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All of these options:
-decreased renal clearance caused by kidney disease
-discontinuance or administration of another drug
-altered serum protein binding caused by disease
Therapeutic drug monitoring is necessary for drugs that have a narrow therapeutic index. Individual differences alter pharmacokinetics, causing lack of correlation between dose and drug blood level. These include age, diet, ingestion with or without food, genetic factors, exercise, smoking, pregnancy, metabolism of other drugs, protein binding, and disease states.
Creatinine 5 mg/dL
Approximately 5 per 1,000 urine samples received for DAU testing have been adulterated by either dilution, substitution, or addition of substances such as glutaraldehyde that interfere with testing. The majority of these situations can be detected by determining temperature (90°F-100°F) pH (4.5-8.0), specific gravity (1.003-1.019), and creatinine (≥20 mg/dL). All of the values listed are within the limits of an acceptable sample with the exception of creatinine. Dry reagent strips are available that test for pH, specific gravity, creatinine, nitrite, peroxide, pyridinium, and glutaraldehyde.
Whole blood
Lead accumulates in RBCs, bones, and neural tissues, and whole blood, hair, and urine are suitable for demonstrating lead toxicity. Greatest sensitivity is obtained by using whole blood, which can detect exposure over time. Because lead is rapidly eliminated from plasma, serum or plasma should not be used to test for lead exposure. Lead binds to sulfhydryl groups of proteins such as delta-aminolevulinic acid (∆-ALA) dehydratase and ferrochelatase and interferes with heme synthesis. This results in increased free erythrocyte protoporphyrin, erythrocyte zinc protoporphyrin, urinary coproporphyrin III, and δ aminolevulinic acid, which are also useful markers for lead poisoning. When screening for lead poisoning in children, the method of choice is graphite furnace atomic absorption spectrophotometry or inductively coupled plasma mass spectroscopy because they offer the best analytical sensitivity. The CDC cutoff for normal lead in children is less than 5.0 μg/dL.