Laboratory Test Results (LB) is a Findings domain used to represent laboratory test data such as hematology, clinical chemistry, and urinalysis. This domain does not include microbiology or pharmacokinetic concentration data, which are stored in separate domains. The laboratory data collected for studies is typically handled by 2 types of labs (i.e., central labs, local labs). Whereas data from local labs are usually captured directly on aCRF, central lab data is usually provided electronically.  

Three different data collection scenarios (see also Section 2.7.6.9, CDASH Laboratory Test Results (LB)) may be used for for laboratory test results. It is up to the applicant to determine which data collection scenario best meets the study needs. 

Scenario 1: Central processing. In this scenario, subject specimens are taken at the site and sent out for processing. Results are provided in an electronic file; the applicant has chosen to collect reconciliation data (e.g., LBDAT, LBTIM, VISITNUM, LBREFID) on the CRF. This scenario may also apply if the central lab results are imported into a applicant's EDC system. The fields for test results are not defined here, as these data are not part of the CRF.

Scenario 2: Central processing with investigator assessment of clinical significance for abnormal values. In this scenario, subject specimens are taken at the site and sent to a central lab for processing. The results are provided in an electronic file to the applicant. In addition, the results are provided to the investigator for assessment of clinical significance for any abnormal values, and that information is provided to the applicant on the CRF.

Scenario 3: Local processing. In this scenario, subject specimens are taken and analyzed, and then the results are recorded directly on the CRF. 

This section only discusses routine safety laboratory tests. For more information on biomarkers typically tested in tobacco studies, see Section 3.3.3.1, Biomarkers of Exposure or Potential Harm (LB, SUPPLB).

Logical Observation Identifiers Names and Codes (LOINC) is clinical terminology that is important for laboratory test orders and results, and is 1 of a suite of designated standards for use in US federal government systems for the electronic exchange of clinical health information. It is recommended that if the laboratory used for testing is able to provide the appropriate LOINC, that these be included in the SDTM dataset. If using LBLOINC, the applicant is expected to provide the dictionary name and version used to map the terms, utilizing Define-XML external codelist attributes. 

Example

This is an example CRF used to collect routine safety laboratory tests from local laboratories in tobacco studies. The lab names may be collected only when multiple labs are used by a site. The lab test name are often preprinted on the CRF. The names are not included as they are study specific. In order to save space, some of the permissible values are only shown in the metadata specifications. 


Section 1 

OrderQuestion TextPromptCase Report Form Completion InstructionsTypeCollection VariableTabulation Target  Mapping Instructions  Controlled Terminology CodeList NamePermissible ValuesPre-Populated Value
1What was the name of the laboratory used?Laboratory NameRecord the laboratory nameTextLBNAMLBNAM



2Was the lab performed?Lab PerformedIndicate whether or not lab specimen was collected, or measurement performed.TextLBPERFLBSTATLBSTAT = "NOT DONE" where LBPERF = "N" and LBSTAT = null where LBPERF = "Y"(NY)Yes; No
3What was the date of the lab specimen collection?Specimen Collection DateRecord the date of specimen collection .DateLBDATLBDTC



4What was the time of the lab specimen collection?Specimen Collection TimeRecord time of collection (as complete as possible).TimeLBTIMLBDTC



5Was the subject fasting? FastingRecord whether the subject was fasting prior to the test being performedTextLBFASTLBFAST



Section 2 

OrderQuestion TextPromptCase Report Form Completion InstructionsTypeCollection VariableTabulation Target  Mapping Instructions  Controlled Terminology CodeList NamePermissible ValuesPre-Populated Value
6What is the lab test name?Lab Test NameRecord the name of the lab measurement or finding, if not pre-printed on the CRF. If collected on the CRF, the applicant may provide additional instructions to ensure the data is entered as intended.TextLBTESTLBTEST;   LBTESTCDLBTEST and  LBTESTCD(LBTEST)WBC;  RBC,  cells,Protein  Urinalysis; Cholesterol, Albumin, Creatinine
7What was the result of the lab test?ResultRecord laboratory test result.TextLBORRESLBORRES



8What was the unit of the lab result?UnitRecord or select the original unit in which these data were collected, if not pre-printed on CRF.TextLBORRESULBORRESU
(UNIT)g/L; mg/dL; mg/L; U/mL; ug/L; sec; RATIO
9What was the lower limit of the reference range for this lab test?Normal Range Lower LimitRecord the lower limit of the reference range of the lab test.TextLBORNRLOLBORNRLO



10What was the high limit of the reference range for this lab test?Normal Range Upper LimitRecord the upper limit of the reference range of the lab test.TextLBORNRHILBORNRHI



11Was this result clinically significant?Clinically SignificantRecord whether lab results were clinically significant.TextLBCLSIGLBCLSIG
(NY)Yes; No

This is an example of the SDTM LB dataset used to represent routine safety laboratory tests.   

The LB dataset used the UNIT codelist for LBORRESU and LBORRESU. The LBLOINC variable contains a code from the LOINC database that identifies a specific laboratory test. The LOINC to LB Mapping Codetable (available at https://www.cdisc.org/standards/terminology/controlled-terminology) may be used to identify appropriate CDISC CT values for a test with a particular LOINC code. 

LBNRIND was added to indicate where a result falls with respect to reference range defined by LBORNRLO and LBORNRHI. LBSTNRC was used to populated a normal range values that are character values for an ordinal scale  (e.g., “NEGATIVE"). LBORNRLO, LBORNRHI, LBSTNRLO, and LBSTNRHI are null for these types of tests. 

TOBA-283 - Getting issue details... STATUS

Rows 1-4:Show records for common tests to evaluate hematology. The applicant used LBCAT (HEMATOLOGY) to group these tests.
Rows 5, 7, 8:Show records for common tests. LBCAT indicates the category assigned for these laboratory tests.
Row 6:Shows a value collected in 1 unit but converted to selected standard unit.
Row 9:Shows use of LBSTNRC for cannabinoids that is not reported as a continuous numeric result. The result was evaluated by the investigator and determined to be clinically significant

lb.xpt

lb.xpt

ROW

STUDYID

DOMAIN

USUBJID

LBSEQ

LBTESTCD

LBTEST

LBCAT

LBORRES

LBORRESU

LBORNRLOLBORNRHI

LBSTRESC

LBSTRESN

LBSTRESU

LBSTNRCLBSTNRLOLBSTNRHILBNRINDLBLOINCLBSPECLBLOBXFLLBCLSIG

VISITNUM

LBDTC

1TBLB001LB001-0011WBCLeukocytesHEMATOLOGY11.010^9/L4.511.011.011.010^9/L
4.511.0
26464-8BLOODY
12020-12-01
2TBLB001LB001-0012RBCRBCHEMATOLOGY5.410^12/L4.76.15.45.410^12/L
4.76.1
33051-4BLOODY
12020-12-01
3TBLB001LB001-0013PLATPlateletsHEMATOLOGY15810^9/L15040015815810^9/L
150400
49497-1BLOODY
12020-12-01
4TBLB001LB001-0014HGBHemoglobinHEMATOLOGY14.5g/dL141814.514.5g/dL
1418
718-7BLOODY
12020-12-01
5TBLB001LB001-0015CHOLCholesterolCLINICAL CHEMISTRY229mg/dL200
229229mg/dL
200

2093-3BLOODY
12020-12-01
6TBLB001LB001-0016ALBAlbuminCLINICAL CHEMISTRY40.0g/L34544.04.0g/dL
3.45.4
2862-1BLOODY
12020-12-01
7TBLB001LB001-0017CREATCreatinineCLINICAL CHEMISTRY0.8mg/dL0.71.30.80.8mg/dl
0.71.3
2160-0BLOODY
12020-12-01
8TBLB001LB001-0018SPGRAVSpecific GravityURINALYSIS1.002
1.0051.030



1.0051.030
2965-2URINEY
12020-12-01
9TBLB001LB001-0019CANNABCannabinoidsDRUG TOXICITYPOSITIVE


POSITIVE

POSITIVE

ABNORMAL18282-4URINEYY12020-12-01
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