Skip to content
Licensed Unlicensed Requires Authentication Published by De Gruyter March 25, 2021

Independent and combined effects of biotin and hemolysis on high-sensitivity cardiac troponin assays

  • Kellisha Harley , Sarah Bissonnette , Rosanna Inzitari , Karen Schulz , Fred S. Apple , Peter A. Kavsak and Ian L. Gunsolus ORCID logo EMAIL logo

Abstract

Objectives

This study compared the independent and combined effects of hemolysis and biotin on cardiac troponin measurements across nine high-sensitivity cardiac troponin (hs-cTn) assays.

Methods

Parallel cTn measurements were made in pooled lithium heparin plasma spiked with hemolysate and/or biotin using nine hs-cTn assays: Abbott Alinity, Abbott ARCHITECT i2000, Beckman Access 2, Ortho VITROS XT 7600, Siemens Atellica, Siemens Centaur, Siemens Dimension EXL cTnI, and two Roche Cobas e 411 Elecsys Troponin T-hs cTnT assays (outside US versions, with and without increased biotin tolerance). Absolute and percent cTn recovery relative to two baseline concentrations were determined in spiked samples and compared to manufacturer’s claims.

Results

All assays except the Ortho VITROS XT 7600 showed hemolysis and biotin interference thresholds equivalent to or greater than manufacturer’s claims. While imprecision confounded analysis of Ortho VITROS XT 7600 data, evidence of biotin interference was lacking. Increasing biotin concentration led to decreasing cTn recovery in three assays, specifically both Roche Cobas e 411 Elecsys Troponin T-hs assays and the Siemens Dimension EXL. While one of the Roche assays was the most susceptible to biotin among the nine studied, a new version showed reduced biotin interference by approximately 100-fold compared to its predecessor. Increasing hemolysis also generally led to decreasing cTn recovery for susceptible assays, specifically the Beckman Access 2, Ortho VITROS XT 7600, and both Roche Cobas e 411 Elecsys assays. Equivalent biotin and hemolysis interference thresholds were observed at the two cTn concentrations considered for all but two assays (Beckman Access 2 and Ortho VITROS XT 7600). When biotin and hemolysis were present in combination, biotin interference thresholds decreased with increasing hemolysis for two susceptible assays (Roche Cobas e 411 Elecsys and Siemens Dimension EXL).

Conclusions

Both Roche Cobas e 411 Elecsys as well as Ortho VITROS XT assays were susceptible to interference from in vitro hemolysis at levels routinely encountered in clinical laboratory samples (0–3 g/L free hemoglobin), leading to falsely low cTn recovery up to 3 ng/L or 13%. While most assays are not susceptible to biotin at levels expected with over-the-counter supplementation, severely reduced cTn recovery is possible at biotin levels of 10–2000 ng/mL (41–8,180 nmol/L) for some assays. Due to potential additive effects, analytical interferences should not be considered in isolation.


Corresponding author: Ian L. Gunsolus, Department of Pathology, Medical College of Wisconsin, 8701 W Watertown Plank Road, Milwaukee, WI, 53226, USA, E-mail:

Funding source: Abbott Laboratories

  1. Research funding: This study was supported in part by funding from Abbott Laboratories. The funding organization played no role in the study design; in the collection, analysis, and interpretation of data; in the writing of the report; or in the decision to submit the report for publication.

  2. Author contributions: All authors have accepted responsibility for the entire content of this manuscript and approved its submission.

  3. Competing interests: Authors state no conflict of interest.

  4. Informed consent: Not applicable.

  5. Ethical approval: The research related to human use has complied with all the relevant national regulations, institutional policies, and in accordance with the tenets of the Helsinki Declaration, and has been approved by the authors’ Institutional Review Board (Medical College of Wisconsin, PRO00036734).

References

1. Thygesen, K, Alpert, JS, Jaffe, AS, Chaitman, BR, Bax, JJ, Morrow, DA, et al.. Fourth universal definition of myocardial infarction (2018). J Am Coll Cardiol 2018;72:2231–64. https://doi.org/10.1016/j.jacc.2018.08.1038.Search in Google Scholar

2. Sandoval, Y, Smith, SW, Shah, ASV, Anand, A, Chapman, AR, Love, SA, et al.. Rapid rule-out of acute myocardial injury using a single high-sensitivity cardiac troponin I measurement. Clin Chem 2017;63:369–76. https://doi.org/10.1373/clinchem.2016.264523.Search in Google Scholar

3. Shah, ASV, Anand, A, Sandoval, Y, Lee, KK, Smith, SW, Adamson, PD, et al.. High-sensitivity cardiac troponin I at presentation in patients with suspected acute coronary syndrome: a cohort study. Lancet 2015;386:2481–8. https://doi.org/10.1016/s0140-6736(15)00391-8.Search in Google Scholar

4. Body, R, Carley, S, McDowell, G, Jaffe, AS, France, M, Cruickshank, K, et al.. Rapid exclusion of acute myocardial infarction in patients with undetectable troponin using a high-sensitivity assay. J Am Coll Cardiol 2011;58:1332–9. https://doi.org/10.1016/j.jacc.2011.06.026.Search in Google Scholar

5. Bandstein, N, Ljung, R, Johansson, M, Holzmann, MJ. Undetectable high-sensitivity cardiac troponin T level in the emergency department and risk of myocardial infarction. J Am Coll Cardiol 2014;63:2569–78. https://doi.org/10.1016/j.jacc.2014.03.017.Search in Google Scholar

6. Body, R, Burrows, G, Carley, S, Cullen, L, Than, M, Jaffe, AS, et al.. High-sensitivity cardiac troponin T concentrations below the limit of detection to exclude acute myocardial infarction: a prospective evaluation. Clin Chem 2015;61:983–9. https://doi.org/10.1373/clinchem.2014.231530.Search in Google Scholar

7. Carlton, EW, Cullen, L, Than, M, Gamble, J, Khattab, A, Greaves, K. A novel diagnostic protocol to identify patients suitable for discharge after a single high-sensitivity troponin. Heart 2015;101:1041–6. https://doi.org/10.1136/heartjnl-2014-307288.Search in Google Scholar

8. Thelin, J, Melander, O, Öhlin, B. Early rule-out of acute coronary syndrome using undetectable levels of high sensitivity troponin T. Eur Heart J Acute Cardiovasc Care 2015;4:403–9. https://doi.org/10.1177/2048872614554107.Search in Google Scholar

9. Rubini Giménez, M, Hoeller, R, Reichlin, T, Zellweger, C, Twerenbold, R, Reiter, M, et al.. Rapid rule out of acute myocardial infarction using undetectable levels of high-sensitivity cardiac troponin. Int J Cardiol 2013;168:3896–901. https://doi.org/10.1016/j.ijcard.2013.06.049.Search in Google Scholar

10. Carlton, E, Greenslade, J, Cullen, L, Body, R, Than, M, Pickering, JW, et al.. Evaluation of high-sensitivity cardiac troponin I levels in patients with suspected acute coronary syndrome. JAMA Cardiol 2016;1:405–12. https://doi.org/10.1001/jamacardio.2016.1309.Search in Google Scholar

11. Greenslade, J, Cho, E, Hise, CV, Hawkins, T, Parsonage, W, Ungerer, J, et al.. Evaluating rapid rule-out of acute myocardial infarction using a high-sensitivity cardiac troponin I assay at presentation. Clin Chem 2018;64:820–9. https://doi.org/10.1373/clinchem.2017.283887.Search in Google Scholar

12. Boeddinghaus, J, Nestelberger, T, Twerenbold, R, Wildi, K, Badertscher, P, Cupa, J, et al.. Direct comparison of 4 very early rule-out strategies for acute myocardial infarction using high-sensitivity cardiac troponin I. Circulation 2017;135:1597–611. https://doi.org/10.1161/circulationaha.116.025661.Search in Google Scholar

13. Bonini, P, Plebani, M, Ceriotti, F, Rubboli, F. Errors in laboratory medicine. Clin Chem 2002;48:691–8. https://doi.org/10.1093/clinchem/48.5.691.Search in Google Scholar

14. Plebani, M. Errors in clinical laboratories or errors in laboratory medicine? Clin Chem Lab Med 2006;44:750–9. https://doi.org/10.1515/cclm.2006.123.Search in Google Scholar

15. Plebani, M. Errors in laboratory medicine and patient safety: the road ahead. Clin Chem Lab Med 2007;45:700–7. https://doi.org/10.1515/cclm.2007.170.Search in Google Scholar

16. Kohn, LT, Corrigan, JM, Donaldson, MS. To err is human: building a safer health system. National Academy Press; 1999.Search in Google Scholar

17. Makary, MA, Daniel, M. Medical error—the third leading cause of death in the US. BMJ 2016;353:i2139. https://doi.org/10.1136/bmj.i2139.Search in Google Scholar

18. Shojania, KG, Dixon-Woods, M. Estimating deaths due to medical error: the ongoing controversy and why it matters. BMJ Qual Saf 2016;26:423–8. https://doi.org/10.1136/bmjqs-2016-006144.Search in Google Scholar

19. Saenger, AK, Jaffe, AS, Body, R, Collinson, PO, Kavsak, PA, Lam, CSP, et al.. Cardiac troponin and natriuretic peptide analytical interferences from hemolysis and biotin: educational aids from the IFCC Committee on Cardiac Biomarkers (IFCC C-CB). Clin Chem Lab Med 2019;57:633–40. https://doi.org/10.1515/cclm-2018-0905.Search in Google Scholar

20. Lippi, G, Salvagno, GL, Favaloro, EJ, Guidi, GC. Survey on the prevalence of hemolytic specimens in an academic hospital according to collection facility: opportunities for quality improvement. Clin Chem Lab Med 2009;47:616–8. https://doi.org/10.1515/cclm.2009.132.Search in Google Scholar

21. Burns, ER, Yoshikawa, N. Hemolysis in serum samples drawn by emergency department personnel versus laboratory phlebotomists. Lab Med 2002;33:378–80. https://doi.org/10.1309/pgm4-4f8l-2p1m-lkpb.Search in Google Scholar

22. Salvagno, GL, Lippi, G, Bassi, A, Poli, G, Guidi, GC. Prevalence and type of pre-analytical problems for inpatients samples in coagulation laboratory. J Eval Clin Pract 2008;14:351–3. https://doi.org/10.1111/j.1365-2753.2007.00875.x.Search in Google Scholar

23. Phelan, MP, Reineks, EZ, Schold, JD, Kovach, A, Venkatesh, A. Estimated national volume of laboratory results affected by hemolyzed specimens from emergency departments. Arch Pathol Lab Med 2016;140:621. https://doi.org/10.5858/arpa.2015-0434-le.Search in Google Scholar

24. Söderberg, J, Jonsson, PA, Wallin, O, Grankvist, K, Hultdin, J. Haemolysis index – an estimate of preanalytical quality in primary health care. Clin Chem Lab Med 2009;47:940–4. https://doi.org/10.1515/cclm.2009.227.Search in Google Scholar

25. Colon, PJ, Greene, DN. Biotin interference in clinical immunoassays. J Appl Lab Med 2018;2:941–51. https://doi.org/10.1373/jalm.2017.024257.Search in Google Scholar

26. Samarasinghe, S, Meah, F, Singh, V, Basit, A, Emanuele, N, Emanuele, MA, et al.. Biotin interference with routine clinical immunoassays: understand the causes and mitigate the risks. Endocr Pract 2017;23:989–98. https://doi.org/10.4158/ep171761.ra.Search in Google Scholar

27. Avery, G. Biotin interference in immunoassay: a review for the laboratory scientist. Ann Clin Biochem Int J Lab Med 2019;56:424–30. https://doi.org/10.1177/0004563219842231.Search in Google Scholar

28. Favresse, J, Burlacu, M-C, Maiter, D, Gruson, D. Interferences with thyroid function immunoassays: clinical implications and detection algorithm. Endocr Rev 2018;39:830–50. https://doi.org/10.1210/er.2018-00119.Search in Google Scholar

29. Bowen, R, Benavides, R, Colón-Franco, JM, Katzman, BM, Muthukumar, A, Sadrzadeh, H, et al.. Best practices in mitigating the risk of biotin interference with laboratory testing. Clin Biochem 2019;74:1–11. https://doi.org/10.1016/j.clinbiochem.2019.08.012.Search in Google Scholar

30. Kavsak, PA, Clark, L. Commercial quality control imprecision estimates for high-sensitivity cardiac troponin deltas used to rule-in myocardial infarction with the ESC 0/1-hour algorithm. J Appl Lab Med 2020;5:1122–4. https://doi.org/10.1093/jalm/jfaa030.Search in Google Scholar

31. Kavsak, PA, Edge, T, Roy, C, Malinowski, P, Bamford, K, Clark, L, et al.. Analytical assessment of ortho clinical diagnostics high-sensitivity cardiac troponin I assay. Clin Chem Lab Med 2021;59:749–55.10.1515/cclm-2020-1115Search in Google Scholar PubMed

32. Kavsak, PA, Clark, L, Caruso, N, Worster, A. Caution when using high-sensitivity cardiac troponin I assay to rule out acute ischemia: when the delta to rule in is within analytical variation. Can J Cardiol 2020;36:1161.e11–2. https://doi.org/10.1016/j.cjca.2020.03.011.Search in Google Scholar

33. Hawkins, RC. Hemolysis interference in the ortho-clinical diagnostics vitros ECi cTnI assay. Clin Chem 2003;49:1226–7. https://doi.org/10.1373/49.7.1226.Search in Google Scholar

34. Bais, R. The effect of sample hemolysis on cardiac troponin I and T assays. Clin Chem 2010;56:1357–9. https://doi.org/10.1373/clinchem.2010.144139.Search in Google Scholar

35. Snyder, JA, Rogers, MW, King, MS, Phillips, JC, Chapman, JF, Hammett-Stabler, CA. The impact of hemolysis on Ortho-Clinical Diagnostic’s ECi and Roche’s elecsys immunoassay systems. Clin Chim Acta 2004;348:181–7. https://doi.org/10.1016/j.cccn.2004.05.017.Search in Google Scholar

36. Florkowski, C, Wallace, J, Walmsley, T, George, P. The effect of hemolysis on current troponin assays—a confounding preanalytical variable? Clin Chem 2010;56:1195–7. https://doi.org/10.1373/clinchem.2009.140863.Search in Google Scholar

37. Lippi, G, Avanzini, P, Dipalo, M, Aloe, R, Cervellin, G. Influence of hemolysis on troponin testing: studies on Beckman Coulter UniCel Dxl 800 Accu-TnI and overview of the literature. Clin Chem Lab Med 2011;49:2097–100. https://doi.org/10.1515/cclm.2011.703.Search in Google Scholar

38. Bruneel, A, Dehoux, M, Barnier, A, Boutten, A. External evaluation of the Dimension Vista 1500® Intelligent Lab System: Dimension Vista 1500® evaluation. J Clin Lab Anal 2012;26:384–97. https://doi.org/10.1002/jcla.21539.Search in Google Scholar

39. Wei, J, Wu, Y, Ling, Y, Chen, X, Zhu, Q, Xu, J. False decrease of high-sensitivity cardiac troponin T assay in pneumatic tube system samples. Clin Chim Acta 2019;495:507–11. https://doi.org/10.1016/j.cca.2019.05.027.Search in Google Scholar

40. Chenevier-Gobeaux, C, Meune, C, Blanc, M-C, Cynober, L, Jaffray, P, Lefevre, G. Analytical evaluation of a high-sensitivity troponin T assay and its clinical assessment in acute coronary syndrome. Ann Clin Biochem 2011;48:452–8. https://doi.org/10.1258/acb.2011.011019.Search in Google Scholar

41. Mzougui, S, Favresse, J, Soleimani, R, Fillée, C, Gruson, D. Biotin interference: evaluation of a new generation of electrochemiluminescent immunoassays for high-sensitive troponin T and thyroid-stimulating hormone testing. Clin Chem Lab Med 2020;58:2037–45. https://doi.org/10.1515/cclm-2020-0214.Search in Google Scholar

42. Frame, IJ, Joshi, PH, Mwangi, C, Gunsolus, I, De Lemos, JA, Das, SR, et al.. Susceptibility of cardiac troponin assays to biotin interference. Am J Clin Pathol 2019;151:486–93. https://doi.org/10.1093/ajcp/aqy172.Search in Google Scholar

43. Trambas, C, Lu, Z, Yen, T, Sikaris, K. Characterization of the scope and magnitude of biotin interference in susceptible Roche Elecsys competitive and sandwich immunoassays. Ann Clin Biochem Int J Lab Med 2018;55:205–15. https://doi.org/10.1177/0004563217701777.Search in Google Scholar

44. Fitzgerald, RL, Hollander, JE, Peacock, WF, Limkakeng, AT, Breitenbeck, N, Blechschmidt, K, et al.. Analytical performance evaluation of the Elecsys® Troponin T Gen 5 STAT assay. Clin Chim Acta 2019;495:522–8. https://doi.org/10.1016/j.cca.2019.05.026.Search in Google Scholar

45. Grimsey, P, Frey, N, Bendig, G, Zitzler, J, Lorenz, O, Kasapic, D, et al.. Population pharmacokinetics of exogenous biotin and the relationship between biotin serum levels and in vitro immunoassay interference. Int J Pharmacokinet 2017;2:247–56. https://doi.org/10.4155/ipk-2017-0013.Search in Google Scholar

46. Piketty, M-L, Prie, D, Sedel, F, Bernard, D, Hercend, C, Chanson, P, et al.. High-dose biotin therapy leading to false biochemical endocrine profiles: validation of a simple method to overcome biotin interference. Clin Chem Lab Med 2017;55:817–25. https://doi.org/10.1515/cclm-2016-1183.Search in Google Scholar

47. U.S. Department of Health and Human Services Food and Drug Administration Center for Biologics Evaluation and Research Center for Devices and Radiological Health. Testing for biotin interference in in vitro diagnostic devices: guidance for industry; 2020.Search in Google Scholar

48. Grecu, DS, Vlad, DC, Dumitrascu, V. Quality indicators in the preanalytical phase of testing in a stat laboratory. Lab Med 2014;45:74–81. https://doi.org/10.1309/lm9zy92ybzrfpfqy.Search in Google Scholar

49. Lippi, G, Plebani, M, Di Somma, S, Cervellin, G. Hemolyzed specimens: a major challenge for emergency departments and clinical laboratories. Crit Rev Clin Lab Sci 2011;48:143–53. https://doi.org/10.3109/10408363.2011.600228.Search in Google Scholar

50. Kavsak, PA, Malinowski, P, Roy, C, Clark, L, Lamers, S. Assessing matrix, interferences and comparability between the Abbott Diagnostics and the Beckman Coulter high-sensitivity cardiac troponin I assays. Clin Chem Lab Med 2018;56:1176–81. https://doi.org/10.1515/cclm-2017-1122.Search in Google Scholar

51. Kavsak, PA, Worster, A, Hill, SA, Jaffe, AS. Evaluation of the Siemens ADVIA Centaur high-sensitivity cardiac troponin I assay in serum. Clin Chim Acta 2018;487:216–21. https://doi.org/10.1016/j.cca.2018.10.012.Search in Google Scholar

52. Vylegzhanina, AV, Kogan, AE, Katrukha, IA, Koshkina, EV, Bereznikova, AV, Filatov, VL, et al.. Full-size and partially truncated cardiac troponin complexes in the blood of patients with acute myocardial infarction. Clin Chem 2019;65:882–92. https://doi.org/10.1373/clinchem.2018.301127.Search in Google Scholar

53. Mock, DM, Mock, NI. Serum concentrations of bisnorbiotin and biotin sulfoxide increase during both acute and chronic biotin supplementation. J Lab Clin Med 1997;129:384–8. https://doi.org/10.1016/s0022-2143(97)90187-6.Search in Google Scholar


Supplementary Material

The online version of this article offers supplementary material (https://doi.org/10.1515/cclm-2021-0124).


Received: 2021-01-26
Accepted: 2021-03-16
Published Online: 2021-03-25
Published in Print: 2021-07-27

© 2021 Walter de Gruyter GmbH, Berlin/Boston

Downloaded on 29.3.2024 from https://www.degruyter.com/document/doi/10.1515/cclm-2021-0124/html
Scroll to top button