Clinical Chemist7y 42:1

125-134 (1996)

Preanalytical considerations in testing

thyroid function

Downloaded from https://academic.oup.com/clinchem/article-abstract/42/1/125/5646210 by guest on 15 June 2020

JOSEPH H. KEFFER

Remarkable technical advances have permitted analytical reliable that they render obsolete many of our previous practices
measurement of thyrotropin (TSH) and estimates of free and procedures” [1].
thyroxine (FF4) with precision, accuracy, and favorable Three concepts are integral to understanding current ad-
economics. Combined with an increased appreciation of the vances in the routine assessment of thyroid function. Each
key insights into the pituitary-thyroid relation, preanalyti- should be considered in the broad view of preanalytical consid-
cal considerations infrequently introduce confounding vari- erations. First, the underlying basis of the TSHJFT4 diagnostic
ables. In reviewing thyroid data, preanalytical consider- strategy is the narrow intraindividual variation of FT’4 and the
ations include physiological and specimen-based issues. associated log-linear relation of TSH to changes of FT4.
Central to the improvement in thyroid assessment is the Second, in contrast to the T4-based testing strategies, preana-
recognition that physiological individuals maintain their lytical variables infrequently and usually insignificantly affect
Fr4 within narrow limits. When this deviates, there is a the TSI-IJFT4 testing strategy in terms of medical relevance.
logarithmic response of the TSH concentration to the Third, technological advances in analytical methods perlnit
arithmetic shift in FF4. In effect, the TSH deviation mag- convenient and economical measurement of TSH and FT4.
nifies the subtle shift in FF4. Artifact and other nonthy- Preanalytical artifact is infrequent and creates minimal im-
roid-related preanalytical considerations are infrequently pact on diagnostic testing. In the context of pragmatic clinical
the cause of nonconcordance when discrepancy occurs application, there is a clear consensus among thyroidologists in
between the reported values for FF4 and TSH. When favor of the TSH/FT’4 strategy [2-4]. In fact, the rare reported
abnormalities of TSH and FF4 are encountered, the prob- dissent is notable by isolated exception [5].
ability strongly favors a disease state rather than a preana- This presentation will focus on preanalytical considerations
lytical variable. Infrequent but real extrathyroidal patho- in thyroid-function testing, with primary emphasis on measure-
physiological states are increasingly recognized as a result mnent of TSH and FT4 rather than the 22 tests currently
of the reliable assessment of the pituitary-thyroid relation. described as appropriate by Lindstedt et al. [6]. Clearly, the
robust nature of these two dominant assays underscores the
1NIEXING TERMS: preanalytical variables . thyrotropin . free relatively minimal impact of routine preanalytical variables on
thyroxine . variation, source of these tests, in contrast to the significant variation in test results
attributable to disease. Most of these variables are of interest for

Through routine sensitive measurement of thyrotropin (TSH) the study of subtle differences in physiological or research
and estimates of free thyroxine (F’T’4), the assessment of thyroid studies rather than for clinical diagnosis or routine monitoring.
function has become a mature field.tm In 1988, Gorman ad- Significant preanalytical variables, when encountered, are al-
dressed a group of thyroidologists with regard to the contribu- most always readily recognized as measurable TSH inappropri-
tion of these newer sensitive assays for measuring serum TSH ately present in definite hyperthyroid states. They often expose
concentration. He stated: “.. . measurements of thyroid hor- clinically relevant underlying pathophysiology, in contrast to the
mone in the blood have been superseded by a new generation of frequently confounding variations of thyroid-binding proteins
thyrotropin . . . assays that are so consistent, sensitive, and associated with T4-based diagnostic strategies. Indeed, current
reviews regarding thyroid assessment and therapy are notable by
virtue of their silence or minimal emphasis on preanalytical
variables, and appropriately so.
Department of Pathology, University of Texas Southwestern Medical Center,
5323 Harry Hines Blvd., CS3.l 14, Dallas, FX 75235-9072. Fax 214-648-8037; For the purpose of this presentation, I have proposed a
e-mail keffer@utsw.swmed.edu. classification of preanalytical variables that is clinically based
Nonstandard abbreviations: TSI-1, thyrotropin; FT4. free thyroxine; T4,
(Table 1), in keeping with some earlier classifications of bio-
thyroxine; TRIl, thyroliberin; T’I’4, total thyroxine; 1’;, triiodothyronine; FICC,
human chorionic gonadotropin.
chemical testing results /7, 8]. As such, I have attempted to
Received July 31, 1995; accepted October I 7. 1995. emphasize the importance of integrating all aspects contributing

125
 NACB Symposium

Table 1. ClassIfication of preanalytical variables in TSII, mU#{241}..

assessment of thyroid function.
Physiological latrogenic causes
Set point for T4 Prior thyroid disease treatment
Log-linear relation of TSH/FT4 Surgical
Circadian rhythm Medical
Seasonal influences Drug therapy
Environmental Systemic
Exercise Topical
Posture and immobilization Plasm apheres is

Downloaded from https://academic.oup.com/clinchem/article-abstract/42/1/125/5646210 by guest on 15 June 2020

Pat hophysiologica! Specimen-based variables
TSH-independent states Stability and storage
Common Lipemia .0..#{149}.._.
Rare Stasis
Trophoblastic tumors Hemolysis
00 #{149}
Struma ovarii lcterus
50 *00 150 200 200 000
Generalized resistance Assay susceptibility

Selective organ resistance Antibodies FT4 index, nmol/L

TSH-dependent states Heterophile Fig. 1. Relation between serum TSH ICMA and FT4 index values in 505
Pituitary adenoma Autoimmune stable ambulatory patients.
Resistance states Protein binding 0, undetectable (<0.005 mlU/L) TSH values. Ft4 index = ‘fl’4 x thyroid
Generalized Human error hormone binding ratio. Modified from Spencer et al. [12].

Pituitary
Psychiatric states exogenous iodide or T4, Snyder and Utiger [23], Vagenakis et al.
Smoking
[24/, and Saberi and Utiger [25] demonstrated a sharp response
Malabsorption
of TSH to a minimal deviation of T4 and FT4. The TSH
Compliance
response is disproportionately exuberant when FT4 concentra-
tions fall, and TSH concentrations plummet when the FT’4
to preanalytical error, including physiological and pathophysi- concentration is raised [4, 23/. Specifically, these reports noted a
ological influences that critically affect testing, rather than focus log response of TSH to a linear change in FT4 [4J: Their data
on the specimen in isolation, as it relates to the concept of show a 100-fold response of TSH to a twofold change in FT4.
interferences with laboratory analyses [9-11]. I prefer the Further, repetitive administration of thyroliberin (TRH) to
linkage to clinical comprehension. The question with regard to individuals elicits a reproducible response in contrast to inter-
interfering preanalytical variables arises for the clinician from individual variability /13]. Thyroid hormone replacement ther-
the incongruence of laboratory data with the clinical context. apy results in restoration of TSH to physiological concentra-
In addition, I attempt to address three additional categories tions, with a variable total T4 (TI’4) and FT4 concentration
of preanalytical error: iatrogenic states, specimen-based issues, [18, 26]. The importance of these observations cannot be over-
and human error. Although several of these issues are addressed emphasized, since the magnitude of this TSH shift, beyond
elsewhere in this symposium, I have included certain aspects commonly used population-based reference limits, characterizes
of these primarily in the overall context of preanalytical pathophysiological states readily, leading to further appropriate
considerations. study or treatment. In contrast, commonly considered preana-
lytical variables such as exercise, fasting, and phlebotomy-
Physiologically Based Preanalytical Variables induced stasis produce relatively insignificant fluctuation. Con-
Although regularly noted by Spencer et al. /4, 12-14], the sequently, when unexpected suppressed or increased TSH
fundamental relation between an individual’s FT4 set point and concentrations are encountered in clinical practice, patients
the logarithmic response / 12, 15, 16/ of TSH to arithmetic demonstrating such findings are usually responding to mild FT4
changes in Fr4 (Fig. I) is not consistently emphasized in deviations [27/.
discussions of thyroid physiology [17, 18/. Yet, these principles In applying thyroid-function testing to monitoring T4 re-
are the very bedrock underlying the robust application of
common approaches to thyroid-function testing (Table 2). First,
each individual has a narrowly confined concentration of T4 and Table 2. Evidence for individual set point for 14.
FT4. According to the FT4 hypothesis /19, 20/, this is the Stable intraindividual values over time.

physiologically active component. The application of popula- Limited circadian amplitude of variation.

tion-based reference norms is inappropriately wide when ap- Narrow range relative to reference populations.
plied to individuals /21, 221. Each person has a narrow range of Log TSH response to linear changes of TI’4 or FT4.
Iodide administration lowering T4, raising TSH.
fluctuation of T4, even with seasonal or annual study /22/. By
Intraindividual reproducibility of TRH response.
manipulating the T4 concentrations with administration of
 Clinical Chemistry 42, No. 1, 1996 127

placement therapy, the same basic principles relating to set point quate caloric intake [3 5/. This has been reversed and prevented
and log-linear response permit precise modulation of TSH by appropriate increased dietary energy intake [36/. Others
concentrations, which define appropriate replacement therapy studying prolonged exercise in training athletes report no
/4, 18/. The goal of therapy is restoration of physiological TSH consistent pattern with regard to the influence of exercise on
concentrations /18J. Hershman et al. recommend application of thyroid-function status /37, 38/. After an acute episode of exer-
the same TSH range for elderly persons as for younger individ- cise, the experimentally predicted hourly pattern of YF4 was
uals [28/. altered but not TT over the subsequent 8-h recovery phase
Although the pituitary response to fluctuations in FF4 is our /39/. Consequently, diagnostically significant alterations due to
usual guide to the euthyroid state, we should recognize variable exercise are not a common and relevant preanalytical variable.
organ response to T4 and triiodothyronine (T3) concentrations.

Downloaded from https://academic.oup.com/clinchem/article-abstract/42/1/125/5646210 by guest on 15 June 2020

This is demonstrated in states of pituitary resistance, with POSTURE AND IMMOBILIZATION
varying responses of heart, liver, and muscle, which testify to the Although long known to affect hematocrit and constituents of
significance of nuclear receptor studies revealing variable bind- the blood that do not leave the circulation under hydrostatic
ing of T4 and T in these tissues [18/. We may anticipate a more forces /40/, little reference is made to the impact of posture and
sophisticated definition of euthyroidism to evolve that will he immobilization on thyroid hormones. Since T4 and T5 are
based not solely on pituitary response but on various end organ 99.9#{176}X, and 99.7% protein-bound, respectively [41/, this variable
responses as well. is operative. TT4 was observed to increase by a mean of 6.8%
after subjects stood for 40 mm /42J.
CIRCADIAN RHYTHM
Although a well-established TSH peak occurs in the late Pathophysiological Influences
evening and a nadir at about midday [29-32], the amplitude of Common thyroid diseases presenting with functional deviations
this fluctuation is small, with a mean of -0.95 mIU/L [31/ and are TSH independent. In routinely encountered hypothyroid-
-2.0 mIU/L in a more recent study [32]. Custro and Scaglione ism and hyperthyroidism, the relation between TSH and FT4 is
(30) observed single individuals with a fluctuation from a low of the expected one, and they are addressed elsewhere. Preanalyti-
2.3 to a peak of 11.2 mIU/L. Although unlikely to create cal variables do not ordinarily affect this relation, especially in an
confusion as a preanalytical variable, the loss of the evening outpatient population. On the other hand, nonthyroidal illness
surge is correlated with central hypothyroidism [32] and may be can alter the individual response and confound diagnosis. This
i diagnostically useful. The appearance of detectable TSH only subject is also addressed elsewhere.
during the nighttime surge proved that exogenous suppression For the sake of completeness, two pathological conditions are
was incomplete /29/. 1’RH response correlates better with presented in this discussion of preanalytical variation. The first,
nocturnal than with daytime TSH concentrations [29, 32]. trophoblastic disease, produces human chorionic gonadotropin
(HCG), which normally has weak thyrotropic potency /43/.
SEASONAL INFLUENCES Some trophoblastic tumors produce modifications of the protein
Seasonal and annual fluctuations of TSH, ‘Fl4, VT4, and TT5 molecule with partial sialylation, which apparently leads to
are minor. Although of interest physiologically, the shift is greater binding to the TSH receptor [43/. In conjunction with
insufficient to reassign an individual from the euthyroid diag- the very high concentrations seen in neoplastic proliferation,
nostic category to an abnormal one [22/. Again emphasizing the hyperthyroidism results /28, 44/. Newer assays for TSH should
sensitivity of the hypothalamic-pituitary relation, peak TRH demonstrate negligible HCG cross-reactivity and not measure
response correlates with peak seasonal TSH /22/. Seasonal HCG /45/.
fluctuation should he considered in assessing pregnant patients A second condition, struma ovarii, constituted by the pres-
because they are followed longitudinally [2 1/. ence of thyroid follicular tissue in the ovary, may potentially
present with hyperthyroidism. In such cases, suppressed TSH in
ENVIRONMENTAL INFLUENCES combination with the absence of thyroid enlargement in the
Exposure to cold temperature is generally associated with neck may provoke a question of preanalytical variables [46, 47J.
adaptive mechanisms. However, these are complex, relating to
the duration and severity of the acute or chronic exposure as well TSH-DEPENDENT PATHOPHYSIOLOGICAL INFLUENCES
as to numerous other variables [33/, not the least of which is Central hypothyroidism is discussed elsewhere and is mentioned
concomitant work effort and feeding status /34/. Observed here as the “common” preanalytical disease state that is depen-
changes are unlikely to create significant preanalytical influence dent on TSH secretion or the lack thereof. Inappropriate
on patient testing under the usual environmental conditions in secretion of TSH in the face of clear clinical and biochemical
North America experienced by the general population. evidence of hyperthyroidism should provoke consideration of
preanalytical variables Tahle 3). Growing evidence indicates
EXERCISE that TSH-producing pituitary adenomnas and genetically deter-
Investigation of the pituitary-thyroid relation in women who mined states of resistance to thyroid hormones are responsible
participate in vigorous athletic activity with associated amenor- for the phenomenon /48/. In short, the preanalytical individual
rhea reveals no intrinsic disruption of thyroid function. How- variable is disease and not artifact or analytical inaccuracy.
ever, the low-T5 syndrome observed appears related to made- Pituitary adenomas that secrete TSH are being recognized
 NACB Symposium

be responsible and at times presents with an inappropriate

Table 3. Causes of detectable TSH in hyperthyroidism.
increase of both T4 and TSH resulting from an attempt to
Resistance-to-thyroid-hormone states
“catch tip” by the hypothyroid patient taking medications in the
Pituitary
several clays before a return visit to the physician /18J. In
Generalized
response to T4 administration, TSH is suppressed in a three-
Pituitary TSH-secreting adenoma
Ectopic secretion of TRH or TSH phase response over time /60/. Thus, normal ‘14 concentrations
were reported with increased TSH /18J. This may account for
Artifact
the seeming anomaly. Clearly, restoration of TSH into a
Autoantibodies to TSH
Human anti-mouse antibodies
physiological range is the accepted goal of replacement therapy
/18, 61, 62/.

Downloaded from https://academic.oup.com/clinchem/article-abstract/42/1/125/5646210 by guest on 15 June 2020

earlier as a result of the newer sensitive TS1-1 assays being used IATROGENIC PREANALYTICAL INFLUENCES
routinely /49/. Measurement of the a-subunit of T’SH is highly These are both common and significant. Prior therapy directed
informative /50/. Over 80% of TSH-secreting pituitary adeno- toward the thyroid gland, including thyroidectomy, radiother-
mas cosecrete free a-subunit /51/. T’his may be the sole distinc- apy to the neck, or drug therapy, would seem obvious but may
non from pituitary resistance if imaging studies fail to disclose be overlooked if arm appropriate clinical history is not obtained.
pituitary enlargement /51/. These are discussed elsewhere.
Syndromes such as “resistance to thyroid hormones” may be
generalized, in which case all tissues including both pitmtary and DRUG THERAPY

peripheral organs are resistant to thyroid hormone /52]. Selec- Drug therapy causes less confusion in assessing thyroid function
tive pituitary resistance or, in some cases, with normal muiry with TSH-based strategies than was formerly encountered with
response, is accompanied by a peripheral organ resistance /53/. measurement of TT4, since the numerous drug-induced T4-
Each is recognized by the presence of an apparently inappro- binding globulin variations become essentially irrelevant. Van-
priate pattern of ISFI and thyroid hormone secretion. The first ations in T4 therapy and compliance should not be overlooked
concern of the clinician and clinical chemist is with preanalytical /18, 62] with regard to other drugs that may affect thyroid
or analytical variables. Thus, with increased confidence in TSH testing. The major impact is experienced with inpatients, since
and FT’4 assays and their routine application, these diagnoses are these drugs are primarily used in a hospital setting. For this
being recognized more frequently. Through the use of molec- reason, some authors recommend avoidance of routine measure-
ular approaches, >20 imitations have been documented /54/. ment of TSH and VT’4 on inpatients /4/. Through this impact on
the synthesis, transport, and metabolism of thyroid hormones,
PSYCFI IA’FRIC S’rA’rES or the hypothalamic-pituitary-thyroid axis, many drugs can
Transient ‘[‘SI-I increase and ‘[‘4 abnormalities potentially alter thyroid function and the concentrations of
are documented hut poorly understood /4, 55]. Mea- related hormones /63-65/. Specifically, the effects of amioda-
sured abnormalities of thyroid function should 1)e repeatal)le in rone include not only those associated with iodine influences on
2 to 4 weeks before instituting therapy in acutely hospitalized the thyroid gland but also direct cytotoxic effects on thyroid
psychiatric patmi1 Studies correlating other findings, such as epithelium. This has been shown both in vivo and in vitro in
the presence of diagnostic antibodies associated with thyroiclitis, tissue culture /65/. Consequently, no simple pattern of TSH!
assist in establishing the significance of these findings. FT4 results can be ascribed to this preanalytical influence.
Glucocorticoids have significant impact. A single dose of
SM 0Km NC clexamethasone was shown to acutely lower T concentations,
Ericsson and Lindgarcle /56] identified a significant effect on the altering deiodimiation of T4 /66]. ‘[‘here are miiinor changes of T4
thyroid gland and its function consistent with measured gland and FT4. Dexamethasone has been shown to diminish basal and
enlargenient and even associated thyrotoxicosis in the preclis- stimulated secretion of TSH in response to TRH after admin-
posed individual. In pregnant smokers, enlargement of the fetal istration of a 16-mg dose daily for 2.5 days /67J. Either
thyroid glan(l may he significant, particularly in geographic iatrogcnic exposure or (nonthyroidlal) illness-associated stress
areas with borderline acceptable dietary iodine intake /57/. may produce these findings.
Thyroid-associated ophthalmopathv is reportedly more coin- Abrupt lowering of the glucocorticoid concentration, as in
mon and more severe in cigarette smokers /56/, but was not surgical correction of Cushing syndrome or withdrawal of
associated with relapse following carbimazole treatment for high-dose glucocorticoids used f’or immune suppression, may
hyperthyroiclisni /58/. produce rebound thyroiditis and associated thyroid dysfunction.
An alternative mechanism lies in the possible exposure of these
MALABSORPTION OR NONCOMPLIANCE individuals to organic and inorganic iodides in preoperative
Malahsorption should he considered when prcamialytical assess- imaging studies while being evaluated for Cushing syndrome
ment of variables is provoked by persistent increase of TSH /68/.
after 14 replacement therapy is initiated /18/. Although uncom- Dopamine is frequently found in association with nonthyroi-
muon, it is clearly described in cases of patients with known short dal illness. Reduction of TSH secretiomi in euthyroid patients as
bowel as a result of surgical resection /59/. Noncompliance may well as in hypothyroid patients establishes this agent as a
 Clinical Chemistry 42, No. 1, 1996 129

significant potential confounding preanalytical variable [69, 70/. /82, 83] or competitive-binding assays /84/ than for classic
As a consequence, confident assessment of true thyroid- colonimetnic analytical methods [85/.
functional status may be precluded in these patients. The Stasis from tourniquet application continues to he important
administration of dopamine induces acute reduction of TSH in regard to specimen collection, especially for peptides and
secretion, which rebounds promptly when dopamnine is discon- proteins that do not equilibrate with the interstitium. Proteins
tinued. So significant are these changes that it has been cited as increase -3-5% with long tourniquet times [86/.
inducing iatrogenic hypothyroidism /71/. T4 stability is good when stored at 4 #{176}C
or frozen at -20 #{176}C
Lithium is widely used in psychiatric disorders [72]. Increase for months, as noted in earlier publications /87/. The possibility
in TSH occurs in 10-20% of treated patients and results from of protein precipitation has been noted and affected earlier
inhibition of T4 synthesis and release. An increase in thyroid assays. More recently, gel barrier tubes have heen reported to

Downloaded from https://academic.oup.com/clinchem/article-abstract/42/1/125/5646210 by guest on 15 June 2020

antibodies has been observed [72]. In lithium-treated patients, have no adverse effect on ‘IT4 concentrations, although proges-
pituitary secretion of TSH appropriately responds to T4 sup- terone was significamuly affected /88/.
plementation therapy [72/. An extensive study compared collection systems and storage
Anticonvulsant drugs, particularly phenytoin and carbamaz- at room temperature or at 4-8 o(. This included serum in plain
epine, affect not only T4 binding but also thyroid hormone glass tubes or barrier gel, and plasma collected in either EDTA
metabolism and TSH secretion, but TSH is not increased in or heparin (Table 4) [89/. These investigators measured the
basal samples. T4 and VF4 are decreased 25-30% /63, 73/. As effects on one assay for TSH and two for FT4. Specimens were
such, a variety of patterns are seen, usually including reduction stored I h-l 3 days. Also studied were the effects on whole blood
of TT4 and FT’4. Bromide exposure has also been linked to of storage for 1 h-S days. In summary, a variety of changes were
impaired thyroid function /74-76]. Sangster et al. failed to observed for all collection and storage conditions; however,
demonstrate an effect of bromide on man in a careful dosing serum drawn in glass and stored at 4-8 #{176}C
was least affected.
study [74/. In vitro studies and studies in rats clearly show the TSH increased gradually when stored at room temperature.
potential for a bromide effect [75/. Allain et al. cogently Generally, changes were slight and not likely to alter clinical
summarize the evidence, concluding that bromide is unlikely to categorization. Literature reports indicate serum as the pre-
commonly interfere with assessment of thyroid function /76/. ferred specimen for measurement of FT4 concentrations ob-
Povidone-iodine skin cleaning preparations used in hemodi- tained from prompt centrifugation of whole blood, and storage
alysis, penitoneal dialysis, treatment of decubitus ulcers, and of the serum at -20 #{176}C
if the assay is to be delayed 190, 91/.
other conditions may lead to hyperthyroidismn and hypothyroid- Others, investigating complex variables regarding FT4 assays,
ism by altering TSH and FT4 concentrations in those who are are notably silent with regard to stability and collection issues
predisposed. Easily overlooked, this cause should he considered /92, 93]. Similarly, studies regarding TSH make little mention
in assessment of possible preanalytical states /77, 78/. of stability, collection, or storage [94-97/. Studies on serum
Plasmapheresis with plasma exchange has been shown to TSH indicated no stability problem with an earlier assay in
acutely lower thyroid-binding proteins and associated concen- conjunction with a complex chromatographic extraction of TSH
trations of TT4 and 1T, possibly in association with diniin- /98j. Expected recovery was 76.6%, hut these studies are prob-
ished peripheral deiodination ofT4 [79/. ably not comparable with routine clinical application. Recently,
extensive data have been published repeating the observation of
Nishi et al. /89], that TSH may increase slightly when stored or
Specimen-Based Influences transported at ambient temperature for long periods [99]. The
As a result of TSH-based strategies and improved assays for changes were seen with some but not all sample pools tested and
TSH and FT4, specimen-related influences on thyroid-function are a subject of debate /100, 101/. Studies of TSH in protein-
testing are less frequently significant. Improved precision and free buffer revealed dissociation of TSH into its subunits at
reduction of these influences permits an approach to published -20 #{176}C
but not at 4 #{176}C
or room temperature /102/. These
goals of hormone testing [80, 81]. However, these consider- workers reported agreement with earlier reports of satisfactory
ations depend not only on the degree of intraindividual variation stability of TSH in serumli. One notable exception occurred in a
and the impact of the interference, but also on the relative report regarding collection of serum for TSH assay in silicone-
magnitude of these compared with observed population refer- coated microtainer collection tubes (Vacutainer Tube; Becton
ence values. When applied serially for an individual, the more Dickinson, Rutherford, NJ) and one specific assay. Wickus et al.
subtle specimen influences become important as a result of the described a negative effect of silicone on the biotin-avidin
set-point precision associated with the individual’s FT4 concen- system used in this assay /103/. This phenomenon illustrates the
tration and the log-linear TSH response to small FT4 deviations importance of assay-specific variables.
within the reference range. Kroll and Elm [9] provide a recent Dried whole-blood spots have been validated widely for
update, noting the method-specific nature of interference, par- stability of use in neonatal screening programs /104/ for con-
ticularly with immunoassays incorporating a washout step. They genital hypothyroidism. TSH and TT are more stable than
emphasize the importance of manufacturer sources of specific ‘Fl4 in dried blood under various storage conditions /105/.
information, notably the package insert for reagents. This is Assay of FT4 has been successfully applied to dried blood spots
particularly true for automated methods. Generally, hemolysis, /106].
lipemia, and icterus are less significant for immunoassays Lipensia contributes preanalytical error to immunoassay for
130 NACB Symposium

individuals. Recently, anti-T3 autoantibodies were reported to

Table 4. Summary of the effect of various sampling and
interfere with immobilized T in a solid-phase assay for FT4,
storage conditIons on TSH and FT4 values.
resulting in spuriously high FT4 measured values. Once again,
Tubes
the unique susceptibility of assays to individual preanalytical
Kit Temp. Glass Separator EDTA.2Na Heparln.Na variables is demonstrated /123] and also is seen with other VT’4
Blood kept in tubes from 1 h to 5 days methods [124].
SPAC-S TSH Room / - / Antibodies to TSH were originally described in Graves
Low#{176} -* -3 -3 disease and may alter assay results for this hormone [125-127],
Amerlex-M Free 14 Room N N N but are believed to be unlikely to activate the TSH receptor.
Low N -
-4 -4 Since TSH is now measured more often, spurious TSH increase

Downloaded from https://academic.oup.com/clinchem/article-abstract/42/1/125/5646210 by guest on 15 June 2020

Free T4 Eiken Room N N N N may he recognized more frequently.
Low -* - -4 -4 Heterophile antibodies, typically human anti-mouse anti-
Serum or plasma stored from I h to 13 days bodies, are encountered with moderate frequency when using
SPAC-S TSH Room -# - assay kits with mouse monoclonal reagents and antibodies [128].
Low -+ - -.* N These may be nonspecific but can significantly alter results
Amerlex-M Free 14 Room N N N N /129]. Although manufacturers add mouse serum to reagent
Low - N - N systems to neutralize these antibodies, it may be insufficient in
Free 14 Eiken Room N N N N some cases to avoid confounding results [130-132]. Autoanti-
Low -* -* bodies to TSH and other pituitary hormones are more common
-, no change; N. decrease; 7, increase. in the empty sella syndrome and with pituitary tumors [133].
4-8
#{176} C. When thyroglobulin is assayed, anti-thyroglobulin antibodies
should routinely be sought since they are significant, common,
and may invalidate the assay [134].
thyroid testing /107, 108], primarily as a result of partitioning
and solute exclusion as in pseudohypokalemnia, resulting in
HUMAN ERROR
underestimation of the analyte. This is unlikely to significantly
A final category representing an inevitable preanalytical error
affect assessment of thyroid function. However, free fatty acids includes errors on order entry [135], phlebotomy error, misla-
have long been associated with interference in T4 assays. RIAs beling, erroneous aliquots, sequencing errors, barcode errors,
are less affected than competitive protein-binding methods
and the like /136]. With modern systems, this can be reduced, as
[109]. More significantly, free fatty acids are well known to
recently reported [137], but it would be foolish to reject
perturb assays for FT4 by displacement of T4 from binding
consideration of this variable. For the individual patient, one
proteins [110/. This explains, in part, the confusing values seen
event represents 100%. The occasional error nurtures the
in nonthyroidal illnesses [110, 111/, and additionally reinforces
clinical aphorism that laboratory data should be rejected if not in
reliance on the TSH assay in preference to FT4 /112/.
keeping with clinical judgment. This is hardly appropriate, now
Variable protein binding associated with familial dysalbu-
that subclinical hypothyroidism [18] and subclinical hyperthy-
minemia, as well as serum albumin fluctuations, significantly roidism /138] both depend on TSH assay data in the absence of
compromise assays for FT4 measurements [2, 113, 114].
clinical findings. Error is far more common in medicine than we
Paraproteinemia causes interference in many assays. At
would like to believe, reportedly affecting 20% of patients
times, the viscosity may produce a “short” sample, resulting in
admitted to a university hospital [139]. Study of error may
falsely low values. At other times, paraproteins nonspecifically
be highly beneficial. One should approach human error
bind either analytes or reagents, which may variably affect the
in medicine as “medical treasures,” sometimes called “gems”
result [9/.
[140]. They present opportunities to learn: to improve practices
Background specimen contamination introduced as a preana-
and to introduce systems for future avoidance of recurrences
lytical activity may also affect the assay, as in the case of
[140].
intravenous fluorophore use for ophthalmic procedures
[115, 116/. This interferes with the fluorescent signal in a
specific method (TDx; Abbott Diagnostics, Chicago, IL). Sim-
ilarly, the problem of background radioisotope contamination References
1. Gorman CA. Thyroid function testing: a new era [Letter]. Mayo
affects dialysates for FT4 assay as an occasional problem for
Clin Proc 1988;63:1026-7.
those still using isotope immunoassays /117].
2. Becker DV, Bigos SI, Gaitan E, Morris JC, Rallison ML. Spencer
Antibodies may be helpful; e.g., antithyroid perd)xidase in
CA, et al. Optimal use of blood tests for assessment of thyroid
thyroiditis provides corroboration of thyroid disease [118, 119/.
function [Letter]. JAMA 1993:269:2736.
In a few cases, autoantibodies to T; and T4 develop, which
3. Hay ID, Klee GG. Linking medical needs and performance goals:
increase the circulating concentrations of ‘TT or ‘TT4 or both clinical and laboratory perspectives on thyroid disease. Clin
[120, 121]. Sensitive testing screened 880 apparently well adults Chem 1993;39:1519-24.
and found an incidence of anti-T; or anti-T4 as high as 1.8% 4. Nicoloff JT, Spencer CA. The use and misuse of the sensitive
[122]. The report indicates minimal effect on the assays in these thyrotropin assays. J Clin Endocrinol Metab 1990:71:553-8.
 Clinical Chemistry 42, No. 1, 1996 131

5. Helfand M, SchmittnerJ. Screening for thyroid dysfunction: which tropin concentration, or something more? [Editorial). N Engl i
test is best? [Letter]. JAMA 1993:270:2297. Med 1994:331:1302-3.
3. Lindstedt G, Berg G, Jansson S. Tarring 0, Valdemarsson S, 28. Hershman JM, PekaryAE, Berg L, Solomon DH, Sawin CT. Serum
Warm B, et al. Clinical use of laboratory thyroid tests and thyrotropmn and thyroid hormone levels in elderly and middle-aged
investigations. I Int Fed Clin Chem 1994:6:136-41. euthyroid patients. J Am Geriatr Soc 1993:41:823-8.
7. Nanji AA. Misleading biochemical laboratory test results. Can 29. Hoffman DP, Surks Ml, Oppenheimer JH, Weitzman ED. Re-
Med Assoc J 1984;130:1435-41. sponse to thyrotropin releasing hormone: an objective criterion
3. Riley JH. Clinical pathology: preanalytical variation in preclinical for the adequacy of thyrotropin suppression therapy. I Clin
safety assessment studies-effect on predictive value of analyte Endocrinol Metab 1977:44:892-901.
tests. Toxicol Pathol 1992;20:490-500. 30. Custro N, Scaglione R. Circadian rhythm of TSH in adult men and
3. Kroll MH, Elm RI. Interference with clinical laboratory analyses women. Acta Endocrinol (Copenh) 1980:95:465-71.
[Review]. Clin Chem 1994:40:1996-2005. 31. Weeke i, Gundersen HJG. Circadian and 30 mm variations in

Downloaded from https://academic.oup.com/clinchem/article-abstract/42/1/125/5646210 by guest on 15 June 2020

D. Statland BE, Winkel P, Killingsworth LM. Factors contributing to serum TSH and thyroid hormones in normal subjects. Acta
intra-individual variation of serum constituents: 6. Physiological Endocrinol (Copenh) 1978:89:659-72.
day-to-day variation in concentrations of 10 specific proteins in 32. Rose SR, Nisula BC. Circadian variation of thyrotropmn in child-
sera of healthy subjects. Clin Chem 1976:22:1635-8. hood. I Clin Endocrmnol Metab 1989;68:1086-9O.
1. Williams GZ, Widdowson GM, Penton J. Individual character of 33. Savourey G, Caravel iP, Barnavol B, Bittel HM, Thyroid hormone
variation in time-series studies of healthy people II. Differences changes in a cold air environment after local cold acclimation. i
in values for clinical chemical analytes in serum among demo- AppI Physiol 1994:76:1963-7.
graphic groups, by age and sex. Clin Chem 1978:24:313-20. 34. Case S, Evans DS, Hesslink RL, Reed HL, Chapman RA, Tibbetts
2. Spencer CA, LoPresti iS, Patel A, Guttler RB, Eigen A, Shen D, et G, et al. Effects of the lditarod sled dog race on serum thyroid
al. Applications of a new chemiluminometric thyrotropin assay to hormones and body composition. Arctic Med Res 1993:52:
subnormal measurement. J Clin Endocrinol Metab 199O;70: 113-7.
453-60. 35. iahreis G, Kauf E, Frbhnert G, Schmidt HE. Influence of intensive
3. Spencer CA, Schwarzbein D, Guttler RB, LoPresti IS, Nicoloff iT. exercise on insulin-like growth factor I, thyroid and steroid
Thyrotropin (TSH)-releasing hormone stimulation test responses hormones in female gymnasts. Growth Regul 1991;1:95-9.
employing third and fourth generation TSH assays. I Clin Endo- 36. Loucks AB, Callister R. Induction and prevention of low-I3
crinol Metab 1993:76:494-8. syndrome in exercising women. Am i Physiol 1993;264:R924-
#{149}.
Spencer CA, LoPresti iS, Van Middlesworth L, Wartofsky L, 30.
Becker DV, Bigos SI, et al. Screening for thyroid dysfunction 37. Poehlman El, McAuliffe TL, Van Houten DR. Danforth E. Influ-
which test is best? [Letterl. JAMA 1993:270:2297-8. ence of age and endurance training on metabolic rate and
5. Wehmann RE, Nisula BC. Radioimmunoassay of human thyro- hormones in healthy men. Am J Physiol 1990:259:E66-72.
tropin: analytical and clinical developments. Crit Rev Clin Lab Sci 38. Alen M, Pakarinen A, H#{227}kkinenK. Effects of prolonged training on
1984:20:243-83. serum thyrotropmn and thyroid hormones in elite strength ath-
B. Kaptein EM. Clinical application of free thyroxine determinations. letes. I Sports Scm 1993;11:493-7.
Clin Lab Med 1993:13:653-72. 39. Hackney AC, Gulledge I. Thyroid hormone responses during an
7. Larsen PR. Thyroid-pituitary interaction: feedback regulation of 8-hour period following aerobic and anaerobic exercise. Physiol
thyrotropin secretion by thyroid hormones. N EngI I Med 1982; Res 1994:43:1-5.
306:23-32. 40. Eisenberg S. Effect of posture and position of the venous
B. Toft AD. Thyroxine therapy. N EngI J Med 1994:331:174-80. sampling site on the hematocrit and serum protein concentra-
9. Ekins R. Measurement of free hormones in blood. Endocrinol Rev tion. I Lab Clin Med 1963;61:755-60.
1990;11:5-46. 41. Cohen iH, lngbar SH, Braverman LE. Thyrotoxicosis due to
0. Ekins R. The free hormone hypothesis and measurement of free ingestion of excess thyroid hormone. Endocr Rev 1993:10:113-
hormones. Clin Chem 1992:38:1289-93. 24.
1. Hbtzel WGE, Deschner W. Intra-individual variation of serum 42. Abalan F, Hum Bon Hoa A, Dufrechou N, Ellison W, Rigal F, Perey
thyroxin and triiodothyronine in pregnancy. Clin Chem 1988;34: F, et al. Effect of posture on total thyroxine plasma concentra-
2063-5. tion. Horm Metab Res 1991;23:404-5.
2. Harrop iS, Ashwell K, Hopton MR. Circannual and within-individ- 43. Pekary AE, iackson IMD, Goodwin TM, Pang XP, Hem MD,
ual variation of thyroid function tests in normal subjects. Ann Clin Hershman IM. Increased in vitro thyrotropic activity of partially
Biochem 1985:22:371-5. sialated human chorionic gonadotropin extracted from hydatidi-
3. Snyder P1, RD. Inhibition
Utiger of thyrotropin response to form moles of patients with hyperthyroidism. I Clin Endocrmnol
thyrotropin-releasing hormone by small quantities of thyroid Metab 1993:76:70-4.
hormones. I Clin Invest 1972:51:2077-84. 44. Giralt SA. Dexeus F, Amato R, Sella A, Logothetis C. Hyperthy-
4. Vagenakis AG, Rapoport B, Azizi F, Portnay GI, Braverman LE, roidism in men with germ cell tumors and high levels of beta-
Ingbar SH. Hyperresponse to thyrotropin-releasing hormone ac- human chorionic gonadotropin. Cancer 1992:69:1286-90.
companying small decreases in serum thyroid hormone concen- 45. Abuaisha B, Barrett E, O’Hare I. Thromboblastic hyperthyroidism:
trations. J Clin Invest 1974:54:913-8. sensitive monoclonal ISH assay demonstrates suppressed im-
5. Saberi M, Utiger RD. Augmentation of thyrotropin response to munoreactive TSH. Ir I Med Sci 1991:160:96-7.
thyrotropmn-releasing hormone following small decreases in se- 46. Kung AW, Ma IT, Wang C, Young RI. Hyperthyroidism during
rum thyroid hormone concentrations. I Clin Endocrinol Metab pregnancy due to coexistence of struma ovarii and Graves’
1975:40:435-41. disease. Postgrad Med i 199O;66:132-3.
6. Cotton GE, Gorman CA, Mayberry WE. Suppression of thyrotropin 47. Devaney K, Snyder R, Norris HI, Tavassoli FA. Proliferative and
(h-TSH) in serums of patients with myxedema of varying etiology histologically malignant struma ovarii: a clmnicopathologic study
treated with thyroid hormones. N Engl i Med 1971:285:529-33. of 54 cases. Int I Gynecol Pathol 1993:12:333-43.
7. Utiger RD. Subclinical hyperthyroidism-just a low serum thyro- 48. Weintraub BD. Gershengom MG, Kourides IA, Fein H. Inappropri-
132 NACB Symposium

ate secretion of thyroid stimulating hormone. Ann Intern Med mal and critically ill subjects. J Clin Endocrinol Metab 1980:51:
1981:95:339-51. 387-93.
49. Wynne AG, Gharib H, Scheithauer BW, Davis DH, Freeman SL, 70. Kaptemn EM, Kletzsky OA, Spencer CA, Nicoloff IT. Effects of
Horvath E. Hyperthyroidism due to inappropriate secretion of prolonged dopammne infusion on anterior pituitary function in
thyrotropmn in 10 patients. Am I Med 1992:92:15-24. normal males. I Clin Endocrmnol Metab 1980:51:488-91.
50. Gesundheit N, Petrick PA, Nissim M, Dahlberg PA, Doppman IL, 71. Van den Berghe G, de Zegher F, Lauwers P. Dopammne and the
Emergson CH, et al. Thyrotropmn-secreting pituitary adenomas: sick euthyroid syndrome in critical illness. Clin Endocrinol 1994;
clinical and biochemical heterogeneity. Ann Intern Med 1989; 41:731-7.
111:827-35. 72. Price LH, Heninger GR. Lithium in the treatment of mood
51. Petrick PA, Wemntraub BD. Inappropriate secretion of thyroid- disorders. N EngI I Med 1994:331:591-8.
stimulating hormone. In: Bardin CW, ed. Current therapy in 73. Smith P1, Surks MI. Multiple effects of 5,5’-diphenylhydantomn on
endocrinology and metabolism, 4th ed. Philadelphia: BC Decker, the thyroid hormone system. Endocr Rev 1984;5:514-24.

Downloaded from https://academic.oup.com/clinchem/article-abstract/42/1/125/5646210 by guest on 15 June 2020

1991:44-9. 74. Sangster B, Blom JL, Sekhuis VM, Loeber 1G. Rauws AG,
52. Refetoff S. Resistance to thyroid hormone revisited. Thyroid Koedam IC. The influence of sodium bromide in man: a study in
Today 1990:13:1-11. human volunteers with special emphasis on the endocrine and
53. McDermott MT. Ridgway EC. Thyroid hormone resistance syn- the central nervous system. Food Chem Toxicol 1983:21:409-
dromes. Am I Med 1993;94:424-32. 19.
54. Brent GA. The molecular basis of thyroid hormone action. N Engi 75. van Leeuwen FXR, Sangster B. The toxicology of bromide ion.
I Med 1994:331:847-53. CRC Crit Rev Toxicol 1987:18:189-213.
55. Chopra IJ, Solomon DH, Huang IS. Serum thyrotropin in hospi- 76. Allain P, Berre S, Krari N, Lame P. Barbot N, Rohmer V. et al.
talized psychiatric patients: evidence for hyperthyrotropinemia as Bromine and thyroid hormone activity. I Clin Pathol 1993;46:
measured by an ultrasensitive thyrotropmn assay. Metabolism 456-8.
1990;39:538-43. 77. Shetty KR, Duthie EH Ir. Thyrotoxicosis induced by topical iodine
56. Ericsson UB, Lindgarde F. Effects of cigarette smoking on thyroid application. Arch Intern Med 1990;150:2400-1.
function and the prevalence of goiter, thyrotoxicosis and autoim- 78. Robey C, Shreedhar K, Batuman V. Effects of chronic peritoneal
mune thyroiditis. I Intern Med 1991;229:67-71. dialysis on thyroid function tests. Am I Kidney Dis 1989;13:99-
57. Chanoine IP, Toppet V, Bourdoux P, Spehl M, Delange F. 103.
Smoking during pregnancy: a significant cause of neonatal 79. Schlienger IL, Sapin R, Faradji A. Plasmapheresis induces high
thyroid enlargement. Br J Obstet Gynecol 1991:98:65-8. reverse 13 levels in euthyroid and hyperthyroid patients. Horm
58. Edmonds Ci, Tellez M. Treatment of Grave’s disease by carbima- Metab Res 1992:24:46-7.
zole: high dose with thyroxine compared to titration dose. Eur I 80. Ric#{244}s
C, ArbOs MA. Quality goals for hormone testing. Ann Clmn
Endocrmnol 1994:131:120-4. Biochem 199O;27:353-8.
59. Stone E, Leiter LA, Lambert IR, Silverberg IDH, Ieejeebhoy KN, 81. Browning MCK, Ford RP, Callaghan Si, Fraser CG. Intra- and
Burrow GN. L-Thyroxmne absorption in patients with short bowel. I interindividual biological variation of five analytes used in as-
Clmn Endocrinol Metab 1984:59:139-41. sessing thyroid function: implications for necessary standards of
60. Spencer CA, LoPresti IS, Nicoloff IT, Dlott R, Schwarzbein D. performance and the interpretation of results. CIin Chem 1986:
Multiphasic thyrotropin response to thyroid hormone administra- 32:962-6.
tion in man. I Clmn Endocrinol Metab 1995:80:854-9. 82. Chan DW. Automation of thyroid function testing. Pathophys Thyr
61. Watts NB. Use of a sensitive thyrotropin assay for monitoring Dis 1993;13:631-44.
treatment with levothyroxine. Arch Intern Med 1989;149:3O9- 83. Mora-Brugues I, Gasc#{244}n-Roche N, Rodriguez-Espinosa I, Cort#{233}s
12. Ruis M, Gonzales-Sastre F. Evaluation
of Ciba Corning ACS:18O
62. Mandel SI, Brent GA, Larsen PR. Levothyroxine therapy in automated immunoassay system. Clin Chem 1994:40:407-10.
patients with thyroid disease. Ann Intern Med 1993;119:492- 84. Seth 1. Work simplification of a competitive protein bindin
502. analysis for serum thyroxine and a study of some laborato
63. Davies PH, Fran klyn IA. The effects of drugs on tests of thyroid factors affecting assay results. CImn Chim Acta 1973;46:431
function. Eur I Clin Pharmacol 1991;4O:439-51. 41.
64. Khanderia U, laffe CA, Theisen V. Amiodarone-induced thyroid 85. Caraway WI. Chemical and diagnostic specificity of laborato
dysfunction. Clmn Pharm 1993:12:774-9. tests. Effect of hemolysis, lipemia, anticoagulants, medication,
65. Chiovato L, Martmno E, Tonacchera M, Santmni F, Lapi P, Mammoli contaminants and other variables. Am I Clmn Pathol 1962;37:
C. et al. Studies on the in vitro cytotoxic effect of amiodarone. 445- 64.
Endocrinology 1994:134:2277-82. 86. Statland BE, Bokelund H, Winkel P. Factors contributing t
66. Duick DS, Warren DW, Nicoloff iT, Otis CL, Croxson MS. Effect of intra-individual variation of serum constituents: 4. Effects o
single dose dexamethasone on the concentration of serum posture and tourniquet application on variation of serum constit
triiodothyronmne in man. J Clin Endocrinol Metab 1974; uents in healthy subjects. CIin Chem 1974:20:1513-9.
39:1151-4. 87. Watson D, Lees S. Comparative study of thyroxine assay
67. Re RN, Kourides IA, Ridgeway EC, Weintraub BD, Maloof F. The employing kit radio-ligand reagents. Ann Clin Biochem 1973:10
effect of glucocorticoid administration on human pituitary secre- 14-22.
tion of thyrotropmn and prolactmn. I Clin Endocrinol Metab 1976: 88. Hilborn S.Krahn I. Effect of time of exposure of serum t
43:338-46. gel-barrier tubes on results for progesterone and some othe
68. Takasu N, Komiya I, Nagasaya Y, Asawa I, Yamada 1. Exacer- endocrine tests [Letter]. Clmn Chem 1987;33:203-4.
bation of autoimmune thyroid dysfunction after unilateral adre- 89. Nishi I, Okada Y, Hayashi J, Takeoka K, Amino N, Miyai K. Effec
nalectomy in patients with Cushing’s syndrome due to an of various sampling condition on the measurement of circulatin
adrenocortical adenoma. N EngI J Med 1990:322:1708-12. ISH and free thyroxine. Ipn I CIin Pathol 1992;4O:417-22.
69. Kaptein EM, Spencer CA, Kamiel MB, Nicoloff IT. Prolonged 90. Midgley IE, Sheehan CP, Christofides ND, Fry IE, Browning 0
dopamine administration and thyroid hormone economy in nor- Mardell R. Concentrations of free thyroxin and albumin in sew
 Clinical Chemistry 42, No. 1, 1996 133

in severe nonthyroidal illness: assay artefacts and physiological interference of fatty acids in the competitive binding radioassay
influences. Clin Chem 1990;36:765-71. and radioimmunoassay for serum 14. Clin Chim Acta 1976;73:
91. Sheehan CP, Christofides ND. One-step, labeled-antibody assay 25-9.
for measuring free thyroxmn. II. Performance in a multicenter trial. 110. Liewendahl K, Helenius I, N#{228}veriH, Tikkanen H. Fatty acid-
Clmn Chem 1992;38:19-25. induced increase in serum dialyzable free thyroxine after physi-
92. Docter R, van Toor H, Krenning EP, de long M, Hennemann G. cal exercise: implication for nonthyroidal illness. I Clin Endocri-
Free thyroxine assessed with three assays in sera of patients nol Metab 1992;74:1361-5.
with nonthyroidal illness and of subjects with abnormal concen- 111. Wong 1K, Pekary AE, Hoo GS, Bradley ME, Hershman IM.
trations of thyroxine-binding proteins. Clin Chem 1993; Comparison of methods for measuring free thyroxin in nonthyroi-
39:1668-74. dal illness. Clin Chem 1992;38:72O-4.
93. Csako G, Zweig MH, Ruddel M, Glickman I, Kestner I. Direct and 112. Sapin R, Schlienger IL, Grunenberger F. Gasser F, Chambrom I.
indirect techniques for free thyroxin compared in patients with In vitro and in vivo effects of increased concentrations of free

Downloaded from https://academic.oup.com/clinchem/article-abstract/42/1/125/5646210 by guest on 15 June 2020

nonthyroidal illness. Ill. Analysis of interference variables by fatty acids on free thyroxine measurements as determined by
stepwise regression. Clmn Chem 199O;36:645-5O. five assays. Clin Chem 199O;36:611-3.
94. klee GG, Hay ID. Assessment of sensitive thyrotropmn assays for 113. Yabu Y, Amir SM, Ruiz M, Braverman LE, Ingbar SH. Heteroge.
an expanded role in thyroid function testing: proposed criteria for neity of thyroxine binding by serum albumins in normal subjects
analytic performance and clinical utility. J Clmn Endocrmnol Metab and patients with familial dysalbummnemic hyperthyroxmnemia. I
1987;64:461-71. Clin Endocrinol Metab 1985;6O:451-9.
95. Hershman JM, Pekary AE, Smith VP, Hershman JD. Evaluation of 114. Nelson IC, Weiss RM, Wilcox RB. Underestimates of serum free
five high-sensitivity American thyrotropin assays. Mayo Clin Proc thyroxine (14) concentrations by free 14 immunoassays. I Clin
1988;63:1133-9. Endocrinol Metab 1994;79:76-9.
96. Ehrmann DA, Weinberg M, Same OH. Limitations to the use of a 115. Bowie U, Kirkpatrick PB, Dohnal IC. Thyroid-function testing with
sensitive assay for serum thyrotropmn in the assessment of the TDx: interference from endogenous fluorophore [Abstract].
thyroid status. Arch Intern Med 1989;149:369-72. Clmn Chem 1987;33:1467.
97. Ross OS, Daniels GH, Gouveia 0. The use and limitations of a 116. Bloom IN, Herman DC, Elm RI, Sliva CA, Ruddel ME, Nussenblatt
chemiluminescent thyrotropin assay as a single thyroid function RB, et al. Intravenous fluorescein interference with clinical
test in an out-patient endocrine clinic. I Clin Endocrinol Metab laboratory tests. Am I Opthalmol 1989;1O8:375-9.
199O;71:764-9. 117. Nelson IC, Wilcox RB, Pandian MR. Dependence of free thyroxine
98. Nisula BC, Louvet IP. Radioimmunoassay of thyrotropin concen- estimates obtained with equilibrium tracer dialysis on the con-
tration from serum. I Clin Endocrinol Metab 1978;46:729-33. centration of thyroxine-binding globulin. Clin Chem 1992;38:
99. Spencer CA, Takeuchi M, Kazarosyan M, Mackenzie F, Beckett 1294-300.
GI, Wilkinson E. Interlaboratory/intermethod differences in func- 118. Beever K, Bradbury I, Phillips 0, McLachlan SM, Pegg C. Goral A,
tional sensitivity of immunometric assays of thyrotropin (TSH) et al. Highly sensitive assays of autoantibodies to thyroglobulmn
and impact on reliability of measurement of subnormal concen- and to thyroid peroxidase. Clin Chem 1989;35:1949-54.
trations of TSH. Clmn Chem 1995;41:367-74. 119. Volp#{233} R. Autoimmune endocrinopathies: aspects of pathogene-
100. Williams IS, lackson TM. Functional sensitivity of thyrotropmn sis and the role of immune assays in investigation and manage-
assays [Letter]. Clin Chem 1995;41:474-6. ment. Clin Chem 1994;4O:2132-45.
101. Spencer CA, Takeuchi MA. Functional sensitivity of thyrotropmn 120. Ginsberg I, Segal 0, Ehrlich RM, Walfish PG. Inappropriate
assays [Letter]. Clmn Chem 1995;41:476-7. triiodothyronmne (13) and thyroxine (14) madioimmunoassay levels
102. Kashiwal I, Ichihara K, Tamaki H, Endo Y, Kimura M, Takeoka K, secondary to circulating thyroid hormone antibodies. Clin Endo-
et al. The stability of immunological and biological activity of crinol 1978;8:133-9.
human thyrotropin in buffer: its temperature-dependent dissoci- 121. Sakata 5, Nakamura 5, Miura K. Autoantibodies against thyroid
ation into subunits during freezing. Scand I Clin Lab Invest hormones or iodothyronine. Ann Intern Med 1985;1O3:579-89.
1991;51:417-23. 122. Sakata 5, Matsuda M, Ogawa I, Takuno H, Matsui I. Sarui H, et
103. Wickus GG, Mordan RI, Mathews EA. Interface in the Allegro al. Prevalence of thyroid hormone antibodies in healthy subjects.
immunoassay system when blood is collected in silicone-coated Clin Endocrmnol 1994;41:365-7O.
tubes [Letter]. Clin Chem 1992:38:2347-8. 123. Sapmn R, Gasser F, Boehn A, Rondeau M. Spuriously high
104. Dussault JH, Coulombe P. Laberge C, et al. Preliminary report on concentration of serum free thyroxine due to anti-triiodothyronmne
a mass screening program for neonatal hypothyroidism. I Pediatr antibodies [Abstract]. Clin Chem 1995;41:117-8.
1975;86:67O-4. 124. Deam D, Goodwin M, Ratnaike S. Comparison of four methods
105. Waite KV, Maberly GF, Eastman Ci. Storage conditions and for free thyroxin. Clin Chem 1991;37:569-72.
stability of thyrotropmn and thyroid hormones on filter paper. Clin 125. Brennan MD, KIee GG, Preissner CM, Hay ID. Heterophilic serum
Chem 1987:33:853-5. antibodies: a cause for falsely elevated serum thyrotropmn levels.
106. Lemonnier F, Masson I, Laroche 0, Travert I, Travert G. Free Mayo Clmn Proc 1987;62:894-8.
thyroxin measured in dried blood spots from normal, low-birth- 126. Noh I, Hamada N, Saito H, Oyanagi H, Ishikawa N, Momotani N,
weight, and hypothyroid neonates. Clmn Chem 1991;37:2114-7. et al. Evidence against the importance in the disease process of
107. Creer MH, Ladenson I. Analytical errors due to lipemia. Lab Med antibodies to bovine thyroid-stimulating hormone found in some
1983;14:351-5. patients with Graves’ disease. I Clmn Endocrinol Metab 1989;
108. H#{252}bIW, Wejbora R, Shafti-keramat I, Haider A, Hajdusich P. 68:107-13.
Bayer PM. Enzymatic determination of sodium, potassium and 127. Ochi Y, Nagamune I, Nakajima Y, Ishida M, Kijita Y, Hachiya I,
chloride in abnormal (hemolyzed, icteric, lipemic, paraprotemne- et al. Anti-ISH antibodies in Graves’ disease and their failure to
mic, or uremic) serum samples compared with indirect determi- interact with ISH receptor antibodies. Acta Endocrinol (Copenh)
nation with ion-selective electrodes. Clmn Chem 1994;40:1528- 1989;12O:773-7.
31. 128. Boscato LM, Stuart MC. Heterophilic antibodies: a problem for
109. Shaw W, Powell I, Hubert IL, Spierto FW. A comparison of the all immunoassays. Clin Chem 1988:34:27-33.
134 NACB Symposium

129. Fiad TM, Duffy I, McKenna TI. Multiple spuriously abnormal F. et al. Assay of thyroglobulmn in serum with thyroglobulmn
thyroid function indices due to heterophilic antibodies. Clin autoantibodies: an unobtainable goal? I Clin Endocrinol Metab
Endocrinol 1994:41:391-5. 1995:80:468-72.
130. Wood IM, Gordon DL, Rudinger AN, Brooks MM, et al. Artifactual 135. Finn AF, Valenstein PN, Burke MD. Alteration of physician orders
elevation of thyroid-stimulating hormone. Am I Med 1991;90: by non-physicians. JAMA 1988;259:2549-52.
261-2.
136. Valenstein PN, Howanitz P1. Ordering accuracy. A College of
131. Zweig MH, Csako G, Benson CC, Weintraub BD, Kahn BB.
American Pathologists Q-probes study of 577 institutions. Arch
Interference by anti-immunoglobulin G antibodies in immunora-
Pathol Lab Med 1995;119:117-22.
diometric assays of thyrotropmn involving mouse monoclonal
137. kazmierczak SC, Catrou PG. Laboratory error undetectable by
antibodies. Clin Chem 1987;33:84O-4.
customary quality control/quality assurance monitors. Arch
132. Kricka U, Schmerfeld-Pruss 0, Senior M, Goodman DBP, Kala-
Pathol Lab Med 1993:117:714-8.
das P. Interference by human anti-mouse antibody in two-site

Downloaded from https://academic.oup.com/clinchem/article-abstract/42/1/125/5646210 by guest on 15 June 2020

immunoassays. Clin Chem 1990:36:892-4. 138. Franklyn IA. The management of hyperthyroidism. N EngI I Med

133. Mau M, Phillips TM, Ratner RE. Presence of anti-pituitary hor- 1994:330:1731-8.

mone antibodies in patients with empty sella syndrome and 139. Leape LL. Error in medicine. IAMA 1994:272:1851-7.
pituitary tumors. Clin Endocrinol 1993;38:495-500. 140. Blumenthal 0. Making medical errors into “medical treasures”
134. Mariotti S. Barbesmno G, Caturegli P, MarinO M, Manetti L, Pacini [Editorial]. IAMA 1994;272:1867-8.