Nick
The concentrations you quote are within the acceptable range found in patients with a hip replacement, but I think the normal range you quote for chromium is very high. It does not make much difference if whole blood or plasma is measured. If your patient has a swollen/painful hip these numberrs would tend to suggest that excessive wear is not the primary issue, but there are no magic cut off limits to this, and any investigation of this must need proper imaging as well. Are there any other relevant symptoms?
There is no apparent toxic risk from the high levels of chromium and cobalt. The chromium may even be beneficial to diabetics! We have looked at cardiac function in a few patients with very high cobalt concentrations and have not seen any abnormalities. Irina Cozma presented some data at FOCUS last week suggesting that there is no effect on renal function. There have been one or two reports of otoneurotoxicity, but I am not certain that I am convinced that these are related to metal exposure.
Barry
________________________________________
From: Clinical biochemistry discussion list [[log in to unmask]] On Behalf Of Nick Miller [[log in to unmask]]
Sent: 17 May 2010 10:15
To: [log in to unmask]
Subject: Re: Cobalt and Chromium in hip replacements
I've just seen the following plasma results on a patient (from K2EDTA
vacutainers as Barry recomends)
Plasma chromium - 75.7 nmol/l (normal less than 33.4 nmol/L or 1.74 ppb)
Plasma cobalt - 94.7 nmol/l (normal less than 8.5 nmol/L or 0.5 ppb)
I know it should have been whole blood that was analysed, but this was
a co-incidental finding from a plasma element profile. The patient is
very ill with a number of problems besides a swollen hip and, it turns
out, a hip prosthesis.
OK, given that this information will find its way to the orthopaedic
surgeon, my question is - what are the immediate health effects of
having such high levels of Cr and Co in the ECF? I know that Co is a
myocardial poison (Bonenfant JL et al, Quebec beer drinkers'
cardiomyopathy Can Med Assoc J 1967 97 910-916) but what about Cr?
Aren't we missing something here? The referring doctor wants to know
if these elevated metal levels are responsible for the patient's ill
health or whether she has something else wrong with her. Has anyone
any ideas?
Nick Miller
London
[Since people have asked, Cr atomic mass is 51.9961, conversion factor
ppb to nmol/L is x 19.2, while Co atomic weight mass is 58.93332,
conversion factor ppb to nmol/L is x 17.0]
[and the beer in Quebec was not to my taste, even ignoring the high
cobalt content!]
On 13 May 2010 11:15, Sampson, Barry <[log in to unmask]> wrote:
> Sampling is no problem as long as you ensure that trace-element free tubes are used. We use K2EDTA vacutainers and analyse whole blood.
>
> Barry
>
>
> ________________________________________
> From: EDWARD KEARNEY [[log in to unmask]]
> Sent: 13 May 2010 10:33
> To: Sampson, Barry; [log in to unmask]
> Subject: Re: Cobalt and Chromium in hip replacements
>
> Dear All,
> I think the units is a minor issue. How can we get samples without contamination?
> Regards,
> Edward
>
>>>> "Sampson, Barry" <[log in to unmask]> 12/05/2010 22:42 >>>
> Dear Michael and all
> I think I can say that we are all going to keep reporting in molar units. I will put a comment on reports, and surgeons will just have to live with that.
> Barry
>
> -----Original Message-----
> From: Clinical biochemistry discussion list [mailto:[log in to unmask]] On Behalf Of Colley, Michael
> Sent: 11 May 2010 16:51
> To: [log in to unmask]
> Subject: Re: Cobalt and Chromium in hip replacements
>
> A major problem here is that the MHRA specify concentration in parts per billion but do not state whether this is a UK billion (10^12) or a US billion (10^9).
> Why can't they use nmol/L then there would be no confusion.
> Anyone have any further info and a guaranteed conversion factor?
> Michael
> Dr C M Colley
> Consultant Chemical Pathologist
> Great Western Hospital
> Swindon SN3 6BB
>
> From: Clinical biochemistry discussion list [mailto:[log in to unmask]] On Behalf Of Verrill Helen (RVW) Pathology
> Sent: 07 May 2010 17:48
> To: [log in to unmask]
> Subject: Re: Cobalt and Chromium in hip replacements
>
> Sally
>
> I've been involved with a group set up to deal with this problem. The approach in this Trust is that measurement of cobalt and chromium in blood must be done in conjunction with a clinical assessment (Harris hip score I think). We're stratifying patients according to hip score, blood analysis and imaging of the affected joint. The orthopaedic directorate here have undertaken to cover our referral costs.
>
> The MHRA alert gives a deadline of 17th June for providers of hip replacement services to have a system in place to follow up patients, there is no mention (or probably expectation) that GP's will be involved in the actual follow up. The one good thing is that the MHRA have clearly taken on board the need for quality, reliable results by their requirement that any lab providing such an analysis is part of the TEQAS scheme,
>
> helen
>
> Helen Verrill
> Consultant Clinical Scientist
> North Tees and Hartlepool NHS Foundation Trust
>
> 01642 624455
>
> Please consider resources and print this e-mail only if essential
> -----Original Message-----
> From: Clinical biochemistry discussion list [mailto:[log in to unmask]] On Behalf Of Benton Sally
> Sent: 06 May 2010 16:30
> To: [log in to unmask]
> Subject: Re: Cobalt and Chromium in hip replacements
> Dear Jessica,
> I was going to post a similar question. I had a phone call earlier from one of our GP's about the same MHRA alert. He was wondering whether this is a "screening test" they can do in the GP practices to avoid having to refer patients to orthopaedics and hence, basically, save the cost of the referral (at least that was my understanding of his question).
> I would also be interested to hear any opinions or recommendations as to what we should do with such queries.
> Thanks
>
> Sally
>
>
>
> Sally C Benton
> Consultant Biochemist
> Barts and the London NHS Trust
> Department Clinical Biochemistry
> Pathology and Pharmacy Building
> Royal London Hospital
> E1 2ES
>
> Tel: 0203 2460386
> -----Original Message-----
> From: Clinical biochemistry discussion list [mailto:[log in to unmask]] On Behalf Of Jessica Schroeder
> Sent: 06 May 2010 16:22
> To: [log in to unmask]
> Subject: Cobalt and Chromium in hip replacements
>
> Following the MHRA Medical Device Alert on all metal-on-metal hip replacements, we have been contacted by one of our Orthopaedic consultants enquiring about measuring blood cobalt and chromium levels.
>
> I would be interested to know:
> Are other labs taking on this service? Has it been funded?
> What labs can do the analysis and what are the sample requirements /costs?
>
> Regards
>
> Jessica Schroeder
>
> Jessica Schroeder
> Principal Biochemist
> Royal Cornwall Hospital
> Truro
>
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