National Health and Nutrition Examination Survey

This battery of measurements are used in the diagnosis and treatment of certain liver, heart, and kidney diseases, acid-base imbalance in the respiratory and metabolic systems, other diseases involving lipid metabolism and various endocrine disorders as well as other metabolic or nutritional disorders.

1. Alanine Aminotransferase (ALT)
Alanine aminotransferase measurements are used in the diagnosis and treatment of certain liver diseases (e.g., viral hepatitis and cirrhosis) and heart diseases. Elevated levels of the transaminases can indicate myocardial infarction, hepatic disease, muscular dystrophy, or organ damage. Serum elevations of ALT activity are rarely observed except in parenchymal liver disease, since ALT is a more liver-specific enzyme than aspartate aminotransferase (AST).

2. Albumin
Albumin measurements are used in the diagnosis and treatment of diseases involving the liver and/or kidneys and are frequently used to assess nutritional status because plasma levels of albumin are dependent on protein intake.

3. Alkaline Phosphatase
Alkaline phosphatase measurements are used in the diagnosis and treatment of liver, bone, and parathyroid disease.

4. Aspartate Aminotransferase (AST)
AST measurements are used in the diagnosis and treatment of certain types of liver and heart disease. Elevated levels of the transaminases can signal myocardial infarction, hepatic disease, muscular dystrophy, or organ damage.

5. Bicarbonate (HCO₃)
Together with pH determination, bicarbonate measurements are used in the diagnosis and treatment of numerous potentially serious disorders associated with acid-base imbalance in the respiratory and metabolic systems.

6. Blood Urea Nitrogen (BUN)
BUN measurements are used in the diagnosis of certain renal and metabolic diseases. The determination of serum urea nitrogen is the most widely used test for the evaluation of kidney function. The test is frequently requested in conjunction with the serum creatinine test for the differential diagnosis of prerenal, renal, and postrenal uremia. High BUN levels are associated with impaired renal function, increased protein catabolism, nephritis, intestinal obstruction, urinary obstruction, metallic poisoning, cardiac failure, peritonitis, dehydration, malignancy, pneumonia, surgical shock, Addison's disease, and uremia. Low BUN levels are associated with amyloidosis, acute liver disease, pregnancy, and nephrosis. Normal variations are observed according to a person's age and sex, the time of day, and diet, particularly protein intake.

7. Calcium
Calcium measurements are used in the diagnosis and treatment of parathyroid disease, bone diseases, chronic renal disease and tetany. Urinary calcium measurement is used in the differential diagnosis of hypercaluria.

8. Cholesterol
An elevated cholesterol level is associated with diabetes, nephrosis, hypothyroidism, biliary obstruction, and those rare cases of idiopathic hypercholesterolemia and hyperlipidemia; low levels are associated with hyperthyroidism, hepatitis, and sometimes severe anemia or infection.

9. Creatine phosphokinase
Measurements of creatine kinase are used in the diagnosis and treatment of myocardial infarction, skeletal muscle diseases, and diseases of the central nervous system.

10. Creatinine
Creatinine measurements are useful in the diagnosis and treatment of renal diseases.

11. Gammaglutamyl Transaminase (GGT)
GT measurement is principally used to diagnose and monitor hepatobiliary disease. It is currently the most sensitive enzymatic indicator of liver disease, with normal values rarely found in the presence of hepatic disease. It is also used as a sensitive screening test for occult alcoholism. Elevated levels are found in patients who chronically take drugs such as phenobarbital and phenytoin.

12. Glucose
Glucose measurements are used in the diagnosis and treatment of pancreatic islet cell carcinoma and of carbohydrate metabolism disorders, including diabetes mellitus, neonatal hypoglycemia, and idiopathic hypoglycemia.

13. Iron
Iron (non-heme) measurements are used in the diagnosis and treatment of diseases such as iron deficiency anemia, chronic renal disease, and hemochromatosis (a disease associated with widespread deposit in the tissues of two iron-containing pigments, hemosiderin and hemofuscin, and characterized by pigmentation of the skin).

14. Lactate Dehydrogenase (LDH)
LDH measurements are used in the diagnosis and treatment of liver diseases such as acute viral hepatitis, cirrhosis, and metastatic carcinoma of the liver; cardiac diseases such as myocardial infarction; and tumors of the lungs or kidneys.

15. Phosphorus
There is a reciprocal relationship between serum calcium and inorganic phosphorus. Any increase in the level of inorganic phosphorus causes a decrease in the calcium level by a mechanism not clearly understood. Hyperphosphatemia is associated with vitamin D hypervitaminosis, hypoparathyroidism, and renal failure. Hypophosphatemia is associated with rickets, hyperparathyroidism, and Fanconi syndrome.

Measurements of inorganic phosphorus are used in the diagnosis and treatment of various disorders, including parathyroid gland, kidney diseases, and vitamin D imbalance.

16-18. Potassium, Chloride, and Sodium
Hypokalemia (low serum potassium level) is associated with body potassium deficiency, excessive potassium loss caused by prolonged diarrhea or prolonged periods of vomiting and increased secretion of mineralocorticosteroids. Hyperkalemia (increased serum potassium level) is associated with oliguria, anuria, and urinary obstruction.

Low serum chloride values are associated with salt-losing nephritis; Addisonian crisis, prolonged vomiting, and metabolic acidosis caused by excessive production or diminished excretion of acids. High serum chloride values are associated with dehydration and conditions causing decreased renal blood flow, such as congestive heart failure.

Sodium measurements are used in the diagnosis and treatment of diseases involving electrolyte imbalance.

19. Total Bilirubin
Elevated levels are associated with hemolytic jaundice, paroxysmal hemoglobinuria, pernicious anemia, polycythemia, icterus neonatorum, internal hemorrhage, acute hemolytic anemia, malaria, and septicemia.

Low bilirubin levels are associated with aplastic anemia, and certain types of secondary anemia resulting from toxic therapy for carcinoma and chronic nephritis.

20. Total Protein
Total protein measurements are used in the diagnosis and treatment of a variety of diseases involving the liver, kidney, or bone marrow, as well as other metabolic or nutritional disorders.

21. Triglycerides
Triglyceride measurements are used in the diagnosis of diabetes mellitus, nephrosis, liver obstruction, and other diseases involving lipid metabolism and various endocrine disorders and in the treatment of patients with these diseases.

22. Uric Acid
Uric acid measurements are used in the diagnosis and treatment of numerous renal and metabolic disorders, including renal failure, gout, leukemia, psoriasis, starvation, or other wasting conditions and in the treatment of patients receiving cytotoxic drugs.

Participants aged 12 years and older are tested.

Serum specimens are processed, stored, and shipped to the Collaborative Laboratory Services for analysis.

Detailed specimen collection and processing instructions are discussed in the NHANES Laboratory/Medical Technologists Procedures Manual (LPM). Vials are stored under appropriate frozen (–30°C) conditions until they are shipped to National Center for Environmental Health for testing.

The 21 analytes described in these methods constitute the routine biochemistry profile. Each analyte is described separately within each pertinent section of this document.

NOTE: Glucose, cholesterol, and triglycerides were analyzed as part of this profile, but the results do not replace the formalized reference methods data from NHANES 2009-2010 samples analyzed at other institutions.

1. Alanine Aminotransferase (ALT)
The DxC800 uses a kinetic rate method to measure ALT activity in serum or plasma.  In the reaction, ALT catalyzes the reversible transamination of L-alanine and a-ketoglutarate to pyruvate and L-glutamate.  The pyruvate is then reduced to lactate in the presence of lactate dehydrogenase (LDH) with the concurrent oxidation of NADH to NAD.  The system monitors the rate of change in absorbance at 340 nm over a fixed-time interval.  The rate of change in absorbance is directly proportional to the ALT activity in the sample.

2. Albumin
The DcX800 method is used to measure the albumin concentration as a bichromatic digital endpoint method. In the reaction, the albumin combines with Bromcresol Purple (BCP) reagent to form a complex. The system monitors the change in absorbance at 600 nm. The change in absorbance is directly proportional to the concentration of albumin in the sample.

3. Aspartate Aminotransferase (AST)
The DxC800 uses an enzymatic rate method to measure the AST activity in serum or plasma.  In the reaction, the AST catalyzes the reversible transamination of L-aspartate and a-ketoglutarate to oxaloacetate and L-glutamate.  The oxaloacetate is then reduced to malate in the presence of malate dehydrogenase with the concurrent oxidation of NADH to NAD.  The system monitors the rate of change in absorbance at 340 nm over a fixed-time interval.  The rate of change in absorbance is directly proportional to the AST activity in the sample.

4. Alkaline Phosphatase
The DxC800 system uses a kinetic rate method using a 2-Amino-2-Methyl-1-Propanol (AMP) buffer to measure ALP activity in serum or plasma. In the reaction, the ALP catalyzes the hydrolysis of the colorless organic phosphate ester substrate, p-Nitrophenylphosphate, to the yellow colored product p-Nitrophenol and phosphate. This reaction occurs at an alkaline pH of 10.3. The system monitors the rate of change in absorbance at 410 nm over a fixed-time interval. This rate of change in absorbance is directly proportional to the ALP activity in the serum.

5. Bicarbonate (HCO₃)
The DxC800 system uses indirect (or diluted) I.S.E. (ion selective electrode) methodology to measure the total CO₂ level in serum, plasma or urine.  The system measures the rate of pH change as CO₂ ions diffuse across a membrane.  The electrode used for CO₂ determination is actually a pH electrode with the tip covered by a silicone rubber membrane and lowers the pH of a bicarbonate solution between the tip of the membrane and the tip of the pH electrode.  The rate of pH change is directly proportional to the carbon dioxide (CO₂) in the sample.

6. Blood Urea Nitrogen (BUN)
The DxC800 modular chemistry (BUN) is used to quantitatively determine the concentration of blood urea nitrogen in serum or plasma by means of the enzymatic conductivity rate method.  A precise volume of sample is injected into the urease reagent in a reaction cup containing an electrode that responds to changes in solution conductivity.  Electronic circuits determine the rate of increase in conductivity, which is directly proportional to the concentration of urea in the sample.

7. Calcium
The DxC800 system uses indirect (or diluted) I.S.E. (ion selective electrode) methodology to measure calcium concentration in serum, plasma, or urine. A calcium ion selective electrode measures un-bound free calcium ions in solution. The system determines calcium concentration by measuring calcium ion activity in solution. When the sample buffer mixture contacts the electrode, calcium ions complex with the ionophore at the electrode surface. Changes in potential develop at the electrode surface as the reaction occurs. These changes in potential are referenced to a sodium reference electrode. The reference signal is used in calculating the analyte concentrations based on the Nernst equation.

8. Cholesterol
The DxC800 uses the timed-endpoint method to measure the cholesterol concentration in serum or plasma.  In the reaction, the cholesterol esterase hydrolyzes cholesterol esters to free cholesterol and fatty acids.  The free cholesterol is oxidized to cholesten-3-one and hydrogen peroxide by cholesterol oxidase.  Peroxidase catalyzes the reaction of hydrogen peroxide with 4-aminoantipyrine and phenol to produce a colored quinoneimine product.  The system monitors the change in absorbance at 520 nm at a fixed-time interval.  The change in absorbance is directly proportional to the concentration of cholesterol in the sample.

9. Creatinine
The DxC800 modular chemistry side uses the Jaffe rate method (kinetic alkaline picrate) to determine the concentration of creatinine in serum, plasma, or urine. The creatinine calibration is traceable to an isotope dilution mass spectrometry (IDMS) reference method. The method on the DxC800 is IDMS Standardized. A precise volume of sample is introduced into a reaction cup containing an alkaline picrate solution. Absorbance readings are taken at 520 nm between 19 and 25 seconds after sample injection. Creatinine from the sample combines with the reagent to produce a red color complex. The absorbance rate has been shown to be a direct measure of the concentration of the creatinine in the sample.

10. Creatine phosphokinase
The DxC800 use an enzymatic rate method to determine CK activity in serum or plasma. In the reaction, the CK catalyzes the transfer of a phosphate group from the creatine phosphate substrate to adenosine diphosphate (ADP). The subsequent formation of adenosine triphosphate (ATP) is measured through the use of two coupled reactions catalyzed by hexokinase (HK) and glucose-6-phosphate dehydrogenase (G6PD) which results in the production of ß Nicotinamide Adenine Dinucleotide (reduced form) (NADH) from ß Nicotinamide Adenine Dinucleotide (NAD). The system monitors the rate of change in absorbance at 340 nm over a fixed time interval. The rate of change in absorbance is directly proportional to the activity of CK in the sample.

11. Gammaglutamyl Transaminase (GGT)
The DxC800 uses an enzymatic rate method to determine the GGT activity in serum or plasma.  In the reaction, the GGT catalyzes the transfer of a gamma-glutamyl group from the colorless substrate, gamma-glutamyl-p-nitroaniline, to the acceptor, glycylglycine with production of the colored product, p-nitroaniline.  The system monitors the rate of change in absorbance at 410 nm over a fixed-time interval.  The rate of change in absorbance is directly proportional to the activity of GGT in the sample.

12. Glucose
On the Modular Chemistry side of the DxC800, glucose concentration in biologic fluids is determined by the oxygen rate method employing a Beckman Oxygen electrode (glucose oxidase method).  A precise volume of sample is introduced in a reaction cup containing an electrode that responds to oxygen concentration.  Electronic circuits determine the rate of oxygen consumption, which is directly proportional to the concentration of glucose in the sample.

13. Iron
The DcX800 method used to measure the iron concentration is a timed-endpoint method.  In the reaction, iron is released from transferrin by acetic acid and is reduced to the ferrous state by hydroxylamine and thioglycolate.  The ferrous ion is immediately complexed with the FerroZine Iron Reagent.  The system monitors the change in absorbance at 560 nm at a fixed-time interval.  This change in absorbance is directly proportional to the concentration of iron in the sample.

14. Lactate Dehydrogenase (LDH)
The DxC800 with LD reagent (using lactate as substrate) utilizes an enzymatic rate method to measure LD activity in biological fluids. In the reaction, the LD catalyzes the reversible oxidation of L Lactate to Pyruvate with the concurrent reduction of ß Nicotinamide Adenine Dinucleotide (NAD) to ß Nicotinamide Adenine Dinucleotide (reduced form) (NADH). The system monitors the rate of change in absorbance at 340 nm over a fixed-time interval. The rate of change in absorbance is directly proportional to the activity of LD in the sample.

15. Phosphorus
The DxC800 system uses a timed-rate method to determine the concentration of phosphorus in serum, plasma and urine.  In the reaction, inorganic phosphorus reacts with ammonium molybdate in an acidic solution to form a colored phosphomolybdate complex.  The system monitors the change in absorbance at 365 nm at a fixed-time interval.  This change in absorbance is directly proportional to the concentration of phosphorus in the sample.

16.-18. Potassium, Chloride, Sodium
Potassium ion concentration is measured by electrolyte activity in solution. The DxC800 system uses indirect (or diluted) I.S.E. (ion selective electrode) methodology to measure potassium in biological fluids. The potassium electrode consists of valinomycin membrane. The voltage (potential) change that takes place within the membrane follows the Nernst equation and allows the calculation of potassium concentration in solution.

Chloride is measured using an Ag/AgCl electrode. At the face of the electrode, solid AgCl dissolves to the extent as to saturate the solution around the tip with silver (Ag⁺) and Chloride (Cl^-) ions until equilibrium is established. The product of the ion concentrations in solution, at equilibrium, with an excess of the slightly soluble AgCl is defined as the solubility product constant (Ksp). When chloride sample is added, the Ksp of the solution at the tip is disrupted as AgCl precipitates out of solution. To reestablish the equilibrium, Ag⁺ ions are generated from the tip causing a change in the potential. According to the Nernst equation, this change is proportional to the concentration of chloride in the sample.

Sodium is measured by the DxC800 system by utilizing indirect (or diluted) I.S.E. (ion selective electrode) methodology. The DxC800 determines sodium ion concentration in biological fluids by measuring electrolyte activity in solution. When the sample/buffer mixture contacts the electrode, sodium ions undergo an ion exchange in the hydrated outer layer of the glass electrode. As the ion exchange takes place, a change in voltage (potential) is developed at the face of the electrode. The potential follows the Nernst equation and allows the calculation of sodium concentration in a solution.

19. Total Bilirubin
The DxC800 uses a timed-endpoint Diazo method (Jendrassik-Grof) to measure the concentration of total bilirubin in serum or plasma. In the reaction, bilirubin reacts with diazo reagent in the presence of caffeine, benzoate, and acetate as accelerators to form azobilirubin. The system monitors the change in absorbance at 520 nm at a fixed-time interval. This change in absorbance is directly proportional to the concentration of total bilirubin in the sample.

20. Total Protein
The DxC800 uses a timed rate biuret method to measure the concentration of total protein in serum or plasma. Proteins in the sample combine with the reagent producing alkaline copper-protein chelate. The rate change in absorbance is monitored by a detector at 545 nm. The observed rate of chelate formation is directly proportional to the total protein concentration in the sample.

21. Triglycerides
The DxC800 uses a timed-endpoint method to determine the concentration of triglycerides in serum or plasma. Triglycerides in the sample are hydrolyzed to glycerol and free fatty acids by the action of lipase. A sequence of three coupled enzymatic steps using glycerol kinase (GK), glycerophosphate oxidase (GPO), and horseradish peroxidase (HPO) causes the oxidative coupling of 3,5-dichloro-2-hydroxybenzenesulfonic acid (DHBS) with 4-aminoantipyrine to form a red quinoneimine dye. The system monitors the change in absorbance at 520 nm for a fixed-time interval. The change in absorbance is directly proportional to the concentration of triglycerides in the sample.   

22. Uric Acid
The DxC800 uses a timed endpoint method to measure the concentration of uric acid in serum, plasma or urine. Uric acid is oxidized by uricase to produce allatoin and hydrogen peroxide. The hydrogen peroxide reacts with 4-aminoantipyrine (4-AAP) and 3, 5-dichloro-2-hydroxybenzene sulfonate (DCHBS) in a reaction catalyzed by peroxidase to produce a colored product. The system monitors the change in absorbance at 520 nm at a fixed time interval. The change in absorbance is directly proportional to the concentration of uric acid in the sample.

The analytical methods are described in the Description of Laboratory Methodology section above.

Many variables were created in this data file. The formula for their creation is as follows:

LBXSAL and LBDSALSI
The albumin in g/dL (LBXSAL) was converted to g/L (LBDSALSI) by multiplying by 10.

LBXSBU and LBDSBUSI
The blood urea nitrogen (BUN) in mg/dL (LBXSBU) was converted to mmol/L (LBDSBUSI) by multiplying by 0.357

LBXSCA and LBDSCASI  
The calcium in mg/dL (LBXSCA) was converted to mmol/L (LBDSCASI) by multiplying by 0.250

LBXSCH and LBDSCHSI  
The cholesterol in mg/dL (LBXSCH) was converted to mmol/L (LBDSCHSI) by multiplying by 0.02586.

LBXSCR and LBDSCRSI  
The creatinine in mg/dL (LBXSCR) was converted to µmol/L (LBDSCRSI) by multiplying by 88.4.

LBXSGL and LBDSGLSI  
The glucose in mg/dL (LBXSGL) was converted to mmol/L (LBDSGLSI) by multiplying by 0.05551.

LBXSIR and LBDSIRSI
The iron in µg/dL (LBXSIR) was converted to µmol/L (LBDSIRSI) by multiplying by 0.1791.

LBXSPH and LBDSPHSI  
The phosphorus in mg/dL (LBXSPH) was converted to mmol/L (LBDSPHSI) by multiplying by 0.3229.

LBXSTB and LBDSTBSI  
The total bilirubin in mg/dL (LBXSTB) was converted to µmol/L (LBDSTBSI) by multiplying by 17.1.

LBXSTP and LBDSTPSI  
The total protein in g/dL (LBXSTP) was converted to g/L (LBDSTPSI) by multiplying by 10.

LBXSTR and LBDSTRSI
The triglycerides in mg/dL (LBXSTR) were converted to mmol/L (LBDSTRSI) by multiplying by 0.01129.

LBXSTR and LBDSTRSI  
The uric acid in mg/dL (LBXSUA) was converted to µmol/L (LBDSUASI) by multiplying by 59.48.

LBXSGB and LBDSGBSI  
The globulin in g/dL (LBXSGB) was converted to g/L (LBDSGBSI) by multiplying by 10.

The NHANES quality control and quality assurance protocols (QA/QC) meet the 1988 Clinical Laboratory Improvement Act mandates. Detailed QA/QC instructions are discussed in the NHANES Laboratory/Medical Technologists Procedures Manual (LPM).

Refer to the 2011-2012 Laboratory Data Overview for general information on NHANES laboratory data.

The analysis of NHANES 2011-2012 laboratory data must be conducted using the appropriate survey design and demographic variables. The NHANES 2011-2012 Demographics File contains demographic data, health indicators, and other related information collected during household interviews as well as the sample weight variables. The Fasting Questionnaire File includes auxiliary information such as fasting status, the time of venipuncture, and the conditions precluding venipuncture. The demographics and fasting questionnaire files may be linked to the laboratory data file using the unique survey participant identifier (i.e., SEQN).

LBXSTR: Triglycerides
This value was obtained from the standard battery of biochemical assessments. Use of the laboratory test result from the reference method (LBXTR), rather than the (LBXSTR) value, is generally recommended. For most triglyceride analyses, the appropriate variable to use is (LBXTR). The value from the biochemistry profile (LBXSTR) should not be used routinely.

LBXSCH: Total Cholesterol
This value was obtained from the standard battery of biochemical assessments. Use of the laboratory test result from the reference method (LBXTC), rather than the (LBXSCH) value, is generally recommended. For most analyses of serum cholesterol, the appropriate variable to use will be (LBXTC). The (LBXSCH) value from the biochemistry profile should not be used routinely

LBXSGL: Glucose  
This value was obtained from the standard battery of biochemical assessments. Use of the laboratory test result from the reference method (LBXGLU), rather than the (LBXSGL) value, is generally recommended. These serum glucose values (LBXSGL) reported in this release should not be used to determine undiagnosed diabetes or prediabetes. Instead, plasma glucose values (LBXGLU) should be used based on the reference analytic method of this analyte. Use the special weights included in this glucose data file when analyzing data.

Exam sample weights should be used for analyses. Please refer to the NHANES Analytic Guidelines and the on-line NHANES Tutorial  for further details on the use of sample weights and other analytic issues.