XN CAL PF

K141955 · Streck · KRX · Dec 5, 2014 · Hematology

Device Facts

• Record ID: K141955
• Device Name: XN CAL PF
• Applicant: Streck
• Product Code: KRX · Hematology
• Decision Date: Dec 5, 2014
• Decision: SESE
• Submission Type: Traditional
• Regulation: 21 CFR 864.8150
• Device Class: Class 2

Intended Use

XN CAL PF is used for the calibration and calibration verification of Sysmex XN series (XN-10, XN-11, XN-20, XN-21) analyzers. Assayed parameters include: PLT-F (10^3/ uL)

Device Story

XN CAL PF is an in-vitro diagnostic calibrator; functions as a substitute for fresh whole blood to calibrate PLT-F measurand on Sysmex XN Series analyzers. Contains stabilized red blood cell and platelet components in preservative medium; packaged in polypropylene vials. Used in clinical laboratory settings by trained personnel to adjust instrument calibration. Healthcare providers use the resulting calibrated analyzer output to ensure accurate hematology parameter reporting for patient diagnosis and monitoring. Benefits include standardized instrument performance and reliable PLT-F measurements.

Clinical Evidence

Bench testing only. Studies included open-vial stability (4 hours), closed-vial stability (49 days), and precision performance. Data demonstrated that the device is reproducible, stable for the claimed dating, and performs equivalently to the predicate.

Technological Characteristics

Stabilized red blood cell and platelet components in preservative medium. Polypropylene vial packaging. Storage 2-8°C. Calibrator for hematology cell indices. No electronic/software components; purely chemical/biological reagent. Referenced standards: CLSI EP05-A2 (precision), CLSI H26-A2 (hematology analyzer validation).

Indications for Use

Indicated for calibration and calibration verification of Sysmex XN series (XN-10, XN-11, XN-20, XN-21) hematology analyzers for the PLT-F parameter.

Regulatory Classification

Identification

A calibrator for cell indices is a device that approximates whole blood or certain blood cells and that is used to set an instrument intended to measure mean cell volume (MCV), mean corpuscular hemoglobin (MCH), and mean corpuscular hemoglobin concentration (MCHC), or other cell indices. It is a suspension of particles or cells whose size, shape, concentration, and other characteristics have been precisely and accurately determined.

Special Controls

*Classification.* Class II (special controls). The device is exempt from the premarket notification procedures in subpart E of part 807 of this chapter subject to the limitations in § 864.9.

Predicate Devices

• XN CAL™ PF (k120747)

Submission Summary (Full Text)

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Food and Drug Administration 10903 New Hampshire Avenue Document Control Center - WO66-G609 Silver Spring, MD 20993-0002

December 5, 2014

Streck. Inc. c/o Ms. Deborah Kipp Regulatory Affairs Manager 7002 South 109th Street Lavista, Nebraska 68128

Re: k141955

Trade/Device Name: XN CAL™ PF Regulation Number: 21 CFR 864.8150 Regulation Name: Calibrator for cell indices Regulatory Class: Class II Product Code: KRX Dated: October 24, 2014 Received: October 27, 2014

Dear Ms. Kipp:

We have reviewed your Section 510(k) premarket notification of intent to market the device referenced above and have determined the device is substantially equivalent (for the indications for use stated in the enclosure) to legally marketed predicate devices marketed in interstate commerce prior to May 28, 1976, the enactment date of the Medical Device Amendments, or to devices that have been reclassified in accordance with the provisions of the Federal Food. Drug. and Cosmetic Act (Act) that do not require approval of a premarket approval application (PMA). You may, therefore, market the device, subject to the general controls provisions of the Act. The general controls provisions of the Act include requirements for annual registration, listing of devices, good manufacturing practice, labeling, and prohibitions against misbranding and adulteration. Please note: CDRH does not evaluate information related to contract liability warranties. We remind you, however, that device labeling must be truthful and not misleading.

If your device is classified (see above) into either class II (Special Controls) or class III (PMA), it may be subject to additional controls. Existing major regulations affecting your device can be found in the Code of Federal Regulations, Title 21, Parts 800 to 898. In addition, FDA may publish further announcements concerning your device in the Federal Register.

Please be advised that FDA's issuance of a substantial equivalence determination does not mean that FDA has made a determination that your device complies with other requirements of the Act or any Federal statutes and regulations administered by other Federal agencies. You must comply with all the Act's requirements, including, but not limited to: registration and listing (21 CFR Part 807); labeling (21 CFR Part 801); medical device reporting (reporting of medical device-related adverse events) (21 CFR 803); good manufacturing practice requirements as set

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forth in the quality systems (QS) regulation (21 CFR Part 820); and if applicable, the electronic product radiation control provisions (Sections 531-542 of the Act); 21 CFR 1000-1050.

If you desire specific advice for your device on our labeling regulation (21 CFR Part 801), please contact the Division of Industry and Consumer Education at its toll-free number [phone] or [phone] or at its Internet address

http://www.fda.gov/MedicalDevices/ResourcesforYou/Industry/default.htm. Also, please note the regulation entitled. "Misbranding by reference to premarket notification" (21CFR Part 807.97). For questions regarding the reporting of adverse events under the MDR regulation (21 CFR Part 803), please go to

http://www.fda.gov/MedicalDevices/Safety/ReportaProblem/default.htm for the CDRH's Office of Surveillance and Biometrics/Division of Postmarket Surveillance.

You may obtain other general information on your responsibilities under the Act from the Division of Industry and Consumer Education at its toll-free number [phone] or [phone] or at its Internet address

http://www.fda.gov/MedicalDevices/ResourcesforYou/Industry/default.htm.

Sincerely yours.

# Maria M. Chan -S

Maria M. Chan, Ph.D. Director Division of Immunology and Hematology Devices Office of In Vitro Diagnostics and Radiological Health Center for Devices and Radiological Health

Enclosure

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# Indications for Use

510(k) Number (if known)

#### k141955

Device Name XN CAL PF

Indications for Use (Describe) XN CAL PF is used for the calibration and calibration verification of Sysmex XN series (XN-10, XN-11, XN-20. XN-21) analyzers. Assayed parameters include:

PLT-F (10^3/ uL)

Type of Use (Select one or both, as applicable)

Prescription Use (Part 21 CFR 801 Subpart D)

Over-The-Counter Use (21 CFR 801 Subpart C)

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FOR FDA USE ONLY

Concurrence of Center for Devices and Radiological Health (CDRH) (Signature)

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# 510(k) Summary

| 510(k) Submitter: | Streck<br>7002 South 109th Street<br>La Vista, NE 68128 |
|-------------------------|---------------------------------------------------------|
| Official Correspondent: | Deborah Kipp, Regulatory Affairs Manager |
| Address: | 7002 South 109th Street; La Vista, NE 68128 |
| Phone: | 402-537-5215 |
| Fax: | 402-537-5317 |
| Date Prepared: | April 18, 2014 |
| Names | |

Trade Name: Common Name: Classification Name: Product Code: Panel:

XN CAL™ PF Assayed Hematology Calibrator Calibrator for Cell Indices (864.8150) KRX Hematology

## Predicate Device:

XN CAL™ PF (K120747)

### Intended Use:

XN CAL PF is used for the calibration and calibration verification of Sysmex XN series (XN-10, XN-11, XN-20, XN-21) analyzers. Assayed parameters include:

PLT-F (103/ µL)

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# Description:

Per the FDA guidance document, The 510(k) Program: Evaluating Substantial Equivalence in Premarket Notifications (510(k)), a predicate device was selected in order to demonstrate substantial equivalence for XN CAL PF. The predicate device is shown in the "Comparison to Predicate Device" section.

# Comparison to Predicate Device

| | XN CAL™ PF (K120747)-Predicate<br>Device | XN CAL™ PF -Candidate Device | Same or Differences |
|------------------------------|--------------------------------------------------------------------------------------------------------------------------------------------------------------------|---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|------------------------------------------------------------|
| Intended<br>Use<br>Statement | XN CAL PF is used for calibration and<br>calibration verification of Sysmex XN<br>series (XN-10, XN-20) analyzers. The<br>assayed parameter is:<br>PLT-F (103/μL) | XN CAL PF is used for calibration and<br>calibration verification of Sysmex XN series<br>(XN-10, XN-11, XN-20, XN-21) analyzers.<br>The assayed parameter is:<br>PLT-F (103/μL) | Addition of the XN-11 and<br>XN-21 analyzers. |
| Open Vial<br>Stability | 4 hours | 4 hours | Same |
| Closed Vial<br>Stability | 35 days | 49 days | Extension of Closed Vial<br>Stability Dating to 49<br>days |
| Reagents | XN CAL PF contains the following:<br>stabilized red blood cell component(s),<br>and stabilized platelet component(s) in a<br>preservative medium. | XN CAL PF contains the following: stabilized<br>red blood cell component(s), and stabilized<br>platelet component(s) in a preservative<br>medium. | Same |
| Storage<br>Conditions | 2 - 8°C | 2 - 8°C | Same |

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### Discussion of Tests and Test Results:

To substantiate the product performance claims for XN CAL PF, Streck collected product performance data for the following studies Open-Vial Stability, Closed-Vial Stability, and Precision Performance. The resultant data set established that XN CAL PF is safe and effective for its intended use and that the product is stable for the entire product dating. The product fulfills its intended use as instructed in the Instructions for Use.

# Conclusions Drawn From Tests:

Study results show XN CAL PF to be consistently reproducible, substantially equivalent to the predicate products, and stable for the entire product dating. XN CAL PF is a safe and effective product, which fulfills its intended use when used as instructed in the Instructions for Use.