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Test ID FRT4D T4 (Thyroxine), Free, Dialysis, Serum

Reporting Name

T4 (Thyroxine), Free by Dialysis, S

Useful For

Determining thyroid status of sick, hospitalized patients


Determining thyroid status of patients in whom abnormal binding proteins have been identified


Possibly useful in pediatric patients

Specimen Type


Ordering Guidance

The routine free T4 is faster and provides useful information for most patients; order FRT4 / T4 (Thyroxine), Free, Serum.

Necessary Information

Include name and telephone number of contact physician

Specimen Required

Collection Container/Tube:

Preferred: Red top

Acceptable: Serum gel

Submission Container/Tube: Plastic vial

Specimen Volume: 2.6 mL

Collection Instructions:

1. Draw blood immediately before next scheduled dose.

2. Centrifuge and aliquot serum into plastic vial within 2 hours of collection.

Specimen Minimum Volume

1.2 mL

Specimen Stability Information

Specimen Type Temperature Time Special Container
Serum Refrigerated (preferred) 28 days
  Frozen  21 days
  Ambient  7 days

Reference Values

0.8-2.0 ng/dL

Reference values apply to all ages.

Day(s) Performed

Monday, Wednesday, Thursday

Test Classification

This test was developed, and its performance characteristics determined by Mayo Clinic in a manner consistent with CLIA requirements. This test has not been cleared or approved by the US Food and Drug Administration.

CPT Code Information


LOINC Code Information

Test ID Test Order Name Order LOINC Value
FRT4D T4 (Thyroxine), Free by Dialysis, S 6892-4


Result ID Test Result Name Result LOINC Value
8859 T4 (Thyroxine), Free by Dialysis, S 6892-4

Clinical Information

Thyroxine (T4) and triiodothyronine (T3) are the 2 biologically active thyroid hormones. T4 makes up more than 80% of circulating thyroid hormones.


Following secretion by the thyroid gland, approximately 70% of circulating T4 and T3 are bound to thyroid-binding globulin (TBG), while 10% to 20% each are bound to transthyretin (TTR) and albumin, respectively. Less than 0.1% circulates as free T4 (FT4) or free T3 (FT3). FT4 and FT3 enter and leave cells freely by diffusion. Only the free hormones are biologically active, but bound and free fractions are in equilibrium. Equilibrium with TTR and albumin is rapid. By contrast, TBG binds thyroid hormones very tightly and equilibrium dissociation is slow. Biologically, TBG-bound thyroid hormone serves as a hormone reservoir, and T4 serves as a prohormone for T3. Within cells, T4 is either converted to T3, which is about 5 times as potent as T4, or reverse T3, which is biologically inactive. Ultimately, T3, and to a much lesser degree T4, bind to the nuclear thyroid hormone receptor, altering gene expression patterns in a tissue-specific fashion.


Under normal physiologic conditions, FT4 and FT3 exert direct and indirect negative feedback on pituitary thyrotropin (TSH) levels, the major hormone regulating thyroid gland activity. This results in tight regulation of thyroid hormone production and constant levels of FT4 and FT3 independent of the binding protein concentration. Measurement of FT4 and FT3, in conjunction with TSH measurement, therefore, represents the best method to determine thyroid function status. It also allows determination of whether hyperthyroidism (increased FT4) or hypothyroidism (low FT4) are primary (most cases; TSH altered in the opposite direction as FT4) or secondary/tertiary (hypothalamic/pituitary origin; TSH altered in the same direction as FT4). By contrast, total T4 and T3 levels can vary widely as a response to changes in binding protein levels, without any change in free thyroid hormone levels and, hence, actual thyroid function status.


FT4 is usually measured by automated analog immunoassays. In most instances, this will result in accurate results. However, abnormal types or quantities of binding proteins found in some patients and most often related to other illnesses or drug treatments, may interfere in the accurate measurement of FT4 by analog immunoassays. These problems can be overcome by measuring FT4 by equilibrium dialysis, free from interfering proteins.


All free hormone assays should be combined with thyrotropin measurements.


Free thyroxine (FT4) levels below 0.8 ng/dL indicate possible hypothyroidism. FT4 levels above 2.0 ng/dL indicates possible hyperthyroidism.


Neonates can have significantly higher FT4 levels. The hypothalamic-pituitary-thyroid axis can take several days or, sometimes, weeks to mature.


Certain drugs may cause short-term free thyroxine fluctuations:



 -Acetylsalicylic acid (aspirin)

 -Salicylic acid (salsalate)



-Mefenamic acid

-Flufenamic acid





Clinical Reference

1. De Brabandere VI, Hou P, Stockl D, Thienpont LM, De Leenheer AP. Isotope dilution-liquid chromatography/electrospray ionization-tandem mass spectrometry for the determination of serum thyroxine as a potential reference method. Rapid Commun Mass Spectrom. 1998;12:1099-1103

2. Jain R, Uy HL. Increase in serum free thyroxine levels related to intravenous heparin treatment. Ann Intern Med. 1996;124:74-75

3. Stockigt JR. Free thyroid hormone measurement. A critical appraisal. Endocrinol Metab Clin North Am. 2001;30(2):265-289

4. Sakai H, Nagao H, Sakurai M, et al. Correlation between serum levels of 3,3',5'-triiodothyronine and thyroid hormones measured by liquid chromatography-tandem mass spectrometry and immunoassay [published correction appears in PLoS One. 2016;11(7):e0159169]. PLoS One. 2015;10(10):e0138864. doi:10.1371/journal.pone.0138864

6. Kahric-Janicic N, Soldin SJ, Soldin OP, West T, Gu J, Jonklaas J. Tandem mass spectrometry improves the accuracy of free thyroxine measurements during pregnancy. Thyroid. 2007;17(4):303-311. doi:10.1089/thy.2006.0303

Method Description

The equilibrium dialysis method separates free thyroxine from serum proteins and, thereby, also from protein-bound thyroxine (T4), before measuring it in the protein-free dialysate using sensitive, tandem mass spectrometry. The results are independent of the concentrations of the T4-binding proteins and unaffected by the presence of molecular variants of these proteins.(Soldin SJ, Soukhova N, Janicic N, et al: The measurement of free thyroxine by isotope dilution tandem mass spectrometry. Clin Chim Acta. 2005;358:113-118; Masika LS, Zhao Z, Soldin SJ. Is measurement of TT3 by immunoassay reliable at low concentrations? A comparison of the Roche cobas 6000 vs. LC-MSMS. Clin Biochem. 2016;49[12]:846-849)

Report Available

3 to 8 days

Reject Due To

Gross hemolysis Reject
Gross lipemia Reject
Gross icterus Reject

Method Name

Equilibrium Dialysis/Tandem Mass Spectrometry (MS/MS)