Title: Chemistry Laboratory Handbook · U/E, Gentamycin and haematinics will require three clotted samples. • If more than one tube is collected from a patient, the potassium EDTA

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Chemistry Laboratory Handbook

Haematology/Blood Transfusion/Clinical Chemistry 11118

Mark Holliday

2.2

General Laboratory

William Newlands

28-Sep-2012

28-Sep-2013

Intranet

All Haematology, Chemistry & Transfusion Locations

28-Sep-2012 15:03

24-Oct-2012 14:41

Department of Haematology, Blood Transfusion & Clinical Chemistry

Authorised

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Chemistry Laboratory Handbook - Version: 2.2. Index: Haematology/Blood Transfusion/Clinical Chemistry 11118. Printed: 24-Oct-2012 14:41

Authorised on: 28-Sep-2012. Authorised by: William Newlands. SOP Unique Reference: 112-23278097. Due for review on: 28-Sep-2013

Author(s): Mark Holliday

Clinical Chemistry Service

USER’S HANDBOOK

Forth Valley Royal Hospital

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CONTENTS

1. Forth Valley Royal Hospital-Essential Information 2. Specimen Collection and Handling. 3. Data Protection. 4. Clinical Chemistry: Tests and Reference Ranges.

• Sample Types and Containers. • General Biochemistry: Blood. • Hormones: Blood and Urine. • Therapeutic Drugs. • Toxicology: Blood and Urine. • Tumour Markers: Blood and Urine. • General Biochemistry: Urine. • General Biochemistry: Faeces. • General Biochemistry: CSF. • General Biochemistry: Fluids. • Cystic Fibrosis Screening: Sweat and Blood. • Nutritional Screening.

5. Special Test Groups. • Paracetamol Poisoning. • Porphyria Screening and Diagnosis. • Thyroid Function Tests. • Lipoproteins: Specialised Investigations Available. • Endocrine Hypertension. • beta-HCG: Gestational Ranges. • Cystic Fibrosis Screening. • CSF Xanthochromia. • Troponin T. • Exocrine Pancreatic Function Testing. • IgG Subclasses. • Serum Tryptase. • Lead Poisoning. • Mercury Poisoning. • Trace Metals.

6. Referral Laboratory Addresses.

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CLINICAL CHEMISTRY SERVICE

1. Forth Valley Royal hospital - Essential Information

EMERGENCY REQUESTS EXT 66695

Address Department of Clinical Chemistry, Forth Valley Royal Hospital Stirling Road Larbert FK5 4WR Below is a floor plan of Level 2 showing the location of the laboratory.

Contacts Dr. M P Holliday, Consultant Chemical Pathologist…………………….….66769 Mrs S Kowalczyk, BMS4………………………………………………………66767 Mr W Newlands, BMS3………………………………………………………..66774 Mr M Gilmour, Quality Manager………………………………………………66773 Emergency Requests, results and general enquiries……………..……….66695

Pathology

Laboratories Transfusion

Wards A21 & A22

Wards B22 & B23

Clinical Offices

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Hours of work The laboratory is fully staffed from 08.45 to 17.00 Monday to Friday and 09.00 to 12.30 on Saturday mornings. Out-with these times an emergency On-Call service is available. On public holidays (excluding Christmas and New Year’s Day) a restricted routine service operates. Consultation and advice For clinical interpretation or advice on test results please contact Dr. Holliday on 66769. Further information or advice about any test not listed below can be obtained by contacting Dr Holliday or a senior member of the department who will be pleased to help. Specimen transport A pneumatic tube system serves the hospital (Note CSF or large volume urine samples should not be transported via the pneumatic tube system). Samples may also be hand delivered to Specimen Reception. Emergency requests and out-of-hours service From 08.45 to 20.00 Monday to Friday and 09.00 to 12.30 Saturday and Sunday all emergency requests must be telephoned to Central Specimen Reception Ext 66695. Out-with these times the On-Call BMS must be contacted using the hospital paging system, page number 1049. This enables Central Reception or the On-Call BMS to look out for the specimen. Please also write “urgent” or “please phone” on the form to indicate the degree of urgency, especially during core daytime hours, but in all cases it is essential to contact the laboratory or On-Call BMS in advance. If additional emergency tests are required beyond those already requested, please contact the laboratory or On-Call BMS. Please write the name of the doctor or nurse responsible for the patient legibly on the request form, including telephone number or page number for results. Availability of results The results of all tests are available via SCI Store approximately 45 minutes after clinical validation (therefore phoning laboratory for results does not save time). Hard copy reports follow daily. Areas that receive direct printing will receive a hard copy of results approximately 5 minutes after clinical validation. The laboratory will telephone grossly abnormal results except for those areas that have already had a directly printed report.

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2. SPECIMEN COLLECTION AND HANDLING Sample containers of any type should be obtained through normal supply routes for consumables. The Clinical Chemistry Department does not supply containers or packing materials except by special arrangement. Please follow these simple rules to help us provide a service of quality to our patients.

a. REQUEST FORM & PATIENT IDENTITY • Ensure the request form is completed correctly (Surname,

Forename, DOB, CHI No, date & time of specimen collection & brief clinical details). CHI No. barcoded addressograph label should be used whenever possible.

• The name and full address to which the report should be sent

(Consultant, GP Surgery, Hospital Ward, Clinic etc) must be included on the request form.

• The laboratory may not process samples that do not have clear

patient identification. Handwriting must be legible.

• Clinical information included on the form permits laboratory staff to assess the validity of results and may prevent unnecessary repeat analyses. Supporting information may be required for correct interpretation. For example, therapeutic drug monitoring requests require information about dosage, time since last dose, and a complete list of prescribed drugs.

• Confirm the identity of the patient prior to sampling.

b. SPECIMEN LABELLING

• Normally, the minimum for adequate identification includes the patient’s forename and surname, plus date-of-birth and CHI number. Date and time of sampling must also be included on the sample label.

• A pre-printed label is preferred: please affix it to all copies of the

request form. Do not wrap labels completely around sample containers. Lab staff must be able to see the sample to visually check for haemolysis etc.

• When emergency tests are required for unidentified patients the

requesting clinician should indicate ‘unknown male/female’ in place of name and surname, and must indicate the exact time of sample withdrawal. The Casualty number, where available, is helpful.

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• The laboratory cannot process specimens that are not clearly identified.

c. PATIENT PREPARATION

• The patient should be resting for at least 5 minutes before withdrawal of blood.

• Venous blood samples should be taken with minimal stasis.

• Hyperventilation by the patient during arterial blood gas sampling

may affect results.

Many analyses require that the specimen be collected under specified conditions, e.g. fasting. In some cases, the requirements are quite stringent. In all cases, you should make sure that the appropriate requirements are met. If in doubt, please contact the laboratory.

d. SPECIMEN COLLECTION

• Ensure that the correct sample container is used for the requested tests.

• For venous blood use vacuum blood collection tubes.

• Do not inject blood from a syringe through a hypodermic

needle (if used) into any specimen tube; this may cause haemolysis. Remove the needle first.

• You must use an appropriate container for each test.

• You must collect sufficient samples for all departments, e.g.

U/E, Gentamycin and haematinics will require three clotted samples.

• If more than one tube is collected from a patient, the

potassium EDTA tube should be filled last to avoid errors in potassium and calcium measurement.

• Anticoagulant tubes should be inverted several times to

ensure adequate mixing.

• When taking arterial blood gas samples expel liquid heparin from arterial blood gas syringes. The heparin should fill only the dead-space of the syringe. Air bubbles should be expelled before the syringe is sealed.

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• Some analyses require that the samples be collected into special containers and/or separated and deep-frozen within minutes of collection. Details of the appropriate collection containers for all samples - blood, urine, CSF, and faeces – can be found in this handbook.

• Where there is any doubt about sample preparation,

storage, or transport please contact the laboratory.

e. SPECIMEN PACKAGING • In order to minimise the risk of interchange of samples and cross

contamination a specimen bag can contain specimens from one patient only.

• Always ensure the sample container is securely capped.

f. STORAGE PRIOR TO TRANSPORT TO LABORATORY

• Do not expose the specimens to extremes of temperature prior to transport unless detailed in the sample requirements below.

• Samples should be transferred to the laboratory with minimal delay

to maintain sample integrity. Delays in centrifugation can affect the values obtained for certain analyses (e.g. potassium).

• Haemolysis will invalidate some tests including potassium, LDH,

phosphate, AST, and Troponin T.

g. SAFETY AND DANGEROUS SPECIMENS • Please note that the laboratory will not process a leaking specimen

or one that arrives with a needle attached.

• All high risk specimens must be sent in the specimen bag or otherwise sealed to protect from leakage. Tick the “High Risk” box and APPLY A YELLOW HIGH RISK STICKER TO EACH RELEVANT PAGE OF THE REQUEST FORM. Separate samples must be sent for each Laboratory Department and also for tests which will be forwarded onto an external referral laboratory.

• In practice, high risk specimens are specimens that carry the

risk of transmitting hepatitis B virus, HIV and other Category 3 pathogens.

• ‘Danger of Infection’ stickers should be put on the bag, form and

container, and the bag then sealed. For large specimens such as 24-hour urine specimens, specimen containers should be enclosed in individual clear plastic bags which must be tied at the neck.

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• The request form should be placed in a plastic envelope which is

then securely tied or taped to the neck of the sack. The request form should state the suspected/confirmed infection.

• Certain 24-hour urine collections require a container with acid –

avoid direct contact with the acid!

h. TURNAROUND TIMES

• Emergency Requests:- <2h from receipt in laboratory: General biochemistry tests, including glucose, blood gases, UE, LFT, bone profile, amylase, paracetamol, salicylate, theophylline, and common anticonvulsant drugs.

• Non-Emergency Requests:- <24h from receipt in laboratory: General biochemistry tests, including glucose, UE, LFT, bone profile, amylase, paracetamol, salicylate, theophylline, common anticonvulsant drugs, cortisol, thyroid profile, PSA. (Note Thyroid profile and PSA <72h if received in laboratory from 12.00 on Friday until Monday morning).

• <7 days: Protein electrophoresis. <14 days for specimens requiring

immunofixation.

All referred tests are subject to the turnaround times of the reference laboratory, available on request.

i. SPECIMEN STORAGE

Serum specimens are stored for up to 7 days. Additional tests, if required, may only be added during this period, with the exception of labile analytes, such as Total CO2, which require a fresh specimen.

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3. DATA PROTECTION The Data Protection Act The Data Protection Act 1998 is based upon eight enforceable principles of good

practice: 1. Personal data shall be obtained and processed fairly and lawfully. 2. Personal data shall be held only for specified and lawful purposes and shall

not be further processed in any manner incompatible with those purposes. 3. Personal data shall be adequate, relevant, and not excessive in the relation to

the required purposes. 4. Personal data shall be accurate and, where necessary, kept up-to-date. 5. Personal data shall not be retained longer than is necessary. 6. An individual shall be entitled to have access to his or her data and where

appropriate, have it corrected or erased. 7. Appropriate technical and organisational measures shall be taken against

unauthorised or unlawful processing of personal data and against accidental loss or destruction of the data.

8. Personal data shall not be transferred outside EU countries unless an adequate level of data protection exists.

Organisations are obliged to comply with these principles. Failure to comply can result in an enforcement notice being issued by the Registrar. Forth Valley guidelines for computer terminal usage • Do not allow unauthorised persons to see the data on screens. • Log off the system when finished. • Do not by any action or inaction allow disclosure of information, either directly or

indirectly, from the system to any unauthorised person.

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4. CLINICAL CHEMISTRY TESTS AND REFERENCE RANGES Sample type and container Code Description Comment sst Serum separation tube yellow cap hep Heparinised tube - all plastic construction green cap and blue/green

label edta EDTA tube purple cap p Plain tube (no preservative or anticoagulant) red cap f Fluoride oxalate grey cap pzn Plain tube for zinc, copper, selenium and

manganese (reference number 368380) royal blue cap

volat Gas-tight tube for volatile organic solvents – contact laboratory or toxbase.org.uk in advance

do not use plastic container

hep sr Heparinsed syringe 24h U 24 hour urine collection rand U Random urine collection (Plain universal, not

Boric Acid)

em U Early morning urine (Plain universal, not Boric Acid)

Guth Dried blood spot on Guthrie card required Minimum volume requirement applies to adults and older children. Notes * available as emergency test a separate tube preferred b telephone laboratory in advance and send immediately c ethanol assay is not suitable for forensic purposes d SST tube suitable for ethanol provided analysis is performed promptly e telephone laboratory in advance and send immediately on ice but not frozen f special preservative or procedure needed; arrange test with laboratory in

advance g maintain tube at 37C; contact laboratory in advance h protect from light; wrap in tin foil i 7-vitamin screen possible on full heparin tube (green cap) j overnight fasting or pre-feed k see age-related immunoglobulin ranges l interference from high dose biotin therapy; collect specimen >8hours after last

dose m collect into hydrochloric acid preservative: obtain container from laboratory n collect after overnight recumbency and remaining so o collect after at least 20min recumbency

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p collect after 4 hours upright posture q result invalid if prednisolone taken during preceding 3 days r derived result s tumour marker: normal level does not exclude malignancy; serial changes may

be more informative than reference intervals t trough level: take sample immediately before oral dose u take sample at least 6 hours after last dose v take sample at 8 hours post dose if on sustained release theophylline w take sample 12 hours post dose x varies widely according to diet y on 100g/day fat intake z only available in special situations; not a first line test A thymol preservative B transport rapidly to the laboratory on ice; store frozen C Keep cool and protect from light. No preservative. Freeze if to be stored

>24h. D Acute porphyria. Preferably collected during the attack. Protect from light. E Indicated in the cutaneous porphyrias. Protect from light. F 4 x 5ml EDTA tubes preferred

(Laboratory note: If a recently collected plain or SST clotted specimen or heparin specimen is received, separate serum immediately and stabilise the lipoproteins by transferring the serum into EDTA tubes.)

G take sample at least 8 hours post dose (Neoral cyclosporin); if on Sandimmun cyclosporin take sample at least 12h post dose.

H 24h or timed urine preferred, although a random urine specimen will be accepted

I Use plastic heparinised tube (green cap, blue/green label); avoid contact with glass.

J Avoid haemolysis (eg. do not inject into specimen tube through hypodermic needle)

K Send minimum 1ml CSF and 1ml serum (2.5 ml blood) within 24h of each other.

L Two 20ml aliquots of EMU urine required, in special preservative obtained in advance from referral laboratory.

M 3 consecutive overnight (15h) fasting specimens; or coinciding with symptoms. N send promptly to laboratory within 2 hours P Avoid Paracetamol-containing medicine for at least 48 hours prior to starting

urine collection. Please enquire for any test not listed below.

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General biochemistry - blood Test Note Sample

Type Vol ml.

Reference Range (adult unless stated otherwise)

Turnaround Time

acetoacetate Not available – measure β-OH butyrate qv.

acyl carnitine blood spot

See report. Mail Guthrie card specimen to Biochemistry at Yorkhill Hospital

ALT (alanine aminotransferase)

sst 2 11-37 iu/L <24 hours

albumin sst 2 36-52 g/L <24 hours alkaline phosphatase sst 2 age dependent:

0-30 days <380 iu/L 31d-17y <425 iu/L >17y <130 iu/L The reference range is approximately doubled in the third trimester of pregnancy.

<24 hours

alkaline phosphatase (bone specific)

see bone specific alkaline phosphatase below

alpha-1-antitrypsin level and phenotype

a sst 5 1.1-2.1 g/L. Phenotypes Z, SZ, S associated with early onset pulmonary emphysema. Z=ZZ or Z-null, S=SS or S-null.

α-galactosidase, (Yorkhill, Glasgow assay)

Stable when dry

Guth

6.3-24.8 pmol/punch/hr (standard 3mm punch).

α-galactosidase (leucocyte), whole blood (Sick Children’s Hosp, Edinburgh assay, to arrive within 24 hours))

b edta 5 0.3-1.3 nmol/min/mg protein. Male range only (x-linked)

aluminium hep 5 normal: <0.5 µmol/L chronic accumulation: >3.0 µmol/L

amino acids ej hep 3 see report ammonia e hep 1 <45 µmol/L (adult)

<100 umol/L (neonate) <60 umol/L (1-4 months)

amylase * sst 2 <90 iu/L <24 hours

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amyloid A (serum) sst 5 <10mg/L angiotensin converting enzyme ACE

sst 2 8-52 iu/L <7 days

apoprotein E phenotype

sst 5 E2,2 phenotype associated with dysbetalipoproteinaemia

AST (aspartate aminotransferase)

sst 2 12-31 iu/L <24 hours

β-quantitation (lipoprotein density subfractions)

jF edta (sst, note F)

20 see report

bicarbonate (venous; true bicarbonate from blood gas analyser)

b hep sr 2 20-28 mmol/L <15 minutes

bicarbonate (serum) – see total CO2

<24 hours

bilirubin (total) * sst 2 <17 µmol/L <24 hours bilirubin (conjugated) * sst 2 0-3.4 µmol/L <24 hours blood gases *b hep sr 2 see H+, pCO2, pO2 bone-specific alkaline phosphatase

p 2 12-31 iu/L female 15-41 iu/L male

β-OH butyrate (plasma)

hep <0.42 mmol/L >12 years <0.29 mmol/L <12 years

caeruloplasmin sst 2 0.16-0.47 g/L calcium * sst 2 2.15-2.60 mmol/L <24 hours carbon monoxide see carboxyhaemoglobin <15 minutes carboxyhaemoglobin * hep 5 <5% (non-smokers)

50%-70% may be fatal <15 minutes

Free carnitine hep 2 10 – 50 umol/L 35 days chloride * sst 2 97-107 mmol/L <24 hours cholesterol (total) sst 2 refer to FV Lipid

Guidelines <24 hours

25OH cholecalciferol see Vitamin D cholinesterase sst 6 cholinesterase “genotype” (ie.biochemical phenotype)

sst 6 see report

cobalt edta 3 Measured in patients with painful metal implants

21 days

copper hep, pzn

2 10-22 µmol/L adult male 11-25 µmol/L adult female

11 days

chromium edta 3 0-40 nmol/L Measured in patients with painful metal implants

21 days

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CK creatine kinase sst 2 23-175 iu/L males 23-142 iu/L females

<24 hours

C-Reactive Protein (CRP)

* sst 2 0- 5 mg/L <24 hours

creatinine * sst 2 60-130 µmol/L <24 hours cryoglobulins g sst 5 nil <7 days cyanide (see also thyocyanate)

edta 3 <10 µmol/L non smokers <20 µmol/L smokers

eGFR (estimated glomerular filtration rate)

sst 2 >59 ml/min/1.73m2 Excludes CKD stages 3,4 and 5

<24 hours

electrophoresis sst 2 No paraprotein or immunosuppression

7 days

erythrocyte galactose-1-phosphate

see galactose-1-phosphate

ethanol *cd sst, f 3 plasma levels: 20 mmol/L driving limit 100 mmol/L may be fatal (plasma levels are about 15% higher than whole blood levels)

<24 hours

∆F508 (cystic fibrosis DNA genotyping)

edta 1 See report

Familial hypercholesterolaemia DNA testing

edta 10 See report

free light chains sst 2 See report galactose-1-phosphate (erythrocyte)

bf hep 3 See report

gamma-glutamyl transferase

sst 2 7-43 iu/L males 7-22 iu/L females

<24 hours

glucose *j f 2 3.3-5.5 mmol/L venous plasma

<24 hours

galactose-1-phosphate uridyl transferase (RBC)(galactosaemia screen)

hep whole blood

2 see report

Gilbert’s syndrome genotype

edta whole blood

5 See report (Ninewells Hosp)

glutathione peroxidase – RBC (whole blood)

hep 4 15-50 u/g Hb

HDL cholesterol sst 3 >0.9 mmol/L <24 hours

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HLA-H gene (haemochromatosis gene)

edta 5 >83% haemochromatosis cases are homozygous for G845A mutation (H-H genotype).

homocysteine bj edta 2 <20 µmol/L hydrogen ion H+ *b hep sr 2 36-43 nmol/L <15 minutes immunoreactive trypsin Guth whole blood <70µg/L immunoglobulins k sst 5 IgG 7.0-16.0 g/L

IgA 0.7-4.0 g/L IgM 0.4-2.3 g/L Adult ranges

<24 hours

iron sst 2 11-29 µmol/L <24 hours iron and TIBC sst 2 see iron, TIBC lactate * f 3 0.7-2.1 mmol/L

Deproteinised plasma sample

LDH lactate dehydrogenase

sst 2 195-415 iu/L Adult range

<24 hours

LDL cholesterol j sst 3 see lipoprotein section <24 hours lead edta 5 <0.5 µmol/L or <1.0µmol/L

depending on environmental exposure history. Toxic >2 µmol/L. Legally permitted occupational level: 2.9 µmol/L. See lead section.

leucocyte steroid sulphatase

b hep 10 see report

lipids j sst 5 Total chol, LDL, HDL, TG lithium sst 2 Age related, see report <72 hours LFT sst 5 ALT,AST,alk

P,bili,alb,prot

magnesium sst 2 0.7-1.0 mmol/L <24 hours mercury see Mercury section osmolality * sst 2 275-295 mosmol/kg <24 hours paracetamol * sst 2 see Paracetamol section <24 hours pCO2 *b hep sr 2 4.6-6.0 kPa <15 minutes phosphate sst 2 1.45-2.91 mmol/L <10 d

1.45-2.16 mmol/L <24 m 1.45-1.78 mmol/L 2-12yr 0.87-1.45 mmol/L 12-60yr 0.74-1.32 mmol/L >60 yr

<24 hours

pO2 *b hep sr 2 10.5-13.5 kPa <15 minutes

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porphobilinogen deaminase

edta 5 see Porphyria Screening and Diagnosis Section.

potassium * sst 2 3.5-5.0 mmol/L <24 hours PIIINP (procollagen 3 aminopeptide)

sst

2 Adult 1.7-4.2 ug/L Consider biopsy (adults on MTX,) if >4.2 3x in 12 months, or >8.0 consecutively. Consider MTX withdrawal if >10.0 3x in 12 months

protein (total) sst 2 62-80 g/L <24 hours RBC protoporphyrin edta 5 see Porphyria Screening

and Diagnosis Section.

pyruvate ef Hep edta, f

4 40-70 umol/L

phytanic acid hep 1 see report salicylate * sst 5 therapeutic <350 mg/L <24 hours selenium pzn,

hep 2 0.8-2.0 µmol/L Adult

0.7-1.7 µmol/L 4-16 yr 0.5-1.3 µmol/L 2-4 yr 0.2-0.9 µmol/L 0-2 yr

Sodium * sst 2 135-145 mmol/L <24 hours steroid sulphatase (leucocyte)

see leucocyte steroid sulphatase

total CO2 (“bicarbonate”)

sst 2 23-30 mmol/L <24 hours

total iron binding capacity

sst 2 45-72 µmol/L <24 hours

thiocyanate sst 2 <70 µmol/L non-smokers thiopurine methyl transferase

edta x2 12 26-50 pmol/h/mgHb

transketolase see Vitamin B1 triglycerides j sst 2 <2.0 mmol/L <24 hours troponin T l sst 2 <50 ng/L <15 hours tryptase sst 5 See tryptase section urea * sst 2 2.5-8.0 mmol/L <24 hours urea and electrolytes * sst 5 Na,K,Cl,urea,creat. Urate sst 2 0.12-0.42 mmol/L <24 hours very long chain fatty acids VLCFA

hep 3 see report

vitamin A (retinol) hi hep 3 1.0-3.0 umol/L vitamin B1 (thiamin) (replaces transketolase)

i hep 5 275-675 ng TDP/gHb NB: whole blood assay

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vitamin B2 (riboflavin) flavin dinucleotide measured

i hep 2 1.0-3.4 nmol/gHb (from Feb. 2008)

vitamin B6 (pyridoxine) pyridoxyl PO4 measured

hi hep 2 250-680 pmol/g Hb (from Feb. 2008)

vitamin C (ascorbic acid) –plasma

if hep 5 15-90 umol/L

vitamin D 25OH cholecalciferol

sst 2 25-170 nmol/L West of Scotland population range. 50-170 nmol/L therapeutic target.

1,25 OH cholecalciferol

sst 3 20-120 pmol/L

vitamin E (tocopherol) hi hep 3 3.5-9.5 umol/mmol Cholesterol (Adult Range)

vitamin K hi hep 3 Cystic fibrosis patients only. Please write “CF” in the clinical history.

14 days

zinc J pzn 3 10.0-18.0 µmol/L Female 10.0-18.0 µmol/L Male 0-9 years 10.7-18.0 Male > 9 years

11 days

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Hormones - Blood and urine Test Note Sample

Type Vol ml.


Turnaround Time

ACTH adrenocorticotrophin

eJ edta

3 <20 mU/L (approx <80 ng/L) Basal levels adrenal adenoma: <2mu/L pituitary Cushings: 5-50mU/L ectopic ACTH: often >75mU/L

active renin concentration

eoz edta See report. Only measure if PRA interpretation is in doubt.

adrenaline m P 24h U <230 nmol/24h >11yr 18 days adrenaline/creat ratio m P 24h U <0.08 mmol/mol creat <12yr aldosterone n sst 5 100-400 pmol/L. (Supine).

See Endocrine Hypertension section.

aldosterone/renin molar ratio

normal <400 >700 suggests primary hyperaldosteronism. See Endocrine Hypertension section.

alpha subunit TSH, alpha subunit, common α-subunit

plain

3 <1 iu/L <3 iu/L mid cycle, post menopause. Not applicable in pregnancy due to HCG cross reaction.

alpha subunit TSH/TSH ratio

plain 3 see report

androstenedione sst 2 1.6-8.4 nmol/L males <41yr 1.3-6.6 nmol/L males >40yr 0.6-8.8 nmol/L females <41yr 0.9-6.8 nmol/L females >40yr <2 nmol/L prepubertal children

C-peptide bj hep 2 0.36-1.12 nmol/L calcitonin bJ hep 2 <15 ng/L catecholamines m P 24h U see noradrenaline,

adrenaline, dopamine

cortisol (serum) lq sst 2 166-773 nmol/L 0800-0900 83-414 nmol/L 1600-1700 60-340 nmol/L 2100-2400

<24 hours

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cortisol (serum) - 0900 specimen after overnight dexamethasone (1mg dexamethasone)

sst 2 <50 nmol/L

cortisol (saliva) 5-25 nmol/L morning ≤10 nmol/L midnight

cortisol (urine free cortisol)

24h U <250 nmol/24h

cortisol/creatinine ratio EMU 20 <25 nmol/mmol creatinine DHAS (dehydro-epiandrosterone sulphate)

sst 2 2-9 µmol/L males 2-11 µmol/L females <50yrs <2 µmol/L prepubertal children

dopamine m P 24h U <3300 nmol/24h >11yrs 18 days dopamine/creatinine ratio

m P 24h U <2.2 mmol/mol creat. <1yr <1.5 mmol/mol creat. 1-3yr <0.8 mmol/mol creat 4-11yr

FAI free androgen index

r sst 2 <7 females FAI not informative in males

Free Metadrenaline Excretion

m P 24h U 0-350 nmol/24 hours

Free Normetadrenaline Excretion

m P 24h U 0-650 nmol/24 hours

FT4 free thyroxine sst 2 9-24 pmol/L <72 hours FSH follicle stimulating hormone

sst 2 3-8 u/L follicular phase 2-16 u/L mid-cycle 1-5 u/L luteal phase 18-150 u/L postmenopausal age related: 0.6-3.6 u/L children <11yr <1.0-4.5 u/L males 24-40yr <1.0-6.4 u/L males 41-59yr 2.5-23 u/L males 60-84yr <1-5.7 u/L females 21-30yr <1-9.2 u/L females 31-40yr 28-102 u/L females 55-83yr

8 days

Gastrin ejJ hep 2 <120 ng/L growth hormone (serum)

j sst 2 <0.40ug/L excludes acromegaly

growth hormone (urine) L 2x 20

see report

gut hormone screen CONTACT LAB IN ADVANCE

ef edta 10 see report

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HCG human chorionic gonadotrophin - early pregnancy

sst 3 see HCG section

17OH Prog 17 hydroxyprogesterone

sst 2 <13 nmol/L adults <13 nmol/L normal infants <40 nmol/L stressed infants >50 nmol/L CAH

IGF1 insulin-like growth factor 1

sst 3 13 – 180ug/L 2 – 4 years 26 – 200ug/L 5 – 7 years 70 – 460ug/L 8 – 10 years 150 – 600ug/L 11 – 13 yrs 200 – 650ug/L 14 – 16 yrs 100 – 580ug/L17 – 25 years 65 – 350ug/L 26 – 39 years 50 – 315ug/L 40 – 54 years 35 – 240ug/L 55 – 65 years 30 – 240ug/L 65+ years

IGFBP3 insulin-like growth factor binding protein 3

sst 2 by arrangement: not routinely available

IGF2/IGF1 ratio insulin-like growth factors 1 & 2

e sst 5 In NIST hypoglycaemia, molar ratio IGF2/IGF1 usually >10

insulin ejJ hep 2 <13 mU/L insulin C-peptide see C-peptide insulin/glucose ratio MeJ ratio = insulin/(glucose-1.7)

units: mU/mmol ratio>30 suggests insulinoma To detect insulinoma: 3 consecutive overnight fasting specimens. Ref: Turner, Oakley, Nabarro. 1971. BMJ vol2 132-135.

LH luteinising hormone sst 2 2-13 u/L follicular phase 34-115 u/L mid-cycle 1-16 u/L luteal phase 16-64 u/L postmenopausal age related: ud-3.4 u/L children <11yr <2.0-8.6 u/L males 24-40yr <2.0-8.0 u/L males 41-59yr <2.0-33 u/L males 60-84yr <2-15 u/L females 21-30yr <2-34 u/L females 31-40yr 23-70 u/L females 55-80yr

8 days

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macroprolactin sst 2 <1% of total prolactin (Clin Endo (1999) 51,119-126)

noradrenaline m P 24h U <900 nmol/24h >11yr 18 days noradrenaline /creat Ratio

m P 24h U <0.42 mmol/mol creat <1yr <0.20 mmol/mol creat <12yr

oestradiol

sst 2 female ranges (GRI): 70-180 pmol/L follicular 430-1650 pmol/L mid-cycle 270-830 pmol/L luteal <100 pmol/L postmeno. 2009 ranges (Also: www.ngtbiochemorg.uk)

PRA plasma renin activity

eo ep

edta 5 0 - 40 uIU/ml supine 0 - 52 uIU/ml upright see Endocrine Hypertension section

PTH parathormone JN edta 2 1.6-7.5 pmol/L PTHRP PTH-related peptide

ef contact lab; special tube needed

prolactin

sst 2 <400 mU/L adult males <630mU/L adult females 80-1720 mU/L o.c. pill 290-1750 mU/L preg <12wk 330-4800 mU/L preg 12-28wk 770-5700 mU/L preg 29-40wk

8 days

progesterone sst 2 <2 nmol/L follicular 1-4 nmol/L mid-cycle 18-72 nmol/L luteal 50-130 nmol/L preg. 9-16wk 65-250 nmol/L preg16-18wk 180-490 nmol/L preg 28-30wk 350-790 nmol/L term <2 nmol/L postmenopausal <2 nmol/L males Progesterone >20 nmol/L in an untreated cycle is consistent with ovulation.

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SHBG sex hormone binding globulin

sst 2 20-155 nmol/l females 14-50yr 13-70 nmol/L males 14-50yr

somatomedin C see IGF1 steroid profile - urine 24h U see report testosterone sst 2 10-36 nmol/L males <50 yr

0.5-3.2 nmol/l females <50 yr 0.7-2.7 nmol/L o.c. pill

TBG thyroxine binding globulin

sst 2 12-30 mg/L (No longer assayed. Not to be confused with Thyroglobulin).

TFT thyroid function tests

sst 3 TSH; FT4, TT3 if indicated

TRAb thyroid receptor antibodies (Haematology Dept)

(please send specimen to FV Haematology Dept)

TRβ gene sequencing (thyroid hormone receptor β)

edta 10 see report

TSAb thyroid stimulating antibody (obsolete nomenclature)

see TRAb thyroid receptor antibodies (Haematology Dept)

TSH thyroid stimulating hormone

sst 2 0.35-5.5 mU/L <72 hours

TSH alpha subunit see alpha subunit TSH TSI thyroid stimulating immunoglobulins (obsolete nomenclature)

see TRAb thyroid receptor antibodies (Haematology)

TT3 total triiodothyronine

sst 2 0.9-2.8 nmol/L <72 hours

TT4 total thyroxine sst 2 55-144 nmol/L (non-pregnant)

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Therapeutic drugs Note: Anticonvulsant therapeutic ranges should be treated as an approximate guide only. Clinical control and evidence of toxicity also guide dose. Test Plasma

half-life hrs

Note Sample Type

Vol ml

Therapeutic Range (adult unless stated otherwise)

Turnaround Time

amiodarone sst 0.5-2.0 mg/L 2 – 3 Weeks azathioprine Assay not available.

Send K-EDTA sample for thiopurine methyl transferase (contact lab)

carbamazepine 12-30 t sst 2 4-12 mg/L <24 hours clozapine edta 2 see report; follow

instructions on special CPMS request form

cyclosporin G edta 2 Microgenics assay, Gartnavel Hospital: 60-200 ug/L NB Varies according to graft and other drugs - seek specialist advice. Therapeutic values also depend on assay manufacturer

Desmethyl-amiodarone

sst 0.5-2.0 mg/L 2 – 3 Weeks

digoxin 36 *u sst 2 0.5-2.0 ug/L <24 hours ethosuximide 40-60 sst 2 40-80 mg/L 2 – 3 Weeks FK506 edta 6 see tacrolimus gabapentin sst 2 <2 mg/L; toxicity >20

mg/L 2 – 3 Weeks

lamotrigine sst 2 1-4 mg/L; some patients respond at levels up to 15 mg/L

2 – 3 Weeks

lithium 18-36 w sst 2 Age related, please see report

<72 hours

methotrexate sst 2 if >0.1 umol/L 24h post dose, increase dose of leucovorin - seek specialist advice

phenobarbitone 96 t sst 2 15-40 mg/L (adults and children) 15-30 mg/L (neonates)

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phenytoin 13-46 t sst 2 10-20 mg/L <24 hours primidone 8 t sst 2 20-70 umol/L sodium valproate 12 t sst 2 50-100 mg/L <24 hours tacrolimus (FK506) [tacrolimus 2 assay]

edta (two tubes)

6 4-25ug/L; toxicity above 30ug/L. Range for FK rescue where cyclosporin is failing: 10-20 µg/L

theophylline 5-10 tv sst 2 10-20 mg/L <24 hours drugs of abuse screening

urine see below

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Toxicology - Urine, Blood and other tissues Specimens are accepted as clinical specimens only, at the request of a registered medical practitioner, for the medical management of the patient. “Normal ranges” do not necessarily correlate with toxic thresholds and there may be considerable inter-patient variability. Please supply as much clinical information as possible, including symptoms and TIME INTERVAL BETWEEN EXPOSURE AND SPECIMEN COLLECTION. Test or toxic substance

Note Sample Type

Vol ml.

Comments Turnaround Time

volatile solvents volat blood and urine required carbon tetrachloride (dry cleaner)

volat blood and urine required

carbon monoxide see General Biochem. - Blood

organophosphates sst serum or RBC cholinesterase

Misc. heavy metals contact laboratory lead see General Biochem. -

Blood

mercury see General Biochem. - Blood

drugs of abuse rand U ecstasy (MDMA) rand U requires polyclonal anti-

amphetamine EMIT reagent

flunitrazepam (Rohypnol)

sst not reliably detectable in urine: blood specimen required

propoxyphene rand U not detected in EMIT opiate screen; contact lab

therapeutic drugs see therapeutic drugs section

ethanol see General Biochem. - Blood

<24 hours

methanol

f, sst metabolic acidosis; osmolal gap often >2 mosmol/kg

ethylene glycol f, sst metabolic acidosis; calcium may be low; requires direct measurement if there is a definite possibility of ingestion

methaemoglobin-forming agents

hep 3 methaemoglobin measurement

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Tumour markers - Blood and urine Test Note Sample

Type Vol ml.


Turnaround Time

AFP alpha-foetoprotein s sst 2 <6 kU/L 8 days CA 125 s sst 2 <35 kU/L

premenopausal <25 kU/L postmenopausal

8 days

CA 15.3 s sst 2 <30 kU/L CA 19.9 s sst 2 <35 kU/L. >2000 kU/L

signifies advanced pancreatic carcinoma

15 days

CEA carcinoembryonic antigen

s sst 2 <5 µg/L 8 days

chromogranin A sst 2 see report free PSA see PSA free/total ratio HCG human chorionic gonadotrophin

s sst 2 <5 U/L also elevated in pregnancy

8 days

5-HIAA 5-OH indoleacetic acid

m 24h U 0 - 42 µmol/24h

NSE neurone specific enolase

s sst 2 <12.5 µg/L

PSA prostate specific antigen

s sst 2 <4 µg/L 3 days

PSA free/total ratio >12% less likely to be associated with malignancy (where total PSA 4-10 µg/L) (Sheffield PRU 23.6.03)

thyroglobulin s sst 2 <55 µg/L

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General Biochemistry - Urine Shorter timed collection, or creatinine ratio, may be acceptable if 24h collection is not possible. Test Note Sample

Type Vol ml


Turnaround Time

amino acids A rand U 100 see report amylase timed

urine 5 120-648 iu/24h <24 hours

amphetamines rand U 5 nil Bence-Jones protein see electrophoresis

(urine)

benzodiazepines rand U 5 nil calcium 24h U 2.5-7.5 mmol/24h <24 hours catecholamines see Hormone section chloride x 24h U 110-250 mmol/24h <24 hours copper 24h U 0.2-0.6 µmol/24h Creatinine 24h U 9.0-18.0 mmol/24h <24 hours cystine A 24h U cystinuria homozygotes:

>1.25 mmol/L or >120 µmol cystine/mmol creat. [mol wt cystine taken as 242]

creatinine clearance 24h U &sst

85-150 ml/min

<24 hours

deoxypyridinoline, free EMU 3.0-7.4 nmol/mmol creat, female 2.3-5.4 nmol/mmol creat, male

electrophoresis rand U 20 no paraprotein; trace of albumin may be normal

7 days

glycosaminoglycans AH 24h U rand U

≥50 see report

haemoglobin rand U 5 not detected 5-hydroxyindole acetic acid

m

24h U see Tumour Markers section

hydroxyproline (bone resorption marker)

superseded by urinary free deoxypyridinoline, qv.

laxative analysis (urine) rand U 20

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lead m 24h U Legally permitted limit: <60 nmol/mmol Creat.. See lead section.

low level albumin (microalbumin)

EMU 5 <30mg/L <24 hours

low level albumin (microalbumin)

rand U 5 0 – 2.5 mg/mmol creatinine (male) 0 – 3.5 mg/mmol creatinine (female)

<24 hours

magnesium 24h U 2.3-10.7 mmol/24h <24 hours methadone rand U 5 nil mucopolysaccharides see glycosaminoglycans myoglobin rand U 5 not detected opiates rand U 5 nil organic acids B rand U 20 see report osmolality * rand U 2 <1400 mosmol/kg:

compare with serum osmolality

<24 hours

phosphate 24h U 16-48 mmol/24h <24 hours porphyrin screen see Porphyria section potassium 24h U 25-125 mmol/24h <24 hours protein 24h U <0.1g/24h <24 hours Sodium *x 24h U 40-220 mmol/24h <24 hours Urea * 24h U 250-580 mmol/24h <24 hours Urate 24h U 1.5 - 4.7 mmol/24h <24 hours

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General Biochemistry - Faeces Test Note Sample

Type Wt g


Turnaround Time

faecal calprotectin random 10 0-50ug/g 28 days faecal chymotrypsin B 10 >13.2 iu/g wet weight faecal elastase random 5 200 - 1000 µg/g 21 days faecal fat (no longer available – replaced by faecal elastase)

<20 mmol/24h fatty acid residues equivalent to <7 g/24h fat

fat globules assay not available; consider faecal elastase

faecal occult blood (only available on selected paediatric patients <3 years old)

5 negative on three occasions

<24 hours

faecal reducing substances (assay no longer available)

B 5 not detected

porphyrin screen see Porphyria section General Biochemistry - CSF Test Note Sample

Type Vol ml


Turnaround Time

CSF glucose f 0.5 >70% of simultaneous plasma glucose

<2 hours

CSF protein 0.5 0.2-0.4 g/L <2 hours CSF IgG/total protein ratio

no longer available – replaced by CSF oligoclonal bands

CSF lactate f 0.8-2.4 mmol/L CSF oligoclonal bands (must be accompanied by serum specimen)

K 1.0 see report

CSF xanthochromia 2.0 bilirubin – not detected oxyhaemoglobin – not detected See CSF xanthochromia section

<24 hours

CSF Pyruvate f 70-140 umol/L (less than 1 month old) 40-80 umol/L (greater than 1 month old)

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General Biochemistry - Fluids Test Note Sample

Type Vol ml


Turnaround Time

glucose f 1 >70% of simultaneous plasma glucose

<24 hours

protein p 1 >30 g/L = exudate <30 g/L = transudate

<24 hours

Cystic fibrosis screening - sweat and blood Test Note Sample

Type Vol ml

Reference Range Turnaround Time

sodium sweat non-CF CF <50 >70 mmol/L child 20-80 >80 mmol/L adults

<2 hours

chloride sweat non-CF CF <50 >60 mmol/L child 10-50 >70 mmol/Ladults

<2 hours

immunoreactive trypsin blood spot

See Cystic Fibrosis Screening under Special Test Groups

DNA genotyping (inc. ∆F508)

edta 1 as above

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Nutritional Screen Suggested protocol; may be modified for individual patients. Test No. of

Tubes Specimen Tube Destination Turnaround

Time zinc copper selenium

1 pzn (royal blue) GRI. Separated serum to be sent to GRI.

11 days

manganese 1 edta or heparin whole blood

GRI as above

RBC glutathione peroxidase [selenium marker]

1 heparin; green GRI. To be sent unseparated to GRI, preferably by taxi on a Monday, to arrive within 24h of collection.

RBC folate 1 edta; purple Refer to haematology handbook

Vitamins B2, B6 1 heparin whole blood; green

GRI as above

vitamins A, B1, C, E, B12, K

1 heparin; green GRI as above. Wrap in foil to protect from light.

calcium, PO4, albumin, protein LFT, UE creatinine, magnesium, iron, CRP

1 sst (gel tube); yellow

FVRH <24 hours

electrolytes, Mg, urea, creatinine

1 24h urine collection

FVRH <24 hours

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5. Special test groups Paracetamol Poisoning

treatment lines in paracetamol poisoning

0

20

40

60

80

100

120

140

160

180

200

220

4 6 8 10 12 14 16 18 20 22 24

hours post ingestion

serum paracetamol

mg/L

high-risktreatment line

normaltreatment line

1 A single level above the treatment line warrants treatment with N-acetyl cysteine or methionine. The high risk line applies to patients exposed to enzyme-inducing drugs (eg. anticonvulsants, rifampicin, alcohol). Otherwise use the normal risk line. Do not take the specimen until after 4 hours after ingestion; before this results may be misleading. 2 If the time of ingestion cannot be established reliably and paracetamol is detected but below the 4 h treatment threshold, repeat the paracetamol level after a further 4 hours. 3 If tricylcic antidepressants (TCA), which delay gastric emptying, have been taken, and the 4 hour level is below the threshold, repeat the paracetamol level at 8 hours. 4 If in doubt always treat with N-acetyl cysteine which can be life-saving. Benefit is not restricted to treatment begun within 24h and NAC should be given if there is a suspicion of serious overdose more than 24h ago even if the paracetamol level is below the line. 5 Ensure that LFTs are also requested in writing and by telephone on the admission specimen for use as a baseline. They will be reported routinely.

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Consult also the chapter on Emergency Treatment of Poisoning in the British National Formulary, the Parvolex protocol in AE, and seek expert advice if a toxic level is found. Porphyria Screening and Diagnosis The porphyrias arise from defects in the haem synthetic pathway. The presentation depends on the site of the defect and may be acute, for example abdominal pain or neurological symptoms (acute intermittent porhyria (AIP), variegate porphyria, coproporphyria), or may be gradual with skin lesions (porphyria cutanea tarda, variegate porphyria, erythrocytic protoporphyria). Acute attacks are often precipitated by enzyme inducing drugs. Prompt diagnosis enables unnecessary laparotomy to be avoided and drug avoidance advice to be given. The acute porphyrias have acute and latent phases. Biochemical diagnosis is best made in the acute phase, or failing that within a week of recovery. Specimens should be collected before the symptoms have subsided, however specimens from the latent phase will be accepted. Typical patterns of positive screening test results on fresh urine in the main porphyria categories (parentheses indicate variable or borderline) presentation Porphyria

type During acute attack

2-3d after acute attack

<7d after acute attack

latent phase

acute AIP U PBG U porphyrins

U PBG U porphyrins

(U PBG) (U porphyrins)

acute Variegate U PBG U porphyrins

(U PBG) U porphyrins

(U porphyrins)

cutaneous U porphyrins Acute porphyrias (AIP, variegate porphyria, coproporphyria): Please send an EDTA whole blood specimen for PBG deaminase and plasma porphyrins, and a random 20ml urine specimen for urine porphyrins collected during or as soon as possible after an acute attack. Although the defect in AIP is deficiency of PBG deaminase, assay of this enzyme alone is not sufficient, because there is overlap in blood PBG deaminase levels between AIP patients and normal subjects. In Variegate Porphyria, after the attack has subsided, urine porphyrins may remain positive longer than PBG. Faeces is not routinely required, and will be requested by the Porphyria Referral Laboratory, Cardiff, only in cases of difficulty.

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Cutaneous porphyrias: In patients with skin lesions only, the urine PBG test is not indicated. Collect EDTA whole blood for red cell protoporphyrin, and a random 20ml urine specimen. IN ALL CASES PLEASE STATE CLINICAL DETAILS INCLUDING SYMPTOMS AND TIME INTERVAL SINCE ANY ACUTE ATTACK. Test Note Sample

type vol ml

Reference range (adult unless stated otherwise)

urine porphyrins screen and quantitation

CDE rand U 20 porphobilinogen <10.2 umol/L total porphyrins 20-320 umol/L

faecal porphyrins F faeces 5g total porphyrins <200 nmol/g dry weight

red cell PBG deaminase D edta 10 see report red cell protoporphyrin E edta 10 0.4-1.7 umol/L plasma porphyrin D edta 10 <11.2 nmol/L Notes C Keep cool and protect from light with aluminium foil. Transport rapidly to

laboratory. No preservative. Freeze if to be stored >24h. D Required in acute porphyrias. Preferably collected during the attack. Protect

from light with aluminium foil. Freeze if to be stored >24h. E Required in cutaneous porphyrias. Protect from light with aluminium foil. F Only required if requested by the Porphyria Referral Laboratory, Cardiff, in

cases of difficulty.

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Thyroid Function Tests Please request “TFT”. TSH is measured as a first line test, with FT4 added automatically if TSH is outwith limits, and TT3 added if FT4 is above its normal limit. Special situations needing FT4 or TT3 measurement irrespective of TSH level: • Carbimazole therapy, recent radioiodine therapy, hypopituitarism – write “TSH,

FT4”. • Amiodarone therapy – please write “TSH, FT4, TT3”. Guide to interpretation TSH and FT4 - patients not on thyroid treatment. In clinical thyrotoxicosis, TSH is usually below the assay detection limit. Interpretation may be difficult in the following conditions: Sick euthyroid syndrome - severe non-thyroidal illness may cause misleading

disturbances in TSH, FT4 and TT3 levels which revert to normal after recovery. Often TSH is normal to low, FT4 usually normal and TT3 suppressed. FT4 may be low in extremely ill patients. In acute psychiatric disturbance, a pattern of normal TSH, normal TT3 and elevated FT4 is recognised. Seek expert advice before making a diagnosis of thyroid disease, or repeat TFTs after the patient has recovered.

Elderly - moderately raised TSH, 5.0-15 mU/L, with normal FT4, is common.

Proceed cautiously. If there are clear symptoms of hypothyroidism, try low dose (25ug) thyroxine. Otherwise, observe for 6 weeks and check thyroid antibodies.

Heterophilic antibodies. Some individuals have serum antibodies that cross

react with the monoclonal mouse proteins used in hormone assays. TSH and FT4 results may be wildly discordant. Total T4 measurement can be arranged to further investigate results where an artefact is suspected.

TSH and FT4 - patients treated with thyroxine. Both TSH and FT4 should be within the normal range for most patients. Suppression of TSH into the range 0.1-0.5 mU/L, or slight elevation of FT4, is not uncommon in patients who are otherwise correctly replaced. TT3 is mainly of use (1) in detecting early thyrotoxicosis and T3 toxicosis where FT4 is not clearly elevated, and (2) occasionally for assessing the adequacy of thyroxine replacement. Obviously TT3 must be measured if replacement is with triiodothyronine. TT3 measurement is not helpful in the diagnosis of hypothyroidism. Amiodarone therapy - If patient has thyroid symptoms or abnormal biochemistry seek expert advice. Amiodarone may induce moderate and misleading elevations of TSH

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and FT4 in a patient whose peripheral tissues are euthyroid (TT3 not elevated), or it may induce genuine hypothyroidism or hyperthyroidsim by virtue of its iodine content. Lipoproteins - Specialised investigations available Specialised lipoprotein investigations may be helpful in the following situations. Please consult the Biochemistry Laboratory for advice. Dysbetalipoproteinaemia (remnant hypercholesterolaemia, Type 3 Fredrickson Hyperlipidaemia): Defective apoprotein E-mediated VLDL catabolism. Molar concentration of serum triglycerides approximates to serum cholesterol. Usually E2,2 homozygosity plus an aggravating metabolic factor. Apoprotein E phenotype usually diagnostic; ultracentrifugation of EDTA plasma (β-quantitation) may also help. Poor vascular risk. Chylomicronaemia: Very high triglyceride levels owing to defect in the clearance of chylomicrons from plasma, with risk of acute pancreatitis: Lipoprotein lipase deficiency (Familial Type 1 Hyperlipidaemia): Post-heparin

plasma lipoprotein lipase activity <10% normal. Restrict dietary long chain fatty acyl triglycerides, partial replacement with medium chain fatty acyl triglycerides.

Type 5 Hyperlipidaemia: Normal post-heparin lipoprotein lipase activity.

General low fat dietary restriction, or treat with fish oils, or nicotinic acid. Abetalipoproteinaemia: Absent chylomicrons, VLDL and LDL, with neurological sequelae. Investigate by β-quantitation or apoprotein B measurement. Analphalipoproteinaemia (Tangier disease): Absent HDL. Non-vascular

complications. Investigate by β-quantitation or apoprotein A measurement. Cholestasis (eg. biliary cirrhosis): Abnormal lipid-rich particle, lipoprotein X, regurgitated into plasma, causing raised total cholesterol. HDL cannot be measured by standard techniques and should be disregarded. Apoprotein B estimation gives indication of true LDL level.

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Endocrine Hypertension - Screening for primary hyperaldosteronism: The random aldosterone/renin ratio may be used as an initial screen for primary hyperaldosteronism (Conn’s adenoma, nodular hyperplasia). (This replaces overnight recumbency plasma renin activity (PRA) measurement.) Patient preparation: Avoid β-blockers, labetolol, methyldopa, clonidine and prazosin for one week before sampling. These drugs suppress PRA and may therefore increase the ratio. Time and posture are unimportant, however patient should preferably have been sitting for 30 minutes. Specimen collection: See separate requirements for aldosterone and PRA (see Hormones section). aldosterone/renin ratio Interpretation <400 Normal 400-700 Borderline. Consider salt loading test (measure

aldosterone) - inpatient procedure if CCF present. Seek expert advice.

>700 Primary hyperaldosteronism. Proceed to imaging. aldosterone >800 pmol/L, renin undetectable

Suggests Conn’s adenoma. Proceed to imaging.

Units: aldosterone molar units (pmol/L)/PRA activity units (ng/mL/h), ie. pmol/ug/h. NB. For proper interpretation of aldosterone and PRA as individual results, it remains necessary to observe the conventional posture requirements. Based on Hypertension Clinic Guidelines, University of Dundee

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ββββ-HCG Gestational Ranges (Cobas e411 method) manufacturer’s data U/L weeks of gestation

5th percentile

95th percentile

3 5.8 71.2 4 9.5 750 5 217 7138 6 158 31795 7 3697 163536 8 32065 149571 9 63803 151410 10 46509 186977 12 27832 210612 Cystic Fibrosis Screening Sweat sodium and chloride is the definitive screening test. The sweat test will be performed on request by Clinical Chemistry staff. See the main reference range section. The fludrocortisone suppression test of sweat sodium and chloride (no suppression in CF), does not provide better diagnostic discrimination than a well performed basal sweat test. Blood spot immunoreactive trypsin cards should be sent directly to Medical Genetics, Yorkhill Hospital, Glasgow.

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CSF Xanthochromia Xanthochromia (yellow discolouration) of CSF may be due to bilirubin, haem pigments, or protein >1g/L. Following a haemorrhage into the CSF, red cells break down rapidly to oxyhaemoglobin and after 12 hours bilirubin is frequently also detectable. The finding of bilirubin in CSF collected 12 hours or more after onset of symptoms is a strong indicator of subarachnoid haemorrhage. The presence of oxyhaemoglobin alone is non-specific and may sometimes reflect a traumatic tap. Methaemoglobin may also be detected but this pigment is considered non-specific. Spectrophotometric scanning of CSF for xanthochromia is indicated where subarachnoid haemorrhage is suspected and the CT scan is negative. Specimen collection: Please send either the 2nd or 3rd aliquot of CSF, whichever is less bloodstained, to Clinical Chemistry. At least 1.5ml of CSF is required. The specimen should be transported directly to Clinical Chemistry by hand for immediate centrifugation and separation of cellular debris. Do not drop or shake specimen as this may lyse red cells. For the same reason do not use the air tube (pneumatic tube) specimen transport system. The specimen must be delivered within 15 minutes; please inform the on-call BMS in advance. Analysis: CSF supernatant samples are sent once daily at 9.00am by taxi to the Southern General Hospital for analysis; specimens received after this will be sent the following day. Please write "?SAH" on the form and supply relevant clinical details as this will help the laboratory at Southern General Hospital to interpret the spectrophotometric scan findings. Please note that spectrophotometric scanning of CSF for xanthochromia is not a routine part of CSF examination, therefore scanning for xanthochromia should only be requested where subarachnoid haemorrhage forms part of the differential diagnosis. Troponin T Troponin T analysis is performed at the following times, 7 days per week: 0930, 1100, 1400, 1600, 2030. Please ensure specimens are sent to arrive in the laboratory before these times; specimens cannot be added to a batch once it has started. Exocrine pancreatic function testing The preferred screening test is Faecal Elastase (5g random faeces, stable at ambient temperature). In common with all biochemical tests of exocrine pancreatic function its

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sensitivity is limited in mild to moderate cases. It replaces the TEFA test (fat absorption test) and faecal fat measurement. IgG Subclasses IgG subclass measurement for investigation of suspected immune deficiency is no longer available, and is replaced by measurement of Functional Antibodies (serum antibodies to pneumococcus and haemophilus); please send specimen to the Microbiology Department. Serum tryptase Serum tryptase measurement may be indicated for the investigation of anaphylactic reaction to anaesthetic agents. In addition to “tryptase”, please also write “latex, penicillin, anaesthetic related drugs” on the request form. Analysis is carried out in the Immunology Department, Western Infirmary, Glasgow, and includes serum patch testing for latex and propofol. Although tryptase is stable in vitro, it has an in vivo half-life of 2.5 hours, therefore the specimen should be collected within 2 hours of the anaphylactic event if possible. Lead poisoning Exposure to inorganic lead (eg. old paint) - please send whole blood specimen (EDTA). Exposure to organic lead (eg. tetraethyl lead) - please send 24 hr urine collected into acid preservative. NB: The reference range for blood lead used to be quoted as <1.0 µmol/L. This is probably still appropriate for older adults in the general population. With the advent of lead-free petrol, general population reference limits are falling, and nowadays for young people normal levels are usually <0.5 µmol/L. Evidence of toxicity (eg. in the porphyrin pathway) may be found at 2.0 µmol/L in some individuals. The legally permitted blood level limit for occupational exposure has recently been reduced to 2.9 µmol/L. Mercury poisoning Acute exposure: please send blood and urine. Chronic exposure, toxicity likely: please send head hair, pubic hair, finger nail and toe nail clippings. Hair and nail samples must be correctly labelled and sent in four separate polythene bags available from the Clinical Chemistry Laboratory. Occupational screening in dental practice: please send head hair only; other samples will be requested later if necessary.

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Test Note Sample type

vol ml

Reference range (adult unless stated otherwise)

Mercury - blood edta, hep

5 <30 nmol/L; Suggested occupational limit for inorganic Hg: 250 nmol/L

Mercury - urine rand U 25 <5 nmol/mmol creat Suggested occupational limit for inorganic Hg: 1000 nmol/L

Mercury - head hair. Same amount as one matchstick. Avoid hair roots.

hair <0.2 µg/g

Mercury - pubic hair. >12 hairs.

hair <0.2 µg/g

Mercury - finger nail. 5 clippings, representing one week’s growth.

nail <0.2 µg/g

Mercury - toe nail. As above.

nail <0.2 µg/g

Trace metals The following trace metal assays are available: Aluminium Chromium Manganese Selenium Arsenic Copper Mercury Zinc Cadmium Lead Nickel Cobalt Where collection requirements are not listed in the tables above please contact the laboratory. Some of these metals are liable to contamination from metal needles, glass, or rubber, and require special collection conditions.

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6. Referral Laboratories Please send samples to the Clinical Chemistry laboratory; they will be forwarded to the appropriate centre. β OH butyrate Biochemistry Department, Royal Hospital for Sick

Children, Yorkhill, Glasgow G3 8SJ α1AT and phenotype Dept Clinical Biochemistry, Western General

Hospital, Crewe Road, Edinburgh EH4 2XU α-galactoidase, plasma, blood spot (Fabry disease)

Biochemistry Department, Royal Hospital for Sick Children, Yorkhill, Glasgow G3 8SJ

α-galactosidase, whole blood (Fabry disease)

Dept Biochemistry, Royal Hospital for Sick Children, Edinburgh

β-quantitation of lipoproteins

Dept Clinical Biochemistry, Royal Infirmary, Glasgow G4 0SF

α-subunit TSH Regional Endocrine Laboratory, Clinical Biochemistry Dept, University Hospital Birmingham NHS Trust, Selly Oak Hospital, Birmingham B29 6JD

5-HIAA Dept Clinical Biochemistry, Royal Infirmary, Glasgow G4 0SF

acetylcholine receptor antibodies (Sent by Haematology)

Neuro-immunology Dept., Institute of Neurological Science, Southern General Hospital, Glasgow G51 4TF

amino acids


Amiodarone Biochemistry Department, Epsom General Hospital, Dorking Road, Epsom. KT18 7EG.

Apoprotein E Dept Clinical Biochemistry, Royal Infirmary, Glasgow G4 0SF

baclofen Medical Toxicology Laboratory, Floor 3, Block 7, South Wing, St Thomas Hospital. 249 Westminster Bridge Road, London, SE1 7EH.

caeruloplasmin Dept Clinical Biochemistry, Royal Infirmary, Glasgow G4 0SF

Calprotectin Dept Clinical Biochemistry, Western General Hospital, Crewe Road, Edinburgh EH4 2XU

cholinesterase and genotype

Dept. Of Clinical Biochemistry, Cholinesterase Investigation Unit, Pathology Sciences Building, Southmead Hospital, Westbury-On-Trym, Bristol. BS10 5NB.

chromogranin A Supraregional Protein Reference Unit, Dept. of Immunology, PO Box 894, Sheffield S5 7YT

Copper (serum and urine)


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CSF xanthochromia Biochemistry Department, Southern General Hospital, Govan Road, Glasgow G51 4TF

cyanide Dept Forensic Medicine, University of Glasgow, Glasgow G12 8QQ

cyclosporin

Biochemistry Department, Southern General Hospital, Govan Road, Glasgow G51 4TF

cystic fibrosis DNA genotyping (∆F508)

Medical Genetics Dept, Royal Hospital for Sick Children, Yorkhill, Glasgow G3 8SJ

cystine Biochemistry Department, Royal Hospital for Sick Children, Yorkhill, Glasgow G3 8SJ

elastase (faeces) Dept Clinical Biochemistry, Western General Hospital, Crewe Road, Edinburgh EH4 2XU

erythrocyte galactose-1-PO4


ethosuximide Medical Toxicology Unit, 3rd Floor, Block 7, South Wing, St. Thomas Hospital, London SE1 7EH

fat globules (faeces) No longer assayed. Send to Dept Clinical Biochemistry, Western General Hospital, Crewe Road, Edinburgh EH4 2XU for Faecal Elastase.

Tacrolimus (FK506) and Sirolimus


gabapentin Medical Toxicology Laboratory, Floor 3, Block 7, South Wing, St Thomas Hospital. 249 Westminster Bridge Road, London, SE1 7EH.

Gilbert’s syndrome genotype

Human Genetics Unit, FAO Dr David Baty, Level 6 Ninewells Hospital, Dundee DD1 9SY

glutathione peroxidase


growth hormone (urine)


gut hormone profile SAS Laboratories, Clinical Biochemistry, Medical Oncology, Charing Cross Hospital, London W6 8RF.

HLA-H Haemochromatosis gene


homocysteine Dept Biochemistry, Royal Hospital for Sick Children, Edinburgh

IGF2/IGF1 molar ratio

Dept Clinical Biochemistry, St Luke’s Hospital, Guildford, Surrey GU1 3NT

imipramine Medical Toxicology Laboratory, Floor 3, Block 7, South Wing, St Thomas Hospital. 249 Westminster Bridge Road, London, SE1 7EH.

immunoreactive trypsin


lamotrigine Medical Toxicology Laboratory, Floor 3, Block 7,

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South Wing, St Thomas Hospital. 249 Westminster Bridge Road, London, SE1 7EH.

lead Dept Clinical Biochemistry, Royal Infirmary, Glasgow G4 0SF

mercury Dept Clinical Biochemistry, Royal Infirmary, Glasgow G4 0SF

methotrexate Biochemistry Department, Western Infirmary, Dumbarton Road, Glasgow. G11 6NT

oligoclonal bands Neuro-immunology Dept., Institute of Neurological Science, Southern General Hospital, Glasgow G51 4TF

organic acids Biochemistry Department, Royal Hospital for Sick Children, Yorkhill, Glasgow G3 8SJ

Peptide hormones: ACTH, C-peptide, insulin Calcitonin, gastrin, PRA, PTH


phytanic acid Dept.Biochemical Genetics, Clinical Chemistry Lab., Southmead Hospital, Bristol BS10 5NB

porphyrins Medical Biochemistry, .UHW Healthcare NHS Trust, Heath Park, Cardiff CF4 4XW

PIIINP Specialist Assay Laboratory, Clinical Research Dept. 2nd Floor Clinical Sciences Building 3, Manchester Royal Infirmary, Oxford Road, Manchester M13 9WL.

PTHRP (PTH Related Peptide)

Dr Allison Chipchase, Specimen Reception, Lab Medicine, Level 1 East Block, Colney Lane, Norwich. NR4 7UY.

RBC gal-1-phosphate uridyl transferase


selenium Dept Clinical Biochemistry, Royal Infirmary, Glasgow G4 0SF

Serum free light chains

Immunology Department, Western Infirmary NHST, Dumbarton Road, Glasgow G11 6NT

Steriods/reproductive hormones: Aldosterone, A-dione, DHAS, FSH, GH, IGF-1, 17-OHprogesterone, LH, Oestradiol, Prolactin, progesterone, SHBG


TBG, TRAbs Dept Clinical Biochemistry, Royal Infirmary, Glasgow G4 0SF

thiopurine methyl Purine Research Laboratory, 4th Floor, North Wing,

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transferase St. Thomas’ Hospital, Lambeth Palace Road, London SE1 7E

Toxicology – specialized including Drug of Abuse


tryptase Immunology Department, First Floor Labs Building, Gartnavel General Hospital, Glasgow. G12 0XL.

TSH (blood spot) S.N. Neonatal Screening Lab, Dept Microbiology, Stobhill NHS Trust, Glasgow G21 3UW

Tumour markers: AFP, CA125, CEA, HCG,

Biochemistry Department, Gartnavel General Hosp., Great Western Road, Glasgow G12 0YN

Tumour markers: CA 19-9, CA 15-3, amyloid A, free PSA, PSA ratio

Supraregional Protein Reference Unit, Dept. of Immunology, PO Box 894, Sheffield S5 7YT

urine catecholamines & metanephrines


Catecholamine metabolites

Biochemistry Dept, Crosshouse Hospital, Kilmarnock, A2 0BE

very long chain fatty acids

Dept.Biochemical Genetics, Clinical Chemistry Lab., Southmead Hospital, Bristol BS10 5NB

Vitamin D Dept Clinical Biochemistry, Royal Infirmary, Glasgow G4 0SF

Vitamin screen Dept Clinical Biochemistry, Royal Infirmary, Glasgow G4 0SF

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Documents

Title: Chemistry Laboratory Handbook · U/E, Gentamycin and haematinics will require three clotted samples. • If more than one tube is collected from a patient, the potassium EDTA