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We evaluated N-methyl-D-glucamine (MEG) as a buffer for assay of alkaline phosphatase (ALP; EC 3.1.3.1) and compared the MEG-based assay with the current International Federation of Clinical Chemistry Reference Method for ALP (IFCC/RM/ALP), in which 2-amino-2-methyl-1-propanol (AMP) is the pH buffer. The ALP assay in MEG at 30 and 37 degrees C shows excellent correlation with the IFCC/RM/ALP at 30 degrees C, but yields proportionately higher ALP activities (8.2% at 30 degrees C and 57% at 37 degrees C). ALP is unstable in both MEG and AMP at 37 degrees C. Serum incubated in MEG undergoes a pH-dependent biphasic loss of ALP activity: an initial rapid 5% loss after 1 min of incubation and a 10% loss per hour thereafter. A similar pattern was seen for incubation with AMP. The use of a serum-initiated reaction (no preincubation of enzyme with buffer) eliminated the early loss in activity. The addition of the metal ion buffer N-hydroxyethylethylenediaminetriacetic acid, along with low concentrations of Zn and Mg, as used in the IFCC/RM/ALP, reduced the slow loss in activity over time, as did decreasing the reaction temperature to 30 degrees C, but had no effect on the early rapid decay in activity seen in the first minute. Moderate transphosphorylation (45%) and nonenzymatic hydrolysis (3.3 U/L) were observed with MEG under the conditions of the assay (37 degrees C). A comparison of different lots of MEG from two manufacturers showed no significant difference in ALP activities.

The manual Reference Method of the Centers for Disease Control for serum iron (CDC/RM/Fe) and a semiautomated adaptation of it were used to evaluate two working methods: one, a detergent solubilization procedure for the Roche Cobas-Bio analyzer, the other, the Kodak Ektachem 700 procedure, based on dry-film technology. The CDC/RM/Fe and its semiautomated version gave essentially the same results for 40 sera from hospital patients. This semiautomated version was in turn compared with the two working procedures in a study involving 200 patients. Each of the working methods correlated well with the semiautomated CDC/RM/Fe method. Separate recovery and interference studies indicated satisfactory analytical recovery of iron in all cases, but the detergent solubilization method was found to be susceptible to interference by hemoglobin, lipemia, and bilirubin.

Three laboratories in the U.S. and two in the Netherlands determined molar absorptivities (epsilon) of Standard Reference Material (SRM) 916a Bilirubin from the National Institute of Standards and Technology. In caffeine reagent the average epsilon values were 50,060 and 48, 980 L.mol-1.cm-1 at 432 and 457 nm, respectively. The epsilon value of the blue azopigment, obtained with the Reference Method for total serum bilirubin, was 76,490 L.mol-1.cm-1 at 598 nm. When the addition of alkaline tartrate was omitted, the molar absorptivity of the red azopigment was 56,600 L.mol-1.cm-1 at 530 nm.

Ion-selective electrode analyzers for measuring lithium (Li/ISE) in serum became available in early 1987. We compared results for patients' samples from three of them vs results from flame atomic emission spectrometry (FAES). Within-run and day-to-day imprecision ranged from 0.01 to 0.03 mmol/L and 0.01 to 0.04 mmol/L, respectively. Comparing Li/ISE results (y) with the FAES results (x) gave the following equations: y = 1.063x - 0.035 for AMDEV's Lytening 2, y = 1.020x + 0.038 for NOVA's Model 11, and y = 1.030x - 0.027 for AVL's Model 985. Unexplained positive errors greater than 0.2 mmol/L were observed for two of the 90 patients' samples, but only a few additional excessively high values were seen in 3000 patients' samples run subsequently (Lytening 2). Causes of error in clinical Li/ISE measurements are still unclear; simply characterizing them as "matrix effects" does not correct the underlying analytical problem. An increase in pH from loss of CO2 gave low results on two of the three Li/ISE analyzers but did not change FAES results. Trimethylammonium bicarbonate used in a reconstitution solution caused extremely high Li/ISE results but did not change FAES results. Performance specifications to help reduce and correct these errors are recommended.

A review of methodology for determining aspartate aminotransferase (ASAT; EC 2.6.1.1), including recent national and international recommendations, indicates that standardization of methodology alone will not bring interlaboratory compatibility of ASAT results. We propose that an additional component to standardization is needed, namely, enzyme reference materials. Furthermore, we suggest that stable, well-defined ASAT materials from human sources are currently available. These primary reference materials and the state-of-the-art IFCC Reference Method for ASAT provide the basis for a unifying reference system for ASAT. Given such a reference system, we propose a practical way to promote compatibility of currently incompatible numerical results for ASAT through the use of one ASAT scale of units, the "International Clinical Enzyme Scale." This scale-unification concept would permit all current methods, instruments, and temperature choices to be used for ASAT determinations in the daily working laboratory. We present illustrative examples and demonstrate the unique ability of this concept to promote compatibility of the ASAT results from numerous laboratories using many different ASAT methods.

During an evaluation of the IFCC reference method for alanine aminotransferase (ALT, EC 2.6.1.2), we noted that the specimen blank activity reaction was markedly increased. Experience with five different lots of D-alanine from four commercial sources indicated that substantial and varying negative bias (up to -10%) could be introduced into the blank-corrected ALT activity, depending on the lot of D-alanine used. Although the IFCC procedure for ALT mentions the possibility of this L-alanine contamination, we believe that the degree of contamination in commercial reagents is underestimated. Analyzing the five lots of D-alanine for L-alanine, we found the magnitude of negative bias to be correlated directly with L-alanine contamination. Here, we describe a quick, sensitive assay based on coupled reactions of L-amino acid oxidase/peroxidase for quantifying L-alanine in the concentration range of 0-15 mmol/L without a sample-dilution step. Results by this alternative L-alanine assay agreed well with those recommended in the IFCC ALT procedure. Further examination suggested an even simpler solution to the L-alanine contamination problem, because we found no difference in the blank-corrected ALT activity determined in Tris HCl buffer, with or without D-alanine (free of L-alanine). We therefore propose that D-alanine be omitted from the IFCC reference ALT procedure.

We studied 53 lots of 4-nitrophenyl phosphate (I), obtained from 20 different commercial suppliers, and used this information to set specifications for it. Using these well-defined specifications, we classified 21 lots of I as "unacceptable," 26 lots as "borderline," and six as "acceptable." All lots were shown to contain some 4-nitrophenol and inorganic phosphate. However, "acceptable" I had < 0.3 mmol of 4-nitrophenol and < 10 mmol of inorganic phosphate per mole of I. The mole concentration of I (based on disodium hexahydrate, formula weight 371) was determined by enzymic conversion to 4-nitrophenol in five lots of "acceptable" materials. The mole fraction of I ranged from 0.982 to 0.998. From these measurements and from estimates of impurities that absorb at 311 nm, as determined by liquid chromatography and spectrophotometry at other wavelengths, our best estimate of the molar absorptivity of I at 311 nm in 10 mmol/L NaOH at 25 degrees C was 9867 L x mol-1 x cm-1, with a total uncertainty of 76 L x mol-1 x cm-1. We recommend that I used in clinical laboratories for measurement of alkaline phosphatase activity in serum meet the specifications given in this paper: I content > 98%, maximum activity > 98% in comparative testing with other "acceptable" lots of I, and impurities not to exceed the values cited above.

We examined 17 lots of 2-oxoglutarate (seven acid forms, three K salt forms, and seven Na salt forms), obtained from eight commercial suppliers, for suitability for measuring aspartate aminotransferase (EC 2.6.1.1) and alanine aminotransferase (EC 2.6.1.2) in human serum. Measurements of the catalytic activity concentrations of these two aminotransferases with each of these 17 preparations were not sufficiently sensitive to distinguish good from poor-quality material. Thus, we ranked these lots for purity, by specific analysis with glutamate dehydrogenase and by liquid chromatography, and determined the water content, acid content, and spectral characteristics of each. On the basis of a 2-oxoglutarate assay value by glutamate dehydrogenase of 98% or greater, we considered seven of the preparations acceptable and 10 unacceptable. The molar absorptivities (L X mol-1 X cm-1, mean +/- SD) of the seven acceptable lots in 1 mol/L HCl were: epsilon 325 nm = 9.12 +/- 0.02 (CV = 0.2%), epsilon 279 nm = 2.63 +/- 0.23 (CV = 9.9%), and epsilon 245 nm = 37.9 +/- 4.1 (CV = 10.9%). Use of these spectrophotometric limits alone unambiguously distinguished the inferior lots of 2-oxoglutarate. We urge the inclusion of detailed spectrophotometric specifications for 2-oxoglutarate in Reference Methods for aminotransferase measurements.

We report a common methodology for determining three antiarrhythmic drugs: disopyramide, lidocaine, and quinidine. Alkalinized serum and internal standard (p-chlorodisopyramide) are extracted into dichloromethane, the organic phase is evaporated, and the redissolved residue is injected onto a reversed-phase column (micron Bondapack C18). Quantitation is via peak-height ratios of analyte vs internal standard (as detected at 205 nm) referenced to a serum-based multiple-drug standard. A mobile phase of 30 mmol/L phosphate buffer and acetonitrile (72/28 by vol) is used. These conditions yiel; optimum separation and band symmetry for the analytes and some of their metabolites. Crucial factors in this simultaneous assay include pH of the mobile phase and injected solution, extraction time, and evaporation technique. Day-to-day precision (CV) for all drugs was less than 5%, and correlation with other assay techniques for each drug is reported. The method enables more efficient use of personnel and instrumentation without sacrificing analytical quality.

This candidate Reference Method for measuring total bilirubin in serum is based on the Jendrassik-Gróf principle (Clin Chem 29: 297-301, 1983). Standard Reference Material no. 916 bilirubin (National Bureau of Standards) is used as the standard. Bilirubin standard solutions may be prepared either in human serum or in 40 g/L albumin solution (human or bovine), because we found the molar absorptivity of the azopigment at 598 nm to be identical in these media. The absorptivities of the unconjugated and conjugated azopigments appear to be identical, but the conjugated azopigment is completely hydrolyzed in the final reaction mixture. Bilirubin added to serum from adults or neonates was quantitatively accounted for. Interference by hemoglobin (up to 2 g/L), ascorbic acid (up to 20 mg/L), or zinc (at physiological concentrations) is negligible. Of the therapeutic drugs we tested, only L-dopa and alpha-methyldopa interfere. We established normal adult reference values for total bilirubin and examined the intraindividual variation in 19 subjects.

A 15-year-old girl with a four-month history of cardiac failure from undetermined cause was admitted to the hospital with weakness, fatigue, and weight loss. During her hospitalization she was found to have abused diet aids, laxatives, and cathartics. Although an electrocardiogram revealed nonspecific T-wave abnormalities and laboratory studies showed supranormal enzyme test results for creatine kinase and lactate dehydrogenase, no definite explanation of the cardiomyopathy was forthcoming. Ipecac abuse leading to cardiomyopathy was suspected early in the hospitalization. HPLC analysis of a urine sample showed emetine, a principle component of ipecac, the presence of which was later confirmed by more-specific HPLC analysis with photodiode array detection.

We describe two cases, hospitalized patients, in whom the activity of creatine kinase (EC 2.7.3.2) isoenzyme-MB was above normal. Both are particularly noteworthy in that creatine kinase-BB and a macro creatine kinase form thought to be type II of mitochondrial origin were also present. The macro creatine kinase component in both cases co-migrated electrophoretically with creatine kinase-MM but was easily identified after the latter was removed by precipitation with M-subunit-specific antibodies. In the first case, the patient had a readily diagnosable acute myocardial infarction while under observation in the cardiac intensive care unit: electrocardiographic changes and the rapid increase and decrease in total creatine kinase were as would be expected. In marked contrast, in the second case, we saw no abrupt changes in either of these characteristics. The latter patient's primary disease was a rectal carcinoma with massive metastases to the liver; however, the presence of abnormally high creatine kinase-MB activity raised the question of possible myocardial infarction.

In this method for measuring metanephrine and normetanephrine in urine, they are freed from their conjugates by hydrolysis in acid, neutralized, and isolated on a cation-exchange resin. Both metanephrines are co-eluted with ammoniacal methanol and the eluate is concentrated 10-fold with respect to the original urine volume by evaporation and reconstitution. The recovered metanephrines ae separated by reversed-phase (C18) "high-pressure" liquid chromatography with use of a mobile phase consisting of 10 mmol/L trichloroacetate, pH 2.7, containing 30 mL of acetonitrile per liter. The metanephrines are detected at 365 nm after being converted to vanillin in a post-column reaction with alkaline periodate. Total metanephrine values for most patients were appreciably lower than values obtained by the comparison procedure, that of Pisano (Clin. Chim. Acta 5: 406, 1970); however, results obtained by the two methods for two patients with pheochromocytomas agreed well.

We describe a method for measurement of 3-methoxy-4-hydroxymandelic acid (vanillylmandelic acid, VMA) in urine. After the pH of the urine is adjusted to 2.7 and the sample is filtered, exactly 15 microL is injected onto a C-18 reversed-phase column. VMA is eluted from the column with 10 mmol/L phosphate buffer, pH 2.7, containing 30 mL of acetonitrile per liter. The eluate stream is combined with alkaline periodate and then passed through a 60 degrees C water bath. The VMA is completely oxidized to vanillin, which is detected and quantitiated by its absorbance at 360 nm. No deterioration of the column was noted after 167 such injections of urine samples. Long-term control data indicate a CV of 12 and 10% at VMA concentrations of 1.5 and 5.8 mg/L, respectively. Although results correlate well (r = 0.976) with those by the method of Pisano et al. [Clin. Chim. Acta 7, 285 (1962)], they average 10% lower. Of 20 compounds tested, only methyl dopa interfered with the procedure as described.

We describe some characteristics of the mode of formation of inhibitors of lactate dehydrogenase from commercial NADH. Inhibitor formation is time- and concentration-dependent and also varies with the commercial source of NADH. At least two inhibitory components can form in concentrated NADH solutions. One of these can be separated from NADH by chromatography on either diethylaminoethyl-celluose or diethylaminoethyl-Sephadex; the second cannot. The NADH-associated inhibitor appeared to be present in each of the three commercial NADH preparations studied. The 260 nm/340 nm absorbance ratio was of no help in locating this inhibitor during chromatography.

The molar absorptivity of NADH at 340 nm has been determined by an indirect procedure in which high-purity glucose is phosphorylated by ATP in the presence of hexokinase, coupled to oxidation of the glucose-6-phosphate by NAD+ in the presence of glucose-6-phosphate dehydrogenase. The average value from 85 independent determinations is 6317 liter mol-1 cm-1 at 25 degrees C and pH 7.8. The overall uncertainty is -4.0 to +5.5 ppt (6292 to 6352 liter mol-1 cm-1), based on a standard error of the mean of 0.48 ppt and an estimate of systematic error of -2.6 to +4.1 ppt. Effects of pH, buffer, and temperature on the molar absorptivity are also reported.

The single-slide method used for creatinine in the Kodak "Ektachem" analyzer is far more precise than the two-slide method. We confirm that sera from patients on intravenous therapy with lidocaine exhibit a positive bias in results for creatinine but that lidocaine itself does not interfere. Instead, N-ethylglycine, a metabolite of lidocaine with a structure similar to that of sarcosine, is probably the cause. A method that allows N-ethyglycine to be measured directly is described. We followed the degree of this interference through five generations of the slide. Our investigations include two detailed comparison studies between the Kodak Ektachem 700 and the Beckman Astra analyzers. Creatinine determinations on lidocaine-treated patients when first-generation slides were used averaged 4.6 mg/L higher than determinations on these same specimens performed in the Astra. Serum creatinine results from patients not on lidocaine showed no significant difference between the two instruments. The average difference in generation 2, 3, and 4 slides was 0.24, 0.22, and 2.5 mg/L, respectively. No more than 2% of our creatinine results had a clinically significant lidocaine-related bias. We show how to identify and correct this small proportion of results that are biased because of lidocaine therapy.

We measured total and dialyzable calcium concentrations in consecutive sera submitted for routine lithium analysis. Of 98 samples from 61 different individuals, six (6.1%) total calcium results and 32 (33%) dialyzable calcium results were above the respective reference intervals. By comparison, when both total and dialyzable calcium were measured on 50 different apparently healthy volunteers, no results were outside either reference interval (2.20--2.58 mmol/L for total and 1.30--1.47 mmol/L for dialyzable calcium). These increases were not due to age or sex differences between the patients and controls. From the dialyzable calcium data, there appears to be an even higher incidence of mild hypercalcemia in patients receiving oral lithium salts than is indicated by the total calcium concentration alone.

We describe specifications for high-purity 4-nitrophenol, which is suitable for spectrophotometric standardization. Such a reference material is needed in clinical enzymology to establish the proper molar absorptivity of 4-nitrophenol under final reaction conditions, particularly for measuring alkaline phosphatase activity in human serum. Some lots of 4-nitrophenol available commercially met these specifications, but several did not. The latter can be purified to meet our specifications by recrystallization or sublimation. The molar absorptivity of 4-nitrophenol (35 mumol/L) IN 10 mmol/L NaOH at 25 degrees C at 401 nm is 18380 +/- 90 L.mol-1.cm-1.

A case of severe methanol intoxication (1300 mg/L) was associated with markedly increased serum creatinine (490 mg/L) despite normal urea values and the absence of any other signs of renal disease. These values declined progressively to normal, and the patient recovered with no visual impairment. Additional laboratory experimentation suggested that the high creatinine value was probably ascribable to some unknown foreign material(s) in the patient's blood that reacted with the alkaline picrate used in the measurement of creatinine. One of the presumed metabolites of methanol, formaldehyde, reacts with creatinine but the product does not react with picrate. We believe that the foreign material was derived from either commercial preparations of methanol or contaminants in the patient's drinking water.

The purity, spectral characteristics, and rate of nonenzymatic hydrolysis of 2,6-dichloro-4-nitrophenyl phosphate (DCNPP) were determined. Rates of DCNPP hydrolysis by prostatic acid phosphatase (PAP) and erythrocytic acid phosphatase (EAP) (both EC 3.1.3.2) were measured in the absence and in the presence of various alcohols. 1.5-Pentanediol was the most effective transphosphorylation agent for specifically enhancing the activity of PAP. 1,4-Butanediol also enhanced PAP activity but markedly inhibited EAP activity. Bovine and human serum albumin preparations also accelerated the hydrolysis of DCNPP. DCNPP can be used for the continuous or multipoint-rate assay of PAP.

The wide numeric variation of alkaline phosphatase (ALP: EC 3.1.3.1) values reported from clinical laboratories is clearly revealed by the grossly incompatible data found in large interlaboratory surveys. The authors suggest that this unsatisfactory situation is readily correctable by simply expressing all numeric results on a single scale, the International Clinical Enzyme Scale (ICES). ICES for ALP (ALP/ICES) rests upon a well-defined reference system that relates the IFCC Reference Method for ALP to numerous stable primary and secondary ALP reference materials. The authors show by calibrations with ALP/ICES reference materials that raw coefficients of variation of 25-30% due to reagent, temperature, or instrument differences could be reduced to as low as 2%. ICES and the reference system approach automatically unifies the numeric outputs of the working clinical laboratories by relating all measurements and reference materials to one clearly defined international reference method, yet this concept allows many technologic options in the individual laboratory.