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D'Aurizio F, Kratzsch J, Gruson D, Petranović Ovčariček P, Giovanella L. Free thyroxine measurement in clinical practice: how to optimize indications, analytical procedures, and interpretation criteria while waiting for global standardization. Crit Rev Clin Lab Sci 2023; 60:101-140. [PMID: 36227760 DOI: 10.1080/10408363.2022.2121960] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Thyroid dysfunctions are among the most common endocrine disorders and accurate biochemical testing is needed to confirm or rule out a diagnosis. Notably, true hyperthyroidism and hypothyroidism in the setting of a normal thyroid-stimulating hormone level are highly unlikely, making the assessment of free thyroxine (FT4) inappropriate in most new cases. However, FT4 measurement is integral in both the diagnosis and management of relevant central dysfunctions (central hypothyroidism and central hyperthyroidism) as well as for monitoring therapy in hyperthyroid patients treated with anti-thyroid drugs or radioiodine. In such settings, accurate FT4 quantification is required. Global standardization will improve the comparability of the results across laboratories and allow the development of common clinical decision limits in evidence-based guidelines. The International Federation of Clinical Chemistry and Laboratory Medicine Committee for Standardization of Thyroid Function Tests has undertaken FT4 immunoassay method comparison and recalibration studies and developed a reference measurement procedure that is currently being validated. However, technical and implementation challenges, including the establishment of different clinical decision limits for distinct patient groups, still remain. Accordingly, different assays and reference values cannot be interchanged. Two-way communication between the laboratory and clinical specialists is pivotal to properly select a reliable FT4 assay, establish reference intervals, investigate discordant results, and monitor the analytical and clinical performance of the method over time.
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Affiliation(s)
- Federica D'Aurizio
- Department of Laboratory Medicine, University Hospital of Udine, Udine, Italy
| | - Jürgen Kratzsch
- Institute for Laboratory Medicine, Clinical Chemistry and Molecular Diagnostics, University Hospital, University of Leipzig, Leipzig, Germany
| | - Damien Gruson
- Department of Clinical Biochemistry, Cliniques Universitaires St-Luc and Université Catholique de Louvain, Brussels, Belgium
| | - Petra Petranović Ovčariček
- Department of Oncology and Nuclear Medicine, University Hospital Center Sestre milosrdnice, Zagreb, Croatia
| | - Luca Giovanella
- Clinic for Nuclear Medicine and Competence Center for Thyroid Diseases, Imaging Institute of Southern Switzerland, Ente Ospedaliero Cantonale, Bellinzona, Switzerland.,Clinic for Nuclear Medicine and Thyroid Center, University and University Hospital of Zurich, Zurich, Switzerland
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2
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Abstract
Thyroid hormones are primarily responsible for regulating the basal metabolic rate but also make important contributions to reproductive function and fetal development. Both hyper- and hypothyroidism in pregnancy have been associated with increased risks of complications that include preeclampsia and low birth weight, among others. Furthermore, thyroid hormone deficiency in the developing fetus results in neurodevelopmental delay. As the fetus is exclusively reliant on maternal thyroid hormone for most of the first trimester and requires continued maternal supply until birth, identifying maternal thyroid dysfunction is critically important. However, evaluating thyroid function in pregnancy is challenging because of the many physiological changes that affect concentrations of thyroid-related analytes. Increasing plasma human chorionic gonadotropin (hCG) concentrations in the second half of the first trimester elicit a corresponding transient decrease in thyroid-stimulating hormone (TSH), and continually increasing estradiol concentrations throughout pregnancy cause substantial increases in thyroxine-binding globulin (TBG) and total thyroxine (T4) relative to the nonpregnant state. Lastly, free T4 concentrations gradually decrease with increasing gestational age. For these reasons, it is essential to interpret thyroid function test results in the context of trimester-specific reference intervals to avoid misclassification of thyroid status. This review summarizes the effects of thyroid dysfunction prior to conception and during pregnancy and describes considerations for the laboratory assessment of thyroid function in pregnant women.
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Affiliation(s)
- K Aaron Geno
- Department of Pathology, Texas Tech University Health Sciences Center, El Paso, TX, USA
| | - Robert D Nerenz
- Department of Pathology and Laboratory Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA.,Geisel School of Medicine, Dartmouth College, Hanover, NH, USA
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3
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Abstract
BACKGROUND Indirect reference intervals require robust statistical approaches to separate the pathological and healthy values. This can be achieved with a data pipeline created in R, a freely available statistical programming language. METHODS A data pipeline was created to ingest, partition, normalize, remove outliers, and identify reference intervals for testosterone (Testo; n = 7,207) and aspartate aminotransferase (AST; n = 5,882) using data sets from NHANES. RESULTS The estimates for AST and Testo determined by this pipeline approximated current RIs. Care should be taken when using this pipeline as there are limitations that depend on the pathology of the analyte and the data set being used for RI estimation. CONCLUSIONS R can be used to create a robust statistical reference interval pipeline.
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Key Words
- ANOVA, Analysis of variance
- AST, aspartate aminotransferase
- CLSI, Clinical Laboratory Standards Institute
- EHR, electronic health record
- IFCC, International Federation of Clinical Chemistry and Laboratory Medicine
- LC-MS/MS, Liquid chromatography tandem mass spectrometry
- LIS, Laboratory informatics system
- Mixtools
- R markdown tutorial
- RI, reference interval
- Reference interval
- SDI, Standard deviation index
- SDR, Standard deviation ratio
- Testo, Testosterone
- TukeyHSD, Tukey multiple pairwise-comparisons
- z5, Critical z-score
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Affiliation(s)
- Dustin R. Bunch
- Nationwide Children’s Hospital, Department of Pathology and Laboratory Medicine, 700 Children’s Dr, Columbus, OH 43205, United States
- The Ohio State University, Department of Pathology, 410 West 10th Ave, Columbus, OH 43210, United States
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4
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Tanguy F, Hamdi S, Chikh K, Glinoer D, Caron P. Central hypothyroidism during pregnancy in a woman with Graves' disease. Clin Endocrinol (Oxf) 2022; 96:89-91. [PMID: 34658049 DOI: 10.1111/cen.14600] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Revised: 09/07/2021] [Accepted: 09/10/2021] [Indexed: 11/30/2022]
Affiliation(s)
- Faustine Tanguy
- Department of Endocrinology and Metabolic Diseases, Cardiovascular and Metabolic Unit, CHU Larrey, Toulouse, France
| | - Safouane Hamdi
- Laboratoire de Biochimie et d'Hormonologie, Institut Fédératif de Biologie, Hôital Purpan, CHU Toulouse, Toulouse, France
| | - Karim Chikh
- Laboratoire de Biochimie et Biologie Moléculaire-Centre Hospitalier Lyon Sud. ISPB, Faculté de Pharmacie de Lyon-UCBL1. Laboratoire CARMEN INSERM U1060, INRA U1397, Université Lyon 1, INSA Lyon, Lyon, France
| | - Daniel Glinoer
- Division of Endocrinology, Hospital Saint Pierre, University of Brussels, Brussels, Belgium
| | - Philippe Caron
- Department of Endocrinology and Metabolic Diseases, Cardiovascular and Metabolic Unit, CHU Larrey, Toulouse, France
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Fernández-Calle P, Díaz-Garzón J, Bartlett W, Sandberg S, Braga F, Beatriz B, Carobene A, Coskun A, Gonzalez-Lao E, Marques F, Perich C, Simon M, Aarsand AK. Biological variation estimates of thyroid related measurands - meta-analysis of BIVAC compliant studies. Clin Chem Lab Med 2021; 60:483-493. [PMID: 34773727 DOI: 10.1515/cclm-2021-0904] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Accepted: 10/18/2021] [Indexed: 11/15/2022]
Abstract
OBJECTIVES Testing for thyroid disease constitutes a high proportion of the workloads of clinical laboratories worldwide. The setting of analytical performance specifications (APS) for testing methods and aiding clinical interpretation of test results requires biological variation (BV) data. A critical review of published BV studies of thyroid disease related measurands has therefore been undertaken and meta-analysis applied to deliver robust BV estimates. METHODS A systematic literature search was conducted for BV studies of thyroid related analytes. BV data from studies compliant with the Biological Variation Data Critical Appraisal Checklist (BIVAC) were subjected to meta-analysis. Global estimates of within subject variation (CVI) enabled determination of APS (imprecision and bias), indices of individuality, and indicative estimates of reference change values. RESULTS The systematic review identified 17 relevant BV studies. Only one study (EuBIVAS) achieved a BIVAC grade of A. Methodological and statistical issues were the reason for B and C scores. The meta-analysis derived CVI generally delivered lower APS for imprecision than the mean CVA of the studies included in this systematic review. CONCLUSIONS Systematic review and meta-analysis of studies of BV of thyroid disease biomarkers have enabled delivery of well characterized estimates of BV for some, but not all measurands. The newly derived APS for imprecision for both free thyroxine and triiodothyronine may be considered challenging. The high degree of individuality identified for thyroid related measurands reinforces the importance of RCVs. Generation of BV data applicable to multiple scenarios may require definition using "big data" instead of the demanding experimental approach.
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Affiliation(s)
- Pilar Fernández-Calle
- Analytical Quality Commission, Spanish Society of Laboratory Medicine (SEQCML), Barcelona, Spain
- Department of Laboratory Medicine, Hospital Universitario La Paz, Madrid, Spain
| | - Jorge Díaz-Garzón
- Analytical Quality Commission, Spanish Society of Laboratory Medicine (SEQCML), Barcelona, Spain
- Department of Laboratory Medicine, Hospital Universitario La Paz, Madrid, Spain
| | - William Bartlett
- Undergraduate Teaching, School of Medicine, University of Dundee, Dundee, Scotland
| | - Sverre Sandberg
- Department of Medical Biochemistry and Pharmacology, Norwegian Organization for Quality Improvement of Laboratory Examinations (NOKLUS), Haukeland University Hospital, Bergen, Norway
| | - Federica Braga
- Research Centre for Metrological Traceability in Laboratory Medicine (CIRME), University of Milan, Milan, Italy
| | - Boned Beatriz
- Analytical Quality Commission, Spanish Society of Laboratory Medicine (SEQCML), Barcelona, Spain
- Department of Laboratory Medicine, Hospital Royo Villanova, Zaragoza, Spain
| | - Anna Carobene
- Servizio Medicina di Laboratorio, Ospedale San Raffaele, Milan, Italy
| | - Abdurrahman Coskun
- Department of Medical Biochemistry Atasehir, School of Medicine, Acibadem Mehmet Ali Aydınlar University, Istanbul, Turkey
| | - Elisabet Gonzalez-Lao
- Analytical Quality Commission, Spanish Society of Laboratory Medicine (SEQCML), Barcelona, Spain
| | - Fernando Marques
- Analytical Quality Commission, Spanish Society of Laboratory Medicine (SEQCML), Barcelona, Spain
- Clinical Biochemistry Department, Metropolitan North Clinical Laboratory (LUMN), Germans Trias i Pujol University Hospital, Barcelona, Spain
| | - Carmen Perich
- Analytical Quality Commission, Spanish Society of Laboratory Medicine (SEQCML), Barcelona, Spain
| | - Margarida Simon
- Analytical Quality Commission, Spanish Society of Laboratory Medicine (SEQCML), Barcelona, Spain
- Department of Clinical Biochemistry, Hospital Universitario Badalona, Badalona, Spain
| | - Aasne K Aarsand
- Department of Medical Biochemistry and Pharmacology, Haukeland University Hospital, Bergen, Norway
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Bohn MK, Adeli K. Physiological and metabolic adaptations in pregnancy: importance of trimester-specific reference intervals to investigate maternal health and complications. Crit Rev Clin Lab Sci 2021; 59:76-92. [PMID: 34587857 DOI: 10.1080/10408363.2021.1978923] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Diagnosis, prognostication, and monitoring of maternal health throughout pregnancy relies on laboratory testing, including but not limited to key markers of thyroid, hepatic, cardiac, hematology, and renal function. Dynamic physiological processes during gestation significantly influence the maternal biochemistry that supports both the mother and fetus. Resultant changes in blood biochemistry alter the expected values of common laboratory tests. However, the importance of pregnancy-specific reference intervals for laboratory test result interpretation and appropriate monitoring of maternal health and complications is underappreciated. Most clinical laboratories continue to use non-pregnant adult reference intervals for laboratory test interpretation in pregnancy. The current review summarizes and critically evaluates the available literature regarding physiological and metabolic adaptations in pregnancy and their influence on common biomarkers of health and disease. The main laboratory parameters discussed include thyroid, hepatic, metabolic, renal, hematology, inflammatory, and cardiac markers. Considering the available data, further studies are urgently needed to establish trimester-specific reference intervals in healthy pregnant women on updated analytical platforms. Without such data, the standard of clinical laboratory service in pregnancy remains compromised and affects the quality of maternal-fetal healthcare.
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Affiliation(s)
- Mary Kathryn Bohn
- CALIPER Program, Pediatric Laboratory Medicine, The Hospital for Sick Children, Toronto, ON, Canada.,Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON, Canada
| | - Khosrow Adeli
- CALIPER Program, Pediatric Laboratory Medicine, The Hospital for Sick Children, Toronto, ON, Canada.,Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON, Canada
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