title: Falsely increased immunoassay measurements of total and unbound phenytoin in critically ill uremic patients receiving fosphenytoin.
abstract: BACKGROUND
  Fosphenytoin, a phosphate ester prodrug of phenytoin, is metabolized to phenytoin in vivo. Phenytoin metabolites accumulate in renal insufficiency and cross-react in some phenytoin immunoassays. Our aim was to determine the accuracy of phenytoin immunoassays in renal patients treated with fosphenytoin.
  
  
  METHODS
  We measured phenytoin with HPLC and with the aca, ACS:180, TDx phenytoin II, Vitros, and AxSYM methods. Specimens were collected 2-120 h after fosphenytoin administration from 17 patients with renal insufficiency.
  
  
  RESULTS
  The AxSYM, TDx phenytoin II, ACS:180, and Vitros assays displayed falsely increased phenytoin results up to 20 times higher than the HPLC results. The aca Star results for these specimens were comparable to the HPLC results. Although fosphenytoin can cross-react with phenytoin immunoassays, no fosphenytoin was detected by a sensitive HPLC method in any sample that was tested for its presence.
  
  
  CONCLUSIONS
  These results are consistent with the formation of one or more novel metabolites or adducts of fosphenytoin that accumulate in some critically ill patients with renal insufficiency and that display significant cross-reactivity with some, but not all, phenytoin immunoassay methods.
authors.affiliation: Department of Pathology, University of Utah Health Science Center, Salt Lake City, UT 84132, USA.
authors.forename: W L
authors.initials: WL
authors.lastname: Roberts
authors.forename: B K
authors.initials: BK
authors.lastname: De
authors.forename: J P
authors.initials: JP
authors.lastname: Coleman
authors.forename: T M
authors.initials: TM
authors.lastname: Annesley
mesh_terms: D058186:Acute Kidney Injury / Q000097:blood* / Q000188:drug therapy; D000927:Anticonvulsants / Q000097:blood* / Q000627:therapeutic use; D002851:Chromatography, High Pressure Liquid; D016638:Critical Illness; D003429:Cross Reactions; D005189:False Positive Reactions; D005260:Female; D006801:Humans; D007118:Immunoassay; D007676:Kidney Failure, Chronic / Q000097:blood* / Q000188:drug therapy; D008297:Male; D008875:Middle Aged; D010672:Phenytoin / Q000031:analogs & derivatives* / Q000097:blood / Q000627:therapeutic use
chemical_list: D000927:Anticonvulsants; D010672:Phenytoin; C043114:fosphenytoin