Skip to content
Licensed Unlicensed Requires Authentication Published by De Gruyter August 8, 2022

Reference intervals of 14 biochemical markers for children and adolescence in China: the PRINCE study

  • Xiaoxia Peng ORCID logo , Yaguang Peng , Chuanbao Zhang ORCID logo , Min Zhao , Hongling Yang , Sancheng Cao , Guixia Li , Yongmei Jiang , Zhenxin Guo , Dapeng Chen , Jin Xu , Hongbing Chen , Yun Xiang , Runqing Mu , Jie Zeng , Ying Shen , Yan Wang , Qiliang Li , Lixin Hu , Na Ren , Yanying Cai , Wei Zhang , Jie Ma , Ruohua Yan , Wenxiang Chen EMAIL logo , Wenqi Song EMAIL logo , Xin Ni EMAIL logo and on behalf of The Study Group of Pediatric Reference Intervals in China (PRINCE)



The Pediatric Reference Intervals in China (PRINCE) was initiated to establish the reference intervals (RIs) of Chinese children, as well as to make it possible to compare the variability of biochemical markers among countries internationally.


Healthy participants, aged up to 20 years, from 11 provinces across China, were enrolled in PRINCE and according to a standard screening procedure, that included a questionnaire survey, physical examinations and laboratory tests. Fasting venous blood specimens were collected. All serum specimens were analyzed with Cobas C702 in the center laboratory, i.e. clinical laboratory of Beijing Children’s Hospital, with certified qualification (ISO15189). The nonparametric method recommended by Clinical Laboratory Standards Institute guidelines, was used to calculate the age- and sex-specified RIs.


Among the 15,150 participants enrolled, 12,352 children (6,093 males and 6,259 females) were included to calculate RIs. The RIs for total protein, albumin, globulin, calcium, phosphate, potassium, sodium, chlorine, alkaline phosphatase, γ-glutamyl transpeptadase, alanine aminotransferase, aspartate aminotransferase, creatinine and urea were established by age- or sex-partitions. Most biochemical markers displayed larger variability and higher dispersion during the periods between 28 days and 1 year old, and included 4–6 age partitions commonly during 1 to <20 years old. In addition, differences of RIs between sexes usually occurs around the initiation of puberty at 12–13 years old.


The age- and sex-specified RIs of 14 biochemical markers in PRINCE study can provide a solid reference, which will be transferred into relevant RIs for other clinical laboratory’s platforms according to the CLSI guidelines.

Corresponding authors: Wenxiang Chen, National Center for Clinical Laboratories, National Center for Children’s Health, Beijing Children’s Hospital, Capital Medical University, No. 1 Dahua Road, Beijing, 100730, P.R. China, Phone: +86-010-58115060, E-mail: ; Wenqi Song, Department for Clinical Laboratory Center, National Center for Children’s Health, Beijing Children’s Hospital, Capital Medical University, No.56 Nanlishi Road, Beijing, 100045, P.R. China, Phone: +86-010-59616962, E-mail: ; and Xin Ni, Beijing Key Laboratory for Pediatric Diseases of Otolaryngology, Head and Neck Surgery, National Center for Children’s Health, Beijing Children’s Hospital, Capital Medical University, No. 56 Nanlishi Road, Beijing, 100045, P.R. China, Phone: +86-010-59616688, E-mail:
Xiaoxia Peng, Yaguang Peng, Chuanbao Zhang, Min Zhao, Hongling Yang, Sancheng Cao, Guixia Li, Yongmei Jiang, Zhenxin Guo, Dapeng Chen, Jin Xu, Hongbing Chen, and Yun Xiang are contributed equally to this work.

Funding source: National Health Commission of the People’s Republic of China

Award Identifier / Grant number: 2017374


We thank the staff members of the PRINCE study team. Special thanks is also due to all participants for their involvement, as well as their parents for their supports during the study. We would also like to that Dr. Ali Abbas for editing the manuscripts’ language.

  1. Research funding: The grand from Medical hospital authority, National Health Commission of the People’s Republic of China (No. 2017374).

  2. Author contributions: All authors have accepted responsibility for the entire content of this manuscript and approved its submission. PX, PY, ZC, ZM, YH, CS, LG, JY, GZ, CD, XJ, CH, and XY were contributed equally for writing the manuscript, as well as the organization and implementation of the study in each center, including epidemiological investigation, physical examination, specimen collection and transfer. MR, ZJ, SY, WY, LQ, HL, RN, CY, ZW, MJ were contributed the specimen management, laboratory test and quality control. YR, PX, and PY were in charge of the epidemiological methodology design, data management and data analysis. CW, SW, and NX were contributed equally for conceive the study.

  3. Competing interests: Authors state no conflict of interest.

  4. Informed consent: Informed consent was obtained from each participant’s legally authorized representative (parent or guardian) in the case of children aged less than 8 years. Otherwise, the informed consent was obtained from both the child and their legally authorized representative.

  5. Ethical approval: The PRINCE study was approved by The Institutional Review Board of Beijing Children’s Hospital (IEC-C-028-A10-V.05).


1. CLSI. Defining, establishing, and verifying reference intervals in the clinical laboratory; approved guideline, 3rd ed. Wayne, Pennsylvania: Clinical and Laboratory Standards Institute; 2010. CLSI EP28-A3c.Search in Google Scholar

2. Ozarda, Y, Ichihara, K, Barth, JH, Klee, G, Committee on Reference Intervals and Decision Limits (C-RIDL), IFCC. Protocol and standard operating procedures for common use in worldwide multicenter study on reference values. Clin Chem Lab Med 2014;51:1027–40.10.1515/cclm-2013-0249Search in Google Scholar PubMed

3. Mu, R, Chen, W, Pan, B, Wang, L, Hao, X, Huang, X, et al.. First definition of reference intervals of liver function tests in China: a large-population-based multi-center study about healthy adults. PLoS One 2014;8:e72916. in Google Scholar PubMed PubMed Central

4. Siest, G, Henny, J, Grasbeck, R, Wilding, P, Petitclerc, C, Josep, M, et al.. The theory of reference values: an unfinished symphony. Clin Chem Lab Med 2014;51:47–64. in Google Scholar PubMed

5. Ozarda, Y. Reference intervals: current status, recent developments and future considerations. Biochem Med 2016;26:5–16. in Google Scholar PubMed PubMed Central

6. Ceriotti, F. Establishing pediatric reference intervals: a challenging task. Clin Chem 2009;58:5. in Google Scholar PubMed

7. Ni, X, Song, W, Peng, X, Shen, Y, Peng, Y, Li, Q, et al.. Pediatric reference intervals in China (PRINCE): design and rationale for a large, multicenter collaborative cross-sectional study. Sci Bull 2018;63:1626–34. in Google Scholar

8. Peng, X, Lv, Y, Feng, G, Peng, Y, Li, Q, Song, W, et al.. Algorithm on age partitioning for estimation of reference intervals using clinical laboratory database exemplified with plasma creatinine. Clin Chem Lab Med 2018;56:1514–23. in Google Scholar PubMed

9. Colantonio, DA, Kyriakopoulou, L, Chan, MK, Daly, CH, Brinc, D, Venner, A, et al.. Closing the gaps in pediatric laboratory reference intervals: a CALIPER database of 40 biochemical markers in a healthy and multiethnic population of children. Clin Chem 2012;58:854–68. in Google Scholar PubMed

10. Thierfelder, W, Dortschy, R, Hintzpeter, B, Kahl, H, Scheidt-Nave, C. Biochemische messparameter im kinder- und jugendgesundheitssurvey (KiGGS). Bundesgesundheitsblatt – Gesundheitsforsch – Gesundheitsschutz 2007;50:757–70. in Google Scholar PubMed

11. Lv, YQ, Feng, GS, Ni, X, Song, W, Peng, X. The critical gap for pediatric reference intervals of complete blood count in China. Clin Chim Acta 2017;469:22–5. in Google Scholar PubMed

12. Liu, J, Dai, Y, Lee, Y, Yuan, E, Wang, Q, Wang, L, et al.. Pediatric reference intervals of liver and renal function tests from birth to adolescence in Chinese children as performed on the olympus AU5400. Clin Chim Acta 2019;490:142–6. in Google Scholar PubMed

13. Zhong, X, Ding, J, Zhou, J, Yu, Z, Sun, S, Bao, Y, et al.. A muiticenter study of reference intervals for 15 laboratory parameters in Chinese children. Zhonghua Er Ke Za Zhi 2018;56:835–45.Search in Google Scholar

14. Li, X, Wang, D, Yang, C, Zhou, Q, Zhuoga, S, Wang, L, et al.. Establishment of age- and gender-specific pediatric reference intervals for liver function tests in healthy Han children. World J Pediatr 2018;14:151–9. in Google Scholar PubMed PubMed Central

15. National Health and Family Planning Commission of the People’s Republic of China. WS/T403-2012 analytical quality specifications for routine markers in clinical biochemistry. Beijing: National Health Commission of the People’s Republic of China; 2012.Search in Google Scholar

16. National Center for Clinical Laboratories (NCCL). External quality assessment programs in laboratory medicine. Beijing. Available from: [Accessed 22 Jul 2022].Search in Google Scholar

17. CLSI. Measurement procedure comparison and bias estimation using patient samples; approved guideline, 3rd ed. Wayne, PA: CLSI; 2013.Search in Google Scholar

18. Harris, EK, Boyd, JC. On dividing reference data into subgroups to produce separate reference ranges. Clin Chem 1990;36:265–70. in Google Scholar

19. Lahti, A. Are the common reference intervals truly common? Case studies on stratifying biochemical reference data by countries using two partitioning methods. Scand J Clin Lab Invest 2004;64:407–30. in Google Scholar PubMed

20. Horn, PS, Pesce, AJ. Reference intervals. A user’s guide. Washington, DC: AACC Press; 2005.Search in Google Scholar

21. Sinton, TJ, Crowley, D, Bryant, SJ. Reference values for calcium, phosphate, and alkaline phosphatase as derived on the basis of multichannel-analyzer profiles. Clin Chem 1986;32:76–9.10.1093/clinchem/32.1.76Search in Google Scholar

22. Estey, MP, Cohen, AH, Colantonio, DA, Chan, MK, Marvasti, TB, Randell, E, et al.. CLSI-based transference of the CALIPER database of pediatric reference intervals from Abbott to Beckman, Ortho, Roche and Siemens clinical chemistry assays: direct validation using reference samples from the CALIPER cohort. Clin Biochem 2013;46:1197–219. in Google Scholar PubMed

23. Thierfelder, W, Dortschy, R, Hintzpeter, B, Kahl, H, Scheidt-Nave, C. Biochemical measures in the German health interview and examination survey for children and adolescents (KiGGS). Bundesgesundheitsblatt – Gesundheitsforsch – Gesundheitsschutz 2007;50:757–70. in Google Scholar PubMed

24. Ichihara, K, Ozarda, Y, Barth, JH, Klee, G, Qiu, L, Erasmus, R, et al.. A global multicenter study on reference values: 1. Assessment of methods for derivation and comparison of reference intervals. Clin Chim Acta 2017;467:70–82. in Google Scholar PubMed

25. Ichihara, K, Ozarda, Y, Barth, JH, Klee, G, Shimizu, Y, Xia, L, et al.. A global multicenter study on reference values: 2. Exploration of sources of variation across the countries. Clin Chim Acta 2017;467:83–97. in Google Scholar PubMed

26. Jia, K, Zhang, C, Huang, X, Wang, L, Hao, X, Mu, R, et al.. Reference intervals of serum sodium, potassium, and chlorine in Chinese han population and comparison of two ISE methods. J Clin Lab Anal 2015;29:226–34. in Google Scholar PubMed PubMed Central

27. Mu, R, Chen, W, Pan, B, Wang, L, Hao, X, Huang, X, et al.. First definition of reference intervals of liver function tests in China: a large-population-based multi-center study about healthy adults. PLoS One 2013;8:e72916. in Google Scholar PubMed PubMed Central

28. Jiang, ZF, Shen, KL, Shen, Y, Zhu, F. Practice of pediatrics, the eighth edition. Beijing: People’s Medical Publishing House; 2015.Search in Google Scholar

29. Ridefelt, P, Hilsted, L, Juul, A, Hellberg, D, Rustad, P. Pediatric reference intervals for general clinical chemistry components – merging of studies from Denmark and Sweden. Scand J Clin Lab Investig 2018;78:365–72. in Google Scholar PubMed

30. Southcott, EK, Kerrigan, JL, Potter, JM, Telford, RD, Waring, P, Reynolds, GJ. Establishment of pediatric reference intervals on a large cohort of healthy children. Clin Chim Acta 2010;411:1421–7. in Google Scholar PubMed

31. Chan, MK, Selden-Long, I, Aytekin, M, Quinn, F, Ravalico, T, Ambruster, D, et al.. Canadian laboratory initiative on pediatric reference interval database (CALIPER): pediatric reference intervals for all integrated clinical chemistry and immunoassay analyzer, Abbott ARCHITECT ci8200. Clin Biochem 2009;42:885–91.10.1016/j.clinbiochem.2009.01.014Search in Google Scholar PubMed

32. Oh, MS. Evaluation of renal function, water, electrolytes, and acid–base balance. In: McPherson, RA, Pincus, MR, editors. Clinical diagnosis and management by laboratory methods, 22nd ed. Philadelphia: Saunders Elsevier; 2011:174–5 pp.10.1016/B978-1-4377-0974-2.00014-2Search in Google Scholar

33. Baxmann, AC, Ahmed, MS, Marques, NC, Menon, VB, Pereira, AB, Kirsztajn, GM, et al.. Influence of muscle mass and physical activity on serum and urinary creatinine and serum cystatin C. Clin J Am Soc Nephrol 2008;3:348–54. in Google Scholar PubMed PubMed Central

34. Tate, JR, Koerbin, G, Adeli, K. Opinion paper: deriving harmonized reference intervals–global activities. EJIFCC 2016;27:48–65.Search in Google Scholar

35. Parker, ML, Adeli, K, On behalf of the CSCC Working Group on Reference Interval Harmonizationa. Pediatric and adult reference interval harmonization in Canada: an update. Clin Chem Lab Med 2018;57:57–60. in Google Scholar PubMed

36. Cho, SM, Lee, SG, Kim, SH, Kim, JH. Establishing pediatric reference intervals for 13 biochemical nalytes derived from normal subjects in a pediatric endocrinology clinic in Korea. Clin Biochem 2014;47:268–71. in Google Scholar PubMed

37. Zierk, J, Arzideh, F, Rechenauer, T, Haeckel, R, Rascher, W, Metzler, M, et al.. Age- and sex-specific dynamics in 22 hematologic and biochemical markers from birth to adolescence. Clin Chem 2015;61:964–73. in Google Scholar PubMed

38. Morkrid, L, Rowe, AD, Elgstoen, KB, Olesen, JH, Ruijter, G, Hall, PL, et al.. Continuous age- and sex-adjusted reference intervals of urinary markers for cerebral creatine deficiency syndromes: a novel approach to the definition of reference intervals. Clin Chem 2015;61:760–8. in Google Scholar PubMed

Supplementary Material

The online version of this article offers supplementary material (

Received: 2022-03-28
Accepted: 2022-07-13
Published Online: 2022-08-08
Published in Print: 2022-09-27

© 2022 Walter de Gruyter GmbH, Berlin/Boston

Downloaded on 29.11.2023 from
Scroll to top button