Skip to content
Licensed Unlicensed Requires Authentication Published by De Gruyter September 21, 2011

Influence of hemolysis on routine clinical chemistry testing

Giuseppe Lippi, Gian Luca Salvagno, Martina Montagnana, Giorgio Brocco and Gian Cesare Guidi


Background: Preanalytical factors are the main source of variation in clinical chemistry testing and among the major determinants of preanalytical variability, sample hemolysis can exert a strong influence on result reliability. Hemolytic samples are a rather common and unfavorable occurrence in laboratory practice, as they are often considered unsuitable for routine testing due to biological and analytical interference. However, definitive indications on the analytical and clinical management of hemolyzed specimens are currently lacking. Therefore, the present investigation evaluated the influence of in vitro blood cell lysis on routine clinical chemistry testing.

Methods: Nine aliquots, prepared by serial dilutions of homologous hemolyzed samples collected from 12 different subjects and containing a final concentration of serum hemoglobin ranging from 0 to 20.6g/L, were tested for the most common clinical chemistry analytes. Lysis was achieved by subjecting whole blood to an overnight freeze-thaw cycle.

Results: Hemolysis interference appeared to be approximately linearly dependent on the final concentration of blood-cell lysate in the specimen. This generated a consistent trend towards overestimation of alanine aminotransferase (ALT), aspartate aminotransferase (AST), creatinine, creatine kinase (CK), iron, lactate dehydrogenase (LDH), lipase, magnesium, phosphorus, potassium and urea, whereas mean values of albumin, alkaline phosphatase (ALP), chloride, γ-glutamyltransferase (GGT), glucose and sodium were substantially decreased. Clinically meaningful variations of AST, chloride, LDH, potassium and sodium were observed in specimens displaying mild or almost undetectable hemolysis by visual inspection (serum hemoglobin <0.6g/L). The rather heterogeneous and unpredictable response to hemolysis observed for several parameters prevented the adoption of reliable statistic corrective measures for results on the basis of the degree of hemolysis.

Conclusion: If hemolysis and blood cell lysis result from an in vitro cause, we suggest that the most convenient corrective solution might be quantification of free hemoglobin, alerting the clinicians and sample recollection.

Corresponding author: Prof. Giuseppe Lippi, MD, Istituto di Chimica e Microscopia Clinica, Dipartimento di Scienze Morfologico-Biomediche, Università degli Studi di Verona, Ospedale Policlinico G.B. Rossi, Piazzale Scuro, 10, 37121 Verona, Italy Phone: +39-045-8074517, Fax: +39-045-8201889,


1. Bonini P, Plebani M, Ceriotti F, Rubboli F. Errors in laboratory medicine. Clin Chem 2002; 48:691–8.10.1093/clinchem/48.5.691Search in Google Scholar

2. Lippi G, Brocco G, Franchini M, Schena F, Guidi G. Comparison of serum creatinine, uric acid, albumin and glucose in male professional endurance athletes compared with healthy controls. Clin Chem Lab Med 2004; 42:644–7.10.1515/CCLM.2004.110Search in Google Scholar PubMed

3. Lippi G, Guidi GC. Effect of specimen collection on routine coagulation assays and D-dimer measurement. Clin Chem 2004; 50:2150–2.10.1373/clinchem.2004.036244Search in Google Scholar PubMed

4. Lippi G, Salvagno GL, Guidi GC. No influence of a butterfly device on routine coagulation assays and D-dimer measurement. J Thromb Haemost 2005; 3:389–91.10.1111/j.1538-7836.2005.01163.xSearch in Google Scholar PubMed

5. Lippi G, Salvagno GL, Brocco G, Guidi GC. Preanalytical variability in laboratory testing: influence of the blood drawing technique. Clin Chem Lab Med 2005; 43:319–25.10.1515/CCLM.2005.055Search in Google Scholar PubMed

6. Lippi G, Salvagno GL, Montagnana M, Brocco G, Guidi GC. Influence of short-term venous stasis on clinical chemistry testing. Clin Chem Lab Med 2005; 43:869–75.10.1515/CCLM.2005.146Search in Google Scholar PubMed

7. Lippi G, Salvagno GL, Montagnana M, Guidi GC. Short-term venous stasis influences routine coagulation testing. Blood Coagul Fibrinolysis 2005; 16:453–8.10.1097/01.mbc.0000178828.59866.03Search in Google Scholar PubMed

8. Kroll MH, Elin RJ. Interference with clinical laboratory analyses. Clin Chem 1994; 40:1996–2005.10.1093/clinchem/40.11.1996Search in Google Scholar

9. Carraro P, Servidio G, Plebani M. Hemolyzed specimens: a reason for rejection or a clinical challenge? Clin Chem 2000; 46:306–7.10.1093/clinchem/46.2.306Search in Google Scholar

10. Rother RP, Bell L, Hillmen P, Gladwin MT. The clinical sequelae of intravascular hemolysis and extracellular plasma hemoglobin: a novel mechanism of human disease. J Am Med Assoc 2005; 293:1653–62.10.1001/jama.293.13.1653Search in Google Scholar PubMed

11. Burns ER, Yoshikawa N. Hemolysis in serum samples drawn by emergency department personnel versus laboratory phlebotomists. Lab Med 2002; 33:378–80.10.1309/PGM4-4F8L-2P1M-LKPBSearch in Google Scholar

12. Jones BA, Calam RR, Howanitz PJ. Chemistry specimen acceptability. A College of American Pathologists Q-Probes study of 453 laboratories. Arch Pathol Lab Med 1997; 121:19–26.Search in Google Scholar

13. National Committee for Clinical Laboratory Standards. Reference and selected procedures for the quantitative determination of hemoglobin in blood: approved standard, 3rd ed. NCCLS document H15-A3. Wayne, PA: NCCLS, 2000.Search in Google Scholar

14. Bland JM, Altman DG. Measuring agreement in method comparison studies. Stat Methods Med Res 1999; 8:135–60.10.1177/096228029900800204Search in Google Scholar PubMed

15. Ricos C, Alvarez V, Cava F, Garcia-Lario JV, Hernandez A, Jimenez CV, et al. Current databases on biologic variation: pros, cons and progress. Scand J Clin Lab Invest 1999; 59:491–500.10.1080/00365519950185229Search in Google Scholar PubMed

16. Ogden-Grable H, Gill GW. Phlebotomy puncture juncture: preventing phlebotomy errors – potential for harming your patients. Lab Med 2005; 36:430–3.10.1309/EXTW9LBM0CD7P9EVSearch in Google Scholar

17. Laessig RH, Hassemer DJ, Paskey TA, Schwartz TH. The effects of 0.1% and 1.0% erythrocytes and hemolysis on serum chemistry values. Am J Clin Pathol 1976; 66:639–44.10.1093/ajcp/66.4.639Search in Google Scholar PubMed

18. Sonntag O. Haemolysis as an interference factor in clinical chemistry. J Clin Chem Clin Biochem 1986; 24:127–39.Search in Google Scholar

19. Yucel D, Dalva K. Effect of in vitro hemolysis on 25 common biochemical tests. Clin Chem 1992; 38:575–7.10.1093/clinchem/38.4.575Search in Google Scholar

20. Jay D, Provasek D. Characterization and mathematical correction of hemolysis interference in selected Hitachi 717 assays. Clin Chem 1993; 39:1804–10.10.1093/clinchem/39.9.1804Search in Google Scholar

21. Grafmeyer D, Bondon M, Manchon M, Levillain P. The influence of bilirubin, haemolysis and turbidity on 20 analytical tests performed on automatic analysers. Results of an interlaboratory study. Eur J Clin Chem Clin Biochem 1995; 33:31–52.Search in Google Scholar

22. Owens H, Siparsky G, Bajaj L, Hampers LC. Correction of factitious hyperkalemia in hemolyzed specimens. Am J Emerg Med 2005; 23:872–5.10.1016/j.ajem.2005.05.011Search in Google Scholar PubMed

23. Hawkins R. Variability in potassium/hemoglobin ratios for hemolysis correction. Clin Chem 2002; 48:796.10.1093/clinchem/48.5.796Search in Google Scholar

24. Dimeski G, Clague AE, Hickman PE. Correction and reporting of potassium results in haemolysed samples. Ann Clin Biochem 2005; 42:119–23.10.1258/0004563053492739Search in Google Scholar PubMed

25. Ismail A, Shingler W, Seneviratne J, Burrows G. In vitro and in vivo hemolysis and potassium measurement. Br Med J 2005; 330:949.10.1136/bmj.330.7497.949Search in Google Scholar PubMed PubMed Central

Received: 2005-10-31
Accepted: 2005-12-5
Published Online: 2011-9-21
Published in Print: 2006-3-1

©2006 by Walter de Gruyter Berlin New York

Scroll Up Arrow