Laboratory Procedure Manual

Analyte: Phosphorous

Matrix: Serum

Method: Roche Cobas 6000 (c501 module)

Method No.:

Revised:

As performed by: University of Minnesota

Advanced Research and Diagnostic Laboratory (ARDL)
1200 Washington Ave S, Suite 175
Minneapolis, MN 55415

Contact: Anthony Killeen, MD, PhD, Laboratory Director

Jennifer Peters, MT, ASCP, Laboratory Manager

Important Information for Users

The Advanced Research and Diagnostic Laboratory (ARDL) periodically refine these
laboratory methods. It is the responsibility of the user to contact the person listed on the title
page of each write-up before using the analytical method to find out whether any changes
have been made and what revisions, if any, have been incorporated.
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Public Release Data Set Information

This document details the Lab Protocol for testing the items listed in the following table:

Data File Name Variable Name SAS Label

BIOPRO_J LBXSLDSI Phosphorous (mg/dL)

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1. SUMMARY OF TEST PRINCIPLE AND CLINICAL RELEVANCE

Eighty percent of phosphorous in the human body is located in the bone in the form of
calcium phosphate as the apatite, Ca2+(Ca3(PO4)2)32-. The remainder is involved in
intermediary carbohydrate metabolism, and in phospholipids, nucleic acids and ATP.
Phosphorous occurs in the blood as inorganic phosphate and in organically bound
phosphoric acid.

In the blood, phosphate occurs at about a 6:10 ratio to calcium. An increase in

phosphorous concentration will induce a reduction in calcium concentration. This
mechanism is influenced by the interactions between parathyroid hormone and vitamin
D. Hypoparathyroidism, vitamin D intoxication, and renal failure with decreased
glomerular phosphate filtration will all give rise to hyperphosphatemia. Decreased levels
of phosphate will occur in rickets, hyperparathyroidism, and Fanconi’s syndrome.

This method utilizes ammonium molybdate as the color-forming reagent. Measurement

of the final product occurs at 340 nm (secondary wavelength 700 nm). Inorganic
phosphate forms an ammonium phosphomolybdate complex having the formula
(NH4)3[PO4(MoO3)12] with ammonium molybdate in the presence of sulfuric acid. The
concentration of phosphomolybdate formed is directly proportional to the inorganic
phosphate concentration.

Cobas 6000 Application Code: 675

2. SAFETY PRECAUTIONS

Caution: This product is of human and animal origin. Handle as though capable of
transmitting infectious disease. Wear appropriate PPE when handling equipment,
reagents, and samples. This kit contains components classified as follows according to
the European Directive 1999/45/EEC: C - Corrosive (Sulfuric acid) R 35; S 26, S
36/37/39, S 45 Causes severe burns. In case of contact with eyes, rinse immediately
with plenty of water and seek medical advice. Wear suitable protective clothing, gloves
and eye/face protection. In case of accident or if you feel unwell, seek medical advice
immediately (show the label where possible).

3. COMPUTERIZATION; DATA SYSTEM MANAGEMENT

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ARDL utilizes a highly specialized Laboratory Information System (LIS) (STARLIMS,

Abbott Informatics Corporation; Hollywood, FL, 33021-6755) for all lab functions. Major
instrument platforms are interfaced directly to the LIS, allowing data to be electronically
transferred directly to the main database. The system provides an extensive quality
assurance package and data management tools. Numerous networked computer
workstations are used in the laboratory for data management and transmission, and
also include software for word and spreadsheet creation and manipulation, statistical
analysis, report presentation, and electronic communication. All workstations are user
password protected with job specific security access levels and have idle time out
functionality. All systems are redundantly backed up on a real time basis.

4. SPECIMEN COLLECTION, STORAGE, AND HANDLING PROCEDURES; CRITERIA

FOR SPECIMEN REJECTION

a. Specimen Type and Requirements: Serum, lithium heparin plasma, K2-EDTA

plasma and urine are acceptable specimens. Urine should be acidified with
hydrochloric acid (HCl) after collection (pH<3). The NHANES Biochem study uses
refrigerated serum. This test is analyzed from NHANES Vial 018.

b. Specimen Volume: Optimum/Minimum volume: 100 μL in a sample cup or 2 mL

microtube (2.5 μL serum for test; remainder for dead volume).

c. Acceptable Specimens/Unacceptable Specimens: Serum, lithium heparin

plasma, K2-EDTA plasma and urine are acceptable specimens.

d. Specimen Stability and Storage: Separated serum or plasma should be removed

from the cells within one hour of collection. Serum or plasma is stable for 24 hours at
15-25°C, 4 days at 2-8ºC, one year at -15 to -25°C, and longer at –70ºC.

e. Interferences or limitations: Icteric index < 60: no interference. There is significant

positive interference at a hemolysis index of >300. Lipemic index < 1250: no
interference. Drugs: No interference was found at therapeutic concentrations using
common drug panels. Exception: Phospholipids contained in liposomal drug
formulations (eg AmBisome) may be hydrolyzed in the test due to the acidic reaction pH
and thus lead to elevated phosphate results. In very rare cases, gammopathy, in
particular type IgM (Waldenström's macroglobulinemia), may cause unreliable results.

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f. Specimen Handling and Transport: Mix specimens well, allow clot to fully form (if
serum), and centrifuge 10 minutes at 2000 x g before use. Aliquot a minimum of 0.1
mL. Store sample in refrigerator until shipment. Ship at refrigerated temperature.

5. PROCEDURES FOR MICROSCOPIC EXAMINATIONS; CRITERIA FOR REJECTION

OF INADEQUATELY PREPARED SLIDES

“Not applicable for this procedure.”

6. EQUIPMENT AND INSTRUMENTATION, MATERIALS, REAGENT PREPARATION,

CALIBRATORS (STANDARDS), AND CONTROLS

a. Reagents and Supplies

Roche Cat. No. 03183793122, PHOS2 reagent kit (250 tests):

b. Reagent Preparation (*Reagents are ready to use; no preparation required)

•R1 reagent. Sulfuric acid: 0.36 mol/L; detergent

•R2 reagent. Ammonium molybdate: 3.5 mmol/L; sulfuric acid: 0.36 mol/L;
sodium chloride: 150 mmol/L

•Storage and stability. Keep reagents refrigerated until use. The reagents are
stable for 12 weeks refrigerated on the analyzer.

c. Equipment/Instrumentation-

•Roche Cobas 6000 Chemistry Analyzer (Roche Diagnostics Corporation,

Indianapolis, IN 46250)

•The Millipore Elix Gulfstream Clinical 35 System is designed to meet CLSI

Clinical Laboratory Reagent Water (CLRW) standards. Water purification is
achieved by reverse osmosis, electrodeionization, bactericidal 254 nm UV lamp
and 0.22 μm filtration.

d. Specimens are run in singleton

e. Quality Control

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• Normal pooled serum control (CQ). Stable at -80°C for up to 4 years, at

refrigerated temperature for up to 1 day and at room temperature for up to 4
hours.

• Roche Precipath U Plus Control (catalog #12149443160). Roche Diagnostics

9115 Hague Road Indianapolis, IN 46250-0457). Stable until expiration date
on package when unopened and stored at 2-8°C. To prepare, open bottle 1
and pipette in exactly 3.0 mL of diluent (bottle 2). Dissolve by gentle swirling
for 30 minutes. Prepared control is stable for 12 hours at room temperature, 5
days at 2-8°C, and one month at -20°C (when frozen once).

7. CALIBRATION AND CALIBRATION VERIFICATION PROCEDURES

Roche Calibrator for Automated Systems (C.F.A.S.), catalog #10759350190. The

calibrator is stable until the expiration date on the bottle when stored at 4ºC. The
lyophilized calibrator is prepared with 3.0 mL of deionized water. Pipette the
water into the bottle, and then dissolve by gentle swirling within 30 minutes.
Avoid formation of foam while mixing. The prepared calibrator is stable for eight
hours at room temperature, two days at 4ºC, and one month at –20ºC (frozen
once). Traceability: This method has been standardized against NERL primary
reference material. Calibration frequency: A two-point calibration (H2O +
C.F.A.S.) must be performed when there is a reagent lot number change. The
Cobas 6000 will not allow testing to proceed until a successful calibration has
been completed. Monitor control values to determine stability of the current
calibration.

Manual calibration should be performed if:

• A reagent lot change has not occurred in the past 6 months

• After major service or repairs

• As needed for troubleshooting

If calibration fails perform the following corrective action steps in sequence:

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• Check reagent and calibrator for appropriate lot numbers, expiration

dates, preparation and storage conditions.

• Repeat calibration with new calibrator.

• Repeat calibration with new reagent and new calibrator

• If successful calibration is not achieved, discontinue testing and notify the

supervisor.

8. OPERATING PROCEDURE INSTRUCTIONS; CALCULATIONS; INTERPRETATION

OF RESULTS

a. Instrument Operation: The Roche/Hitachi Cobas 6000 analyzer series is a fully

automated, random-access, software controlled system for immunoassay and
photometric analyses intended for qualitative and quantitative in vitro determinations
using a wide variety of tests. The Cobas 6000 analyzer series is optimized for
workloads using a combination of photometric and ion-selective electrode (ISE)
determinations (c501 module), and electrochemiluminescence (ECL) signal in the
immunoassay analysis module (e601 module). The ISE system is used in the
quantitation of sodium, potassium and chloride. The photometric system can
measure colorimetric or immunoturbidimetric reactions utilizing end point or kinetic
(rate) absorbance measurements. Test ordering end execution on the Cobas 6000
and data entry in the STARLIMS host computer system may be done manually or
these tasks may be executed via a barcode-based bi-directional interface. The
Cobas 6000 can utilize both of these two systems simultaneously.

b. Professional Judgement: Check results for error flags and take appropriate
corrective action. Investigate alert values and delta checks.

c. Result Entry

STARLIMS test code: PHOS, UPHOS

Manual entry

• Results are reported to one decimal place, as in x.x mg/dL.

• Report low results as <0.3 mg/dL for serum or <3 mg/dL for urine.

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• Check results for error flags and take appropriate corrective action.

• Investigate alert values and delta checks.

9. REPORTABLE RANGE OF RESULTS

Out of Range results: Certain tests have pre-programmed limits that trigger an automatic
re-analysis by the COBAS. These limits may be low-end values or high-end values (but
within technical range). If the duplicate value is in agreement with the initial value, then the
initial value is reported.

Results are reported to one decimal places (as x.x) in mg/dL. Report low results as <0.3
mg/dL.

a. Reportable Range of Test Results: Reportable Range 0.3-40 mg/dL

Intra-assay %CV (10 within-day replicates at a concentration of 4.0 mg/dL) 0.0%

Intra-assay %CV (10 within-day replicates at a concentration of 6.14 mg/dL) 0.8%

Inter-assay %CV (between day replicates at a concentration of 3.66 mg/dL) 1.6%

Inter-assay %CV (between day replicates at a concentration of 6.74 mg/dL) 1.3%

Dilutions: The confirmed analytical measurement range of the assay is 0.3-20 mg/dL for
serum, and 3-285 mg/dL for urine. Specimens exceeding the high limit are automatically
diluted (1:2) by the instrument. Results from samples diluted using the rerun function are
automatically multiplied by 2. If a manual dilution is required, dilute the specimen in normal
saline, and multiply the result by the dilution factor. For example, to perform a 1:5 dilution,
pipette 50 μL of the patient sample into 200 μL of normal saline. Mix thoroughly, perform
the assay, and multiply the result by a factor of 5. The maximum allowable manual dilution
is 1:5.

Reference Range: Plasma, adult 2.7-4.5 mg/dL

Critical Results: None

Analytical Measurement Range: 0.3-20 mg/dL

Reportable Range: 0.30-40 mg/dL

Limit of Detection (standard 1 + 3 SD): 0.3 mg/dL

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10. QUALITY CONTROL (QC) PROCEDURE

•Normal pooled serum control (CQ). Stable at -80°C for up to 4 years, at refrigerated
temperature for up to 1 day and at room temperature for up to 4 hours.

•Roche Precipath U Plus Control (catalog #12149443160). Roche Diagnostics 9115

Hague Road Indianapolis, IN 46250-0457). Stable until expiration date on package
when unopened and stored at 2-8°C. To prepare, open bottle 1 and pipette in
exactly 3.0 mL of diluent (bottle 2). Dissolve by gentle swirling for 30 minutes.
Prepared control is stable for 12 hours at room temperature, 5 days at 2-8°C, and
one month at -20°C (when frozen once).

•Both levels of quality control are analyzed at the start of the day and results are
verified for acceptability prior to testing specimens. Quality control is also analyzed
at the end of the shift, with change in reagent, after major maintenance, or as
needed for troubleshooting.

•The analytical measurement range (AMR) must be validated every 6 months or

after major maintenance or service procedures. The laboratory enrolls in the College
of American Pathologist (CAP) linearity program. Phosphorous is included in the
LN2 kit that is shipped twice per year. Follow kit instructions for preparation. Analyze
samples in duplicate. Results are due within two to four weeks of receipt of kit.
Results are submitted online to the CAP website by the lead or supervisor. The
linearity report is available online at the CAP website shortly after the due date.
Confirm reported values are within acceptability limits. Place instrument printouts,
worksheets and CAP results in the CAP three ring binder.

•New Lot Verification: Each new reagent lot must be verified for acceptability before
being placed into use. Calibration, quality control, and comparison of at least 5
patient samples on the old and new lots must be performed and found to be within
acceptable limits before a new lot can be placed into use.

11. REMEDIAL ACTION IF CALIBRATION OR QC SYSTEMS FAIL TO MEET

ACCEPTABLE CRITERIA

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• If QC values are outside of specified ranges, do the following, in order, until QC

is acceptable:

1. Repeat the analysis using fresh QC material.

2. Perform a calibration.

3. Check for system problems.

4. Contact Roche Technical Support for assistance and possible service dispatch.
Phone: 1-800-428-2336; account number: 55042919

12. LIMITATIONS OF METHOD; INTERFERING SUBSTANCES AND CONDITIONS

a. Limit of Detection (standard 1 + 3 SD): 0.3 mg/dL

b. Analytical Measurement Range: 0.3-20 mg/dL

c. Interferences or limitations: Icteric index < 60: no interference. There is significant

positive interference at a hemolysis index of >300. Lipemic index < 1250: no
interference. Drugs: No interference was found at therapeutic concentrations using
common drug panels. Exception: Phospholipids contained in liposomal drug
formulations (eg AmBisome) may be hydrolyzed in the test due to the acidic reaction
pH and thus lead to elevated phosphate results. In very rare cases, gammopathy, in
particular type IgM (Waldenström's macroglobulinemia), may cause unreliable
results.

13. REFERENCE RANGES (NORMAL VALUES)

Plasma, adult 2.7-4.5 mg/dL

14. CRITICAL CALL RESULTS ("PANIC VALUES")

Not applicable.

15. SPECIMEN STORAGE AND HANDLING DURING TESTING

Specimens are stored at refrigerated temperature between sample receipt and analysis
on the instrument. Specimens must be at room temperature prior to assay. Specimens
are returned to refrigerated or frozen temperature post analysis depending on the study
specific requirements.

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16. ALTERNATE METHODS FOR PERFORMING TEST OR STORING SPECIMENS IF

TEST SYSTEM FAILS

Should the testing system become inoperable, discontinue testing and notify the
supervisor. While instrument trouble-shooting or repair occurs; keep specimens at
refrigerated or frozen temperature depending on study specific requirements.

17. TEST RESULT REPORTING SYSTEM; PROTOCOL FOR REPORTING CRITICAL

CALLS (IF APPLICABLE)

All data is reported electronically via an eFile that is uploaded to the WESTAT secure
website within 21 days of receipt of specimens.

18. TRANSFER OR REFERRAL OF SPECIMENS; PROCEDURES FOR SPECIMEN

ACCOUNTABILITY AND TRACKING

Specimen Receipt:

Shipments for NHANES generally will arrive on Tuesdays and/or Wednesdays. These
shipments are recorded on the Log of Quality Assurance located in a binder labeled
NHANES Shipping Log in the receiving area. The specimen barcode numbers in the
boxes are checked against the manifests. The receipt date is written on top of the
boxes. The frozen samples (vial 11-Iron/UIBC & vial 13-CRP) are placed in the
designated -70°C freezer and the refrigerated samples (vial 18-Biochem panel) are
placed in the designated 2-8°C refrigerator until analysis. The manifests are filed in a
binder labeled NHANES Shipping Manifests located in the receiving area. All labels are
removed from the shipping box and the provided airbill is attached for return shipment.

Quality Assurance Log:

A Quality Assurance Specimen Receipt and Specimen Return Log is maintained by

laboratory staff. The following parameters are tracked: NHANES shipper I.D., NHANES
Container I.D., Vial #, Date Received, Specimen Receipt Conditions, Number of
Specimens Received, 2.5% QC Repeats, Total Number of Specimens, 21 Day Due
Date, Analysis Date, Date Results Sent, Number of Days For Result Return, Thaw Date
(if applicable), Return To Freezer Date, Number of Days at Refrigerated Temperature, 1
Year Discard or Return Date, NHANES Quarterly Report Date

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Specimen Ordering/Labeling:

Electronic files for all NHANES specimens are sent via email from Westat, Inc to the
NHANES contact person shortly before they are to be received. These files include the
Sample ID, Analyte Type, Slot No, Sample Collection Date, Sample Comment, Age
Grouping, Astro ID, Receipt Date, Analysis Date, Run Number, Tech ID, Analyte Result,
Result Comment, Adjusted Result, QC Repeat, LOD, Change Reason, and Change
Reason Other. The first seven columns are protected and cannot be altered. The files
are saved on the laboratory’s common S drive in the NHANES Biochem folder. After
analysis, the contact person returns the completed files via their website to Westat, Inc.

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The NHANES spreadsheets are used to set up pending batches for batch accession
upload in the Laboratory Information system (STARLIMs). New labels are generated out
of the Laboratory Information System (STARLIMs). The new bar-coded labels are
attached to a carrier tube. The Cobas analyzer reads the bar-coded label for the sample
ID and test information.

Specimen Storage:

The temperatures for all freezers and refrigerators are monitored 24 hours a day/ 7 days
a week. If the temperature for any unit falls outside the allowable range, action is taken
to resolve the problem. If the temperature cannot be corrected, the contents are moved
to a different unit.

Specimen Handling/Specimen Return:

Prior to analysis, the specimens are stored in the designated 2-8°C refrigerator. On the
day of analysis, the specimens are selected and thawed by the technician operating the
COBAS. After analysis and the QC repeats have been run, the specimens are refrozen.
After 1 year, the specimen vials that have at least 0.2ml of sample remaining will be
shipped to SriSai Biopharmaceuticals in Frederick, MD. These specimens will be
shipped on dry ice via Federal Express.

19. SUMMARY STATISTICS AND QC GRAPHS

See following page.

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Summary Statistics and QC Chart for Phosphorus (mg/dL)

Start End Standard Coefficient of

Lot N Date Date Mean Deviation Variation
186345 84 18JAN17 30MAY18 6.72 0.08 1.1
Q 122 18JAN17 22JAN19 3.67 0.05 1.5
203060 38 04JUN18 22JAN19 6.70 0.08 1.1

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REFERENCES

1. Cobas 6000 Analyzer Operator’s Manual. Roche Diagnostics Inc., 9115 Hague Road
Indianapolis, IN 46250-0457. Version 5.0.

2. Roche Calibrator for Automated Systems (C.F.A.S.) package insert. Version 2011-
08, V6. Roche Diagnostics Inc., 9115 Hague Road Indianapolis, IN 46250-0457.

3. Roche PHOS2 reagent package insert. Version 2010-10, V5. Roche Diagnostics
Inc., 9115 Hague Road Indianapolis, IN 46250-0457.

4. Roche Precipath U Plus package insert, Version 2011-04, V4. Roche Diagnostics
Inc., 9115 Hague Road Indianapolis, IN 46250-0457.

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