"Direct" and total bilirubin tests: contemporary problems

In eight unique challenges mailed by The College of American Pathologists Comprehensive Chemistry Survey to participating laboratories within 3 years, results for direct-reacting bilirubin (DBIL) were highly variable among the 12 largest peer groups, and most of the results differed greatly from the values obtained by a referred method. Peer-group mean values for total bilirubin (TBIL) were in much better agreement with each other and with those obtained by the Reference Method for TBIL. From a review of the information on the assay of DBIL provided to us by the manufacturers, we conclude that among the major causes of the large variability and bias in DBIL assays are problems with calibration, lack of a serum blank measurement, inadequate concentrations of HCl in the reaction mixture, inappropriate use of bichromatic correction methods, and possibly the use of wetting agents or surfactants in the reagent. Within-group SDs were small and generally acceptable. The among-peer-group variability in DBIL values is attributable to bias, not imprecision. We recommend several simple changes that could improve the accuracy of DBIL determinations in clinical laboratories.