Derivation and internal validation of an equation for albumin-adjusted calcium

Background: Previously published equations to adjust calcium for albumin concentration may vary depending on factors such as the type of reagents used. Albumin-adjusted calcium equations derived from laboratories using the bromocresol purple (BCP) albumin binding reagent have not been described. Methods: The linear regression equation for the binding of calcium and BCP-albumin was derived in a cohort of 4613 outpatients, and the albumin-adjusted calcium equation was internally validated in a separate cohort of 1538 subjects. The performance of this equation was compared with a previously published equation (adjusted [Ca](mmol/L) = total [Ca](mmol/L) + 0.02 (40 - [albumin] (g/L)) in 343 subjects with albumin < 33 g/L (below reference range). Results: The local adjustment equation was expressed by the relationship; adjusted [Ca](mmol/L) = total [Ca](mmol/L) + 0.012 (39.9 - [albumin](g/L)). The equation showed evidence of good internal validity (shrinkage value of adjusted r(2) = -0.0059). Classification of calcium status differed between the two equations in 47 of 343 subjects with low serum albumin (weighted kappa = 0.46; moderate agreement). Conclusion: A locally derived and internally validated albumin-adjusted calcium equation differed from previously published equations and resulted in important differences in classification of calcium status in hypoalbuminemia patients. Individual laboratories should determine their own linear regression equation for calcium on albumin rather than relying on published formulas.