PLENARNE SEKCIJE

PLENARY SESSIONS

Sekcija 1

SLOBODNI RADIKALI U CIRKULACIJI:

DETEKCIJA IKLINI^KI ZNA^AJ

Session 1

FREE RADICALS IN CIRCULATION:DETECTION ANDCLINICAL SIGNIFICANCE

J Med Biochem 2010; 29 (4) 359

KOMPLEKSNOST METABOLIZMASLOBODNIH RADIKALA

U HUMANIM ERITROCITIMA

A. Nikoli}-Koki}, D. Blagojevi}, M. B. Spasi}

Univerzitet u Beogradu, Institut za biolo{ka istra`ivanja»Sini{a Stankovi}«, Odeljenje za fiziologiju,

Beograd, Srbija

Produkcija slobodnih radikala u eritroci timauglavnom se odnosi na nastajanje superoksid anjonradikala (O2.–) putem autooksidacije oksihemoglobinau methemoglobin. Ljudski eritrociti izlo`eni su pro oksi -dacio nom delovanju vodonik-peroksida nastalog dis -mu tacijom O2.– ili iz cirkulacije, kao i azot oksidu (NO)iz cirkulacije. Od di rektnih reakcija slobodnih radikala,reakcija O2.– i NO uz nastajanje peroksinitrita jereakcija sa primarno {tetnim po sledicama po eritrocite.U eritrocitima se nalaze enzimi za{tite od oksidacioniho{te}enja, kao {to su superoksid dis mu taza (SOD, EC1.15.1.1), katalaza (CAT, EC 1.11.1.6), glutationperoksidaza (GSHPx, EC 1.11.1.9) i glutation re -duktaza (GR, EC 1.6.4.2) kao i komponente male mo -lekul ske mase (glutation, vitamini E i C). Njihovimsadej stvom se kanali{u reakcije slobodnih radikala takoda di rektna o{te }enja biomakromolekula budu {to ma -nja. Me|u tim, kako nema de novo sinteze enzima uma turiranim eri trocitima, kapacitet ovih sistema jeogra ni~en, jer slobo d noradikalske vrste i direktno inhi -biraju neke od enzima. Promene na enzimima i njihovainhibicija slobodnim radi kalima uti~u na kapacitetza{tite od oksidacionih o{te}enja i relativni udeo poje -dinih komponenti u ukupnom antioksi da tivnom poten -ci jalu. To se mo`e pratiti i preko promena aktiv nostipojedi na~nih komponenti, ali i me |u sobnih odnosaizme|u kom ponenti antioksidativne odbrane diskrimi -na cio nim sta ti sti ~kim metodama, koje ukazuju na sve -ukupnost i kompleksnost odnosa antioksida tivnih kom -po nenti u eritro citima i njihov sistemski zna~aj.

COMPLEXITY OF FREE RADICAL METABOLISM

IN HUMAN ERYTHROCYTES

A. Nikoli}-Koki}, D. Blagojevi}, M. B. Spasi}

University of Belgrade, Institute for Biological Research»Sini{a Stankovi}«, Department of Physiology,

Belgrade, Serbia

The auto-oxidation of oxyhaemoglobin to methae -mo globin generating superoxide anion radical (O2.–)represents the main source of free radicals in theerythro cytes. Hydrogen peroxide is produced by O2.–dismutation or originates from the circulation. Humanerythrocytes are also exposed to the prooxidative actionsof nitric oxide (NO) from circulation. Free radicals thatmay induce reactions with direct dangerous conse -quences to erythrocytes are also preceded by thereaction of O2.– and NO producing per oxynitrite. Inphysiological settings, erythrocytes show a self-sustai -ning activity of antioxidative defence (AD) enzymes,such as: superoxide dismutase (SOD, EC 1.11.16),catalase (CAT, EC 1.11.1.6), glutathione peroxidase(GSHPx, EC 1.11.1.9) and glutathione reductase (GR,EC 1.6.4.2), as well as low molecular weight anti -oxidants: glutathione and vitamins E and C. Theircoordinate actions protect the erythro cyte’s bio -macromolecules from free radical-mediated da mage.Since there is no de novo synthesis of AD enzymes inmature erythrocytes, their defence capacity is limited.Free radicals influence antioxidative enzymes capacitiesand relative share of particular components in the wholeanti oxidative system. Therefore, by measuring changesin the activity of individual AD components, as well astheir inter relations by statistical canonical discriminantmethods, valuable data about the com plexity, overallrelations and coordi nated actions in the AD system inerythrocytes and its relevance for systemic effects canbe acquired.

UDK 577.1 : 61 ISSN 1452-8258

J Med Biochem 29: 359–361, 2010 Plenarne sekcijePlenary sessions

360

ELEKTRONSKA PARAMAGNETNAREZONANCA – MO]NO ORU\E

MEDICINSKE BIOHEMIJE U OTKRIVANJUMEHANIZAMA OBOLJENJA

I MOGU]IH TRETMANA

I. Spasojevi}

Univerzitet u Beogradu, Institut za multidisciplinarna istra`ivanja,

Beograd, Srbija

U patofiziolo{kim uslovima povezanim sa oksi -da tivnim stresom, primenjivanje odre|enih anti oksi -da tiv nih materija mo`e biti od koristi za ljudskozdravlje. Elek tron ska paramagnetna rezonantna (EPR)spektroskopija predstavlja tehniku koja pru`a jedin -stveni uvid u biohe mijske redoks procese, zahvaljuju}isvom kapacitetu da: (i) razlikuje i kvantifikuje razli~itereaktivne vrste, kao {to su hidroksil radikal, super -oksid, ugljeni~ni radikali, vodoni~ni atom, azot mono -ksid, askorbil radikal, melanin i druge; (ii) odrediantioksidativne kapacitete razli ~itih jedinjenje, eks tra - kata i namirnica; (iii) pru`i infor macije o drugimva`nim parametrima biolo{kih sistema. KombinacijaEPR spektro sko pije i tradicionalnih biohe mijskih me -toda pred stavlja efi kasno oru|e u ispitivanju mehani -zama oboljenja i mogu}e antioksidativne terapije,pru ̀ aju}i kompletniji uvid u redoks procese uljudskom organizmu.

DIJAGNOSTI^KI I TERAPIJSKI ZNA^AJPARAMETARA OKSIDATIVNOG STRESA

KOD DECE

M. Baj~eti}1, M. Brajovi}2, R. Korkut-Te{i}3

1Institut za farmakologiju, klini~ku farmakologiju i toksikologiju,

Medicinski fakultet, Univerzitet u Beogradu1Jedinica za klini~ku farmakologiju,

Univerzitetska De~ija Klinika, Beograd2Odeljenje za kardiologiju,

Klini~ko bolni~ki centar »Zvezdara«, Beograd3De~ija bolnica Korkut-Te{i}, In|ija, Srbija

Farmakoterapija oboljenja kod dece predstavljaveliki izazov s obzirom da najve}i broj lekova koji se sva -kodnevno koristi nije pedijatrijski evalurian. Efikasnostterapije zavisi u velikoj meri od poznavanja patofizio -lo{kih procesa u organizmu dece razli~itih uzrasta teistra`ivanja u tom pravcu predstavljaju imperativ. Na -ru{en balans u pro dukciji slobodnih kiseoni~kih/azot -nih vrsta i parametara antioksidantne za{tite zna~ajanje patofiziolo{ki ~inilac brojnih oboljenja (npr. sr~anainsuficijencija, plu}na hiper ten zija, astma, neonatalnasepsa, karcinom i dr.) u razli~i tim de~ijim uzrastnimperio dima. Reaktivne kiseoni ~ne/azot ne vrste imaju

ELECTRON PARAMAGNETIC RESONANCE– A POWERFUL TOOL OF MEDICALBIOCHEMISTRY IN DISCOVERINGMECHANISMS OF DISEASE AND

TREATMENT PROSPECTS

I. Spasojevi}

University of Belgrade, Institute for Multidisciplinary Research,

Belgrade, Serbia

In pathophysiological conditions related to oxi -dative stress, the application of selected antioxidantscould have beneficial effects on human health. Elec -tron para magnetic resonance (EPR) spectroscopy is atechnique that provides unique insight into the redoxbiochemistry, due to its ability to: (i) distinguish andquantify different reactive species, such as hydro xylradical, superoxide, carbon cente red ra dicals, hy dro -gen atom, nitric oxide, ascorbyl radical, melanin, andothers; (ii) evaluate the antioxidative capacity of variouscompounds, extracts and foods; (iii) provide infor -mation on other important para meters of biological sys -tems. A combination of EPR spectro scopy and tradi -tional biochemical methods represents an efficient toolin the studies of disease mechanisms and antioxidativetherapy prospects, providing a more complete view intothe redox processes in the human organism.

DIAGNOSTIC AND THERAPEUTICSIGNIFICANCE OF THE OXIDATIVE STRESS

PARAMETERS IN CHILDREN

M. Baj~eti}1, M. Brajovi}2, R. Korkut-Te{i}3

1Institute of Pharmacology, Clinical Pharmacology and Toxicology,

School of Medicine, University of Belgrade1Clinical Pharmacology Unit,

University Children’s Hospital, Belgrade2Department of Cardiology, Clinical Hospital Centre

»Zvezdara«, Belgrade, Serbia3Children’s Hospital Korkut-Te{i}, In|ija, Serbia

Pharmacotherapy of pediatric diseases repre -sents a major challenge considering that the majorityof medi cines in everyday practice have not beenpediatrically evaluated. The efficacy of therapy de -pends to a large extent on the knowledge of patho -physiological processes in the children organism atdifferent ages. Therefore, research in that direction isof the utmost importance. An imbalance in the pro -duction of free oxygen/nitrogen species andparameters of antioxidative protection is a significantfactor in many diseases (e.g. heart failure, pulmo naryhypertension, asthma, neonatal sepsis, cancer etc.) in

J Med Biochem 2010; 29 (4) 361

funkciju signalnih molekula u normal nim fiziolo{kimprocesima. Njihova pove}ana produkcija mo`e izazvatio{te}enja koja mogu naru{iti normalne fiziolo{ke pro -cese u }eliji i u krajnjem ishodu izazvati }elijsku smrt. Uovom radu dat je pregledni prikaz dosada{njih ispiti -vanja parametara oksidativnog stresa kod dece razli~itestarosne dobi za pojedina oboljenja. Tako|e, razmotrilismo sve poten cijalne dijagnosti~ke i terapijske mogu} -nosti parametara oksidativnog stesa u de~ijem uzrastu.

children of different age groups. Reactive oxy gen/nitrogen species serve as cell signaling molecules fornormal biologic processes. An increase in theirgeneration can cause damages which can disruptnormal physiological cellular processes and eventuallycause cell death. This review outlines the previousassessments of oxidative stress parameters in childrenof different ages for some diseases. Also, the po -tential diagnostic and thera peutic possibilities for theoxydative stress parameters in children have beenconsidered.

Sekcija 2

DIJAGNOSTIKA TIROIDNE

BOLESTI

Session 2

THYROID DISEASE DIGNOSTICS

J Med Biochem 2010; 29 (4) 365

DIJAGNOSTIKA TIROIDNE BOLESTI: PRINCIPI I PROBLEMI

M. @arkovi}

Medicinski fakultet,Univerzitet u Beogradu,

Klinika za endokrinologiju,Klini~ki centar Srbije, Beograd, Srbiija

Konceptualno, poreme}aji {titaste `lezde se mogusvrstati u ~etiri grupe: 1. poreme}aji morfo logije {titaste`lezde, 2. poreme}aji tiroidne funkcije, 3. pri sustvo tiro -idne autoimunosti i 4. dijagnoza i pra}enje karci noma{titaste `lezde. Naravno, ove grupe se ~esto pre kla paju.Za dijagnostiku poreme}aja morfologije {titaste `lezdenaj bi tniji je ultrazvu~ni pregled. Za dijagnozu pore -me}aja tiroidne funkcije neophodno je odre|ivanje TSHi tiroidnih hormona. Prisustvo tiroidne autoimunosti po -tvr|uje se mere njem anti tela na tiroidno specifi~ne anti -gene. Za dijagnozu, pra} enje i prognozu autoimunihbolesti {titaste `lezde koriste se antitela na tiroidnuperoksidazu (TPO), tireoglobulin (TG) i antitela na TSHreceptore. Odre|ivanje tireoglobulina u seru mu nemazna~aj u dijagnostici karcinoma {titne `lezde, ali sekoristi u pra}enju bolesnika le~enih od diferentovanogkarci noma ti roide. Medularni tiroidni karcinom (MTK)sekretuje kalcitonin i karcinoembrioni antigen (CEA), alije kalcitonin specifi~an za MTK. Kod obolelih od MTKneophodno je genetsko testi ranje a u pozitivnim slu~a -jevima potrebno je i gensko testi ranje srodnika.

ZNA^AJ ODRE\IVANJA HORMONA I PROTEINA U MATERIJALU

DOBIJENOM ASPIRACIJSKOM PUNKCIJOM TANKOM IGLOM

B. Trbojevi}, B. Nedeljkovi} Beleslin

Medicinski fakultet, Univerzitet u Beogradu, Klinika za endokrinologiju, Klini~ki centar Srbije,

Beograd, Srbija

Vi{e od pola veka iskustva sa aspira cij skom punk -ci jom nodoznih promena u {titastoj `lezdi utvrdi lo jeovaj postupak kao zlatni standard u ispitivanju tiroidne

DIAGNOSIS OF THYROID DISEASE:PRINCIPLES AND PROBLEMS

M. @arkovi}

School of Medicine, University of Belgrade

Clinic of Endocrinology, Clinical Center of Serbia, Belgrade, Serbia

Conceptually, thyroid disorders can be clas sifiedinto four groups, namely: 1. disorders of thyroid morp -hology, 2. disorders of thyroid func tion, 3. presence ofthyroid auto immunity, and 4. diagnosis and follow-up ofthyroid carcinoma. Of course, these groups are non-exclusive, and often there is overlap between thegroups. Ultrasound exam is a standard for the diagnosisof the disorders of thyroid morphology. To diagnosedisorders of thyroid function TSH and thyroid hormonesshould be mea sured. Presence of thyroid autoimmunityis confirmed by measuring antibodies against thyroid-specific antigens. Thy roid peroxidase (TPO), thyroglo -bulin (Tg) and TSH receptors antibodies are used in thediagnosis, follow-up and prognosis of autoimmunethyroid disorders. The measu rement of serum thyro -globulin has no role in the diagnosis of thyroid cancer,but it is used in the follow-up of patients treated fordifferentiated thyroid carcinoma of the follicularepithelium. Medullary thyroid cancer (MTC) producescal citonin and carcinoembryonic antigen (CEA), butcalcitonin is specific for MTC. In subjects with MTC,genetic testing should be done, and in positive casesfamily screening is necessary.

IMPORTANCE OF HORMONES AND PROTEINS DETERMINATION

IN THE MATERIAL OBTAINED BY FINE-NEEDLE ASPIRATION

B. Trbojevi}, B. Nedeljkovi} Beleslin

School of Medicine, University of Belgrade,Clinic of Endocrinology, Clinical Centre of Serbia,

Belgrade, Serbia

More than a half century of experience with aspi -ration punch of nodal changes in the thyroid gland hasconfir med this procedure as a golden standard in the

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366

nodozne bolesti. Iako su osetljivost, specifi~nost, pouz -da nost i reproducibilnost dokazano visoke, ovaj po stu -pak ipak u skoro petini slu~ajeva ne mo`e jednozna -~no da odgovori da li je ispitivana promena benigne ilimaligne prirode. Mno go brojni poku{aji da se postupakpopravi doveli su do zna ~ajnog pobolj{anja vrednostinjime dobijenih nalaza. Po red rafiniranja tehnika cito -pa tolo{kih pretraga, dokaziva nje ili odre|ivanje hor -mo na, proteina i drugih supstanci u ma te ri jalu dobije -nom aspiracijom tankom iglom danas pred stavljanajve}i doprinos u pobolj{anju dijagnosti~ke vrednostipo stup ka. Ovi belezi se danas u najve}em broju centa -ra prate u aspiratima nodoznih promena u {titastoj`lezdi ali i okolnih limfnih nodusa kako bi se sa ve}omsigurno{}u ocenile vrsta promene, obim i stepen pro -{i renosti, {to je od zna~aja u pri premi terapijskih po -stupaka ali i za ocenu rezidualne bolesti posle pri me -njenog le~enja.

GENETIKA KARCINOMA [TITASTE @LEZDE:DIJAGNOSTI^KE I KLINI^KE IMPLIKACIJE

S. Damjanovi}

Medicinski fakultet,Univerzitet u Beogradu,

Klinika za endokrinologiju,Klini~ki centar Srbije, Beograd, Srbiija

Apstrakt nije dostavljen.

MERENJE KONCENTRACIJETIREOGLOBULINA KOD PACIJENATASA DIFERENTOVANIM KARCINOMIMA

[TITASTE @LEZDE

S. Savin1, D. Cveji}1,Lj. Mijatovi}2, S. @ivan~evi} Simonovi}2

1Institut za primenu nuklearne energije – INEPUniverzitet u Beogradu, Zemun-Beograd

2Medicinski fakultet, Univerzitet u Kragujevcu,Kragujevac, Srbija

Tiroidni karcinomi su naj~e{}i maligni endo krinitumori. Tireoglobulin (Tg), specifi~ni protein {ti ta ste`lezde, najva`niji je tumorski marker u tireoidnojonkologiji. Kod pacijenata sa diferentovanim karcino -mima tireo ideje, nakon operativnog le~enja, koncen -tracija Tg odre|uje se radi otkrivanja rezidualnogtumorskog tkiva ili postojanja lokalnih, odnosno uda -lje nih metastaza. Na koncentraciju Tg u serumuuti~u: masa prisutnog tireoid nog tkiva (benignog ilimalignog), intenzitet stimulacije receptora za tireo -stimuli{u}i hormon (TSH) i sposobnost tumorskih

exami nation of thyroid nodal disease. Althoughsensitivity, spe cificity, reliability and reproducibility areincontestably high, this procedure cannot give asimple answer on whether the change examined isbenign or malignant. Numerous attempts to im provethe procedure resulted in considerably advancedfindings. Besides refining the cytopathologic exami -nation techniques, confirmation or determination ofhormones, proteins and other substances in thematerial obtained by fine-needle aspiration areactually the greatest contribution to improvement theof procedure’s diagnostic value. These markers areactually followed, in most medical centers, in aspiratesof thyroid nodal changes but also surrounding lymphnodes in order to evaluate with greater certainty thetype, volume and spread; this is important to establishtreatment procedures and to evaluate the residualdisease after accomplishing the treatment.

GENETICS OF THYROID CANCER:DIAGNOSTIC AND CLINICAL IMPLICATIONS

S. Damjanovi}

School of Medicine, University of Belgrade

Clinic of Endocrinology, Clinical Center of Serbia, Belgrade, Serbia

Summary not submited.

MEASURING THYROGLOBULINCONCENTRATIONS IN PATIENTS

WITH DIFFERENTIATEDTHYROID CARCINOMA

S. Savin1, D. Cveji}1,Lj. Mijatovi}2, S. @ivan~evi} Simonovi}2

1Institute for the Application of Nuclear Energy – INEP,University of Belgrade, Zemun-Belgrade

2Faculty of Medicine, University of Kragujevac,Kragujevac, Serbia

Thyroid carcinomas are the most common mal -ignant endocrine tumors. Thyroglobulin (Tg), a specificthyroid protein, is the most important tumor marker inthyroid oncology. After total thyroidectomy or radio -iodine therapy, detectable or increasing serum Tglevels in patients with differentiated thyroid carcinomaindicate persistence of active thyroid tissue or cancerrecurrence. Serum Tg concentration primarily reflectsthree variables: the mass of differentiated thyroid tissuepresent; the degree of thyrotropin receptor stimulationand the intrinsic ability of the tumor to synthesize and

J Med Biochem 2010; 29 (4) 367

}elija da sinteti{u i lu~e Tg. Savremene metode, imu -nometrijske (IMA) i radioimunolo{ke (RIA), koji ma seodre|uje koncentracija Tg u serumu ispitanika, imajuodre|ena ograni~enja koja mogu da umanje klini~kizna~aj dobijenih rezultata. Usled metodolo{kih razlika,koncen tra cije Tg u istim uzorcima seruma, izmerenerazli~itim testo vima, mogu se razlikovati. Faktori kojimogu prouzrokovati razlike u izmerenim koncentraci -jama Tg su brojni: razli~iti referentni materijali, razlike uspecifi~nosti primarnih i sekundarnih anti tela za anti -genske determinante Tg, razli ~it afinitet vezivanja tihantitela za epitope Tg, i interfe ren cija serumskih faktora.Princip testa, kao i eventualno prisu stvo TgAt u seru -mima ispi tanika, mo ̀e uticati na izmerenu koncentra -ciju Tg. Svako odstupanje izmerenih koncentra cija Tgod stvarnih vrednosti mo`e imati ozbiljne posledice:la`no niske vrednosti Tg mogu odlo`iti neophodnitretman pacijenata, dok la`no pove}ane vrednosti Tgmogu prouzrokovati nepotrebni stres, ili ~ak tretmanpacijenata. I pored ograni~enih mogu}nosti savre me nihmetoda, odre|ivanje koncentracije Tg u serumu paci je -nata operisa nih od diferentovanog tiroidnog karcino maje koristan test za otkrivanje pogor{anja bolesti i za pra -}enje efe kata tera pije.

secrete Tg. Measurement of serum Tg by currentimmunometric (IMA) and radioimmunological (RIA)assays encounters some methodological problemswhich can diminish its clinical importance. Discrepancybetween the results for Tg using different methods maybe caused by: different reference materials, specificproperties of the primary and secondary antibodies forantigenic deter minants on Tg and diverse bindingaffinities of these epitopes, together with interferenceby serum factors (usually antibodies to Tg (TgAb)) withthe primary and secondary Tg antibodies from thediagnostic set. In the presence of endo genous TgAb,Tg values measured by immuno radio metric assay(IRMA) and similar assays are usually lower than thereal concentrations, while in RIA apparently lower orhigher results can be obtained. Falsely low values maylead to delay in necessary treatment, while aninappropriately high Tg value can cause patient anxietyand unnecessary scans. Despite current methodolo -gical limitations, serum Tg mea su rement is a usefultest for determining worsening dise ase and monitoringthe effects of therapy in patients who have undergonesurgery for differentiated thyroid carcinoma.

Sekcija 3

NOVI BIOHEMIJSKIMARKERI

Session 3

NEW BIOCHEMICALMARKERS

J Med Biochem 2010; 29 (4) 371

KLINI^KA VREDNOSTLIPOPOLISAHARID-VEZUJU]EG PROTEINA

(LBP) I INFEKCIJI I SEPSI

D. Schmidt

Medical Marketing & Scientific SupportSiemens Healthcare Diagnostics GmbH,

Eschborn, Germany

Apstrakt nije dostavljen.

ESR TEST: STARI TESTSA NOVOM NAMENOM

E. Piva, M. Plebani

Department of Laboratory MedicineUniversity School of Medicine, Padua, Italy

Brzina sedimentacije eritrocita (ESR) osta jejedan od naj~e{}e kori{}enih laboratorijskih testova.Klini~ku primenu i korisnost ovaj test ima u pra}enjuinfla matornih bolesti, naro~ito reumatoidnog artritisa,tempo ralnog arteritisa i reumatske polimijalgije. Refe -rentni metod za merenje ESR predlo`en od straneMe|u narodnog komiteta za standardizaciju u hema -tologiju koristi punu krv sa antikoagulansom EDTA zaizvo|enje testa pomo}u me tode koju je 1921. opisaoWestergren. Trenutno zanima nje za metodologiju fo ku sirano je na razvoj automatizovanih za tvorenihsis te ma koji omogu}avaju odre|ivanje brzine sedi -men tacije uz odabrane radne metode, koje koriste je -dan uzorak za vi{e hematolo{kih testova i unapre|ujubio hazardne aspekte postupka testiranja. Usled toga,standar dizacija postaje neophodna. Rezultati ESRmoraju biti po uzdani uprkos pove}anom broju razli -~itih metoda i vari jabli za testiranje. Danas su do -stupni kontrolni materijali i {eme za osiguranje spo lja -{njeg kvaliteta i treba ih koristiti. Dakle, inovativnetehnike mogu dalje opravdati korisnost ESR u klini~ -koj praksi, ali pored toga moraju garantovati sledivostrezultata u pore|enju sa referentnom metodom kakobi se obezbedila uporedivost rezultata izme|u vi{eklini~kih laboratorija.

CLINICAL VALUE OFLIPOPOLYSACCHARIDE-BINDING PROTEIN

(LBP) IN INFECTION AND SEPSIS

D. Schmidt

Medical Marketing & Scientific SupportSiemens Healthcare Diagnostics GmbH,

Eschborn, Germany

Summary not submited.

THE ESR TEST: AN OLD TESTWITH NEW CONTENTS

E. Piva, M. Plebani

Department of Laboratory MedicineUniversity School of Medicine, Padua, Italy

The erythrocyte sedimentation rate (ESR) remainsone of the most widely used laboratory tests. Its clinicalusefulness and interpretation are in the monitoring ofinflammatory diseases, in particular rheumatoidarthritis, temporal arteritis and polymyalgia rheumatica.At present, the reference method for measuring theESR proposed by the International Committee forStandardization in Haematology (ICSH) utilizes EDTA-anticoagulated-undiluted blood to perform the testusing the method described by Westergren in 1921.Current interest in the methodology focuses on thedevelopment of an automated closed system that allowsthe determination of the sedimentation rate withselected working methods, using a single sample formore than one haematological test, improving the bio-hazardous aspects of the testing procedures. As aconsequence, standardization becomes necessary. ESRresults should be reliable, despite the increased numberof different methods and testing variables. Controlmaterials and External Quality Assurance Schemes arenow available, and should be used. In conclusion,innovative techniques may improve the appro-priateness and usefulness of ESR in clinical practice, butin addition, they need to guarantee the traceability ofresults in comparison to the reference method in orderto ensure comparability of results among differentclinical laboratories.

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372

PRA]ENJE VENSKOG TROMBOEMBOLIZMA(VTE) POMO]U D-DIMERA

– [TA LABORATORIJA I KLINI^ARITREBA DA ZNAJU?

G. Le Gal

Department of Internal Medicine and Chest DiseasesBrest University Hospital, France

D-dimer je proizvod razgradnje fibrina koji se userumu mo`e otkriti pomo}u vi{e razli~itih testova.Zahva ljuju}i visokoj osetljivosti na prisustvo tromba ineinvazivnom karakteru, merenje D-dimera se ~estopri menjuje kao test prve dijagnosti~ke linije da bi seisklju~ila bolest kod paci jenata sa sumnjom naduboku vensku trombozu (DVT) ili plu}nu emboliju(PE). S druge strane, specifi~nost testa za D-dimer jeniska, {to spre~ava njegovu samostalnu upo trebuprilikom dono{enje dijagnoze (~ak i sumnje na) VTE.Dostupni testovi za D-dimer su heterogeni i nisu svipro{li isti nivo klini~ke validacije. Svaki test za D-dimermora biti inte grisan u sveobuhvatne, validiranesekven cijalne dijag nosti~ke strategije koje obuhvatajuklini~ku verovatno}u procene i imaging tehnike, kao{to je ultrasonografija venske kompresije u donjimekstremitetima kod sumnje na DVT ili multislajskompjuterizovana tomografija kod sumnje na PE.Rezultate testa za D-dimer potrebno je tuma~iti ukombi na ciji sa procenom klini~ke izvesnosti: negativnitest dozvo ljava isklju~ivanje VTE kod pacijenata samalom klini~ kom izvesno{}u za testove aglutinacijepune krvi i kod paci je nata sa nevelikom klini~komizvesno{}u za najosetljivije testove (ELISA ili nekiimunoturbidimetrijski testovi). Korisnost testa za D-dimer je naro~ito velika u ambulantnim klini~kimuslovima, jer dozvoljava isklju~ivanje VTE bez da ljegtestiranja kod pribli`no jedne tre}ine sumnjivih pacije -nata. Neka stanja povezana sa povi{enim nivoima D-dimera ograni~avaju korisnost testa u klini~koj praksi:trudno}a, primljeni i pacijenti posle hirur{keintervencije, pacijenti sa istorijom prethodne VTE,maligniteti, stariji pacijenti. Me|u tim, ~ak i kada sutakva stanja prisutna, osetljivost D-dimera ostajenepromenjena a test je ~esto i dalje finansijski ispla tiv.Dalji klini~ki razvoj testa za Ddimer uklju~ujevalidaciju novih cut-off vrednosti kod starijihpacijenata i predvi|anje rekurentne VTE posle prvetromboembolijske epizode.

D-DIMER IN THE MANAGEMENTOF VENOUS THROMBOEMBOLISM

(VTE) – WHAT LABORATORIANSAND CLINICIANS SHOULD KNOW?

G. Le Gal

Department of Internal Medicine and Chest DiseasesBrest University Hospital, France

D-Dimer is a degradation product of cross-linked fibrin. It can be detected in serum using a vari -ety of different assays. Thanks to its high sensitivity tothe presence of a thrombus and to its non-inva -siveness, D-Dimer measurement is widely used as afirst-line test to rule out the disease in patients withsuspected deep vein thrombosis (DVT) or pulmonaryembolism (PE). On the other hand, D-Dimer testspecificity is low, precluding its use alone for ruling in(and even for suspecting) the diagnosis of VTE.Available D-Dimer assays are quite heterogeneous,and not all of them received the same level of clinicalvalidation. Each D-Dimer assay must be integrated incomprehensive, validated sequential diagnosticstrategies that include clinical probability assessmentand imaging techniques such as lower limb venouscompression ultrasonography for suspected DVT ormulti-slice computed tomography for suspected PE.D-Dimer test result needs to be interpreted incombination with clinical probability assessment: anegative test allows ruling out VTE in low-clinicalprobability patients for whole blood agglutinationassays and in non-high clinical probability patients forthe most sensitive tests (ELISA or some immuno -turbidimetric assays). The usefulness of D-Dimer testis particularly high in outpatient settings, allowingruling out VTE in approximately one third of sus -pected patients without further testing. Some condi -tions are associated with increased d-dimer levels andlimit D-Dimer test usefulness in clinical practice:pregnancy, admitted and post-surgical patients,patients with a history of previous VTE, malignancy,elderly patients. However, even when these conditionsare present, D-dimer sensitivity is not altered, and thetest is often still cost-effective. New clinical develop -ments for D-Dimer test include validation of new cut -off values in elderly patients, and prediction of recur -rent VTE after a first thrombo embolic episode.

J Med Biochem 2010; 29 (4) 373

»POINT-OF-CARE« TESTIRANJE D-DIMERA

J. P. Antovi}

Coagulation, Hematology, Clinical ChemistryKarolinska University Laboratory,

Karolinska University Hospital & Department ofMolecular Medicine and Surgery,

Karolinska Institutet Stockholm, Sweden

Odre|ivanje D-dimera omogu}ava efi kasnoisklju~ivanje venskog tromboembolizima (VTE). La bo -ratorijsko testiranje D-dimera prete`no se izvodi ucen tralizovanim laborato rijama u okviru bolnica, iakose ve}ina pacijenata kod kojih se sumnja na VTE javljana pregled u ustanove primarne zdravstvene za{tite.Tako|e, skra}enje ukupnog trajanja laboratorijskogtestiranja bi znatno po bolj{alo efikasnost u urgentnimcentrima. Stoga bi uvo|e nje brzog »Point of Care(POC)« D-dimer testa koji se lako izvodi, dovelo dopobolj{anja dijagnostike VTE u primarnoj zdravstvenojza{titi kao i u urgentnim centrima, ali tako|e i udijagnostici drugih te{kih klini~kih stanja (disemino -vana intravaskularna koagulacija (DIK), aneurizmaaorte) u ko jima je D-dimer povi{en. Ve}ina dostupnihPOC D-dimer testova ispunjava kriterijume za brzo isigurno isklju~ivanje VTE-a. U na{em ispitivanju tritesta (Stratus, Pathfast i Cardiac) pokazala su karakte -ristike sli~ne D-dimer testu koji je u rutinskoj upotrebiu na{oj laboratoriji (Tinaquant).

OSETLJIVI TESTOVI ZASR^ANI TROPONIN: MIT I MAGIJA

ILI PRAKTI^AN NAPREDAK?

D. C. Gaze

Department of Chemical Pathology, Clinical Blood Sciences

St. George’s Hospital and Medical School, Tooting, London, United Kingdom

Sr~ani troponini (cTn) smatraju se »zlatnim stan -dardom« me|u biomarkerima za dijagnosti ko vanjeakutnog koronarnog sindroma (ACS), patolo{kogspektra koji obuhvata sr~anu ishemiju, anginu, infarktmio karda i kona~no prestanak rada srca. Sve ve}i brojdokaza koji idu u prilog dijagnosti~koj i prognosti~kojupotrebi cTn u ACS doveo je do op{teg ponovnogdefinisanja akutnog infarkta miokarda (AMI). Dijag no -za AMI uklju~uje detekciju povi{enog cTn (ili CK-MB) –najmanje jednom u 24 ~asa od sr~ane epizode izmerenje nivo > gornjeg 99. procenta referentne populacije –uz dokaze o ishemiji miokarda. Izra |e no je nekolikoveoma osetljivih imunoeseja s navodno superiornom

»POINT-OF-CARE« D-DIMER TESTING

J. P. Antovi}

Coagulation, Hematology, Clinical ChemistryKarolinska University Laboratory,

Karolinska University Hospital & Department ofMolecular Medicine and Surgery,

Karolinska Institutet Stockholm, Sweden

D-dimer testing is efficient in the exclusion ofvenous thromboembolism (VTE). D-dimer laboratoryassays are predominantly performed in centralisedlabo ratories in intra-hospital settings although mostpatients with suspected VTE are presented in primarycare. On the other hand decreasing turnaround timefor laboratory testing may significantly improveefficacy in emergency departments. Therefore anintroduction of a rapid, easy to perform point of care(POC) assay for the identification of D-dimer mayoffer improvement in diagnostics flow of VTE both inprimary care and emergency departments while itcould also improve our diagnostic possibilities insome other severe clinical conditions (e.g. dissemi -nated intra vascular coagulation (DIC) and aorticaneurism (AA)) asso ciated with increased D-dimer.Several POC D-dimer assays have been evaluatedand majority of them have met the criteria for rapidand safe exclusion of VTE. In our hands three assays(Stratus, Pathfast and Cardiac) have the labo ratoryperformance profile comparable with our routine D-di -mer laboratory assay (Tinaqaunt).

SENSITIVE CARDIAC TROPONIN ASSAYS: MYTH AND MAGIC OR A PRACTICAL

WAY FORWARD?

D. C. Gaze

Department of Chemical Pathology, Clinical Blood Sciences

St. George’s Hospital and Medical School, Tooting, London, United Kingdom

Cardiac troponins (cTn) are considered to be the‘gold standard’ biomarkers for the diagnosis of acutecoronary syndrome (ACS) a pathological spectrumwhich includes cardiac ischemia, angina, myocardialinfarction and ultimately cardiac failure. The growingevidence base for the diagnostic and prognostic use ofcTn in ACS has resulted in a universal redefinition ofacute myocardial infarction (AMI). A diagnosis of AMIincludes the detection of an elevated cTn (or CK-MB)with at least one measurement within 24 hours of thecardiac episode being >upper 99th percentile of areference population, in conjunction with evidence ofmyo cardial ischemia. A number of high sensitivity

374

neprecizno{}u i 99. procentilnom vredno{}u koji semo`e definisati. U klini~kom smislum, oni imaju dvo -jaku va`nost. Prvo, postoji te`nja da se vrednostipromene u cele brojeve, menjanjem jedinice koja unosizabunu. Drugo, gotovo normal na Gaussova raspodelaosetljivog cTn kod zdravih subjekata pove}a}e u~esta -lost pozitivnog cTn u populaciji bez ACS. Problem jekako utvrditi da li su ti blago povi{eni nivoi cTn od kli -ni~kog zna~aja. Ono {to je sigurno jeste da AMI ostajeklini~ka a ne biohemijska dijagnoza i da se tuma ~enjekoncentracije cTn mora izvoditi u skladu s klini~kimkontekstom.

DIJAGNOSTI^KE I PROGNOSTI^KEINFORMACIJE DOBIJENE ODRE\IVANJEM

VISOKO OSETLJIVOG SR^ANOGTROPONINA T

J. Jarausch

Clinical Trials Roche Diagnostics GmbH, Penzberg, Germany

Sr~ani troponini (cTns) preporu~uju se kao bio -markeri za dijagnozu akutnog infarkta miokarda, pro -cenu rizika i prognoze, kao i za odre|ivanje anti -trombotske terapije i strategije revaskularizacije kodpacijenata sa akutnim koronarnim sindromima. Imple -mentacija visoko osetljivih testova za cTn u klini~kojpraksi je pove}ala broj pacijenata kod kojih je dijag -nostikovan infarkt mio karda. Pored toga, pove}an je ibroj pacijenata sa povi{e nim nivo ima cTn koji se nemogu pripisati akutnom ishe mijskom o{te }enju, {to jeprime}eno kod pacijenata sa hro ni~nim sr~anim bole -stima i drugim neishemijskim sr~a nim o{te}e njima ilikod pacijenata sa o{te}enom renalnom funkcijom.Nova definicija infarkta miokarda podr`ava tu ma ~enjepovi{enih cTn izmerenih pomo}u visokoosetljivihtestova za cTn kod pacijenata kod kojih se sumnja naakutni koro narni sindrom. Ovde se prikazuju kli ni~kestu dije sa nedavno uvedenim visokoosetljivim testom zacTnT (TnT hs) uz uop{teni osvrt na iskustva sa viso ko -osetljivim cTn testovima.

immunoassays with claims of superior imprecision anda definable 99th percentile have been produced.Clinically, these have two important impacts. First, thereis a drive to change the values into whole numbers bythe application of a unit change which carries thescope for confusion. Secondly, the near-normalGaussian distribution of sensitive cTn in healthysubjects will increase the frequency of cTn positivity inthe non-ACS population. The problem is to decipher ifsuch minor elevations in cTn are of clinical concern.What is certain is that AMI remains a clinical not abiochemical diagnosis and the interpretation of cTnconcentrations should be made according to theclinical context.

DIAGNOSTIC AND PROGNOSTICINFORMATION PROVIDED

BY A HIGH SENSITIVITY ASSAY FOR CARDIAC TROPONIN T

J. Jarausch

Clinical Trials Roche Diagnostics GmbH, Penzberg, Germany

Cardiac troponins (cTns) are the preferredbiomarkers for the diagnosis of acute myocardialinfarction, assessment of risk and prognosis, and fordetermination of antithrombotic and revascularizationstrategy in patients with acute coronary syndromes.The implementation of high sensitivity cTn assays intothe clinical routine has increased the number ofpatients diagnosed with myo cardial infarction. Inaddition, the number of patients with elevated cTnlevels that cannot be explained by acute ischemicinjury was increased, which is observed in patientswith chronic heart disease and other nonischemiccardiac injury or in patients with impaired renalfunction. The new definition of myocardial infarctionprovides support for the interpretation of elevated cTnmeasured with high sensi tivity cTn assays in patientswith suspected acute coronary syndrome. This reviewwill summarize clinical studies with the recentlyintroduced high sensitivity cTnT assay (TnT hs) withreference to recent experience with high sensitivitycTn assays in general.

Sekcija 4

BIOHEMIJSKI MARKERIBUBRE@NIH OBOLJENJA

Session 4

BIOCHEMICAL MARKERSOF THE KIDNEY DISEASES

J Med Biochem 2010; 29 (4) 377

ODRE\IVANJE BIOMARKERAU SERUMU I MOKRA]I

I NJIHOV ZNA^AJ U DIJAGNOSTICIBOLESTI BUBREGA

V. Le`ai}

Klinika za nefrologiju, Klini~ki centar Srbije,Medicinski fakultet, Univerzitet u Beogradu, Srbija

Zbog neprekidnog porasta boles ni ka koji se le~enekom od metoda za zamenu rada bubrega i visokogprate}eg kardiovaskularnog morbiditeta i morta li teta,hroni~ne bolesti bubrega (HBB) predstavljaju zdrav -stveni problem {irom sveta. Jedini pravilan pristupovom problemu je prevencija i rano le~enje HBB. Sdruge strane, uprkos napretku u le~enju, akutno o{te -}enje bubrega (AOB) i dalje je pra}eno visokim morbi -ditetom i mortali tetom bolesnika. Nedostatak ranihpokazatelja za AOB i nedovoljno brzo zapo~i njanjele~enja predstavljaju va`ne uzroke. Zbog svega na -vedenog postoji potreba za uvo|e njem ranih poka -zatelja o{te}enja bubrega, tzv. biomarkera (proteini idrugi molekuli u serumu i mokra}i), koji }e po mo}i udijagnostici i prognozi bolesti i pra}enju toka bolesti uslu~ajevima primene lekova za usporavanje progresijebolesti bubrega. Pored odre|ivanja kreatinina u seru -mu, po ka zatelji AOB se mogu otkriti u plazmi(neutrophil gela tinase-associated lipocalin-NGAL icistatin C) i u mokra}i (NGAL, kidney injury molecule-1= KIM-1, interleukin-18, cistatin C, alfa1-mikro -globulin, fetuin-A, Gro-alfa, i me prin). Pokazatelji HBBsu sli~ni biomarkeri u serumu i urinu (NGAL,asimetri~ni dimetilarginin, protein koji se vezuje zamasne kiseline). Povi{ena koncentracija TGF-b1 uplazmi i urinu mogla bi da bude odgovorna za razvojfibroze u tubu lointersticijumu tokom HBB, {to ukazujei na mogu}e tera pijsko dejstvo. Tako|e, da bi se razli -kovala infekcija donjih izvodnih puteva i pijelonefritisauvedeni su kao dobri poka zatelji interleukin-6 i pro -kalcitonin. Bilo bi korisno odre diti senzitivnost i speci -fi~nost navedenih biomarkera kao i njihovu upotreb -ljivost u klini~koj praksi u ve}im studijama.

DETERMINATION OF BIOMARKERSIN SERUM AND URINE AND THEIRSIGNIFICANCE IN DIAGNOSTICS

KIDNEY DISORDERS

V. Le`ai}

Clinic of Nepfrology, Clinical Center of Serbia,School of Medicine, University of Belgrade, Serbia

Chronic kidney disease (CKD) is becoming amajor public health problem worldwide due to theepidemic increase of patients on renal replacementtherapy and their high cardiovascular morbidity andmortality. The only effective approach to this problemis prevention and early detection of CKD. In addition,despite significant impro ve ments in therapeutics, themortality and morbidity associated with acute kidneyinjury (AKI) remain high. A major reason for this is the lack of early markers for AKI, and hence anunacceptable delay in initiating therapy. Therefore,there is a pressing need to develop biomarkers(proteins and other molecules in the blood or urine)for renal disease, which might assist in diagnosis andprognosis and might provide endpoints for clinicaltrials of drugs designed to slow the pro gression ofrenal insufficiency. Besides serum creatinine, promisingnovel biomarkers for AKI include a plasma panel(neutrophil gelatinase-associated lipocalin-NGAL andcystatin C) and a urine panel (NGAL, kidney injurymolecule-1, interleukin-18, cystatin C, alpha1-micro -globulin, Fetuin-A, Gro-alpha, and meprin). For CKD,these include a similar plasma panel and a urine panel (NGAL, asymmetric dime thyl arginine, andliver-type fatty acid-binding protein). Incre ased plasmaand urinary TGF-b1 levels might contribute to thedevelopment of chronic tubulointerstitial disease, indi -cating the possible therapeutic implications. Further -more, to differentiate lower urinary tract infection andpyelonephritis interleukin-6 and serum procalcitoninlevels were intro duced. It will be important in futurestudies to validate the sensitivity and specificity ofthese biomarker panels in clinical samples from largecohorts and in multiple clinical situations.

UDK 577.1 : 61 ISSN 1452-8258

J Med Biochem 29: 377–380, 2010 Plenarne sekcijePlenary sessions

378

BIOHEMIJSKI MARKERIKARDIOVASKULARNIH BOLESTI UHRONI^NOJ BOLESTI BUBREGA

M. \eri}, V. S. ^abarkapa

Centar za laboratorijsku medicinu, Klini~ki centar Vojvodine, Novi Sad, Srbija

Kod pacijenata sa hroni~nim oboljenjem bu -brega, kardiovaskularni morbiditet i mortalitet su zn a -~aj no povi{eni. Iako se ne mo`e smatrati ekvivalen -tom rizika za kar dio vaskularne bolesti, veruje se da jebubre`na insu fici jencija nezavisni prediktor pove}anogkardiovasku lar nog rizika i da se taj rizik pove}ava saslabljenjem bubre`ne funkcije. Ova udru`enost jeveoma kompleksna i danas se {iroko koristi terminkardiorenalni sindrom. Kardiovasku larna bolest u hro ni~noj bolesti bubrega obi~no se ispoljava kaoishemijska bolest srca (u obliku angine, akutnog koro -narnog sindroma ili nagle sr~ane smrti), cerebro vas -kularna bolest, periferna vaskularna bolest i konge -stivna bolest srca. Vaskularna bolest obuhvataate ro sklerozu i vaskularne kalcifikacije, dok kardio - miopatija obuhvata hipertrofiju leve komore, kardi -jalnu fibrozu i sistolnu i dijastolnu disfunkciju levekomore. Pored dobro poznatih tradicionalnih faktorarizika kao {to su hipertenzija, dislipidemija, insulinskarezi stencija i diabetes mellitus, u osnovi ove udru -`enosti je i siner gi sti~ko delovanje netradicionalnihfaktora rizika kao {to su pove}anje odnosa kalcijum-fosfor, hiperpara tireoi dizam, anemija, hemodinamskooptere}enje, pothranje nost, za pa ljenje, hiperhomo -cisteinemija, izme njena sinteza azot-mo noksida ipove}an oksida tivni stres. U radu se raz ma traju dosa-da{nja saznanja o zna~aju pojedinih ure mij skih toksi -na, natriureti~kih peptida, biohemijskih marke ra pore -me}aja u home o stazi kalcijuma i fosfora, sistem skeinflamacije, oksida tivnog stresa i dislipidemije.

URINSKI NGAL – NOVI BIOMARKERZA RANO OTKRIVANJE AKUTNOG

BUBRE@NOG O[TE]ENJA

K. M. Schmidt-Ott1,2

1Department of Nephrology,Experimental and Clinical Research Center,

Charité Universitätsmedizin Berlin, Max-DelbrueckCenter for Molecular Medicine, Berlin, Germany

2Department of Medicine, Division of Nephrology,Columbia University College of Physicians

and Surgeons, New York, NY, USA

Akutno o{te}enje bubrega (AKI) je glavni faktorrizika za intra-hospitalni mortalitet. U svakodnevnojklini~koj praksi dijagnoza AKI je obi~no zasnovana naodre|ivanju serumskog kreatinina i urinskog uzorka.

CARDIOVASCULAR BIOMARKERS IN CHRONIC

KIDNEY DISEASE

M. \eri}, V. S. ^abarkapa

Center for Laboratory Medicine, Clinical Center of Vojvodina, Novi Sad, Serbia

Cardiovascular morbidity and mortality aremarkedly increased in chronic renal failure patients.Although it cannot be regarded as a cardiovasculardisease risk equivalent, kidney dysfunction is consi -dered an independent predictor of increased cardio -vascular risk that increases with deteriorating kidneyfunction. The asso ci ation is a very complex one, andthe term cardiorenal syndrome is now widely used.Cardiovascular disease in chronic kidney diseasepatients usually manifests as ischemic heart disease (inthe form of angina, acute coro nary syndrome orsudden cardiac death), cerebrovascular disease,peripheral vascular disease, and congestive heartfailure. Vascular disease includes atherosclerosis andvascular calcifications, and cardiomyopathy comprisesleft ventricular hypertrophy, cardiac fibrosis and leftventricular systolic and diastolic dysfunction. Inaddition to the well-established traditional risk factorssuch as hypertension, hyperlipidemia, insulin resis -tance and diabetes mellitus, the association issupported by syner gistic action of non-tra ditional riskfactors such as excessive calcium-phos phorus load,hyperparathyroidism, anemia, hemo dynamic over -load, malnutrition, inflammation, hyper homocystei -nemia, altered nitric oxide synthase and incre asedoxidative stress. This paper summarizes the currentunderstanding of the significance of specific uremicreten tion solutes, natriuretic peptides, biochemicalmarkers of disorders in calcium-phosphorus homeo -stasis, systemic inflammation, oxidative stress, anddyslipidemia.

URINE NGAL – A NOVEL BIOMARKERFOR THE EARLY DETECTIONOF ACUTE KIDNEY INJURY

K. M. Schmidt-Ott1,2

1Department of Nephrology,Experimental and Clinical Research Center,

Charité Universitätsmedizin Berlin, Max-DelbrueckCenter for Molecular Medicine, Berlin, Germany

2Department of Medicine, Division of Nephrology,Columbia University College of Physicians

and Surgeons, New York, NY, USA

Acute kidney injury (AKI) is a major risk factor forin-hospital mortality. In every day clinical practice thediagnosis of AKI is usually based on measu rements ofserum creatinine and urinary output. Since these

J Med Biochem 2010; 29 (4) 379

Po{to ovi markeri reflektuju funkciju pre nego o{te -}enje, dijagnoza akutnog o{te}enja bubrega je ~esto u zaka{njenju do 48 sati. Nekoliko markera akutnogtubularnog o{te}enja je predlo`eno, koji se odre|uju uurinu i serumu. Od njih, marker koji najvi{e obe}ava,koji trenutno ulazi u klini~ku praksu, je NGAL(lipokalin udru`en sa neutrofilnom `elatinozom).Istra`ivanja genoma su pokazala da je NGAl jedan odnaj~e{}e ushodno regulisanih gena u tubularnomo{te}enju. NGAL je ekspresovan od strane o{te}enihrenalnih tubula distalnog nefrona i sekretuje sebazolateralno u krv i apikalno u urin. Prema tome,urinarni NGAL ukazuje na o{te}enje i proksimalnog idistalnog nefrona. Urinarni NGAL zna~ajno se pove -}ava za manje od dva sata posle renalnog o{te}enja idosti`e svoj koncentracioni pik posle 24 sata. Nivoindukcije je u korelaciji sa stepenom o{te}enja koji ~e -sto dovodi do pove}anja za vi{e od 30 puta. Labora -torijski testovi za urinarni NGAL se razvijaju i proce njujuza dijagnozu akutnog o{te}enja bubrega u razli~itimklini~kim situacijama, uklju~uju}i perioperativni AKI,kontrastom indukovani AKI, post-transplantacioni AKI iostale uzroke AKI u urgentnoj slu`bi. Ve}ina ovih klini~kihispitivanja je pokazala dobre do odli~ne karakteristiketesta za NGAL da detektuje AKI, i superiornije perfor -manse u pore|enju sa drugim bubre`nim biomarkerima iustanovljenim testovima. Va`no je da NGAL nije samoprediktivni marker akutnog bubre`nog o{te}enja (utvr|e -nog na osnovu kriterijuma zasnovanih na kreatininu), ve}tako|e i dodatnih klini~kih ishoda, uklju~uju}i uvo|enjeterapije renalne transplantacije i intrahospitalni morta -litet. Nivoi NGAL u urinu, pojedina~no ili kada sekombinuju sa drugim klini~kim informacijama, utica}e napra}enje pacijenata i olak{a}e razvoj novih terapeutskihstrategija zasnovanih na ranom otkrivanju AKI. Prematome, za ovaj marker se o~ekuje da }e uskoro imatiglavnu ulogu u dijagnozi, prognozi i tretmanu AKI.

ZNA^AJ ODRE\IVANJA KIM-1 U TKIVU I URINU BOLESNIKA

SA RAZLI^ITIM BOLESTIMA BUBREGA

S. Simi}-Ogrizovi}

Univerzitet u Beogradu, Medicinski fakultet,Klinika za nefrologiju, Klini~ki centar Srbije,

Beograd, Srbija

U poslednje vreme je postala o~igledna potrebaza novim bubre`nim biomarkerima za monitoringo{te}enja proksimalnih tubula jer je pokazano dapromene u tubulointersticijumu zna~ajno doprinoseprogresiji hroni~ne bubre`ne slabosti i vode katerminalnoj fazi bolesti. Jedan od njih je i kidneyinjury molecule-1 (KIM-1), novi, specifi~an biomarker

markers reflect function rather than injury, thediagnosis of acute kidney injury is frequently delayedby up to 48 hours. Several biomarkers of acute tubulardamage have been proposed, which are measured inurine and serum. The most promising of thesemarkers, which is currenty entering clinical practice, isneutrophil gelatinase-associated lipocalin (NGAL).Genome-wide screens have demonstrated that NGALis one of the most up-regulated genes in tubular injury.NGAL is expressed by damaged renal tubules of thedistal nephron and secreted basolaterally to enterblood and apically to enter urine. Circulating NGALundergoes glomerular filtration and, in the setting ofinjury-induced impediment to its proximal tubularuptake, is rapidly excreted into urine. Thus, urinaryNGAL indicates damage of both the proximal and thedistal nephron. Urine NGAL is markedly increased asearly as two hours following renal injury and reaches itspeak concentration at 24 hours. The level of inductionis correlated with the degree of damage frequentlyresulting in more than 30-fold increases. Labo ratorytests for urinary NGAL have been developed andevaluated for the diagnosis of acute kidney injury invarious clinical settings, including perioperative AKI,contrast-induced AKI, post-transplant AKI and all -cause AKI in the emergency room setting. Most ofthese clinical studies have revealed good to excellenttest characteristics of NGAL to detect AKI, and superiorperformance compared with other biomarkers andestablished tests. Importantly, NGAL is not onlypredictive of acute kidney injury (defined by creatininecriteria), but also of additional clinical endpoints,including renal replacement therapy initiation and in -hospital mortality. Urine NGAL levels, alone or whencombined with other clinical information, will affectpatient mana gement and facilitate the development ofnovel therapeutic strategies based on an early detectionof AKI. Thus, this marker is expected to soon play amajor role in diagnosis, prognosis and treatment of AKI.

THE IMPORTANCE OF KIM-1DETERMINATION IN TISSUE AND URINE

OF PATIENTS WITH DIFFERENT KIDNEY DISEASES

S. Simi}-Ogrizovi}

University of Belgrade, School of Medicine, Clinic of Nephrology, Clinical Center of Serbia,

Belgrade, Serbia

There is an urgent need for early renal bio -markers for the monitoring of proximal tubular injurybecause tubulointerstitial disease accompanies manyprocesses leading to chronic and end stage kidneydisease. One of these is kidney injury molecule-1(KIM-1) a new specific histological biomarker fordiagnosing early tubular injury from renal biopsies but

380

za dijagnozu ranih tubulskih o{te}enja koji se odre -|uje u tkivu bubrega ali i u urinu bolesnika. Ovajtrans membranski tubulski protein sa nepo znatomfunkcijom se ne detektuje u zdravim bubrezima, ali jeobele`je skoro svih proteinuri~nih, toksi~nih iishemi~nih bolesti bubrega. Nedavna istra`ivanja suukazala na nje go vu eventualnu patofiziolo{ku ulogu umoduliranju tubul skog o{te}enja i reparaciji. U ovompreglednom ~lanku bi}e predstavljen strukturalni ibiohemijski aspekt KIM-1, njegova ekspresija ipatofiziolo{ka uloga u bubre`nim bolestima. Tako|e}e biti razmatrana i njegova prognosti~ka uloga uodno su na proteinuriju kao i uloga biomarkerabubre`nog o{te}enja i prediktora smanjenja bubre`nefunkcije ali i perspektive za monitoring odgovora naterapiju.

also in urine. This trans membrane tubular proteinwith unknown function is unde tectable in normalkidneys, but is the hallmark of virtually all proteinuric,toxic and ischaemic kidney diseases. Recent datarevealed its possible pathophysiological role in modu -lating tubular damage and repair. This review isfocused on the structural and biochemical aspects ofKIM-1, its expression pattern and its pathophy -siological role in renal disease. Also, the prognosticvalue of KIM-1 in relation to urinary protein excretionwill be discussed, as well the potential of KIM-1, asthe biomarker of renal damage, as a predictor ofrenal function decline and its perspectives formonitoring therapy response.

6th EFCC Symposium for Balkan Region

»Implementing Laboratory Automation, Quality and Efficiency«

J Med Biochem 2010; 29 (4) 383

PRIMENA KVALITETA I EFIKASNOSTILABORATORIJSKE AUTOMATIZACIJE

S. Ignjatovi}, N. Majki}-Singh

Centar za medicinsku biohemiju, Klini~ki centar Srbijei Katedra za medicinsku biohemiju, Farmaceutski

fakultet, Univerzitet u Beogradu, Srbija

Krajnji cilj za klini~ke laboratorije je unapre|enjenege pacijenata putem ta~nosti i doslednosti labora -to rijskog odre|ivanja. U klini~kom laboratorijama,kva litet je neophodan uslov za zdravlje pacijenta.Paralelno sa o~ekivanjima o kvalitetu, postoji sve ve}ipritisci na laboratorije da obezbede pove}anje pro -duktivnosti i isplativosti. Optimalna laboratorijska efi -kasnost se posti`e kori{}enjem automatizacije ukombinaciji sa informatikom i six sigma kvalitet/leanprincipima. Laboratorijska automatizacija koristimehani~ke i kompjuterske tehnologije u izvr{avanjuplaniraniog niza zadataka koji pove}avaju ta~nost,pouzdanost i propusnost laboratorijskih odre|ivanja.Komponente automatizovane laboratorije uklju~ujumehanizme za pripremu uzoraka, transport, odre|i -vanje, skladi{tenje, kao i kontrolu i informacioni si stem.Postoje tri najva`nija oblika automatizacije kli ni~kihlaboratorija: totalna laboratorijska automa tiza cija,integrisana modularna laboratorijska automatizacija ilaboratorijske automatizacija pored postelje pacijenta(point of care, POC). Potpuno integrisana totalna la -bo ratorijska automatizacija uklju~uje sortiranje, usme -ravanje, centrifugiranje, pripremu alikvota, odre|i va nje,a ponekad i post-analiti~ko skladi{tenje i pre tr a`ivanje.Modularni sistemi laboratorijske automatizacije omo -gu}avaju fleksibilno kori{}enje prostora ili pozicio ni -ranja funkcija u postoje}im objektima, kao i mogu}nostmodifikacije u budu}em pro{irenju klini~ke labora -torije. Trend u automatizaciji se promenio na mo du larnipristup iz vi{e razloga: velika ulaganja, neflek si bilnost idug proces implementacije totalne la bo ratorijskeautomatizacije. Drugi modeli automa tizacije klini~kihlaboratorija uklju~uju decentralizaciju pomo}u auto -matizovanog POC testiranja. Potencijalni problemi uPOC testiranju su kori{}enje manje ta~nih instru -menata, neadekvatna upotreba kontrole kvaliteta inedovoljna stru~nost laboratorijske ekspertize. O~e -ku je se da POC analizatori prerastu u jo{ manje, lak{eza rukovanje i ta~nije instrumente. Ciljne platformelaboratorijske automatizacije se poklapaju sa ~etiri

IMPLEMENTING LABORATORYAUTOMATION QUALITY AND EFFICIENCY

S. Ignjatovi}, N. Majki}-Singh

Centre for Medical Biochemistry, Clinical Centre of Serbia and Department of Medical Biochemistry,School of Pharmacy, University of Belgrade, Serbia

The overall goal for clinical laboratories is toimprove patient care through accuracy and consis -tency in laboratory analyses. In clinical laboratories,quality is a necessary condition for patient health. Inparallel with expectations about quality, there areincre asing pressures for laboratories to ensureincreasing laboratory productivity and cost effecti -veness. Optimal laboratory efficiency can be achievedthrough using automation in combination withinformatics and six sigma quality/lean principles.Labo ratory automation uses mechanical andcomputer technologies to perform a scheduled seriesof tasks that increase the accuracy, reliability andthroughput of laboratory tests. Components of anautomated laboratory include the mechanisms forsample preparation, transport, analysis, storage andthe control and information system. There are threemost important forms automation of clinicallaboratories: total laboratory automation, integratedmodular laboratory automation and point-of care(POC) testing laboratory automation. Fully integratedtotal laboratory automation systems include samplesorting, routing, centrifugation, aliquot preparation,analysis, and sometimes, post-analytical storage andretrieval. Modular systems of laboratory automationallow more flexible use of space or positioning offunctions in existing facilities and can be modified forfuture expansion of clinical laboratory. The trend inautomation has moved to a modular approach for anumber of reasons: large investment, inflexibility andlong implementation time of total laboratory auto -mation. Other models of automation of clinicallaboratories include the decentralization through theuse of automated POC testing. Potential problems inPOC testing are use a fewer accurate instruments,inadequate use of quality control and insufficientlaboratory expertise. POC analyzers are expected toevolve into even smaller, easier to operate and moreaccurate instruments. The target test platforms oflaboratory automation are in four areas coinciding

UDK 577.1 : 61 ISSN 1452-8258

J Med Biochem 29: 383–389, 2010 Plenarne sekcijePlenary sessions

384

tradicionalna laboratorijska odseka: klini~ka hemija,imunohemija, rutinska hematologija i koagulacija.Analizatori koji integri{u klini~ku hemiju i platforme zaimunoodre|ivanja imaju {iroki test »meni«, uklju~ujuop{tu klini~ku hemiju, tumorske markere, hormone,pra}enje koncentracije i zlouptrebe lekova, specifi~neproteine i serologiju. Automatizacija preanaliti~kih ipost-analiti~kih poslova koji predstavljaju mesto jav lja -nja ve}ine gre{aka u laboratoriji, mo`e da ima zna -~ajnu ulogu u smanjenju broja medicinskih gre{aka iu pobolj{anju sigurnosti pacijenta. Automatizovanitransport uzoraka elimini{e ru~no rukovanje uzorci -ma, smanjuje rizik od infekcije zaposlenih, obezbe |u -je pozitivnu identifikaciju uzoraka, kao i procesuiranjerezultata na najefikasniji mogu}i na~in. Automatskoizdavanje rezultata (autoverifikacija) sa klini~kih instru -menata primenom algoritama se obavlja prekolaboratorijskog informacionog sistema/»middlevare«-amo`e pobolj{ati efikasnost, smanjuje ukupno vremeobrta (turnaround time) i mo`e pozitivno da uti~e naradni protok u laboratoriji. U zaklju~ku, laboratorijskaautomatizacija elimini{e ve}inu ru~nih procesa, sma -njuje izlo`enost ljudi opasnim materijama, smanjujepotrebu za treniranim obu~enim tehni~arima. Zbogtoga, pacijentima su dostupni precizniji i pouzdanijirezultati zbog ve}e dostupnosti i efikasnosti klini~kelaboratorije.

MEDICINSKE GRE[KE: PRE-ANALITI^KA FAZA I BEZBEDNOST PACIJENTA

M. Plebani1,2, E. Piva1

1Department of Laboratory Medicine, University Hospital of Padova

2Leonardo Foundation, Abano Terme General Hospital, Italy

U poslednjih nekoliko decenija zna~ajno je sma -njena stopa analiti~kih gre{aka u klini~kim labora to -rijama, dok sve ve}i broj dokaza pokazuje da su pre- ipost-analiti~ki koraci u ukupnom postupku testiranja(TTP) podlo`niji gre{kama od analiti~ke faze. Preci -znije, ve}ina gre{aka je otkrivena u pre-preanaliti~kimkoracima, izvan laboratorije i van njene kontrole. Me -|u tim, u okviru pristu pa pru`anju zdravstvenih uslugaorijentisanog na pacijenta postoji potreba da se istra -`i, u ukupnom postupku testi ra nja, svaki po ten cijalninedostatak koji mo`e negativno uticati na pacijenta,nezavisno od toga o kom se koraku radi i da li gre{kazavisi od laboratorije (npr. kali bracija ili gre{ka utestiranju) ili nelaboratorijskog osoblja (npr. ne odgo -varaju}i zahtev za test, gre{ka u identifikaciji pacijentai/ili uzimanju krvi). U pre-analiti~koj fazi u~estalostpo gre{ne identifikacije pacijenta/uzorka i prisustvopotencijal nih razloga za odbijanje uzorka (hemoliza,zgru{avanje, ne dovoljna zapremina itd.) predstavljajuva`an rizik za bez bed nost pacijenta. Spre~avanjegre{aka u pre-anali ti ~kim koracima zahteva kako

with traditional laboratory divisions: clinical chemistry,immunochemistry, routine hematology and coagu -lation. Analyzers that integrate clinical chemistry andimmunoassay testing platforms have broad testmenu, including general clinical chemistry, tumormarkers, hormones, TDM, drug of abuse, specificproteins and serology. Automating pre- and post-analytical tasks, which is where most errors in the laboccur, can play a significant role in the reduction ofnumber of medical errors and in the improvement ofpatient safety. Automated sample transport eliminatesmanual sample handling, minimizes the risk ofinfection to staff members, ensures positive sampleidentification, and processes results in most efficientway. The automatic release of results (autoveri -fication) from clinical instruments via algorithmsrunning in a laboratory information system/»middle -ware« may improve efficiency, reduce overall turn -around time, and can positively affect workflow in thelaboratory. In conclusion, the laboratory automationeliminates most of the manual processes, decreaseshuman exposure to hazardous material, decreasesneed to find and train skilled technicians. Conse -quently, patients get more precious and reliableresults because of greater availability and efficiency ofclinical laboratory.

MEDICAL ERRORS: PRE-ANALYTICAL ISSUE IN PATIENT SAFETY

M. Plebani1,2, E. Piva1

1Department of Laboratory Medicine, University Hospital of Padova

2Leonardo Foundation, Abano Terme General Hospital, Italy

The last few decades have seen a significantdecrease in the rates of analytical errors in clinicallabo ra tories, while a growing body of evidencedemonstrates that the pre- and post-analytical stepsof the total testing process (TTP) are more error-prone than the analytical phase. In particular, mosterrors are identified in pre-pre-analytic steps outsidethe walls of the laboratory, and beyond its control.However, in a patient-centred approach to thedelivery of health care services, there is the need toin ve stigate, in the total testing process, any possibledefect that may have a negative impact on thepatient, irres pective of which step is involved andwhether the error depends on a laboratoryprofessional (e.g. calibration or testing error) or anon-laboratory operator (e.g. inap pro priate testrequest, error in patient identification and/or bloodcollection). In the pre-analytic phase, the frequency ofpatient/specimens misidentification and the presenceof possible causes of specimen rejection (haemolysis,clot ting, insufficient vo lu me, etc.) represent a valu -

J Med Biochem 2010; 29 (4) 385

tehno lo{ki razvoj (narukvice, barko dovi, pre-analiti~keradne stanice) tako i blisku sa radnju u klini~komsvetu, radi postizanja efikasnog timskog rada. Naj -va`nija lekcija koju smo nau~ili je, dakle, da se labo -ratorijske gre{ke i radnje {tetne za pacijenta moguspre ~iti preoblikovanjem sistema koji zdravstvenimradni cima u svim koracima ukupnog postupka testi -ranja ote`a vaju prav ljenje gre{aka.

PRE-ANALITI^KE RADNE STANICE KAO SREDSTVO ZA REDUKCIJULABORATORIJSKIH GRE[AKA

G. Da Rin

Laboratory Medicine – ASL n°3 Bassano del Grappa

Redukcija gre{aka i pobolj{anje kvaliteta su inte -gralni deo laboratorijske medicine. Laboratorijsko tes -ti r anje, vrlo slo`en postupak koji se ~esto naziva pro -cesom totalnog testiranja (TTP), obi~no se deli na tritradi cio nalne faze: pre-analiti~ku, intra-analiti~ku ipost-ana li ti~ku. Niz radova objavljenih po~ev od1989. skrenuo je pa`nju laboratorijskih stru~njaka napre-analiti~ku fazu, koja se trenutno ~ini najpodlo` -nijom gre{kama. Stoga bi pre-ana li ti~ka faza trebaloda bude glavna meta za dalje pobolj{anje kvaliteta.Prepoznavanje kriti~nih koraka u pre-analiti~koj fazipreduslov je za stalno unapre|enje kva liteta, dalju re -duk ciju gre{aka, kao i za unapre|enje bez bed nostipaci jenta. Kori{}enje automatizovanih sistema kadgod je to mogu}e i uvid u redukciju gre{a ka/po bolj -{anje kvaliteta kao faktor pri izboru instrumenata jesuglavna sredstva ko jima raspola`emo u nastojanju daosi gu ra mo visok kvalitet i smanjimo broj gre{aka upre-ana liti~koj fazi. Razlozi za automatizaciju pre-analiti~ke faze postali su toliko jaki da je ona sadaneophodna, a ne vi{e samo prednost u odnosu nakonkurenciju. Takvi sistemi mogu uticati na klini ~ki/laboratorijski interfejs i odraziti se na delotvornost,efikas nost i kvalitet nege.

PROGRESIVNA AUTOMATIZACIJA – IZBOR RE[ENJA ZA POBOLJ[ANJE

LABORATORIJSKE EFIKASNOSTI

J.M. Valid

Beckman Coulter International SA, Nyon, Switzerland

Primarni je cilj svake laboratorije da uma nji oneprocese koji su izvor gre{aka. Ovo se posti`e pri me -nom razli~itih metoda, po~ev od tradicionalnih na~ina

able risk for patient safety. Pre venting errors in thepre-analytical steps requires both techno logicaldevelopments (wristband, bar-codes, pre-analyticalworkstations) and closer relationships with the clinicalworld to achieve an effective team-working co ope -ration. The most important lesson we have learned,there fore, is that laboratory errors and injuries topatients can be prevented by redesigning systems thatrender it difficult for all caregivers and in all steps ofthe total testing process to make mistakes.

PRE-ANALYTICAL WORKSTATIONS AS A TOOL FOR REDUCING

LABORATORY ERRORS

G. Da Rin

Laboratory Medicine – ASL n°3 Bassano del Grappa

Reducing errors and improving quality are anintegral part of Laboratory Medicine. Laboratorytesting, a highly complex process commonly calledthe total testing process (TTP), is usually subdividedinto three traditional (pre-, intra-, and post-) analyticalphases. A series of papers published from 1989 drewthe attention of laboratory professionals to the pre-analytical phase, which currently appears to be morevulnerable to errors than the other phases.Consequently, the preanalytical phase should be themain target for further quality improvement.Therefore, identifying the critical steps in the pre-analytical phase is a prerequisite for continuousquality improvement, further error reduction and thusfor improving patient safety. Use of automatedsystems where feasible, and use of error reduc -tion/improved quality as a factor when selectinginstrumen tation are the main tools we have to insurehigh quality and minimize errors in the pre-analyticalphase. The reasons for automation of the pre-analytical phase have become so compelling that it isno longer simply a com petitive advan tage forlaboratories, but rather a competitive neces sity. Thesesystems can impact on the clini cal/labo ratoryinterface and affect the efficiency, effectiveness andquality of care.

PROGRESSIVE AUTOMATION – THE SOLUTION OF CHOICE

FOR IMPROVING LAB EFFICIENCY

J.M. Valid

Beckman Coulter International SA, Nyon, Switzerland

The primary goal of every laboratory should be toreduce those processes that present an opportunity forerror. This can be achieved through a variety of meth -

386

konsolidacije i funkcionalne integracije do potpuneauto ma tizacije. Zavisno od izbora na~ina auto matiza -cije labo ratorija }e pove}ati kvalitet, umanjiti varija -bilnosti i pove}ati konzistentnost rezultata. Potpunoautomatizovani proces laboratorijskog ispitivanjadove{}e do unapre|enja proeca rada te }e ovo pod -sticati bolnice da investiraju u labo ra to rije. Da bi seovaj proces podsticao izra|ena su uputstva koja }eomogu}iti laboratorijama da automatizuju svoj pro cesrada. Primenom LEAN metodologije postignut je je -dan od najboljih na~ina automatizovanja laboratorij -skog pro cesa. Laboratorijski rezultati se dobijaju mno -go br`e, odr`ava se konzistentno turnaroud vreme(TAT) i po bolj{a va se celokupni proces rada. Pacijentise dijagnostikuju i zbrinjavaju br`e, {to dovodi i dobr`eg oporavka. Vreme provedeno u bolnici se sma -njuje, a protok pacijenata je ve}i.

KONCEPTI IN VITRO DIJAGNOSTIKE:KONSALTING USLUGE PRI RAZVOJU

EKONOMI^NIH I VISOKOKVALITETNIH IN VITRO DIJAGNOSTI^KIH RE[ENJA

G. Wirl

Roche Diagnostics Deutschland GmbH, Mannheim, Germany

U gotovo svim evropskim zemljama sve ve}i pri-tisak na javno zdravstvo da snizi tro{kove primorao jebolnice da uvedu ekonomi~nija re{enja koja }e toomogu}iti. Kako bi se snizili tro{kovi opreme i osobljau bolni~koj laboratoriji, testiranje uzoraka se sve ~e{}eseli u velike referentne laboratorije, ponekad bez te -meljnog razmatranja posledica. Dono{enje odluka,umesto upravnika laboratorije, postaje zadatak uprav -nih odbora (CEO, CFO, MD). Novi igra~i, npr. predu -ze}a sa privatnim kapitalom, stupaju na scenu, ~ak iako bolnica nastavi da pru`a neke osnovne uslu gelaboratorijskog testiranja za hitnu medicinsku po mo},ograni~na je fleksibilnost za dodatne zahteve poje -dina~nih bolnica. Umre`avanje bolni~kih labora torijamoglo bi biti alternativa opisanom scenariju. Imple -men tacija integrisanih sistemskih re{enja u glavnojlabo ratoriji i umre`ena point-of-care re{enja u peri -fernim laboratorijskim ustanovama otvoreno podr`a -va ju gorepomenuti pristup konsolidacije. Roche Diag -no stics nudi dokazane koncepte za konsalting u ciljuizrade individualnih ekonomi~nih i visokokvalitetnih invitro dijagnosti~kih re{enja.

ods, from traditional workstation menu consolidationand function integration to full automation. Regardlessof the choice, automating processes will help thelaboratory increase quality, decrease variability andincrease consistency. Streamlining testing processes inthis way provides a compelling argument for hospitalsto invest in their laboratories so they can benefit fromautomation. To support this, there are independentguidelines for laboratories to use when taking the firststeps towards deciding which processes to automate.Greater use of LEAN analysis has confirmed that oneof the best ways of achieving this is by automatinglaboratory processes. Test results are delivered morequickly, maintaining a more consistent turnaround time(TAT) and improving the overall patient care process.Patients are then diagnosed and admitted more quicklyfor timely treatment resulting in improved recovery.The time spent in hospital is reduced, with the flow ofpatients to the wards managed more efficiently.

CONCEPTS FOR AN IN VITRO DIAGNOSTIC ORGANIZATION:

CONSULTING SERVICES TO DEVELOPCUSTOMIZED ECONOMICAL AND HIGH

QUALITY IN VITRO DIAGNOSTIC SOLUTIONS

G. Wirl

Roche Diagnostics Deutschland GmbH, Mannheim, Germany

The increasing cost pressure in public healthcare in nearly all European countries forces hospitalsto implement more cost-efficient solutions. In order toreduce cost for hospital laboratory equipment andpersonnel, sample testing is more and more out -sourced to large reference labs, sometimes withoutthoroughly considering the consequences. Decisionshave moved from lab director towards managementboard (CEO, CFO, MD). New players, e.g. privateequity companies are entering the arena. Even if thehospital keeps some basic laboratory testing servicefor emergency medical aid, there is limited flexibilityfor additional individual hospital requirements. Thenetworking of hospital labs could be an alternative tothe above-described scenario. The implementation ofintegrated system solutions in the core laboratory andcross-linked Point of Care solutions in peripheral labfacilities would clearly support the above-describedconsolidation approach. Roche Diagnostics deliversproven Consulting Concepts for tailored economicaland high quality In Vitro Diagnostic Solutions.

J Med Biochem 2010; 29 (4) 387

KONCEPT ORGANIZACIJE LEAN LABORATORIJE

G. Halwachs-Baumann

Department for Laboratory Medicine, Central Hospital Steyr, Steyr, Austria

U poslednjih nekoliko decenija, bolni~ke labora -torije suo~ene su sa zahtevima za smanjenje tro{kovalaboratorijskih postupaka i istovremeno i) pru`anjebr`ih i dostupnijih usluga i ii) obra|ivanje {ireg spektraparame tara i iii) ve}e frekvencije uzoraka. Ovi zahtevipoti~u od pa cijenata, lekara, bolni~kih uprava i vladi -nih agencija. Tako se od uprave laboratorije o~ekujeda snizi tro{kove, pobolj {a efikasnost i omogu}i zado -voljstvo klijenata, pri ~e mu kva litet ima presudnu ulo -gu. Pored glavnih poslova labo ratorije (npr. analizi ra -nje uzoraka pacijenata, tuma ~e nje rezultata, stru~nosavetovanje klini~ara), va`ni zadaci i odgo vornosti ti~use upravljanja kvalitetom, edukacije teh ni ~ara i medi -cinskog osoblja, istra`ivanja i razvoja, kao i razvijanjaekonomskih strategija. Organizacija »Lean« labo ra -torije va`an je uslov za uspe{no obavljanje tih zada -taka. Koncept »Lean« laboratorije mora obuhvatitipre-analiti~ki, analiti~ku i post-ana liti~ku fazu. Stra -te{ke odluke o plani ra nju moraju biti dugoro~ne i presvega zasnovane na infor ma cijama iz spolja{nje sre -dine. Koncept »Lean« labora torije uvek podrazumevaholisti~ki pristup, koji uklju~uje medi cin ske zahteve iekonomske aspekte. Bi}e dat primer na koji na~inkoncept »Lean« laboratorije uti~e na orga nizaciju,efikasnost i delatnost bolni~ke labora torije.

AUTOMATIZACIJA, LEAN, SIX SIGMA: SINERGIJA U POBOLJ[ANJU

LABORATORIJSKE EFIKASNOSTI

D. Villa

Monza, Italy

Patolo{ke slu`be {irom sveta, okru`ene pro izvo -dima, tragaju za re{enjima. Pristup ovom cilju je ubliskoj saradnji izme|u medicinskih radnika i labora -torijskih stru~njaka. Uprkos bud`etima ograni~enimna 2–3% uku p nih tro{kova zdravstva, laboratorijepru`aju informacije za >70% medicinskih postupaka.»Peri-analitika« postaje fo kus, razumevanje protokainformacija i uzoraka kroz ~itavo putovanje i procese.Analiza procesa je glavna stavka za razumevanje ioblikovanje najbolje kombinacije kompo nenata udizajniranju finansijski zaista povoljnog re{enja zalaboratoriju. Metodologije poput Lean (ili Toyota Pro -duction System) i Six Sigma nedavno su po~ele da seusvajaju u zdravstvu kao i u laboratorijskom okru`e -

CONCEPTS FOR LEAN LABORATORY ORGANIZATION

G. Halwachs-Baumann

Department for Laboratory Medicine, Central Hospital Steyr, Steyr, Austria

In the last decades, hospital laboratories arebeset on all sides by demands to lower the costs oflaboratory procedures and at the same time toprovide (i) more rapid and usable services, (ii) abroader spectrum of parameters, and (iii) process ahigher frequency of spe cimens. These demands arevoiced by patients, physicians, hospital administrators,and governmental agencies. Thus, laboratory mana -gement is required to decrease costs, increaseefficiency, and promote customer satisfaction underthe consideration of quality to be of primary impor -tance. Beside the main task of a laboratory (i.e. theana lysing of patient specimens, interpretation ofresults, expert advice for clinicians), quality mana -gement, education of technicians and medical staff,research and development, and development of eco -nomic strategies are important duties and respon -sibilities. A lean laboratory organisation is an impor -tant condition to cope these duties. Lean labo ratoryconcepts have to include the pre-analytical, analyticaland post-analytical period. Strategic planning deci -sions have to be based primarily on informationderived from the external environment and have to belong-term. Lean laboratory concepts always have aholistic view, including medical demands andeconomic aspects. An example will be shown of howlean laboratory concepts influence the organisation,efficacy and performance of a hospital labo ratory.

AUTOMATION, LEAN, SIX SIGMA: SYNERGIES FOR IMPROVING

LABORATORY EFFICIENCY

D. Villa

Monza, Italy

The Pathology Services worldwide, surroundedby products are today requesting solutions. Theapproach aims towards the brain-to-brain cyclebetween caregivers and laboratory professionals.Despite budgets limited to 2–3% of total healthcareexpenses, Laboratories are pro viding information for>70% of medical actions. »Peri-analytics« is be -coming the focus; understanding infor ma tion andsample flow in the whole journey and pro cesses. Pro -cess analysis is the main component to understandand shape the best combination of components indesigning a truly cost-effective Laboratory solution.Methodologies like Lean (or Toyota ProductionSystem) and Six Sigma have started recently to be

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nju. Posle razvoja u drugim sektorima, te tehnike su uzdravstvu pokazale uspe {nu primenu. Njihove alatkeobra}aju se definicijama »vrednosti«, »otpada«, »pro -toka« kao klju~nim pokreta~ima za pobolj{anje per -formansi. Sinergija izme|u metoda do zvoljava do -nosiocima odluka da prepoznaju koji je stepenauto matizacije stvarno potreban u njihovoj labo ra -toriji, uz modernizovane procese. Razli~ite platformena pravljene u industriji, za in vitro dijagnosti~ko testi -ranje, mogle bi po stati finansijski nepristupa~ne ineefikasne bez pa`ljive pro cene potreba, putanja ivarijabli vezanih za vred nost. Ukup na laboratorijskaautomatizacija ili samostalna »ostrva« za sistememogu se identifikovati i izabrati posle mapiranjaprocesa i preporuka primenjenih u tehnikama Lean iSix Sigma. Ovaj ~lanak isti~e neke klju~ne koncepteLeana i njegovog mesta u laboratorijskoj organizaciji,kao meto do logije koju treba implementirati preodabira i usvajanja automatizovanog sistema.

ANALIZA PRIMERA LEAN SIX SIGMA PROCESA

U MIKROBIOLO[KOJ LABORATORIJI

V. Stoiljkovi}1, J. Trajkovi}2, B. Stoiljkovi}1

1CIM Grupa d.o.o. Ni{, Srbija2bioMerieux Belgrade Rep. Office, Beograd, Srbija

Suo~ene sa smanjenjem bud`eta, rastom obimaposla i nedostatkom osoblja, mikrobiolo{ke labora to -rije se sve vi{e okre}u automatizaciji, sa ciljem maksi -mi zacije u~inka i efikasnosti. Najbolji konceptpobolj{anja procesa danas je Lean Six Sigma. Ovajkoncept izvla~i broj ne koristi iz automa tizacije. Leanproces u laboratorijama se usred sre|uje na ispitivanjeproizvoda i materijala, da bi se na efikasan na~indobili najbolji rezultati {to se ti~e vremena ciklusa itro{kova, ili obe komponente zajedno. Pla ni ra nirezultat Lean laboratorije podrazumeva manje na -pora, manje re sur sa i manje vremena za ispitivanjeuzo raka, sa ciljem oslo ba|anja ljudskog potencijala. Sdruge strane, Six Sigma koncept obezbe|uje tokprocesa i proizvoda/usluga bez gre{aka. Lean SixSigma pristup analizira tok aktivnosti u laboratorijamaradi utvr|ivanja neefikasnosti i otkrivanja prilika zaosloba|anje kapaciteta, kao i radi smanjenja vre menai tro{kova. Dokazane Lean Six Sigma tehnike pove -}avaju produktivnost u okru`enju laboratorije iosiguravaju najbolje rezultate. U radu se analiziraidentifikovani zna ~ajni proces, defini{e pristup i dajepregled rezultata do bijenih kori{}enjem Lean SixSigma koncepta. Analiziran je proces u mikrobiolo -{koj labora to riji. Tradicionalni proces koji pri me njujestandardne metode analize obuhvata jedan broj aktiv -nosti koje ne dodaju vrednost, zahteva mnogovremena i pru`a prilike za pojavu gre{aka. Snimanjem

adopted also in healthcare and in the Laboratoryenvironment. Those techniques showed alreadysuccessful implementations in healthcare, after theirdevelopment in other sectors. Their tools areaddressing the definition of »value«, »waste«, »flow«as key drivers to improve performances. The synergyamong the methods allows decision makers toidentify the degree of auto mation really necessary intheir laboratory, with stream lined processes. Thedifferent platforms made available by industries, for invitro diagnostic testing, could become not cost-effective or efficient without a careful assessment ofneeds, pathways and value-related variables. Totallabo ratory automation or stand-alone islands forsystems can be identified and chosen after processmapping and recommendations deployed with Leanand Six Sigma techniques. This article highlightssome key concepts of Lean and their fit in laboratoryorganization, as metho do logies to be implementedbefore selecting and adopting automated systems.

LEAN SIX SIGMA SAMPLE ANALYSISPROCESS IN A MICROBIOLOGY

LABORATORY

V. Stoiljkovi}1, J. Trajkovi}2, B. Stoiljkovi}1

1CIM Grupa d.o.o. Ni{, Serbia2bioMerieux Belgrade Rep. Office, Belgrade, Serbia

Faced with shrinking budgets, growing volumes,and personnel shortages, clinical laboratories areincreasingly moving to automation to maximizeoutput and efficiency. The best tool for improvementis the Lean Six Sigma concept. The concept reaps thefull benefits of automation. A Lean process in alaboratory is focused on testing products andmaterials to deliver results in the most efficient way interms of cost, speed, or both. The goal of a Leanlaboratory is to use less effort, less resources and lesstime to test incoming samples. On the other hand,the Six Sigma concept provides process workflow andproducts/ services without defects. The Lean SixSigma approach analyzes laboratory workflow to helpidentify inefficiencies and uncover opportunities tofree capacity, reduce turn-around time and lowercosts. The assessment examines the end-to-endprocess looking closely at workflow as well as overalllaboratory efficiency. The proven techniques of Leanand Six Sigma enhance productivity in the laboratoryenvironment and ensure the best outcomes. Thisarticle analyzes a particular process, defines theapproach, and gives a review of results obtained bydeployment of the Lean Six Sigma concept. Thearticle discusses a sample analysis process in amicrobiology laboratory. A traditional process thatapplies standard analysis methods has a number ofnon-value-added activities, takes too much time, and

J Med Biochem 2010; 29 (4) 389

postoje}eg procesa kori{}enjem SIPOC mo delaidentifikovano je 12 aktivnosti. Primenom Lean alataidentifikovane su ~etiri aktivnosti, koje nisu potrebneako se koristi novi sistem. [est aktivnosti pru ̀a prilikeza pobolj{anje u pogledu zna ~aj nog smanjenjavremena trajanja procesa i u{tede re sursa. Samo dveaktivnosti u postoje}em tradicionalnom pro cesu subile optimalno re{ene kori{}enjem stan dar dnihmetoda i nisu zahtevale redizajn ni uklanja nje.Primena Lean Six Sigma koncepata i automatizo vanisistemi analize u novom procesu utvr|uju samo do 9aktivnosti u procesu, pa je tako potrebno mnogomanje vremena i resursa. Ovde se opisuju osnovniprincipi, praksa i metode kori{}enih Lean i Six Sigmakoncepta. Posebno su analizirani Lean alati 5S i spag -hetti dijagram. Za Six Sigma koristi se DMAIC meto do -logija i daje se pregled pri me njenih alatki za pobolj{a -nje kvaliteta za pojedine faze pobolj{anja pro cesa.

has opportunities for defects. By mapping an existingprocess using a SIPOC model, 12 activities wereidentified. With the use of Lean tools four non-value-adding activities, which are not needed if a newsystem is used, were identified. Six activities hadopportunities for improvement in terms of significantreduction in process time, and saving resources. Onlytwo activities in the existing traditional process, withthe use of standard analysis methods were optimallysolved, and this did not require redesign or removal.The application of Lean Six Sigma concepts andautomated analysis systems on a new process led toonly nine activities in the process that now takesmuch less time and uses less resources. This articlepresents a description of the main principles, prac -tices, and methods used in Lean and Six Sigma. TheLean tools particularly discussed here are 5s andspaghetti diagram. For Six Sigma, DMAIC methodo -logy is used, and a review of applied quality tools forcertain process improvement phases is given.

Sekcija 5

ANALIZA PROTEINA NAMOLEKULARNOM NIVOU:

OD FUNDAMENTALNIHISTRA@IVANJA DO PRIMENE U MEDICINI

Session 5

PROTEIN ANALYSIS ATTHE MOLECULAR LEVEL:FROM FUNDAMENTALRESEARCH TOAPPLICATION IN MEDICINE

J Med Biochem 2010; 29 (4) 393

INDIVIDUALIZOVANA TERAPIJA: ULOGA PROTEINSKIH I GENETSKIH

VARIJANTI TIOPURIN S-METILTRANSFERAZE

S. Pavlovi}, B. Zuki}

Institut za molekularnu genetiku i genetsko in`enjerstvo,

Univerzitet u Beogradu, Srbija

Tiopurin S-metiltransferaza (TPMT: EC 2.1.1.67)jeste enzim koji metaboli{e imunosu presivne tiopurin skelekove, koji se koriste za le~enje autoimunih bolesti,malignih oboljenja i u transplantacionoj medicini. Aktiv -nost enzima TPMT kod pojedinih ljudi je izrazito sma -njena ili pove}ana u odnosu na normalni nivo aktivnosti.Istra`ivanja strukture i biohemijskih karakteristika pro -teina TPMT su uka zala na postojanje odre|enih pro -teinskih varijanti koje imaju izmenjenu aktivnost.Otkriveni su polimorfizmi u genu za TPMT koji dajurazli~ite TPMT alozime. Smanjenoj aktivnosti enzimamo`e doprineti i manja koli~ina sintetisanog proteina,{to zavisi i od transkripcione aktivnosti promotora genaza TPMT. Polimorfizmi u samom promotoru, kao {to jepro menjiv broj tandemskih ponovaka (VNTR), mogu damoduli{u transkripciju. Primena tiopurin skih lekova kodpacije nata sa odre|enim genetskim varijan tama TPMTiza ziva te{ku hematolo{ku toksi~nost. Da bi se toksi~ -nost izbegla, terapija se modifikuje u skladu sa geno ti -pom TPMT (farma kogenetika). Mi smo izu~avali poli -mor fizme u egzonima i re gu latornim elementima(promotor) gena za TPMT koji do vode do promeneaktivnosti enzima TPMT u srpskoj po pu laciji. Koristilismo metodologiju baziranu na PCR i DNK sekven -ciranje za detekciju genetskih varijanti TPMT. Pokazalismo da su u na{oj populaciji prisutne genetske varijanteu egzonima koje ukupno daju 7,5% varijantnih alozimaTPMT koji imaju smanjenu enzimsku aktivnost. Terapijaza pacijente koji imaju ove farmako gene ti~ke markere jemodifikovana, {to je doprinelo uspe{nijem le~enju.Funk cio nalnim esejima in vitro smo pokazali da aktiv -nost promotora gena za TPMT, a samim tim i koli~inasintetisanog enzima TPMT, zavisi od arhitekture (broja itipa) VNTR u promotoru. Promotor gena za TPMTspecifi~no odgovara na tretman }elija K562 tiopurinomzavisno od tipa VNTR. Izu~avanje interakcija DNK iproteina je otkrilo da transkripcioni faktori Sp1 i Sp3interaguju sa VNTR. Na{a istra`ivanja ukazuju na to dabi region VNTR u promotoru gena za TPMT mogaopostati novi farma kogeneti~ki marker od klini~kogzna~aja za individualizaciju tiopurinske terapije.

INDIVIDUALIZED THERAPY: ROLE OF THIOPURINE

S-METHYLTRANSFERASE PROTEIN AND GENETIC VARIANTS

S. Pavlovi}, B. Zuki}

Institute of Molecular Genetics and Genetic Engineering,

University of Belgrade, Serbia

Thiopurine S-methyltransferase (TPMT: EC2.1.1.67) is an enzyme that metabolizes immuno -suppressive thiopurine medications, used in the treat -ment of autoimmune diseases, cancer and intransplantation medicine. In some individuals, TPMTenzyme activity is significantly increased or decreasedcompared to the normal TPMT activity level. Struc turaland biochemical analyses of the TPMT proteinrevealed the existence of certain protein variants withaltered activity. It has been shown that certain TPMTgene polymorphisms exist, that define different TPMTallozymes. Decreased TPMT enzyme activity can alsobe a consequence of lower protein synthesis, whichdepends on the promoter transcription activity.Promoter polymorphisms, such as variable number oftandem repeats (VNTR), can modulate the trans crip -tion. Admini ste ring thiopurine drugs in patients withcertain genetic TPMT variants leads to severe hema -tologic toxicity. To avoid toxicity, therapy is beingmodified according to the TPMT genotype (pharma -co ge netics). We investigated the polymor p hisms inexons and regu la tory elements (promoter) of theTPMT gene which affect TPMT enzyme activity in theSerbian popu lation. We used PCR-based methodologyand sequen cing in the detection of genetic variants onTPMT gene. We showed that genetic variants in exonsaccount for 7.5% of all TPMT variants with decreasedenzyme activity. The therapy for patients with thesepharmacogenetic markers was modified, whichcontributed to the efficiency of treatment. Functionalassays in vitro showed that the TPMT promoter activityand, therefore, the quantity of TPMT protein synthe -sized, depended on the architecture of VNTRs (i.e.number and type) in the promoter. Promoter of theTPMT gene specifically responds to mercapto purinetreatment of K562 cells in a VNTR-dependent man -ner. Study of DNA-protein interactions revealed thatSp1 and Sp3 transcription factors interact with VNTRs.Our research pointed out that the VNTR promoterregion of the TPMT gene could become a new phar -ma cogenetic marker, clinically s