Lipid Cascade With Reflex to Lipoprotein Particle Assessment by NMR (With Graph if Reflexed)

TEST: 123836
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CPT: 80061. If reflex testing is performed, concomitant CPT codes/charges will apply.
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Test Includes

The reflex criteria below are in effect.

• If triglycerides are >800, the LDL cholesterol will reflex to the direct LDL at an additional charge.

• If LDL direct is <130, will reflex to NMR Lipoprotein Analysis by NMR without IR (insulin resistance) markers (with color graphical report) performed at an additional charge.

• If LDL calculation is <130, will reflex to NMR Lipoprotein Analysis by NMR without IR (insulin resistance) markers (with color graphical report) performed at an additional charge.

Special Instructions

Two specimens must be included with all test requests. See requirements under the Specimen section below.

Expected Turnaround Time

Within 1 day

Turnaround time is defined as the usual number of days from the date of pickup of a specimen for testing to when the result is released to the ordering provider. In some cases, additional time should be allowed for additional confirmatory or additional reflex tests. Testing schedules may vary.

Related Documents

For more information, please view the literature below.

Lipid Cascade Brochure

Specimen Requirements

Specimen

Lipid profile: Serum (preferred) or plasma. Lipoprotein reflex: Spun NMR LipoTube (preferred), serum from a plain red-top tube, plasma from a lavender-top (EDTA-no gel) tube, or green-top (heparin-no gel) tube. Ship with frozen cool packs.

Volume

2 mL (each tube)

Minimum Volume

1 mL (each tube)

Container

Lipid profile: Gel-barrier transport, green-top (heparin), or lavender-top (EDTA) tube. Lipoprotein reflex: One of the following: NMR LipoTube (black-and-yellow-top tube), preferred, plain red-top tube, lavender-top (EDTA-no gel) tube, or green-top (heparin-no gel) tube. Two specimens must be submitted with this profile, one for the lipid profile and another for lipoprotein reflex testing.

Collection

Lipid profile: Separate serum or plasma from cells within 45 minutes of collection. Lipoprotein reflex: Collect specimen in NMR LipoTube (black-and-yellow-top tube), which is the preferred specimen. Plain red-top tube, green-top (heparin-no gel), or lavender-top (EDTA-no gel) tubes are also acceptable. Serum or plasma drawn in gel-barrier collection tubes other than the NMR LipoTube should not be used. The LipoTube is the only acceptable gel barrier tube. Gently invert tube 8 to 10 times to mix contents and allow specimen to clot for 30 minutes upright at room temperature prior to centrifugation (plasma tubes should not clot). Centrifuge specimen within two hours of collection at 1800xg for 10 to 15 minutes to separate serum/plasma from the red cells and to avoid red cell contamination during shipment. If the sample cannot be centrifuged immediately, the sample should be refrigerated (at 2°C to 8°C) and centrifuged within 24 hours of collection. Note: Centrifuging the specimen while still cold may negatively affect the migration of the gel to the serum/red cell interface and may increase the likelihood of specimens being contaminated with red cells during shipment. All specimens should be centrifuged by the client, prior to shipment to LabCorp, to ensure sample integrity. Do not open NMR LipoTube (black-and-yellow top). Immediately after centrifugation, pipette separated red-top serum or green-top/lavender-top plasma into a transport tube and label accordingly (serum, heparin plasma, EDTA plasma). Keep samples refrigerated until shipment to the laboratory, and ship with frozen cool packs.

Storage Instructions

Lipid profile: Room temperature: Gel-barrier tube, green-top (heparin) tube, or lavender-top (EDTA) tube. Stable at room temperature for six hours or refrigerated for 10 days. Frozen is not acceptable. Lipoprotein reflex: Refrigerate all acceptable tube types as soon as possible after centrifugation and within 24 hours of collection. Keep refrigerated prior to shipment, and ship on frozen cool packs. Do not store at room temperature. Do not freeze the sample. Sample is stable refrigerated for six days.

Patient Preparation

Patient should be fasting for eight hours.

Causes for Rejection

Lipid profile: hemolysis. Lipoprotein reflex: Unspun specimens; Plasma/serum contaminated with red cells; Citrated plasma (light blue-top tube); gross hemolysis; specimen received in inappropriate container; specimen stored at room temperature for more than a total preanalytical time of 24 hours; specimen more than six days old.

Test Details

Use

The lipid cascade supports risk assessment and management of patients who present with cardiometabolic risk (CMR) factors (e.g., elevated blood pressure, abdominal obesity, insulin resistance (IR), lipoprotein abnormalities and elevated blood glucose).

Conventional lipid profile results are indirect estimates of the actual lipoproteins that transport cholesterol, many of which may be atherogenic. Additionally, basic lipid profile results do not: (1) account for the variability in cholesterol subfraction content; (2) measure lipoprotein particle size and number; or (3) provide information suggestive of changes associated with IR progression.

In patients with an LDL cholesterol result <130 mg/dL, the lipid cascade automatically reflexes to lipoprotein analysis by NMR to evaluate LDL particle number (additional charge on reflex). This reflex is derived from the Multi-Ethnic Study of Atherosclerosis (MESA), a medical research study involving more than 6,000 men and women from six communities in the United States and sponsored by the National Heart Lung and Blood Institute of the National Institutes of Health.1 In this study, it was found that where the LDL cholesterol (LDL-C) and LDL particle number (LDL-P) are discordant (i.e., LDL/C "normal," but the LDL-P is elevated), CVD risk always follows the LDL-P. This means the patient with high LDL-P but "normal" LDL-C is really at high risk for future cardiovascular events. The reflex is therefore designed to look for residual CVD risk in patients where cholesterol does not tell the whole story. The lipid cascade provides a lipoprotein IR score as a qualitative indicator of the patient's insulin resistance and risk for diabetes. In patients with a triglyceride result >800 mg/dL, the lipid cascade automatically reflexes to a direct LDL (additional charge on reflex). If the direct LDL result is <130 mg/dL, the lipid cascade automatically reflexes to lipoprotein analysis by NMR.

Limitations

If triglyceride level is >800 mg/dL, LDL cholesterol will not be calculated.

Methodology

Lipid profile: Enzymatic; lipoprotein reflex: Nuclear magnetic resonance (NMR)

Footnotes

1. Degoma EM, Davis MD, Dunbar RL, Mohler ER, Greenland P, French B. Discordance between non-HDL-cholesterol and LDL-particle measurements: results from the Multi-Ethnic Study of Atherosclerosis. Atherosclerosis. 2013 Aug;229(2):517-523.23591415

References

Grabner M, Winegar DA, Punekar RS, Quimbo RA, Cziraky MJ, Cromwell WC. Cost Effectiveness of Achieving Targets of Low-Density Lipoprotein Particle Number Versus Low-Density Lipoprotein Cholesterol Level. Am J Cardiol. 2017 Feb 1;119(3):404-409.27887691
Mora S, Buring JE, Ridker PM. Discordance of low-density lipoprotein (LDL) cholesterol with alternative LDL-related measures and future coronary events. Circulation. 2014 Feb 4;129(5):553‐561.24345402
Tehrani DM, Zhao Y, Blaha MJ, et al. Discordance of Low‐Density Lipoprotein and High‐Density Lipoprotein Cholesterol Particle Versus Cholesterol Concentration for the Prediction of Cardiovascular Disease in Patients With Metabolic Syndrome and Diabetes Mellitus (from the Multi‐Ethnic Study of Atherosclerosis [MESA]). Am J Cardiol. 2016 Jun 15;117(12):1921-1927.27156827

LOINC® Map

Order Code Order Code Name Order Loinc Result Code Result Code Name UofM Result LOINC
123836 Lipid Cascade(w/Graph if Rflx) 24331-1 001065 Cholesterol, Total mg/dL 2093-3
123836 Lipid Cascade(w/Graph if Rflx) 24331-1 011817 HDL Cholesterol mg/dL 2085-9
123836 Lipid Cascade(w/Graph if Rflx) 24331-1 011852 LDL/HDL Ratio ratio 11054-4
123836 Lipid Cascade(w/Graph if Rflx) 24331-1 011976 Non-HDL Cholesterol mg/dL 43396-1
123836 Lipid Cascade(w/Graph if Rflx) 24331-1 001172 Triglycerides mg/dL 2571-8
123836 Lipid Cascade(w/Graph if Rflx) 24331-1 012059 LDL Chol Calc (NIH) mg/dL 13457-7
123836 Lipid Cascade(w/Graph if Rflx) 24331-1 011923 LDL Calc Comment: N/A
Reflex Table for Triglycerides
Order Code Order Name Result Code Result Name UofM Result LOINC
Reflex 1 123506 LDL Cholesterol (Direct) 120297 LDL Chol. (Direct) mg/dL 18262-6
Reflex Table for Triglycerides
Order Code Order Name Result Code Result Name UofM Result LOINC
Reflex 1 123506 LDL Cholesterol (Direct) 120297 LDL Chol. (Direct) mg/dL 18262-6
Reflex Table for Triglycerides
Order Code Order Name Result Code Result Name UofM Result LOINC
Reflex 1 123506 LDL Cholesterol (Direct) 120297 LDL Chol. (Direct) mg/dL 18262-6
Reflex 2 123482 Lipoprotein Analysis, by NMR 884294 LDL-P nmol/L 54434-6
Reflex Table for Triglycerides
Order Code Order Name Result Code Result Name UofM Result LOINC
Reflex 1 123506 LDL Cholesterol (Direct) 120297 LDL Chol. (Direct) mg/dL 18262-6
Reflex Table for Triglycerides
Order Code Order Name Result Code Result Name UofM Result LOINC
Reflex 1 123506 LDL Cholesterol (Direct) 120297 LDL Chol. (Direct) mg/dL 18262-6
Reflex 2 123482 Lipoprotein Analysis, by NMR 884296 HDL-P (Total) umol/L 49748-7
Reflex Table for Triglycerides
Order Code Order Name Result Code Result Name UofM Result LOINC
Reflex 1 123506 LDL Cholesterol (Direct) 120297 LDL Chol. (Direct) mg/dL 18262-6
Reflex 2 123482 Lipoprotein Analysis, by NMR 884297 Small LDL-P nmol/L 43727-7
Reflex Table for Triglycerides
Order Code Order Name Result Code Result Name UofM Result LOINC
Reflex 1 123506 LDL Cholesterol (Direct) 120297 LDL Chol. (Direct) mg/dL 18262-6
Reflex 2 123482 Lipoprotein Analysis, by NMR 884309 LDL Size nm 17782-4
Reflex Table for Triglycerides
Order Code Order Name Result Code Result Name UofM Result LOINC
Reflex 1 123506 LDL Cholesterol (Direct) 120297 LDL Chol. (Direct) mg/dL 18262-6
Reflex Table for Triglycerides
Order Code Order Name Result Code Result Name UofM Result LOINC
Reflex 1 123506 LDL Cholesterol (Direct) 120297 LDL Chol. (Direct) mg/dL 18262-6
Reflex 2 123482 Lipoprotein Analysis, by NMR 884312 LP-IR Score 62255-5
Reflex Table for Triglycerides
Order Code Order Name Result Code Result Name UofM Result LOINC
Reflex 1 123506 LDL Cholesterol (Direct) 120297 LDL Chol. (Direct) mg/dL 18262-6
Reflex 2 123482 Lipoprotein Analysis, by NMR 123811 PDF N/A
Reflex Table for Triglycerides
Order Code Order Name Result Code Result Name UofM Result LOINC
Reflex 1 123506 LDL Cholesterol (Direct) 120297 LDL Chol. (Direct) mg/dL 18262-6
Reflex 2 123482 Lipoprotein Analysis, by NMR 123469 Historical Reporting N/A
Reflex Table for Triglycerides
Order Code Order Name Result Code Result Name UofM Result LOINC
Reflex 1 123506 LDL Cholesterol (Direct) 120297 LDL Chol. (Direct) mg/dL 18262-6
Reflex 2 123482 Lipoprotein Analysis, by NMR 123460 NMR Fractions-Std. N/A
Reflex Table for Triglycerides
Order Code Order Name Result Code Result Name UofM Result LOINC
Reflex 1 123506 LDL Cholesterol (Direct) 011924 LDL Direct Comment: N/A

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