Glycated albumin, not hemoglobin A1c, predicts cardiovascular hospitalization and length of stay in diabetic patients on dialysis

BACKGROUND

The utility of glycated hemoglobin (HbA1c) and glycated albumin (GA) in diabetic dialysis patients remains unknown. GA was previously associated with all-cause hospitalization and patient survival. Relationships between GA, HbA1c, and casual plasma glucose (PG) with cause-specific cardiovascular (CV) disease, infectious disease (ID), and vascular access- (VA) related hospitalization rates and length of stay (LOS) were assessed.

METHODS

444 prevalent diabetic dialysis patients had monthly PG, quarterly GA, and all HbA1c values recorded for 2.33 years; hospitalizations within 17 and 30 days of testing were evaluated. Best-fit, time-dependent Cox models were constructed in unadjusted, case-mix-adjusted (age, sex, race, BMI, diabetes duration, dialysis vintage), and case-mix- plus lab-adjusted (hemoglobin, albumin, phosphorus) models.

RESULTS

Mean ± SD diabetes duration was 18.5 ± 10.8 years and dialysis vintage 2.9 ± 2.6 years. In fully adjusted models, CV hospitalization rates were associated with increasing GA (HR 1.32; 95% CI 1.11-1.57; p = 0.002 at 17 days; HR 1.21; p = 0.02 at 30 days) and PG (HR 1.10; 95% CI 1.02-1.17; p = 0.01 at 17 days; HR 1.07; p = 0.03 at 30 days), not HbA1c (HR 1.24; 95% CI 0.89-1.73; p = 0.21 at 17 days; HR 1.26; p = 0.10 at 30 days). LOS for CV admissions was positively associated with GA (HR 1.18; 95% CI 1.01-1.39; p = 0.03), not PG (HR 1.04; 95% CI 0.99-1.10; p = 0.15) or HbA1c (HR 1.03; 95% CI 0.92-1.15; p = 0.21). Admissions due to ID and VA complications (and LOS) did not correlate with these assays.

CONCLUSIONS

Improved glycemic control based on GA and PG predicted CV-related hospitalizations; GA also predicted CV hospitalization LOS. HbA1c did not predict cause-specific hospitalizations in dialysis populations.

Basic performance of an enzymatic method for glycated albumin and reference range determination

BACKGROUND

Glycated albumin (GA) is a medium-term glycemic control marker of diabetes and may be more sensitive to changes in plasma glucose than hemoglobin A1c. We studied where and how many fructosyl groups bind to albumin, and which glycation sites are measured by the enzymatic method for GA. We also studied the basic performance of the enzymatic method for GA.

METHODS

Glycated albumin was measured using an enzymatic method (Lucica®GA-L, Asahi Kasei Pharma) on a biochemical autoanalyzer. Molecular weights of purified GA and nonglycated albumin were measured by a mass spectrometry system. Two hundred one healthy volunteers with normal results of oral glucose tolerance testing were recruited to determine the reference range in Americans.

RESULTS

The present method measured only glycated amino acids from albumin in serum protein. We estimate that the number of glycated amino acids measured by this method was approximately two per molecule of albumin. The general performance (sensitivity, specificity, reproducibility, linearity, interference) of the method was good. The reference range of GA% in Americans with normal glucose tolerance was determined to be 11.9-15.8% (mean ± 2 standard deviations). Significant differences were not observed between the sexes; however, race differences were observed (higher levels in blacks relative to whites).

CONCLUSIONS

The method was specific for measuring glycated amino acids in albumin and had good basic performance characteristics. The reference range in Americans was 11.9-15.8%. This method may be a useful indicator for diabetes control.

Glycated albumin and risk of death and hospitalizations in diabetic dialysis patients

BACKGROUND AND OBJECTIVES

Relative to hemoglobin (Hb) A(₁c), glycated albumin (GA) more accurately reflects glycemic control in patients with diabetes mellitus and ESRD. We determined the association between GA, HbA(₁c), and glucose levels with survival and hospitalizations in diabetic dialysis patients.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

Quarterly GA levels were measured for up to 2.33 years in 444 prevalent patients with diabetes and ESRD. Proportional hazard time-dependent covariate models were computed with adjustment for demographic characteristics, comorbidities, and laboratory variables. Similar analyses were performed for available HbA(₁c) and monthly random serum glucose determinations.

RESULTS

The participants were 53% male, 54% African American, 43% Caucasian, 90% on hemodialysis, with a mean (SD) age of 62 (12) years and median follow-up duration of 2.25 years. GA and HbA(₁c) mean ± SD 21.5% ± 6.0%, median 20.4% and mean ± SD 6.9% ± 6.6%, median 1.6%, respectively. There were 156 deaths during the observation period. In best-fit models, predictors of death included increasing GA, increasing age, presence of peripheral vascular disease, decreasing serum albumin, and decreasing hemoglobin concentrations. HbA(1c) and random serum glucose concentrations were not predictive of survival. Increasing GA levels were associated with hospitalization in the 17 days after measurement, whereas HbA(₁c) was not.

CONCLUSIONS

In contrast to the HbA(₁c) and random serum glucose values, GA accurately predicts the risk of death and hospitalizations in patients with diabetes mellitus and ESRD. The GA assay should be considered by clinicians who care for patients with diabetes on dialysis.

Comparison of glycated albumin and hemoglobin A1c concentrations in diabetic subjects on peritoneal and hemodialysis

BACKGROUND

Relative to hemoglobin A(1c) (HbA(1c)), percentage of glycated albumin (GA%) more accurately reflects recent glycemic control in diabetic hemodialysis (HD) patients.

METHODS

To determine the accuracy of glycemic assays in a larger sample including patients on peritoneal dialysis (PD), HbA(1c) and GA% were measured in 519 diabetic subjects: 55 on PD, 415 on HD, and 49 non-nephropathy controls.

RESULTS

Mean +/- SD serum glucose levels were higher in HD and PD patients relative to non-nephropathy controls (HD 169.7 +/- 62 mg/dL, PD 168.6 +/- 66 mg/dL, controls 146.1 +/- 66 mg/dL; p = 0.03 HD vs controls, p = 0.13 PD vs controls). GA% was also higher in HD and PD patients (HD 20.6% +/- 8.0%, PD 19.0% +/- 5.7%, controls 15.7% +/- 7.7%; p < 0.02 HD vs controls and PD vs controls). HbA(1c) was paradoxically lower in dialysis patients (HD 6.78% +/- 1.6%, PD 6.87% +/- 1.4%, controls 7.3% +/- 1.4%; p = 0.03 HD vs controls, p = 0.12 PD vs controls). The serum glucose/HbA(1c) ratio differed significantly between dialysis patients and controls (p < 0.0001 HD vs controls, p = 0.002 PD vs controls), while serum glucose/GA% ratio was similar across groups (p = 0.96 HD vs controls, p = 0.64 PD vs controls). In best-fit multivariate models with HbA(1c) or GA% as outcome variable, dialysis status was a significant predictor of HbA(1c) but not GA%.

CONCLUSIONS

The relationship between HbA(1c) and GA% differs in diabetic patients with end-stage renal disease who perform either PD or HD compared to those without nephropathy. HbA(1c) significantly underestimates glycemic control in peritoneal and hemodialysis patients relative to GA%.

Relationship between assays of glycemia in diabetic subjects with advanced chronic kidney disease

BACKGROUND

Relative to hemoglobin A(1c) (HbA(1c)), glycated albumin (GA) more accurately reflects recent glycemic control in diabetic patients on hemodialysis and peritoneal dialysis. These assays have yet to be compared in patients with advanced chronic kidney disease (CKD).

METHODS

HbA(1c) and GA were simultaneously measured in 303 diabetic subjects: 70 with CKD prior to dialysis (CKD-stage 4), 184 with CKD after transplantation (TXP-stage 3) and 49 non-nephropathy controls.

RESULTS

Mean estimated GFR was 76, 46 and 26 ml/min in controls, TXP-3 and CKD-4 cases, respectively. Mean (SD) HbA(1c) (%) and GA (%) concentrations were 7.30 (1.40) and 16.8 (4.9) in controls, 7.28 (1.66) and 21.5 (6.4) in CKD-4 cases, and 7.21 (1.62) and 21.2 (5.5) in TXP-3 cases, respectively. The GA:HbA(1c) ratio differed significantly between non-nephropathy controls and both groups of CKD patients (both p < 0.001), but not between CKD-4 and TXP-3 cases (p = 0.92). The glucose:HbA(1c) ratio was inversely associated with GFR in all 254 nephropathy cases (r = -0.13; p = 0.04), while glucose:GA did not vary significantly based upon GFR (r = -0.08; p = 0.24).

CONCLUSIONS

The relationship between glycated albumin and HbA(1c) is influenced by the presence of reduced GFR in diabetic patients with CKD. The accuracy of the HbA(1c) assay in diabetic subjects with severe nephropathy requires further investigation, although HbA(1c) performs relatively well with milder CKD.

A chronic iron-deficient/high-manganese diet in rodents results in increased brain oxidative stress and behavioral deficits in the morris water maze

Iron deficiency (ID) is especially common in pregnant women and may even persist following childbirth. This is of concern in light of reports demonstrating that ID may be sufficient to produce homeostatic dysregulation of other metals, including manganese (Mn). These results are particularly important considering the potential introduction of the Mn-containing gas additive, methyl cyclopentadienyl manganese tricarbonyl (MMT), in various countries around the world. In order to model this potentially vulnerable population, we fed female rats fed either control (35 mg Fe/kg chow; 10 mg Mn/kg chow) or low iron/high-manganese (IDMn; 3.5 mg Fe/kg chow; 100 mg Mn/kg chow) diet, and examined whether these changes had any long-term behavioral effects on the animals' spatial abilities, as tested by the Morris water maze (MWM). We also analyzed behavioral performance on auditory sensorimotor gating utilizing prepulse inhibition (PPI), which may be related to overall cognitive performance. Furthermore, brain and blood metal levels were assessed, as well as regional brain isoprostane production. We found that treated animals were slightly ID, with statistically significant increases in both iron (Fe) and Mn in the hippocampus, but statistically significantly less Fe in the cerebellum. Additionally, isoprostane levels, markers of oxidative stress, were increased in the brain stem of IDMn animals. Although treated animals were indistinguishable from controls in the PPI experiments, they performed less well than controls in the MWM. Taken together, our data suggest that vulnerable ID populations exposed to high levels of Mn may indeed be at risk of potentially dangerous alterations in brain metal levels which could also lead to behavioral deficits.

Rapid quantitation of hemoglobin S in sickle cell patients using the Variant II Turbo analyzer

A rapid ( approximately 90 sec), fully automated method is described for quantifying hemoglobin S (HbS) by high performance liquid chromatography (HPLC) using the Bio-Rad Variant II Turbo analyzer. Although this instrument is designed to quantify only blood hemoglobin A1c (HbA1c), we show that it can also quantify accurately, without modification, HbS levels in sickle cell patients, provided the blood samples meet certain conditions. The samples should contain detectable hemoglobin F (HbF), but should not contain hemoglobin C (HbC). Under these conditions, blood HbS levels obtained by this method correlate well with those obtained by agarose electrophoresis (r(2) = 0.97, n = 81 patients). We also show that quantitation of blood HbF in sickle cell patients is more accurate by this method than by agarose electrophoresis when the HbF level is in the range from 0.2 to 10%.

Comparison of glycated albumin and hemoglobin A(1c) levels in diabetic subjects on hemodialysis

Glycated albumin is thought to more accurately reflect glycemic control in diabetic hemodialysis patients than hemoglobin A(1c) because of shortened red cell survival. To test this, glycated hemoglobin and albumin levels were measured in blood samples collected from 307 diabetic subjects of whom 258 were on hemodialysis and 49 were without overt renal disease. In diabetic subjects with renal disease, relative to those without, the mean serum glucose and glycated albumin concentrations were significantly higher while hemoglobin A(1c) tended to be lower. The glycated albumin to hemoglobin A(1c) ratio was significantly increased in dialysis patients compared with the controls. Hemoglobin A(1c) was positively associated with hemoglobin and negatively associated with the erythropoietin dose in hemodialysis patients, whereas these factors and serum albumin did not significantly impact glycated albumin levels. Using best-fit multivariate models, dialysis status significantly impacted hemoglobin A(1c) levels without a significant effect on glycated albumin. Our results show that in diabetic hemodialysis patients, hemoglobin A(1c) levels significantly underestimate glycemic control while those of glycated albumin more accurately reflect this control.

Direct analysis of hydrogen peroxide by capillary electrophoresis

A method is described for analysis of hydrogen peroxide directly by CZE in borate buffer based on its absorption in UV light at 185 nm, without reaction with dyes. The absorption at 185 nm was about 3.5 times better than that at 214 nm. Hydrogen peroxide was generated enzymatically from glucose in aqueous solutions and in serum and was removed by the catalase enzyme. To improve the sensitivity of detection, samples were concentrated on the capillary based on stacking by ACN. The method is rapid (approximately 7 min) and specific.

Serum iohexol analysis by micellar electrokinetic capillary chromatography

A simple and rapid ( approximately 4 min) method for the measurement of iohexol in serum for assessing the glomerular filtration rate is described. It is based on direct serum injection on the capillary by MEKC. The method is linear between 8 and 260 mg/L, with an RSD of peak height of 2.9%. Several simple steps have contributed to an improved daily precision, such as choosing a high pH buffer, increasing the SDS concentration, frequent standardization, and eliminating any sample pretreatment.

Cryoglobulins: an important but neglected clinical test

Cryoglobulin (CR) denotes a serum immunoglobulin that precipitates at temperatures below 37 degrees C and dissolves on re-warming. CRs are heterogeneous in chemical composition and behave differently in vivo and in vitro. The majority are mixed antigen-antibody complexes that occur with high incidence in autoimmune and infectious disorders. Their measurement is important in the management of patients with vasculitis. CRs elicit variable symptoms in patients, mostly purpura, weakness, and arthralgias, and they require various methods of treatment. Sometimes CRs are not associated with any symptoms; but they can be associated with very severe conditions such as nephropathy and neuropathy. Treatment depends on the symptoms and causes, and on the phenotyping of the CR. Considering the high incidence of CR in diseases such as hepatitis C virus (HCV) infection, together with the high worldwide prevalence of this disease, it is clear that testing for CR is underutilized in clinical practice. CR testing has been neglected in routine clinical laboratories and by clinicians due to several factors, such as the lengthy time for serum CR analysis and failure to appreciate that low levels of CR can be associated with severe symptoms. In a series of 194 serum samples that gave positive tests for CR at our institution, the majority contained low CR concentrations (65% of the samples were type II with a mean of 372 mg/L and 39% of type III with a mean of 216 mg/L; reference range 0-60 mg/L). Case studies are presented to illustrate the importance of such low levels of CR. There is a need for more rapid and more reliable methods for quantification and phenotyping of low concentrations of serum CR. Based on our experience in the routine analysis, quantification, and phenotyping of serum CR, some practical solutions to these problems are presented.

Simplified hemoglobin chain detection by capillary electrophoresis

Hemoglobin (Hb) chains have been analyzed traditionally by cellulose acetate electrophoresis after sample extraction with acetone and denaturation with concentrated urea in order to detect thalassemia (Thal). A few capillary electrophoresis (CE) methods have been also described for separation of Hb chains also after sample extraction. We describe a CE method for analysis of Hb chains without sample preparation. Red blood cells were diluted (hemolyzed) in water and injected directly onto the capillary. The separation was performed in concentrated phosphate buffer at pH 12.6 and 2.15. Under these conditions of pH and buffer concentration, the chains were denatured and separated from the heme during electrophoresis. The common variants of the beta-chains, such as beta(S), beta(C), and beta(E), are also separated from each other. The intact Hb molecule is analyzed using the same sample and CE conditions but in an arginine-Tris buffer, pH 8.6. The data from the three separations are used to complement each other for interpretation of the presence of Hb variants and for thalassemia. The main advantages of this method are simplicity and speed. This method illustrates the flexibility and simplicity of the CE for analysis of the hemoglobinopathies.

Organic solvent high-field amplified stacking for basic compounds in capillary electrophoresis

Many water-miscible organic solvents, especially acetonitrile and acetone, bring along significant degrees (approximately 30 times) of stacking by electroinjection through high-field amplified injection for the basic compounds compared to that for aqueous buffers or water. The relative stacking of different compounds in acetonitrile or acetone is different compared to that for water. Stacking by electroinjection in organic solvents is less stringent and easier to accomplish in practice. Acids and salts, in aqueous solutions, can ruin the stacking for both organic and aqueous solvents; however, this effect can be better tolerated by diluting the sample in acetonitrile. Thus, this stacking is termed "organic solvent high-field amplified injection". This stacking by electroinjection is enhanced by increasing the electrophoresis buffer concentration and can be better than that by pressure injection. From the practical aspects, some cationic drugs present in serum such as amiodarone can be detected at the therapeutic levels by electroinjection on the capillary after protein precipitation by acetonitrile.

Analysis of Tamm-Horsfall protein by high-performance liquid chromatography with native fluorescence

Tamm-Horsfall (TH) is a large glycoprotein which originates in the kidney and is very abundant in the urine. This protein has been measured mainly by immunoassays. Here we describe a different approach for its measurement based on high-performance liquid chromatography (HPLC) using a molecular exclusion column with native fluorescence detection in the ultraviolet range. This method in addition to measuring the level of the protein has the advantage of detecting changes in size or aggregation. Urine, 1 ml was mixed with 100 microl of 30% NaCl and left at 37 degrees C for 30 min. The urine was centrifuged at 12000 rpm for 20 s. The precipitate was vortex-mixed and dissolved in a triethanolamine buffer. A 20 microl aliquot was injected on a Macrosphere GPC column which was eluted with phosphate buffer and the effluent was detected by a fluorometer set at 280 nm for excitation and 325 nm for emission. Since the protein has a very large molecular mass compared to other urinary and serum proteins we did not experience any interference. It elutes as the first peak (in approximately 2.5 min on a 500 A and 2.7 min on 1000 A). The protein precipitates rapidly < 60 min at 37 degrees C. The detection in the UV is sensitive for this protein down to 1 mg/l in absence of any concentration steps. The method was linear between 1 and 100 mg/l. The R.S.D. was 10.4% (mean 62, n = 10). The mean level in 42 normal individuals was 31 mg/g creatinine and in 30 patients with proteinuria (different renal disorders) was 23 mg/g creatinine.

Fenofibrate and fenofibric acid analysis by capillary electrophoresis

A capillary electrophoresis method has been developed to measure fenofibrate in capsules based on micellar electrokinetic capillary chromatography with detection at 280 nm using a borate buffer containing sodium dodecyl sulfate (SDS). However, the metabolite of this drug (fenofibric acid) in serum and whole blood was analyzed by capillary zone electrophoresis (CZE) in a borate-carbonate buffer using acetonitrile stacking. The analysis is rapid, < 7 min with no interferences. Incubation of fenofibrate in whole blood caused hydrolysis of the ester bond with the release of fenofibric acid.

Effect of sample composition on electrophoretic migration

The electrophoretic migration, in routine analysis, is crucial for compound identification especially when multiple components are present in the sample. In complex or crude samples, such as those obtained from biological fluids, electrophoretic migration often does not correspond well to that of a pure standard compound. Several factors, related to the sample itself, have been identified as modulating the electrophoretic migration in zone electrophoresis both in gel and capillary electrophoresis (CE): solute mobility and concentrations, salt content, and protein interaction in the sample. Peak shape asymmetry often signals changes in migration especially when comparing samples with wide differences in concentration or those containing high ionic strength. Also, the migration of a protein can be influenced by the presence of a high concentration of another slowly migrating protein in the sample. A weak interaction during the separation between the two proteins which lead to a decreased velocity has been postulated. This was confirmed by finding a curve-linear relationship between the ratio of the two hemoglobin (Hb) variants, hemoglobin F (Hb F) and hemoglobin S (Hb S), and the distance between the two in gel electrophoresis (GE); and also by the observation of formation of a new small peak based on the analysis of hemoglobin F by capillary electrophoresis upon the addition of Hb S to the separation buffer. These factors when present together have an additive effect on the migration. As an example, Hb F, present in low but variable concentration in patients with sickle cell disease (Hb S), migrates in gel electrophoresis slightly slower than it is expected; enough to be confused with other unknown variants. However, the small peaks with different migration distances between Hb S and the adult Hb (Hb A) correlated well (r = 0.98) with Hb F performed by an alkali-denaturing assay indicating that these peaks are indeed Hb F in spite of the difference in their migration.

IgD-kappa myeloma: an unusual case

A rare case of biclonal IgD-kappa and IgG-kappa myeloma is described. The patient initially presented with anemia, renal insufficiency, and proteinuria. The IgD-kappa, initially, was overlooked as a light chain; however, it decreased in serum concentration after treatment by approximately 90%, in contrast to the IgG-kappa that decreased in serum by approximately 40 % over a 9-yr period. Clinically, the patient responded well to treatment and improved greatly during this period. Practical recommendations are suggested in order to detect such cases.

Analysis of the antiepileptic drug keppra by capillary electrophoresis

A simple and rapid method for determination of the new antiepileptic drug keppra (levetiracetam) by capillary electrophoresis in borate buffer containing sodium dodecyl sulfate is described. The serum was injected without any treatment. The method compared well to high performance liquid chromatography. The mean of keppra in the serum of 35 patients was 25 mg/l (range 7-77 mg/l).

Stacking by electroinjection with discontinuous buffers in capillary zone electrophoresis

The work presented here demonstrates that electroinjection can be performed using discontinuous buffers, which can result in better stacking than that obtained by hydrodynamic injection. The sample can be concentrated at the tip of the capillary leaving practically the whole capillary for sample separation. This results in several advantages, such as better sample concentration, higher plate number and shorter time of stacking. However, sample introduction by electromigration is suited for samples free or low in salt content. Samples, which are high in salt content, are better introduced by the hydrodynamic injection for stacking by the discontinuous buffers. Different simple methods to introduce the discontinuity in the buffer for electroinjection are discussed.

Multisite evaluation of a new dipstick for albumin, protein, and creatinine

The goal of our study was to perform a multisite evaluation of a new urine dipstick called Multistix PROtrade mark (Bayer, Elkhart, IN), which has reagent pads for the simultaneous assay of urinary albumin, protein, and creatinine. Patients' urine specimens were assayed at four sites with these dipsticks and with the familiar Bayer Multistix 10SG dipsticks for protein. The new dipstick pads for albumin are impregnated with bis (3',3"-diiodo-4',4"-dihydroxy-5',5"-dinitrophenyl)-3,4,5,6-tetrabromo-sulfonephthalein (DIDNTB) dye. These dipsticks also have a novel pad that estimates urinary creatinine using the peroxidase activity of the copper-creatinine complex. We determined the interlaboratory agreement of these dipsticks by comparing dipstick results to values obtained by quantitative analytical methods. We found that dividing the dipsticks' albumin or protein results by the creatinine concentration reduced the number of false-positive albumin or protein values observed in concentrated urines, and reduced the number of false negatives in dilute urines. The ratio of albumin to creatinine, or protein to creatinine gives a better measure of albumin or protein excretion. Compared to reading by eye, the dipstick results agreed better with the quantitative assays when they were read by a reflectometer (Bayer Clinitek).

Albuminuria and proteinuria in hospitalized patients as measured by quantitative and dipstick methods

We tested patients' urines for albumin, protein, and creatinine by quantitative and dipstick methods. The concentrations of these analytes were established by quantitative, cuvet-based chemistry methods that we assumed gave the "correct" values. There was good to excellent agreement of the dipstick results with the quantitative methods for the above three analytes. We found many patients who excreted pathological amounts of albumin and/or protein who did not have a diagnosis of kidney disease or other likely causes of proteinuria, suggesting that albuminuria and/or proteinuria were underdiagnosed in our group of patients. Those with cardiovascular disease, kidney disease, or diabetes showed the greatest predictive value of a positive test for albumin or protein by dipstick. Dipstick testing for albumin, protein, and creatinine had good or excellent agreement with quantitative methods. The dipstick tests were easy to use, simple, and low in cost, and can serve well for point-of-care testing.

Analysis of glutathione by capillary electrophoresis based on sample stacking

Glutathione is a small peptide, which participates in cellular oxidation-reduction and detoxification. It is present in most biological tissues at different concentrations. The oxidized and reduced forms of the peptide were measured in erythrocytes and myocardial tissue by capillary electrophoresis based on stacking. After tissue homogenization or hemolysis of the red blood cells, the samples were deproteinized with acetonitrile and injected filling about 13% of the capillary volume. The electrophoresis was performed at 10 kV using a separation buffer of 250 mM borate, 50 mM Tris, pH 8.0. Sample stacking increased the sensitivity of detection by 10-20-fold.

Decreasing the variability observed in urine analysis

Urine analysis is affected significantly by biological variability. The objective of this study was to study the feasibility of reducing the biological variability of excretion of various analytes in urine, especially albumin in children with diabetes, by mixing small volumes of early morning samples. Twenty-two male children with type 1 diabetes collected early morning aliquots of approximately 10 ml of urine on 3 consecutive days and kept them refrigerated in sealed containers. The urine collection was repeated every 4-6 months in the diabetic children. Ten normal children and 10 normal adults participated as controls. The specimens were analyzed individually and as mixed samples for each subject. Mixing the 3 urine samples before analysis decreased the biological variability of all urine assays (albumin, glucose, creatinine, total protein, potassium). The diabetic children had 3 times higher variability of urine albumin (as a ratio to creatinine) compared to normal children, when the urine samples were collected individually (61% vs 19%, respectively). The variability in the diabetic children decreased when the 3 specimens were analyzed as a single sample after mixing, especially when urine albumin was expressed as a ratio to creatinine. Blood glycated hemoglobin levels correlated better with urine glucose levels when 3 urine samples were mixed before analysis.

Stacking in capillary zone electrophoresis

Due to the short light path of the capillaries, the CE detection limit based on concentration, is far less than that of HPLC and not sufficient for many practical applications. Several methods, based on different electrophoretic maneuvers, can concentrate the sample (stack) easily on the capillary before the separation step of capillary zone electrophoresis (CZE). These methods incorporate different types of discontinuous buffers as the means for invoking different velocities to the same analyte molecules to produce a sharpening of the band (stacking). In CZE, these buffers can be often very simple such as sample dilution or adding to the sample a high concentration of a fast mobility ion. However, in other applications these buffers can be as complicated as those required for isotachophoresis. Stacking can often yield a concentration factor of 5-30-fold, which can improve greatly in CZE the detection limits bringing them very close to those of HPLC. Different methods of stacking, the importance of discontinuous buffers and the different mechanism for concentration on the capillary are reviewed here. As there is a need for more practical applications, there will be more methods devised for stacking in CZE.

Stacking and discontinuous buffers in capillary zone electrophoresis

Discontinuous buffers for capillary zone electrophoresis (CZE) can be used under less rigid conditions compared to those for isotachophoresis for stacking. They can be prepared simply by modifying the sample itself, either by addition of small inorganic ions, low conductivity diluents, or both, and also by adjusting its pH, meanwhile injecting a large volume on the capillary. Zwitterionic and organic-based buffers such as triethanolamine and tris(hydroxymethyl)aminomethane (Tris) are well suited for stacking due to their low conductivity, provided the buffer is discontinuous as demonstrated here. A simple mechanism based on discontinuous buffers is described to explain many of the observed stacking types in CZE, pointing out the many similarities to transient isotachophoresis.

Comparison of instrument-read dipsticks for albumin and creatinine in urine with visual results and quantitative methods

Three hospital sites evaluated the Bayer two-pad urine dipstick as a screening test for microalbuminuria. One pad estimates albumin concentrations between 10 and 150 mg/L, and the second estimates creatinine values between 300 and 3,000 mg/L. The Boehringer Mannheim (BMD) Micral dipstick was also compared and evaluated. The accuracy of the dipsticks was judged by comparison with cuvet-based immunonephelometry for albumin and to standard rate-Jaffe methods for creatinine; these assays were well standardized and controlled and were assumed to give accurate values. Precision of these methods and that of the dipsticks was determined by multiple assays of control materials. Visual or instrument (Clinitek 50 or 100) evaluation of the Bayer or visual checks of the BMD albumin dipstick pad with patients' urines gave clinically acceptable accuracy. The albumin/creatinine ratio from the Bayer dipsticks gave better accuracy for albumin excretion than the albumin pads alone from either manufacturer. This ratio should permit making a good estimate of the 24-hr albumin excretion in a randomly collected urine.

Hemoglobin A2 quantification by capillary zone electrophoresis

Hemoglobin A2 (HbA2) comprises about 2.2% of the total hemoglobin in the erythrocytes. The separation and quantitation of this minor hemoglobin by capillary electrophoresis (CE) using an arginine Tris buffer is described. Some of the variables affecting the accuracy and precision of HbA2 quantification are investigated. Furthermore, the quantification of this hemoglobin by CE is compared to that of a microcolumn chromatography method. The CE method is better suited than the microcolumn method for measuring HbA2 in the sickle cell trait.

Analysis of angiotension-converting enzyme by capillary electrophoresis

A method is described for determination of serum angiotension-converting enzyme by capillary electrophoresis (CE) based on incubation of the substrate, a synthetic peptide, with the serum outside the capillary and cleaving hippuric acid and a dipeptide. The reaction is stopped by the addition of acetonitrile, followed by injection of the supernatant on the capillary. The acetonitrile allows injection of a large volume of sample on the capillary. Both the substrate and the reaction product (hippuric acid) can be monitored at the same time. The CE step is rapid and can be performed in about 6 min. The CE method compared well to a kinetic assay method (= 0.98).

Capillary electrophoresis of double-stranded DNA in an untreated capillary

Using the zwitterionic buffer N-2-hydroxyethylpiperazine-N'-2-ethanesulfonic acid (HEPES) in the presence of a high-molecular-mass hydroxypropylmethylcellulose (HPMC) as a sieving polymer and ethidium bromide double-stranded DNA (dsDNA) was separated in an untreated capillary. The HEPES buffer shielded the DNA against the capillary wall interaction and decreased the electroosmotic flow enabling a good separation of the DNA similar to that obtained in a commercially coated capillary. In addition to the low cost of the untreated capillary it can be washed after each run. Furthermore, stacking with hydrodynamic injection filling about half of the capillary volume is demonstrated.

Field amplified injection in the presence of salts for capillary electrophoresis

Salts in the sample are detrimental to the stacking by the field-amplified injection. However, physiological samples often contain salts at levels of about 1% which can diminish the peak height or cause band spreading instead of stacking. Using different analytes which contain salts, we demonstrate that the presence of acetonitrile at 66% in the sample reverses the deleterious effect of salts and favors the stacking by the electrokinetic injection. The advantage of this type of stacking is that it favors certain analytes over others and it can give, in some instances, better theoretical plate numbers.

Acetonitrile stacking : serum phenobarbital as an example

Capillary electrophoresis (CE) has several advantages, such as high resolution, speed, and low cost of operation. However, it suffers from two major drawbacks: poor detection limits and matrix effects. Several approaches have been used to overcome these two problems. Here, acetonitrile stacking (AS) is presented as a simple, easy, and practical approach that can solve these two problems for many analytes, with minimum sample preparation. This laboratory successfully used AS for the analysis of several compounds by CE (1).

Myoglobin analysis

Myoglobin represents the stores of oxygen in muscle tissues. Because of its relatively small mol wt, myoglobin is often used in electrophoretic techniques as a mol wt marker, and also as a test for separation efficiency in capillary electrophoresis (CE). The separation of myoglobin can be accomplished based on mol wt (1), based on charge, or both together (as used here).

Comparison of instrument-read dipsticks for albumin and creatinine in urine with visual results and quantitative methods

Three hospital sites evaluated the Bayer two-pad urine dipstick as a screening test for microalbuminuria. One pad estimates albumin concentrations between 10 and 150 mg/L, and the second estimates creatinine values between 300 and 3,000 mg/L. The Boehringer Mannheim (BMD) Micral dipstick was also compared and evaluated. The accuracy of the dipsticks was judged by comparison with cuvet-based immunonephelometry for albumin and to standard rate-Jaffe methods for creatinine; these assays were well standardized and controlled and were assumed to give accurate values. Precision of these methods and that of the dipsticks was determined by multiple assays of control materials. Visual or instrument (Clinitek 50 or 100) evaluation of the Bayer or visual checks of the BMD albumin dipstick pad with patients' urines gave clinically acceptable accuracy. The albumin/creatinine ratio from the Bayer dipsticks gave better accuracy for albumin excretion than the albumin pads alone from either manufacturer. This ratio should permit making a good estimate of the 24-hr albumin excretion in a randomly collected urine.

Serum procainamide analysis based on acetonitrile stacking by capillary electrophoresis

Stacking methods are important in capillary electrophoresis (CE) to overcome the poor detection limits. Cationic drugs are difficult to stack because they tend to interact with the capillary wall. As an example of the stacking of the cationic compounds, procainamide, an anti-arrhythmic drug, is analyzed in serum by CE using an acetonitrile treatment. Serum was deproteinized with acetonitrile containing quinine as an internal standard. About 12% of the capillary volume was filled with sample and separated using an electrophoresis buffer composed of triethanolamine, 2-(N-cyclohexylamino)ethanesulfonic acid (CHES) and 20% isopropanol, pH 8.2. Both the triethanolamine and the CHES were critical for the stacking. The addition of isopropanol improved the plate number for the procainamide and decreased the interfering compounds. Procainamide, its metabolite N-acetyl procainamide, and quinine were separated in about 7 min. The CE compared well with an immunoassay method.

Insulin stacking for capillary electrophoresis

Stacking methods are very important in overcoming the poor detection limits in capillary electrophoresis. Human insulin, a polypeptide, was concentrated on the capillary (stacked) based on three different and simple treatment methods to the sample: dilute buffers, high salt content, and acetonitrile (66%) were added to the sample to induce stacking. A dilute buffer in the sample caused a limited stacking, while acetonitrile treatment and high salt content in the sample caused much greater (approximately 20-fold) stacking. High salt concentration in the sample caused stacking presumably by a transient isotachophoretic method. In addition to stacking, the acetonitrile treatment removed the excess proteins in the sample. Insulin did not denature or precipitate in 66% acetonitrile as confirmed by high-performance liquid chromatography (HPLC) and immunoassays. Acetonitrile treatment enabled one-third of the capillary to be loaded with sample thus increasing the detection signal greatly. The insulin peak after acetonitrile treatment and separation by capillary electrophoresis (CE) was confirmed by HPLC and by CE fraction collection followed by immunoassay. Based on acetonitrile treatment, insulin detection in pancreatic tissue homogenates is shown to be feasible.

Therapeutic drug monitoring by capillary electrophoresis

Because of the ease of analysis and the high resolution, drug analysis is becoming the best example for the application of capillary electrophoresis. Therapeutic drug monitoring is a specialized area of drug analysis performed in clinical laboratories for patient care. CE offers high resolution and speed with the low operating costs needed in patient care. However, CE has a few limitations, mainly poor detection limits and precision. Simple methods of stacking, which enhance drug detection to overcome the poor sensitivity of CE are stressed. Serum has a unique matrix with a high content of proteins and salts which can have adverse effects on separation by CE. For successful analysis, special maneuvers are employed to decrease these matrix effects. Studies that have addressed the improvement of the precision of CE are summarized. CE offers the possibility of bringing chiral separations into the routine arena.

Analysis of nitrate in biological fluids by capillary electrophoresis

Nitrite and nitrate represent the products of the final pathway of nitric oxide metabolism. These two ions were analyzed by capillary electrophoresis (CE) in serum, cerebrospinal fluid, urine and tissue homogenates by mixing the sample with acetonitrile containing NaBr as an internal standard, followed by centrifugation. The supernatant was injected hydrodynamically on a capillary 50 cm x 75 microns (I.D.) and electrophoresed at 6 kV (reversed polarity) in 1.4% sodium chloride in phosphate buffer for 13 min with detection at 214 nm. In addition to removal of the proteins, acetonitrile caused sample stacking. Urinary nitrate analysis by CE was compared to that by the enzymatic Aspergillus nitrate reductase method, with a correlation coefficient of 0.96.