Precisely Wrong? Urinary Fractionated Metanephrines and Peer-Based Laboratory Proficiency Testing

Abstract

Measurements of urinary fractionated metanephrines (normetanephrine and metanephrine), the O-methylated metabolites of norepinephrine and epinephrine, provide a sensitive test for diagnosis of pheochromocytoma. We present evidence suggesting inaccurate metanephrine and normetanephrine calibration by US laboratories. Metanephrines are present in urine mainly as sulfate- and glucuronide-conjugated metabolites produced from free metanephrines by the actions of conjugating enzymes (1). An acid hydrolysis step is usually performed to liberate the free metanephrines from the conjugated metabolites. This step minimizes requirements for high analytical sensitivity, simplifying subsequent measurement. Urinary fractionated metanephrines are usually measured by HPLC with electrochemical detection (HPLC-EC). Gas chromatography with mass spectrometry (GC-MS) and liquid chromatography with tandem mass spectrometry (LC-MS/MS) are more recent alternatives offering high sample throughput and improved analytical specificity (2)(3). Clinical laboratories in the US participate in proficiency testing programs, primarily aimed at determining agreement in diagnostic test results among laboratories. Identical survey samples are distributed to participating laboratories, with results stratified according to testing methodologies. Laboratories that report results deviating by more than a certain amount from the mean of their peer groups fail the proficiency test. Until the spring of 2004, the only source of commercially available urine metanephrine calibrators in the US was Bio-Rad. As with … aE-mail steve_binder{at}bio-rad.com