The Glomerular Filtration Rate: From the Diagnosis of Kidney Function to a Public Health Tool

The prevalence of chronic kidney disease (CKD) continues to increase worldwide, as well as the associated morbidity and mortality and the consequences on the patients' quality of life and countries' economies. CKD often evolves without being recognized by patients and physicians, although the diagnosis is based on two simple laboratory data: the estimated glomerular filtration rate (eGFR) and urine analysis. To measure GFR, the knowledge about the physiologic processes at the nephron level, the concept of clearance, and the identification of creatinine as a suitable endogenous marker for measuring the creatinine clearance (CrCl) had to be previously developed. On those bases, different equations to calculate CrCl (Cockcroft and Gault, 1976), or estimated GFR (four variables MDRD, 1999; CKD-Epi, 2009, among others) were generated. They all include creatinine and some demographic data, such as sex and age. However, to compare results throughout life or among laboratories, the creatinine determination must be standardized. In addition, the accuracy of these equations remains controversial in certain subgroups of patients. For these reasons, other mathematical models to improve CrCl estimation have been developed, such as when urine cannot be collected, in debilitated elderly patients and patients with trauma, diabetes, or obesity. Currently, eGFR in adults can be measured and reported immediately, using isotope dilution mass spectrometry traceable creatinine-based equations. In conclusion, based on knowledge obtained from renal physiology, eGFR can be used in the clinic for the diagnosis and early treatment of CKD, as well as a public instrument to estimate the prevalence.

Evaluating kidney function using a point-of-care creatinine test in Ugandan children with severe malaria: a prospective cohort study

Background Acute kidney injury (AKI) disproportionately affects individuals in low-and middle-income countries (LMIC). However, LMIC—particularly countries in sub-Saharan Africa— are under-represented in global AKI research. A critical barrier in diagnosing AKI is access to reliable serum creatinine results. We evaluated the utility of a point-of-care test to measure creatinine and diagnose AKI in Ugandan children with malaria. Methods Paired admission creatinine was assessed in 539 Ugandan children 6 months to 4 years of age hospitalized with severe malaria based on blood smear or rapid diagnostic test. Creatinine levels were measured using isotope dilution mass spectrometry (IDMS)-traceable methods. The reference creatinine was measured using the modified Jaffe method by a certified laboratory and the point-of-care testing was conducted using an i-STAT blood analyzer (i-STAT1, with and without adjustment for the partial pressure of carbon dioxide). AKI was defined and staged using the Kidney Disease: Improving Global Outcomes criteria. Results The mean age of children was 2.1 years, and 21.6% of children were stunted. Mortality was 7.6% in-hospital. Over the entire range of measured creatinine values (<0.20mg/dL-8.4mg/dL), the correlation between the reference creatinine and adjusted and unadjusted point-of-care creatinine was high with R2 values of 0.95 and 0.93 respectively; however, the correlation was significantly lower in children with creatinine values <1mg/dL (R2 of 0.44 between the reference and adjusted and unadjusted i-STAT creatinine). The prevalence of AKI was 45.5% using the reference creatinine, and 27.1 and 32.3% using the unadjusted and adjusted point-of-care creatinine values, respectively. There was a step-wise increase in mortality across AKI stages, and all methods were strongly associated with mortality (p<0.0001 for all). AKI defined using the reference creatinine measure was the most sensitive to predict mortality with a sensitivity of 85.4% compared to 70.7 and 63.4% with the adjusted and unadjusted point-of-care creatinine values, respectively. Conclusions Point-of-care assessment of creatinine in lean Ugandan children <4 years of age underestimated creatinine and AKI compared to the clinical reference. Additional studies are needed to evaluate other biomarkers of AKI in LMIC to ensure equitable access to AKI diagnostics globally.

Preparation of Three New Certified Reference Materials for Food and Environmental Analysis and Certification Using Laboratory Intercomparison as well as Primary Reference Measurement Procedures

Three new reference materials: MODAS-3 Herring Tissue (M-3 HerTis), MODAS-4 Cormorant Tissue (M-4 CormTis), and MODAS-5 Cod Tissue (M-5 CodTis) were prepared and certified on the basis of results of a worldwide intercomparison exercise. Independently of our proven method of establishing the certified and information values, the content of several essential and toxic elements was additionally determined by the use of ratio primary reference measurement procedures (definitive methods) based on radiochemical neutron activation analysis (RNAA) in the case of As, Cd, Co, Cr, Fe, Mo, Se, and U and isotope dilution mass spectrometry (IDMS) in the case of Hg, respectively. Good agreement of the established certified values and the results obtained by ratio primary reference measurement procedures confirmed the validity of the certification procedure. The total number of elements which could be certified amounted to 30, 21, 18 in M-3 HerTis, M-4 CormTis, and M-5 CodTis, respectively. The relative frequency of use of individual analytical techniques in this intercomparison campaign was calculated and discussed. Inductively coupled plasma mass spectrometry (ICP-MS) is now a dominant technique, followed by atomic absorption spectroscopy (AAS), NAA, and emission spectroscopy (ES). The decreasing share of NAA as compared to several earlier intercomparison exercises should be noticed. NAA is the only method in the array of highly sensitive methods of inorganic trace analysis, which is essentially free from blank. The lack of this method in the foreseeable future may be an obstacle in the prospective certification campaigns and may endanger the implementation of quality assurance in trace analysis.

Determination of lithium in human serum by isotope dilution atomic absorption spectrometry

The therapeutic dose of lithium (Li) compounds, which are widely used for the treatment of psychiatric and hematologic disorders, is close to its toxic level; therefore, drug monitoring protocols are mandatory. Herein, we propose a fast, simple, and low-cost analytical procedure for the traceable determination of Li concentration in human serum, based on the monitoring of the Li isotope dilution through the partially resolved isotope shift in its electronic transition around 670.80 nm using a commercially available high-resolution continuum source graphite furnace atomic absorption spectrometer. With this technique, serum samples only require acidic digestion before analysis. The procedure requires three measurements—an enriched 6Li spike, a mixture of a certified standard solution and spike, and a mixture of the sample and spike with a nominal 7Li/6Li ratio of 0.82. Lanthanum has been used as an internal spectral standard for wavelength correction. The spectra are described as the linear superposition of the contributions of the respective isotopes, each consisting of a spin-orbit doublet, which can be expressed as Gaussian components with constant spectral position and width and different relative intensity, reflecting the isotope ratio in the sample. Both the spectral constants and the correlation between isotope ratio and relative band intensity have been experimentally obtained using commercially available materials enriched with Li isotopes. The Li characteristic mass (mc) obtained corresponds to 0.6 pg. The procedure has been validated using five human serum certified reference materials. The results are metrologically comparable and compatible to the certified values. The measurement uncertainties are comparable to those obtained by the more complex and expensive technique, isotope dilution mass spectrometry. Graphical abstract

30 years of IRMM-1027 reference materials for fissile material accountancy and control: development, production and characterisation

The IRMM-1027 Large-sized dried (LSD) spikes are certified reference materials applied to measure the uranium and plutonium content of dissolved fuel solutions using isotope dilution mass spectrometry. High quality starting metals of uranium and plutonium are dissolved to produce a stock solution, which is dispensed into individual vials and dried down. The present spikes are mixtures of typically 50 mg 20% enriched U and 2 mg enriched 239Pu as dried nitrates, conditioned in an organic substance for stability. Each vial of an IRMM-1027 LSD spike comes with certified masses of uranium (235U and 238U) and 239Pu and isotopic composition with associated uncertainty. This article will discuss major developments since the production of the first batch of LSD spikes and will reflect on the current preparation and certification approaches.

Combining Isotope Dilution and Standard Addition—Elemental Analysis in Complex Samples

A new method combining isotope dilution mass spectrometry (IDMS) and standard addition has been developed to determine the mass fractions w of different elements in complex matrices: (a) silicon in aqueous tetramethylammonium hydroxide (TMAH), (b) sulfur in biodiesel fuel, and (c) iron bound to transferrin in human serum. All measurements were carried out using inductively coupled plasma mass spectrometry (ICP–MS). The method requires the gravimetric preparation of several blends (bi)—each consisting of roughly the same masses (mx,i) of the sample solution (x) and my,i of a spike solution (y) plus different masses (mz,i) of a reference solution (z). Only these masses and the isotope ratios (Rb,i) in the blends and reference and spike solutions have to be measured. The derivation of the underlying equations based on linear regression is presented and compared to a related concept reported by Pagliano and Meija. The uncertainties achievable, e.g., in the case of the Si blank in extremely pure TMAH of urel (w(Si)) = 90% (linear regression method, this work) and urel (w(Si)) = 150% (the method reported by Pagliano and Meija) seem to suggest better applicability of the new method in practical use due to the higher robustness of regression analysis.