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Ma C, Yu Z, Qiu L. Development of next-generation reference interval models to establish reference intervals based on medical data: current status, algorithms and future consideration. Crit Rev Clin Lab Sci 2024; 61:298-316. [PMID: 38146650 DOI: 10.1080/10408363.2023.2291379] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Accepted: 11/30/2023] [Indexed: 12/27/2023]
Abstract
Evidence derived from laboratory medicine plays a pivotal role in the diagnosis, treatment monitoring, and prognosis of various diseases. Reference intervals (RIs) are indispensable tools for assessing test results. The accuracy of clinical decision-making relies directly on the appropriateness of RIs. With the increase in real-world studies and advances in computational power, there has been increased interest in establishing RIs using big data. This approach has demonstrated cost-effectiveness and applicability across diverse scenarios, thereby enhancing the overall suitability of the RI to a certain extent. However, challenges persist when tests results are influenced by age and sex. Reliance on a single RI or a grouping of RIs based on age and sex can lead to erroneous interpretation of results with significant implications for clinical decision-making. To address this issue, the development of next generation of reference interval models has arisen at an historic moment. Such models establish a curve relationship to derive continuously changing reference intervals for test results across different age and sex categories. By automatically selecting appropriate RIs based on the age and sex of patients during result interpretation, this approach facilitates clinical decision-making and enhances disease diagnosis/treatment as well as health management practices. Development of next-generation reference interval models use direct or indirect sampling techniques to select reference individuals and then employed curve fitting methods such as splines, polynomial regression and others to establish continuous models. In light of these studies, several observations can be made: Firstly, to date, limited interest has been shown in developing next-generation reference interval models, with only a few models currently available. Secondly, there are a wide range of methods and algorithms for constructing such models, and their diversity may lead to confusion. Thirdly, the process of constructing next-generation reference interval models can be complex, particularly when employing indirect sampling techniques. At present, normative documents pertaining to the development of next-generation reference interval models are lacking. In summary, this review aims to provide an overview of the current state of development of next-generation reference interval models by defining them, highlighting inherent advantages, and addressing existing challenges. It also describes the process, advanced algorithms for model building, the tools required and the diagnosis and validation of models. Additionally, a discussion on the prospects of utilizing big data for developing next-generation reference interval models is presented. The ultimate objective is to equip clinical laboratories with the theoretical framework and practical tools necessary for developing and optimizing next-generation reference interval models to establish next-generation reference intervals while enhancing the use of medical data resources to facilitate precision medicine.
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Affiliation(s)
- Chaochao Ma
- Department of Laboratory Medicine, Peking Union Medical College, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
- Department of Occupational and Environmental Health Sciences, School of Public Health, Peking University, Beijing, China
| | - Zheng Yu
- Department of Operations Research and Financial Engineering, Princeton University, Princeton University, Princeton, NJ, USA
| | - Ling Qiu
- Department of Laboratory Medicine, Peking Union Medical College, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
- State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Science, Beijing, China
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Abbam G, Mensah K, Appiah SK, Nkansah C, Daud S, Aikins CN, Osei-Afoakwa AN, Osei-Boakye F, Derigubah CA, Mohammed S, Tandoh S, Bani SB. Complete Blood Count Reference Intervals for Children Aged Less Than 1 to 12 Years in the Northern Region of Ghana. BIOMED RESEARCH INTERNATIONAL 2024; 2024:6607281. [PMID: 38764534 PMCID: PMC11101252 DOI: 10.1155/2024/6607281] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/30/2023] [Revised: 04/11/2024] [Accepted: 04/29/2024] [Indexed: 05/21/2024]
Abstract
Reliable laboratory diagnostic results are key for evaluating and improving children's health. To interpret these results, child-specific reference intervals (RIs), which account for constant biological changes and physiological development with sex and age, are required, as recommended by the Clinical and Laboratory Standards Institute (CLSI). This study presents age- and sex-specific reference intervals for complete blood count (CBC) parameters in children (<1-12 years old) in the Northern Region of Ghana. In this cross-sectional study, 600 healthy children from randomly sampled schools in Tamale (the Northern Region) were recruited and screened. Data from 388 eligible children were used to nonparametrically determine the reference intervals of CBC parameters at the 2.5th and 97.5th percentiles. The CBC reference intervals were compared for variations in sex and age groups using the Wilcoxon rank-sum test. There were no statistically significant differences in most CBC parameters by sex (RBC, Hb, HCT, MCH, RDW (CV/SD), WBC, LYM#, MON#(%) NEU#(%), EOS#(%), and BAS#(%); p > 0.05) and age group (RBC, MCV, RDW (CV/SD), WBC, LYM#, MON#(%) NEU#(%), EOS#(%), and BAS%; p > 0.05). However, there were observable differences between this locally established CBC reference interval and that used for children at Tamale Teaching Hospital (manufacturer's RIs). This study emphasises the importance of determining reference intervals representative of the local child population and incorporating them into the current reporting system of laboratories in the Northern Region to ensure the provision of effective and efficient healthcare services.
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Affiliation(s)
- Gabriel Abbam
- Department of Haematology, School of Allied Health Sciences, University for Development Studies, Tamale, Ghana
| | - Kofi Mensah
- Department of Haematology, School of Allied Health Sciences, University for Development Studies, Tamale, Ghana
- Department of Medical Laboratory Science, Faculty of Health Science and Technology, Ebonyi State University, Abakaliki, Nigeria
| | - Samuel Kwasi Appiah
- Department of Haematology, School of Allied Health Sciences, University for Development Studies, Tamale, Ghana
- Department of Medical Laboratory Science, Faculty of Health Science and Technology, Ebonyi State University, Abakaliki, Nigeria
| | - Charles Nkansah
- Department of Haematology, School of Allied Health Sciences, University for Development Studies, Tamale, Ghana
- Department of Medical Laboratory Science, Faculty of Health Science and Technology, Ebonyi State University, Abakaliki, Nigeria
| | - Samira Daud
- Department of Haematology, School of Allied Health Sciences, University for Development Studies, Tamale, Ghana
| | - Cheryl Namusoke Aikins
- Department of Biomedical Laboratory Sciences, School of Allied Health Sciences, University for Development Studies, Tamale, Ghana
| | - Akua Nyarko Osei-Afoakwa
- Department of Biomedical Laboratory Sciences, School of Allied Health Sciences, University for Development Studies, Tamale, Ghana
| | - Felix Osei-Boakye
- Department of Medical Laboratory Science, Faculty of Health Science and Technology, Ebonyi State University, Abakaliki, Nigeria
- Department of Medical Laboratory Technology, Faculty of Applied Science and Technology, Sunyani Technical University, Sunyani, Ghana
| | - Charles Angnataa Derigubah
- Department of Medical Laboratory Science, Faculty of Health Science and Technology, Ebonyi State University, Abakaliki, Nigeria
- Department of Medical Laboratory Technology, School of Applied Science and Arts, Bolgatanga Technical University, Bolgatanga, Ghana
| | - Sanda Mohammed
- Systems Solutions Geospatial Research Services, Accra, Ghana
- Research Department, SSNIT, Accra, Ghana
| | - Samuel Tandoh
- University Clinic Laboratory, University of Education, Winneba, Ghana
| | - Simon Bannison Bani
- Department of Biomedical Laboratory Sciences, School of Allied Health Sciences, University for Development Studies, Tamale, Ghana
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Doyle K, Bunch DR. Reference intervals: past, present, and future. Crit Rev Clin Lab Sci 2023; 60:466-482. [PMID: 37036018 DOI: 10.1080/10408363.2023.2196746] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Revised: 03/03/2023] [Accepted: 03/24/2023] [Indexed: 04/11/2023]
Abstract
Clinical laboratory test results alone are of little value in diagnosing, treating, and monitoring health conditions; as such, a clinically actionable cutoff or reference interval is required to provide context for result interpretation. Healthcare practitioners base their diagnoses, follow-up treatments, and subsequent testing on these reference points. However, they may not be aware of inherent limitations related to the definition and derivation of reference intervals. Laboratorians are responsible for providing the reference intervals they report with results. Yet, the establishment and verification of reference intervals using conventional direct methods are complicated by resource constraints or unique patient demographics. To facilitate standardized reference interval best practices, multiple global scientific societies are actively drafting guidelines and seeking funding to promote these initiatives. Numerous national and international multicenter collaborations demonstrate the ability to leverage combined resources to conduct large reference interval studies by direct methods. However, not all demographics are equally accessible. Novel indirect methods are attractive solutions that utilize computational methods to define reference distributions and reference intervals from mixed data sets of pathologic and non-pathologic patient test results. In an effort to make reference intervals more accurate and personalized, individual-based reference intervals are shown to be more useful than population-based reference intervals in detecting clinically significant analyte changes in a patient that might otherwise go unrecognized when using wider, population-based reference intervals. Additionally, continuous reference intervals can provide more accurate ranges as compared to age-based partitions for individuals that are near the ends of the age partition. The advantages and disadvantages of different reference interval approaches as well as the advancement of non-conventional reference interval studies are discussed in this review.
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Affiliation(s)
- Kelly Doyle
- Department of Pathology, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Dustin R Bunch
- Nationwide Children's Hospital & College of Medicine, The Ohio State University, Columbus, OH, USA
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Ammer T, Schützenmeister A, Prokosch HU, Rauh M, Rank CM, Zierk J. A pipeline for the fully automated estimation of continuous reference intervals using real-world data. Sci Rep 2023; 13:13440. [PMID: 37596314 PMCID: PMC10439150 DOI: 10.1038/s41598-023-40561-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Accepted: 08/12/2023] [Indexed: 08/20/2023] Open
Abstract
Reference intervals are essential for interpreting laboratory test results. Continuous reference intervals precisely capture physiological age-specific dynamics that occur throughout life, and thus have the potential to improve clinical decision-making. However, established approaches for estimating continuous reference intervals require samples from healthy individuals, and are therefore substantially restricted. Indirect methods operating on routine measurements enable the estimation of one-dimensional reference intervals, however, no automated approach exists that integrates the dependency on a continuous covariate like age. We propose an integrated pipeline for the fully automated estimation of continuous reference intervals expressed as a generalized additive model for location, scale and shape based on discrete model estimates using an indirect method (refineR). The results are free of subjective user-input, enable conversion of test results into z-scores and can be integrated into laboratory information systems. Comparison of our results to established and validated reference intervals from the CALIPER and PEDREF studies and manufacturers' package inserts shows good agreement of reference limits, indicating that the proposed pipeline generates high-quality results. In conclusion, the developed pipeline enables the generation of high-precision percentile charts and continuous reference intervals. It represents the first parameter-less and fully automated solution for the indirect estimation of continuous reference intervals.
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Affiliation(s)
- Tatjana Ammer
- Chair of Medical Informatics, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
- Roche Diagnostics GmbH, Penzberg, Germany
| | | | - Hans-Ulrich Prokosch
- Chair of Medical Informatics, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Manfred Rauh
- Department of Pediatrics and Adolescent Medicine, Universitätsklinikum Erlangen, Loschgestr. 15, 91054, Erlangen, Germany
| | | | - Jakob Zierk
- Department of Pediatrics and Adolescent Medicine, Universitätsklinikum Erlangen, Loschgestr. 15, 91054, Erlangen, Germany.
- Center of Medical Information and Communication Technology, Universitätsklinikum Erlangen, Erlangen, Germany.
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Simpong NL, Afefa CT, Yimpuri L, Akum B, Safo A, Edziah SJ, Simpong DL, Adu P. Establishing pregnancy-specific haematological reference intervals in Ghana; a three-center cross-sectional study. PLoS One 2023; 18:e0274422. [PMID: 36735666 PMCID: PMC9897535 DOI: 10.1371/journal.pone.0274422] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Accepted: 08/30/2022] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Abnormal intra-pregnancy haematological variables are associated with adverse feto-maternal outcomes. However, the reference intervals (RIs) employed in sub-Saharan Africa to inform clinical decisions are generally imported. Since RIs are influenced by age, geographical location, and race, we hypothesized that context specific RIs should be established in Ghana to contextualize intra-pregnancy decision making. METHODS This cross-sectional study retrospectively retrieved data of 333 pregnant women with no known clinically determined intra-pregnancy complications; 22 participants in their first trimester (T1; 1-13 weeks), 177 in their T2 (14-27 weeks), and 132 in T3 (28-41 weeks). RIs for haematological parameters were non-parametrically determined at 2.5th and 97.5th percentiles in accordance with CLSI guidance document EP28-A3c. Two-sample comparisons were undertaken using Wilcoxon rank-sum tests whereas more than two-sample comparisons were undertaken using Kruskal-Wallis test. Statistical significance was set at p <0.05 under the two-tailed assumptions. RESULTS In accordance with WHO trimester-specific haemoglobin cutoffs, anaemia prevalence was a moderate (T1: 36.4%; 8/22 & T2: 31.6%; 56/177) to severe (T3:68.0%; 90/132) public health problem. Additionally, 9.3% (31/333) individuals had high gestational haemoglobin levels (Hb >13.0 g/dL). Moreover, haemoglobin (T2: 8.6-14.3 vs T3: 7.5-13.6 g/dL), MCH (T2: 22.5-69.8 vs T3: 21.6-31.9 pg), MCHC (T2: 30.2-51.8 g/L vs T3: 30.5-37.9 g/L), TWBC (T2: 4.0-13.4 vs T3: 4.1-13.0 x 109/L) required trimester specific RIs, compared to RBC (2.8-5.1 x 1012/L), MCV (66.2-100.2 fL), and platelet counts (106.3-388.3 x 109/L) that each required combined reference intervals. CONCLUSIONS The intra-pregnancy haematological RIs determined have appreciable lower limits; there is the need to determine context-specific thresholds for haematological variables predictive of positive and/or adverse maternal and infant health outcomes.
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Affiliation(s)
| | - Charity Tenu Afefa
- Department of Medical Laboratory Science, School of Allied Health Science, University of Cape Coast, Cape Coast, Ghana
| | - Leander Yimpuri
- Department of Medical Laboratory Science, School of Allied Health Science, University of Cape Coast, Cape Coast, Ghana
| | - Betty Akum
- Department of Medical Laboratory Science, School of Allied Health Science, University of Cape Coast, Cape Coast, Ghana
| | - Afia Safo
- Department of Medical Laboratory Science, School of Allied Health Science, University of Cape Coast, Cape Coast, Ghana
| | - Simon-Junior Edziah
- Department of Medical Laboratory Science, School of Allied Health Science, University of Cape Coast, Cape Coast, Ghana
| | - David Larbi Simpong
- Department of Medical Laboratory Science, School of Allied Health Science, University of Cape Coast, Cape Coast, Ghana
| | - Patrick Adu
- Department of Medical Laboratory Science, School of Allied Health Science, University of Cape Coast, Cape Coast, Ghana
- * E-mail:
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Wilson SM, Bohn MK, Madsen A, Hundhausen T, Adeli K. LMS-based continuous reference percentiles for 14 laboratory parameters in the CALIPER cohort of healthy children and adolescents. Clin Chem Lab Med 2023; 61:1105-1115. [PMID: 36639844 DOI: 10.1515/cclm-2022-1077] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Accepted: 01/02/2023] [Indexed: 01/15/2023]
Abstract
OBJECTIVES Marked physiological changes in growth and development present challenges in defining pediatric reference intervals for biomarkers of health and disease. Lambda, Mu, and Sigma (LMS)-based statistical modeling provides a continuous normal distribution by negating skewness and variation, and is commonly used to establish growth charts. Such LMS reference curves are suggested to enhance laboratory test result interpretation. The current study establishes LMS-based continuous reference percentiles for 14 biomarkers in the CALIPER cohort of healthy children and adolescents. METHODS Data from healthy children and adolescents aged 1-<19 years were used to establish continuous reference percentiles using a novel LMS-based statistical method, including 2.5th, 25th, 50th, 75th, and 97.5th percentiles. The LMS approach applies a Box-Cox data transformation and summarizes continuous distributions by age via three curves: skewness (Lambda), median (Mu), and coefficient of variation (Sigma). RESULTS LMS-based percentiles and z-scores were generated for 14 common pediatric biomarkers that demonstrate dynamic concentration patterns with age (e.g., alkaline phosphatase) and/or wherein the magnitude of difference from the population mean may be clinically relevant (e.g., triglycerides). The LMS model captured age- and sex-specific distributions accurately and was not substantially influenced by outlying points. CONCLUSIONS This is the first study to establish LMS-based continuous reference percentiles for biochemical markers in a healthy Canadian pediatric population. The current LMS-based approach builds upon previous continuous reference interval models by providing graded percentiles to improve test result interpretation, particularly with repeated measures over time. This method may assist in facilitating a patient-centered approach to laboratory medicine.
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Affiliation(s)
- Siobhan M Wilson
- CALIPER Program, Department of Pediatric Laboratory Medicine, The Hospital for Sick Children, Toronto, ON, Canada.,Department of Laboratory Medicine & Pathobiology, Faculty of Medicine, 1 King's College Cir, University of Toronto, Toronto, ON, Canada
| | - Mary Kathryn Bohn
- CALIPER Program, Department of Pediatric Laboratory Medicine, The Hospital for Sick Children, Toronto, ON, Canada.,Department of Laboratory Medicine & Pathobiology, Faculty of Medicine, 1 King's College Cir, University of Toronto, Toronto, ON, Canada
| | - Andre Madsen
- Department of Medical Biochemistry and Pharmacology, Haukeland University Hospital, Bergen, Norway
| | - Thomas Hundhausen
- Department of Medical Biochemistry, Southern Norway Hospital Trust, Kristiansand, Norway.,Department of Natural Sciences, University of Agder, Kristiansand, Norway
| | - Khosrow Adeli
- CALIPER Program, Department of Pediatric Laboratory Medicine, The Hospital for Sick Children, Toronto, ON, Canada.,Department of Laboratory Medicine & Pathobiology, Faculty of Medicine, 1 King's College Cir, University of Toronto, Toronto, ON, Canada
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Zhang X, Zhang Y, Xu Y, Liu J, Fu M, Ding Y, Dai Y, Yuan E. Age- and sex-specific reference intervals for complete blood count parameters in capillary blood for Chinese neonates and infants: A prospective study. Clin Chim Acta 2023; 538:104-112. [PMID: 36400320 DOI: 10.1016/j.cca.2022.11.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Revised: 11/10/2022] [Accepted: 11/11/2022] [Indexed: 11/17/2022]
Abstract
BACKGROUND The reference intervals (RIs) of laboratory tests are essential for disease diagnosis, therapy monitoring, and health assessment. They are also significant for clinicians to discriminate between subjects with disease and healthy subjects. However, RIs for complete blood count (CBC) parameters in capillary blood for children are deficient. This study aimed to establish capillary blood RIs for blood cell parameters in neonates and infants from birth to 2 years of age in Zhengzhou. METHODS We prospectively collected a total of 1840 capillary blood specimens from healthy subjects from birth to 2 years of age. Hematology RIs were established by analyzing capillary blood sample data, and RIs and 90 % confidence intervals (CIs) were calculated according to Clinical and Laboratory Standards Institute (CLSI) C28-A3 guidelines. RESULTS RIs were established for hematological parameters of capillary blood in neonates and infants from birth to 2 years of age. The levels of almost all hematological parameters, except for the lymphocyte (LYMPH), platelet (PLT), and thrombocytocrit (PCT) parameters, peaked in the first month after birth and then decreased to lower levels within 6 months. There were significant sex differences in most erythrocyte-related parameters, with higher levels in males than in females. Erythrocyte-related parameters showed an increasing tendency with increasing age after the second month. Neutrophil (NEUT) levels were high on the third day of life, declined to a nadir in the first month, and then slowly increased with age. LYMPH levels were low at birth and began to increase after birth, peaked at approximately-six months of age and then gradually declined with age. PLT and PCT levels showed an increasing trend during the first month, while the other parameters showed a decreasing trend. All platelet-related and leukocyte-related parameters showed no significant difference with sex. CONCLUSION We provide comprehensive age- and sex-specific RIs, including RIs for neonates in Henan. Our study provides more comprehensive reference ranges for Child Health Hospital and children's medical institutions, which may facilitate preliminary screening, diagnosis, and therapy.
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Affiliation(s)
- Xuewei Zhang
- Department of Clinical Laboratory, the Third Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Yurong Zhang
- Department of Clinical Laboratory, the Third Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Yajuan Xu
- Department of Clinical Laboratory, the Third Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Junjie Liu
- Henan Human Sperm Bank, the Third Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Mengyu Fu
- Department of Clinical Laboratory, the Third Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Yanzi Ding
- Department of Clinical Laboratory, the Third Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Yanpeng Dai
- Department of Clinical Laboratory, the Third Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Enwu Yuan
- Department of Clinical Laboratory, the Third Affiliated Hospital of Zhengzhou University, Zhengzhou, China.
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