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Synthesis and Regulation of Thyroid Hormones01:20

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Low blood levels of the thyroid hormones — triiodothyronine (T3) and thyroxine (T4) — signal the hypothalamus to release the thyrotropin-releasing hormone (TRH). TRH then reaches the pituitary gland and stimulates the release of thyroid-stimulating hormone(TSH) into the bloodstream.
Upon reaching the thyroid gland, TSH stimulates the follicular cells' active uptake of iodide ions from the blood. The ions diffuse to the apical surface of the cells and are oxidized to iodine. The...
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TSH Receptor Antibody Test Utilization Patterns From a National Reference Laboratory: TRAb, TSI, or Both?

Heather A Nelson1, Kelly Doyle1, Joely A Straseski1

  • 1Department of Pathology, University of Utah Health, Salt Lake City, UT 84108, USA.

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|June 7, 2025
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Summary

Paired thyroid-stimulating hormone receptor (TSHR) antibody tests, TRAb and TSI, are often redundant for diagnosing hyperthyroidism. Using a single TSHR antibody test can improve diagnostic accuracy and reduce healthcare costs.

Keywords:
TRAbTSIclinical guidelinesthyroid-stimulating hormone receptor antibodiesutilization

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Area of Science:

  • Endocrinology
  • Clinical Chemistry
  • Immunodiagnostics

Background:

  • Two classes of TSHR antibody assays exist: TRAb and TSI.
  • Clinical guidelines lack specificity for TSHR autoantibody test selection in hyperthyroidism diagnosis.
  • This leads to paired testing, discordant results, and increased healthcare expenditure.

Purpose of the Study:

  • To evaluate the clinical and analytical redundancy of paired TRAb and TSI assays for diagnosing autoimmune hyperthyroidism.
  • To analyze the frequency of paired orders, assay concordance, and clinical correlation.
  • To estimate the financial impact of unnecessary paired testing.

Main Methods:

  • Analysis of over 189,000 patient encounters with TRAb and TSI bioassay (TSI-BA) or bridge immunoassay (TSI-Br) orders.
  • Assessment of paired order frequency and qualitative agreement between TRAb and TSI.
  • Chart review for clinical correlation and cost analysis of paired testing.

Main Results:

  • TRAb and TSI were co-ordered in 14.3% (TSI-BA) and 17.4% (TSI-Br) of encounters.
  • Discordance was observed in 12.5% (TSI-BA) and 6.6% (TSI-Br) of paired orders.
  • TSI assays showed better alignment with hyperthyroidism and Graves' disease diagnoses; paired testing increased costs by 31%–325%.

Conclusions:

  • Paired TRAb and TSI testing for autoimmune hyperthyroidism is largely redundant.
  • A single TSHR antibody assay is sufficient for most diagnostic scenarios.
  • Streamlining TSHR antibody testing can lead to significant healthcare cost savings.