Clinical Chemistry Reviewer by MTR

MUST TO KNOW IN CLINICAL CHEMISTRY
(From CC by Rodriguez)
Quality Control
Practicability
Method is easily repeated
Reliability
Maintain accuracy and precision
Intralab/Interlab QC
Daily monitoring of accuracy and precision
Interlab/External QC
Proficiency testing (Reference lab)
Long-term accuracy
Difference of >2: not in agreement w/ other lab
QC materials
Available for a min. of 1 yr
Bovine control
Preferred (Human: biohazard)
materials
Not for immunochem, dye-binding and bilirubin
Matrix effect
Improper product manufacturing
Unpurified analyte
Altered protein
Precision study
First step in method evaluation
Nonlab. personnel
29% of errors (lab results)
SD
Dispersion of values from the mean
CV
Index of precision
Relative magnitude of variability (%)
Variance
SD2
Measure of variability
Inferential statistics
Compare means or SD of 2 groups of data
T-test
Means of 2 groups of data
F-test
SD of 2 groups of data
Cumulative Sum Graph V-mask
(CUSUM)
Earliest indication of systematic errors (trend)
Youden/Twin Plot
Compare results obtained from diff. lab
Shewhart LeveyGraphic representation of the acceptable limits of variation
Jennings Chart
Trend
Gradual loss of reliability
Cause: Deterioration of reagents (Systematic error)
Shift
Values: one side or either side of the mean
Cause: Improper calibration (Systematic error)
Outliers
Values: far from the main set of values
Highly deviating values
Random or systematic errors
Kurtosis
Degree of flatness or sharpness
Precision
Random error
Accuracy
Systematic error
Random error
Causes:
(Imprecision;
-Mislabeling
Indeterminate)
-Pipetting error
-Improper mixing of sample and reagents
-Voltage/Temperature fluctuation
-Dirty optics
Parameters: SD and CV
Systematic error
Causes:
(Inaccuracy/Determinat -Improper calibration
e)
-Deterioration of reagents
-Contaminated solution
-Sample instability/unstable reagent blanks
lec.mt 04 |Page | 1
Multirule Shewhart
procedure
Test method
Reference method
Analytical Run
Physiologic Limit
POCT
Quality Assurance
Quality Patient Care

Reference Range/
Interval Range/
Reference Values
Wavelength
Spectrophotometric
meas.
Photometric
measurement
LASER
Visible region
UV
IR
Stray light
Diffraction gratings
Prisms
Nickel sulfate
Cutoff filter
Bandpass
Alumina silica glass
cuvet
Quartz/plastic cuvet
Borosilicate glass cuvet
Photodetector
Barrier layer cell/
-Diminishing lamp power

-Incorrect sample and reagent volume
Parameter: Mean
Control rules + Control chart
Westgard: at least 40 samples
Westgard: preferably 100 samples
Control and patient specimens assayed, evaluated, and report
together
Referred to as absurd value
Performed by nonlab personnel
Tripod:
Program development
Assessment and monitoring
Quality improvement
Test request forms, clear instruction for patient prep., specimen
handling
At least 120 individuals should be tested in each age and sex
category
Analytical Methods
Distance bet 2 successive peaks (nm)
Lower frequency = Longer wavelength (Ex. Red)
Higher frequency = Shorter wavelength (Ex. Violet)
Meas. light intensity in a narrower wavelength
Meas. light intensity w/o consideration of wavelength
Multiple wavelength (uses filter only)
Light Amplification by Stimulated Emission of Radiation
Light source for spectrophotometry
Tungsten light bulb
Mercury arc
Deuterium lamp
Mercury arc
Xenon lamp
Hydrogen lamp
Merst glower
Globar (Silicone carbide)
Wavelength outside the band
Most common cause of loss of linearity
Most commonly used monochromator
Cutting grooves
Rotatable
Prevents stray light
Anti-stray light
peak transmittance
Most commonly used cuvet
UV
Strong bases
Converts transmitted light into photoelectric energy
Simplest detector
lec.mt 04 |Page | 2
photocell/ photovoltaic
cell
Phototube
Photomultiplier tube
Galvanometer/Ammete
r
Absorbance
Double beam spectro.
Double-beam in space
Double-beam in time
Dydimium filter
Holmium oxide filter
Reagent blank
Sample blank
FEP
Cesium and Lithium

Lithium
AAS
Atomizer (nebulizer)
Chopper
Lanthanum/Strontium
chloride
Volumetric (Titrimetric)
Turbidimetry
Nephelometry
Electrophoresis
Iontophoresis
Zone electrophoresis
Endosmosis
No external voltage
For filter photometers
Contains anode and cathode
Req external voltage
Most common type
Most sensitive
UV and visible region
Meter or read-out device
A = abc (a = absorptivity; b = length of light (1cm); c =
concentration)
A = 2 log%T
Splits monochromatic light into two components:
One beam sample
One beam reference soln or blank (corrects for variation in light
source intensity)
2 photodetectors (sample beam and reference beam)
1 photodetector
Monochromatic light sample cuvet and reference cuvet
600 nm
360 nm
Color of reagents
Optical interference (Hgb)
Meas. light emitted by a single atom burned in a flame
Principle: Excitation
Lt. source and cuvette: Flame
For excited ions (Na+, K+)
Internal standards (FEP)
Correct variations in flame
Preferred internal std
Potent antidepressant
Meas. light absorbed by atoms dissociated by heat
Principle: Dissociation (unionized, unexcited, ground state)
Lt. source: Hollow-cathode lamp
For unexcited trace metals (Ca++ and Mg++)
More sensitive than FEP
Convert ions atoms
Modulate the light source
Complex with phosphate
Avoid calcium interference
Unknown sample is made to react with a known solution in the
presence of an indicator
Light blocked
Meas. abundant large particles (Proteins)
Depend on specimen concentration and particle size
Meas. amt of Ag-Ab complexes
Scattered light
Depends on wavelength and particle size
Migration of charged particles in an electric field
Migration of small charged ions
Migration of charged macromolecules
Movement of buffer ions and solvent relative to the fixed support
lec.mt 04 |Page | 3
Cellulose acetate
Agarose gel
Polyacrylamide gel
Electrophoretic mobility
Isoelectric focusing
Densitometry
Capillary
electrophoresis
Southern blot
Northern blot
Western blot
Chromatography
Paper chromatography
TLC
Retention factor (Rf)
value
Gas chromatography
Gas Solid
chromatography
Gas Liquid
chromatography
Mass Spectrometry
GC-MS
MS/MS
HPLC
Hydrophilic gel
Hydrophobic gel
Ion exchange
chromatography
Partition
chromatography
Affinity
chromatography
Adsorption
Ex: gamma globulins

Molecular size
Electrical charge
Charge and molecular size
20 fractions (ex. isoenzymes)
Directly proportional to net charge
Inversely proportional to molecular size & viscosity of the
supporting medium
Molecules migrate through a pH gradient
pH = pI
For isoenzymes: same size, different charge
Scan & quantitate electrophoretic pattern
Electro-osmotic flow
DNA
RNA
Proteins
Separation by specific differences in physical-chemical
characteristics of the different constituents
Fractionation of sugar and amino acid
Sorbent: Whatman paper
Screening: Drugs
Relative distance of migration from the point of application
Rf = Distance leading edge of component moves
Total distance solvent front moves
Separation of steroids, barbiturates, blood, alcohol, and lipids
Volatile compounds
Specimens vaporized
Mobile phase: Inert gases
Differences in absorption at the solid phase surfaces
Differences in solute partitioning between the gaseous mobile
phase and the liquid stationary phase
Fragmentation and ionization
Gold standard for drug testing
Detect 20 inborn errors of metabolism from a single blood spot
Most widely used liquid chromatography
Fractionation of drugs, hormones, lipids, carbohydrates and
proteins
Gel filtration
Separation of enzymes, antibodies and proteins
Ex: Dextran and agarose
Gel permeation
Separation of triglyceride and fatty acid
Ex: Sephadex
Separation depends on the sign and ionic charge density
Based on relative solubility in an organic solvent (nonpolar) and an
aqueous solvent (polar)
For lipoproteins, CHO and glycated hemoglobins
Based on differences between the adsorption and desorption of
lec.mt 04 |Page | 4
chromatography
Fluorometry/Molecular
Luminescence Spectro.
Quenching
Borosilicate glasswares
Boron-free/Soft
glasswares
Corex (Corning)
Vycor (Corning)
Flint glass
TD: To deliver
TC: To contain
Blowout
Self-draining
Transfer pipet
Graduated or
measuring pipet
Micropipettes
Air displacement pipet

Positive displacement
pipet
Dispenser/Dilutor pipet
solutes at the surfaces of a solid particle

Det. amt. of lt. emitted by a molecule after excitation by
electromagnetic radiation
Lt. sources: Mercury arc and Xenon lamp (UV)
Lt. detector: Photomultiplier tubes
2 monochromators:
Primary filter selects wavelength absorbed by the solution to be
measured
Secondary filter prevents incident light from striking the
photodetector
Sensitivity: 1000x than spectro
Major disadvantage of fluorometry
pH and temperature changes, chemical contaminants, UVL
changes
Instrumentation
For heating and sterilization
Ex: Pyrex and Kimax
High resistance to alkali
Special alumina-silicate glass
Strengthened chemically than thermally
6x stronger than borosilicate
For high thermal, drastic heat and shock
Can be heated to 900OC
Soda-lime glass + Calcium, Silicon, Sodium oxides
Easy to melt
For making disposable glasswares
Exact amount
Does not disperse the exact volume
w/ etched rings on top of pipet
w/ o etched rings
Drain by gravity
Volumetric: for non-viscous fluid; self-draining
Ostwald folin: for viscous fluid; w/ etched ring
Pasteur: w/o consideration of a specific volume
Automatic macro-/micropipets
Serological: w/ graduations to the tip (blowout)
Mohr: w/o graduations to the tip (self-draining)
Bacteriologic
Ball, Kolmer and Kahn
Micropipettes: <1 mL
TC pipets:
Sahli-Hellige pipet
Lang-Levy pipet
RBC and WBC pipets
Kirk and Overflow pipets
Piston: suction
Disposable tip
Piston barrel (like a hypodermic syringe)
Liquid: common reservoir dispense repeatedly
lec.mt 04 |Page | 5
Distilled H2O
Mercury
Acid dichromate
(H2SO4 + K2Cr2O4)
Continuous flow
analyzer
Centrifugal analyzer
Discrete Analyzer
Thin-Film Analyzers
(Dry slide technology)
Carry over
Batch testing
Calibrating medium for TD pipettes

Calibrating medium for TC pipettes
Cleaning solution for glasswares
Common reaction vessel
Air bubbles: separates and cleans
Glass coil: mix
Examples: STS
Simultaneous Multiple Analyzer (SMA)
Technicon Autoanalyzer II
SMAC
Acceleration and deceleration of the rotor
Advantage: Batch analysis
Examples: RICC
Cobas-Bio (Roche)
IL Monarch
CentrifiChem
RotoChem
Most popular
Req. vol: 2-6 L
Uses positive-displacement pipets
Run multiple-tests-one-sample-at-a-time
Random access capability (STAT)
Examples:
Vitros
Dimension Dade
Beckman ASTRA System (4 & 8)
Hitachi
Bayer Advia
Roche Cobas Integra 800
Roche Analytics P Module
Automated Clinical Analyzer (ACA) Star (Dade)
Dupont ACA
Abbott ABA-100 Bichromatic Analyzer
ABA-200
VP Analyzer
American Monitor KDA
Olympus Demand
4 or 5 layers:
-Spreading layer
-Scavenger layer - Ascorbate Oxidase
-Reagent layer
-Indicator layer
-Support layer
Colored reaction Reflectance spectrophotometry
Examples: KV2(75)
Kodak Ektachem
Vitros 750XRC
Vitros 550XRC
Transport of quantity of analyte or rgt from one specimen rxn into
another, and contaminating a subsequent one
All samples loaded at the same time
lec.mt 04 |Page | 6
Parallel testing
Random access testing
Sequential testing
Open reagent system
Closed reagent system
Exercise
Fist clenching
Fasting
Basal state collection
Diet
Single test is conducted on each sample

One specimen
More than one test is analyzed
Any sample
Any test
Any sequence
STAT
Multiple tests analyzed one after another on a given specimen
System other than manufacturers reagents can be utilized for
measurement
The operator can only use the manufacturers reagents
Patient Preparation
Increased: GU2FT C2L3A5P2
GH
Urea
Urinary protein (Proteinuria)
Fatty acid
Testosterone
CPK (muscle)
Creatinine (muscle)
Lactate
LH
LD (muscle)
ACP
Aldolase (muscle)
AST
ALT
Ammonia
Pyruvate
Prolactin
Decreased:
Glucose
Increased: LPP
Lactate
Potassium
Phosphate
8-16 hours:
Glucose
Lipids
Lipoproteins
Increased:
Bilirubin (48 hours)
Triglyceride (72 hours)
Glucose
Cholesterol
Triglyceride
Electrolytes
Increased: GLUC2H
Glucose
Lipids
Urea (High protein diet)
Caffeine: increases glucose
Catecholamines
lec.mt 04 |Page | 7
Turbidity/Lactescence
Icterisia
Icteric samples
Upright/supine (lying)
position
Supine
Sitting/Standing
Sitting Supine
Standing Supine
Prolonged standing
Prolonged bedrest
Tourniquet
Prolonged tourniquet
app.
Tobacco smoking
(Nicotine)
Alcohol ingestion
5-HIAA (From Serotonin)

Triglyceride >400mg/dL
Bilirubin: 25.2 mg/dL
Interfere with: "TACGu
Total Protein
Albumin
Cholesterol
Glucose
Preferred position
Patient should be seated/supine at least 20 mins before blood
collection to prevent hemodilution or hemoconcentration
Vasoconstriction Reduced plasma volume
Increased: ECA
Enzymes
Calcium
Albumin
Hemoconcentration
Increased: P(u)BLIC
Proteins
BUN
Lipids
Iron
Calcium
Hemodilution
Decreased: TLC
Triglycerides
Lipoproteins
Cholesterol
Increased: K+ (muscles)
Decreased: Albumin (Fluid retention)
Recommended: 1 minute application
Hemoconcentration
Anaerobiosis
Increased: C2LEA2K
Calcium
Cholesterol
Lactate
Enzymes
Ammonia
Albumin
K+
Increased: TUNG2C3
Triglycerides
Urea
Nonesterified fatty acid
Glucose
GH
Catecholamines
Cortisol
Cholesterol
Increased: THUG
Triglycerides
Hypoglycemia (chronic alcoholism)
lec.mt 04 |Page | 8
Ammonia
Stress (anxiety)
Drugs
Diurnal variation
Sleeping patients
Unconscious patients
Venipuncture
Tourniquet
Needle
After blood collection
BP cuff as tourniquet
Benzalkonium chloride
(Zephiran)
IV line on both arms
IV fluid contamination
Renin blood level

Basal state collection
Uric acid/Urates
GGT
Increases by 100-200g/L/cigar
Increased: LAGIC
Lactate
Albumin
Glucose
Insulin
Cholesterol
Medications affecting plasma volume can affect protein, BUN, iron,
calcium
Hepatotoxic drugs: increased liver function enzymes
Diuretics: decreased sodium and potassium
"CA3PI2TG
Cortisol
ACTH
ACP
Aldosterone
Prolactin
Iron
Insulin
Thyroxine
GH
Specimen Collection and Handling
Must be awakened before blood collection
Ask nurse or relative
Identification bracelet
Median Cubital (1st) Cephalic (2nd) Basilic (3rd)
Velcro or Seraket type
3-4 inches above the site
Not exceed 1 minute
Bevel up
15-30O angle
Length: 1 or 1.5 inch (Butterfly needle: to inch)
Cotton site
Apply pressure for 3-5 minutes
Inflate to 60 mmHg
Disinfectant for ethanol testing
Dilution 1:750
Discontinue IV for 2 minutes
Collect sample below the IV site
Initial sample (5mL) discard
Increased:
Glucose (10% contam. w/ 5% dextrose increased bld glucose by
500 mg/dL)
Chloride
Potassium
Sodium
Decreased:
Urea
Creatinine
Collected after a 3-day diet, from a peripheral vein
Early morning blood collection
lec.mt 04 |Page | 9
Lancet
Incision (Skin puncture)
1.5-2.4mm
Arterialized capillary
blood
Flea
Indwelling umbilical
artery
1000-3000 RCF for 10
mins
Hemolysis
Refrigeration/Chilling
(Low temp)
Photosensitive analytes
Oxalate
Citrate
EDTA
12 hours after the last ingestion of food

1.75mm: preferred length to avoid penetrating the bone
<2.0mm (infants and children)
2-3mm (adults)
Distance from the skin surface to bone or cartilage (middle finger)
Earlobe: Preferred site
Lateral plantar heel surface: most commonly used site
Minute metal filling which may be inserted into the capillary tube
before collecting blood to help mix the specimen while the blood is
entering the tube
Best site for blood gas analysis (newborns)
Centrifugation requirement
Increased:
KLA6MP ITC2
-K+
-LDH (150x)
-ACP
-ALP
-Aldolase
-ALT
-AST
-Albumin
-Mg2+
-Phosphorus
-Iron
-Total protein
Affects bilirubin levels
Inhibits lipase
Required for: ABCGLRP2
Ammonia
Blood gases
Catecholamines
Gastrin
Lactic acid
Renin
PTH
Pyruvate
Decreased:
LD 4 and 5
Increased:
ALP
Bilirubin
Beta-carotene
Folate
Porphyrins
Vitamins A and B6
Insoluble salt
1-2 mg/mL blood
Non-ionized form
3.2-3.8 g/dL (1:9 ratio)
Chelation
lec.mt 04 |Page | 10
Fluoride
Heparin
Lithium heparin
Orange top tube
Royal blue top tube
Brown top tube

Tan top tube
Black top tube
Respinning gel tubes
Thixotropic gel
% w/v
% v/v
% w/w
Molarity
Moles
To prepare a molar
solution
To convert % w/v to
Molarity
Normality
Equivalent weight (EW)
To prepare a normal
solution of solids
To convert % w/v to
Normality
Normality
Molarity
1-2 mg/mL blood

Versene: disodium salt
Sequestrene: Dipotassium salt
Weakly dissociated calcium component
2 mg/mL blood: anti-glycolytic
10 mg/mL blood: anticoagulant
A.k.a. Mucoitin polysulfuric acid
Universal anticoagulant
Antithrombin
0.2 mg/mL blood
For glucose, BUN, ionized calcium, electrolyte studies (K +: best)
and creatinine
Additive: Thrombin
Additives:
None;
Na2EDTA
Sodium heparin
Lead testing
Lead testing
Additive: Buffered sodium citrate
For ESR
Increases potassium
Gel separator (SG: 1.04)
Serum: (SG: 1.03)
RBC: (SG: 1.05)
Laboratory Mathematics
Grams of solute = % solution desired x total volume desired
100
mL of solute = % solution desired x total volume desired
100
Grams of solute = % solution desired x grams of the total solution
100
M=
_grams of solute_______
GMW x volume of solution
Mol = weight (grams)
GMW
Grams of solute = Molarity x GMW of the solute x Volume (L)
desired
M = % w/v 10
GMW
N = _Grams of solute_
EW x volume (L)
EW = __MW___
valence
Grams of solute = Normality x EW x Volume (L)
N = w/v 10
EW
N = Molarity x Valence
M = Normality
valence
Molality
Milliequivalents
Millimoles
Ratio
Dilution
0.179
0.01
2.27
Analytical reagent (AR)
grade
Ultrapure reagents
Chemically Pure (CP) or
Pure Grade
Technical/Commercial
grade
United States
Pharmacopoeia (USP)
and National Formulery
(NF)
Preparation of reagent
grade water
Type I Rgt Water
m=
Grams of solute__
MW x kg of solvent
mEq/L = mg/dL 10 valence
MW
mmol/L = mg/dL 10
MW
Ratio = _Volume of solute_
Volume of solvent
Dilution = __Volume of solute__
Volume of solution
Conversion factor for iron (mg/dL mol/L)
Conversion factor for phospholipid (g/dL to g/L)
Conversion factor for folate
For qualitative and quantitative analyses
For accuracy
Established by American Chemical Society (ACS)
Uses: Trace metal analysis and preparation of standard solutions
Additional purification steps
Ex: Spectrograde, nanograde, HPLC grade
Uses: Chromatography, atomic absorption, immunoassays
Indicates that the impurity limitations are not stated
Purity is delivered by meas. of melting point or boiling point
In manufacturing
Never used in clin. lab. testing
For human consumption
Not applicable for lab. analysis
Purpose: For drug manufacturing
Filtration (1st) Distillation, Ion exchange, Reverse Osmosis
Occupational Safety
and Health Act (OSHA)
Min. interference
Max. water purity
Used immediately
For ultramicrochemical analyses, measurements of nanogram or
subnanogram concentrations, tissue or cell methods (microscopy)
and preparation of standard solutions
Uses: FEP, AAS, blood gases and pH, enzyme studies, electrolyte
testing, HPLC, trace metal and iron studies
For clinical laboratory use (hematology, microbiology, immunology,
chemistry)
For prep. of rgts and QC materials
For washing glasswares
For urinalysis, parasitology and histology
Purified to remove almost all organic materials
Free from mineral salts; removed by ion exchange processes
Organic material may still be present
Req. manuf. to indicate lot no., physical or biological health hazard
of the chem.. rgts, and precautions for safe use and storage
College of American
Pathologists (CAP)
Tests for water purity
Recommends that a lab. document culture growth, pH and specific

water resistance on reagent grade water
Microbiological content
Type II Rgt Water

Type III
Distilled water
Deionized water
Detergentcontaminated water
Hard water
NCCLS
Dilute solution
Concentrated solution
Saturated solution
Super saturated
solution
Primary standard
(IUPAC)
pH
Resistivity
Chemical oxygen demand
Ammonia
Ions
Metals
Alkaline pH
Contains calcium, iron and other dissolved elements

Now: Clinical and Laboratory Standards Institute (CLSI)
Relatively little solute
Large quantity of solute in solution
Excess of undissolved solute particles
Greater concentration of undissolved solute particles than does a
saturated solution of the same substance
Highly purified
Measured directly to produce a substance of exact known
concentration
Secondary standard
Low purity
Concentration is determined by comparison w/ a primary standard
Laboratory Safety
National Fire Protection Association (NFPA) Classification of Fires
Class A fire
Ordinary combustibles: paper, cloth, rubbish, plastics, wood
Extinguisher: Water (A), Dry chemical (ABC), loaded steam
Class B fire
Flammable liquids: grease, gasoline, paints, oil
Extinguisher: Dry chemical (ABC), carbon dioxide (BC), halon foam
(BC)
Class C fire
Electrical equipment and motor switches
Extinguisher: Dry chemical (ABC), Carbon dioxide (BC), halon (BC)
Class D fire
Flammable metals: mercury, magnesium, sodium, lithium
Extinguisher: Metal X
Fought be fire fighters only
Class E fire
Detonation (Arsenal fire)
Allowed to burn out and nearby materials protected
Standard Hazards Identification System (Diamond-shaped color coded symbol)
Blue quadrant
Health hazard
Red quadrant
Flammable hazard
Yellow quadrant
Reactivity/Stability hazard
White quadrant
Other special information
Chemical spills
1st step: assist/evacuate personnel
1:10 dilution of chlorine To disinfect and clean bench tops
bleach (10%)
In contact with the area for at least 20 minutes
HBV: 10 minutes
HIV: 2 minutes
Poisonous vapors
Chloroform
Methanol
Carbon tetrachloride
Bromide
Ammonia
Formaldehyde
Mercury
Flammable and
Acetone
combustible solvents
Flammable liquids
Combustible liquids
Strong acids or bases
Ether
Benzidine
Fumehoods
Safety showers
Glycol aldehyde
Sucrose
Pancreas
Hyperglycemic
Hormones
Hyperglycemia
(126 mg/dL)
Hypoglycemia
Whipples triad
(Hypoglycemia)
6:1
Type 1 DM
Complications of Type I
DM
Ethanol
Toluene
Methanol
Xylene
Benzene
Isopropanol
Heptane
Flash point below 37.8OC
Flash point at or above 37.8OC
Neutralized before disposal
Water should NEVER be added to concentrated acid
Deteriorate over time hazardous
Forms explosive peroxides
Known carcinogen
Ventilation: velocity of 100-120 ft/min
Deliver 30-50 gal/min of H2O at 20-50 psi
Carbohydrates
The simplest carbohydrate
Most common nunreducing sugar
Exocrine: Enzymes (AMS, LPS)
Endocrine: Hormones (Insulin, glucagon, somatostatin)
GAG CHET
Glucagon
ACTH
GH
Cortisol
Human Placental Lactogen
Epinephrine
Thyroxine
Electrolyte Imbalance:
Decreased: Sodium, Bicarbonate
Increased: Potassium
50-55 mg/dL = Symptoms
50 mg/dL = Diagnostic
Low blood glucose concentration
Typical symptoms
Symptoms alleviated by glucose administration
Ratio of BHA to AA in severe DM
(Normal = 1:1)
IDDM
Juvenile Onset
Brittle
Ketosis-prone
80-90% reduction of beta-cells Symptomatic Type 1 DM
HLA-DR3 and DR4
(+) Glutamic acid decarboxylase (GAD65)
(+) Insulin autoantibodies
(+) Microalbuminuria: 50-200 mg/24 hours = Diabetic nephropathy
(-) C-peptide
Microvascular disorders:
Nephropathy
Neuropathy
Type 2
Gestational DM
OGTT (GDM)
Impaired fasting
glucose (Pre-diabetes)
Impaired glucose
tolerance
FBS
CSF glucose
Peritoneal fluid glucose
Plasma glucose
increases w/ age
w/in 1 hour
(Preferably w/in 30
mins)
5-7%/hr
1-2 mg%/hr
Copper reduction
methods
Folin Wu
Nelson-Somogyi
Neocuproine method
Benedicts method
Alkaline Ferric
Reduction method
(Hagedorn-Jensen)
Ortho-toluidine
(Dubowski method)
Glucose oxidase
Mutarotase
Retinopathy
NIDDM
Adult type/Maturity Onset
Stable
Ketosis-resistant
Receptor-deficient
Insulin resistance: relative insulin deficiency
Strong genetic predisposition
Geneticists nightmare
If untreated glucose: >500 mg/dL nonketotic hyperosmolar
coma
Screening: 1hr GCT (50g) bet. 24 and 28 weeks of gestation
Confirmatory: 3-hr GTT (100g)
Infants: at risk for respiratory distress syndrome, hypocalcemia,
hyperbilirubinemia
After giving birth, evaluate 6-12 weeks postpartum
Converts to DM w/in 10 years in 30-40% of cases
FBS = 95 mg/dL
1-Hr = 180 mg/dL
2-Hr = 155 mg/dL
3-Hr = 140 mg/dL
GDM = 2 plasma values of the above glucose levels are exceeded
FBS = 100-125 mg/dL
FBS = <126 mg/dL
2-Hr OGTT = 140-199 mg/dL
WB = 15% lower than in serum or plasma
VB = 7 mg/dL lower than capillary and arterial blood
60-70% of the plasma glucose
Same with plasma glucose
Fasting: 2 mg/dL/decade
Postprandial: 4 mg/dL/decade
Glucose challenge: 8-13 mg/dL/decade
Separate serum/plasma from the cells
Glycolysis at room temperature
Glycolysis at refrigerated temperature
Cupric Cuprous Cuprous oxide
Cuprous ions + phosphomolybdate phosphomolybdenum blue
Cuprous ions + arsenomolybdate arsenomolybdenum blue
Cuprous ions + neocuproine Cuprous-neocuproine complex
(yellow)
Reducing substances in blood and urine
Ferricyanide ---(Glucose)--> Ferrocyanide
(Yellow)
(Colorless)
Schiffs base
Measures beta-D-glucose (65%)
Converts alpha-D-glucose (35%) to beta-D-glucose (65%)
NADH/NADPH
Polarographic glucose
oxidase
Hexokinase method
G-6-PD
Interfering substances
(Glucose oxidase)
Hemolysis (>0.5 g/dL
Hgb)
Dextrostics
OGTT
IVGTT
Requirements for OGTT
Glucose load
HbA1c
IDA and older RBCs

RBC lifespan disorders
Fructosamine
(Glycosylated albumin/
plasma protein
ketoamine)
Galactosemia
Essential fructosuria
Hereditary fructose
intolerance
Fructose-1,6biphosphate deficiency
Absorbance at 340nm
Consumption of oxygen on an oxygen-sensing electrode
O2 consumption glucose concentration
Most specific method
Reference method
Uses G-6-PD
Most specific enzyme rgt for glucose testing
False-decreased
Bilirubin
Uric acid
Ascorbate
Major interfering substance in hexokinase method (falsedecreased)
Cellular strip
Strip w/ glucose oxidase, peroxidase and chromogen
Janney-Isaacson method (Single dose) = most common
Exton Rose (Double dose)
Drink the glucose load within 5 mins
For patients with gastrointestinal disorders (malabsorption)
Glucose: 0.5 g/kg body weight
Given w/in 3 mins
1st blood collection: after 5 mins of IV glucose
Ambulatory
Fasting: 8-14 hours
Unrestricted diet of 150g CHO/day for 3 days
Do not smoke or drink alcohol
75 g = adult (WHO std)
100 g = pregnant
1.75 g glucose/kg BW = children
2-3 months
Glucose = beta-chain of HbA1
1% increase in HbA1c = 35 mg/dL increase in plasma glucose
18-20% = prolonged hyperglycemia
7% = cutoff
Specimen: EDTA whole blood
Test: Affinity chromatography (preferred)
High HbA1c
Low HbA1c
2-3 weeks
Useful for patients w/ hemolytic anemias and Hgb variants
Not used in cases of low albumin
Specimen: Serum
Congenital deficiency of 1 of 3 enzymes in galactose metabolism
Galactose-1-phosphate uridyl transferase (most common)
Galactokinase
Uridine diphosphate galactose-4-epimerase
Autosomal recessive
Fructokinase deficiency
Defective fructose-1,6-biphosphate aldolase B activity
Failure of hepatic glucose generation by gluconeogenic precursors
such as lactate and glycerol
Glycogen Storage
Disease
Ia = Von Gierke
II = Pompe
III = Cori Forbes
IV = Andersen
V = McArdle
VI = Hers
VII = Tarui
XII = Fanconi-Bickel
CSF glucose
< 0.5
C-peptide
5:1 to 15:1
D-xylose absorption
test
Gerhardts ferric
chloride test
Nitroprusside test
Acetest tablets
Ketostix
KetoSite assay
Normal Values
(Carbohydrates)
Phospholipids
Sphingomyelin
Forms of phospholipids
TLC + Densitometric
quantitation
Microviscosity
Cholesterol
Autosomal recessive
Defective glycogen metabolism
Test: IVGTT (Type I GSD)
Glucose-6-Phosphatase deficiency (most common worldwide)
Alpha-1,4-glucosidase deficiency (most common in the Philippines)
Debrancher enzyme deficiency
Brancher enzyme deficiency
Muscle phosphorylase deficiency
Liver phosphorylase deficiency
Phosphofructokinase deficiency
Glucose transporter 2 deficiency
Collect blood glucose at least 60 mins (to 2 hrs) before the lumbar
puncture
(Because of the lag in CSF glucose equilibrium time)
Normal CSF : serum glucose ratio
Formed during conversion of pro-insulin to insulin
Normal C-peptide : insulin ratio
Differentiate pancreatic insufficiency from malabsorption (low
blood or urine xylose)
Acetoacetate
10x more sensitive to acetoacetate than to acetone
Acetoacetate and acetone
Detects acetoacetate better than acetone
Detects beta-hydroxybutyrate but not widely used
RBS = <140 mg/dL
FBS = 70-100 mg/dL
HbA1c = 3-6%
Fructosamine = 205-285 mol/L
2-Hr PPBS = <140 mg/dL
GTT:
30 mins = 30-60 mg/dL above fasting
1-Hr = 20-50 mg/dL above fasting
2-Hr = 5-15 mg/dL above fasting
3-Hr = fasting level or below
Lipids
Most abundant lipid
Amphipathic: polar (hydrophilic head) and nonpolar (hydrophobic
side chain)
Reference material during 3rd trimester of pregnancy
Concentration is constant as opposed to lecithin
Not derived from glycerol but from sphingosine (amino alcohol)
70% Lecithin/Phosphatidyl choline
20% Sphingomyelin
10% Cephalin
Method for L/S ratio
Measured by fluorescence polarization
Not a source of fuel
Not affected by fasting
70% Cholesterol ester (plasma/serum)
30% Free cholesterol (plasma/serum and RBC)
LCAT
Apo A-1
Cholesterol increases
after the age of 50
Liebermann Burchardt
Salkowski
Color developer
mixture (Cholesterol)
One-step method
Two-step method
Three-step method
Four-step method
Abell, Levy and Brodie
mtd
(Chemical method)
Triglycerides
Triglyceride increases
after the age of 50
Van Handel &
Zilversmith
(Colorimetric)
Hantzsch Condensation
(Fluorometric)
Modified Van Handel
and Zilversmith
(Chemical method)
Fatty acids
Palmitic acid
Stearic acid
Oleic acid
Linoleic acid
Arachidonic acid
Lipoprotein lipase
(Lipemia clearing
factor)
Hepatic lipase
Esterification of cholesterol
Activator of LCAT
2 mg/dL/year between 50 and 60 years old
Cholestadienyl Monosulfonic acid
Green end color
Cholestadienyl Disulfonic acid
Red end color
Glacial acetic acid
Acetic anhydride
Conc. H2SO4
Colorimetry (Pearson, Stern and Mac Gavack)
Color. + Extraction (Bloors)
Color. + Extract. + Saponification (Abell-Kendall)
Color. +Extract. + Sapon. + Precipitation
(Schaenheimer Sperry, Parekh and Jung)
CDC reference method for cholesterol:
-Hydrolysis/saponification (Alc. KOH)
-Hexane extraction
-Colorimetry (Liebermann-Burchardt)
Most insoluble lipid
Main storage lipid in man (adipose tissue) 95%
Fasting: 12 hours
2 mg/dL/year between 50 and 60 years old
Chromotropic acid
(+) Blue color compound
Diacetyl acetone
(+) Diacetyl lutidine compound
CDC reference method for triglycerides:
-Alkaline hydrolysis
-Chloroform extraction extract treated w/ silicic acid
-Color reaction w/ chromotropic acid meas. HCHO
(+) Pink colored
Short chain = 4-6 C atoms
Medium chain = 8-12 C atoms
Long chain = >12 C atoms
Saturated = w/o double bonds
Unsaturated = w/ double bonds
Substrate for gluconeogenesis
Most is bound to albumin
16:0
18:0
18:1
18:2
20:4
Hydrolyzes TAG in lipoproteins, releasing fatty acid and glycerol
Hydrolyzes TAG and phospholipids from HDL
Hydrolyzes lipids on VLDL and IDL
Endothelial lipase
Apolipoprotein
Chylomicrons
VLDL
LDL
HDL
IDL
Lp(a)
LpX
Beta-VLDL
Lipoprotein
methodologies
Ultracentrifugation
Hydrolyzes phospholipids and TAG in HDL

Protein component of lipoprotein
Amphipathic helix ability of proteins to bind to lipids
Largest and least dense
Produced by the intestine
SG: <0.95
80-95% TAG (exogenous)
Apo B-48 (Major)
EP: Origin
Secreted by the liver
SG: 0.95-1.006
65% TAG (endogenous)
Apo B-100 (Major)
EP: pre-beta
Synthesized by the liver
SG: 1.006-1.063
50% CE
Apo B-100 (Major)
EP: beta
Cholesterol transport: LiverTissues
Target of cholesterol lowering therapy
Better marker for CHD risk
Smallest but dense
SG: 1.063-1.21
45-55% protein
26-32% phospholipid
Apo A-1 (Major)
EP: alpha
Produced by the liver and intestine
Reverse cholesterol transport: TissueLiver
Product of VLDL catabolism
Seen in Type 3 hyperlipoproteinemia (Apo E-III def.; beta-VLDL)
SG: 1.006-1.019
Sinking pre-beta lipoprotein
SG: 1.045-1.080
Apo B-100
EP: pre-beta (VLDL)
UC: like LDL
Independent risk factor for atherosclerosis
Found in obstructive jaundice (cholestasis) and LCAT deficiency
90% FC and PL
Apo C and albumin
Floating beta-lipoprotein
SG: <1.006
EP: beta (LDL)
UC: like VLDL
Found in type 3 hyperlipoproteinemia (Apo E-III def; IDL)
Rich in cholesterol content than VLDL
Specimen: sample from serum separator tubes (preferred)
EDTA plasma: choice for research studies of LPP fractions
Fasting state: TAG VLDL
Nonfasting state: TAG CM
Reference method for LPP quantitation
Electrophoresis
Chemical precipitation
3-step procedure:
Ultracentrifugation
Precipitation
Abell-Kendall assay
Beta quantification +
Ultracentrifugation +
Chemical precipitation
Immunoturbidimetric
assay
LDL Cholesterol
Friedewald method
Reagent: Potassium bromide (SG: 1.063)

Ultracentrifugation of plasma for 24 hours
Expressed in Svedberg units
Electrophoretic pattern:
(+) HDL VLDL LDL CM (Origin) (-)
Agarose gel: sensitive medium
VLDL: migrates w/ alpha2-globulin (pre-beta)
Uses polyanions (heparin and divalent cations) and polyethylene
glycol
Dextran sulfate-Mg2+
Heparin-Mn2+
CDC Reference method for HDL
Method for LDL

Sample: EDTA plasma
Measures Lipoprotein (a)
Total Cholesterol HDL VLDL

Most commonly used
VLDL = TAG/2.175 (mmol/L)
VLDL = TAG/5 (mg/dL)
Not applicable if TAG is >400 mg/dL
De Long method
VLDL = TAG/2.825 (mmol/L)
VDL = TAG/6.5 (mg/dL)
Apo A-1
Activates LCAT
Apo B-100
LDL LDL receptor
Apo B-48
CM (major)
Not recognized by LDL receptor
Apo C-II
Activates LPL
Apo D
Activates LCAT
Apo E
Apo E-4: associated w/ high LDL, higher risk of CHD and
Alzheimers disease
Apo(a)
Lp(a)
Homologous to plasminogen
Abetalipoproteinemia
Autosomal recessive
(Basses-Kornzweig
Defective apo B synthesis
syn.)
Deficient fat soluble vitamins
Niemann-Pick disease
Sphingomyelinase deficiency
Tangiers disease
Deficiency of HDL (1-2 mg/dL)
Defects in the gene for the ABCA1 transporter
LPL deficiency
TAG = 10,000 mg/dL
(Chylomicronemia)
Do not develop premature coronary disease (CM are not
atherogenic)
Abdominal pain and pancreatitis
LCAT deficiency
Fish-eye disease
Low HDL
Tay-Sachs disease
Hexosaminidase A deficiency
Fredrickson Classification
Type 1
LPL deficiency (Chylomicronemia)
Type 2a
Type 2b
Type 3
Type 4
Type 5
Normal Values
(Lipids)
Proteis
Proteins
Primary structure
Secondary structure
Tertiary structure
Quarternary structure
Albumin
Glucogenic amino acids
Ketogenic amino acids
Increased: CM (TAG)
Familial hypercholesterolemia
Increased: LDL (cholesterol)
Combined hyperlipidemia (most common primary hyperlipidemia)
Increased: LDL (cholesterol), VLDL (TAG)
Dysbetalipoproteinemia
Increased: IDL, (+) beta-VLDL
(+) Apo E-II
(+) Eruptive and palmar xanthomas
Hypertriglyceridemia
Increased: VLDL (TAG)
Increased: VLDL (Endo.TAG), CM (Exo.TAG)
Cholesterol:
Desirable = <200 mg/dL
Borderline high = 200-239 mg/dL
High = >240 mg/dL
Triglycerides:
Desirable = <150 mg/dL
High = 200-499
Very high = >500 mg/dL
HDL:
Low = <40 mg/dL (Cutoff)
High = >60 mg/dL
LDL:
Optimal = <100 mg/dL
Near/above optimal = 100-129 mg/dL
High = 160-189 mg/dL
Very high = >190 mg/dL
Proteins
First rank of importance
Amphoteric: positive and negative charges
Effective blood buffers
Synthesized by the liver except immunoglobulins (plasma cells)
Provide 12-20% of total daily body energy requirement
Composed of 50-70% of the cells dry weight
Amino acid sequence
Det. the identity of protein, molecular structure, function binding
capacity, recognition ability
Winding of polypeptide chain
Specific 3-D conformations: alpha-helix, beta-pleated sheath, bend
form
Actual 3-D configuration
Folding pattern
Physical and chemical properties of proteins
Association of 2 or more polypeptide chains protein
No quarternary structure
Alanine (pyruvate)
Arginine (alpha-ketoglutarate)
Aspartate (oxaloacetate)
Degraded to acetyl-CoA
Simple proteins
Conjugated proteins
Nitrogen balance
Negative nitrogen
balance
Positive nitrogen
balance
Prealbumin
(Transthyretin)
Albumin
Alpha1-antitrypsin
Alpha1-fetoprotein
Alpha1-acid
glycoprotein/
orosomucoid
Alpha1antichymotrypsin
Haptoglobin (alpha2)
Ceruloplasmin (alpha2)
Alpha2-macroglobulin
Group-specific
component (Gc)globulin (bet. alpha1
and alpha2)
Hemopexin (beta)
Beta2-microglobulin
Leucine
Lysine
Hydrolysis Amino acids
Fibrous: fibrinogen, troponins, collagen
Globular: hemoglobin, plasma proteins, enzymes, peptide
hormones
Protein (apoprotein) + nonprotein moiety (prosthetic group)
Metalloproteins: ferritin, ceruloplasmin, hemoglobin, flavoproteins
Lipoproteins: VLDL, HDL, LDL, CM
Glycoproteins: haptoglobin, alpha1-antitrypsin (10-40% CHO)
Mucoproteins or proteoglycans: Mucin (CHO > CHON)
Nucleoproteins: Chromatin (combined w/ nucleic acids)
Balance bet. anabolism and catabolism
Catabolism > anabolism
Excessive tissue destruction
Anabolism > catabolism
Growth and repair processes
Transports thyroxine and retinol (Vit. A)
Landmark to confirm that the specimen is really CSF
Maintains osmotic pressure
Negative acute phase reactant
Acute phase reactant
Major inhibitor of protease activity
90% of alpha1-globulin band
Gestational marker
Tumor marker: hepatic and gonodal cancers
Screening test for fetal conditions (Spx: maternal serum)
Amniotic fluid: confirmatory test
Increased: Hepatoma, spina bifida, neural tube defects
Decreased: Down Syndrome (Trisomy 21)
Low pI (2.7)
Negatively charged even in acid solution
Binds and inactivates PSA
Increased: Alzheimers disease, AMI, infection, malignancy, burns
Binds free hemoglobin (alpha chain)
Copper binding (6-8 atoms of copper are attached to it)
Has enzymatic activities
Decreased: Wilsons disease (copper skin, liver, brain, cornea
[Kayser-Fleisher rings])
Larges major nonimmunoglobulin protein
Increased: Nephrotic syndrome (10x)
Forms a complex w/ PSA
Affinity w/ vitamin D and actin
Binds free heme

HLA
Filtered by glomeruli but reabsorbed
Transferrin/Siderophilin
(beta)
Complement (beta)
Fibrinogen (bet. beta
and gamma)
CRP (gamma)
Immunoglobulins
(gamma)
Myoglobin
Troponins
TnT (Tropomyosinbinding subunit)
TnI (Inhibitory subunit
or Actin-binding unit)
TnC
Glomerular proteinuria
Tubular proteinuria
Overload proteinuria
Postrenal proteinuria
Microalbuminuria
CSF Oligoclonal
banding
Serum Oligoclonal
banding
Alkaptonuria
Homocystinuria
MSUD
Negative acute phase reactant

Major component of beta2-globulin fraction
Pseudoparaproteinemia in severe IDA
Increased: Hemochromatosis (bronze-skin), IDA
C3: major
Between beta and gamma globulins
General scavenger molecule
Undetectable in healthy individuals
hsCRP: warning test to persons at risk of CAD
Synthesized by the plasma cells
IgG>IgA>IgM>IgD>IgE
Marker: Ischemic muscle cells, chest pain (angina), AMI
Most important marker for AMI
Specific for heart muscle
Det. unstable angina (angina at rest)
Only found in the myocardium
Greater cardiac specificity than TnT
Highly specific for AMI
13x more abundant in the myocardium than CK-MB
Very sensitive indicator of even minor amount of cardiac necrosis
Binds calcium ions and regulate muscle contractions
Most common and serious type
Often called albuminuria
Defective reabsorption
Slightly increased albumin excretion
Hemoglobinuria
Myoglobinuria
Bence-Jones proteinuria
Urinary tract infection, bleeding, malignancy
Type 1 DM
Albumin excretion 30 mg/g creatinine (cutoff: DM) but 300 mg/g
creatinine
Microalbuminuria: 2 out of 3 specimens submitted are w/ abnormal
findings (w/in 6 months)
2 or more IgG bands in the gamma region:
Multiple sclerosis
Encephalitis
Neurosyphilis
Guillain-Barre syndrome
Neoplastic disorders
Leukemia
Lymphoma
Viral infections
Ochronosis (tissue pigmentation)
Impaired activity of cystathione beta-synthetase
Elevated homocysteine and methionine in blood and urine
Screen: Modified Guthrie test (Antagonist: L-methionine
sulfoximine)
Markedly reduced or absence of alpha-ketoacid decarboxylase
4 mg/dL of leucine is indicative of MSUD
PKU
Normal Values
(Proteins)
Tests for GFR
Tests for Renal Blood

Flow
Tests Measuring Tubular
Function
GFR
Inulin clearance
Creatinine clearance
Urea clearance
Cystatin C
BUN
2.14
Fluoride or citrate
Thiosemicarbazide
Ferric ions
Diacetyl monoxime
method
Urease method
Coupled urease
Isotope dilution mass
spectrometry
NPN
Screen: Modified Guthrie test (Antagonist: 4-azaleucine)

Diagnostic: Amino acid analysis (HPLC)
Deficiency of tetrahydrobiopterin (BH4) elevated blood
phenylalanine
Total protein = 6.5-8.3 g/dL
Albumin = 3.5-5.0 g/dL
Globulin = 2.3-3.5 g/dL
Kidney Function Tests
Clearance:
-Inulin clearance
-Creatinine clearance
-Urea clearance
Phenolsulfonphthalein dye test
Cystatin C
BUN
Creatinine
Uric acid
Excretion:
-Para-amino hippurate test (Diodrast test)
-Phenolsulfonphthalein dye test
Concentration:
-Specific gravity
-Osmolality
Decreases by 1.0 mL/min/year after age 20-30 years
150 L of glomerular filtrate is produced daily
Reference method
Best alternative method
Measure of the completeness of a 24-hour urine collection
Excretion: 1.2-1.5 g creatinine/day
Demonstrate progression of renal disease or response to therapy
Low MW protease inhibitor
FilteredNot secretedCompletely reabsorbed (PCT)
Indirect estimates of GFR
Its presence in urine denotes damage to PCT
Synthesized from Ornithine or Krebs Henseleit cycle
First metabolite to elevate in kidney diseases
Better indicator of nitrogen intake and state of hydration
BUN Urea (mg/dL)
Inhibit urease
Enhance color development (BUN mtd)
Yellow diazine derivative
Routinely used
Urease: prepared from jack beans
Urea ---(Urease)--> NH4 + Berthelot reagent (Measure ammonia)
Glutamate dehydrogenase method
UV enzymatic method
Reference method
For research purposes
45% Urea
20% Amino acid
Creatinine
Enzymatic methods
(Creatinine)
Direct Jaffe method
Interferences (Direct
Jaffe)
Folin Wu Method
Lloyds or Fullers Earth
method
Lloyds reagent
Fullers earth reagent
Jaffe reagent (Alk.
picrate)
Kinetic Jaffe method
Azotemia
Pre-renal azotemia
Renal azotemia
Post renal azotemia
Uremia
Uric acid
Hyperuricemia
20% Uric acid

5% Creatinine
1-2% Creatine
0.2% Ammonia
Derived from alpha-methyl guanidoacetic acid (creatine)
Produced by 3 amino acids (methionine, arginine, lysine)
Most commonly used to monitor renal function
Creatinine Aminohydrolase CK method
Creatinase-Hydrogen Peroxide method benzoquinonemine dye
(red)
Creatininase (a.k.a. creatinine aminohydrolase)
Formation of red tautomer of creatinine picrate
Falsely increased:
Ascorbate
Glucose
Uric acid
Alpha-keto acids
(+) Red orange tautomer
True measure of creatinine
Sensitive and specific
Uses adsorbent to remove interferences (UA, Hgb, Bili)
Sodium aluminum silicate
Aluminum magnesium silicate
Satd. picric acid + 10% NaOH
Popular, inexpensive, rapid and easy to perform
Requires automated equipment
Elevated urea and creatinine in blood
Decreased GFR but normal renal function
Dehydration, shock, CHF
Increased: BUN
Normal: Creatinine
True renal disease
Decreased GFR
Striking BUN level but slowly rising creatinine value
BUN = >100 mg/dL
Creatinine = >20 mg/dL
Uric acid = >12 mg/dL
Urinary tract obstruction
Decreased GFR
Nephrolithiasis, cancer or tumors of GUT
Creatinine = normal or slightly increased
Marked elevation of urea, accompanied by acidemia and
electrolyte imbalance (K+ elevation) of renal failure
Normocytic, normochromic anemia
Uremic frost (dirty skin)
Edema
Foul breath
Urine-like sweat
From purine (adenine and guanine) catabolism
Excretion: 1g/day
-Gout
-Increased nuclear metabolism (leukemia, lymphoma, MM,
Hypouricemia
Methods (Uric acid)
Phosphotungstic acid
mtd
NaCN
NaCO3
Lagphase
Uricase method
Para-amino hippurate
test
Phenolsulfonphthalein
dye test
Concentration tests
Specific gravity
Osmolality
Direct methods
(Osmolality)
Incr. plasma osmolality
Tubular failure
Osmolal gap
Osmolal gap: >12
polycythemia, hemolytic and megaloblastic anemia) Tx:

Allopurinol
-Chronic renal disease
-Lesch-Nyhan syndrome (HGPRT deficiency)
Fanconis syndrome
Wilsons disease
Hodgkins disease
Stable for 3 days
Potassium oxalate cannot be used
Major interferences: Ascorbate and bilirubin
Uric acid + Phosphotungstic acid ---(NaCN/NaCO3)--> Tungsten blue
+ Allantoin
Folin
Newton
Brown
Benedict
Archibald
Henry
Caraway
Incubation period after the addition of an alkali to inactivate nonuric acid reactants
Simplest and most specific method
Candidate reference method
Uric acid (Absorbance at 293nm) ---[Uricase]--> Allantoin (No
absorbance)
Decrease in absorbance uric acid concentration
Measures renal plasma flow
Reference method for tubular function
Measures excretion of dye proportional to renal tubular mass
6 mg of PSP is administered IV
Collecting tubules and loops of Henle
Specimen: 1st morning urine
Affected by solute number and mass
SG >1.050: X-ray dye and mannitol
1.010 = SG of ultrafiltrate in Bowmans space
Total number solute particles present/kg of solvent (moles/kg
solvent)
Affectted only by number of solutes present
Urine osmolality = due to urea
Serum osmolality = due to sodium and chloride
Det. by Colligative properties:
Freezing point (incr. osm. = decr. FP)
Vapor pressure (incr. osm. = decr. VP)
Osmotic pressure (incr. osm. = incr. OP)
Boiling point (incr. osm. = incr. BP)
Freezing point osmometry = popular method
Vapor pressure osmometry (Seebeck effect)
Incr. vasopressin (H2O reabsorption) decr. plasma osmolality
Increased: BUN, creatinine, calcium
Decreased: Phosphate
Difference between measured and calculated osmolality
Sensitive indicator of alcohol or drug overdose
DKA
mOsm/kg
Normal Values
(Kidney Function Tests)
Liver
Synthetic function
Conjugation function
Detoxification and Drug
metabolism
Excretory and
Secretory functions
Storage function
Test measuring the
Hepatic Synthetic
Ability
Test measuring
Conjugation/Excretion
Function
Test for Detoxification
Function
Drug overdose
Renal failure
Creatinine Clearance:
Male = 85-125 mL/min
Female = 75-112 mL/min
BUN = 8-23 mg/dL
Creatinine = 0.5-1.5 mg/dL
Uric acid:
Male = 3.5-7.2 mg/dL
Female = 2.6-6.0 mg/dL
Renal plasma flow (PAH) = 600-700 mL/min
Renal blood flow (PSP) = 1200 mL/min
SG = 1.005-1.030
Osmolality:
Serum = 275-295 mOsm/kg
Urine (24-hr) = 300-900 mOsm/kg
[<290 mOsm/kg = kidney damage]
Urine osmolality: Serum osmolality = 1:1 to 3:1
[>1:1 = Glomerular disease]
[1.2:1 = loss of renal concentrating ability]
[<1:1 = Diabetes Insipidus]
Liver Function Tests
Receives 15 mL of blood per minute
Lobule: anatomic unit
Proteins, CHO, lipids, LPP, clotting factors, ketone bodies, enzymes
Albumin: 12g/day
Bilirubin metabolism
Bilirubin: 200mg/day
Drugs
Ammonia Urea Excreted
Bile acids: cholic acid and chenodeoxycholic acid
Bile salts: bile acids + amino acids (glycine and taurine)
Vitamins
Glycogen
Total Protein Determination:
-Kjeldahl method
-Biuret method
-Folin-Ciocalteu (Lowry) method
-UV absorption method
-Electrophoresis
-Refractometry
-Turbidimetric and Nephelometric methods
-Salt fractionation
Prothrombin Time (Vitamin K Response Test)
Bilirubin Assay:
-Evelyn and Malloy method
-Jendrassik and Grof
Bromsulfonphthalein (BSP) Dye Excretion test
Enzyme tests: ALP, AST, ALT, 5NT, GGT, OCT, LAP, LDH
Ammonia:
-Kjeldahl (Digestion) method
-Nesslerization reaction
Plasma protein
Kjeldahl (Digestion)
mtd
Biuret method
Folin-Ciocalteu (Lowry)
method
Electrophoresis
Gamma-spike
Beta-gamma bridging
Alpha2-globulin band
spike
Alpha1-globulin flat
curve
Alpha1, alpha2, betaglobulin band spikes
Polyclonal gammopathy
Small spikes in beta
region
Free hemoglobin
Refractometry
Turbidimetric and
nephelometric methods
Salt fractionation
Albumin
Globulin
-Berthelot reaction
0.2-0.4 g/dL higher than serum due to fibrinogen
Standard reference method
Measurement of nitrogen content
Serum + Tungstic acid PFF
1g N2 = 6.54g protein
15.1-16.8% = N2 content of proteins
Rgt: H2SO4
End product: NH3
Most widely used method (IFCC recommended)
Req. at least 2 peptide bonds and an alkaline medium
Rgts:
Alkaline CuSO4
Rochelle salt (NaK Tartrate)
NaOH
KI
End product: Violet color (545nm)
Highest analytical sensitivity
Oxidation of phenolic compounds (tyrosine, tryptophan, histidine)
Rgts:
Phenol (or phosphotungstic-molybdic acid)
Biuret (color enhancer)
End product: Blue color
MI: elevated APRs (AAT, HPG, a1-x)
Monoclonal gammopathy (multiple myeloma)
In serum: Hepatic cirrhosis (IgA)
In plasma: normal (fibrinogen)
Nephrotic syndrome
Juvenile cirrhosis (AAT deficiency)
Inflammation
Chronic inflammation (RA, malignancy)
IDA (transferrin)
Blip in the late alpha2 or early beta region
Refractive index
SSA
TCA
Salt: Sodium sulfate
Soluble:
Water
Moderately concentrated salt solution
Concentrated salt solution
Insoluble:
Hydrocarbon solvents
Highly concentrated salt solution
Saturated salt solution
Soluble:
Prothrombin time
Albumin
Hepatic cirrhosis
Bromcresol green
Bromcresol purple
Other dyes for albumin
Nephrotic syndrome
Analbuminemia
Bisalbuminemia
Inverted A/G ratio
Bilirubin
Heme oxygenase
Biliverdin reductase
Urobilinogen
Bilirubin 1
Bilirubin 2
Delta bilirubin
Jaundice
Pre-hepatic jaundice
Hepatic jaundice
Post-hepatic jaundice
Hydrocarbon solvents
Weak salt solution
Insoluble:
Water
Saturated salt solution
Concentrated salt solution
Differentiates intrahepatic disorder (prolonged PT) from
extrahepatic obstructive liver disease (normal PT)
Inversely proportional to the severity of the liver disease
Low total protein + low albumin
Most commonly used dye for albumin
Most specific dye for albumin
Hydroxyazobenzene benzoic acid (HABA)
Methyl orange (MO)
Albumin excretion: 20-30 g/day
(-) albumin
EP: 2 albumin bands
Therapeutic drugs in serum
Hepatic cirrhosis (IgA)
Multiple Myeloma (IgG)
Waldenstrms macroglobulinemia (IgM)
Chronic inflammation
Derived from hemoglobin myoglobin, catalase and cytochrome
oxidase
Protoporphyrin Biliverdin
Biliverdin B1
Deconjugated bilirubin
Non-polar bilirubin
Free/Slow bilirubin
Polar bilirubin
One-minute/prompt bilirubin
Regurgitative bilirubin
Bilirubin tightly bound to albumin
Delta bilirubin = TB-DB+IB
Bilirubin >2 or 3 mg/dL
Hemolytic
B1 = increased
B2 = normal
UG = increased
UB = negative
Hepatocellular
B1 = increased
B2 = increased
UG = increased
UB = positive
ALT = increased
AST = increased
Obstructive
B1 = normal
B2 = increased
UG = decreased/negative
UB = positive
Gilberts syndrome
Crigler-Najjar syndrome
Dubin-Johnson
syndrome & Rotor
syndrome
Lucey-Driscoll
syndrome
Methods (Bilirubin)
Van den Berg reaction
Evelyn and Malloy
method
Jendrassik and Grof
Bilirubin
Rosenthal White
method
Mac Donald method
Ammonia
ALP = increased
GGT = increased
Cholesterol = increased
Bilirubin transport deficit (uptake)
B1 = increased
B2 = decreased
Conjugation deficit
Type I = total UDPGT deficiency
Type II = partial UDPGT deficiency
B1 = increased
B2 = decreased
Danger: Kernicterus
Bile is colorless
Bilirubin excretion deficit
Blockade of excretion into the canaliculi
TB = increased
B2 = increased
Circulating inhibitor of bilirubin conjugation
B1 = increased
Free from hemolysis and lipemia
Store in the dark
Measured ASAP or w/in 2-3 hours
Diazotization of bilirubin
Accelerator: Methanol
Diazo rgts:
Diazo A (0.1% Sulfanilic acid + HCl)
Diazo B (0.5% Sodium nitrite)
Diazo blank (1.5% HCl)
(+) pink to purple azobilirubin
Affected by hemolysis
Candidate reference method
Accelerator: Caffeine sodium benzoate
Buffer: Sodium acetate
Ascorbic acid: terminates the initial reaction and destroys the
excess diazo rgt
Not falsely elevated by hemolysis
Total bilirubin is measured 15 minutes after adding methanol or
caffeine soln
Absorbs light maximally at 450nm
Double collection method
Collection:
-After 5 mins (50% dye retention)
-After 30 mins (0% dye retention)
Single collection method
Collection:
-After 45 mins (+/- 5% dye retention)
From deamination of amino acids
Elevated levels are neurotoxic and often associated w/
encephalopathy and acetaminophen poisoning
Diagnosis of hepatic failure and Reyes syndrome
In severe liver disorder: NH3 circulation brain (conv. to
glutamine) increases pH compromise the Krebs cycle
Coma due to lack of ATP for the brain
Methods (Ammonia)
Kjeldahl (Digestion)
method
Nesslerization of
ammonia
Berthelot reaction
Normal Values
(Liver Function Tests)
Enzyme concentration
Substrate
concentration
Saturation kinetics
Cofactors
Coenzymes
Activators
Metalloenzymes
Inhibitors
Competitive inhibitor
Noncompetitive
inhibitor
Specimen: Heparin or EDTA plasma

Fasting is required
Avoid smoking
Prolonged standing of specimen: increased NH3 due to deamination
Place on iced water immediately
Avoid hemolysis
Specimen PFF
N2 ----------(hot conc. H2SO4 + CuSO4 + Hg + Selenium)----------> NH3
NH3 + K2Hg2I2 ----------(Gum Ghatti)----------> NH2Hg2I2
End color:
Yellow (low to moderate N2)
Orange brown (high N2)
NH3 + Phenol + Hypochlorite -----(Na Nitroprusside)----->
Indophenol blue
Total protein = 6.5-8.3 g/dL
Albumin = 3.5-5.0 g/dL
Globulin = 2.3-3.5 g/dL
1-globulin = 0.1-0.3 g/dL
2-globulin = 0.6-1.0 g/dL
-globulin = 0.7-1.1 g/dL
-globulin = 0.8-1.6 g/dL
Total bilirubin = 0.2-1.0 mg/dL
Indirect bilirubin = 0.2-0.8 mg/dL
Direct bilirubin = 0-0.2 mg/dL
Urobilinogen:
Urine = 0.1-1.0 Ehrlich units/2hrs (or 0.54 Ehrlich units/day)
Stool = 75-275 Ehrlich units/100g feces (or 75-400 Ehrlich
units/24hrs)
Ammonia = 19-60 g/dL
Enzymes
Serum
Enzyme concentration = reaction rate
Reagent
If enzyme > substrate, substrate = reaction rate
When substrate concentration reaches a maximal value, higher
concentration of substrate no longer results in increased rate of
reaction
Nonprotein entities
Organic compound
Ex. NADP
Coenzyme = Velocity
Inorganic ions
Alters spatial configuration of the enzyme for proper substrate
binding
Ex. Ca2+ (#1 activator), Zn2+ (LDH), Cl- (AMS), Mg2+ (CK, ALP)
Inorganic ion attached to a molecule
Ex. Catalase, cytochrome oxidase
Interferes with the enzymatic reactions
Binds to the active site of an enzyme
Reversible (Substrate > Inhibitor)
Binds to the allosteric site (cofactor site)
Irreversible
Uncompetitive inhibitor
Isoenzymes
Temperature
40-50C
60-65C
Temperature coefficient
(Q10)
pH
Storage
Hemolysis
Lactescence or milky
specimen
Enzyme nomenclature
Enzyme classification
Oxidoreductases
Transferases
Hydrolases
Binds to the enzyme-substrate complex

Substrate = ES = Inhibition
Same catalytic reactions but slightly different molecular structures
Fractionation of isoenzymes
37C = optimum temperature for enzyme activity
Temperature = Reaction rate (movement of molecules)
Denaturation of enzymes
Inactivation of enzymes
For every 10OC increase in temperature, there will be a two-fold
increase in enzyme activity
Most physiologic reactions occur in the pH range of 7-8
Enzymes: -20C = for longer period of time
Substrate and Coenzymes: 2-8C
LDH (LD4 & 5): Room temperature
Mostly increases enzyme concentration
Decreases enzyme concentration
1st digit: classification
2nd and 3rd digits: subclass
4th digit(s): serial number
OTHLIL
Oxidoreductases
Transferases
Hydrolases
Lyases
Isomerases
Ligases
Redox reaction
Dehydrogenases:
-Cytochrome oxidase
-LDH
-MDH
-Isocitrate dehydrogenase
-G-6-PD
Transfer of a chemical group other than hydrogen from 1 substrate
to another
Kinases, Transaminases, Aminotransferases:
-CK
-GGT
-AST
-ALT
-OCT
Hydrolysis/splitting by addition of water
Esterases:
-ACP
-ALP
-CHS
-LPS
Peptidases:
-Trypsin
-Pepsin
-LAP
Glycosidases:
Lyases
Isomerases
Ligases
Active site
Allosteric site
Prosthetic group
Holoenzyme
Zymogen/proenzyme
Emil Fishers/Lock and
Key theory
Kochlands/Induced fit
theory
Enzyme kinetics
Absolute specificity
Group specificity
Bond specificity
Zero-order reaction
First-order reaction
Measurement of
enzyme activity
International Unit
Katal Unit
Nonkinetic assay
Alkaline Phosphatase
Phenylalanine
L-leucine
Levamisole
3M urea
Methods (ALP)
-AMS
-Galactosidases
Removal of groups w/o hydrolysis (product contains double bonds)
Aldolase
Decarboxylases:
-Glutamate decarboxylase
-Pyruvate decarboxylase
-Tryptophan decarboxylase
Intramolecular arrangements
Glucose phosphate isomerase
Ribose phosphate isomerase
Joining of 2 substrate molecules
Synthases
Water-free cavity
Where the substrate interacts
Cavity other than the active site
May bind regulatory molecules
Coenzyme that is bound tightly to the enzyme
Apoenzyme + Prosthetic group
Inactive form of enzyme
Shape of the key (substrate) must fit into the lock (enzyme)
Based on the substrate binding to the active site of the enzyme
Acceptable theory
Enzymes catalyze reactions by lowering the activation energy level
that the substrate must reach for the reaction to occur
Enzyme combines w/ only 1 substrate and catalyzes only 1
reaction
Enzymes combine w/ all the substrates in a chemical group
Enzymes reacting w/ specific chemical bonds
Reaction rate depends only on enzyme concentration
Independent on substrate concentration
Reaction rate is directly proportional to substrate concentration
Independent on enzyme concentration
Change in substrate concentration
Change in product concentration
Change in coenzyme concentration
1 micromole of substrate/minute
1 mole of substrate/second
Absorbance is made at 10-second intervals for 100 seconds
pH = 10.5
405nm
Electrophoresis:
(+) Liver Bone (Regan) Placenta Intestine (-)
Heat fractionation:
( Stable) Regan Placenta Intestine Liver Bone ( Labile)
Inhibits Regan, placental and intestinal ALP
Inhibits Nagao ALP
Inhibits liver and bone ALP
Inhibits bone ALP
Low temperature = Increased ALP
1. Bowers and McComb (PNPP) IFCC recommended
Increased ALP
Acid Phosphatase
Prostatic ACP
RBC ACP
Methods (ACP)
Aspartate
Aminotransferase
(AST/SGOT)
Alanine
Aminotransferase
(ALT/SGPT)
Methods (AST and ALT)
Increased
Transaminases
Amylase
Methods (AMS)
Saccharogenic
2. Bessy, Lowry and Brock (PNPP)

3. Bodansky, Shinowara, Jones, Reinhart = BGP (beta
glycerophosphate)
4. King and Armstrong = PP (phenylphosphate)
5. Klein, Babson & Read = Buffered PPP (phenolphthalein
phosphate)
6. Huggins and Talalay = PPDP (phenolphthalein diphosphate)
7. Moss = ANP (alpha naphthol phosphate)
Sprue
Hyperparathyroidism
Rickets (children) and osteomalacia (adults)
pH = 5.5
405nm
Sources: Prostate (major), RBC, platelets, bone
Inhibited by L-tartrate ions
Inhibited by cupric and formaldehyde ions
Room temperature (1-2 hrs) = decreased ACP
Thymolphthalein monophosphate = specific substrate, substrate of
choice (endpoint)
Alpha-naphthyl phosphate = preferred for continuous monitoring
methods
1. Gutman and Gutman = PP
2. Shinowara = PNPP
3. Babsonm Read and Phillips = ANP (continuous monitoring)
4. Roy and Hillman = Thymolphthalein monophosphate (endpoint)
pH 7.5
340nm
Sources: Cardiac tissue > Liver > Skeletal muscle > Kidney,
pancreas, RBCs
pH 7.5
340nm
Major Source: Liver
1. Karmen method = Kinetic
2. Reitman and Frankel = Endpoint
-Color developer: DNPH
-Color intensifier: 0.4N NaOH
DeRitis ratio (ALT:AST) >1.0 = Acute hepatitis (Highest)
20x = viral or toxic hepatitis
Moderate elevation = chronic hepatitis, hepatic cancer, IM
Slight elevation = Hepatic cirrhosis, alcoholic hepatitis, obstructive
jaundice
Smallest enzyme (appears in urine)
Earliest pancreatic marker
P3: most predominant pancreatic AMS isoenzyme in AP
Isoenzymes:
S-type (ptyalin): anodal
P-type (amylopsin): cathodal
Samples w/ high activity of AMS should be diluted w/ NaCl to prev.
inactivation
Salivary AMS = inhibited by wheat germ lectin
Substrate: Starch
Reducing sugars produced
Classic reference method (SU)
Amyloclastic
Chromogenic
Coupled-enzyme
Lipase
Methods (LPS)
Lactate dehydrogenase
Methods (LDH)
10-fold increase (LDH)

2-3x URL
Creatine Kinase
Duchennes muscular
dystrophy
CK-MB
Methods (CK)
Adenylate kinase
N-acetylcysteine
Liver cells and RBC
Clelands reagent and
glutathione
Electrophoresis
CK relative index (CKI)
Aldolase
5 Nucleotidase
Degradation of starch
Increase in color intensity
Continuous-monitoring technique
Late marker (AP)
Most specific pancreatic marker
Substrate: Olive oil/Triolein
1. Cherry Crandal (Reference method)
2. Tietz and Fiereck
3. Peroxidase coupling (most commonly used method)
Lacks specificity
RBC: 150x LDH than in serum
Sources:
LD1 (-HBD) and LD2 = Heart, RBC, Kidneys
LD3 = pancreas, lungs, spleen
LD4 an LD5 = liver and muscle
LD6 = alcohol dehydrogenase
1. Wacker method (forward/direct) = pH 8.8, 340 nm, most
commonly used
2. Wrobleuski LaDue (reverse/indirect) = pH 7.2, 2x faster
3. Wrobleuski Cabaud
4. Berger Broida
Hepatic carcinoma and toxic hepatitis
Viral hepatitis and cirrhosis
Isoenzymes:
CK-BB = most anodal, brain
CK-MB = myocardium (20%)
CK-MM = least anodal, skeletal and smooth muscles (Major, 94100%)
Total CK: 50x URL (highest)
Most specific indicator of myocardial damage (AMI)
Not elevated in angina
1. Tanzer-Gilbarg (forward/direct) = pH 9.0, 340nm
2. Oliver-Rosalki/ Rosalki & Hess (reverse/indirect) = most
commonly used method, faster reaction; pH 6.8, 340nm
Inside RBCs
Interferes w/ CK assay
Inhibited by adenosine monophosphate
Activate CK
Do not contain CK
Partially restore lost activity of CK
Reference method for CK
CKI (%) = CK-MB/Total CK x 100
Isoenzymes:
Aldolase A = Skeletal muscles
Aldolase B = WBC, liver, kidney
Aldolase C = brain tissue
Marker for hepatobiliary diseases and infiltrative lesions of the liver
Methods:
1. Dixon and Purdon
2. Campbell, Belfield and Goldberg
GGT
Methods (GGT)
Cholinesterase/
Pseudocholinesterase
Angiotensin-Converting
Enzyme
Ceruloplasmin
Ornithine carbamoyl
transferase
G-6-PD
Normal Values
(Enzymes)
Located in the canaliculi of the hepatic cells

Differentates the source of an elevated ALP level
Sensitive indicator of occult alcoholism
Increased:
Obstructive jaundice
Alcoholic hepatitis (most sensitive)
Substrate: gamma-glutamyl-p-nitroanilide
1. Szass
2. Rosalki and Tarrow
3. Orlowski
Monitor effects of relaxants (succinylcholine) after surgery
Marker for organophosphate poisoning (Low CHS)
Methods:
1. Ellman technic
2. Potentiometric
A.k.a. peptidyldipeptidase A or Kininase II
Converts angiotensin I angiotensin II (lungs)
Indicator of neuronal dysfunction (Alzheimers disease CSF)
Ferrooxidase enzyme
For hepatobiliary diseases
Drug induced hemolytic anemia (primaquine, antimalarial drug)

ALP = 30-90 U/L
ACP:
Total ACP (male) = 2.5-11.7 U/L
Prostatic ACP = 0-3.5 ng/mL
AST = 5-37 U/L
ALT = 6-37 U/L
AMS = 60-180 SU/dL (95-290 U/L)
LPS = 0-1.0 U/mL
LDH:
Forward = 100-225 U/L
Reverse = 80-280 U/L
Acute Myocardial Infarction Markers
Myoglobin
Troponin T
Troponin I
CK-MB
AST
LD
Rise
1-3 h
3-4 h
3-6 h
4-8 h
6-8 h
12-24 h
Peak
5-12 h
10-24 h
12-18 h
12-24 h
24 h
48-72 h
Normalize
18-30 h
7 d (10-14
5-10 d
48-72 h
5d
10-14 d
d)
Acute Pancreatitis Markers
Amylase
Lipase
Rise
2-12 h
6h
Peak
24 h
24 h
Normalize
3-5 d
7d
Electrolytes
Electroneutrality
Equal no. of cations and anions
Balance of charges
40-75%
Average water content of the human body
ECF
1/3 of total body water
ICF
2/3 of total body water
Normal plasma
93% water (Plasma: 13% > Whole blood)
Vasopressin deficiency
Volume and Osmotic
regulation
Electrolytes
Myocardial rhythm and
contractility
Neuromuscular
excitability
Cofactors (enzyme)
ATPase ion pump

Production and use of
ATP from glucose
Acid-base balance
Replication of DNA and
translation of mRNA
Sodium
Aldosterone
Atrial natriuretic factor
Hypernatremia
Hyponatremia
Thirst
Pseudohyponatremia
(artifactual)
Methods (Na+)
Potassium
7% solutes: (Increased in dehydration)

-Proteins
-Glucose
-NPN
-Lipids
-Ions
Excretion of 10-20L H2O everyday
Sodium
Potassium
Chloride
EC = Na+ > Cl- > HCO3- > Ca2+(5th) > iPO4
IC = K+ > Mg2+(4th)
Potassium
Calcium
Magnesium
Calcium
Magnesium (CK)
Zinc
Chloride (AMS)
Potassium
Magnesium
Magnesium
Phosphate
Bicarbonate
Magnesium
Major contributor of osmolality (92%, together w/ Chloride and
Bicarbonate)
100 mg/dL glucose = 1.6 mmol/L sodium
Sodium
Potassium = Magnesium
Sodium
Excess water loss
Decreased water intake
Hyperaldosteronism (Conns disease)
Hypothalamic disease (Chronic hypernatremia)
Renal failure
SIADH (increased water retention)
Marked hemolysis (dilutional effect)
<125 mmol/L = severe neuropsychiatric symptoms
Major defense against hyperosmolality and hypernatremia
1-2% water deficit = severe thirst
150-160 mEq/L Na+ = Moderate deficit of water
>165 mEq/L Na+ = Severe water deficit
Hyperlipidemia (turbidity)
Hyperproteinemia
1. FEP
2. AAS
3. ISE = Glass aluminum silicate
4. Colorimetry = Albanese Lein
Concentration in RBC is 105 mmol/L
Specimen
Considerations (K+)
Hyperkalemia
Hypokalemia
pH and K+
Methods (K+)
Chloride
Specimen
Considerations (Cl-)
Methods (Cl-)
Hyperchloremia
Hypochloremia
Reciprocal relationship with H+

0.5% hemolysis = 0.5 mmol/L
Gross hemolysis = 30%
Serum K+ > Plasma K+ by 0.1-0.7 mmol/L because of platelets
(clot)
10-20% in muscle activity
0.3-1.2 mmol/L = mild to moderate exercise
2-3 mmol/L = vigorous exercise; fist clenching
Decreased resting membrane potential incr. contractility lack
of muscle excitability
Decreased renal excretion (Dehydration, renal failure, Addisons
disease)
Acidosis (DM)
Muscle injury
Spironolactone
Increased resting membrane potential arrhythmia
Leads to hypomagnesemia
Vomiting
Diuretics
Cushings syndrome
Alkalosis
Insulin overdose
pH by 0.1 = K+ by 0.2-1.7 mmol/L
Lithium heparin plasma = preferred
1. FEP
2. AAS
3. ISE = Valinomycin gel
4. Colorimetry = Lockhead and Purcell
Chief counter ion of sodium in ECF
Chloride methods measure bromide and iodide
Cl- = HCO31. Schales and Schales:
-Mercurimetric titration
-Diphenylcarbazone
-Excess Hg++
-(+) Blue violet
2. Whiterhorn Titration method
-Mercuric thiocyanate
-Reddish complex
3. Ferric perchlorate
4. Cotlove chloridometer
-Coulometric amperometric titration
-Excess Ag++
5. ISE
-Ion exchange membrane
-Tri-n-octylpropylammonium chloride decanol
Renal tubular acidosis
Metabolic acidosis
Diabetes insipidus (Dehydration)
Prolonged diarrhea
Prolonged vomiting (HCl)
Aldosterone deficiency (Na+ = Cl- = K+)
Calcium
3 Forms of Calcium
Vitamin D3
PTH
Calcitonin
Practical considerations
(Ca2+)
Hypercalcemia
Hypocalcemia
Primary hypocalcemia
Secondary
hypocalcemia
Methods (Ca2+)
Inorganic Phosphorus
3 Forms of Inorganic
Phosphorus
PTH
Calcitonin
Growth hormone
Metabolic alkalosis (HCO3- = Cl-)

Marked hemolysis (dilutional effect)
99% Bones
1% ECF
Absorbed in the duodenum
Absorption is favored at an acidic pH
50% = Free/Ionized/Unbound/Active Calcium
40% = Protein-bound (Albumin)
10% = Complexed with anions
Ca2+ = absorption (intestine) and reabsorption (kidney)
Ca2+ = resorption (bone) and reabsorption (kidney)
Ca2+ = urinary excretion (major net loss of calcium)
Serum = specimen of choice
Albumin (1g/dL) = Ca2+ (0.8 mg/dL)
Acidosis (Ca2+: from Bones Blood)
Cancer
Hyperthyroidism
Milk-alkali syndrome
Tetany
Alkalosis (Ca2+: from Blood Bones)
Acute pancreatitis (Ca2+: binds to damage pancreatic tissues)
Low PTH
Parathyroid gland disease
High PTH
Renal failure ( excretion)
1. Clark Collip precipitation method
-(+) Oxalic acid
-Renal calculi
2. Ferro Ham Chloranilic acid precipitation method
-(+)Chloranilic acid
3. Colorimetric = Ortho-Cresolphthalein complexone dyes
-Dye: Arzeno III
-8-hydroxyquinoline = chelates (inhibits) Mg2+
4. EDTA titration method (Bachra, Dawer and Sobel)
5. AAS = Reference method
6. ISE = Liquid membrane
7. FEP
85% Bones
15% ECF (iPO4)
Maximally absorbed in the jejunum (Ca2+: duodenum)
Trancellular shift: Once absorbed inside cells, it no longer comes
out used for energy production
Dirunal variation: late morning, evening
Organic phosphate = principal anion within cells
Inorganic phosphate = part of the blood buffer (Measured in the
clin.lab.)
55% = Free
35% = Complexed with ions
10% = Protein-bound
PO4 = Ca2+
PO4 = Ca2+
PO4 (renal reabsorption)
Practical considerations
Hyperphosphatemia
Hypophosphatemia
Methods (iPO4)
Magnesium
3 Forms of Magnesium
PTH
Aldosterone (&
Thyroxine)
Hypermagnesemia
Hypomagnesemia
Methods (Mg2+)
Bicarbonate
Chloride shift
Anion Gap
Increased AG
Decreased AG
Cystic Fibrosis
(Mucoviscidosis)
Fasting is required (Nonfasting: PO4)

Hypoparathyroidism
Renal failure
Hypervitaminosis D
Alcohol abuse = most common cause
Primary hyperparathyroidism
Avitaminosis D (Rickets, Osteomalacia)
Most accurate: unreduced phosphomolybdate formation (340nm)
1. Fiske Subbarow Method (Ammonium molybdate method)
-Reducing agents: Pictol, Elon, Senidine, Ascorbic acid
-(+) Phosphomolybdenum blue
53% Bones
46% Muscles and soft tissues
1% Serum and RBC
Vasodilator
55% = Free/Ionized/Physiologically active
30% = Protein-bound
10% = Complexed with ions
Mg2+ = Ca2+ = PO4
Mg2+ = K+ = Na+
Addisons disease
Chronic renal failure
Acute renal failure
Chronic alcoholism
1. Calmagite
-(+) Reddish-violet complex
2. Formazen dye method
-(+) Colored complex
3. Magnesium Thymol blue method
-(+) Colored complex
4. AAS = reference method
5. Dye-lake Method
-Titan Yellow dye (Clayton Yellow or Thiazole yellow)
90% of the total CO2
HCO3- diffuses out of the cell in exchange for Cl - to maintain ionic
charge neutrality w/in the cell
Difference between unmeasured anions and unmeasured cations
QC for ISE
Uremia/renal failure
Ketoacidosis
Lactic acidosis
Methanol poisoning
Ethanol poisoning
Ethylene glycol poisoning
Salicylate poisoning
Hypoalbuminemia
Hypercalcemia
Hyperlipidemia
Multiple myeloma
Defective gene: Cystic fibrosis transmembranous conductance
regulator (Chromosome 7)
Miconeum ileus (Infants)
Pilocarpine
Gibson & Cooke
pilocarpine
iontophoresis
Iron
Methods (Iron)
Increased iron
Decreased iron
TIBC
UIBC
% Transferrin
Saturation
Transferrin
Note
Normal Values
(Electrolytes)
Foul-smelling stool
URT infection
Na+ and ClSweat inducer
Reference method (Sweat sodium and chloride)
Prooxidant
3-5g = Total body iron
Ferrous = Hgb
Ferric = Transferrin and Ferritin
1. Colorimetric = HCl and Ferrozine
-(+) Blue color
2. Anodic stripping voltammetry
Hemochromatosis
Viral hepatitis
Non-IDA
IDA
Malnutrition
Chronic infection
UIBC + Serum Iron
Increased: IDA, hepatitis, iron-supplemented pregnancy
Decreased: Non-IDA, nephrosis
TIBC Serum iron
Measure of reserve iron binding capacity of transferrin
Index of iron storage
Increased: Iron overdose, hemochromatosis, sideroblastic anemia
Decreased: IDA (lowest), malignancy, chronic infection
TIBC (g/dL) x 0.70 = mg/dL
Sodium 1/ Potassium
Potassium 1/ Hydrogen ion
Potassium Magnesium
Magnesium Calcium
Calcium 1/ Inorganic phosphate
Chloride 1/ Bicarbonate
Sodium:
Serum = 135-145 mmol/L
[Critical: 160 mmol/L and 120 mmol/L]
CSF = 136-150 mmol/L
Potassium:
Serum = 3.5-5.2 mmol/L
[Critical: 6.5 mmol/L and 2.5 mmol/L]
Chloride:
Serum = 98-107 mmol/L
Sweat = 5-40 mmol/L [Critical: >65 mmol/L]
Calcium:
Total = 8.6-10 mg/dL (adult) and 8.8-10.8 mg/dL (child)
Ionized = 4.6-5.3 mg/dL (adult) and 4.8-5.5 mg/dL (child)
[Critical: <7.5 mg/dL]
Inorganic Phosphate:
Adult = 2.7-4.5 mg/dL
Child = 4.5-5.5 mg/dL

Magnesium:
Serum = 1.2-2.1 mEq/L
Anion Gap:
w/ K+ = 10-20 mmol/L
w/o K+ = 7-16 mmol/L
Iron:
Male = 50-160 g/dL
Female = 45-150 g/dL
TIBC:
Adult = 245-425 g/dL
>40 y.o. = 10-250 g/dL
NB and Child = 100-200 g/dL
% Transferrin Saturation = 20-50%
Regulation of Acid-Base
balance
20:1
4:1
Expanded HendersonHasselbalch equation
Chloride-isohydric shift
pCO2
pO2
Metabolic Acidosis
Metabolic Alkalosis
Respiratory Acidosis
Respiratory Alkalosis
Blood Gases and pH

Lungs and Kidneys
CO2 + H2O <--(Carbonic anhydrase)--> H2CO3
H2CO3 <-------(Carbonic anhydrase)--> H+ + HCO3HCO3-: H2CO3 ratio
HPO4: H2PO4 ratio
pH = 6.1 + log [Total CO2 (pCO2 x 0.03)]
pCO2 x 0.03
Buffering effect of hemoglobin
Index of efficiency of gas exchange
Increased: Barbiturates, morphine, alcohol, heparin (12-15%)
Reflects the availability of the gas in blood but not its content
Excessive O2 supply acidosis
Causes:
-Bicarbonate deficiency
-DKA (normochloremic acidosis)
-Renal failure
-Diarrhea (HCO3-)
Compensation: Hyperventilation
Compensated: HCO3- + pCO2 + pH <7.4
Causes:
-Bicarbonate excess
-Vomiting (Cl-)
-Hypochloremia
-Hypokalemia
Compensation: Hypoventilation
Compensated: HCO3- + pCO2 + pH >7.4
Causes:
-CO2 excess (Hypoventilation)
-COPD
-Drug overdose (morphine, barbiturates, opiates)
Compensation: Bicarbonate retention
Compensated: HCO3- + pCO2 + pH <7.4
Causes
-CO2 loss (Hyperventilation)
Compensation: Bicarbonate excretion
Compensated: HCO3- + pCO2 + pH >7.4
Full compensation
Partial compensation
Buffer base
Methods for Blood
Gases and pH
Factors affecting Blood
gases & pH
measurements
pH normal range
pH near normal
All forms of base that will titrate hydrogen ions
Specimen: Arterial blood
Blood gas analyzers: meas. pH, pCO2, pO2
For every 1OC above 37OC:
pH by 0.015
pO2 by 7%
pCO2 by 3%
Bacterial contamination: consume O2 (pO2)
Excess heparin (acid MPS) = pH
Air exposure (bubbles):
pO2 = 4 mmHg/2mins
pCO2 = 4 mmHg/2mins
Methods
(Blood gases & pH)
1. Gasometer
a. Van Slyke
b. Natelson
-Mercury: produce vacuum
-Caprylic alcohol: anti-foam reagent
-Lactic acid
-NaOH
-NaHSO3
2. Electrodes
a. pH = potentiometry
-Silver-silver chloride electrode (Reference electrode)
-Calomel electrode [Hg2Cl2] (Reference electrode)
b. pCO2 = Severinghaus electrode (potentiometry)
c. pO2 = Clark electrode (polarography-amperometry)
Dissolved CO2 + H2CO3 + HCO3Continuous monitoring of pO2
Directly placed on the skin
Min. requirement:
-1 sample every 8 hours
-3 levels of control (acidosis, normal, alkalosis) every 24 hours
pH = 7.35-7.45
pCO2 = 35-45 mmHg
Total CO2:
WB arterial = 19-24 mmol/L
WB venous = 22-26 mmol/L
HCO3- = 21-28 mEq/L
pO2 = 81-100 mmHg
[Hypoxemia:]
-Mild (61-80 mmHg)
-Moderate (41-60 mmHg)
-Severe (40 mmHg or less)
O2 saturation = 94-100%
Endocrinology
Hormone blood circulation specific receptor
Hormone interstitial space adjacent cell
Hormone self-regulation
Hormone direct cell-to-cell contact
Hormone gut
Whole blood total CO2

Transcutaneous
electrodes
Blood gas QC
Normal Values
(Blood gases and pH)
Endocrine
Paracrine
Autocrine
Juxtacrine
Exocrine
Neurocrine
Neuroendocrine
Glycoproteins
Polypeptides
Steroids
Amines
Hypothalamus
Pineal gland
Pituitary gland
Anterior Pituitary
(Adenohypophysis)
GH (Somatotropin)
Dwarfism
Acromegaly
GH deficiency tests
Tests for Acromegaly
FSH
LH
TSH (Thyrotropin)
ACTH (Corticotropin)
Prolactin
Panhypopituitarism
Pituitary ischemia
(Shechans)
Posterior pituitary
(Neurohypophysis)
Hormone neurons extracellular space

Hormone neurons nerve endings
FSH, hCG, TSH, LH
ACTH, ADH, GH, angiotensin, calcitonin, CCK, gastrin, glucagons,
insulin, MSH, oxytocin, PTH, PRL, somatostatin
Precursor: cholesterol
Aldosterone, cortisol, estrogen, progesterone, testosterone,
vitamin D
Derived from amino acids
Catecholamines, T3, T4
Connected to the posterior pituitary by the infundibulum stalk
Hypophyseal hormones: TRH, GnRH, GH-IH, GH-RH, PIF
Melatonin: decreases pigmentation of the skin
Master Gland
Located in the sella turcica or Turkish saddle
True endocrine gland
Hormones: PRL, GH, FSH, LH, TSH, MSH, ACTH
Most abundant of all pituitary hormones
Structurally similar to PRL and HPL
Markedly elevated during deep sleep
Decreased GH
Increased GH
1. Insulin tolerance test = Gold standard (Confirmatory test)
2. Arginine stimulation test = 2nd confirmatory test
1. Somatomedin C or insulin-like growth factor I (Screening)
-Increased: Acromegaly
-Decreased: GH deficiency
2. OGTT (Confirmatory)
-75g glucose
Spermatogenesis
Helps Leydig cells to produce testosterone (male)
Ovulation (female)
Synthesis of androgens, estrogens, and progesterone
Stimulates thyroid gland to produce T3 and T4
Increased: 1 hypothyroidism, 2 hyperthyroidism
Decreased: 1 hyperthyroidism, 2 hypothyroidism, 3
hypothyroidism
Highest: 6-8 AM
Lowest: 6-11 PM
Not allowed to have contact with glass because it adheres to glass
surface
Collect blood in plastic tubes
Initiation and maintenance of lactation
Inhibited by Dopamine
Highest: 4AM and 8AM, and 8PM and 10PM
Increased: Menstrual irregularity, infertility, amenorrhea,
galactorrhea
From pituitary tumor (adenoma) or Ischemia
Hemorrhage or shock in a pregnant female at the time of deliver
Release but not produce oxytocin and vasopressin
Oxytocin
ADH/AVP (Arginine
vasopressin)
Overnight water
deprivation test (Conc.
test)
Neurogenic DI
Nephrogenic DI
SIADH
Thyroid Gland
Follicle
Follicular cells
Parafollicular or C cells
Thyroglobulin
Thyroid hormone
Biosynthesis
Protein-bound
hormones
Free hormones
(FT3/FT4)
Reverse T3 (rT3)
I2 intake <50 g/day
T3
T4
TBG
TBPA (Transthyretin)
TBA
Thyroid autoantigens
Thyroid disorders
Uterine contraction and milk ejection

H2O reabsorption (DCT and CD)
Stimulus: Increased plasma osmolality (>295 mOsm/kg),
decreased blood vol.
Promotes factor VII and vWF release
Diagnostic test for ADH
True Diabetes Insipidus
Failure of the pituitary gland to secrete ADH
Failure of the kidneys to respond to normal or elevated ADH
Syndrome of inappropriate ADH
Sustained production of ADH
Decreased urine volume
Low plasma osmolality
Low serum electrolytes
Butterfly-shaped
2 lobes = connected by the isthmus
Fundamental structural unit of the thyroid gland
Secrete T3 and T4
Secrete calcitonin
Preformed matrix containing tyrosyl groups
Stored in the follicular colloid of the thyroid gland
1. Trapping of Iodine
2. Iodination: I2 Tyrosine ring MIT and DIT
3. Condensation: MIT+DIT=T3 / DIT+DIT=T4
4. Release: T3/T4 Blood circulation
5. Transport of T3/T4 by proteins
Metabolically inactive
Biologically inert
Do not enter cells
Storage sites
Physiologically active
Readily enters cells
From removal of one iodine from T4 (product of T4 metabolism)
Metabolically inactive
Deficiency of hormone secretion
3,5,3-Triiodothyronine
Most active thyroid hormonal activity
75-80% is produced from the tissue deiodination of T4
Diagnosis of T3 thyrotoxicosis
3,5,35-Tetraiodothyronine
Principal secretory product
All originated in the thyroid gland
Transports 70-75 of TT4, and majority of T3
Transports 15-20% of TT4
No affinity for T3
Transports T3 and 10% of T4
TPO
Tg
TSHR
Screening is recommended when a person reaches 35 yrs old and
Primary
hyperthyroidism
Secondary
hyperthyroidism
T3 Thyrotoxicosis
(Plummers disease)
Graves disease
(Diffuse toxic goiter)
Riedels thyroiditis
Subclinical
hyperthyroidism
Subacute
granulomatous/
Subacute
nonsuppurative/ De
Quervains thyroditis
Hypothyroidism
Primary hypothyroidism
Hashimotos disease
(Chronic autoimmune
thyroiditis)
Myxedema coma
Secondary
hypothyroidism
Tertiary hypothyroidism
Congenital
hypothyroidism
(Cretinism)
Subclinical
hypothyroidism
TRH stimulation test
Radioactive Iodine
Uptake (RAIU)
Thyroglobulin (Tg)
assay
every 5 yrs thereafter

T3 and T4
TSH
T3 and T4
TSH
T3
N-T4
TSH
1 Hyperthyroidism
Most common cause of thyrotoxicosis (autoimmune)
Women > Men
Anti-TSH receptor
Thyroid woody or stony-hard mass
No symptoms
N-T3 and T4
TSH
Hyperthyroidism
Painful thyroiditis
Neck pain, low-grade fever
(-) anti-TPO, ESR and Tg
Treatment: Levothyroxine
T3 and T4
TSH
Most common cause of 1 hypothyroidism
Thyroid is replaced by a nest of lymphoid tissue (T cells)
Goiter
(+) anti-TPO
TSH
Severe form of 1 hypothyroidism
Peculiar nonpitting swelling of the skin
Skin is infiltrated by mucopolysaccharides
Puffy face, thin eyebrows
T3 and T4
TSH
T3 and T4
TSH
TRH
Mental retardation (child)
Screening: T4
Confirmatory: TSH
N-T3 and T4
TSH
Most specific and sensitive test for diagnosing thyroid disease
Confirm borderline cases and euthyroid Graves disease
: 1 hypothyroidism
: Hyperthyroidism
Measure the ability of the thyroid gland to trap iodine
Postoperative marker of thyroid cancer
: Untreated and metastatic differentiated thyroid cancer,
hyperthyroidism
rT3
Free Thyroxine Index
(FT4I)
TT3, FT3, FT4
T3 Uptake test
TBG test
Fine-needle aspiration
Recombinant Human
TSH
Tanned Erythrocyte
Hemagglutination
method
Serum calcitonin test
FT4 and TSH
FT3 and FT4
Euthyroid sick
syndrome
Parathyroid gland
PTH
1 hyperparathyroidism
: Hypothyroidism, thyrotoxicosis factitia

Assess borderline or conflicting laboratory results
Indirectly assesses the level of FT4 in blood
Equilibrium relationship of bound T4 and FT4
Reference method: Equilibrium dialysis
FT4I = TT4 x T3U(%) or TT4 x THBR
100
FT4 test: differentiates drug induced TSH elevation and
hypothyroidism
TT3 or FT3: confirm hyperthyroidism
Reference method (FT4): Equilibrium dialysis
Measures the number of available binding sites of the thyroxine
binding proteins (TBG)
TBG = T3U
TBG = T3U
Confirm results of FT3 or FT4 or abnormalities in the relationship of
TT4 and THBR test
Estrogen: TBG
Androgen: TBG
Most accurate tool in the evaluation of thyroid nodules
Test patients w/ thyroid cancers for the presence of residual or
recurrent dis.
Test for anti-Tg disorders
Marker for familial medullary thyroid carcinoma
Best indicators of thyroid status
More specific indicators of thyroid function than meas. of total
hormone
Not affected by TBG
Acutely ill but without thyroid disease
T3 and T4
N/ TSH
rT3
4 parathyroid glands
Smalles endocrine gland
Hypercalcemic hormone
Ca2+ (bone resorption and renal reabsorption) and Mg 2+
iPO4
Defective: Parathyroid gland
Most common cause of hypercalcemia
Parathyroid adenoma
PTH and iCa2+
Hypercalciuria
Phosphaturia Hypophosphatemia
If goes undetected severe demineralization (osteitis fibrosa
cystica)
In response to Ca2+
Hyperplasia of all 4 glands
Causes: Vit. D deficiency and chronic renal failure
PTH
Ca2+
Occurs w/ 2 hyperparathyroidism ( Ca2+)
Hypoparathyroidism
Hyperparathyroidism
Hypoparathyroidism
Adrenal glands
Adrenal cortex
CPPP ring
3 layers (Adrenal
cortex)
Cortisol
Porter-Silber method
Zimmerman reaction
Pisano method
Kober reaction
Cushings syndrome
(Hypercortisolism)
Screening tests
(Cushings)
Confirmatory tests
(Cushings)
Addisons disease
(1 Hypocorticolism)
Autonomous function of hyperplastic PT glands or PT adenoma

PO4
Calcium phosphates precipitate in soft tissues
Accidental injury of the PT glands (neck) during surgery
Autoimmune parathyroid destruction
PTH = Ca2+
Acidosis
Alkalosis
Pyramid-shaped
Above the kidneys
Adrenal cortex = outer (yellow)
Adrenal medulla = inner (dark mahogany)
Has prime effects on blood pressure
Major site of steroid hormone production
G cells: convert cholesterol pregnenolone
17-carbon skeleton derived from cholesterol
1. Zona Glomerulosa = Mineralocorticoids (Aldosterone)
2. Zona Fasciculata = Glucocorticoids (Cortisol)
3. Zona Reticularis = Weak androgens (androstenedione, DHEA)
Gluconeogenesis hyperglycemia
The only adrenal hormone that inhibit the secretion of ACTH
Anti-inflammatory and immunosuppressive
Diurnal: 6-8AM / 10PM-12AM
Urinary metabolites: 17-OHCS and 17-KGS
Meas. 17-OHCS
Rgt: DNPH in H2SO4 + Alcohol
(+) Yellow
Meas. 17-KGS
Rgt: m-dinitrobenzene
(+) Reddish purple
Oxidation procedure: Norymberski (Na+ bismuthate)
For quantitating metanephrines and normetanephrines
For estrogen
Rgt: H2SO4 + hydroquinone
(+) Reddish brown color
Excessive production of cortisol and ACTH
Overuse of corticosteroids
Buffalo hump
Hyperglycemia
Hypertension
Hypercholesterolemia
Lymphocytes
1. 24-hour urine free cortisol test
2. Overnight dexamethasone suppression tests = Most widely used
(1mg)
3. Salivary cortisol test
1. Low-dose dexamethasone suppression test (0.5mg)
2. Midnight plasma cortisol
3. CRH stimulation test
Primary adrenal insufficiency
Cortisol and aldosterone
ACTH
(+) Hyperpigmentation
Screen: ACTH Stimulation Test
2 Hypocorticolism
Secondary adrenal insufficiency
Hypothalamic-pituitary insufficiency
ACTH
Test: ACTH Stimulation test
ACTH Stimulation test
Corsyntropin: synthetic coritsol and aldosterone stimulator
(Corsyntropin
Differentiates:
stimulation test)
2 adrenal insufficiency (ACTH) from
3 adrenal insufficiency ( ACTH)
Metyrapone test
Metyrapone: inhibitor of 11 -hydroxylase
Measures the ability of the pituitary gland to respond to declining
levels of circulating cortisol, thereby secrete ACTH
Alternative diagnostic or confirmatory test for 2 or 3 adrenal
insufficiency
(+): ACTH
24-hour urine free
Most sensitive and specific screening test for excess cortisol
cortisol
production because plasma cortisol is affected by diurnal variation
Methods: HPLC or GC-MS
HPLC-MS
Reference method for measuring urinary free cortisol
ITT (Insulin tolerance
Gold standard for 2 and 3 hypocorticolism
test)
Confirms borderline response to ACTH stimulation test
Serum ACTH
Differentiates:
Cushings disease (ACTH)
Cushings syndrome (0-ACTH)
ACTH
17-OHCS and 17-KS
Congenital Adrenal
Enzyme deficiencies:
Hyperplasia
1.) 21-hydroxylase = most common
2.) 11 -hydroxylase = 2nd most common
3.) 3-hydroxysteroid dehydrogenase-isomerase
4.) C-17,20-lyase/17-hydroxylase
Cortisol
ACTH
Androgens (hirsutism, virilization, amenorrhea,
pseudohermaphroditism)
Aldosterone (Aldo)
Electro-regulating hormone
Na+ and Cl K+ and H+
at night
18-hydroxysteroid dehydrogenase: enzyme needed for aldosterone
synthesis
Conns disease
Aldosterone-secreting adrenal adenoma
(1 hyperaldosteronism) Screen: Plasma Aldo conc./Plasma renin activity ratio (PAC/PRA
ratio)
-(+): >50 ratio
Confirm: Saline suppression test
-(+): >5 ng/dL aldosterone
2 Hyperaldosteronism
Excessive production of renin
Liddles syndrome
Pseudohyperaldosteronism
Resembles 1 aldosteronism clinically
Aldosterone
(-) Hypertension
Bartters syndrome
Gitelmans syndrome
Hypoaldosteronism
Postural stimulation
test
Florinef
Weak androgens
DHEA
(Dehydroepiandrostero
ne)
Adrenal medulla
9:1
Norepinephrine
Epinephrine
Dopamine
Pheochromocytoma
Clonidine test
Neuroblastoma
Methods
(Catecholamines)
Bumetanide-sensitive chloride channel mutation

Aldosterone and Renin
Thiazide-sensitive transporter mutation
Aldosterone
Destruction of the adrenal glands
Glucocorticoid deficiency
21-hydroxylase deficiency
Test for aldosterone
Synthetic mineralocorticoid
Precursors for the production of more potent androgens and
estrogens
Precursors: Pregnenolone and 17-OH pregnenolone
Examples: DHEA and androstenedione
Bound to steroid hormone binding globulin (SHBG)
: Virilization (pseudohermaphroditism)
Principal adrenal androgen
Converted to estrone
Chromaffin cells: secrete catecholamines
Precursor: L-tyrosine
Norepinephrine/Epinephrine ---(Monoamine oxidase and Catechol0-methyl-transferase)---> Metanephrines and VMA
Norepinephrine: Epinephrine ratio
Primary amine
in CNS
Metabolites:
-3-methoxy-4-hydroxyphenylglycol (MHPG) = Major metabolite
-VMA
Secondary amine
Most abundant medullary hormone
Flight or fight hormone
Metabolites:
-Vanillylmandelic acid (VMA) = Major metabolite
-Metanephrines
-Normetanephrines
-HVA
Primary amine
From the decarboxylation of 3,4-Dihydroxyphenylalanine (DOPA)
Major metabolite: Homovanillic acid (HVA)
Tumors of the adrenal medulla
Catecholamines
Classic Spells: tachycardia, headache, chest tightness, sweating,
hypertension
Differentiates:
Pheochromocytoma (Catecholamines not suppressed) from
Neurogenic hypertension (50% decreased in catecholamines)
Norepinephrine (Children)
urinary HVA, VMA or both and dopamine
Specimen: 24-hr urine and plasma
1. Chromatography: HPLC or GC-MS
2. RIA: sensitive screening test
->2000pg/mL = diagnostic for pheochromocytoma
Estrogens
Markers for Down

Syndrome
Karyotyping or FISH
typing
Progesterone
Tests for menstrual
cycle dysfunction and
anovulation
Tests for female
infertility
Pancreas (Exocrine)
Pancreas (Endocrine)
hCG
Human placental
lactogen (HPL)
Gastrin
Serotonin
(5-hydroxytryptamine)
5-HIAA
Somatostatin
1 amenorrhea
2 amenorrhea
Cushings disease
Cushings syndrome
Estrone = Postmenopausal women

Estradiol = Premenopausal women (most potent, secreted by the
ovary)
Estriol = Pregnancy (placenta)
AFP
Unconjugated Estriol
hCG
Inhibin A
Test for Down syndrome (amniotic fluid)
Produced mainly by the corpus luteum
Det. whether ovulation has occurred
Luteal phase
Estrogen
Progesterone
FSH
LH
hCG
PRL
FT4
TSH
FSH
LH
Estradiol
Progesterone
Digestive enzymes (AMS, LPS)
Acinus: functional secretory unit
Hormones:
Alpha cells (20-30%) = glucagon
Beta cells (60-70%) = insulin
Delta cells (2-8%) = somatostatin
Produced by the syncytiotrophoblasts (placenta)
Maintain progesterone production by the corpus luteum
Stimulates development of mammary gland
Increases maternal plasma glucose levels
Diagnosis of intrauterine growth retardation
Secreted by G cells (stomach)
Stimulates parietal cells to secrete HCl
Stimulus: Amino acid
Zollinger-Ellison syndrome
Pernicious anemia
Synthesized by argentaffin cells (GIT)
Metabolite: 5-HIAA
Diagnostic marker for carcinoid syndrome
Test: Ehrlichs aldehyde test = (+) purple color
A.k.a. GH-IH
Inhibitor of GH, glucagon and insulin
Menstruation having never occurred
Absence of menses for 6 months
Abnormal increased secretion of ACTH
Chronic excessive production of cortisol by the adrenal cortex
Gynecomastia
Hirsutism
Mullerian agenesis
Nonthyroidal illness
Sipples syndrome (MEN
II)
Stein-Leventhal
syndrome
Thyroid stones
Normal Values
(Endocrinology)
Mixed function oxidase

(MFO) system
Intravenous route
Liberation
Absorption
Distribution
Metabolism
Excretion
Bioavailable fraction (f)
Vd of a drug
First-pass hepatic
metabolism
First order elimination
Pharmacodynamics
Pharmacokinetics
Pharmacogenomics
Therapeutic index
Trough concentration
Peak concentration
Cardioactive Drugs
Class I
-Large doses of glucocorticoids

-Pituitary tumor (ACTH) = most common cause
Development of breast tissue in males
Excessive hair growth w/ a male distribution pattern in a female
Most common endocrine disorder in women
Congenital malformation or absence of the fallopian tubes, uterus
or vagina
N-FSH, LH and testosterone
Illness that do not directly involve the thyroid gland
Medullary carcinoma of the thyroid
Pheochromocytoma
Parathyroid adenoma
Mild hirsutism w/ normal menses to excessive hirsutism w/
amenorrhea
A.k.a. thyroid crisis
Life-threatening
Uncontrolled thyrotoxicosis
T3:
Adult = 80-200 ng/dL
Children 1-14 y.o. = 105-215 ng/dL
T4:
Adult = 5.5-12.5 g/dL
Neonate = 11.8-22.6 g/dL
T3U = 25-35%
Therapeutic Drug Monitoring
Biochemical pathway responsible for the greatest portion of drug
metabolism
100% bioavailability
Drug Release
Drug Blood (most: by passive diffusion)
Drug Tissues
Drug Chemical modification
Drug metabolites excreted
Fraction of the dose that reaches the blood
Dilution of the drug after it has been distributed in the body
Drugs Liver Decreased bioavailability
Linear relationship bet. the amt. of drug eliminated per hour and
the blood level of drug
Relationship bet. drug concentration at the target site and
response of the tissues
Relationship bet. drug dose and drug blood level
Study of genes that affect the performance of a drug in an
individual
Ratio bet. the minimum toxic and maximum therapeutic serum
conc.
Lowest concentration of a drug obtained in the dosing interval
Drawn immediately (or 30 mins) before the next dose
Highest concentration of a drug obtained in the dosing interval
Drawn one hour after an orally administered dose (except digoxin)
Rapid Na+ channel blockers (Procainamide, Lidocaine, Quinidine)
Class II
Class III
Class IV
Digoxin
Lidocaine (Xylocaine)
Quinidine
Procainamide
(Pronestyl)
Disopyramide
Propanolol
Amiodarone
(Cordarone)
Verapamil
Antibiotics
Aminoglycosides
Vancomycin
Antiepileptic Drugs
Phenobarbital
Phenytoin (Dilantin)
Valproic acid
(Depakene)
Carbamazepine
(Tegretol)
Ethosuximide
(Zarontin)
Gabapentin (Neurontin)
Others (Antiepileptic)
Psychoactive Drugs
Lithium
Tricyclic
antidepressantas (TCA)
Fluoxetine (Prozac)
Beta receptor blockers (Propanolol)

K+ channel blockers (Amiodarone)
Ca2+ channel blockers (Verapamil)
Tx: CHF
Local anesthetic
1 product of hepatic metabolism: MEGX
(monoethylglycinexylidide)
Common formulations: Quinidine sulfate and Quinidine gluconate
Hepatic metabolite: NAPA (N-acetylprocainamide)
Toxic effect: reversible lupus-like syndrome
Substitute for quinidine
Anticholinergic effects
Tx: angina pectoris
Iodine-containing drug
Tx: angina, hypertension, supraventricular arrhythmias
Tx: Gram (-) bacterial infections
Nephrotoxic and ototoxic
Tx: Gram (+) cocci and bacilli
Toxic effects:
Red man syndrome
Nephrotoxic and ototoxic
Long acting barbiturate
Enhances bilirubin metabolism
Inactive proform: Primidone
Injectable proform: fosphenytoin
Tx: petit mal and grand mal
Tx: grand mal
Drug of choice for controlling petit mal seizure
Similar to neurotransmitter GABA
Topiramate
Lamotrigine (Lamictal)
Felbamate
Tx: Bipolar disorders (Manic depression)
Imipramine
Amitriptyline
Doxepin
Nortriptyline
Tradazone
Major metabolite: Desipramine
Blocks reuptake of serotonin
Tx: Obsessive-compulsive disorders
Bronchodilator
Theophylline
Tx: Asthma and other COPD
Anti-inflammatory and Analgesic Drugs
Salicylates/Aspirin
Antiplatelet (inhibits cyclooxygenase)
(Acetylsalicylic acid)
Method: Trinder assay
Acetaminophen
Hepatotoxic
(Tylenol)
Ibuprofen
Lower risk of toxicity than salicylates and acetaminophen
Neuroleptics (Antipsychotic major tranquilizers)
Neuroleptics
Block the action of dopamine and serotonin
Tx: Schizophrenia
2 classes:
-Phenothiazines (chlorpromazine)
-Butyrophenones (haloperidol)
Examples:
-Risperdal
-Olonzapine (Zyprexa)
-Quetiapine (Seroquel)
-Aripiprazole (Abilify)
Immunosuppressant Cyclosporine
s
Tacrolimus (FK-506)
Rapamycin (Sirolimus)
Mycophenolate mofetil
Lefluamide
Chemotherapeutic
Busulfan
agents
Methotrexate
Toxicology
Toxic Agents
Alcohols (%w/v)
Common CNS depressants
0.01-0.05
No obvious impairment, some changes observable on performance
testing
0.03-0.12
Mild euphoria, decr. inhibitions, some impairment of motor skills
0.09-0.25
Decr. inhibitions, loss of critical judgment, memory impairment,
decr. rxn time
0.18-0.30
Mental confusion, dizziness, strongly impaired motor skills (slurred
speech)
0.27-0.40
Unable to stand/walk, vomiting, impaired consciousness
0.35-0.50
Coma and possible death
0.10
Presumptive evidence of driving under influence of alcohol
Ethanol (Grain alcohol)
Most common abused drug
Ethanol Acetic acid
Major metabolic pathway:
Ethanol ------(Alcohol Dehydrogenase)------> Acetaldehyde
Testing: Use benzalkonium chloride as antiseptic
Methanol (Wood
Cause blindness
alcohol)
Methanol Formaldehyde Formic acid (liver)
Isopropanol
Liver metabolism:
(Rubbing alcohol)
Isopropanol Acetone
Ethylene glycol
Antifreezing agent
(1,2-ethanediol)
Ethylene glycol Oxalic acid and glycolic acid
(+) Monohydrate calcium oxalate crystals
Carbon Monoxide
Colorless, odorless, tasteless gas
Has 210x greater affinity than O2 for Hgb
Cherry-red color of the face and blood
Specimen: EDTA whole blood
Method: Co-oximetry (HbCO measurement)
Cyanide
Arsenic
Cadmium
Lead
Mercury
Drugs of Abuse
Opiates
Tranquilizers
Barbiturates:
Sedative Hypnotics
Dopaminergic pathway
stimulants
Hallucinogens
Amphetamines
Annabolic steroids
Cannabinoids
Tetrahydrocannabinol
(THC)
Cocaine (Crack)
Opiates
Binds to iron (ferric and ferrous) containing substances like

hemoglobin and cytochrome oxidase
Odor of bitter almonds
Antidote: Sodium thiosulfate, amyl and sodium nitrite
Odor of garlic
Metallic taste
Hair and nails: Mees lines
Method: Reinsch test (Flat black)
Significant environmental pollutant
(+) GGT in urine sample
Blocks D-ALA synthase and Ferrocheletase
Wrist drop or Foot drop manifestation
Tx: EDTA and dimercaptosuccinic acid (DMA) remove lead
Free erythrocyte protoporphyrin
(+) Basophilic stippling (course)
Amalgamate: mix or merge w/ other substances
Specimen:
-Whole blood (organic mercury)
-Urine (inorganic mercury)
Method: Reinsch test (Silvery gray)
Morphine
Codeine
Heroin
Methadone
Diazepam (Valium)
Oxazepam
Phenobarbital
Pentobarbital
Amobarbital
Cocaine
Benzoylecgonine
Amphetamine
Phencyclidine
Lysergic acid diethylamide
Tetrahydrocannabinol
Methaqualone
Increase mental alertness (Uppers)
MDMA (methylenedioxymethamphetamine) = ecstasy
Methamphetamine HCl = shabu
Improves athletic performance by increasing muscle mass
Marijuana and hashish
Psycoactive substance of marijuana
Urinary metabolite: 11-nor-deltatetrahydrocannabinol (THC-COOH)
Alkaloid salt
Admin: Insufflation of IV or by inhalation/snorting
Derived from coca plant (erythroxylon)
Cardiac toxicity
Prozac: inhibit the action of cocaine
Urine metabolite: benzoylecgonine
From opium poppy
Heroin
Morphine
Phencyclidine
(Angel dust or angel
hair)
Sedative hypnotics
Lysergic acid
diethylamide (LSD,
Lysergide)
Methaqualone
(Quaalude)
Vitamins
Vitamin A
Vitamin E
Vitamin D2
Vitamin D3
Vitamin K
Vitamin B1
Vitamin B2
Vitamin B3
Vitamin B5
Vitamin B6
Vitamin B9
Vitamin B12
Vitamin C
Biotin
Carnitine
Codeine
Methadone
Major metabolites: N-acetylmorphine (heroin) and morphine
Antagonist: Nalaxone (Narcan)
Hallucinogen
Admin: Ingestion or inhalation
Major metabolite: Phencyclidine HCl
Barbiturates (Secobarbital, pentobarbital, Phenobarbital)
Benzodiazopines: Diazepam (Valium), Lorazepam (Ativan),
Chlordiazepoxide (Librium)
Major metabolite (barbiturates): Secobarbial
Undulating vision
Bad trip panic reactions
Pyramidal signs (Hypertonicity, hyperreflexia, myoclonus)
Vitamins
Water soluble: B1, B2, B3, B5, B6, B9, B12, Biotin, C, Carnitine
Fat soluble: A, D, E, K
CN: Retinol
Def: Night blindness
CN: Tocopherol
Def: Mild hemolytic anemia, RBC fragility
CN: Ergocalciferol, Cholecalciferol (D2), 1,25dihydroxycholecalciferol (D3)
Def: Rickets (young), Osteomalacia (adult)
CN: Phylloquinones, Menaquinones
Def: Hemorrhage
CN: Thiamine
Def: Beriberi, Wernicke-Korsakoff syndrome
CN: Riboflavin
Def: Angular stomatitis, dermatitis, photophobia
CN: Niacin/Niacinamide/Nicotinic acid/Nicotinamide
Def: Pellagra (dermatitis, disorientation, weight loss)
CN: Panthotenic acid
Def: Depressed immune system, muscle weakness
CN: Pyridoxine, Pyridoxal
Def: Facial seborrhea
CN: Folic acid, Pteroylglutamic acid
Def: Megaloblastic anemia
CN: Cyanocobalamin
Def: Megaloblastic anemia, neurologic abnormalities
CN: Ascorbic acid
Def: Scurvy
Def: Dermatitis
Def: Muscle weakness, fatigue

Clinical Chemistry Reviewer by MTR

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What are some important quality control practices mentioned?

What are some important quality control practices mentioned?

What are some common analytical methods discussed?

What are some common analytical methods discussed?

MUST TO KNOW IN CLINICAL CHEMISTRY

Quality Patient Care

-Diminishing lamp power

Cesium and Lithium

Ex: gamma globulins

Air displacement pipet

solutes at the surfaces of a solid particle

Calibrating medium for TD pipettes

Basal state collection

Single test is conducted on each sample

5-HIAA (From Serotonin)

Renin blood level

12 hours after the last ingestion of food

Brown top tube

1-2 mg/mL blood

Recommends that a lab. document culture growth, pH and specific

Type II Rgt Water

Contains calcium, iron and other dissolved elements

Requirements for OGTT

IDA and older RBCs

Hydrolyzes phospholipids and TAG in HDL

Reagent: Potassium bromide (SG: 1.063)

Method for LDL

Total Cholesterol HDL VLDL

Binds free heme

Negative acute phase reactant

Tests for Renal Blood

Screen: Modified Guthrie test (Antagonist: 4-azaleucine)

Post renal azotemia

20% Uric acid

polycythemia, hemolytic and megaloblastic anemia) Tx:

Jendrassik and Grof

Specimen: Heparin or EDTA plasma

Binds to the enzyme-substrate complex

2. Bessy, Lowry and Brock (PNPP)

10-fold increase (LDH)

Located in the canaliculi of the hepatic cells

Drug induced hemolytic anemia (primaquine, antimalarial drug)

ATPase ion pump

7% solutes: (Increased in dehydration)

Reciprocal relationship with H+

Metabolic alkalosis (HCO3- = Cl-)

Fasting is required (Nonfasting: PO4)

Child = 4.5-5.5 mg/dL

Blood Gases and pH

Whole blood total CO2

Hormone neurons extracellular space

Uterine contraction and milk ejection

every 5 yrs thereafter

TT3, FT3, FT4

: Hypothyroidism, thyrotoxicosis factitia

Autonomous function of hyperplastic PT glands or PT adenoma

Bumetanide-sensitive chloride channel mutation

Markers for Down

Estrone = Postmenopausal women