INTERNAL POLICY AND PROCEDURE

IPP

DEPARTMENT
LABORATORY AND BLOOD BANK

TITLE/DESCRIPTION POLICY NUMBER

)CREATINE KINASE(
EFFECTIVE DATE REVIEW DUE REPLACES NUMBER NO. OF PAGES
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APPROVED BY APPLIES TO
HOSPITAL DIRECTOR ALL CHEMISTRY SECTION STAFF

:INTENDED USE .1
In vitro test for the quantitative determination of creatine kinase (CK) in human serum and plasma on cobas
.integra 400 plus
:CLINICAL SIGNIFICANCE .2
The CK enzyme is a dimer composed of subunits derived from either muscle (M) or brain (B). Three isoenzymes
have been identified: MM, MB, and BB. Normal serum CK is predominantly the CK-MM isoenzyme. Elevated
CK-serum levels are found in skeletal muscle disease, particularly muscular dystrophy. The CK-MB fraction is
found primarily in myocardial tissue and its presence is generally detected within the 48-hour period following
the onset of a myocardial infarction. The use of total CK and CK-MB in the diagnosis of myocardial infarction is
the most important single application of CK measurement in clinical chemistry. Serum CK activity is also
increased after cerebral ischemia, acute cerebrovascular disease, and head injury. Standardized methods for the
determination of CK using the “reverse reaction” and activation by NAC were recommended by the German
Society for Clinical Chemistry (DGKC) and the International Federation of Clinical Chemistry (IFCC) in 1977

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.and 1989 respectively
This assay follows the recommendations of the IFCC and DGKC, but was optimized for performance and
.stability
:TEST PRINCIPLE .3
UV-test
)Creatine phosphate + ADP( CK ) →creatine + ATP
ATP + D-glucose (HK ) → ADP + G6P
+G6P + NADP+ (G6PDH ) → D-6-phosphogluconate + NADPH + H
The rate of the NADPH formation is directly proportional to the catalytic CK activity. It is determined by
measuring the increase in absorbance. Equimolar quantities of NADPH and ATP are formed at the same rate. The
photometrically measured rate of formation of NADPH is directly proportional to the CK activity
:REAGENTS &WORKING SOLUTIONS .4
R1 Imidazole: 58.0 mmol/L, pH 6.00; N-acetylcysteine: 40.0 mmol/L; EDTA: 3.00 mmol/L; AMP: 10.0 mmol/L;
diadenosine pentaphosphate: 24.0 μmol/L; NADP+: 9.5 mmol/L; Mg2+: 20.0 mmol/L; D-glucose: 40.0 mmol/L;
preservative; stabilizer
R2 EDTA: 3.00 mmol/L, pH 9.1; HK (yeast): ≥600 μkat/L; G6PDH (microbial): ≥600 μkat/L; ADP: 12.0
mmol/L; creatine phosphate: 180 mmol/L; N-methyldiethanolamine: 69.0 mmol/L; preservative; stabilizer;
detergent
:Storage and stability
Shelf life at 2-8°C: See expiration date. On-board in use and refrigerated on the analyzer: 8 weeks
:SPECIMEN COLLECTION AND PREPARATION .5
.Only the specimens listed below were tested and found acceptable
.Serum (free from hemolysis):Nonhemolyzed serum is the specimen of choice and also recommended by IFCC
Plasma (free from hemolysis): Li-heparin plasma
.Centrifuge samples containing precipitates before performing the assay .
:Stability
days at 15-25°C 7 days at 2-8°C 4 weeks at (-15)-(-25)°C 2

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6. ASSAY:
For optimum performance of the assay, follow the directions given in this document for the analyzer concerned.
Refer to the appropriate operator manual for analyzer-specific assay instructions. The performance of applications
.not validated by Roche is not warranted and must be defined by the user
Application for serum and plasma
:Test definition
Assay type Rate A
Reaction time / Assay points 10 / 14-28
Wavelength (sub/main) 546/340 nm
Reaction direction Increase
Units U/L
Reagent pipetting Diluent (H2O)
R1 61 μL 38 μL
– R2 20 μL
Sample volumes Sample Sample dilution
Sample Diluent (NaCl)
– – Normal 3 μL
Decreased 3 μL 15 μL 135 μL
– – Increased 6 μL
:CALIBRATION .7
Calibrators S1: H2O
.S2: C.f.a.s
Calibration mode Linear
Calibration frequency 2-point calibration
after reagent lot change -
and as required following quality control procedures -
Traceability: This method has been standardized against the original IFCC formulation using calibrated pipettes
.together with a manual photometer providing absolute values and the substrate-specific absorptivity

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:QUALITY CONTROL .8
The control intervals and limits should be adapted to each laboratory’s individual requirements. Values obtained
should fall within the defined limits. Each laboratory should establish corrective measures to be taken if values
.fall outside the limits
:CALCULATION .9
.cobas systems automatically calculate the analyte activity of each sample
Conversion factor: U/L x 0.0167 = μkat/L
:INTERFERENCES .10
. Criterion: Recovery within ±10% of initial value at a creatine kinase activity of 140 U/L
Icterus: No significant interference up to an I index of 60 (approximate conjugated and unconjugated bilirubin
.concentration: 1026 μmol/L
Hemolysis: No significant interference up to an H index of 200 (approximate hemoglobin concentration: 124
μmol/L. Contamination with erythrocytes will elevate results, because the analyte level in erythrocytes is higher
than in normal sera. The level of interference may be variable depending on the content of analyte in the lysed
.erythrocytes
Lipemia (Intralipid): No significant interference up to an L index of 1000. There is poor correlation between the
L index (corresponds to turbidity) and triglycerides concentration. Highly lipemic specimens (L index >1000)
.may cause high absorbance flagging. Choose diluted sample treatment for automatic rerun
Drugs: No interference was found using common drug panels. In very rare cases gammopathy, in particular type
.IgM (Waldenström’s macroglobulinemia), may cause unreliable results
:EXPECTED VALUES .11
.Reference intervals strongly depend on the patient group regarded and the specific clinical situation
:.For healthy people, according to Klein et al
Males 39-308 U/L
Females 26-192 U/L
For myocardial infarction diagnosis using the combination CK and CK-MB (activity), and representing a CK
:consensus value based on long-term experience

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CK men >190 U/L .1
CK women >167 U/L
CK-MB >24 U/L .2
.The CK-MB activity accounts for 6-25% of the total CK activity .3
:For hospitalized patients, according to Tietz
Males 38-174 U/L
Females 26-140 U/L
The reference values according to Klein et al. are based on the 95th percentile of a group of healthy
persons (202 men and 217 women) not involved in high-intensity athletic activities. In order to ensure high
..sensitivity in the diagnosis of heart diseases
The loss of diagnostic specificity thereby incurred can be compensated for by additionally determining
CK-MB and/or troponin T. When myocardial infarction is suspected the diagnostic strategy proposals in the
.consensus document of European and American cardiologists should in general be followed
If despite the suspicion of myocardial infarction the values found remain below the stated limits, a fresh
.infarction may be involved. In such cases, the determinations should be repeated after 4 hours
CK varies with physical activity level and race in healthy individuals. Each laboratory should investigate
the transferability of the expected values to its own patient population and if necessary determine its own
.reference ranges
:PRECISION .12
Reproducibility was determined using human samples and controls in an internal protocol (within-run n = 21,
:total n = 63). The following results were obtained
% Within-run Mean U/L SD U/L CV
Precinorm U 174 1.0 0.5
Precipath U 390 2.0 0.5
Human serum 1 49.1 1.1 2.3
Human serum 2 702 5.0 0.7
% Total Mean U/L SD U/L CV
Precinorm U 164 3.0 1.8

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Precipath U 350 6.0 1.8
Human serum 3 90.3 3.0 3.3
Human serum 4 309 8.0 2.5
Measuring range: 7-2000 U/L
Determine samples having higher activities via the rerun function. Dilution of samples via the rerun functions is a
.1:10 dilution. Results from samples diluted by the rerun function are automatically multiplied by a factor of 10
Lower detection limit 7 U/L
The lower detection limit represents the lowest measurable analyte level that can be distinguished from zero. It is
calculated as the value lying three standard deviations above that of the lowest standard (standard 1 + 3 SD,
.within-run precision, n = 21)
13. REFERENCES :
Reference Procedure for the Measurement of Catalytic Concentration of Creatine Kinase. Clin Chem Lab Med .1
.2002; 40(6):635-642
Breuer J Report on the Symposium “Drug Effects in Clinical Chemistry Methods”. Eur J Clin Chem Clin .2
.Biochem 1996;34:385-386
Klein G, Berger A, Bertholf R et al. Abstract: Multicenter Evaluation of Liquid Reagents for CK, CK-MB and .3
.LDH with Determination of Reference Intervals on Hitachi Systems. Clin Chem 2001;47:Suppl. A30
.Zawta B, Klein G, Bablok W. Temperature Conversion in Clinical Enzymology? Klin lab 1994;40:33-42 .4
.Tietz NW. Clinical Guide to Laboratory Tests, 3rd edition. Philadelphia, PA: WB Saunders Co, 1995:180-181 .5
Myocardial Infarction Redefined - A Consensus Document of the Joint European Society of .6
Cardiology/American College of Cardiology Committee for the Redefinition of Myocardial Infarction. Eur Heart
.J 2000;21:1502-1513

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14.APPROVAL PAGE:

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PREPARED /Dr LAB. CONSULTANT

BY

/ .Mr LAB. DIRECTOR

REVIEWED
/Dr TQM DIRECTOR

BY

APPROVED /.Mr HOSPITAL DIRECTOR

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