Model for Predicting the Impact of Gadolinium on Plasma Calcium Measured by the o-Cresolphthalein Method

Effect of Media with Different Glycerol Concentrations on Sheep Red Blood Cells' Viability In Vitro

The use of high doses of glycerol as a livestock feed supplement is followed by a rapid increase in plasma concentrations and consequently in plasma osmolality. Moreover, glycerol is a highly diffusible molecule that can readily permeate the red blood cell (RBC) membrane following a concentration gradient. A rise in glycerol plasma concentrations can thus alter RBC homeostasis. The present study aimed at investigating both glycerol osmotic effects on sheep RBCs and their oxidative response under in vitro conditions. Sheep blood samples were suspended in media supplemented with increasing glycerol concentrations (0, 25, 50, 100, 150, 200, 250, 300, 350, 400 mg/dL), which reflected those found in vivo in previous studies, and incubated at 37 °C for 4h. Thereafter, osmolality and hemolysis were determined in spent media, while cell extracts were used to assay intracellular concentration of glycerol, ATP, Ca2+ ions, oxidative stress markers and reactive oxygen species (ROS).The study confirmed that glycerol intracellular concentrations are directly related with its concentration in the incubation media, as well as hemolysis (p < 0.001) which increased significantly at glycerol concentrations higher form 200 mg/dL. ROS intracellular level increased at all glycerol concentration tested (p < 0.01) and total thiols decreased at the highest concentrations. However, RBCs proved to be able to cope by activating their antioxidant defense system. Superoxide dismutase activity indeed increased at the highest glycerol concentrations (p < 0.001), while total antioxidant capacity and malonyldialdehyde, a typical product of lipid peroxidation by ROS, did not show significant changes. Moreover, no alterations in intracellular Ca2+ ions and ATP concentrations were found. In conclusion, glycerol-induced hemolysis can be related to the induced osmotic stress. In sheep, nutritional treatments should be designed to avoid reaching glycerol circulating concentrations higher than 200 mg/dL.

Analytical Interference by Contrast Agents in Biochemical Assays

Objective

To provide a clinically relevant overview of the analytical interference by contrast agents (CA) in laboratory blood test measurements.

Materials and Methods

The effects of five CAs, gadobutrol, gadoterate meglumine, gadoxetate disodium, iodixanol, and iomeprol, were studied on the 29 most frequently performed biochemical assays. One-day-old plasma, serum, and whole blood were spiked with doses of each agent such that the gadolinium agents and the iodine agents reached concentrations of 0.5 mM and 12 mg iodine/mL, respectively. Subsequently, 12 assays were reexamined using 1/2 and 1/4 of these CA concentrations. The results were assessed statistically by a paired Student's t-test.

Results

Iodixanol produced a negative interference on the bicarbonate (p = 0.011), lactate dehydrogenase (p < 0.0001), and zinc (p = 0.0034) assays and a positive interference on the albumin (p = 0.0062), calcium (p < 0.0001), ionized calcium (p = 0.0086), iron (p < 0.0001), and potassium (p = 0.0003) assays. Iomeprol produced a negative interference on the bicarbonate (p = 0.0057) and magnesium (p = 0.0001) assays and a positive interference on the calcium (p < 0.0001) and potassium (p = 0.0012) assays. Gadoxetate disodium produced a negative interference on the iron (p < 0.0001) and zinc (p < 0.0001) assays and a positive interference on the sodium (p = 0.032) assay.

Conclusion

CAs cause analytical interference. Attention should be given to the above-mentioned analyte-CA combinations when assessing laboratory blood test results obtained after CA administration.

Interference of medical contrast media on laboratory testing

The use of contrast media such as organic iodine molecules and gadolinium contrast agents is commonplace in diagnostic imaging. Although there is widespread perception that side effects and drug interactions may be the leading problems caused by these compounds, various degrees of interference with some laboratory tests have been clearly demonstrated. Overall, the described interference for iodinate contrast media include inappropriate gel barrier formation in blood tubes, the appearance of abnormal peaks in capillary zone electrophoresis of serum proteins, and a positive bias in assessment of cardiac troponin I with one immunoassay. The interference for gadolinium contrast agents include negative bias in calcium assessment with ortho-cresolphthalein colorimetric assays and occasional positive bias using some Arsenazo reagents, negative bias in measurement of angiotensin converting enzyme (ACE) and zinc (colorimetric assay), as well as positive bias in creatinine (Jaffe reaction), total iron binding capacity (TIBC, ferrozine method), magnesium (calmagite reagent) and selenium (mass spectrometry) measurement. Interference has also been reported in assessment of serum indices, pulse oximetry and methaemoglobin in samples of patients receiving Patent Blue V. Under several circumstances the interference was absent from manufacturer-supplied information and limited to certain type of reagents and/or analytes, so that local verification may be advisable to establish whether or not the test in use may be biased. Since the elimination half-life of these compounds is typically lower than 2 h, blood collection after this period may be a safer alternative in patients who have received contrast media for diagnostic purposes.

Spurious electrolyte disorders: a diagnostic challenge for clinicians

Spurious electrolyte disorders refer to an artifactually elevated or decreased serum electrolyte values that do not correspond to their actual systemic levels. When a clinician is confronted with a case of electrolyte disturbance, the first question should be whether it is an artifact. Spurious electrolyte disorders (pseudohyponatremia, pseudohypernatremia, pseudohypokalemia, pseudohyperkalemia, pseudohypomagnesemia, pseudohypophosphatemia, pseudohyperphosphatemia, pseudohypocalcemia and pseudohypercalcemia) are not infrequently observed in clinical practice. The recognition that an electrolyte disturbance may be an artifact may prevent inappropriate therapeutic interventions that could potentially have unfavorable outcomes. Clinicians must be alert to the possibility of spurious laboratory abnormalities when faced with conflicting laboratory values or measurements that are discordant with the clinical presentation. Moreover, in the presence of conditions that predispose to spurious electrolyte disorders, the normal measured electrolyte levels should raise the suspicion that true electrolyte disorders may be present.

Trace element analysis of human urine collected after administration of Gd-based MRI contrast agents: characterizing spectral interferences using inorganic mass spectrometry

Analysis of human urine is commonly used in biomonitoring studies to assess exposure to essential (e.g., Cu, Zn, Se) and non-essential (Pb, Cd, Pt) trace elements. These data are also used in epidemiological studies to evaluate potential associations between trace element exposure and various health outcomes within a population. Today most trace element analyses are typically performed using quadrupole-based inductively coupled plasma mass spectrometry (Q-ICP-MS). However, there is always the potential for spectral interferences with Q-ICP-MS instrumentation, especially when analyzing human specimens that may contain medications and other exogenous substances. Moreover, such xenobiotics may be unknown to the investigators. In a recent study focusing on environmental exposures and endometriosis: Endometriosis: Natural History, Diagnosis, and Outcomes (ENDO Study), urine specimens (n=619) were collected from participating women upon enrollment into the study or prior to surgery or pelvic magnetic resonance imaging (MRI), and analyzed for 21 trace elements by Q-ICP-MS. Here we report on some anomalous results observed for Se and Pt with elevated concentrations up to several orders of magnitude greater than what might be expected based on established reference intervals. Further investigations using Sector Field (SF-) ICP-MS instrumentation led to identification of doubly charged and polyatomic gadolinium (Gd) species traced to a Gd-based contrast agent that was administered to some subjects just prior to urine collection. Specifically, interferences from Gd2+ and several minor polyatomics were identified as interferences on all of the major isotopes of Se including 74Se, 76Se, 77Se, 78Se, 80Se, and 82Se. While trace amounts of Pt were present in the urine, a number of Gd-containing polyatomic species were also evident as major interferences on all isotopes of Pt (190Pt, 192Pt, 194Pt, 195Pt, 196Pt, and 198Pt), including Gd-chlorides, Gd-argides, and Gd-oxides. These observations underscore the importance of considering potential isobaric interferences when interpreting unusual trace element results for clinical specimens.

Development of novel measurement assay for calcium in serum by the chlorophosphonazo-III vanadate method

Background

Chlorophosphonazo-III (2,7-bis[4-chloro-2-phosphonophenylazo]-1,8-dihydroxy-3,6-naphthalenedisulphonic acid, disodium salt; CPZ-III) reacts with calcium and magnesium in a sample under acidic to neutral conditions. However, the specific method of measuring calcium in serum using CPZ-III has not been established because of the difficulty of avoiding the interaction between CPZ-III and albumin.

Methods

In this study, we found that the non-specific reaction between CPZ-III and albumin could be controlled and calcium in serum could be specifically detected using CPZ-III combined with vanadate. On the basis of this finding, we evaluated a novel method of serum calcium determination using CPZ-III.

Results

This CPZ-III vanadate method gave linear results from 0 to 7.0 mmol/L. The coefficient of variation was 0.63–0.76%. There was no interference except with Omniscan. There was no change in control performance during 60 d under open-air conditions. The assay results correlated well with those of the Arsenazo-III (2,7-bis(2-arsonophenylazo)-1,8-dihydroxy-3,6-naphthalenedisulphonic acid) method (slope = 1.067; intercept = −0.120; r = 0.989; Sy/ x = 0.036 mmol/L), o-cresolphthalein complexone method (slope = 0.911; intercept = 0.186; r = 0.988; Sy/ x = 0.035 mmol/L), amylase enzymatic method (slope = 0.981; intercept = 0.072; r = 0.989; Sy/ x = 0.036 mmol/L) and inductively coupled plasma emission spectroscopy method (slope = 0.955; intercept = −0.001; r = 0.979; Sy/ x = 0.048 mmol/L).

Conclusions

These results suggested that the present method has great clinical potential for measuring calcium.

New method for calcium on the ADVIA analyzer is free from interference of gadolinium-type contrast agents

Recently, Siemens Diagnostics released a new calcium assay (CA_2) based on complex formation of calcium with Arsenazo III dye for use on the three automated, random access ADVIA Chemistry analyzers (1650, 2400, and 1200). We evaluated this method for analytical performance as well as potential interference from gadolinium-containing magnetic contrast agents. With Siemens Chemistry serum and urine controls, 2-levels each, the imprecision for the new method was (n=40 each): within-run and total CV of <2.2 and <3.8%, respectively, over all three platforms. The analytical range/linearity of the method (all three systems) was 1-16 mg/dl (serum or plasma) and 1-32 mg/dl (urine). The new method on all three platforms correlated well with a reference (Inductively Coupled Plasma Atomic Emission Spectroscopy) method (n=61, range 4.03-10.30 mg/dl). The ADVIA 1650 CA_2 method also correlated well with the Roche Modular system((R)) Calcium method. The new method showed <10% interference with unconjugated or conjugated bilirubin (50 mg/dl), hemoglobin (1,000 mg/dl), lipids (1,000 mg/dl), and two magnetic resonance contrast agents containing Gadolinium (OptiMARK((R)) 1 mmol/l and Omniscan 1.5 mmol/l). On the contrary, the Roche Calcium method showed significant negative interference with gadolinium-containing contrast agents. We conclude that the ADVIA Ca_2 method can measure serum, plasma, or urine calcium concentrations accurately and is also free from interferences of gadolinium-containing agents.

Gadolinium-Loaded Polychelating Polymer-Containing Cancer Cell-Specific Immunoliposomes

Liposome loading with Gd via the membrane-incorporated polychelating amphiphilic polymers (PAPs) significantly increases the Gd content and relaxivity (T1 parameter) of PEGylated liposomes, which can be used as contrast agents for magnetic resonance imaging (MRI). Here, we demonstrate that such Gd-containing liposomes can be additionally modified with the monoclonal anticancer antibody 2C5 (mAb 2C5) possessing the nucleosome(NS)-restricted specificity via the PEG spacer. Liposome-bound antibody preserves its specific activity (ELISA) and such Gd-loaded PEGylated 2C5-immunoliposomes specifically recognize various cancer cells in vitro and target an increased amount of Gd to their surface compared to antibody-free Gd-liposomes or Gd-liposomes modified with tumor nonspecific antibody. Gd-loaded cancer cell-targeted immunoliposomes may represent promising agents for enhanced tumor MRI.

What nephrologists need to know about gadolinium

Gadolinium chelates are commonly used to improve tissue contrast in MRI. Until recently the use of gadolinium was thought to be risk-free compared with alternative contrast agents. Recent studies, however, have raised serious concerns regarding the safety of gadolinium chelates. Although safe in patients with normal kidney function, administration of these agents in people with renal dysfunction can result in up to three clinical problems that the nephrologist should be familiar with. The first is nephrogenic systemic fibrosis (NSF), which was initially observed in 1997. Although manifesting primarily in skin, NSF can also cause systemic fibrosis, leading to disabling contractures and even death. Gadodiamide is the agent that has been most frequently associated with NSF, but other chelates might also pose a risk. The second clinical problem is that gadolinium chelates cause acute kidney injury, especially at high doses required for angiography. The third problem is that several laboratory artifacts are associated with gadolinium administration, with pseudohypocalcemia being the most important. The risk of a patient experiencing all three of these complications increases as renal function declines. In light of these problems, nephrologists need to re-evaluate the risks and benefits of gadolinium administration in patients with chronic kidney disease stage 3 or greater, as well as in those with acute kidney injury.

Candida albicans inactivation and cell membrane integrity damage by microwave irradiation

In indicating the microwave irradiation for disinfecting dentures it is necessary to see how this procedure influences Candida albicans integrity and viability. The aim of this study was to evaluate the ability of microwaves to inactivate C. albicans and damage cell membrane integrity. Two 200-ml C. albicans (ATCC 10231) suspensions were obtained. A sterile denture was placed in a beaker containing the Experimental (ES) or the Control suspension (CS). ES was microwaved at 650 W for 6 min. Suspensions were optically counted using methylene blue dye uptake as indicative of membrane-damaged cells; spread on Agar Sabouraud dextrose (ASD) for viability assay; or spectrophotometrically measured at 550 nm. Cell-free solutions were submitted to content analyses of protein (Bradford and Pyrogallol red methods); Ca++ (Cresolftaleine complexone method); DNA (spectrophotometer measurements at 260 nm) and K+ (selective electrode technique). Data were analysed by Student's t- or Wilcoxon z-tests (alpha = 0.05). All ES cells demonstrated cell membrane damage. Viable cells were non-existent in the ES ASD plates. No significant difference in optical density between ES and CS was observed (P=0.272). ES cells released significantly high protein (P<0.001, Bradford; P=0.005, Pyrogallol red), K+ (P<0.001), Ca++ (P=0.012) and DNA (P=0.046) contents. Microwaves inactivated C. albicans and damaged cell membrane integrity.

Application of arsenazo III in the preparation and characterization of an albumin-linked, gadolinium-based macromolecular magnetic resonance contrast agent

A macromolecular magnetic resonance contrast agent (MMCA) was prepared by linking bovine serum albumin (BSA) to gadolinium (Gd) via a chelating agent, diethylenetriaminepentaacetic acid (DTPA). Colorimetric testing with 2,7-bis(o-arsenophenylazo)-1,8-dihydroxynaphthalene-3,6-disulfonic acid (arsenazo III) was performed to check for the appearance of free gadolinium during preparation and to quantify the Gd content in the final product. The complex was purified by dialysis, concentrated by lyophilyzation and characterized by magnetic resonance (MR) proton relaxation times. The resultant product had a molecular weight of about 90 kDa, Gd:BSA ratio of 14:1, and T1 and T2 relaxation times of 128.3 and 48.9 ms, respectively, at a field strength of 7Tesla (T) and at 20% concentration. Contrast enhancement of Gadomer-17 (a dendritic MMCA) and Gd-linked to BSA (Gd-BSA) was sequentially evaluated in a rat brain gliosarcoma model (n = 5) by MR imaging (MRI). Following intravenous injection, the blood concentration of Gadomer-17 fell rapidly, whereas that of Gd-BSA was almost constant for the duration of imaging. The areas of enhancement of both MMCAs were comparable. The spatial distribution of Gd-BSA showed good agreement with Evans blue-tagged albumin. Treatment with dexamethasone decreased Gd-BSA enhancement in the tumor. These results suggest that the arsenazo III method is applicable in preparing Gd-BSA to image brain tumors and their response to treatment. This simple method may also be useful for preparing other gadolinium-linked MMCAs.

Profound Pseudohypocalcemia Due to Gadolinium (Magnevist) Contrast in a Hemodialysis Patient

We report the first case of profound "pseudohypocalcemia" after the administration of the gadolinium-based contrast media dimeglumine gadopentate (Magnevist; Schering Diagnostics AG, Berlin, Germany) to a long-standing hemodialysis patient. Initial calcium measurements were made by using our routine laboratory colorimetric method based on o-Cresolphthalein (Roche Modular-P; Roche Diagnostics Ltd, Lewes, Sussex, UK). Because the patient was well, with no signs of hypocalcemia, retrospective testing using both another o-Cresolphthalein colorimetric method (Roche Integra 800) and measurement of ionized calcium with an ion-selective electrode were performed, and confirmed laboratory pseudohypocalcemia.

Spurious hypocalcemia after gadodiamide administration

Severe hypocalcemia may require prompt intervention to avoid life-threatening consequences. We report a case in which a 78-year-old man had a critically low serum calcium level measured with use of standard colorimetric assay after gadodiamide administration during magnetic resonance angiography. Reanalysis of the same serum specimen using absorption spectroscopy revealed normal calcium values, confirming the diagnosis of spurious hypocalcemia. The increasing use of gadolinium chelates during magnetic resonance imaging and anglography will lead to a marked increase in reports of critically low serum calcium values. Increasing physicians' awareness of gadodiamide-induced spurious hypocalcemia may prevent unnecessary and potentially inappropriate therapeutic interventions.

Interference of Gadolinium-Containing Contrast-Enhancing Agents With Colorimetric Calcium Laboratory Testing

OBJECTIVES

The purpose of this study was to evaluate the extent to which various commercially available gadolinium-containing contrast-enhancing (CE) agents can interfere with the measurement of calcium levels by currently used laboratory methods, suggesting (spurious) hypocalcemia or hypercalcemia with a potential risk for the patient.

MATERIALS AND METHODS

Serum and plasma from healthy volunteers were spiked with various concentrations of 4 marketed CE agents. The calcium concentration was measured by widely used laboratory methods: the colorimetric systems Cobas Mira and Vitros 950 analyzer.

RESULTS

The measurement of calcium in serum and in plasma was not affected by the presence of gadopentetate dimeglumine (Magnevist, Schering AG, Berlin, Germany) or gadobenate dimeglumine (MultiHance, Bracco-Byk Gulden, Constance, Switzerland) in clinically relevant concentrations (up to 5 mM CE agent). Gadodiamide (Omniscan, Amersham Health, Cork, Ireland) and gadoversetamide (OptiMARK, Mallinckrodt, St. Louis, MO) did produce noticeable-and therefore potentially misleading-effects at these concentrations.

CONCLUSIONS

The study demonstrates that gadopentetate dimeglumine and gadobenate dimeglumine generate no interference with colorimetric methods for calcium determination, whereas strong interference was shown for gadodiamide and gadoversetamide under clinically relevant conditions.

Spurious Hypocalcemia After Omniscan- or OptiMARK-Enhanced Magnetic Resonance Imaging: An Algorithm for Minimizing a False-Positive Laboratory Value

Contrast-enhanced magnetic resonance imaging has become a routine diagnostic imaging procedure. Reports in the literature document that 2 of the 4 available gadolinium-based magnetic resonance imaging contrast agents, gadodiamide (Omniscan) and gadoversetamide (OptiMARK), are less stable and readily undergo dechelation. In vitro, this dechelation can result in interference with the most common laboratory methods used to measure total plasma or serum calcium. The result of total calcium measurement soon after contrast-enhanced magnetic resonance imaging with these interfering contrast agents is a spurious lowering of the total calcium level. This low calcium measurement may result in a value consistent with hypocalcemia and can persist in patients with renal insufficiency and in patients receiving higher doses of contrast agent. Alternatively, a clinically significant elevated calcium level may be overlooked because of the artificially lowered value. Two of the available gadolinium-based contrast agents, gadoteridol (ProHance) and gadopentetate dimeglumine (Magnevist), have not been to shown to interfere with total calcium measurement. A clinical practice algorithm for the laboratorian, the radiologist, and the clinician is presented to minimize the occurrence and consequences of a spuriously lowered total calcium level due to Omniscan- or OptiMARK-enhanced magnetic resonance imaging.