Usage and limitations of liquid chromatography-tandem mass spectrometry (LC-MS/MS) in clinical routine laboratories

Technical maturation of liquid chromatography tandem mass spectrometry (LC-MS/MS) brought this technology into most tertiary care clinical laboratories worldwide. It extended the technological armamentarium of clinical laboratories significantly, both in analytical and economical terms. Especially in therapeutic drug monitoring, endocrinology, and toxicology, it became an indispensable routine tool. Although well-designed LC-MS/MS assays generally outperform immunoassays because of increased accuracy, sensitivity, precision, and analytical multiplexing capability, they are not free from analytical problems. Besides limitations in selectivity due to the occurrence of "isobaric" interferences, unpredictable ion yield attenuations, known as "ion suppression effect," have to be considered. In addition, most LC-MS/MS methods used in clinical laboratories are still laboratory-developed tests ("in-house assays") operating on very heterogeneous instrument configurations. Consequently, assay heterogeneity and lack of traceability to reference procedures or materials may lead to an increased imprecision in proficiency testing as well as inaccurate result reporting if basic rules of assay validation and "post marketing" surveillance are violated.