Françoise Schiele

Need for revisiting the concept of reference values.

Abstract The reference values concept has been adopted by health care professionals, including clinical chemists, laboratory scientists, and clinicians and simultaneously by all the official organizations in charge of the establishment of legislation. But the estimation of reference limits, and the evaluation of biological variability need to be improved at the level of the procedures, which are currently too long and too expensive and not feasible easily for all laboratories. The procedures for obtaining reference values, if we follow the original documents, are complex, and that is the main reason that clinical chemists or diagnostic kit manufacturers have not used them systematically. There is clearly a need that scientific societies and international organizations propose practical recommendations: 1) Recommendations to describe methods linked to systematic error. · How to transfer reference limits from one laboratory to another laboratory using different methods? · Should we determine reference limits for each method? · How can we differentiate bias due to the populations from these due to the method? Clear collaborations with manufacturers involved in kits and diagnostic systems are needed. 2) Practical recommendations linked to the reference population. · How to transfer reference limits from one laboratory to another laboratory using different methods? · Should we determine reference limits for each method? · How can we differentiate bias due to the populations from these due to the method? Clear collaborations with manufacturers involved in kits and diagnostic systems are needed. · How to select a homogenous population? (Careful recommendations on the choice between healthy individuals, blood donors and individuals hospitalised for other diseases should be given.) · How to estimate ethnic differences? · How to define the exclusion and inclusion criteria according to quantity? · How to deal with the question of reference limits for unstable periods, aging or old people particularly, when the difference between aging and disease is very difficult to define? 3) Practical recommendations on the statistical methods to be used. · How to transfer reference limits from one laboratory to another laboratory using different methods? · Should we determine reference limits for each method? · How can we differentiate bias due to the populations from these due to the method? Clear collaborations with manufacturers involved in kits and diagnostic systems are needed. · How to select a homogenous population? (Careful recommendations on the choice between healthy individuals, blood donors and individuals hospitalised for other diseases should be given.) · How to estimate ethnic differences? · How to define the exclusion and inclusion criteria according to quantity? · How to deal with the question of reference limits for unstable periods, aging or old people particularly, when the difference between aging and disease is very difficult to define? · How to make a good choice of the interquantile interval? Should we use and present only the centiles 2.5 or 97.5, or on the contrary should we give other centiles in addition, for example 5, 10, 75, 80, 85, 90? 4) Practical recommendations linked to the use of the concept of the reference values. · How to transfer reference limits from one laboratory to another laboratory using different methods? · Should we determine reference limits for each method? · How can we differentiate bias due to the populations from these due to the method? Clear collaborations with manufacturers involved in kits and diagnostic systems are needed. · How to select a homogenous population? (Careful recommendations on the choice between healthy individuals, blood donors and individuals hospitalised for other diseases should be given.) · How to estimate ethnic differences? · How to define the exclusion and inclusion criteria according to quantity? · How to deal with the question of reference limits for unstable periods, aging or old people particularly, when the difference between aging and disease is very difficult to define? · How to make a good choice of the interquantile interval? Should we use and present only the centiles 2.5 or 97.5, or on the contrary should we give other centiles in addition, for example 5, 10, 75, 80, 85, 90? · How to make this concept more concrete and to have official definitions which are better understandable and not only abstract? · How to demonstrate the value of using simultaneously reference limits and decision limits, and what does each of these limits bring to results interpretation? · How to improve the presentation of the results? How to give more information on biological variability in the laboratory data, taking into account the scientific validity of their determination? Should we use new information techniques and new communication systems for reaching these objectives? The responses to all these questions could only be provided if there is a concerted effort at the international level. Practical recommendations should be given, which would be very useful for a better understanding and use of reference values by laboratory scientists and clinicians.

Apolipoprotein E polymorphisms and concentration in chronic diseases and drug responses.

Abstract Apolipoprotein (apo) E is an important circulating and tissue protein involved in cholesterol homeostasis and many other functions. The common polymorphism in the coding region of the gene, four polymorphisms in the promoter region, other additional single nucleotide polymorphisms, as well as several apo E variants have been identified. The common coding polymorphism strongly influences the lipid metabolism and the circulating concentration of apo E itself. This polymorphism is at the origin of the implication of apo E in cardiovascular and neurodegenerative diseases, but also of the relation of apo E with longevity. Probably due to its many metabolic and functional consequences, apo E polymorphism has been shown to influence the responses of patients to several drugs (fibrates, statins, hormone replacement therapy, anti-Alzheimer drugs) or environmental interventions (black tea, alcohol, diet). Apo E genotyping may be clinically helpful in defining the risk of patients and their responses to therapeutics. Finally, circulating apo E concentration appears to be altered in diseases and can be modulated by some of the drugs cited above. This parameter can thus also give interesting clinical information and could be a therapeutic target, providing it is validated. At the present time, we cannot exclude that apo E concentration may be the most prominent apo E parameter to be considered in health and disease, while apo E polymorphisms would represent only secondary parameters influencing apo E concentration.

Determinants of hormonal replacement therapy in recently postmenopausal women

Although the efficacy of hormonal replacement therapy (HRT) on the consequences of the menopause is not questioned, it appears that in Europe and in the USA only a small proportion of women are users of HRT. In this study, we examined the prevalence and the determinants of HRT among 1986 French menopausal women, aged 45 to 55 years, presenting to a preventive medicine centre. Overall, 8.1% of women reported current use of HRT. The estrogen preparation most commonly reported was transcutaneous 17 beta-oestradiol. The first determinant of current HRT was birth-place. Women born in France were nearly four times more likely to be on treatment than foreign-born women. A surgical menopause multiplied the probability of current HRT by 2, as did a high level of education. An age at first pregnancy of more than 20 and less than 4 children were also positively linked with HRT use. Even in this population of recently menopausal women, volunteering to undergo health evaluation, the prevalence of HRT was low. The reservations towards HRT may be partly due to the women themselves, and partly due to the physicians. It seems very important to inform the medical profession about the risks and benefits of HRT, and to understand more precisely the reasons why so few women use HRT.

Effects of pro-inflammatory cytokines on apolipoprotein E secretion by a human astrocytoma cell line (CCF-STTG1)

Apolipoprotein (apo) E has been implicated in Alzheimers disease; however, little is known about the regulation of its secretion in astrocytes. To investigate the effects of pro‐inflammatory cytokines such as interleukin‐1β (IL‐1β), tumour necrosis factor‐α (TNF‐α) and interferon‐γ (IFN‐γ) on apoE secretion by CCF‐STTG1 cells, a sensitive and specific double sandwich Enzyme‐Linked ImmunoSorbent Assay (ELISA) was developed. Using a monoclonal anti‐human apoE antibody as the capture antibody, this assay was carried out with commercially available reagents. The assay had a sensitivity of 0·013 ng per well, within‐run and between‐run variation coefficients of 6·0 and 8·6 per cent respectively. There was no cross‐reactions between antibodies used and apoAI, apoAII, apoB, apoCI, apoCII and apoCIII. Low apoE concentrations were assessed using a serum‐free HepG2 culture medium as secondary calibrator, containing 59 μg l−1 of apoE. In serum‐free medium, CCF‐STTG1 cells secreted apoE, the accumulation of which in the cell medium increased linearly with time (27 μg per 48 h). After 48 h of incubation, apoE secretion was inhibited by TNF‐α but not affected by IL‐1β and IFN‐γ. However, the effect of regulatory factors may depend upon culture conditions since in the presence of 10 per cent fetal calf serum, IFN‐γ significantly inhibited apoE secretion. Thus, apoE secretion by CCF‐STTG1 cells is inhibited by specific pro‐inflammatory cytokines. This new apoE ELISA presents the great advantage of using commercially available reagents which permit inter‐laboratory comparability of results, involves relatively low cost and is adaptable for the measurement of low levels of apoE. Copyright

Biological effects of eleven combined oral contraceptives on serum triglycerides, gamma-glutamyltransferase, alkaline phosphatase, bilirubin and other biochemical variables.

Abstract The objectives of this paper are to update and quantify the biological effects of the most commonly used oral contraceptives (OC) on 15 biochemical tests currently determined in clinical laboratories and to compare these effects between the different types of OC. The sample population was constituted by 1604 women using combined OCs and the control group comprised 3466 women in the same age range not taking medication. Women taking OC were divided into 11 groups according to the estrogen/progestogen combination. The effects of OCs were studied after adjustment for age, weight, height, body mass index and alcohol and tobacco consumption. The changes observed with the new progestogens were less important than in the past. In comparison with the controls, the mean serum triglyceride concentration was significantly increased by ＋8.5 % to ＋36.0 % (p<0.05 to p<0.001) in each group while those of total cholesterol and γ-glutamyltransferase were increased only in 3 and 4 estrogen/progestogen combinations respectively. Conversely, the mean concentrations of alkaline phosphatase, total bilirubin, phosphate and albumin were significantly decreased. Using a discriminant analysis, three main groups according to the type of progestogen were defined: cyproterone acetate, DL-norgestrel and levonorgestrel, and all other progestogens. The changes in serum triglyceride concentration induced by OC intake must be considered by the clinician and are useful for taking a clinical and risk decision in an individual woman.

Measurement of plasma gamma-glutamyltransferase in clinical chemistry: kinetic basis and standardisation propositions☆

The conditions for the measurement of gamma-glutamyltransferase (EC 2.3.2.2) activity of human plasma were studied at 30 degrees C using the kinetic technique of Szasz [3]. The optimum pH in Tris (hydroxymethylaminomethane) buffer and 2-amino-2-methyl-1.3-propanediol at a concentration of 100 mmol/1 are 8.0 and 8.1. The kinetic characteristics of human plasma gamma-glutamyltransferase were studied using gamma-L-glutamyl p-nitroanilide and its carboxyl derivative as donor substrates. Glycylglycine was chosen as the best acceptor of the gamma-glutamyl radical. Under these conditions, we have shown that the inhibition by the donor substrate was more important at acidic pH and vanished at alkaline pH. This inhibition was obviously related to the presence of the acceptor, but did not vary with glycylglycine concentration. At pH 8.0, by increasing the acceptor concentration some competition occurs at the donor binding site, as reported by other authors in relation to the known ping-pong bi-bi enzyme mechanism for the gamma-glutamyltransferase. Some displacement of donor substrate by increasing amounts of acceptor substrate could be observed at all pH values we studied. However, the influence of glycylglycine on the enzymes maximum velocity and affinity for the donor substrate was also pH dependent. Studying the kinetic characteristics of the enzyme as a function of the pH suggests that the enzyme works with more than one active site at pH 7.5-8.0. Based on the results of this study, we propose measurement conditions for gamma-glutamyltransferase at 30 degrees C in routine clinical chemistry without preference in the choice of substrate.

Interassay calibration as a major contribution to the comparability of results in clinical enzymology

OBJECTIVE Factors contributing to the applicability of interassay calibration of methods measuring enzyme catalytic activities are described. Also discussed are the properties essential for such a material. Similarity of specificity for the methods to be calibrated as well as commutability between the material(s) intended to be used as calibrator are the main criteria to be satisfied. RESULT Several examples demonstrated that interassay calibration is feasible but a multi-enzyme calibrator with a wide commutability for the most popular methods remains to be developed. This is the project of the IFCC Working Group on Calibrators in Clinical Enzymology (WG-CCE). Several experimental data are also presented that indicate that the temperature at which the reaction is carried out is not a limiting factor in the implementation of interassay calibration in clinical enzymology.

Usefulness of Reference Materials in Calibration of Enzyme Activities

alpha-Amylase, alkaline phosphatase and gamma-glutamyltransferase were studied in a multicentre evaluation. Analyses were performed on different patient samples. Each enzyme was assayed in two different laboratories at both 30 and 37 degrees C, with widely used reagent kits and with the IFCC reference method (if in existence). Results differed considerably according to the measurement procedure. Data also showed that it was not possible to employ a constant conversion factor for one enzyme and different techniques between 30 and 37 degrees C. Calibration with three reference materials extensively improved the intermethod consistency for most of the tested measurement procedures. It was possible to transfer accuracy from the method used for the certification of the reference material to routine procedures, by using the reference material as calibrator. Temperature did not seem to be a crucial variable for the implement of the enzyme calibrator approach.

Production and certification of an enzyme reference material for adenosine deaminase 1 (BCR 647)

BACKGROUND We describe the preparation of a lyophilised reference material containing purified human adenosine deaminase 1 and the certification of its catalytic concentration. METHODS The enzyme was purified from human erythrocytes. RESULTS The enzyme was >99% pure on polyacrylamide gel electrophoresis. Only trace amounts (<0.4%) of alanine aminotransferase, aspartate aminotransferase and L-lactate dehydrogenase were detected in the purified fraction. The purified adenosine deaminase had a molar mass of 41600 g/mol and an isoelectric pH at 4.7, 4.85 and 5.0. The material was prepared by diluting the purified adenosine deaminase in a matrix containing 50 mmol/l Tris-HCl buffer pH 7.4 and 30 g/l human serum albumin; dispensing in vials and freeze-drying. The batch was homogeneous and the predicted loss of adenosine deaminase activity per year on the basis of accelerated degradation studies was 0.006% at -20 degrees C and 0.04% at 4 degrees C. The certified value for adenosine deaminase catalytic concentration in the reconstituted reference material is (2.55+/-0.09) microkat/l when measured by the method that uses adenosine as substrate and glutamate dehydrogenase as auxiliary enzyme at 37 degrees C. CONCLUSIONS The material can be used to verify the comparability of results from different laboratories, for intra-laboratory quality control, or for calibration of the adenosine deaminase catalytic concentration measurements.

Certification of an enzyme reference material for alkaline phosphatase (CRM 371).

We have produced a batch of lyophilized alkaline phosphatase (AP) for use as an enzyme reference material. The enzyme was partly purified from pig kidney to a specific activity of 400 U/mg of protein and is essentially free from contaminating enzyme activities. The kinetic properties of the preparation are very close to those of the enzyme present in human serum. The partly purified AP was lyophilized in a matrix containing bovine serum albumin (40 g/L), MgCl2, ZnCl2 and NaCl. The vial-to-vial variability with respect to the catalytic concentration of the final product was 0.008. The predicted annual relative loss of activity was less than 0.01% at -20 degrees C and 0.04% at 4 degrees C. This material was certified using the IFCC proposed method. The certification procedure involved 19 laboratories throughout the world. The certified alkaline phosphatase catalytic concentration in the reconstituted material was 254 U/L with a 0.95 confidence interval of +/- 6 U/L.