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Herrmann M, Zelzer S, Cavalier E, Kleber M, Drexler-Helmberg C, Schlenke P, Curcic P, Keppel MH, Enko D, Scharnagl H, Pilz S, März W. Functional Assessment of Vitamin D Status by a Novel Metabolic Approach: The Low Vitamin D Profile Concept. Clin Chem 2023; 69:1307-1316. [PMID: 37798100 DOI: 10.1093/clinchem/hvad151] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Accepted: 08/24/2023] [Indexed: 10/07/2023]
Abstract
BACKGROUND Determining serum 25-hydroxyvitamin D [25(OH)D], 24,25-dihydroxyvitamin D [24,25(OH)2D] and the vitamin D metabolite ratio (VMR) allows the identification of individuals with a low vitamin D metabolite profile. Here, we evaluated if such a functional approach provides superior diagnostic information to serum 25(OH)D alone. METHODS 25(OH)D, 24,25(OH)2D, and the VMR were determined in participants of the DESIRE (Desirable Vitamin D Concentrations, n = 2010) and the LURIC (Ludwigshafen Risk and Cardiovascular Health, n = 2456) studies. A low vitamin D metabolite profile (vitamin D insufficiency) was defined by a 24,25(OH)2D concentration <1.2 ng/mL (<3 nmol/L) and a VMR <4%. Parathyroid hormone (PTH) and bone turnover markers were measured in both cohorts, whereas 10-year mortality data was recorded in LURIC only. RESULTS The median age in DESIRE and LURIC was 43.3 and 63.8 years, respectively. Median 25(OH)D concentrations were 27.2 ng/mL (68.0 nmol/L) and 15.5 ng/mL (38.8 nmol/L), respectively. Serum 25(OH)D deficiency, defined as <20.2 ng/mL (<50 nmol/L), was present in 483 (24.0%) and 1701 (69.3%) participants of DESIRE and LURIC, respectively. In contrast, only 77 (3.8%) and 521 (21.2%) participants had a low vitamin D metabolite profile. Regardless of the serum 25(OH)D concentration, a low vitamin D metabolite profile was associated with a significantly higher PTH, accelerated bone metabolism, and higher all-cause mortality than an unremarkable vitamin D metabolite profile. CONCLUSIONS The personalized assessment of vitamin D status using a functional approach better identifies patients with accelerated bone metabolism and increased mortality than the use of a fixed 25(OH)D cutoff of 20 ng/mL (50 nmol/L).
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Affiliation(s)
- Markus Herrmann
- Clinical Institute of Medical and Chemical Laboratory Diagnostics, Medical University of Graz, Graz, Austria
| | - Sieglinde Zelzer
- Clinical Institute of Medical and Chemical Laboratory Diagnostics, Medical University of Graz, Graz, Austria
| | - Etienne Cavalier
- Department of Clinical Chemistry, University of Liege, Liege, Belgium
| | - Marcus Kleber
- Department of Internal Medicine 5 (Nephrology, Hypertensiology, Endocrinology, Diabetology, Rheumatology), Mannheim Medical Faculty, University of Heidelberg, Mannheim, Germany
- Synlab Human Genetics Laboratory, Synlab AG, Mannheim, Germany
| | - Camilla Drexler-Helmberg
- Department for Blood Group Serology and Transfusion Medicine, Medical University of Graz, Graz, Austria
| | - Peter Schlenke
- Department for Blood Group Serology and Transfusion Medicine, Medical University of Graz, Graz, Austria
| | - Pero Curcic
- Clinical Institute of Medical and Chemical Laboratory Diagnostics, Medical University of Graz, Graz, Austria
| | - Martin H Keppel
- Clinical Institute of Medical and Chemical Laboratory Diagnostics, Medical University of Graz, Graz, Austria
| | - Dietmar Enko
- Clinical Institute of Medical and Chemical Laboratory Diagnostics, Medical University of Graz, Graz, Austria
| | - Hubert Scharnagl
- Clinical Institute of Medical and Chemical Laboratory Diagnostics, Medical University of Graz, Graz, Austria
| | - Stefan Pilz
- Division of Endocrinology and Diabetology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Winfried März
- Clinical Institute of Medical and Chemical Laboratory Diagnostics, Medical University of Graz, Graz, Austria
- Synlab Human Genetics Laboratory, Synlab AG, Mannheim, Germany
- Synlab Academy, Synlab Holding Germany GmbH, Mannheim, Germany
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Theiler-Schwetz V, Trummer C, Grübler MR, Keppel MH, Zittermann A, Tomaschitz A, März W, Meinitzer A, Pilz S. Associations of Parameters of the Tryptophan-Kynurenine Pathway with Cardiovascular Risk Factors in Hypertensive Patients. Nutrients 2023; 15:nu15020256. [PMID: 36678127 PMCID: PMC9862689 DOI: 10.3390/nu15020256] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2022] [Revised: 12/22/2022] [Accepted: 12/26/2022] [Indexed: 01/05/2023] Open
Abstract
Accumulating evidence suggests an association of the tryptophan−kynurenine (TRP-KYN) pathway with atherosclerosis and cardiovascular risk factors. In this cross-sectional analysis we investigated whether TRP-KYN pathway parameters are associated with 24 h blood pressure (BP) and other risk factors in patients with arterial hypertension from a tertiary care centre. In 490 participants, we found no significant and independent association of 24 h systolic and diastolic BP with parameters of the TRP-KYN pathway. However, linear regression analyses of HDL as dependent and TRP, KYN and quinolinic acid (QUIN) as explanatory variables adjusted for BMI and sex showed significant associations. These were found for KYN, BMI and sex (unstandardised beta coefficient −0.182, standard error 0.052, p < 0.001; −0.313 (0.078), p < 0.001; −0.180 (0.024), p < 0.001, respectively) as well as for QUIN, BMI and sex (−0.157 (0.038), p < 0.001; −0.321 (0.079), p < 0.001; −0.193 (0.024), p < 0.001, respectively). Smokers had significantly lower levels of KYN (2.36 µmol/L, IQR 2.01−2.98, versus 2.71 µmol/L, IQR 2.31−3.27, p < 0.001), QUIN (384 nmol/L, IQR 303−448, versus 451 nmol/L, IQR 369−575, p < 0.001) and KYN/TRP ratio (38.2, IQR 33.7−43.2, versus 43.1, IQR 37.5−50.9, p < 0.001) compared to non-smokers. We demonstrated that TRP/KYN pathway metabolites are associated with some cardiovascular risk factors, warranting further studies to elucidate the diagnostic and therapeutic potential of the TRP-KYN pathway for cardiovascular diseases.
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Affiliation(s)
- Verena Theiler-Schwetz
- Division of Endocrinology and Diabetology, Department of Internal Medicine, Medical University of Graz, 8036 Graz, Austria
- Correspondence:
| | - Christian Trummer
- Division of Endocrinology and Diabetology, Department of Internal Medicine, Medical University of Graz, 8036 Graz, Austria
| | - Martin R. Grübler
- Regional Hospital Wiener Neustadt, 2700 Wiener Neustadt, Austria
- Department of Aging Medicine and Aging Research, University of Zurich, 8006 Zurich, Switzerland
| | - Martin H. Keppel
- Department of Laboratory Medicine, Paracelsus Medical University Salzburg, 5020 Salzburg, Austria
| | - Armin Zittermann
- Clinic for Thoracic and Cardiovascular Surgery, Herz-und Diabeteszentrum Nordrhein-Westfalen (NRW), Ruhr University Bochum, 32545 Bad Oeynhausen, Germany
| | | | - Winfried März
- SYNLAB Academy, Synlab Holding Deutschland GmbH, 68159 Mannheim, Germany
- Vth Department of Medicine (Nephrology, Hypertensiology, Rheumatology, Endocrinology, Diabetology, Lipidology), Medical Faculty Mannheim, University of Heidelberg, 68167 Mannheim, Germany
- Clinical Institute of Medical and Chemical Laboratory Diagnostics, Medical University of Graz, 8036 Graz, Austria
| | - Andreas Meinitzer
- Clinical Institute of Medical and Chemical Laboratory Diagnostics, Medical University of Graz, 8036 Graz, Austria
| | - Stefan Pilz
- Division of Endocrinology and Diabetology, Department of Internal Medicine, Medical University of Graz, 8036 Graz, Austria
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Cadamuro J, Simundic AM, von Meyer A, Haschke-Becher E, Keppel MH, Oberkofler H, Felder TK, Mrazek C. Diagnostic Workup of Microcytic Anemia: An Evaluation of Underuse or Misuse of Laboratory Testing in a Hospital Setting Using the AlinIQ System. Arch Pathol Lab Med 2023; 147:117-124. [PMID: 35472855 DOI: 10.5858/arpa.2021-0283-oa] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/19/2021] [Indexed: 12/31/2022]
Abstract
CONTEXT.— Underuse of laboratory testing has been previously investigated in preselected populations, such as documented malpractice claims. However, these numbers might not reflect real-life situations. OBJECTIVE.— To evaluate the underuse and misuse of laboratory follow-up testing in a real-life hospital patient population with microcytic anemia, using laboratory results ordered during routine patient care. DESIGN.— From all patients in whom a microcytic anemia was detected during routine diagnostics in 2018, all available laboratory data were collected and screened for appropriateness of diagnostic workup of iron deficiency and thalassemia. Subgroup analysis was performed for patient groups with mean corpuscular volume values 75 to 79 μm3 (group 1), 65 to 74 μm3 (group 2), and <65 μm3 (group 3). RESULTS.— A total of 2244 patients with microcytic anemia were identified. Follow-up testing for iron deficiency was not performed in 761 cases (34%). For inconclusive ferritin levels due to elevated C-reactive protein results (n = 336), reticulocyte hemoglobin content or soluble transferrin receptor levels were missing in 86 cases (26%). In patients with suspected thalassemia (n = 127), follow-up testing for hemoglobin variants was not performed in 70 cases (55%). Subgroup analysis showed that the frequency of underuse of iron status as well as thalassemia/hemoglobinopathy testing decreased from group 1 to group 3. When considering relevant preexisting anemia diagnoses, laboratory tests were underused in 904 cases (40.3%). CONCLUSIONS.— Because 40% (n = 904) of the patients with microcytic anemia were potentially not followed up correctly, laboratory specialists are advised to act by implementing demand management strategies in collaboration with clinicians to overcome underuse of laboratory tests and to improve patient safety.
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Affiliation(s)
- Janne Cadamuro
- From the Department of Laboratory Medicine, Paracelsus Medical University Salzburg, Salzburg, Austria (Cadamuro, Haschke-Becher, Keppel, Oberkofler, Felder, Mrazek)
| | - Ana-Maria Simundic
- The Department of Medical Laboratory Diagnostics, Faculty of Pharmacy and Biochemistry, University Hospital Sveti Duh, University of Zagreb, Zagreb, Croatia (Simundic)
| | - Alexander von Meyer
- The Institute for Laboratory Medicine and Medical Microbiology, München Clinic, Munich, Germany (von Meyer)
| | - Elisabeth Haschke-Becher
- From the Department of Laboratory Medicine, Paracelsus Medical University Salzburg, Salzburg, Austria (Cadamuro, Haschke-Becher, Keppel, Oberkofler, Felder, Mrazek)
| | - Martin H Keppel
- From the Department of Laboratory Medicine, Paracelsus Medical University Salzburg, Salzburg, Austria (Cadamuro, Haschke-Becher, Keppel, Oberkofler, Felder, Mrazek)
| | - Hannes Oberkofler
- From the Department of Laboratory Medicine, Paracelsus Medical University Salzburg, Salzburg, Austria (Cadamuro, Haschke-Becher, Keppel, Oberkofler, Felder, Mrazek)
| | - Thomas K Felder
- From the Department of Laboratory Medicine, Paracelsus Medical University Salzburg, Salzburg, Austria (Cadamuro, Haschke-Becher, Keppel, Oberkofler, Felder, Mrazek)
| | - Cornelia Mrazek
- From the Department of Laboratory Medicine, Paracelsus Medical University Salzburg, Salzburg, Austria (Cadamuro, Haschke-Becher, Keppel, Oberkofler, Felder, Mrazek)
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Cadamuro J, Decho C, Frans G, Auer S, von Meyer A, Kniewallner KM, Drerup M, Heinrich E, Keppel MH, Mrazek C, Felder TK, Oberkofler H, Haschke-Becher E, Kipman U, Salek T, Vermeersch P. Acidification of 24-hour urine in urolithiasis risk testing: An obsolete relic? Clin Chim Acta 2022; 532:1-9. [PMID: 35597305 DOI: 10.1016/j.cca.2022.05.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Revised: 05/09/2022] [Accepted: 05/09/2022] [Indexed: 11/15/2022]
Abstract
BACKGROUND Recommendations on the optimal preservation of 24 h urine for the metabolic work-up in urolithiasis patients are very heterogeneous. In case two such tests with different storage condition recommendations are being analysed, multiple collections would be needed, challenging especially elderly and very young patients. We therefore aimed to evaluate the stability of urine constituents under different storage conditions. MATERIAL AND METHODS We collected urine samples from ten healthy volunteers and prepared aliquots to be stored either at room temperature or 4 °C. Some aliquots were preserved using hydrochloric acid prior to storage, some thereafter, some using the BD Urine preservation tube and some were not preserved at all. Storage duration was 0, 24, 48 or 72 h. In all samples calcium, magnesium, phosphorus, creatinine, oxalate, citrate and uric acid were measured and compared to the according reference sample. RESULTS We could not find any significant deviation for any of the analytes and preanalytical treatment conditions compared to the associated reference sample. CONCLUSION Preservation of 24 h urine for the metabolic evaluation in stone formers might not be necessary for sample storage up to 72 h.
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Affiliation(s)
- Janne Cadamuro
- Department of Laboratory Medicine, Paracelsus Medical University, Salzburg, Austria.
| | - Cosima Decho
- Department of Laboratory Medicine, Paracelsus Medical University, Salzburg, Austria
| | - Glynis Frans
- Clinical Department of Laboratory Medicine, University Hospitals Leuven, Leuven, Belgium
| | - Simon Auer
- Department of Laboratory Medicine, Paracelsus Medical University, Salzburg, Austria
| | - Alexander von Meyer
- Institute for Laboratory Medicine and Medical Microbiology, Medizet, München-Klinik, Munich, Germany
| | - Kathrin M Kniewallner
- Institute of Molecular Regenerative Medicine, Paracelsus Medical University, Salzburg, Austria; Spinal Cord Injury and Tissue Regeneration Center Salzburg (SCI-TreCS), Paracelsus Medical University, Salzburg, Austria
| | - Martin Drerup
- Department of Urology, Barmherzige Brüder Hospital, Salzburg, Austria
| | - Elmar Heinrich
- Department of Urology, Barmherzige Brüder Hospital, Salzburg, Austria
| | - Martin H Keppel
- Department of Laboratory Medicine, Paracelsus Medical University, Salzburg, Austria
| | - Cornelia Mrazek
- Department of Laboratory Medicine, Paracelsus Medical University, Salzburg, Austria
| | - Thomas K Felder
- Department of Laboratory Medicine, Paracelsus Medical University, Salzburg, Austria
| | - Hannes Oberkofler
- Department of Laboratory Medicine, Paracelsus Medical University, Salzburg, Austria
| | | | | | - Tomas Salek
- Department of Clinical Biochemistry and Pharmacology, The Tomas Bata Hospital in Zlín, Havlíčkovo nábřeží 600, 76275 Zlín, The Czech Republic
| | - Pieter Vermeersch
- Clinical Department of Laboratory Medicine, University Hospitals Leuven, Leuven, Belgium; Department of Cardiovascular Sciences, KU Leuven, Leuven Belgium
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Grübler MR, Zittermann A, Verheyen ND, Trummer C, Theiler-Schwetz V, Keppel MH, Malle O, Richtig G, Gängler S, Bischoff-Ferrari H, Scharnagl H, Meinitzer A, März W, Tomaschitz A, Pilz S. Randomized trial of vitamin D versus placebo supplementation on markers of systemic inflammation in hypertensive patients. Nutr Metab Cardiovasc Dis 2021; 31:3202-3209. [PMID: 34629245 DOI: 10.1016/j.numecd.2021.07.028] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Revised: 07/21/2021] [Accepted: 07/28/2021] [Indexed: 01/17/2023]
Abstract
BACKGROUND AND AIMS Animal and cell models indicated that vitamin D modulates inflammatory activity, which is considered relevant in the pathogenesis of arterial hypertension and cardiovascular diseases. We therefore aimed to investigate the effect of vitamin D supplementation on systemic markers of inflammation in a cohort of hypertensive patients. METHODS AND RESULTS The Styrian Vitamin D Hypertension Trial is a single-centre, double-blind, placebo-controlled study conducted from 2011 to 2014 in Austria. We enrolled 200 study participants with arterial hypertension and 25-hydroxy-vitamin-D (25(OH)D) concentration below 30 ng/mL. Study participants were randomized to receive either 2800 IU of vitamin D3 per day or placebo for 8 weeks. The present investigation is a post-hoc analysis using analysis of co-variance (ANCOVA). Outcome measures were biomarkers of inflammation including CRP, leukocytes including subtypes and leukocyte-to-lymphocyte ratio, leucine and kynurenic acid. A total of 187 participants (mean age 60.1 ± 11.3years; 47% women; mean baseline 25(OH)D 21.1 ± 5.6 ng/mL) completed the trial. ANCOVA revealed a mean treatment effect for none of the respective outcomes and no significant results were detected in various subgroup analyses. CONCLUSION Vitamin D3 supplementation in hypertensive patients with insufficient 25(OH)D concentrations has no significant effect on lowering markers of systemic inflammation. Further studies investigating the effect of vitamin D on other inflammatory pathways and in populations with severe vitamin D deficiency and a significant inflammatory burden are required. REGISTRATION ClinicalTrials.gov Identifier: NCT02136771; EudraCT No. 2009-018,125-70. Start Date: 2011-04-06.
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Affiliation(s)
- Martin R Grübler
- Department of Internal Medicine, Division of Endocrinology and Diabetology, Medical University of Graz, Graz, Austria; Centre on Aging and Mobility, University Hospital Zurich, Waid City Hospital, and University of Zurich, Zurich, Switzerland.
| | - Armin Zittermann
- Clinic for Thoracic and Cardiovascular Surgery, Herz- und Diabeteszentrum NRW, Ruhr University Bochum, Bad Oeynhausen, Germany
| | - Nicolas D Verheyen
- Department of Internal Medicine, Division of Cardiology, Medical University of Graz, Graz, Austria
| | - Christian Trummer
- Department of Internal Medicine, Division of Endocrinology and Diabetology, Medical University of Graz, Graz, Austria
| | - Verena Theiler-Schwetz
- Department of Internal Medicine, Division of Endocrinology and Diabetology, Medical University of Graz, Graz, Austria
| | - Martin H Keppel
- Department of Laboratory Medicine, Paracelsus Medical University Salzburg, Salzburg, Austria
| | - Oliver Malle
- Department of Internal Medicine, Division of Endocrinology and Diabetology, Medical University of Graz, Graz, Austria
| | - Georg Richtig
- Otto Loewi Research Center, Pharmacology Section, Medical University of Graz, Graz, Austria; Department of Oncology, Medical University of Graz, Graz, Austria
| | - Stephanie Gängler
- Centre on Aging and Mobility, University Hospital Zurich, Waid City Hospital, and University of Zurich, Zurich, Switzerland
| | - Heike Bischoff-Ferrari
- Centre on Aging and Mobility, University Hospital Zurich, Waid City Hospital, and University of Zurich, Zurich, Switzerland
| | - Hubert Scharnagl
- Clinical Institute of Medical and Chemical Laboratory Diagnostics, Medical University of Graz, Graz, Austria
| | - Andreas Meinitzer
- Clinical Institute of Medical and Chemical Laboratory Diagnostics, Medical University of Graz, Graz, Austria
| | - Winfried März
- Synlab Academy, Synlab Services GmbH, Mannheim, Germany; Vth Department of Medicine, (Nephrology, Hypertensiology, Rheumatology, Endocrinology, Diabetology), Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany
| | | | - Stefan Pilz
- Department of Internal Medicine, Division of Endocrinology and Diabetology, Medical University of Graz, Graz, Austria
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Mrazek C, Haschke-Becher E, Felder TK, Keppel MH, Oberkofler H, Cadamuro J. Laboratory Demand Management Strategies-An Overview. Diagnostics (Basel) 2021; 11:diagnostics11071141. [PMID: 34201549 PMCID: PMC8305334 DOI: 10.3390/diagnostics11071141] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2021] [Revised: 06/19/2021] [Accepted: 06/21/2021] [Indexed: 01/07/2023] Open
Abstract
Inappropriate laboratory test selection in the form of overutilization as well as underutilization frequently occurs despite available guidelines. There is broad approval among laboratory specialists as well as clinicians that demand management strategies are useful tools to avoid this issue. Most of these tools are based on automated algorithms or other types of machine learning. This review summarizes the available demand management strategies that may be adopted to local settings. We believe that artificial intelligence may help to further improve these available tools.
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Affiliation(s)
- Cornelia Mrazek
- Department of Laboratory Medicine, Paracelsus Medical University Salzburg, A-5020 Salzburg, Austria
| | - Elisabeth Haschke-Becher
- Department of Laboratory Medicine, Paracelsus Medical University Salzburg, A-5020 Salzburg, Austria
| | - Thomas K Felder
- Department of Laboratory Medicine, Paracelsus Medical University Salzburg, A-5020 Salzburg, Austria
| | - Martin H Keppel
- Department of Laboratory Medicine, Paracelsus Medical University Salzburg, A-5020 Salzburg, Austria
| | - Hannes Oberkofler
- Department of Laboratory Medicine, Paracelsus Medical University Salzburg, A-5020 Salzburg, Austria
| | - Janne Cadamuro
- Department of Laboratory Medicine, Paracelsus Medical University Salzburg, A-5020 Salzburg, Austria
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Pilz S, Theiler-Schwetz V, Trummer C, Keppel MH, Grübler MR, Verheyen N, Odler B, Meinitzer A, Voelkl J, März W. Associations of Serum Cortisol with Cardiovascular Risk and Mortality in Patients Referred to Coronary Angiography. J Endocr Soc 2021; 5:bvab017. [PMID: 33869979 PMCID: PMC8041336 DOI: 10.1210/jendso/bvab017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Indexed: 12/26/2022] Open
Abstract
CONTEXT Serum cortisol may be associated with cardiovascular risk factors and mortality in patients undergoing coronary angiography, but previous data on this topic are limited and controversial. OBJECTIVE We evaluated whether morning serum cortisol is associated with cardiovascular risk factors, lymphocyte subtypes, and mortality. METHODS This is a prospective cohort study performed at a tertiary care centre in south-west Germany between 1997 and 2000. We included 3052 study participants who underwent coronary angiography. The primary outcome measures were cardiovascular risk factors, lymphocyte subtypes, and all-cause and cardiovascular mortality. RESULTS Serum cortisol was associated with an adverse cardiovascular risk profile, but there was no significant association with coronary artery disease or acute coronary syndrome. In a subsample of 2107 participants, serum cortisol was positively associated with certain lymphocyte subsets, including CD16+CD56+ (natural killer) cells (P < 0.001). Comparing the fourth versus the first serum cortisol quartile, the crude Cox proportional hazard ratios (with 95% CIs) were 1.22 (1.00-1.47) for all-cause and 1.32 (1.04-1.67) for cardiovascular mortality, respectively. After adjustments for various cardiovascular risk factors, these associations were attenuated to 0.93 (0.76-1.14) for all-cause, and 0.97 (0.76-1.25) for cardiovascular mortality, respectively. CONCLUSIONS Despite significant associations with classic cardiovascular risk factors and natural killer cells, serum cortisol was not a significant and independent predictor of mortality in patients referred to coronary angiography. These findings might reflect that adverse cardiovascular effects of cortisol could be counterbalanced by some cardiovascular protective actions.
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Affiliation(s)
- Stefan Pilz
- Department of Internal Medicine, Division of Endocrinology and Diabetology, Medical University of Graz, 8036 Graz, Austria
| | - Verena Theiler-Schwetz
- Department of Internal Medicine, Division of Endocrinology and Diabetology, Medical University of Graz, 8036 Graz, Austria
| | - Christian Trummer
- Department of Internal Medicine, Division of Endocrinology and Diabetology, Medical University of Graz, 8036 Graz, Austria
| | - Martin H Keppel
- University Institute for Medical and Chemical Laboratory Diagnostics, Paracelsus Medical University, 5020 Salzburg, Austria
| | - Martin R Grübler
- Department of Internal Medicine, Division of Endocrinology and Diabetology, Medical University of Graz, 8036 Graz, Austria
- Department of Geriatrics and Aging Research, University Hospital Zurich and University of Zurich, 8091 Zurich, Switzerland
| | - Nicolas Verheyen
- Department of Cardiology, Medical University of Graz, 8036 Graz, Austria
| | - Balazs Odler
- Department of Internal Medicine, Division of Nephrology, Medical University of Graz, 8036 Graz, Austria
| | - Andreas Meinitzer
- Clinical Institute of Medical and Chemical Laboratory Diagnostics Medical, University of Graz, 8036 Graz, Austria
| | - Jakob Voelkl
- Institute for Physiology, Johannes Kepler University Linz, 4040 Linz, Austria
- Departments of Nephrology and Medical Intensive Care and Internal Medicine and Cardiology, Charité University Medicine, Campus Virchow-Klinikum, 10117 Berlin, Germany
- DZHK (German Centre for Cardiovascular Research), partner site Berlin, 10785 Berlin, Germany
| | - Winfried März
- Department of Internal Medicine, Division of Nephrology, Medical University of Graz, 8036 Graz, Austria
- Synlab Academy, 68159 Mannheim, Germany
- Medical Clinic V (Nephrology, Hypertensiology, Rheumatology, Endocrinology, Diabetology), Medical Faculty Mannheim, University of Heidelberg, 68167 Mannheim, Germany
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Cadamuro J, von Meyer A, Johannis W, Haschke-Becher E, Keppel MH, Streichert T. Effect of five different pneumatic tube carrier inserts on mechanical sample stress: a multicentre evaluation. Clin Chem Lab Med 2021; 59:e313-e316. [PMID: 33655735 DOI: 10.1515/cclm-2020-1818] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Accepted: 02/16/2021] [Indexed: 11/15/2022]
Affiliation(s)
- Janne Cadamuro
- Department of Laboratory Medicine, Paracelsus Medical University, Salzburg, Austria
| | - Alexander von Meyer
- Institute for Laboratory Medicine and Medical Microbiology, Medizet, München-Klinik, Munich, Germany
| | - Wibke Johannis
- Institute for Clinical Chemistry, University Hospital Köln, Cologne, Germany
| | | | - Martin H Keppel
- Department of Laboratory Medicine, Paracelsus Medical University, Salzburg, Austria
| | - Thomas Streichert
- Institute for Clinical Chemistry, University Hospital Köln, Cologne, Germany
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Cadamuro J, Mrazek C, Keppel MH, Felder TK, Oberkofler H, Haschke-Becher E. Effect of two organizational interventions on the frequency of haemoglobin A 1c and erythrocyte sedimentation rate testing. Clin Chem Lab Med 2021; 59:e77-e78. [DOI: 10.1515/cclm-2020-1206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Accepted: 09/13/2020] [Indexed: 11/15/2022]
Affiliation(s)
- Janne Cadamuro
- Department of Laboratory Medicine , Paracelsus Medical University , Salzburg , Austria
| | - Cornelia Mrazek
- Department of Laboratory Medicine , Paracelsus Medical University , Salzburg , Austria
| | - Martin H. Keppel
- Department of Laboratory Medicine , Paracelsus Medical University , Salzburg , Austria
| | - Thomas K. Felder
- Department of Laboratory Medicine , Paracelsus Medical University , Salzburg , Austria
| | - Hannes Oberkofler
- Department of Laboratory Medicine , Paracelsus Medical University , Salzburg , Austria
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Mrazek C, Lippi G, Keppel MH, Felder TK, Oberkofler H, Haschke-Becher E, Cadamuro J. Errors within the total laboratory testing process, from test selection to medical decision-making - A review of causes, consequences, surveillance and solutions. Biochem Med (Zagreb) 2021; 30:020502. [PMID: 32550813 PMCID: PMC7271754 DOI: 10.11613/bm.2020.020502] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Accepted: 04/23/2020] [Indexed: 12/18/2022] Open
Abstract
Laboratory analyses are crucial for diagnosis, follow-up and treatment decisions. Since mistakes in every step of the total testing process may potentially affect patient safety, a broad knowledge and systematic assessment of laboratory errors is essential for future improvement. In this review, we aim to discuss the types and frequencies of potential errors in the total testing process, quality management options, as well as tentative solutions for improvement. Unlike most currently available reviews on this topic, we also include errors in test-selection, reporting and interpretation/action of test results. We believe that laboratory specialists will need to refocus on many process steps belonging to the extra-analytical phases, intensifying collaborations with clinicians and supporting test selection and interpretation. This would hopefully lead to substantial improvements in these activities, but may also bring more value to the role of laboratory specialists within the health care setting.
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Affiliation(s)
- Cornelia Mrazek
- Department of Laboratory Medicine, Paracelsus Medical University, Salzburg, Austria
| | - Giuseppe Lippi
- Section of Clinical Chemistry, University of Verona, Verona, Italy
| | - Martin H Keppel
- Department of Laboratory Medicine, Paracelsus Medical University, Salzburg, Austria
| | - Thomas K Felder
- Department of Laboratory Medicine, Paracelsus Medical University, Salzburg, Austria
| | - Hannes Oberkofler
- Department of Laboratory Medicine, Paracelsus Medical University, Salzburg, Austria
| | | | - Janne Cadamuro
- Department of Laboratory Medicine, Paracelsus Medical University, Salzburg, Austria
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11
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Steinberger E, Pilz S, Trummer C, Theiler-Schwetz V, Reichhartinger M, Benninger T, Pandis M, Malle O, Keppel MH, Verheyen N, Grübler MR, Voelkl J, Meinitzer A, März W. Associations of Thyroid Hormones and Resting Heart Rate in Patients Referred to Coronary Angiography. Horm Metab Res 2020; 52:850-855. [PMID: 32886945 DOI: 10.1055/a-1232-7292] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Resting heart rate (RHR) is associated with increased risk of cardiovascular morbidity and mortality. Thyroid hormones exert several effects on the cardiovascular system, but the relation between thyroid function and RHR remains to be further established. We evaluated whether measures of thyroid hormone status are associated with RHR in patients referred to coronary angiography. Thyroid-stimulating hormone (TSH), free triiodothyronine (FT3), free thyroxin (FT4), and RHR were determined in 2795 participants of the Ludwigshafen Risk and Cardiovascular Health (LURIC) Study. Median (25th to 75th percentile) serum concentrations were 1.25 (0.76-1.92) mU/l for TSH, 4.8 (4.2-5.3) pmol/l for FT3 and 17.1 (15.4-19.0) pmol/l for FT4, and mean (±standard deviation) RHR was 68.8 (±11.7) beats/min. Comparing the highest versus the lowest quartile, RHR (beats/min) was significantly higher in the fourth FT4 quartile [3.48, 95% confidence interval (CI): 2.23-4.73; p <0.001] and in the fourth FT3 quartile (2.30, 95% CI: 1.06-3.55; p <0.001), but there was no significant difference for TSH quartiles. In multiple linear regression analyses adjusting for various potential confounders, FT3 and FT4 were significant predictors of RHR (p <0.001 for both). In subgroups restricted to TSH, FT3, and FT4 values within the reference range, both FT3 and FT4 remained significant predictors of RHR (p <0.001 for all). In conclusion, in patients referred to coronary angiography, FT3 and FT4 but not TSH were positively associated with RHR. The relationship between free thyroid hormones and RHR warrants further investigations regarding its diagnostic and therapeutic implications.
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Affiliation(s)
- Eva Steinberger
- Department of Internal Medicine, Division of Endocrinology and Diabetology, Medical University of Graz, Graz, Austria
| | - Stefan Pilz
- Department of Internal Medicine, Division of Endocrinology and Diabetology, Medical University of Graz, Graz, Austria
| | - Christian Trummer
- Department of Internal Medicine, Division of Endocrinology and Diabetology, Medical University of Graz, Graz, Austria
| | - Verena Theiler-Schwetz
- Department of Internal Medicine, Division of Endocrinology and Diabetology, Medical University of Graz, Graz, Austria
| | | | - Thomas Benninger
- Institute of Automation and Control, Graz University of Technology, Graz, Austria
| | - Marlene Pandis
- Department of Internal Medicine, Division of Endocrinology and Diabetology, Medical University of Graz, Graz, Austria
| | - Oliver Malle
- Department of Internal Medicine, Division of Endocrinology and Diabetology, Medical University of Graz, Graz, Austria
| | - Martin H Keppel
- Department of Laboratory Medicine, Paracelsus Medical University Salzburg, Salzburg, Austria
| | - Nicolas Verheyen
- Department of Cardiology, Medical University of Graz, Graz, Austria
| | - Martin R Grübler
- Department of Internal Medicine, Division of Endocrinology and Diabetology, Medical University of Graz, Graz, Austria
| | - Jakob Voelkl
- Institute for Physiology and Pathophysiology, Johannes Kepler University Linz, Linz, Austria
- DZHK (German Centre for Cardiovascular Research), Berlin, Germany
- Department of Nephrology and Medical Intensive Care, Charite - Universitätsmedizin Berlin, Berlin, Germany
| | - Andreas Meinitzer
- Clinical Institute of Medical and Chemical Laboratory Diagnostics, Medical University of Graz, Graz, Austria
| | - Winfried März
- Clinical Institute of Medical and Chemical Laboratory Diagnostics, Medical University of Graz, Graz, Austria
- Synlab Academy, Synlab Holding GmbH, Mannheim, Germany
- Medical Clinic 5, Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany
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12
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Steinberger E, Pilz S, Trummer C, Theiler-Schwetz V, Reichhartinger M, Benninger T, Pandis M, Malle O, Keppel MH, Verheyen N, Grübler MR, Voelkl J, Meinitzer A, März W. Correction: Associations of Thyroid Hormones and Resting Heart Rate in Patients Referred to Coronary Angiography. Horm Metab Res 2020; 52:e5. [PMID: 32927495 DOI: 10.1055/a-1260-4769] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Affiliation(s)
- Eva Steinberger
- Department of Internal Medicine, Division of Endocrinology and Diabetology, Medical University of Graz, Graz, Austria
| | - Stefan Pilz
- Department of Internal Medicine, Division of Endocrinology and Diabetology, Medical University of Graz, Graz, Austria
| | - Christian Trummer
- Department of Internal Medicine, Division of Endocrinology and Diabetology, Medical University of Graz, Graz, Austria
| | - Verena Theiler-Schwetz
- Department of Internal Medicine, Division of Endocrinology and Diabetology, Medical University of Graz, Graz, Austria
| | | | - Thomas Benninger
- Institute of Automation and Control, Graz University of Technology, Graz, Austria
| | - Marlene Pandis
- Department of Internal Medicine, Division of Endocrinology and Diabetology, Medical University of Graz, Graz, Austria
| | - Oliver Malle
- Department of Internal Medicine, Division of Endocrinology and Diabetology, Medical University of Graz, Graz, Austria
| | - Martin H Keppel
- Department of Laboratory Medicine, Paracelsus Medical University Salzburg, Salzburg, Austria
| | - Nicolas Verheyen
- Department of Cardiology, Medical University of Graz, Graz, Austria
| | - Martin R Grübler
- Department of Internal Medicine, Division of Endocrinology and Diabetology, Medical University of Graz, Graz, Austria
| | - Jakob Voelkl
- Institute for Physiology and Pathophysiology, Johannes Kepler University Linz, Linz, Austria
- DZHK (German Centre for Cardiovascular Research), Berlin, Germany
- Department of Nephrology and Medical Intensive Care, Charite - Universitätsmedizin Berlin, Berlin, Germany
| | - Andreas Meinitzer
- Clinical Institute of Medical and Chemical Laboratory Diagnostics, Medical University of Graz, Graz, Austria
| | - Winfried März
- Clinical Institute of Medical and Chemical Laboratory Diagnostics, Medical University of Graz, Graz, Austria
- Synlab Academy, Synlab Holding GmbH, Mannheim, Germany
- Medical Clinic 5, Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany
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Keppel MH, Auer S, Lippi G, von Meyer A, Cornes M, Felder TK, Oberkofler H, Mrazek C, Haschke-Becher E, Cadamuro J. Heparin and citrate additive carryover during blood collection. Clin Chem Lab Med 2020; 57:1888-1896. [PMID: 31377734 DOI: 10.1515/cclm-2019-0433] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2019] [Accepted: 07/11/2019] [Indexed: 11/15/2022]
Abstract
Background Published evidence on the risk of additive carryover during phlebotomy remains elusive. We aimed to assess potential carryover of citrated and heparinized blood and the relative volume needed to bias clinical chemistry and coagulation tests. Methods We simulated standardized phlebotomies to quantify the risk of carryover of citrate and heparin additives in distilled water, using sodium and lithium as surrogates. We also investigated the effects of contamination of heparinized blood samples with increasing volumes of citrated blood and pure citrate on measurements of sodium, potassium, chloride, magnesium, total and ionized calcium and phosphate. Likewise, we studied the effects of contamination of citrated blood samples with increasing volumes of heparinized blood on heparin (anti-Xa) activity, lithium, activated partial thromboplastin time (APTT), prothrombin time (PT) and thrombin time (TT). We interpreted these results based on measurement deviations beyond analytical, biological and clinical significance. Results Standardized phlebotomy simulations revealed no significant differences in concentration of surrogate markers. Clinically significant alterations were observed after contamination of heparinized blood samples with volumes of citrated blood beyond 5-50 μL for ionized calcium and beyond 100-1000 μL for sodium, chloride and total calcium. Investigations of pure citrate carryover revealed similar results at somewhat lower volumes. Heparinized blood carryover showed clinically significant interference of coagulation testing at volumes beyond 5-100 μL. Conclusions Our results suggest that during a standardized phlebotomy, heparin or citrate contamination is highly unlikely. However, smaller volumes are sufficient to severely alter test results when deviating from phlebotomy guidelines.
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Affiliation(s)
- Martin H Keppel
- Department of Laboratory Medicine, Paracelsus Medical University Salzburg, Salzburg, Austria
| | - Simon Auer
- Department of Laboratory Medicine, Paracelsus Medical University Salzburg, Salzburg, Austria
| | - Giuseppe Lippi
- Section of Clinical Chemistry, University of Verona, Verona, Italy
| | - Alexander von Meyer
- Institute of Laboratory Medicine, Kliniken Nordoberpfalz AG and Klinikum St. Marien, Weiden and Amberg, Germany
| | - Michael Cornes
- Biochemistry Department, Worcester Acute Hospitals NHS Trust, Worcester, UK
| | - Thomas K Felder
- Department of Laboratory Medicine, Paracelsus Medical University Salzburg, Salzburg, Austria
| | - Hannes Oberkofler
- Department of Laboratory Medicine, Paracelsus Medical University Salzburg, Salzburg, Austria
| | - Cornelia Mrazek
- Department of Laboratory Medicine, Paracelsus Medical University Salzburg, Salzburg, Austria
| | | | - Janne Cadamuro
- University Hospital Salzburg, Paracelsus Medical University, Department of Laboratory Medicine, Salzburger Landeskliniken, Müllner Hauptstr. 48, 5020 Salzburg, Austria
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Keppel MH, Kolbitsch T, Hoppe UC, Auer S, Felder TK, Oberkofler H, Mrazek C, Haschke-Becher E, Cadamuro J. The clinically effective use of cardiac markers by restructuring laboratory profiles at Cardiology wards. Clin Chem Lab Med 2020; 58:1565-1571. [PMID: 32305953 DOI: 10.1515/cclm-2019-1229] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Accepted: 03/04/2020] [Indexed: 12/20/2022]
Abstract
Background Laboratory overutilization is associated with diagnostic error and potential patient risk. We applied a demand management strategy in collaboration with the local Department of Cardiology to reduce the cardiac markers high-sensitive troponin T (hsTropT) and N-terminal pro brain natriuretic peptide (NTproBNP) in laboratory ordering profiles (LOPs). The present study aimed to retrospectively evaluate the implemented strategies. Methods Strategies included educational measures and evidence-guided, active test de-selection from all cardiology ward LOPs, and/or permanent removal from LOPs. Tests remained available at all times. We evaluated overutilization by reductions in monthly orders, and assessed differences in 30-day all-cause readmission rate and length of patients' hospital stay. Results Overall, we observed a mean reduction of 66.1% ± 7.6% (n = 277 ± 31) in hsTropT tests. Educational measures effectively reduced NTproBNP orders by 52.8% ± 17.7% (n = 60 ± 20). Permanent removal of tests from LOPs additionally decreased orders to a final extent of 75.8% ± 8.0% (n = 322 ± 31) in NTproBNP tests. The 30-day readmission rate and overall length of hospital stay did not increase. Conclusions Our results indicate that cardiac markers in routine care are subject to extensive overutilization when used within LOPs. Educational measures are an effective strategy to overcome the overutilization of cardiac markers but may be more effective when combined with the removal of cardiac markers from LOPs.
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Affiliation(s)
- Martin H Keppel
- Department of Laboratory Medicine, Paracelsus Medical University, Salzburg, Austria
| | - Tobias Kolbitsch
- Department of Cardiology, Clinic of Internal Medicine II, Paracelsus Medical University, Salzburg, Austria
| | - Uta C Hoppe
- Department of Cardiology, Clinic of Internal Medicine II, Paracelsus Medical University, Salzburg, Austria
| | - Simon Auer
- Department of Laboratory Medicine, Paracelsus Medical University, Salzburg, Austria
| | - Thomas K Felder
- Department of Laboratory Medicine, Paracelsus Medical University, Salzburg, Austria
| | - Hannes Oberkofler
- Department of Laboratory Medicine, Paracelsus Medical University, Salzburg, Austria
| | - Cornelia Mrazek
- Department of Laboratory Medicine, Paracelsus Medical University, Salzburg, Austria
| | | | - Janne Cadamuro
- Department of Laboratory Medicine, Paracelsus Medical University, Salzburg, Austria
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15
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Mrazek C, Simundic AM, Salinas M, von Meyer A, Cornes M, Bauçà JM, Nybo M, Lippi G, Haschke-Becher E, Keppel MH, Oberkofler H, Felder TK, Cadamuro J. Inappropriate use of laboratory tests: How availability triggers demand - Examples across Europe. Clin Chim Acta 2020; 505:100-107. [PMID: 32084382 DOI: 10.1016/j.cca.2020.02.017] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2020] [Revised: 02/17/2020] [Accepted: 02/17/2020] [Indexed: 12/14/2022]
Abstract
INTRODUCTION The appropriate use of laboratory diagnostics is increasingly at stake. The aim of this study was to depict some paradigmatic examples of under- and overutilization, as well as possible solutions across Europe. METHODS We collected six examples from five European countries where a rise or decline of orders for specific laboratory parameters was observed after organizational changes but without evidence of changes in patient collective characteristics as source of this variation. RESULTS The collected examples were the following: 1-Germany) Switch from a Brain-Natriuretic-Peptide assay to NT-pro Brain-Natriuretic-Peptide assay, resulting in a 374% increase in these analytics; 2-Spain) Implementation of a gatekeeping strategy in tumor marker diagnostics, resulting in a 15-61% reduction of these diagnostics; 3-Croatia) Stepwise elimination of creatine-kinase-MB assay from the laboratory portfolio; 4-UK) Removal of γ-glutamyl transferase from a "liver function" profile, resulting in 82% reduction of orders; 5-Austria) Implementation of a new device for rapid Influenza-RNA detection, resulting in a 450% increase of Influenza testing; 6-Spain) Insourcing of 1,25-(OH)2-Vitamin D measurements, leading to a 378% increase of these analyses. CONCLUSION The six paradigmatic examples described in this manuscript show that availability of laboratory resources may considerably catalyze the demand, thus underscoring that inappropriate use of laboratory resources may be commonplace in routine laboratories all across Europe and most probably beyond. They also demonstrate that the application of simple strategies may assist in overcoming this issue. We believe that laboratory specialists need to refocus on the extra-analytical parts of the testing process and engage more in interdisciplinary patient-care.
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Affiliation(s)
- Cornelia Mrazek
- Department of Laboratory Medicine, Paracelsus Medical University Salzburg, Salzburg, Austria
| | - Ana-Maria Simundic
- Department of Medical Laboratory Diagnostics, University Hospital Sveti Duh, Zagreb, Croatia; Faculty of Pharmacy and Biochemistry, University of Zagreb, Croatia
| | - Maria Salinas
- Clinical Laboratory, Hospital Universitario de San Juan, San Juan de Alicante, Alicante, Spain
| | - Alexander von Meyer
- Institute of Laboratory Medicine, Kliniken Nordoberpfalz AG and Klinikum St. Marien, Weiden and Amberg, Germany
| | - Michael Cornes
- Biochemistry Department, Worcester Acute Hospitals NHS Trust, Worcester, UK
| | - Josep Miquel Bauçà
- Department of Laboratory Medicine, Hospital Universitari Son Espases, Palma, Spain
| | - Mads Nybo
- Dept. of Clinical Biochemistry and Pharmacology, Odense University Hospital, Odense, Denmark
| | - Giuseppe Lippi
- Section of Clinical Biochemistry, University Hospital of Verona, Verona, Italy
| | | | - Martin H Keppel
- Department of Laboratory Medicine, Paracelsus Medical University Salzburg, Salzburg, Austria
| | - Hannes Oberkofler
- Department of Laboratory Medicine, Paracelsus Medical University Salzburg, Salzburg, Austria
| | - Thomas K Felder
- Department of Laboratory Medicine, Paracelsus Medical University Salzburg, Salzburg, Austria
| | - Janne Cadamuro
- Department of Laboratory Medicine, Paracelsus Medical University Salzburg, Salzburg, Austria.
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16
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Trummer O, Schweighofer N, Haudum CW, Trummer C, Pilz S, Theiler-Schwetz V, Keppel MH, Grübler M, Pieber TR, Renner W, Obermayer-Pietsch B, Lerchbaum E. Genetic Components of 25-Hydroxyvitamin D Increase in Three Randomized Controlled Trials. J Clin Med 2020; 9:jcm9020570. [PMID: 32093012 PMCID: PMC7074051 DOI: 10.3390/jcm9020570] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Revised: 02/11/2020] [Accepted: 02/14/2020] [Indexed: 12/30/2022] Open
Abstract
The 25-Hydroxyvitamin D (25[OH)D) serum concentration depends on vitamin D intake, endogenous vitamin D production and genetic factors. The latter have been demonstrated in large genome-wide association studies indicating that single nucleotide polymorphisms (SNPs) in genes related to the vitamin D metabolism are as important for serum 25(OH)D levels as the influence of season. The mechanism on how these SNPs influence serum 25(OH)D levels are still unclear. The aim of the present study was to investigate the genetic effects of ten selected SNPs related to vitamin D metabolism on 25-hydroxyvitamin D increase (∆25(OH)D) after vitamin D supplementation in three randomized controlled trials. Genotypes of SNPs related to vitamin D metabolism were determined in 411 participants with 25(OH)D concentrations < 75 nmol/l receiving 20,000 IU cholecalciferol per week for 8 or 12 weeks after study inclusion. For the vitamin D receptor (VDR) rs10783219 polymorphism, the minor A-allele was associated with lower ∆25(OH)D values in the entire study population (p = 0.022), which was not consistent in all three cohorts when analysed separately. VDR rs10783219 might therefore be a genetic modulator of increasing 25-hydroxyvitamin D concentrations. Considering the wide-spread use of vitamin D supplementation, future large and well-designed randomized controlled trials (RCTs) should investigate the clinical impact of this polymorphism.
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Affiliation(s)
- Olivia Trummer
- Division of Endocrinology and Diabetology, Department of Internal Medicine, Medical University of Graz, 8036 Graz, Austria; (N.S.); (C.W.H.); (C.T.); (S.P.); (V.T.-S.); (M.G.); (T.R.P.); (B.O.-P.); (E.L.)
- Correspondence: ; Tel.: +43-316-385-72935
| | - Natascha Schweighofer
- Division of Endocrinology and Diabetology, Department of Internal Medicine, Medical University of Graz, 8036 Graz, Austria; (N.S.); (C.W.H.); (C.T.); (S.P.); (V.T.-S.); (M.G.); (T.R.P.); (B.O.-P.); (E.L.)
- Center for Biomarker Research in Medicine, CBmed, 8010 Graz, Austria
| | - Christoph W. Haudum
- Division of Endocrinology and Diabetology, Department of Internal Medicine, Medical University of Graz, 8036 Graz, Austria; (N.S.); (C.W.H.); (C.T.); (S.P.); (V.T.-S.); (M.G.); (T.R.P.); (B.O.-P.); (E.L.)
- Center for Biomarker Research in Medicine, CBmed, 8010 Graz, Austria
| | - Christian Trummer
- Division of Endocrinology and Diabetology, Department of Internal Medicine, Medical University of Graz, 8036 Graz, Austria; (N.S.); (C.W.H.); (C.T.); (S.P.); (V.T.-S.); (M.G.); (T.R.P.); (B.O.-P.); (E.L.)
| | - Stefan Pilz
- Division of Endocrinology and Diabetology, Department of Internal Medicine, Medical University of Graz, 8036 Graz, Austria; (N.S.); (C.W.H.); (C.T.); (S.P.); (V.T.-S.); (M.G.); (T.R.P.); (B.O.-P.); (E.L.)
| | - Verena Theiler-Schwetz
- Division of Endocrinology and Diabetology, Department of Internal Medicine, Medical University of Graz, 8036 Graz, Austria; (N.S.); (C.W.H.); (C.T.); (S.P.); (V.T.-S.); (M.G.); (T.R.P.); (B.O.-P.); (E.L.)
| | - Martin H. Keppel
- Department of Laboratory Medicine, Paracelsus Medical University Salzburg, 5020 Salzburg, Austria;
| | - Martin Grübler
- Division of Endocrinology and Diabetology, Department of Internal Medicine, Medical University of Graz, 8036 Graz, Austria; (N.S.); (C.W.H.); (C.T.); (S.P.); (V.T.-S.); (M.G.); (T.R.P.); (B.O.-P.); (E.L.)
| | - Thomas R. Pieber
- Division of Endocrinology and Diabetology, Department of Internal Medicine, Medical University of Graz, 8036 Graz, Austria; (N.S.); (C.W.H.); (C.T.); (S.P.); (V.T.-S.); (M.G.); (T.R.P.); (B.O.-P.); (E.L.)
- Center for Biomarker Research in Medicine, CBmed, 8010 Graz, Austria
| | - Wilfried Renner
- Clinical Institute of Medical and Chemical Laboratory Diagnostics, Medical University of Graz, 8036 Graz, Austria;
| | - Barbara Obermayer-Pietsch
- Division of Endocrinology and Diabetology, Department of Internal Medicine, Medical University of Graz, 8036 Graz, Austria; (N.S.); (C.W.H.); (C.T.); (S.P.); (V.T.-S.); (M.G.); (T.R.P.); (B.O.-P.); (E.L.)
| | - Elisabeth Lerchbaum
- Division of Endocrinology and Diabetology, Department of Internal Medicine, Medical University of Graz, 8036 Graz, Austria; (N.S.); (C.W.H.); (C.T.); (S.P.); (V.T.-S.); (M.G.); (T.R.P.); (B.O.-P.); (E.L.)
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17
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Francic V, Ursem SR, Dirks NF, Keppel MH, Theiler-Schwetz V, Trummer C, Pandis M, Borzan V, Grübler MR, Verheyen ND, März W, Tomaschitz A, Pilz S, Heijboer AC, Obermayer-Pietsch B. The Effect of Vitamin D Supplementation on its Metabolism and the Vitamin D Metabolite Ratio. Nutrients 2019; 11:nu11102539. [PMID: 31640241 PMCID: PMC6836132 DOI: 10.3390/nu11102539] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2019] [Revised: 10/08/2019] [Accepted: 10/11/2019] [Indexed: 01/14/2023] Open
Abstract
25-hydroxyvitamin D (25(OH)D) is commonly measured to assess vitamin D status. Other vitamin D metabolites such as 24,25-dihydroxyvitamin D (24,25(OH)2D) provide additional insights into vitamin D status or metabolism. Earlier studies suggested that the vitamin D metabolite ratio (VMR), calculated as 24,25(OH)2D/25(OH)D, could predict the 25(OH)D increase after vitamin D supplementation. However, the evidence for this additional value is inconclusive. Therefore, our aim was to assess whether the increase in 25(OH)D after supplementation was predicted by the VMR better than baseline 25(OH)D. Plasma samples of 106 individuals (25(OH)D < 75 nmol/L) with hypertension who completed the Styrian Vitamin D Hypertension Trial (NC.T.02136771) were analyzed. Participants received vitamin D (2800 IU daily) or placebo for 8 weeks. The treatment effect (ANCOVA) for 25(OH)D3, 24,25(OH)2D3 and the VMR was 32 nmol/L, 3.3 nmol/L and 0.015 (all p < 0.001), respectively. Baseline 25(OH)D3 and 24,25(OH)2D3 predicted the change in 25(OH)D3 with comparable strength and magnitude. Correlation and regression analysis showed that the VMR did not predict the change in 25(OH)D3. Therefore, our data do not support routine measurement of 24,25(OH)2D3 in order to individually optimize the dosage of vitamin D supplementation. Our data also suggest that activity of 24-hydroxylase increases after vitamin D supplementation.
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Affiliation(s)
- Vito Francic
- Division of Endocrinology and Diabetology, Endocrinology Lab Platform, Department of Internal Medicine, Medical University of Graz, 8036 Graz, Austria.
| | - Stan R Ursem
- Department of Clinical Chemistry, Endocrine Laboratory, Amsterdam Gastroenterology & Metabolism, Vrije Universiteit Amsterdam and University of Amsterdam, Amsterdam UMC, 1105 Amsterdam, The Netherlands.
| | - Niek F Dirks
- Department of Clinical Chemistry, Endocrine Laboratory, Amsterdam Gastroenterology & Metabolism, Vrije Universiteit Amsterdam and University of Amsterdam, Amsterdam UMC, 1105 Amsterdam, The Netherlands.
| | - Martin H Keppel
- Department of Laboratory Medicine, Paracelsus Medical University Salzburg, 5020 Salzburg, Austria.
| | - Verena Theiler-Schwetz
- Division of Endocrinology and Diabetology, Endocrinology Lab Platform, Department of Internal Medicine, Medical University of Graz, 8036 Graz, Austria.
| | - Christian Trummer
- Division of Endocrinology and Diabetology, Endocrinology Lab Platform, Department of Internal Medicine, Medical University of Graz, 8036 Graz, Austria.
| | - Marlene Pandis
- Division of Endocrinology and Diabetology, Endocrinology Lab Platform, Department of Internal Medicine, Medical University of Graz, 8036 Graz, Austria.
| | - Valentin Borzan
- Division of Endocrinology and Diabetology, Endocrinology Lab Platform, Department of Internal Medicine, Medical University of Graz, 8036 Graz, Austria.
| | - Martin R Grübler
- Division of Endocrinology and Diabetology, Endocrinology Lab Platform, Department of Internal Medicine, Medical University of Graz, 8036 Graz, Austria.
| | - Nicolas D Verheyen
- Division of Cardiology, Department of Internal Medicine, Medical University of Graz, 8036 Graz, Austria.
| | - Winfried März
- Synlab Academy, Synlab Holding Germany GmbH, 68163 Mannheim, Germany.
| | | | - Stefan Pilz
- Division of Endocrinology and Diabetology, Endocrinology Lab Platform, Department of Internal Medicine, Medical University of Graz, 8036 Graz, Austria.
| | - Annemieke C Heijboer
- Department of Clinical Chemistry, Endocrine Laboratory, Amsterdam Gastroenterology & Metabolism, Vrije Universiteit Amsterdam and University of Amsterdam, Amsterdam UMC, 1105 Amsterdam, The Netherlands.
| | - Barbara Obermayer-Pietsch
- Division of Endocrinology and Diabetology, Endocrinology Lab Platform, Department of Internal Medicine, Medical University of Graz, 8036 Graz, Austria.
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18
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Pilz S, Keppel MH, Trummer C, Theiler-Schwetz V, Pandis M, Borzan V, Pittrof M, Obermayer-Pietsch B, Grübler MR, Verheyen N, Stepan V, Meinitzer A, Voelkl J, März W, Tomaschitz A. Diagnostic Accuracy of the Aldosterone-to-Active Renin Ratio for Detecting Primary Aldosteronism. J Endocr Soc 2019; 3:1748-1758. [PMID: 31528833 PMCID: PMC6735732 DOI: 10.1210/js.2019-00145] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2019] [Accepted: 07/15/2019] [Indexed: 11/19/2022] Open
Abstract
Context The aldosterone-to-active renin ratio (AARR) is the recommended screening test for primary aldosteronism (PA), but prospective study data on its sensitivity and specificity are sparse. Objective To investigate the diagnostic accuracy of the AARR for detecting PA. Design Prospective diagnostic accuracy study. Setting This study was conducted from February 2009 to August 2015 at the outpatient clinic of the Department of Endocrinology and Diabetology of the Medical University of Graz, Austria. Participants Four hundred patients with arterial hypertension who were referred to a tertiary care center for screening for endocrine hypertension. Intervention Participants had a determination of the AARR (index test) and a second AARR determination followed by a saline infusion test (SIT) after 2 to 6 weeks. PA was diagnosed in individuals with any AARR ≥3.7 ng/dL/µU/mL [including a plasma aldosterone concentration (PAC) of ≥9 ng/dL] who had a PAC ≥10 ng/dL after the SIT. We did not substantially alter antihypertensive drug intake. Main Outcome Measures Primary outcome was the receiver-operating characteristic (ROC) curve of the AARR in diagnosing PA. Results A total of 382 participants were eligible for analyses; PA was diagnosed in 18 (4.7%) patients. The area under the ROC curve of the AARR in detecting PA was 0.973 (95% CI, 0.956 to 0.990). Sensitivity and specificity for a positive AARR in diagnosing PA were 100% (95% CI, 81.5% to 100.0%) and 89.6% (95% CI, 86.0% to 92.5%), respectively. Conclusions The AARR has good diagnostic accuracy for detecting PA.
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Affiliation(s)
- Stefan Pilz
- Department of Internal Medicine, Division of Endocrinology and Diabetology, Medical University of Graz, Graz, Austria
| | - Martin H Keppel
- University Institute for Medical and Chemical Laboratory Diagnostics, Paracelsus Medical University, Salzburg, Austria
| | - Christian Trummer
- Department of Internal Medicine, Division of Endocrinology and Diabetology, Medical University of Graz, Graz, Austria
| | - Verena Theiler-Schwetz
- Department of Internal Medicine, Division of Endocrinology and Diabetology, Medical University of Graz, Graz, Austria
| | - Marlene Pandis
- Department of Internal Medicine, Division of Endocrinology and Diabetology, Medical University of Graz, Graz, Austria
| | - Valentin Borzan
- Department of Internal Medicine, Division of Endocrinology and Diabetology, Medical University of Graz, Graz, Austria
| | - Matthias Pittrof
- Department of Internal Medicine, Division of Endocrinology and Diabetology, Medical University of Graz, Graz, Austria
| | - Barbara Obermayer-Pietsch
- Department of Internal Medicine, Division of Endocrinology and Diabetology, Medical University of Graz, Graz, Austria.,CBmed, Center for Biomarker Research in Medicine, Graz, Austria
| | - Martin R Grübler
- Department of Cardiology, Swiss Cardiovascular Center Bern, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Nicolas Verheyen
- Department of Cardiology, Medical University of Graz, Graz, Austria
| | - Vinzenz Stepan
- Department of Internal Medicine, Division of Endocrinology and Diabetology, Medical University of Graz, Graz, Austria
| | - Andreas Meinitzer
- Clinical Institute of Medical and Chemical Laboratory Diagnostics Medical, University of Graz, Graz, Austria
| | - Jakob Voelkl
- Institute for Physiology, Johannes Kepler University Linz, Linz, Austria.,Departments of Nephrology and Medical Intensive Care and Internal Medicine and Cardiology, Charité University Medicine, Campus Virchow-Klinikum, Berlin, Germany.,German Centre for Cardiovascular Research, Berlin, Germany
| | - Winfried März
- Clinical Institute of Medical and Chemical Laboratory Diagnostics Medical, University of Graz, Graz, Austria.,Synlab Academy, Mannheim, Germany.,Nephrology, Hypertensiology, Rheumatology, Endocrinology, Diabetology, Medical Clinic V, Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany
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19
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Keppel MH, Piecha G, März W, Cadamuro J, Auer S, Felder TK, Mrazek C, Oberkofler H, Trummer C, Grübler MR, Schwetz V, Verheyen N, Pandis M, Borzan V, Haschke-Becher E, Tomaschitz A, Pilz S. The endogenous cardiotonic steroid Marinobufagenin and decline in estimated glomerular filtration rate at follow-up in patients with arterial hypertension. PLoS One 2019; 14:e0212973. [PMID: 30817774 PMCID: PMC6394930 DOI: 10.1371/journal.pone.0212973] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2018] [Accepted: 02/12/2019] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Marinobufagenin (MBG) is an endogenous cardiotonic steroid (CTS) that inhibits the Na+/K+-ATPase. Human MBG is significantly increased in end-stage renal disease and immunization against MBG attenuates cardiovascular fibrosis in a rat model of uremic cardiomyopathy. Mineralocorticoid antagonists (MRA) block MBG binding sites and decrease proteinuria in chronic kidney disease (CKD) patients. We therefore aimed to investigate the association of MBG and albuminuria, as a marker of renal damage, as well as MBG and decline of glomerular filtration rate (GFR). METHODS The Graz endocrine causes of hypertension (GECOH) study is a single center study of adults routinely referred for screening of endocrine hypertension. Plasma MBG was measured by an enzyme-linked immunoassay, and in a post-hoc analysis, follow-up creatinine levels were obtained. Patients with proteinuria >3.5g/day at baseline were excluded from further evaluation. RESULTS We measured MBG concentrations in 40 hypertensive subjects and excluded one patient due to pre-existing proteinuria. Plasma MBG was significantly correlated with albuminuria (Spearman ρ = .357; p = .028) and proteinuria (ρ = .336; p = .039). In linear regression analysis, the association remained significant after adjustment for age, sex, and BMI (β = .306; p = .036), and for mean systolic blood pressure (β = .352; p = .034). In follow-up analyses (N = 30), MBG was significantly associated with decline in GFR after adjustment for time-to-follow-up (β = -.374; p = .042). CONCLUSION The findings suggest that MBG plasma concentrations were associated with albuminuria as well as decline in kidney function. Whether MBG predicts hard renal endpoints warrants further investigations.
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Affiliation(s)
- Martin H. Keppel
- University Institute for Medical and Chemical Laboratory Diagnostics, Paracelsus Medical University, Salzburg, Austria
| | - Grzegorz Piecha
- Department of Nephrology, Transplantation and Internal Medicine, Medical University of Silesia, Katowice, Poland
| | - Winfried März
- Synlab Academy, Mannheim, Germany
- Medical Clinic V (Nephrology, Hypertensiology, Rheumatology, Endocrinology, Diabetology), Medical Faculty Mannheim, University of Heidelberg, Heidelberg, Germany
- Clinical Institute of Medical and Chemical Laboratory Diagnostics Medical, University of Graz, Graz, Austria
| | - Janne Cadamuro
- University Institute for Medical and Chemical Laboratory Diagnostics, Paracelsus Medical University, Salzburg, Austria
| | - Simon Auer
- University Institute for Medical and Chemical Laboratory Diagnostics, Paracelsus Medical University, Salzburg, Austria
| | - Thomas K. Felder
- University Institute for Medical and Chemical Laboratory Diagnostics, Paracelsus Medical University, Salzburg, Austria
| | - Cornelia Mrazek
- University Institute for Medical and Chemical Laboratory Diagnostics, Paracelsus Medical University, Salzburg, Austria
| | - Hannes Oberkofler
- University Institute for Medical and Chemical Laboratory Diagnostics, Paracelsus Medical University, Salzburg, Austria
| | - Christian Trummer
- Department of Endocrinology and Diabetology, Medical University of Graz, Graz, Austria
| | - Martin R. Grübler
- Department of Cardiology, Swiss Cardiovascular Center Bern, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Verena Schwetz
- Department of Endocrinology and Diabetology, Medical University of Graz, Graz, Austria
| | - Nicolas Verheyen
- Department of Cardiology, Medical University of Graz, Graz, Austria
| | - Marlene Pandis
- Department of Endocrinology and Diabetology, Medical University of Graz, Graz, Austria
| | - Valentin Borzan
- Department of Endocrinology and Diabetology, Medical University of Graz, Graz, Austria
| | - Elisabeth Haschke-Becher
- University Institute for Medical and Chemical Laboratory Diagnostics, Paracelsus Medical University, Salzburg, Austria
| | | | - Stefan Pilz
- Department of Endocrinology and Diabetology, Medical University of Graz, Graz, Austria
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20
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Pilz S, Zittermann A, Trummer C, Theiler-Schwetz V, Lerchbaum E, Keppel MH, Grübler MR, März W, Pandis M. Vitamin D testing and treatment: a narrative review of current evidence. Endocr Connect 2019; 8:R27-R43. [PMID: 30650061 PMCID: PMC6365669 DOI: 10.1530/ec-18-0432] [Citation(s) in RCA: 119] [Impact Index Per Article: 23.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Accepted: 01/16/2019] [Indexed: 12/11/2022]
Abstract
Vitamin D testing and treatment is a subject of controversial scientific discussions, and it is challenging to navigate through the expanding vitamin D literature with heterogeneous and partially opposed opinions and recommendations. In this narrative review, we aim to provide an update on vitamin D guidelines and the current evidence on the role of vitamin D for human health with its subsequent implications for patient care and public health issues. Vitamin D is critical for bone and mineral metabolism, and it is established that vitamin D deficiency can cause rickets and osteomalacia. While many guidelines recommend target serum 25-hydroxyvitamin D (25[OH]D) concentrations of ≥50 nmol/L (20 ng/mL), the minimum consensus in the scientific community is that serum 25(OH)D concentrations below 25-30 nmol/L (10-12 ng/mL) must be prevented and treated. Using this latter threshold of serum 25(OH)D concentrations, it has been documented that there is a high worldwide prevalence of vitamin D deficiency that may require public health actions such as vitamin D food fortification. On the other hand, there is also reason for concern that an exploding rate of vitamin D testing and supplementation increases costs and might potentially be harmful. In the scientific debate on vitamin D, we should consider that nutrient trials differ from drug trials and that apart from the opposed positions regarding indications for vitamin D treatment we still have to better characterize the precise role of vitamin D for human health.
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Affiliation(s)
- Stefan Pilz
- Division of Endocrinology and Diabetology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Armin Zittermann
- Clinic for Thoracic and Cardiovascular Surgery, Herz- und Diabeteszentrum NRW, Ruhr University Bochum, Bad Oeynhausen, Germany
| | - Christian Trummer
- Division of Endocrinology and Diabetology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Verena Theiler-Schwetz
- Division of Endocrinology and Diabetology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Elisabeth Lerchbaum
- Division of Endocrinology and Diabetology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Martin H Keppel
- University Institute for Medical and Chemical Laboratory Diagnostics, Paracelsus Medical University, Salzburg, Austria
| | - Martin R Grübler
- Department of Cardiology, Swiss Cardiovascular Center Bern, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Winfried März
- Clinical Institute of Medical and Chemical Laboratory Diagnostics, Medical University of Graz, Graz, Austria
- Medical Clinic V (Nephrology, Hypertensiology, Rheumatology, Endocrinology, Diabetology), Medical Faculty Mannheim, Ruperto-Carola University of Heidelberg, Heidelberg, Germany
- Synlab Medical Center of Human Genetics Mannheim, Mannheim, Germany
| | - Marlene Pandis
- Division of Endocrinology and Diabetology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
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