The influence of sampling time on indirect reference limits, decision limits, and the estimation of biological variation of random plasma glucose concentrations

Abstract

Plasma glucose concentrations exhibit a pronounced daytime-dependent variation. The oscillations responsible for this are currently not considered in the determination of reference limits (RL) and decision limits. We characterized the daily variation inherent in large-scale laboratory data from two different university hospitals (site 1 n=513,682, site 2 n=204,001). Continuous and distinct RL for daytime and night were estimated. Diurnal characteristics of glucose concentrations were further investigated by quantile regression analyses introducing age and cosinor-functions as predictors in the model. Diurnal variations expressed as amplitude/Midline Estimating Statistic of Rhythm (MESOR) ratio, averaged 7.7% (range 5.9-9.3%). The amplitude of glucose levels decreased with increasing concentrations. Between 06:00 and 10:00 h an average decrease of 4% has to be considered. Nocturnal glucose samples accounted for only 5% of the total amount but contributed to 19.5% of all findings over 11.1 mmol/L. Partitioning of RL between day and night is merely justified for the upper reference limit. The nocturnal upper RLs for both genders differed from those obtained during the day by 11.0 and 10.6% at site 1 and by 7.6 and 7.5% at site 2. We conclude that indirect approaches to estimate upper RL of random plasma glucose concentrations require stratification concerning the time of sample collection.