentrations of analyte in calibrators can be traced back to concentrations determined by a reference procedure.(ABSTRACT TRUNCATED AT 400 WORDS)

Reference methods for total cholesterol and total glycerol.

In internal and external quality assessment of clinical chemical analyses, the use of reference method values is prescribed in the Federal Republic of Germany as a measure of accuracy control. In the field of lipid analyses, reference methods are available for measuring total cholesterol and total glycerol in control sera. The reference measurement procedures are based on the highly accurate analytical principle of isotope dilution mass spectrometry. A very detailed protocol that ensures a high level of reliability must be followed when reference measurement procedures are carried out. The introduction of reference methods as a basis for accuracy control has greatly limited the unacceptable use of inaccurate routine methods.

Development, validation, and certification by isotope dilution gas chromatography-mass spectrometry of lyophilized human serum reference materials for cortisol (CRM 192 and 193) and progesterone (CRM 347 and 348).

The Community Bureau of Reference of the European Communities has produced four batches of lyophilized serum Certified Reference Materials, two for cortisol (CRM 192 and 193) and two for progesterone (CRM 347 and 348). For cortisol, one of the pools consisted of serum from healthy blood donors, whereas the second batch was supplemented with pure cortisol. The progesterone Reference Materials contained only endogenous hormone concentrations. Assessment of vial-to-vial variability in the cortisol and progesterone concentrations showed no between-sample inhomogeneity, and the materials were stable. The quality of the materials was therefore considered sufficient for certification of the values for the cortisol and progesterone concentrations by a collaborative study involving several laboratories from the European Communities, using isotope dilution gas chromatography-mass spectrometry. Inaccuracy in reconstitution of the lyophilized materials was less than 0.3%; imprecision of sampling was less than 0.2%. For determinations of cortisol and progesterone concentrations, the mean within-laboratory coefficients of variation (CVs) were 1.76% (CRM 192), 1.19% (CRM 193), 1.64% (CRM 347), and 1.75% (CRM 348). The between-laboratory CVs were greater: CRM 192, 1.79%; CRM 193, 1.48%; CRM 347, 2.08%; and CRM 348, 2.16%. The concentrations in the reconstituted Reference Materials were certified to be 273 nmol/L in CRM 192 and 763 nmol/L in CRM 193 for cortisol and 10.13 nmol/L in CRM 347 and 40.3 nmol/L in CRM 348 for progesterone. Uncertainties at the 0.95 confidence level--6 (CRM 192), 14 (CRM 193), 0.21 (CRM 347), and 1.0 nmol/L (CRM 348)--were considered compatible with the intended use of the materials.

Analyses with the KODAK-Ektachem. Accuracy control using reference method values and the influence of protein concentration. Part II. Substrates.

The reliability of the determination of the most common substrates with the Ektachem 700 was evaluated. Accuracy control was performed in various ways including the comparison of results with reference method values. The influence of protein concentration was investigated systematically using sera containing varying amounts of protein obtained by ultracentrifugation. Bilirubin. Deviation from the reference method values was within limits of the guidelines (Dt. Arztebl. 85 (1988) B517-B532). The influence of protein concentration was negligible. Cholesterol. The results agreed well with the reference method values. The method was not influenced by different protein concentrations. Creatinine. The results were in good agreement with reference method values, when the method was calibrated with the primary assigned values of the calibrators. At high protein concentrations, the results were higher than those of the comparative method. Glucose. The mean deviation from the reference method values was 1.0%. There was a clear positive bias at high protein concentrations. Protein. The results from the Ektachem deviated from the reference method values by -6.8%. Total glycerol (triacylglycerols). In the analysis of control sera, the Ektachem values differed greatly (+32.1%) from the reference method values. This difference was not found in a comparative study with native sera. At high protein concentrations the Ektachem results were higher than those of the comparative method. Urea. The results were lower than the method-dependent assigned values (-16.6%). This deviation was not observed in a comparative study with native sera. Interference by protein was not observed. Uric acid. In accuracy control with reference method values, a small bias was observed (+3.3%), which increased at high protein concentrations.

Measurement of thyroxine in human serum by isotope dilution mass spectrometry. Definitive methods in clinical chemistry, V.

The determination of thyroid hormones is widely used for the diagnosis and therapy control of thyroid disorders. In particular, thyroxine in serum is one of the most frequently determined endocrine parameters. Unfortunately, the results obtained by the use of different commercial test kits vary significantly, and until now there has been no means to decide whether a particular enzyme or radioimmunoassay kit yields accurate results or not. It seemed, therefore, necessary to develop definitive or reference methods for the measurement of thyroxine and to apply this technique for the assessment of target values in control sera for internal and external quality control. In the present investigation, an analytical protocol using the isotope dilution mass spectrometry technique is described which is herewith proposed as a definitive method for the measurement of thyroxine in human serum. The procedure consists of the following steps. (i) Equilibration of endogenous thyroxine in a serum sample with 100 ng [13C2]thyroxine. (ii) Isolation of the thyroid hormones by using a cation exchange resin. (iii) Formation of the methyl ester by reaction with methanolic hydrochloric acid. (iv) Purification of the methyl ester by column chromatography on Sephadex LH-20. (v) Formation of the N,O-bistrifluoroacetyl derivative with trifluoracetic anhydride. (vi) Selected ion monitoring of fragment ions of the thyroxine and the [13C2]thyroxine derivatives at m/z 870 and 872 using a magnetic sector field mass spectrometer with electron impact ionization combined with a capillary gas chromatography column. This method is now used to assign target values in a German quality control scheme. The precision of the method is of the order of 1-2% (coefficient of variation).