Plasma versus Serum Potasium

On 10/14/2011 5:47 PM, Gilbert Hill wrote:

2010-10-14
Clem,
I am afraid that I have let down on two questions high sensitivity troponin
and plasma potassium. I will try to deal with the latter in this letter and the
former soon.
The plasma potassium topic has a very long history, with varying periods of
high and low interest, punctuated by the publication of reports of
pseudohyperkalemia (apparently related to the type of specimen presented
for analysis), versus true hyperkalemia. The clinical challenge is to
distinguish between true hyperkalemia, which may benefit from active
treatment, and pseudohyperkalemia, which in principle should not be
treated. The LOINC challenge is how our existing model might be used to
separate the two.
My thoughts proceed along these lines:
1)
There are numerous publications showing that under controlled
circumstances, the potassium (K) concentration in a sample that has been
permitted to clot prior to analysis (i.e. serum) will be higher than the K
concentration in a sample that has not been permitted to clot prior to
analysis (i.e. plasma), and this is generally believed to be due to the release
of K from platelets, and possibly other cells, during clotting. The difference
may be increased in the presence of significant thrombocytosis or
leukocytosis.
2)
However, there are also publications showing that for a specimen
collected into a tube containing an anticoagulant, (the product of which
would be plasma), many factors can lead to an increase in the K
concentration of the plasma towards that found in serum. These factors
include (1) the collection process (use of tourniquet, type of specimen
container, (2) the type of anticoagulant), (3) the mode of specimen
transportation, and (4) the interval between collection and analysis. In other
words, the act of collecting the sample into a tube containing an
anticoagulant is no guarantee that the final K concentration in the sample
will reflect the K concentration in plasma.
3)
I have not found a publication that describes a standardized
method of collection and post collection handling that will ensure the product
truly represents plasma,

4)
It has been argued that given the vagaries of specimen collection
and transport in the real world, any attempt to distinguish between serum
and plasma K would be futile and potentially misleading, if not dangerous. It
may be a very useful thing to do, but simply calling one tube plasma and one
tube serum is unlikely to work.
5)
The question is, given all of the other variables (not even
considering patient variables, but including collection technique, collection
container, specimen transport, specimen separation each of which has its
own set of variables, as well of course of the difficulty of documenting any of
the foregoing), whether in a particular patient we can be confident that an
apparent difference between serum and plasma K is real, or an artefact. If we
could be confident that the difference is real, then a unique LOINC code
would be justified.
6)
If a new LOINC entry is created for potassium_plasma, a comment
in the Method field might be helpful, or the Status could be Trial but I would
not see these measures protecting the entry from potentially providing
misinformation specifically, leading the clinician to think that the result
actually represented the in vivo plasma concentration. I would think that a
carefully worded comment in the test request would be a better way to
communicate the clinical problem, rather than to depend on a remote
LOINC code to convey the message.
So . . . you can see that while I understand the basis for the request and
accept the logic behind it, I have serious doubts about its practical value.
For the record, here at the Hospital For Sick Children we have used plasma
samples for all electrolyte measurements since at 1965, and have not been
aware of significant differences in reference ranges from other institutions but then, our definition of a plasma sample was simply one collected into a
heparin containing tube, and did not imply any special care with collection or
transport (although of course, all samples are given special TLC!). I believe
that such a definition (probably widened to include other anticoagulants)
represents common practice and leads me to doubt whether LOINC can
contribute to solving this particular clinical challenge by creating a
potassium_plasma code.
Gil