Hypertonic Saline Dilution: A Simple Technique to Offset Interference of IgM

Paraproteins in Uric Acid Analysis

Sanders Sebastian1, Ashley Teo2, Alan McNeil2, Christina Trambas1

1Department of Biochemistry, St Vincent’s Hospital Melbourne, Victoria, Australia; 2Department of
Biochemistry, Dorevitch Pathology, Victoria, Australia.

Background
The presence of paraproteins, particularly IgM, can cause
interference in many biochemical assays, including uric acid. For
some paraproteins, interference may derive from their propensity
to precipitate, depending on the ionic strength of the assay
reaction. Irrespective of the mechanism, the net result of
interference is an inaccurate result, which may confound clinical
decision making and lead to adverse events for the patient1-4.
Aim
To determine whether increasing the sample ionic strength with
hypertonic saline can overcome IgM paraprotein interference in
Results
In all ten samples with falsely low uric acid results, dilution in
hypertonic saline restored the reaction curves to normal
appearance (Figure 1B) and increased the uric acid results (Table
1). In contrast, dilution of affected samples in isotonic saline or
distilled water had no effect on uric acid results or the reaction
curve morphology (not shown).
Dilution of control samples with hypertonic saline had no
appreciable effect on reaction curves or uric acid measurement
(Figure 1C-D; Figure 2 and Table 2).
Figure 2 Hypertonic saline has little effect on uric acid
measurement in the absence of IgM paraprotein interference
Method comparison: Neat Results, Post hypertonic dilution v6 .15

the Siemens Atellica uric acid assay. Sheet1 A1:I21

Fi l ter: No fi l ter

La st upda ted 19 Ja nua ry 2023 a t 11:31 by Sa nders Seba stia n

Descriptives
Di fference pl ot
0.01
Post hypertonic dilution -Neat Results (mmol/L)

0.005

Methods 0

-0.005
Mean
(-0.0 113)
-0.01
95% L oA
(-0.0 273 to 0.0047)
-0.015

The Siemens Atellica uric acid assay is based on the Fossati -0.02

-0.025

enzymatic reaction, which uses uricase with a Trinder-like end -0.03

0.15 0.2 0.25 0.3 0.35 0.4 0.45 0.5

point. The absorbance of the coloured complex is measured at (Neat Res ul ts + Pos t hypertoni c di l uti on) / 2 (mmol /L)

545/694 nm5. Paraprotein interference with this assay can cause Table 2 Hypertonic saline has little effect on uric acid
falsely low uric acid results. measurement in the absence of IgM paraprotein interference
Neat Results (mmol/L) Post hypertonic dilution (mmol/L)
Interference in ten suspiciously low uric acid results from patients 0.2 0.18
with IgM paraproteins was confirmed by demonstration of 0.44 0.43
0.25 0.23
abnormal reaction curves (Figure 1A). After 1 in 3 dilution of the 0.19 0.19
samples with 18% saline, uric acid was re-measured and the 0.47 0.45
0.23 0.22
reaction curves re-assessed. Samples with normal uric acid
0.19 0.18
reaction curves were employed as controls. 0.25 0.25
0.36 0.35
0.36 0.35
0.36 0.34
Figure 1 Hypertonic saline restores uric acid reaction curve 0.26 0.25
0.45 0.42
morphology in samples with IgM paraprotein interference 0.3 0.3
A. Abnormal reaction curve in a sample B. Normal reaction curve on dilution of 0.39 0.38
with IgM paraprotein interference affected sample in hypertonic saline 0.28 0.27
0.5 0.49
0.18 0.18
0.42 0.4
0.4 0.39

Discussion
Our data suggests that increasing the ionic strength of a sample
with hypertonic saline can mitigate the effect of IgM paraprotein
C. Normal reaction curve in a sample D. Normal reaction curve on dilution of interference on the Siemens Atellica uric acid assay. This was
without IgM paraprotein interference unaffected sample in hypertonic saline
demonstrated by the “normalisation” of reaction curves upon
dilution of affected samples with hypertonic saline. In tandem
with restored reaction curves, uric acid results also increased.
Further investigation using an interference-resistant reference
method is required to determine whether hypertonic saline
dilution can completely remove IgM paraprotein interference and
restore accurate uric acid measurement. In the interim, our study
suggests that hypertonic saline dilution is a useful technique to
Table 1 Hypertonic saline reverses spuriously low uric acid establish the presence of paraprotein interference in the Siemens
results in samples showing IgM paraprotein interference Atellica uric acid assay. It is also possible that other paraprotein
related interference may be amenable to this technique.
Neat Results (mmol/L) Post Hypertonic dilution (mmol/L)
<0.03 0.25
0.04 0.26
<0.03 0.24
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0.03 0.26
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0.1 0.23