Introduction to Laboratory Medicine

and Interferences in Laboratory Testing

Prepared by the fourth year students

Revised by
Dr .Waleed Shaaban Dr. Rihab Ibrahim
Assistant Professors
University of Tabuk

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Objectives:

By the end of this session the student should be able to:

Describe the components of laboratory medicine in clinical
practice
Describe the role of laboratory medicine in clinical management
Describe the terms, range, mean, median and standard deviation
Describe causes of in vitro hemolysis in laboratory samples
Discuss the influence of hemolysis on various electrolytes and
tests
Describe the effect of circadian rhythm on various tests
Describe methods by which drugs can interfere with laboratory
testing (e.g., cross-reaction with antibodies, interference with
enzyme reactions, enhancement or inhibition of reactions)

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Laboratory Medicine

 A discipline of medicine that functions to provide

diagnostic tests which are utilized by physicians to
assess the health of an individual.
 Must be more than just a “service”. Dynamic
interaction with all hospital departments (Emergency
(ER), Intensive Care Unit (ICU), Cardiac Care Unit (CCU)
as well as physicians outside of the hospital to
maximize health care

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Laboratory medicine
 through:
• Consultation regarding tests to be requested
• Education
– Medical students, residents
– Medical Technologists
– Medical Staff
• Development, Evaluation and Implementation of New Diagnostic
• Assays Supporting Clinical and Basic Research
• Interaction with all departments to maintain and/or improve the
flow
• and accuracy of information (i.e test results)

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 Laboratory Medicine components include

Pathology &
Cytology
Clinical Chemistry
Immunology
Microbiology Hematology
Urine analysis

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Why are laboratory tests ordered?

• Diagnosis
• Monitor progression of disease
• Monitor effectiveness of treatment
• Screening population for diseases
• To identify complications of treatment
• To check the accuracy of an unexpected data
• To conduct research
• To prevent malpractice
• For educating residents
• To assess nutritional status and health of an health individual

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Some definition in laboratory medicine

 The "mean" : is the "average" you're used to, where you add up all
the numbers and then divide by the number of numbers.
 The "median“: is the "middle" value in the list of numbers. To find
the median, your numbers have to be listed in numerical order, so
you may have to rewrite your list first.
 The "mode" : is the value that occurs most often. If no number is
repeated, then there is no mode for the list.
 The "range" : is just the difference between the largest and
smallest values.

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Cont.
 standard deviation (represented by the symbol sigma,
σ): shows how much variation or "dispersion" exists
from the average (mean, or expected value).
• A low standard deviation indicates that the data points
tend to be very close to the mean.
• High standard deviation indicates that the data points
are spread out over a large range of values.

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 A-interference of hemolysis with laboratory tests.

• Def. of Hemolysis: is the release of hemoglobin and other

intracellular components
• from erythrocytes to the surrounding plasma, following damage or
disruption of the cell membrane.

Mechanisms of hemolysis:
Mechanical
Chemical or osmotic
Aging
Temperature (both heat and cold)

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 Causes of in vitro Hemolysis
Blood drawing
Type of syringe
Specimen transport.
Specimen processing
Causes of in vivo Hemolysis
Autoimmune hemolytic anaemia
Hemoglobinopathies
Drugs
Severe infections

Invisible Less than 30 mg/dL hemoglobin

Barely visible 30 mg/dL hemoglobin (barely pink)

Visible 60 mg/dL hemoglobin (red) or 90 mg/dL hemoglobin (burgundy)

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A-interference of hemolysis with laboratory tests.

Detection of hemolysis:
􀂾 Visual recognition:
haemolysis is visible to the eye by the red colour of serum or
plasma at 60 mg/dL free hemoglobin
􀂾 Spectrofotometric detection:
by comparison of the absorption of samples at two
wavelengths
􀂾 Analytical measurement:
by measurement of free haemoglobin in the sample
In-vivo or in-vitro haemolysis?
In-vivo haemolysis In-vitro haemolysis
􀂾 ↓ haptoglobin 􀂾 ↑ free Hgb and all
􀂾 ↑Indirect bilirubin 􀂾 ↑constituents of erytrocytes
􀂾 ↑Retikulocytes (↑ K+, LDH, ASAT/GOT)

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 Types of Interferences of Hemolysis with Laboratory tests

Interference Type 1
Interference with chemical procedure:
a) Participation of hemoglobin in the reaction through augmentation or inhibition
b) Spectrophotometric interference .
All are totally dependent upon the particular analytical methodology utilized for
measurement.

Analyte Examples Degree of Hemolysis Allowable Mechanism

(Depends on analytical method)
Amylase Slight hemolysis Increases value
Carotene No hemolysis Increases value
Ceruloplasmin No hemolysis or turbidity Decreases value
Protein electrophoresis No hemolysis May augment
beta1 between
alpha2 and beta 13
 Interference Type 2

Leakage of constituents of red cells into plasma or serum (Analytes

higher in erythrocytes than in serum)

Analyte Examples Degree of Hemolysis Allowable Mechanism

(Depends on analytical method)
Alkaline phosphatase Slight hemolysis
AST Very slight hemolysis
LDH Absolutely no hemolysis
Potassium Absolutely no hemolysis
Greater concentration
in RBC’s than in serum
Greater concentration
in RBC’s than in serum
Much greater
concentration in RBC’s
than in serum
Much greater
concentration in RBC’s
than in serum

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Interference Type 3

Dilution of plasma or serum constituents (Analytes lower in erythrocytes then in

serum) .

Analyte Examples Degree of Hemolysis Allowable Mechanism

(Depends on analytical method)
Chloride Slight hemolysis Dilutional effect
Lithium Slight to moderate hemolysis Gross hemolysis has
a dilutional effect
Magnesium No hemolysis Dilutional effect
Sodium Slight hemolysis Dilutional effect

Interference Type 4

Interference by blood contamination of other body fluids such as amniotic,

spinal, etc.

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Cont:
Hemolysis interference is approximately linearly dependent on the final
concentration of free Hb in the specimen.
• It generates a consistent trend towards overestimation of:
– ALT & AST
– Creatinine
– Sreatine kinase (CK)
– Iron
– LDH
– Lipase
– Magnesium
– Phosphorus
– Potassium
– Urea
• It generates a consistent trend towards underestimation of:
– Albumin
– ALP
– Chloride & Sodium
– GGT
– Glucose

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 B: INTERFERENCE CAUSED BY NATURAL
CIRCADIAN RHYTHMS

 Changes in concentration of analytes (any substance that

can be measured by an analytical technique) that occur over a
course of a single day

Cortisol (secondary to ACTH secretion) AM levels > PM levels

Growth hormone Elevated during sleep
Serum iron AM levels > PM levels (30%)
Thyroxine PM levels > AM levels (15%)

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C: DRUG INTERFERENCES

Drug interference is important because large number of people are

on prescription drugs and others on non-prescription medicine.
Some of these drugs interfere in complex ways with laboratory tests
Therefore, it is extremely important that you know which drugs your
patient is using when you request laboratory tests
• All drugs may affect the results of clinical laboratory tests by:
a) In vivo effects (inside the body).
b) In vitro effects (Interference with the analytical procedure).

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The main effects of drug interferences are:
a) In vivo effects (pharmacological effects)
1. Intended or therapeutic effects:
o Pantomax
• Decrease the level of HCL in stomach through proton
pump inhibition in treatment of peptic ulcer.
2. Side effects
o Oral Contraceptives
• increases in thyroxine binding globulin (TBG).
• Increases levels of fibrinogen
• Increases levels of cortisol binding globulin (CBG).
o Barbiturates and phenytoin (Dilantin)
• Induction of the liver enzymes
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b) In vitro interferences with analytical procedure (methodological
effects)
Results may be increased or decreased. The most frequent modes
of action are:
1. Alterations of chemical reactions (enhancement or inhibition)
2. Cause of turbidity in the reaction system
3. Interference with enzyme reactions
4. Cross-reaction with antibodies
5. Radioactive interference, due to in vivo use of radioactive
compounds

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Common drug-induced modifications of clinical chemistry test
values
Albumin
Decrease (false) Aspirin
Increase Heparin

Alkaline phosphatase
Decrease Anticoagulants
Increase Estrogens

Amylase
Decrease Anticoagulation
Increase Opiates

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Total T4
Decrease Phenytoin (Dilantin) and salicylates
Increase Oral contraceptives

Potassium
Decrease Diuretics
Increase Blood transfusions

Cholesterol
Decrease Androgens decrease synthesis
Increase Bilirubin and Corticosteroids

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Thank you

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