# Lab Grading

# Introduction

Within the ADLB ADaM data set there is a concept of lab grading, where there is a set of criteria for particular lab tests that grade the severity or abnormality of a lab value. The grades are from 0 to 4, where grade 0 can be viewed generally as a “NORMAL” value. The higher the grade the more severe or more abnormal the lab value is. There are several sets of lab grading criteria, currently `{admiral}` has implemented NCI-CTCAEv4, NCI-CTCAEv5, NCI-CTCAEv6 and DAIDS grading criteria. In future releases `{admiral}` may look to implement further grading criteria.

The NCI-CTCAEv4 criteria can be found under the heading CTCAE and CTEP Codes

The NCI-CTCAEv5 and NCI-CTCAEv6 criteria can be found under the heading CTEP CTCAE

The DAIDS grading criteria can be found here: https://rsc.niaid.nih.gov/clinical-research-sites/daids-adverse-event-grading-tables .

The DAIDS criteria can be found under the heading DAIDS Table for Grading the Severity of Adult and Pediatric Adverse Events Corrected Version 2.1

# Grading metadata

`{admiral}` will store two sets of metadata data set for each set of grading criteria in the data folder of `{admiral}`, one for SI units, and one for US (conventional) units. These are as follows:

NCI-CTCAEv4

- `atoxgr_criteria_ctcv4` for SI units.
- `atoxgr_criteria_ctcv4_uscv` for US (conventional) units.

NCI-CTCAEv5

- `atoxgr_criteria_ctcv5` for SI units.
- `atoxgr_criteria_ctcv5_uscv` for US (conventional) units.

NCI-CTCAEv6

- `atoxgr_criteria_ctcv6` for SI units.
- `atoxgr_criteria_ctcv6_uscv` for US (conventional) units.

DAIDS

- `atoxgr_criteria_daids` for SI units.
- `atoxgr_criteria_daids_uscv` for US (conventional) units.

Each metadata data set has required variables and optional variables, the optional variables are purely for transparency, and will contain detailed information about the grading criteria. The required variables are those used by`{admiral}` to create the grade.

## Structure of metadata set

Each metadata data set has the following structure for the required variables:

Variable | Scope | Type | Example Value
--- | --- | --- | ---
TERM | Term describing the criteria applied to a particular lab test. | Character | “Anemia”
DIRECTION | The direction of the abnormality of a particular lab test value | Character | “L” or “H”.
UNIT_CHECK | Unit of lab test, to check against input data if criteria is based on absolute values. | Character | “mmol/L”
VAR_CHECK | Comma separated list of variables used in criteria, to check input data that variables exist. | Character | “AVAL, ANRLO”
FILTER | Only required for DAIDS grading. Variable to hold code that filters the lab data based on contents of column SUBGROUP. | Character | R code that is valid within a `filter` function call.
GRADE_CRITERIA_CODE | Variable to hold code that creates grade based on defined criteria. | Character | R code that is a valid case statement within a `mutate` function call.

The metadata data set has the following structure for the optional variables:

Variable | Scope | Type | Example Value
--- | --- | --- | ---
SOC | System Organ Class the lab test belongs to. | Character | “Investigations”
SUBGROUP | Only required for DAIDS grading. Description of subgroup of lab data. | Character | “> 15 years of age”.
GRADE_1 | Grade 1 criteria for lab test, normally straight from source document. | Character | “>ULN - 3.0 x ULN”.
GRADE_2 | Grade 2 criteria for lab test, normally straight from source document. | Character | “>3.0 - 5.0 x ULN”.
GRADE_3 | Grade 3 criteria for lab test, normally straight from source document. | Character | “>5.0 - 20.0 x ULN”.
GRADE_4 | Grade 4 criteria for lab test, normally straight from source document. | Character | “>20.0 x ULN”.
DEFINITION | Definition of abnormality, normally from source document. | Character | “A finding based on laboratory test results that indicate an increase in the level of alanine aminotransferase (ALT or SGPT) in the blood specimen.”.
COMMENT | Description of any decisions made by `{admiral}` to implement grading criteria, where grading criteria alone was ambiguous. | Character | “Take worst case and assume on anticoagulation”.

# Handling floating points when comparing numeric values

When comparing numeric values, for example `AVAL > 1.1*ANRHI`, unexpected results can occur due to floating point issues. To solve this issue {admiral} used the `signif()` function on both side of the equation, the number of significant digits used to compare is passed into the function `derive_var_atoxgr_dir()` via the argument `signif_dig`. Please see documentation of the function for more details and the blog post How admiral handles floating points for more context.

# Creating the Lab Grade

## Mapping `ADLB` to the `TERM` variable in the `{admiral}` metadata data set

    library(admiral)
    library(pharmaversesdtm)
    library(dplyr, warn.conflicts = FALSE)
    library(stringr)
    library(tibble)

    lb <- pharmaversesdtm::lb
    adsl <- admiral::admiral_adsl

    lb <- convert_blanks_to_na(lb)

Each company needs to map their lab test to a term that describes the criteria being applied. The list of terms defined in the `{admiral}` metadata to implement NCI-CTCAEv4 is below:

TERM
Anemia
Leukocytosis
Activated partial thromboplastin time prolonged
Alanine aminotransferase increased
Alkaline phosphatase increased
Aspartate aminotransferase increased
Blood bilirubin increased
CD4 lymphocytes decreased
Cholesterol high
CPK increased

Likewise, the list of terms defined in the `{admiral}` metadata to implement NCI-CTCAEv5 is below: (Terms identical to NCI-CTCAEv4, except `Hyperglycemia`, `Hyperglycemia (Fasting)` and `Hypophosphatemia`) which are not present in NCI-CTCAEv5.

TERM
Anemia
Leukocytosis
Activated partial thromboplastin time prolonged
Alanine aminotransferase increased
Alkaline phosphatase increased
Aspartate aminotransferase increased
Blood bilirubin increased
CD4 lymphocytes decreased
Cholesterol high
CPK increased

Similarly, the list of terms defined in the `{admiral}` metadata to implement NCI-CTCAEv6 is below:

TERM
Anemia
Leukocytosis
Thrombocytopenia
Activated partial thromboplastin time prolonged
Alanine aminotransferase increased
Alkaline phosphatase increased
Aspartate aminotransferase increased
Blood bilirubin increased
Blood lactate dehydrogenase increased
CD4 lymphocytes decreased

Finally, the list of terms defined in the `{admiral}` metadata to implement DAIDS is below:

TERM
Acidosis
Albumin, Low
Alkaline Phosphatase, High
Alkalosis
ALT, High
Amylase, High
AST, High
Bicarbonate, Low
Direct Bilirubin, High
Total Bilirubin, High

Using CDISC data these lab tests can be mapped to the correct terms, firstly create `PARAMCD`, `PARAM`, `AVAL`, `ANRLO` and `ANRHI`, also some lab grading criteria require `BASE` and `PCHG`, so these would also need to be created before running `derive_var_atoxgr_dir()` function.

    # Look-up tables ----

    # Assign PARAMCD, PARAM, and PARAMN
    param_lookup <- tibble::tribble(
      ~LBTESTCD, ~PARAMCD,  ~PARAM,                                             ~PARAMN,
      "ALB",     "ALB",     "Albumin (g/L)",                                    1,
      "ALP",     "ALKPH",   "Alkaline Phosphatase (U/L)",                       2,
      "ALT",     "ALT",     "Alanine Aminotransferase (U/L)",                   3,
      "ANISO",   "ANISO",   "Anisocytes",                                       4,
      "AST",     "AST",     "Aspartate Aminotransferase (U/L)",                 5,
      "BASO",    "BASO",    "Basophils (10^9/L)",                               6,
      "BASOLE",  "BASOLE",  "Basophils/Leukocytes (FRACTION)",                  7,
      "BILI",    "BILI",    "Bilirubin (umol/L)",                               8,
      "BUN",     "BUN",     "Blood Urea Nitrogen (mmol/L)",                     9,
      "CA",      "CA",      "Calcium (mmol/L)",                                 10,
      "CHOL",    "CHOLES",  "Cholesterol (mmol/L)",                             11,
      "CK",      "CK",      "Creatinine Kinase (U/L)",                          12,
      "CL",      "CL",      "Chloride (mmol/L)",                                13,
      "COLOR",   "COLOR",   "Color",                                            14,
      "CREAT",   "CREAT",   "Creatinine (umol/L)",                              15,
      "EOS",     "EOS",     "Eosinophils (10^9/L)",                             16,
      "EOSLE",   "EOSLE",   "Eosinophils/Leukocytes (FRACTION)",                17,
      "GGT",     "GGT",     "Gamma Glutamyl Transferase (U/L)",                 18,
      "GLUC",    "GLUC",    "Glucose (mmol/L)",                                 19,
      "HBA1C",   "HBA1C",   "Hemoglobin A1C (1)",                               20,
      "HCT",     "HCT",     "Hematocrit (1)",                                   21,
      "HGB",     "HGB",     "Hemoglobin (mmol/L)",                              22,
      "K",       "POTAS",   "Potassium (mmol/L)",                               23,
      "KETONES", "KETON",   "Ketones",                                          24,
      "LYM",     "LYMPH",   "Lymphocytes (10^9/L)",                             25,
      "LYMLE",   "LYMPHLE", "Lymphocytes/Leukocytes (FRACTION)",                26,
      "MACROCY", "MACROC",  "Macrocytes",                                       27,
      "MCH",     "MCH",     "Ery. Mean Corpuscular Hemoglobin (fmol(Fe))",      28,
      "MCHC",    "MCHC",    "Ery. Mean Corpuscular HGB Concentration (mmol/L)", 29,
      "MCV",     "MCV",     "Ery. Mean Corpuscular Volume (f/L)",               30,
      "MICROCY", "MICROC",  "Microcytes",                                       31,
      "MONO",    "MONO",    "Monocytes (10^9/L)",                               32,
      "MONOLE",  "MONOLE",  "Monocytes/Leukocytes (FRACTION)",                  33,
      "PH",      "PH",      "pH",                                               34,
      "PHOS",    "PHOS",    "Phosphate (mmol/L)",                               35,
      "PLAT",    "PLAT",    "Platelet (10^9/L)",                                36,
      "POIKILO", "POIKIL",  "Poikilocytes",                                     37,
      "POLYCHR", "POLYCH",  "Polychromasia",                                    38,
      "PROT",    "PROT",    "Protein (g/L)",                                    39,
      "RBC",     "RBC",     "Erythrocytes (TI/L)",                              40,
      "SODIUM",  "SODIUM",  "Sodium (mmol/L)",                                  41,
      "SPGRAV",  "SPGRAV",  "Specific Gravity",                                 42,
      "TSH",     "TSH",     "Thyrotropin (mU/L)",                               43,
      "URATE",   "URATE",   "Urate (umol/L)",                                   44,
      "UROBIL",  "UROBIL",  "Urobilinogen",                                     45,
      "VITB12",  "VITB12",  "Vitamin B12 (pmol/L)",                             46,
      "WBC",     "WBC",     "Leukocytes (10^9/L)",                              47
    )

    adlb <- lb %>%
      ## Add PARAMCD PARAM and PARAMN - from LOOK-UP table
      derive_vars_merged_lookup(
        dataset_add = param_lookup,
        new_vars = exprs(PARAMCD, PARAM, PARAMN),
        by_vars = exprs(LBTESTCD)
      ) %>%
      ## Calculate PARCAT1 AVAL AVALC ANRLO ANRHI
      ## Dummy the values for BASE
      mutate(
        PARCAT1 = LBCAT,
        AVAL = LBSTRESN,
        AVALC = ifelse(
          is.na(LBSTRESN) | as.character(LBSTRESN) != LBSTRESC,
          LBSTRESC,
          NA
        ),
        ANRLO = LBSTNRLO,
        ANRHI = LBSTNRHI,
        BASE = AVAL - 10
      )
    #> All `LBTESTCD` are mapped.

Another look-up table is used to add on `ATOXDSCL` and `ATOXDSCH` using `PARAMCD`. `ATOXDSCL` holds the terms for grading low lab values, and `ATOXDSCH` holds the terms for grading high lab values. The names of these variables can be user-defined. `ATOXDSCL` and `ATOXDSCH` are the link from ADLB data to the `{admiral}` metadata that holds the grading criteria.

    # Assign ATOXDSCL and ATOXDSCH to hold lab grading terms
    # ATOXDSCL and ATOXDSCH hold terms defined by NCI-CTCAEv4.
    grade_lookup <- tibble::tribble(
      ~PARAMCD, ~ATOXDSCL,                    ~ATOXDSCH,
      "ALB",    "Hypoalbuminemia",            NA_character_,
      "ALKPH",  NA_character_,                "Alkaline phosphatase increased",
      "ALT",    NA_character_,                "Alanine aminotransferase increased",
      "AST",    NA_character_,                "Aspartate aminotransferase increased",
      "BILI",   NA_character_,                "Blood bilirubin increased",
      "CA",     "Hypocalcemia",               "Hypercalcemia",
      "CHOLES", NA_character_,                "Cholesterol high",
      "CK",     NA_character_,                "CPK increased",
      "CREAT",  NA_character_,                "Creatinine increased",
      "GGT",    NA_character_,                "GGT increased",
      "GLUC",   "Hypoglycemia",               "Hyperglycemia",
      "HGB",    "Anemia",                     "Hemoglobin increased",
      "POTAS",  "Hypokalemia",                "Hyperkalemia",
      "LYMPH",  "CD4 lymphocytes decreased",  NA_character_,
      "PHOS",   "Hypophosphatemia",           NA_character_,
      "PLAT",   "Platelet count decreased",   NA_character_,
      "SODIUM", "Hyponatremia",               "Hypernatremia",
      "WBC",    "White blood cell decreased", "Leukocytosis",
    )

    adlb <- adlb %>%
      derive_vars_merged(
        dataset_add = grade_lookup,
        by_vars = exprs(PARAMCD),
      )

It is now straightforward to create the grade, for low lab values the grade will be held in `ATOXGRL` and for high lab values the grade will be held in `ATOXGRH`.

Note: for NCICTCAEv5 grading, you would update `meta_criteria` parameter to `atoxgr_criteria_ctcv5` and for DAIDS grading you would update `meta_criteria` parameter to `atoxgr_criteria_daids`

    adlb <- adlb %>%
      derive_var_atoxgr_dir(
        new_var = ATOXGRL,
        tox_description_var = ATOXDSCL,
        meta_criteria = atoxgr_criteria_ctcv4,
        criteria_direction = "L",
        get_unit_expr = extract_unit(PARAM)
      ) %>%
      derive_var_atoxgr_dir(
        new_var = ATOXGRH,
        tox_description_var = ATOXDSCH,
        meta_criteria = atoxgr_criteria_ctcv4,
        criteria_direction = "H",
        get_unit_expr = extract_unit(PARAM)
      )

Note: `{admiral}` does not grade ‘Anemia’ or ‘Hemoglobin Increased’ because the metadata is based on the SI unit of ‘g/L’, however the CDISC data has SI unit of ‘mmol/L’. Please see `UNIT_CHECK` variable in `{admiral}` metadata `atoxgr_criteria_ctcv4()` or `atoxgr_criteria_ctcv5()` or `atoxgr_criteria_daids()`, the metadata is in the data folder of `{admiral}`.

TERM | UNIT_CHECK
--- | ---
Anemia | g/L
Leukocytosis | 10^9/L
CD4 lymphocytes decreased | 10^9/L
Cholesterol high | mmol/L
Fibrinogen decreased | g/L
Hemoglobin increased | g/L
Lymphocyte count decreased | 10^9/L
Lymphocyte count increased | 10^9/L
Neutrophil count decreased | 10^9/L
Platelet count decreased | 10^9/L

`{admiral}` also gives the option to combine `ATOXGRL` and `ATOXGRH` into one variable, namely `ATOXGR`. Grades held in `ATOXGRL` will be given a negative value in `ATOXGR` to distinguish between low and high values.

    adlb <- adlb %>%
      derive_var_atoxgr()

ATOXDSCL | ATOXDSCH | ATOXGRL | ATOXGRH | ATOXGR
--- | --- | --- | --- | ---
CD4 lymphocytes decreased | NA | 1 | NA | -1
Hypoalbuminemia | NA | 1 | NA | -1
Hypoalbuminemia | NA | 1 | NA | -1
Hypoalbuminemia | NA | 1 | NA | -1
Hypoalbuminemia | NA | 1 | NA | -1
Hypoalbuminemia | NA | 1 | NA | -1
Hypoalbuminemia | NA | 1 | NA | -1
Hypoalbuminemia | NA | 1 | NA | -1
Hypoalbuminemia | NA | 1 | NA | -1
Hypoalbuminemia | NA | 1 | NA | -1

# NCI-CTCAEV4 implementation

## Terms graded

Grading is implemented for those lab tests where a lab value is included in the grading definition, `{admiral}` does NOT try to read any other data to determine the grade, and only the `ADLB` dataset is used. The following CTCAE v4.0 SOC values were identified for grading, these are “Investigations”, “Metabolism and nutrition disorders” and “Blood and lymphatic system disorders”.

From these SOC values the following terms criteria is implemented in `{admiral}`

From SOC = “Investigations” there are 21 CTCAE v4.0 Terms:

- Activated partial thromboplastin time prolonged
- Alanine aminotransferase increased
- Alkaline phosphatase increased
- Aspartate aminotransferase increased
- Blood bilirubin increased
- CD4 lymphocytes decreased
- Cholesterol high
- CPK increased
- Creatinine increased
- Fibrinogen decreased
- GGT increased
- Haptoglobin decreased
- Hemoglobin increased
- INR increased
- Lipase increased
- Lymphocyte count decreased
- Lymphocyte count increased
- Neutrophil count decreased
- Platelet count decreased
- Serum amylase increased
- White blood cell decreased

From the SOC = “Metabolism and nutrition disorders” there are 16 CTCAE v4.0 Terms:

- Acidosis
- Alkalosis
- Hypercalcemia
- Hyperglycemia
- Hyperkalemia
- Hypermagnesemia
- Hypernatremia
- Hypertriglyceridemia
- Hyperuricemia
- Hypoalbuminemia
- Hypocalcemia
- Hypoglycemia
- Hypokalemia
- Hypomagnesemia
- Hyponatremia
- Hypophosphatemia

From the SOC = “Blood and lymphatic system disorders” there are 2 CTCAE v4.0 Terms:

- Anemia
- Leukocytosis

## Updates made to TERM

For terms “Hypocalcemia” and “Hypercalcemia” the criteria is provided for Calcium and Ionized Calcium, therefore `{admiral}` created a row for each in the metadata, this is noted in the COMMENT variable of the metadata:

TERM | COMMENT
--- | ---
Hypercalcemia | Split Corrected Calcium and Ionized Calcium into 2 separate terms.
Hypercalcemia (Ionized) | Split Corrected Calcium and Ionized Calcium into 2 separate terms.
Hypocalcemia | Split Corrected Calcium and Ionized Calcium into 2 separate terms.
Hypocalcemia (Ionized) | Split Corrected Calcium and Ionized Calcium into 2 separate terms.

Similarly, there is criteria applicable to Fasting Glucose as well as non-Fasting Glucose for “Hyperglycemia” so again this was split into 2 rows, and noted in the COMMENT variable. Note “Hypoglycemia” does not require to be split into 2 rows:

TERM | COMMENT
--- | ---
Hyperglycemia (Fasting) | Split Fasting Glucose and Glucose into 2 separate terms.
Hyperglycemia | Split Fasting Glucose and Glucose into 2 separate terms.
Hypoglycemia | NA

## Assumptions made when grading

For term “INR Increased” there is the following criteria:

TERM | GRADE_1
--- | ---
INR increased | >1 - 1.5 x ULN; >1 - 1.5 times above baseline if on anticoagulation

`{admiral}` assumed worst case and used both parts of the criteria for grading, so comparing lab value against ULN and also BASE. The decision made was put in the `COMMENT` field.

TERM | COMMENT
--- | ---
INR increased | Take worst case and assume “on anticoagulation”

For TERM “Hyperuricemia”, the criteria for Grade 1 and Grade 3 is the same with respect to the lab value, so worse case is assumed as grade 3. The decision made was put in the `COMMENT` field.

TERM | GRADE_1 | GRADE_3 | COMMENT
--- | --- | --- | ---
Hyperuricemia | >ULN - 10 mg/dL (0.59 mmol/L) without physiologic consequences | >ULN - 10 mg/dL (0.59 mmol/L) with physiologic consequences | Take worst case and assume “with physiologic consequences”

A similar approach was taken for TERM “Hypokalemia” where Grade 1 and Grade 2 criteria is the same with respect to the lab value, so worse case is assumed as grade 2. The decision made was put in the `COMMENT` field.

TERM | GRADE_1 | GRADE_2 | COMMENT
--- | --- | --- | ---
Hypokalemia | <LLN - 3.0 mmol/L | <LLN - 3.0 mmol/L; symptomatic; intervention indicated | Take worst case and assume “symptomatic OR intervention indicated”

Here is a complete list of all assumptions in the metadata for NCI-CTCAE-v4

TERM | GRADE_1 | GRADE_2 | GRADE_3 | GRADE_4 | COMMENT
--- | --- | --- | --- | --- | ---
INR increased | >1 - 1.5 x ULN; >1 - 1.5 times above baseline if on anticoagulation | >1.5 - 2.5 x ULN; >1.5 - 2.5 times above baseline if on anticoagulation | >2.5 x ULN; >2.5 times above baseline if on anticoagulation | - | Take worst case and assume “on anticoagulation”
Hyperuricemia | >ULN - 10 mg/dL (0.59 mmol/L) without physiologic consequences | - | >ULN - 10 mg/dL (0.59 mmol/L) with physiologic consequences | >10 mg/dL; >0.59 mmol/L; life-threatening consequences | Take worst case and assume “with physiologic consequences”
Hypokalemia | <LLN - 3.0 mmol/L | <LLN - 3.0 mmol/L; symptomatic; intervention indicated | <3.0 - 2.5 mmol/L; hospitalization indicated | <2.5 mmol/L; life-threatening consequences | Take worst case and assume “symptomatic OR intervention indicated”

# NCI-CTCAEV5 implementation

## Terms graded

Grading is implemented for those lab tests where a lab value is included in the grading definition, `{admiral}` does NOT try to read any other data to determine the grade, and only the `ADLB` dataset is used. The following CTCAE v5.0 SOC values were identified for grading, these are “Investigations”, “Metabolism and nutrition disorders” and “Blood and lymphatic system disorders”.

From these SOC values the following terms criteria is implemented in `{admiral}`

From SOC = “Investigations” there are 21 CTCAE v5.0 Terms:

- Activated partial thromboplastin time prolonged
- Alanine aminotransferase increased
- Alkaline phosphatase increased
- Aspartate aminotransferase increased
- Blood bilirubin increased
- CD4 lymphocytes decreased
- Cholesterol high
- CPK increased
- Creatinine increased
- Fibrinogen decreased
- GGT increased
- Haptoglobin decreased
- Hemoglobin increased
- INR increased
- Lipase increased
- Lymphocyte count decreased
- Lymphocyte count increased
- Neutrophil count decreased
- Platelet count decreased
- Serum amylase increased
- White blood cell decreased

Note: These are the same terms identified for NCI-CTCAEv4.

From the SOC = “Metabolism and nutrition disorders” there are 14 CTCAE v5.0 Terms:

- Acidosis
- Alkalosis
- Hypercalcemia
- Hyperkalemia
- Hypermagnesemia
- Hypernatremia
- Hypertriglyceridemia
- Hyperuricemia
- Hypoalbuminemia
- Hypocalcemia
- Hypoglycemia
- Hypokalemia
- Hypomagnesemia
- Hyponatremia

Note: These are the same terms identified for NCI-CTCAEv4, except “Hypophosphatemia” and “Hyperglycemia” which are not gradable by quantitative lab values in NCICTCAEv5 grading criteria.

From the SOC = “Blood and lymphatic system disorders” there are 2 CTCAE v5.0 Terms:

- Anemia
- Leukocytosis

Note: These are the same terms identified for NCI-CTCAEv4.

## Updates made to TERM

For terms “Hypocalcemia” and “Hypercalcemia” the criteria is provided for Calcium and Ionized Calcium, therefore `{admiral}` created a row for each in the metadata, this is noted in the COMMENT variable of the metadata:

TERM | COMMENT
--- | ---
Hypercalcemia | Split Corrected Calcium and Ionized Calcium into 2 separate terms.
Hypercalcemia (Ionized) | Split Corrected Calcium and Ionized Calcium into 2 separate terms.
Hypocalcemia | Split Corrected Calcium and Ionized Calcium into 2 separate terms.
Hypocalcemia (Ionized) | Split Corrected Calcium and Ionized Calcium into 2 separate terms.

## Criteria dependent on the Baseline Value

For terms “Alanine aminotransferase increased”, “Alkaline phosphatase increased”, “Aspartate aminotransferase increased”, “Blood bilirubin increased” and “GGT increased” the criteria is dependent on the Baseline Value being normal or abnormal. We use the variable `BNRIND` to determine this, and users can pass in the value(s) of `BNRIND` that indicate the baseline is abnormal via the arguments `high_indicator` and `low_indicator` in the function `derive_var_atoxgr_dir()`. For example, setting `high_indicator = "HIGH"` would mean any observations with `BNRIND = "HIGH"` would be deemed to have a high abnormal Baseline Value. Likewise, setting `low_indicator = "LOW"` would mean any observations with `BNRIND = "LOW"` would be deemed to have a low abnormal Baseline Value. Note: you can pass in multiple values, `high_indicator = c("H", "HIGH")`

For these 5 terms, this means if `BNRIND` is abnormal then the grade is always zero for the baseline observation. This is the conservative approach, to ensure you don’t see big changes in grade for a patient after they take treatment. Some companies may not want the baseline observation graded at all, so would post-process, if necessary.

## Assumptions made when grading

For term “INR Increased” there is the following criteria:

TERM | GRADE_1
--- | ---
INR increased | >1.2 - 1.5; >1 - 1.5 x baseline if on anticoagulation; monitoring only indicated

`{admiral}` assumed worst case and used both parts of the criteria for grading, so comparing lab value against ULN and also BASE. The decision made was put in the `COMMENT` field.

TERM | COMMENT
--- | ---
INR increased | Take worst case and assume “on anticoagulation”

Similarly, for terms “Lipase Increased” and “Serum amylase increased” there is the following criteria:

TERM | GRADE_2 | GRADE_3 | GRADE_4
--- | --- | --- | ---
Lipase increased | >1.5 - 2.0 x ULN; >2.0 - 5.0 x ULN and asymptomatic | >2.0 - 5.0 x ULN with signs or symptoms; >5.0 x ULN and asymptomatic | >5.0 x ULN and with signs or symptoms
Serum amylase increased | >1.5 - 2.0 x ULN; >2.0 - 5.0 x ULN and asymptomatic | >2.0 - 5.0 x ULN with signs or symptoms; >5.0 x ULN and asymptomatic | >5.0 x ULN and with signs or symptoms

`{admiral}` assumed worst case and implemented highest grade possible. The decision made was put in the `COMMENT` field.

TERM | COMMENT
--- | ---
Lipase increased | Take worst case and assume “signs and symptoms”
Serum amylase increased | Take worst case and assume “signs and symptoms”

For TERM “Hyperuricemia”, the criteria for Grade 1 and Grade 3 is the same with respect to the lab value, so worse case is assumed as grade 3. The decision made was put in the `COMMENT` field.

TERM | GRADE_1 | GRADE_3 | COMMENT
--- | --- | --- | ---
Hyperuricemia | >ULN without physiologic consequences | >ULN with physiologic consequences | Take worst case and assume “with physiologic consequences”

A similar approach was taken for TERM “Hypokalemia” and “Hyponatremia”. For “Hypokalemia”, where Grade 1 and Grade 2 criteria is the same with respect to the lab value, then worse case is assumed as grade 2. For “Hyponatremia”, where Grade 2 and Grade 3 criteria is the same with respect to the lab value, then worse case is assumed as grade 3. The decision made was put in the `COMMENT` field.

TERM | GRADE_1 | GRADE_2 | GRADE_3 | COMMENT
--- | --- | --- | --- | ---
Hypokalemia | <LLN - 3.0 mmol/L | Symptomatic with <LLN - 3.0 mmol/L; intervention indicated | <3.0 - 2.5 mmol/L; hospitalization indicated | Take worst case and assume “symptomatic”
Hyponatremia | <LLN - 130 mmol/L | 125-129 mmol/L and asymptomatic | 125-129 mmol/L symptomatic; 120-124 mmol/L regardless of symptoms | Take worst case and assume “symptomatic”

Here is a complete list of all assumptions in the metadata for NCI-CTCAE-v5

TERM | GRADE_1 | GRADE_2 | GRADE_3 | GRADE_4 | COMMENT
--- | --- | --- | --- | --- | ---
INR increased | >1.2 - 1.5; >1 - 1.5 x baseline if on anticoagulation; monitoring only indicated | >1.5 - 2.5; >1.5 - 2.5 x baseline if on anticoagulation; dose adjustment indicated | >2.5; >2.5 times above baseline if on anticoagulation | - | Take worst case and assume “on anticoagulation”
Lipase increased | >ULN - 1.5 x ULN | >1.5 - 2.0 x ULN; >2.0 - 5.0 x ULN and asymptomatic | >2.0 - 5.0 x ULN with signs or symptoms; >5.0 x ULN and asymptomatic | >5.0 x ULN and with signs or symptoms | Take worst case and assume “signs and symptoms”
Serum amylase increased | >ULN - 1.5 x ULN | >1.5 - 2.0 x ULN; >2.0 - 5.0 x ULN and asymptomatic | >2.0 - 5.0 x ULN with signs or symptoms; >5.0 x ULN and asymptomatic | >5.0 x ULN and with signs or symptoms | Take worst case and assume “signs and symptoms”
Hyperuricemia | >ULN without physiologic consequences | - | >ULN with physiologic consequences | Life-threatening consequences | Take worst case and assume “with physiologic consequences”
Hypokalemia | <LLN - 3.0 mmol/L | Symptomatic with <LLN - 3.0 mmol/L; intervention indicated | <3.0 - 2.5 mmol/L; hospitalization indicated | <2.5 mmol/L; life-threatening consequences | Take worst case and assume “symptomatic”
Hyponatremia | <LLN - 130 mmol/L | 125-129 mmol/L and asymptomatic | 125-129 mmol/L symptomatic; 120-124 mmol/L regardless of symptoms | <120 mmol/L; life-threatening consequences | Take worst case and assume “symptomatic”

# NCI-CTCAEV6 implementation

## Terms graded

Grading is implemented for those lab tests where a lab value is included in the grading definition, `{admiral}` does NOT try to read any other data to determine the grade, and only the `ADLB` dataset is used. The following CTCAE v6.0 SOC values were identified for grading, these are “Investigations”, “Metabolism and nutrition disorders” and “Blood and lymphatic system disorders”.

From these SOC values the following terms criteria is implemented in `{admiral}`

From SOC = “Investigations” there are 22 CTCAE v6.0 Terms:

- Activated partial thromboplastin time prolonged
- Alanine aminotransferase increased
- Alkaline phosphatase increased
- Aspartate aminotransferase increased
- Blood bilirubin increased
- Blood lactate dehydrogenase increased
- CD4 lymphocytes decreased
- Cholesterol high
- Creatinine clearance decreased
- Creatinine increased
- Fibrinogen decreased
- GGT increased
- Haptoglobin decreased
- HDL decreased
- Hemoglobin increased
- INR increased
- LDL increased
- Lipase increased
- Lymphocyte count increased
- Neutrophil count decreased
- Serum amylase increased
- White blood cell decreased

Note: These are 4 new terms added and 3 removed from the terms identified for NCI-CTCAEv5. “Blood lactate dehydrogenase increased”, “Creatinine clearance decreased”, “HDL decreased” and “LDL increased” have been added, and “CPK increased” and “Lymphocyte count decreased” have been removed, and “Platelet count decreased” has been moved to “Thrombocytopenia” under SOC “Blood and lymphatic system disorders”.

From the SOC = “Metabolism and nutrition disorders” there are 15 CTCAE v6.0 Terms:

- Acidosis
- Alkalosis
- Hypercalcemia
- Hyperglycemia
- Hyperkalemia
- Hypermagnesemia
- Hypernatremia
- Hypertriglyceridemia
- Hyperuricemia
- Hypoalbuminemia
- Hypocalcemia
- Hypoglycemia
- Hypokalemia
- Hypomagnesemia
- Hyponatremia

Note: These are the same terms identified for NCI-CTCAEv5, except “Hyperglycemia” which has been added to NCICTCAEv6 grading criteria.

From the SOC = “Blood and lymphatic system disorders” there are 3 CTCAE v6.0 Terms:

- Anemia
- Leukocytosis
- Thrombocytopenia

Note: These are the same terms identified for NCI-CTCAEv5, except “Thrombocytopenia” which as mentioned above has moved from “Platelet count decreased” under SOC “Investigations”.

## Updates made to TERM

For terms “Hypocalcemia” and “Hypercalcemia” the criteria is provided for Calcium and Ionized Calcium, therefore `{admiral}` created a row for each in the metadata, this is noted in the COMMENT variable of the metadata:

TERM | COMMENT
--- | ---
Hypercalcemia | Split Corrected Calcium and Ionized Calcium into 2 separate terms.
Hypercalcemia (Ionized) | Split Corrected Calcium and Ionized Calcium into 2 separate terms.
Hypocalcemia | Split Corrected Calcium and Ionized Calcium into 2 separate terms.
Hypocalcemia (Ionized) | Split Corrected Calcium and Ionized Calcium into 2 separate terms.

## Criteria dependent on the Baseline Value

For terms “Alanine aminotransferase increased”, “Aspartate aminotransferase increased”, “Blood bilirubin increased”, “Creatinine increased” and “GGT increased” the criteria is dependent on the Baseline Value being normal or abnormal. We use the variable `BNRIND` to determine this, and users can pass in the value(s) of `BNRIND` that indicate the baseline is abnormal via the arguments `high_indicator` and `low_indicator` in the function `derive_var_atoxgr_dir()`. For example, setting `high_indicator = "HIGH"` would mean any observations with `BNRIND = "HIGH"` would be deemed to have a high abnormal Baseline Value. Likewise, setting `low_indicator = "LOW"` would mean any observations with `BNRIND = "LOW"` would be deemed to have a low abnormal Baseline Value. Note: you can pass in multiple values, `abnormal_indicator = c("H", "HIGH")`

Excluding “Creatinine increased”, for the other 4 terms, this means if `BNRIND` is abnormal then the grade is always one for the baseline observation. For “Creatinine increased” if `BNRIND` is abnormal then the grade could be zero, one or four, as grade 1 and 4 are independent of `BNRIND`. Additionally, for “Alkaline phosphatase increased” the baseline grade is always zero, as the value has to be above the baseline value to have a grade greater than zero. This is the conservative approach, some companies may not want the baseline observation graded at all, so would post-process, if necessary.

## Assumptions made when grading

For term “INR Increased” there is the following criteria:

TERM | GRADE_1
--- | ---
INR increased | >1.2 - 1.5; >1 - 1.5 x baseline if on anticoagulation; monitoring only indicated

`{admiral}` assumed worst case and used both parts of the criteria for grading, so comparing lab value against ULN and also BASE. The decision made was put in the `COMMENT` field.

TERM | COMMENT
--- | ---
INR increased | Take worst case and assume “on anticoagulation”

Similarly, for terms “Lipase Increased” and “Serum amylase increased” there is the following criteria:

TERM | GRADE_2 | GRADE_3 | GRADE_4
--- | --- | --- | ---
Lipase increased | >1.5 - 3.0 x ULN; >3.0 - 5.0 x ULN and asymptomatic | >3.0 - 5.0 x ULN with signs or symptoms; >5.0 x ULN and asymptomatic | >5.0 x ULN and with signs or symptoms
Serum amylase increased | >1.5 - 2.0 x ULN; >2.0 - 5.0 x ULN and asymptomatic or with mild signs or symptoms | >2.0 - 5.0 x ULN with moderate or severe signs or symptoms; >5.0 x ULN and asymptomatic | >5.0 x ULN and with signs or symptoms

`{admiral}` assumed worst case and implemented highest grade possible. The decision made was put in the `COMMENT` field.

TERM | COMMENT
--- | ---
Lipase increased | Take worst case and assume “signs and symptoms”
Serum amylase increased | Take worst case and assume “signs and symptoms”

For TERM “Hyperuricemia”, the criteria for Grade 1 and Grade 3 is the same with respect to the lab value, so worse case is assumed as grade 3. The decision made was put in the `COMMENT` field.

TERM | GRADE_1 | GRADE_3 | COMMENT
--- | --- | --- | ---
Hyperuricemia | >ULN without physiologic consequences | >ULN with physiologic consequences | Take worst case and assume “with physiologic consequences”

A similar approach was taken for TERM “Hypokalemia” and “Hyponatremia”. For “Hypokalemia”, where Grade 1 and Grade 2 criteria is the same with respect to the lab value, then worse case is assumed as grade 2. For “Hyponatremia”, where Grade 2 and Grade 3 criteria is the same with respect to the lab value, then worse case is assumed as grade 3. The decision made was put in the `COMMENT` field.

TERM | GRADE_1 | GRADE_2 | GRADE_3 | COMMENT
--- | --- | --- | --- | ---
Hypokalemia | <LLN - 3.0 mmol/L | Symptomatic with <LLN - 3.0 mmol/L; intervention indicated | <3.0 - 2.5 mmol/L; hospitalization indicated | Take worst case and assume “symptomatic”
Hyponatremia | <LLN - 130 mmol/L | 125 - <130 mmol/L and asymptomatic | 125 - <130 mmol/L symptomatic; 120 - <125 mmol/L regardless of symptoms | Take worst case and assume “symptomatic”

Here is a complete list of all assumptions in the metadata for NCI-CTCAE-v6

TERM | GRADE_1 | GRADE_2 | GRADE_3 | GRADE_4 | COMMENT
--- | --- | --- | --- | --- | ---
Creatinine clearance decreased | - | 26 - 49 ml/min | 10 - 25 ml/min | - | Set grade to missing if AVAL < 10. Report Grade 4 as Renal and urinary disorders: Acute kidney injury or Chronic kidney disease
INR increased | >1.2 - 1.5; >1 - 1.5 x baseline if on anticoagulation; monitoring only indicated | >1.5 - 2.5; >1.5 - 2.5 x baseline if on anticoagulation; dose adjustment indicated | >2.5; >2.5 x baseline if on anticoagulation; bleeding | - | Take worst case and assume “on anticoagulation”
Lipase increased | >ULN - 1.5 x ULN | >1.5 - 3.0 x ULN; >3.0 - 5.0 x ULN and asymptomatic | >3.0 - 5.0 x ULN with signs or symptoms; >5.0 x ULN and asymptomatic | >5.0 x ULN and with signs or symptoms | Take worst case and assume “signs and symptoms”
Serum amylase increased | >ULN - 1.5 x ULN | >1.5 - 2.0 x ULN; >2.0 - 5.0 x ULN and asymptomatic or with mild signs or symptoms | >2.0 - 5.0 x ULN with moderate or severe signs or symptoms; >5.0 x ULN and asymptomatic | >5.0 x ULN and with signs or symptoms | Take worst case and assume “signs and symptoms”
Hyperuricemia | >ULN without physiologic consequences | - | >ULN with physiologic consequences | Life-threatening consequences | Take worst case and assume “with physiologic consequences”
Hypokalemia | <LLN - 3.0 mmol/L | Symptomatic with <LLN - 3.0 mmol/L; intervention indicated | <3.0 - 2.5 mmol/L; hospitalization indicated | <2.5 mmol/L; life-threatening consequences | Take worst case and assume “symptomatic”
Hyponatremia | <LLN - 130 mmol/L | 125 - <130 mmol/L and asymptomatic | 125 - <130 mmol/L symptomatic; 120 - <125 mmol/L regardless of symptoms | <120 mmol/L; life-threatening consequences | Take worst case and assume “symptomatic”

# DAIDS implementation

## Terms graded

Grading is implemented for those lab tests where a lab value is included in the grading definition, `{admiral}` does NOT try to read any other data to determine the grade, and only the `ADLB` dataset is used. The following DAIDS SOC values were identified for grading, these are “Chemistries” and “Hematology”.

From these SOC values the following terms criteria is implemented in `{admiral}`

From SOC = “Chemistries” there are 31 DAIDS Terms:

- Acidosis
- Albumin, Low
- Alkaline Phosphatase, High
- Alkalosis
- ALT, High
- Amylase, High
- AST, High
- Bicarbonate, Low
- Direct Bilirubin, High
- Total Bilirubin, High
- Calcium, High
- Calcium (Ionized), High
- Calcium, Low
- Calcium (Ionized), Low
- Creatine Kinase, High
- Creatinine, High
- Glucose Fasting, High
- Glucose Nonfasting, High
- Glucose, Low
- Lactate, High
- Lipase, High
- Cholesterol, Fasting, High
- LDL, Fasting, High
- Triglycerides, Fasting, High
- Magnesium, Low
- Phosphate, Low
- Potassium, High
- Potassium, Low
- Sodium, High
- Sodium, Low
- Uric Acid, High

Note: {admiral} does not grade for TERM = “Total Bilirubin, High” when AGE <= 28 days, these criteria are in Appendix of DAIDS Table for Grading the Severity of Adult and Pediatric Adverse Events Corrected Version 2.1.

From the SOC = “Hematology” there are 11 DAIDS Terms:

- Absolute CD4+ Count, Low
- Absolute Lymphocyte Count, Low
- Absolute Neutrophil Count (ANC), Low
- Fibrinogen Decreased
- Hemoglobin, Low
- INR, High
- Methemoglobin
- PTT, High
- Platelets, Decreased
- PT, High
- WBC, Decreased

## Terms with age or sex dependent grading criteria

Some terms defined in DAIDS have age or sex dependent grading criteria, {admiral} handles this in variable `FILTER` in the metadata. We use {admiral} function `compute_duration` to calculate age, see TERM = “Cholesterol, Fasting, High”:

TERM | FILTER
--- | ---
Cholesterol, Fasting, High | compute_duration(start_date = BRTHDT, end_date = ADT, trunc_out = TRUE, out_unit = “years”, add_one = FALSE, type = “interval”) >= 18 | is.na(BRTHDT) | is.na(ADT)
Cholesterol, Fasting, High | compute_duration(start_date = BRTHDT, end_date = ADT, trunc_out = TRUE, out_unit = “years”, add_one = FALSE, type = “interval”) < 18 | is.na(BRTHDT) | is.na(ADT)

Note: All possible values must be covered for each TERM defined, for TERM = “Absolute Lymphocyte Count, Low” and “Absolute CD4+ Count, Low” there is only grading criteria defined for age > 5 years. Therefore, we add another row with age <= 5 years and set grade to missing. Similarly, for TERM = “LDL, Fasting, High” there is only grading criteria defined for age > 2 years. Therefore, we add another row with age <= 2 years and set grade to missing.

TERM | FILTER | GRADE_CRITERIA_CODE
--- | --- | ---
LDL, Fasting, High | compute_duration(start_date = BRTHDT, end_date = ADT, trunc_out = TRUE, out_unit = “years”, add_one = FALSE, type = “interval”) <= 2 | is.na(BRTHDT) | is.na(ADT) | NA_character_
Absolute CD4+ Count, Low | compute_duration(start_date = BRTHDT, end_date = ADT, trunc_out = TRUE, out_unit = “years”, add_one = FALSE, type = “interval”) <= 5 | is.na(BRTHDT) | is.na(ADT) | NA_character_
Absolute Lymphocyte Count, Low | compute_duration(start_date = BRTHDT, end_date = ADT, trunc_out = TRUE, out_unit = “years”, add_one = FALSE, type = “interval”) <= 5 | is.na(BRTHDT) | is.na(ADT) | NA_character_

## Assumptions made when grading

For terms “INR, High”, “PT, High” and “PTT, High”, the criteria is based on subjects “not on anticoagulation therapy”, this is captured in COMMENT field.

TERM | COMMENT
--- | ---
INR, High | Assume “not on anticoagulation”
PTT, High | Assume “not on anticoagulation”
PT, High | Assume “not on anticoagulation”

Similarly, for terms “Absolute CD4+ Count, Low” and “Absolute Lymphocyte Count, Low”, the criteria is based on subjects “not HIV infected”, this is captured in COMMENT field.

TERM | COMMENT
--- | ---
Absolute CD4+ Count, Low | Assume “not HIV infected”
Absolute Lymphocyte Count, Low | Assume “not HIV infected”

For term “Acidosis”, “Alkalosis” and “Direct Bilirubin, High (> 28 days of age)”, {admiral} grades as high as possible, so assumes worst case and subject has “life-threatening consequences”. This is captured in COMMENT field.

TERM | COMMENT
--- | ---
Acidosis | Assume “with lifethreatening consequences”
Alkalosis | Assume “with lifethreatening consequences”
Direct Bilirubin, High | Assume worst case of “lifethreatening consequences (e.g., signs and symptoms of liver failure)”

Similarly, for term “Lactate, High”, {admiral} only grade 1 and 2, and there is the following criteria:

TERM | GRADE_1
--- | ---
Lactate, High | ULN to < 2.0 x ULN without acidosis

`{admiral}` assumed worst case and assume “without acidosis”. The decision made was put in the `COMMENT` field.

TERM | COMMENT
--- | ---
Lactate, High | Assume “without acidosis” (only grade 1 and 2)

For TERM “Direct Bilirubin, High (<= 28 days of age)” and “Uric Acid, High” the criteria is not given in SI unit. The conversion to SI unit is in the comment field.

TERM | COMMENT
--- | ---
Direct Bilirubin, High | 17.1 used as conversion from “mg/dL” to “umol/L”
Uric Acid, High | To convert “mmol/L” to “umol/L” multiply by 1000

Here is a complete list of all assumptions in the metadata for DAIDs

TERM | COMMENT
--- | ---
Absolute CD4+ Count, Low | Assume “not HIV infected”
Absolute Lymphocyte Count, Low | Assume “not HIV infected”
Acidosis | Assume “with lifethreatening consequences”
Alkalosis | Assume “with lifethreatening consequences”
Direct Bilirubin, High | Assume worst case of “lifethreatening consequences (e.g., signs and symptoms of liver failure)”
Direct Bilirubin, High | 17.1 used as conversion from “mg/dL” to “umol/L”
INR, High | Assume “not on anticoagulation”
Lactate, High | Assume “without acidosis” (only grade 1 and 2)
Methemoglobin | % hemoglobin
PT, High | Assume “not on anticoagulation”

# US (Conventional) unit implementation

The metadata for the US (Conventional) units is the same as the metadata for SI units except when checking for units, when the criteria is based on numeric values. The `UNIT_CHECK` variable will then contain the US (Conventional) unit, and if the unit is not a synonym for the SI unit then the grading criteria is updated accordingly. There were some lab tests where it made sense to have 2 sets of US (Conventional) units, these were lab tests related to `"WBC"`, `"Lymphocytes"`, `"Neutrophils"` and `"Platelets"`. We have the US unit `"10^3/uL"` which is a synonym of the SI unit `"10^9/L"`, and also the US unit `"10^3/ml"` which is a synonym for `"/mm3"` which is included in the grading criteria documentation. If companies have lab tests that have units that don’t exactly match what is in the `UNIT_CHECK` variable, but the unit is a one-to-one mapping, then the `UNIT_CHECK` variable can be updated with company-specific code to reflect this.

# Conclusion

With NCI-CTCAEv4, NCI-CTCAEv5, NCI-CTCAEv6 and DAIDS grading now implemented, {admiral} may look to implement other industry standard grading criteria. Providing tools for users to easily interact with the metadata to update criteria, based on their companies needs will also be looked at. Ideally, users should be able to create their own metadata for company specific grading schemes.