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Different immunoassays do not always yield the same results&#44; given that techniques can have different sample pretreatments&#44; drug metabolite cross-reactivity&#44; or quantification limits&#46;</p><p class="elsevierStylePara">The aim of our study was to compare sirolimus limits in kidney transplant patients&#44; obtained by analysing the same blood sample with the two immunoassays &#40;IMx<span class="elsevierStyleSup">&#174;</span> and Architect<span class="elsevierStyleSup">&#174;</span>&#41;&#46; The sirolimus concentration analysis included the samples received at Del Mar Hospital during the first half of 2010 &#40;period in which both reagents were available&#41;&#46; We analysed 21 samples from 13 kidney transplant patients &#40;10 men&#44; age&#58; 57&#46;5 years &#91;SD&#61;12&#46;4&#93;&#44; post-transplant time&#58; 5&#46;25 years &#91;Q1-Q3&#61;4&#46;13-9&#46;44&#93;&#41;&#46;</p><p class="elsevierStylePara">Average concentrations obtained were 4&#46;98ng&#47;ml &#40;SD&#61;2&#46;14&#41; for IMx<span class="elsevierStyleSup">&#174;</span> and 8&#46;37ng&#47;ml &#40;SD&#61;3&#46;01&#41; for Architect<span class="elsevierStyleSup">&#174;</span>&#46; The mean absolute difference between the techniques was &#43;3&#46;39ng&#47;ml &#40;SD&#61;1&#46;76&#41; for Architect<span class="elsevierStyleSup">&#174;</span> compared to IMx<span class="elsevierStyleSup">&#174;</span>&#46;</p><p class="elsevierStylePara">The Bland-Altman graph in Figure 1 shows the differences between the two techniques&#46; Figure 2 shows the correlation of least squares between both techniques&#46; The Pearson&#8217;s correlation coefficient was r&#61;0&#46;819&#46;</p><p class="elsevierStylePara">For 13 of the 21 samples&#44; the difference between the two techniques was more than 50&#37;&#44; especially for samples less than 5ng&#47;ml &#40;9&#47;11 compared to 4&#47;10&#59; <span class="elsevierStyleItalic">P</span>&#61;&#46;080&#41;&#46;</p><p class="elsevierStylePara">Two of the samples analysed by IMx<span class="elsevierStyleSup">&#174;</span> &#40;9&#46;5&#37;&#41; were below their quantification limit &#40;QL&#58; 2&#46;5ng&#47;ml&#41;&#44; while this was not found for the Architect<span class="elsevierStyleSup">&#174;</span>-analysed samples &#40;QL&#58; 0&#46;7ng&#47;ml&#41;&#46;</p><p class="elsevierStylePara">For the IMx<span class="elsevierStyleSup">&#174;</span>-analysed samples&#44; 47&#46;6&#37; &#40;10&#47;21&#41; were within the therapeutic window &#40;5-15ng&#47;ml&#41;&#44; the remaining 52&#46;4&#37; &#40;11&#47;21&#41; were at an infra-therapeutic level&#46; However&#44; of the Architect<span class="elsevierStyleSup">&#174;</span>-analysed samples&#44; 76&#46;2&#37; &#40;16&#47;21&#41; were within the therapeutic window&#44; 19&#46;0&#37; &#40;4&#47;21&#41; were at an infra-therapeutic level and 4&#46;8&#37; &#40;1&#47;21&#41; at a supra-therapeutic level&#46;</p><p class="elsevierStylePara">Various immunoassays have been developed&#44; making immunosuppressive drug monitoring easier&#46;<span class="elsevierStyleSup">7&#44;8</span> Immunoassays use reagents with monoclonal antibodies against the drug analysed&#46; Depending on the antibody&#8217;s specificity&#44; cross-reactivity may exist with the drug&#8217;s metabolites&#46; This cross-reactivity varies for each technique&#44; giving rise to differences in the results from different immunoassays&#46; This variance could cause conflict in deciding upon an immunosuppressive dose&#46;</p><p class="elsevierStylePara">Our results show that Architect<span class="elsevierStyleSup">&#174;</span> shows 3ng&#47;ml more than IMx<span class="elsevierStyleSup">&#174;</span>&#46; Courtais et al obtained similar results with slightly lower difference &#40;2&#46;28&#177;1&#46;28ng&#47;ml&#41;&#46; However&#44; only 4 out of the 53 patients studied had undergone a kidney transplant&#46;<span class="elsevierStyleSup">9</span> Furthermore&#44; the difference was only calculated for 51 out of the 100 samples analysed&#44; meaning that the infra-therapeutic or the supra-therapeutic ones were not considered&#46;</p><p class="elsevierStylePara">According to the HPLC data provided at that time by the United Kingdom External Quality Assessment Service &#40;UK NEQAS&#41; for Clinical Laboratories&#44; IMx<span class="elsevierStyleSup">&#174;</span> presents a bias of around -10&#37;&#44; and Architect<span class="elsevierStyleSup">&#174;</span> of &#43;15&#37;-20&#37;&#46;<span class="elsevierStyleSup">10</span></p><p class="elsevierStylePara">These differences can be due to different causes&#46; Firstly&#44; the two techniques use different methods for extracting the drug from the protein FKBP12&#46; Dimethyl sulfoxide &#40;DMSO&#41; is used in Architect<span class="elsevierStyleSup">&#174;</span> pretreatment to heat the sample so that more sirolimus can be extracted&#46;<span class="elsevierStyleSup">11</span> Secondly&#44; Architect&#174; has better metabolite cross-reactivity&#46; This cross-reactivity is always positive with metabolites F2 &#40;8&#46;7&#37;&#41;&#44; F3 &#40;4&#46;1&#37;&#41;&#44; F4 &#40;36&#46;8&#37;&#41; and F5 &#40;20&#46;3&#37;&#41; &#40;data provided by Abbott Laboratories<span class="elsevierStyleSup">&#174;</span>&#41;&#46; For IMx<span class="elsevierStyleSup">&#174;</span>&#44; these interferences are lower&#58; F2 &#40;2&#46;8&#37;&#41;&#44; F4 &#40;26&#46;2&#37;&#41; and F5 &#40;6&#46;8&#37;&#41;&#44; but higher with F3&#44; and&#44; also&#44; negative &#40;-22&#37;&#41;&#46; This difference was extended when we directly compare IMx<span class="elsevierStyleSup">&#174;</span> and Architect<span class="elsevierStyleSup">&#174;</span>&#46;</p><p class="elsevierStylePara">The decrease in QL from 2&#46;5ng&#47;ml &#40;IMx<span class="elsevierStyleSup">&#174;</span>&#41; to 0&#46;7ng&#47;ml &#40;Architect<span class="elsevierStyleSup">&#174;</span>&#41; allows for regimen adjustment when lower levels are required&#46;<span class="elsevierStyleSup">1</span></p><p class="elsevierStylePara">Recently&#44; the laboratory that markets sirolimus sent a communication to health care professionals warning of the changes made to immunoassays and the consequences that this has on monitoring levels&#46;<span class="elsevierStyleSup">12</span> This communication especially emphasised the need for doctors to contact the laboratory to find out which assay is used&#44; given that changes between different immunoassays or between one immunoassay and HPLC could produce clinically significant differences in results&#46; These differences could provoke inadequate dosage adjustments&#44; possibly causing adverse consequences&#46; In our study&#44; IMx<span class="elsevierStyleSup">&#174;</span> had more infra-therapeutic results than Architect<span class="elsevierStyleSup">&#174;</span> &#40;52&#37; vs&#46; 19&#37;&#41;&#44; which could mean that there more patients&#8217; doses would be increased than with Architect<span class="elsevierStyleSup">&#174;</span>&#46;</p><p class="elsevierStylePara">To date&#44; therapeutic windows have not been standardised for each measurement technique&#46; Recently&#44; the University of Colorado Hospital tried to adapt this therapeutic windows&#46;<span class="elsevierStyleSup">13</span> Given that the levels obtained by Architect<span class="elsevierStyleSup">&#174;</span> are higher&#44; the window has increased from 3-8ng&#47;ml &#40;with HPLC&#41; to 4&#46;5-13ng&#47;ml &#40;with Architect<span class="elsevierStyleSup">&#174;</span>&#41;&#46;</p><p class="elsevierStylePara">Our study&#8217;s most significant limitation is that we have included a small amount of measurements in the sample&#44; which could not have been increased as Abbott Laboratories<span class="elsevierStyleSup">&#174;</span> stopped marketing the IMx<span class="elsevierStyleSup">&#174;</span> reagent&#46; Furthermore&#44; our study includes the most kidney transplant patients to date&#46;</p><p class="elsevierStylePara">It confirms that the laboratories that determine the sirolimus levels should inform doctors when they make changes to the immunoassay employed&#44; and the consequences that could arise&#46; This information is of vital importance so that appropriate dose adjustments can be made&#46; Furthermore&#44; this information should be considered when conducting clinical studies or comparisons between different hospitals&#46; Similarly&#44; sirolimus therapeutic windows should be standardised for each of the techniques in use&#46;</p><p class="elsevierStylePara"><a href="grande&#47;10857&#95;108&#95;17665&#95;en&#95;f1&#46;10857&#46;jpg" class="elsevierStyleCrossRefs"><img src="10857_108_17665_en_f1.10857.jpg" alt="Bland-Altman graph showing the sirolimus concentration differences between IMx&#174; and Architect&#174; &#40;n&#61;21 samples&#41;"></img></a></p><p class="elsevierStylePara">Figure 1&#46; Bland-Altman graph showing the sirolimus concentration differences between IMx&#174; and Architect&#174; &#40;n&#61;21 samples&#41;</p><p class="elsevierStylePara"><a href="grande&#47;10857&#95;108&#95;17666&#95;en&#95;f2&#46;10857&#46;jpg" class="elsevierStyleCrossRefs"><img src="10857_108_17666_en_f2.10857.jpg" alt="Linear correlation between sirolimus concentrations of IMx&#174; and Architect&#174; &#40;n&#61;21&#41;"></img></a></p><p class="elsevierStylePara">Figure 2&#46; Linear correlation between sirolimus concentrations of IMx&#174; and Architect&#174; &#40;n&#61;21&#41;</p>"
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