Biological Variation:

a practical review
Carmen Rics
Brussels & Amsterdam
2010 Bio-Rad_QC Seminars

C Rics
2010 QC Seminars
 Within-subject
biological variation

Age, sex
Diet, physic exercise
Pathology, treatment
Within-day variation, season
variation
Homeostasis

Fraser CG. Biological Variation: from theory to practice. AACC press, 2001

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 Within-subject
biological variation

Fluctuation of the
concentration
of blody fluid components
around the setting point

Fraser CG. Biological Variation: from theory to practice. AACC press, 2001

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 Between-subject
biological variation

Differences in concentration

of the components of

biologic fluids

among persons

Fraser CG. Biological Variation: from theory to practice. AACC press, 2001

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 How to estimate the
components of BV

1. To obtain n samples from m healthy

volunteers

n, m and sampling interval are irrelevant

Key factors: sample obtention and
maintenance

Fraser CG. Biological Variation: from theory to practice. AACC press, 2001

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2010 QC Seminars
 How to estimate the
components of BV

2. To eliminate outliers

Cochran test outlier values

Reed test outlier individuals

Rics C et al. Clin Chem 1994;40:472-477

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2010 QC Seminars
 How to estimate the
components of BV

3. To applicate the ANOVA test

sI2 =s (W+A)2 sA2

sG2 = stotal2 sI2 M1 M2 M3 Var
within-
subject
S1 Var s1
S2 Var s2
S3 Var s3
S4 Var s4
S(W+A)2

Rics C et al. Clin Chem 1994;40:472-477

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2010 QC Seminars
 Compilation of data on
Biological variation

Ross JW. Handbook of clinical chemistry.

Boca Raton: CRC press, 1982:391-42
Fraser CG. Arch Pathol Lab Med
1988;112:404-15
Fraser CG. Arch Pathol Lab Med
1992;116:916-23
Sebastin-Gambaro et al. Eur J Clin Chem
Clin Biochem 1997;35:845-52

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 What else?

a DATABASE

selective
permanently updated

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2010 QC Seminars
 Why?

To give information on
quality specifications for
Imprecision (CV,%)
Bias (SE,%)
Total error (TE,%)

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2010 QC Seminars
 Material
1. PAPERS SEARCH: BIOS, CURRENT CONTENTS,
EMBASE, MEDLINE, PUBMED

2. CLASSIFICATION of the information obtained

- BV components CVW, CVG

- Calculations Individuality,
Critical differences

- Descriptions N, days, samples

- Observations Health status, fasting

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2010 QC Seminars
 Method (1)

1. EXCLUSSIONS
Papers with too high analytical variation
(CVA> 0.5 CVW)
Papers not specifically designed to estimate CVW
and CVG

Studies made within a day

Studies made on non-healthy subjects

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2010 QC Seminars
 Method (2)
2. EXPRESSION (for each analyte)
Papers in ascending order according to the CVW
Search for relationships between CVW and
number of subjects, sex, health status, fasting;
number of samples per subject, time span of the
study
If no relationships are observed: calculation of
the median of CVW and CVG values from all
papers compiled
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2010 QC Seminars
 Example: s- Glucose
CVW CVG CVA N Td Ss Mean Unit Year

4.2 10.8 2.4 40 28 3 5.5 mmol/L 1994

4.7 5.4 2.4 27 140 10 5.2 1989
4.7 6.1 2.1 14 70 10 5.3 1988
5.0 7.7 3.4 20 365 12 5.2 1989
5.5 7.8 2.5 68 112 11 94 mg/dL 1970
5.7 5.8 1.7 48 365 12 140 2002
6.5 2.7 1.6 9 70 10 94 1971
6.5 8.7 2.2 1105 60 9 4.8 mmol/L 1978
8.0 14.0 1.8 10 5 5 4.4 1986
10.4 NC 1.5 126 180 6 4.4 1985
13.1 3.2 3.0 10 5 5 4.8 1993
13.2 NC 1.5 148 180 6 4.0 1985

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2010 QC Seminars
 Method (3)

3. CALCULATION OF SPECIFICATIONS

CVA(%) < 0.5 CVW

SEA (%) < 0.25 (CVW2 + CVG2)1/2

TEA (%) < 1.65*CVA + SEA

- Elevitch FR editor. AP Conference II. Skokie IL 1976

- Gowans EMSs et al. Scan J Clin Lab Invest 1988;48:757-764
- Fraser CG et al. Scand J Clin Lab Invest 1993; 53 suppl 212:8-9

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 Results
(Database, 2010 update)

319 analytes

213 papers (12 rejected)

182 authors (>15 countries)

59 journals
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2010 QC Seminars
 Database 2010 update
Example

Analyte Biological Desirable

Variation Specifications
CVW CVG CV(%) SE(%) TE(%)
Srm- -Amilase 8,7 28,3 4,4 7,4 14,6
Srm- -Amilasa, pancreatic 11,7 29,9 5,9 8,0 17,7
Srm- -Carotene 35,8 65,0 17,9 18,6 48,1
Srm- -Fetoprotein 12,0 46,0 6,0 11,9 21,8
Srm- -Tocoferol 13,8 15,0 6,9 5,1 16,5

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2010 QC Seminars
 Database 2010 update
References

http:// www. Westgard.com/biodatabase1.htm

http:// www. seqc.es/es/Sociedad/51/102

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2010 QC Seminars
 Database - contras

Discrepancies among authors in

some analytes (hormones)

A single paper available for 90

analytes

Many analytes not studied

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2010 QC Seminars
 Database - pros

Wide source of information

Papers poorly reliable have been

disegarded

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2010 QC Seminars
 Database - Applications

 Quality specifications
 Delta check
 Reference change value

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2010 QC Seminars
 Quality specifications
Stockholm international consensus
1999

Effect on clinical outcome

Effect on general clinic decisions

Professional recommendations

Regulatory bodies / EQAS proposals

Current state of the art

Hyltoft P et al. Strategies to set global analytical quality specifications
in laboratory medicine. Scand J Clin Lab Invest 1999;57,7
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2010 QC Seminars
Use of Q specifications
1. To design internal control rule
To calculate the critical error increase
CE = TEA / 1,96 CVA
To select the control procedure

CE Rule Controls/run
1:2s N=2
<2 1:2,5s N=4
1:3s N=6

1:2s N=1
(2-3) 1:3 N=2
1:3,5s N=4

1;2,5s N=1
>3 1:3s N=2
1:3,5s N=4
Hyltoft P et al. Strategies to set global analytical quality specifications
in laboratory medicine. Scand J Clin Lab Invest 1999;57,7
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2010 QC Seminars
Use of Q specifications
2. to evaluate internal QC results

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2010 QC Seminars
Use of Q specifications
3. to evaluate EQA results

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2010 QC Seminars
Use of Q specifications
3. to evaluate EQA results
- SEQC

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2010 QC Seminars
Use of Q specifications
3. to evaluate EQA results
- SEQC
% of results reaching specifications based on BV

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2010 QC Seminars
 Delta Check

Check < 2 * Zp (CVA2 +CVW2)

Z = 1.96 significant autovalidation

Z = 2.58 highly significant manual verification

Fraser CG. Accred & Qual Assur 2002;7:455-460

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2010 QC Seminars
Reference change value

Difference between two consecutive

results that may indicate a change in
the patient health state

Fraser CG. Biological variation: from principles to practice. Washington DC. AACC Press ,2001

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2010 QC Seminars
Reference change value

SOULD BE USED
For analytes with high individuality
CVI/CVG<0.6

Fraser CG. Biological variation: from principles to practice. Washington DC. AACC Press ,2001

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2010 QC Seminars
Reference change value

SHOULD BE USED
In 276 of the 319 analytes
from the current database

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2010 QC Seminars
Reference change value

RCV = 21/2*Zp*(CVA2 + CVW2)1/2

RCV = 2.77 * (CVA2 + CVW2)1/2

Fraser CG. Biological variation: from principles to practice. Washington DC. AACC Press ,2001

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2010 QC Seminars
 Reference change vlaue

 Interpreting resultas of analytes with highindividuality

Fraser CG. Biological variation: from principles to practice. Washington DC. AACC Press ,2001

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2010 QC Seminars
 Reference change value
- reporting
NINEWELLS HOSPITAL AND MEDICAL SCHOOL
Result Units Ref.
values
Sodium 138 * mmol/L 135-147
Potassium 5.0 mmol/L 3.5-5.0
Urea 9.5 ** mmol/L 3.3-6.6
Creatinine 137 > mmol/L 50-100
Bilirubins 100 >> mmol/L NAME
Albumin 23 << g/L 36-50
Calcium 2.27 ** mmol/L 2.1-2.6
Fraser CG. Biological Variation: From Principles to Practice. Washington, DC, AACC Press, 2001
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2010 QC Seminars
 Reference change value
- in pathology
Pathology Analyte CVI (%)
Cancer ovarium CA 125 46
Cancer mamarian CA 15.3 17
C. colorectal CEA 45
Diabetes HbA1C 9
mellitus Microalbumin 36
Hepatic disease -fetoprotein 40
Paget Alkaline phos. 12
Rics C et al. Ann Clin Biochem 2007; 44: 343352
 Reference change value
- two analytes combined
VRC combinado
100
Uratos Diferencias (%)

50

-50

-100
-100 -50 0 50 100 150
Creatinina Diferencias (%)

estables i.r.aguda obstructiva toxicidad FK506

infeccin citomegalovirus rechazo agudo

Biosca C. Clin Chem 2001;47:2146-8

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2010 QC Seminars
 References (1)
Fraser CG. Biological Variation: From Principles to Practice.
AACC Press, Washington DC, 2001.
Rics C, lvarez V, Cava F, Garca-Lario JV et al. Current
databases on biological variation: pros,cons and progress.
Scand J Clin Lab Invest 2004; 64: 17584.
Rics C, Iglesias N, Garca-Lario JV, Simn M et al. Within-
subject biological variation in disease: collated data and clinical
consequences. Ann Clin Biochem 2007; 44: 343352 .
Biosca C, Rics C, Jimnez CV, Lauzurica R et al. Are equally
spaced specimen collections necessary to assess biological
variation?. Evidence from renal transplant recipients. Clin Chim
Acta 2000;301:79-85.

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2010 QC Seminars
 References (2)
Hyltoft Petersen P, Sandberg S, Fraser CG, Goldsmith H.
Influence of index of individuality on false positives in repeated
sampling from healthy individuals. Clin Chem Lab med
2001;391:160-165
Comit de garanta de la Calidad y Acreditacin de
Laboratorios. Comisin de Calidad analtica. Base de datos de
Variacin biolgica. Actualizacin del ao 2010.
http://www.seqc.es/es/Sociedad/51/102
Fraser CG, Stevenson HP, Kennedy IMG. Biological variation
data are necessary prerequisites for objective autoverification
of clinical laboratory data. Accred Qual Assur 2002;7:455-460.
Biosca C, Rics C, Lauzurica R, Galimany R et al. Reference
Change Value Concept Combining Two Delta Values to Predict
Crises in Renal Posttransplantation. Clin Chem 2001;47:2146-8
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2010 QC Seminars
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2010 QC Seminars