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【检验临床面对面】AST结果一天内怎么会相差1300U/L?

时间:2019-03-05       作者:检验视界网      浏览量:3133 次

作者:徐奕胜,赣南医学院第二附属医院


【前言】


生化分析仪作为检验科必不可少的一个重要角色,在测试标本时候,遇到脂血或结果为负值情况下,我们往往会进行稀释,最终报告数值以稀释倍数乘以稀释后结果为准。但最近临床疑惑的一例AST结果在一天之内相差1300U/L,着实让自己头疼了一回。


【案例经过】


晚饭时间,接到临床同学的信息,告知一患者的AST结果相差甚大,问是何缘故,是否为仪器原因?还是检验人员做错了?这顿时把自己问得愣住了,首先可以肯定的是,这结果不会有错的,同事还是很负责的。同时,自己也慢慢的将整个过程梳理遍。


患者,男,74岁,早上八点在门诊挂号,门诊医生开了肝功能、肾功能3项、血糖、血脂检查,其结果如表1。


1.jpg

表1,患者上午门诊结果,生化仪西门子2400


后发现ALT、AST、TBIL均达危急值,将患者转为住院,中午时分由临床同学收入院,同学为完善相关检查,开出心功能、肾功能5项、电解质6项,其结果如表2。


2.jpg

表2,患者下午住院结果,生化仪贝克曼AU-680


我们知道,AST既可以是肝功能中的一个指标,同时它又是心功能(有的地方叫心肌酶谱)的一个指标。而问题恰恰又出在这,早上08:40分的AST:5110U/L,下午13:27分AST:3840U/L,中间就相隔那么四个小时左右的时间,其结果就相差了1300U/L,虽说都达危急值,患者严重程度不言而喻,但这结果简直是差别太大了吧。


同学也因此高度怀疑检验结果是否可靠,毕竟这关系到临床治疗;对我们来说,这关系到结果是否准确,更关系到临床是否相信检验科。当时自己第一反应就是,难道是两台不同的生化仪导致的?可这两一起使用的都是同一厂家的生化试剂、朗道校准品、朗道质控品。而且,可以从表1、表2发现,即便是两台不同的仪器,重复的项目如肾功能相差也不大啊,如表3。


3.jpg

表3,两台生化仪肾功能结果对比


排除了仪器的因素,两台生化仪的质控又都在控。那问题来了,为什么唯独AST会相差如此之大,难道是因为稀释倍数的原因吗?在检验科,我们知道生化仪有些项目是有上限范围的,当标本的值太高(俗称“超线性”)、严重脂血、严重黄疸、大分子蛋白等因素时候,仪器会报警或结果为负值,就需要我们对血清进行稀释?;颊哐缤?。


4.jpg

图1,患者血清、正常对照血清


稀释倍数的不同,也会导致结果相差大,特别是对于成千上万的结果,想起自己在深圳工作时候,曾经对一个十几万的血HCG样本进行了20倍和50倍稀释,结果是两者之间相差了几千。


翻阅相关文献,在杨敏老师的文章中也有提及:不同稀释液由于基质效应的不同,对酶活力超线性样本血清ALT、AST测定结果的影响不同;随着稀释倍数的增加,使用纯化水稀释对血清ALT、AST测定结果的影响越明显;随着稀释倍数的增加,使用小牛血清稀释对血清ALT、AST测定结果无明显影响。[1]


问过生化组长,得到的是两台仪器测试时,均对患者血清使用蒸馏水稀释10倍,是的,稀释的都是相同倍数。


事情发展到这,自己只能是怀疑患者是否使用自带的药物,或临床是否进行了治疗干预,在得到临床同学的否定后,好吧,所有的猜测均被否决,这下把自己头疼大了。


由于是晚上,自己只能让同学先按AST:3840U/L的结果先行处理。明天一早将昨天下午AU-680测试的血样在西门子2400上进行复检,稀释10倍后,最终结果为AST:3950U/L。


虽然两者相差了110U/L,但考虑到经过一晚冷藏,且不同仪器、不同环境测试。跟同学说明测试结果,同学说,患者自门诊到入院到做各种检查,其彩超结果到下午五点多下班时候才做完,期间一直在大量喝水,可能跟饮水有关。


【案例分析】


此案例中,患者一天内自始至终未服用药物,但AST结果相差如此之大,同学和自己也只能暂且考虑到是由于大量饮水缘故。


清晨八点采血时间,患者血液为浓缩状态,中午时分入院后,忙于各种检查,特别是彩超由于未憋到尿,期间进行了大量饮水,后行至检验科采血。


不过,自己仍然是很好奇,大量饮水虽说稀释血液粘稠度,但导致AST从5100U/L降至3840U/L,且是在一天时间内,这也太奇怪了,一直未找到很合理的解释。


同时,也暴露出个问题,结果过于异常的样本,最好还是使用同一仪器进行检测,以排除不同仪器原理、构造不同导致的差异。


【心得体会】


通过这个案例发现,有时做出来的结果还是要及时跟临床沟通说明,特别是非常异常的结果,切勿等到临床医生拿着检验单找我们寻求原因、要说法,倒逼着我们找答案才恍然觉悟。


参考文献

1. 杨敏.朱征.不同稀释液对酶活力超线性样本血清ALT、AST测定的影响不同稀释液对酶活力超线性样本血清ALT、AST测定的影响[J].四川医学,2016, 38(8):901-903







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