ERNDIM DPT Centre Basel University Children s Hospital Metabolic Unit Postfach, CH-4005 Basel, Switzerland phone: ++41 61 685 62 75 or ++41 61 685 63 23 Diagnostic Proficiency Testing Survey 2009 Annual Report prepared by Brian Fowler, Katharina Honegger, Marianne Zaugg 1
1. Geographical distribution of participants This year, 21 laboratories from 9 countries participated in our scheme. Originally 22 labs registered but 1 lab had subscribed falsely to this scheme. Country Number of participants Austria 1 Canada 3 Estonia 1 Germany 6 Norway 1 Sweden 2 Switzerland 2 UK 1 USA 4 2. Samples The samples contain a small amount of thimerosal and have been heat-treated. They were preanalysed in our institute after 3 days incubation at ambient temperature (to mimic possible changes that might arise during transport). In all six samples the typical metabolic profiles were preserved after this process. 3. Shipment of the samples The urinary samples were distributed to participants on April 20 at ambient temperature using the courier TNT Swiss Post. Delivery of samples took between 1 and 3 days according to the tracking by the courier, however, the delivery times stated by the participants varied between 1 to 7 days. Unfortunately 3 labs received their samples after more than 7 days due to problems at the US customs. Nineteen participants returned their results by the deadline, 2 with a short delay. Regardless of the delay all reported results were accepted by the organisers. 4. Tests Analyses of amino acids, organic acids, mucopolysaccharides, oligosaccharides and purines/ pyrimidines were required in 2009. 5. Schedule of the scheme in 2009 Task Sample distribution Start of analysis of Survey 2009/1 Survey 2009/1 - Results submission Survey 2009/1 - Reports Start of analysis of Survey 2009/2 Survey 2009/2 Results submission Survey 2009/2 - Reports Annual meeting of participants Annual Report 2009 Due April 20, Monday May 04, Monday May 25, Monday June 15, Monday June 22, Monday July 13, Monday August 07, Friday October 23, in Basel December 2
6. Receipt of samples and results Date of receipt of samples (sent on April 20, 2009) Receipt (days after shipment) Receipt (reported by participants) Delivery (by TNT Swiss Post) 1 day 7 13 2 days 6 4 3 days 2 1 4 days 1 0 more than 7 days 5 3 Date of reporting of results Receipt of results Part 1 (deadline May 25) Part 2 (deadline July 13) deadline or before 19 participants 20 1 day delay - 1 2 days delay 1-7 days delay 1-7. Scoring system Three criteria are evaluated: analytical performance, interpretative proficiency and recommendations for further investigations. Due to the large variability in reporting results in various countries, recommendations pertaining to treatment are not evaluated in proficiency testing. However, they are still reported and summarised by the scheme organisers. A I R Analytical performance Interpretative proficiency Recommendations Correct results of the appropriate tests 2 Partially correct or non-standard methods 1 Unsatisfactory or misleading 0 Good (diagnosis was established) 2 Helpful but incomplete 1 Misleading or wrong diagnosis 0 Helpful 1 Unsatisfactory or misleading 0 max 2 max 2 max 1 The total score is calculated as a sum of these three criteria. The maximum to be achieved is 5 points per sample. The scores were calculated only for laboratories submitting results. 3
8. Results of samples and evaluation of reporting Sample A: ß-Ketothiolase Deficiency / 3-Oxothiolase Deficiency Patient: the sample was obtained from a 3 year old girl with ketothiolase deficiency/2- oxothiolase deficiency who was receiving no treatment. The diagnosis was based on urine organic acid analysis, with confirmation by enzyme assay. This sample was contributed by Dr. M. Engval, Huddinge/Stockholm, Sweden. Analytical performance: 21 laboratories reported organic acid analyses, 20 were able to correctly identify at least 2 of the 3 key metabolites (2-methyl-3-hydroxybutyric acid, Tiglyglycine, 2-methylacetoacetate) which scored 2 points. The analytical performance of this sample was 98%. Interpretative proficiency: diagnosis of ketothiolase deficiency/2-oxothiolase deficiency was considered correct. The finding of 2-methyl-3-hydroxybutyryl-CoA dehydrogenase deficiency was considered to be partially correct and received 1 point. The proficiency score was 95%. In fact, close inspection of the chromatogram reveals two peaks of 2-methyl-3-hydroxy-butyric acid which is indicative of ketothiolase deficiency but not found in the dehydrogenase deficiency (see figure 2). Recommendations: we consider follow-up by enzyme assay (ß-ketothiolase), mutation analysis (ACAT1 gene), carnitine and acylcarnitine analysis as important. Overall impression: relatively straight forward sample with very good analytical and interpretative performance (overall 95%). Figure 1: Organic acid chromatogram Abundance 4000000 2-Methyl-3-Hydroxy-Butyric TIC: 1201012.D 3500000 Benzoic 3000000 2500000 2000000 1500000 Tiglyglycine 1000000 500000 Time--> 10.00 15.00 20.00 25.00 30.00 35.00 40.00 45.00 50.00 4
Figure 2: Organic acid chromatogram and spectrum Abundance 9000000 TIC: 1201012.D 8500000 8000000 7500000 7000000 6500000 6000000 5500000 5000000 4500000 4000000 3500000 3000000 2500000 2000000 1500000 1000000 500000 2-Methyl-3-Hydroxy-Butyric Time--> 12.50 13.00 13.50 14.00 14.50 15.00 15.50 16.00 16.50 17.00 Abundance 130000 120000 110000 100000 90000 80000 70000 60000 50000 40000 30000 20000 10000 0 m/z--> 73 88 117 133 Scan 1542 (13.742 min): 1201012.D 147 191 218 247 101 171 204 231 261276 340353369 80 100 120 140 160 180 200 220 240 260 280 300 320 340 360 5
Sample B: Triple H syndrome (Hyperammonemia-Hyperornithinemia-Homocitrullinuria) Patient: this sample came from a 26 year old patient with triple H syndrome (Hyperammonemia-Hyperornithinemia-Homocitrullinuria). The patient is under the following treatment: citrulline, creatine, moderate protein restriction. The sample was provided by Dr. C. Dionisi, Rome, Italy. The diagnosis had been confirmed by mutation analysis of the ORNT1 gene (homozygous c.861insg). Analytical performance: Amino acid analysis was considered essential for the diagnosis in this case and was performed by 20 laboratories and received 1 point. Although the level of the key metabolite, homocitrulline, was not very high, 3 laboratories correctly identified this. However, since this sample was collected on treatment and therefore not typical we gave 1 point for the finding of abnormal amino acids pointing to a urea cycle defect. The finding of orotic acid and uracil in organic acid and/or purine/pyrimidine analysis also scored 1 point each, as reported by 15 labs (max. points: 2). Analytical performance was 86%. Interpretative proficiency: the diagnosis of triple H syndrome (reported by 4 labs) was considered correct and received 2 points. 1 point was given for indication of another urea cycle disorder. Proficiency score was 57%. Recommendations: follow-up by plasma amino acid and ammonia analysis was important. Confirmation of diagnosis by enzyme assay (ornithine transporter) and mutation analysis (ORNT1 gene) were considered helpful. Overall impression: This was a difficult sample, particularly because the patient was under treatment with citrulline. The analytical performance highlights the difficulty of separating homocitrulline from methionine using conventional ion chromatography. Nevertheless, homocitrulline was identified by 3 labs using either tandem MS or even (in 1 case) ion exchange chromatography. Another possible approach to aid identification could be oxidation using performic acid which destroys methionine but not homocitrulline. 6
Figure 3: Amino acid chromatogram, +/- oxidation and methionine 600 untreated sample.430 50 53.263 Glycin 54.780 Alanin 56.380 Citrullin 61.496 Valin 66.279 Cystin 69.429 Methionin 73.262 Cystathionin 76.462 79.095 Leucin 500 400 300 200 50 60 70 80 90 100 110 120 130 140 Minutes + Oxidation + Methionine + Met + Ox 50.413 52.447 Glycin 54.013 Alanin 55.530 66.096 Cystin 70.579 69.362 Methionin 77.162 82.161 89.644 Phenylalanin 50.097 52.513 Glycin 54.080 Alanin 55.596 Citrullin 57.513 a-abs 66.146 Cystin 69.729 Methionin 73.762 77.162 82.195 89.694 Phenylalanin 50.497 52.580 Glycin 54.147 Alanin 55.713 Citrullin 60.746 Valin 66.162 Cystin 69.629 Methionin 77.112 82.195 89.794 Phenylalanin 81.861 83.245 Cys-Hcys Dis 84.328 85.295 Tyrosin 86.311 b-alanin 89.378 Phenylalanin 91.177 b-aiba 92.194 92.394 94.377 103.160 Ammoniak 109.310 AminoEthylCystein 111.093 Ornithin 114.659 Lysin 116.709 1-MeHistidin 118.626 Histidin 123.309 133.941 Arginin mvolts Citrulline Ornithine Methionine + Homocitrulline Arginine 50 60 70 80 90 Minutes 50 60 70 80 90 Minutes 50 60 70 80 90 Minutes Methionine + Homocitrulline peak 7
Figure 4: Amino acid chromatogram overlaid with homocitrulline standard chromatogram (faint line) Source Figure 4: participating lab 8
Sample C: MPS II (Mucopolysaccharidosis type II, Hunter) Patient: this sample was obtained from a 4.5 year old boy suffering from mucopolysaccharidosis type II (Hunter). This urine was obtained in our hospital, Basel, Switzerland. The diagnosis had been confirmed by the finding of severe iduronate sulphate sulphatase deficiency in serum and leucocytes (Prof. B. Steinmann, Zurich, Switzerland). Analytical performance: mucopolysaccharide analysis was considered essential. The finding of increased GAG, heparan and dermatan sulphate was considered correct. 20 laboratories performed mucopolysaccharide analysis. All found increased GAG which received 1 point, 17 reported quantitative values for GAG (see Figure 5). One additional point was given for GAG differentiation with identification of dermatan sulphate. The analytical performance of this sample was 76%. Interpretative proficiency: a diagnosis of MPS in general received 1 point, and 1 point was given for mention of MPS type II. The interpretative proficiency for this sample was 86%. Recommendations: confirmation of diagnosis by enzyme assay (iduronate-2-sulfatase, α- iduronidase), mutation analysis (ARSB gene), GAG analysis and differentiation were considered helpful. Overall impression: The overall performance with this straightforward sample was 84%. All labs which performed MPS analysis satisfactorily detected an MPS disorder and 15 mentioned the diagnosis of MPS II. The variation of GAG values was large, although this was mainly due to 2 particularly high values. Quantitative data: mean = 4.6, median = 4.7, range: 3.0 5.9 Sample C: GAG and creatinine values Figure 5: GAG and creatinine values 200 180 160 140 GAG (g/mol creat) 120 100 80 60 40 20 Lab number 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 GA G (g/mol creat) 38.65 33.8 46 57.9 50.8 29.65 38.9 29.65 161 60 22 38 51.75 49.1 53.5 38.1 191 Creatinine (mmol/l) 3.42 4.67 5.27 3 4.496 5.91 4.78 5.29 4.62 4.8 4.5 4.32 4.15 4.77 0 4.1 3.372 4.5 Figure 6: MPS TLC Heparan Dermatan 9
Sample D: Fumarase deficiency Patient: the sample was obtained from a 20 year old male patient with fumarase deficiency who was receiving no treatment. The diagnosis was based on urine organic acid analysis and confirmation by enzyme assay. This sample was contributed by Dr. Jim. R. Bonham, Sheffield, UK. Analytical performance: 21 laboratories reported organic acid analyses, 19 were able to correctly identify the key metabolite fumaric acid with or without other related metabolites (malic acid, succinic acid) which scored 2 points. The analytical performance of this sample was 91%. Interpretative proficiency: diagnosis of fumarase deficiency was considered correct and received 2 points. A general mitochondrial disorder received 1 point. The proficiency score was 67%. Recommendations: we consider follow-up by enzyme assay (fumarase/ fumarate hydratase) and mutation analysis (FH gene), as important. Overall impression: fairly good overall performance of 78%. Only 11 labs found the correct diagnosis. Although most labs reliably identified increased amounts of fumaric acid, several were mislead by the presence of malic acid. The presence of malic acid could occur due to the presence of both cytosolic and mitochondrial fumarase activity. Thus, the mitochondrial form may be somewhat deficient. The cumulated fumarate may be converted to malate. Figure 7: Organic acid chromatogram Abundance TIC: 1001010.D 6500000 6000000 Succinic 5500000 5000000 Fumaric 4500000 4000000 3500000 3000000 Malic 2500000 2000000 1500000 1000000 500000 Time--> 10.00 15.00 20.00 25.00 30.00 35.00 40.00 45.00 50.00 10
Sample E: ASA (Argininosuccinic aciduria, Argininosuccinate lyase deficiency) Patient: this sample came from a 20 year old male patient with ASA who is under treatment with arginine. This urine was obtained in our hospital, Basel, Switzerland. Enzymatic or mutational analysis has not been performed but the plasma and urine amino acid profiles and clinical symptoms leave no doubt as to the diagnosis. Analytical performance: Amino acid analysis was considered essential for the diagnosis in this case and was performed by 20 laboratories. The finding of argininosuccinate as the key amino acid received 2 points. Anhydrides of argininosucciniate, citrulline and arginine were also considered important. Analytical performance was 95%. Interpretative proficiency: the diagnosis of ASA was considered correct and received 2 points. Proficiency score was 95%. Recommendations: follow-up by plasma amino acid and ammonia analysis, confirmation of diagnosis by enzyme assay (argininosuccinate lyase, ASL) and mutation analysis (ASL gene) were considered helpful. Overall impression: 20 out of 21 labs scored the maximum points which led to a very good overall performance of 95%. This sample is the same as that distributed in 2006. At that time proficiency was 75% compared with the improved level of 95% in this round of testing. Figure 8: Amino acid chromatogram (German spelling) mvolts 450 400 350 300 250 570nm U 304-09 DPT09 ASA-sample vom 9.3.09 20090309_U 304-09 DPT09 ASA-sample vom 9.3.09_01.dat Retention Time Name 4.066 4.866 Phosphoserin 6.800 Taurin 8.133 10.766 Urea 13.432 Glucosaminic 18.815 20.249 Aspnsäure 22.699 27.465 Threonin 29.681 Serin 34.048 Asparagin 38.381 Glutamin 51.263 53.380 54.946 56.480 Citrullin 66.229 Cystin 69.496 Methionin 85.228 Tyrosin 87.911 89.444 Phenylalanin ASA 94.394 97.760 g-aba 100.010 Aethanolamin 103.293 Ammoniak 109.293 AminoEthylCystein 111.076 Ornithin 114.743 Lysin 118.742 Histidin 122.592 3-MeHistidin 134.441 Arginin 450 400 350 300 250 mvolts 200 81.695 200 0 10 20 30 40 50 60 70 80 90 100 110 120 130 140 Minutes anhydrides 11
Sample F: Salla disease, Sialuria Patient: this was the common sample distributed in all 5 DPT schemes. This sample was obtained from a 6 year old female patient suffering from Salla disease. This urine was provided by Dr. J.-E. Månsson, Molndal, Sweden. The diagnosis had been confirmed by the finding of homozygosity for the Finnish sialin mutation R39C. Analytical performance: the finding of increased free sialic acid using colorimetric, TLC and HPLC methods was considered essential and received 2 points. The analytical performance of this sample was 26%. See figure 9 for a TLC of this sample and aged matched controls. Interpretative proficiency: a diagnosis of Salla received 2 points. The interpretative proficiency for this sample was 24% (5 labs found Salla disease) Recommendations: confirmation of diagnosis by finding of lysosomal membrane protein (sialin) and mutation analysis (SLC17A5 gene) were considered helpful. This was a difficult sample and required specific testing for sialic acid which could have been selected because of the clinical signs in the patient. Overall impression: this common sample was of high difficulty. Overall performance was very poor with only 29%. Only 5 labs found the correct diagnosis. Please see the ERNDIM website under Meetings for detailed presentation of this common DPT sample at the ERNDIM meeting held in Basel, October 22-23, 2009 (www.erndim.org). Figure 9: Sialic acid chromatogram Sialic acid Source Figure 9: Alan Cooper, Manchester, UK 12
9. Scores Sample Diagnosis A (%) I (%) R (%) total (%) A Ketothiolase deficiency 98 95 91 95 B Triple H syndrome 86 57 86 74 C MPS type 2 (Hunter) 76 86 95 84 D Fumarase deficiency 91 67 76 78 E ASA 95 95 95 95 F Salla disease 26 24 43 29 Survey 1 Survey 2 Lab no. A B C D E F total 1 5 4 5 4 5 0 23 2 4 4 4 4 5 0 21 3 5 1 3 5 0 0 14 4 5 4 4 5 5 0 23 5 5 5 2 5 5 0 22 6 4 4 4 5 5 2 24 7 5 3 3 0 5 5 21 8 5 4 5 2 5 5 26 9 5 4 5 5 5 0 24 10 5 4 5 2 5 5 26 11 4 4 3 5 5 0 21 12 5 4 4 5 5 5 28 13 5 4 4 3 5 5 26 14 5 4 5 4 5 0 23 15 5 3 5 4 5 0 22 16 4 5 5 4 5 1 24 17 5 4 2 5 5 0 21 18 4 3 5 0 5 1 18 19 5 2 5 5 5 0 22 20 5 4 5 5 5 1 25 22 5 4 5 5 5 0 24 Total score of all 6 samples average points = 22.8 of max. 30, or 76% 30 25 20 points 15 10 5 0 Lab number 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 22 total points 23 21 14 23 22 24 21 26 24 26 21 28 26 23 22 24 21 18 22 25 24 13
Sample A Sample B Sample C Lab Ketothiolase deficiency Triple H syndrome MPS type 2 (Hunter) no A I R Total A I R Total A I R Total 1 2 2 1 5 2 1 1 4 2 2 1 5 2 2 2 0 4 1 2 1 4 1 2 1 4 3 2 2 1 5 1 0 0 1 1 1 1 3 4 2 2 1 5 2 1 1 4 1 2 1 4 5 2 2 1 5 2 2 1 5 1 1 0 2 6 2 1 1 4 2 1 1 4 1 2 1 4 7 2 2 1 5 1 1 1 3 1 1 1 3 8 2 2 1 5 2 1 1 4 2 2 1 5 9 2 2 1 5 2 1 1 4 2 2 1 5 10 2 2 1 5 2 1 1 4 2 2 1 5 11 2 2 0 4 2 1 1 4 1 1 1 3 12 2 2 1 5 2 1 1 4 1 2 1 4 13 2 2 1 5 2 1 1 4 2 1 1 4 14 2 2 1 5 2 1 1 4 2 2 1 5 15 2 2 1 5 2 1 0 3 2 2 1 5 16 2 1 1 4 2 2 1 5 2 2 1 5 17 2 2 1 5 2 1 1 4 0 1 1 2 18 1 2 1 4 1 1 1 3 2 2 1 5 19 2 2 1 5 1 1 0 2 2 2 1 5 20 2 2 1 5 1 2 1 4 2 2 1 5 22 2 2 1 5 2 1 1 4 2 2 1 5 ratio 41/42 40/42 19/21 100/105 36/42 24/42 18/21 78/105 32/42 36/42 20/21 88/105 % 98 95 91 95 86 57 86 74 76 86 95 84 Sample D Sample E Sample F Lab Fumarase deficiency ASA Salla disease no A I R Total A I R Total A I R Total 1 2 1 1 4 2 2 1 5 0 0 0 0 2 2 1 1 4 2 2 1 5 0 0 0 0 3 2 2 1 5 0 0 0 0 0 0 0 0 4 2 2 1 5 2 2 1 5 0 0 0 0 5 2 2 1 5 2 2 1 5 0 0 0 0 6 2 2 1 5 2 2 1 5 1 0 1 2 7 0 0 0 0 2 2 1 5 2 2 1 5 8 2 0 0 2 2 2 1 5 2 2 1 5 9 2 2 1 5 2 2 1 5 0 0 0 0 10 2 0 0 2 2 2 1 5 2 2 1 5 11 2 2 1 5 2 2 1 5 0 0 0 0 12 2 2 1 5 2 2 1 5 2 2 1 5 13 2 1 0 3 2 2 1 5 2 2 1 5 14 2 1 1 4 2 2 1 5 0 0 0 0 15 2 1 1 4 2 2 1 5 0 0 0 0 16 2 1 1 4 2 2 1 5 0 0 1 1 17 2 2 1 5 2 2 1 5 0 0 0 0 18 0 0 0 0 2 2 1 5 0 0 1 1 19 2 2 1 5 2 2 1 5 0 0 0 0 20 2 2 1 5 2 2 1 5 0 0 1 1 22 2 2 1 5 2 2 1 5 0 0 0 0 ratio 38/42 28/42 16/21 82/105 40/42 40/42 20/21 100/105 11/42 10/42 9/21 30/105 % 91 67 76 78 95 95 95 95 26 24 43 29 14
10. Assessment of performance Steps have been taken within the Scientific Advisory Board of ERNDIM to set the level of good performance within a proficiency scheme. Letters of support to those laboratories with clear poor performance will be issued. This year 18 points or more has been set as the level for satisfactory performance. Thus, only 1 lab did not reach this level. 11. Annual meeting The annual meeting of participants of the 5 DPT centres took place in Basel Switzerland at the ERNDIM meeting on October 23, 2009. Twelve participants and 2 guests attended the meeting of the Basel centre. Agreement was received for the allocated points. 12. Changes planned for 2010 We plan important changes for 2010. First you will be requested to submit results online to our website. You will be contacted soon with more details and you will be given the opportunity to practice using the website with 2009 data. Second as part of the professionalisation of our schemes it is the intention of the ERNDIM board to delegate the administrative aspects of the DPT schemes to an accredited organisation i.e. the Swiss Centre for Quality Control (CSCQ) in Geneva in a similar role to that of SKML for the quantitative schemes. As the first step we will collaborate with CSCQ just for the Basel scheme. This means that you will receive samples from CSCQ but we will remain responsible for the scientific and evaluation aspects of the scheme. 13. Tentative schedule and fee in 2010 Task Sample distribution Start of analysis of Survey 2010/1 Survey 2010/1 - Results submission Survey 2010/1 - Reports Start of analysis of Survey 2010/2 Survey 2010/2 Results submission Survey 2010/2 - Reports Annual meeting of participants Annual Report 2010 Due May 3, Monday May 17, Monday June 7, Monday June 28, Monday June 28, Monday July 19, Monday August 13, Friday August 31, Istanbul December The next annual meeting of DPT participants will take place on August 31 in Istanbul Turkey at the SSIEM meeting. The Executive Board of ERNDIM determined the fee for 2010 in the amount of 320. 14. Certificate of participation The certificate of participation will be provided by ERNDIM to all participants who returned the results of both surveys. In addition, we are introducing a new type of certificate which will now indicate whether satisfactory performance was achieved in the scheme. Brian Fowler Katharina Honegger Marianne Zaugg Scientific advisor Scheme organiser Scheme organiser 15