clinical chemistry reviewer by mtr

7/24/2019 Clinical Chemistry Reviewer by MTR

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MUST TO KNOW IN CLINICAL CHEMISTRY(From CC by Rodriguez)

u!"i#y Co$#ro"Practicability Method is easily repeatedReliability Maintain accuracy and precisionIntralab/Interlab QC Daily monitoring of accuracy and precisionInterlab/External QC Prociency testing Reference lab!

"ong#term accuracy

Di$erence of %&' not in agreement (/ other labQC materials )*ailable for a min+ of , yr-o*ine controlmaterials

Preferred .uman' biohaard!0ot for immunochem1 dye#binding and bilirubin

Matrix e$ect Improper product manufacturing2npuried analyte)ltered protein

Precision study 3irst step in method e*aluation0onlab+ personnel &45 of errors lab results!6D Dispersion of *alues from the meanC7 Index of precision

Relati*e magnitude of *ariability 5!7ariance 6D&

Measure of *ariabilityInferential statistics Compare means or 6D of & groups of data

8#test Means of & groups of data3#test 6D of & groups of dataCumulati*e 6um 9raphC262M!

7#mas:Earliest indication of systematic errors trend!

;ouden/8(in Plot Compare results obtained from di$+ lab6he(hart "e*ey#

urtosis Degree of ?atness or sharpnessPrecision Random error)ccuracy 6ystematic errorRandom error

Imprecision@Indeterminate!

Causes'

#Mislabeling#Pipetting error#Improper mixing of sample and reagents#7oltage/8emperature ?uctuation#Dirty opticsParameters' 6D and C7

6ystematic errorInaccuracy/Determinate!

Causes'#Improper calibration#Deterioration of reagents#Contaminated solution#6ample instability/unstable reagent blan:s

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#Diminishing lamp po(er#Incorrect sample and reagent *olumeParameter' Mean

Multirule 6he(hartprocedure

Control rules Control chart

8est method estgard' at least BA samplesReference method estgard' preferably ,AA samples)nalytical Run Control and patient specimens assayed1 e*aluated1 and report

togetherPhysiologic "imit Referred to as absurd *alueP=C8 Performed by nonlab personnelQuality )ssurance 8ripod'

Program de*elopment)ssessment and monitoringQuality impro*ement

Quality Patient Care 8est reFuest forms1 clear instruction for patient prep+1 specimenhandlingG

Reference Range/Inter*al Range/

Reference 7alues

)t least ,&A indi*iduals should be tested in each age and sexcategory

A$!"y#i%!" Me#&od'a*elength Distance bet & successi*e pea:s nm!

"o(er freFuency H "onger (a*elength Ex+ Red!.igher freFuency H 6horter (a*elength Ex+ 7iolet!

6pectrophotometricmeas+

Meas+ light intensity in a narro(er (a*elength

Photometricmeasurement

Meas+ light intensity (/o consideration of (a*elengthMultiple (a*elength uses lter only!

")6ER "ight )mplication by 6timulated Emission of Radiation"ight source for spectrophotometry

7isible region 8ungsten light bulbMercury arc27 Deuterium lamp

Mercury arcenon lamp.ydrogen lamp

IR Merst glo(er9lobar 6ilicone carbide!

6tray light a*elength outside the bandMost common cause of loss of linearity

Di$raction gratings Most commonly used monochromatorCutting groo*es

Prisms Rotatable0ic:el sulfate Pre*ents stray lightCuto$ lter )nti#stray light-andpass J pea: transmittance)lumina silica glasscu*et

Most commonly used cu*et

Quart/plastic cu*et 27-orosilicate glass cu*et 6trong basesPhotodetector Con*erts transmitted light into photoelectric energy-arrier layer cell/ 6implest detector

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photocell/ photo*oltaiccell

0o external *oltage3or lter photometers

Phototube Contains anode and cathodeReF external *oltage

Photomultiplier tube Most common typeMost sensiti*e27 and *isible region

9al*anometer/)mmete

r

Meter or read#out de*ice

)bsorbance ) H abc a H absorpti*ity@ b H length of light ,cm!@ c Hconcentration!) H & K log58

Double beam spectro+ 6plits monochromatic light into t(o components'=ne beam sample=ne beam reference soln or blan: corrects for *ariation in lightsource intensity!

Double#beam in space & photodetectors sample beam and reference beam!Double#beam in time , photodetector

Monochromatic light sample cu*et and reference cu*et

Dydimium lter LAA nm.olmium oxide lter LA nmReagent blan: Color of reagents6ample blan: =ptical interference .gb!3EP Meas+ light emitted by a single atom burned in a ?ame

Principle' Excitation"t+ source and cu*ette' 3lame3or excited ions 0a1 >!

Cesium and "ithium Internal standards 3EP!Correct *ariations in ?ame

"ithium Preferred internal std

Potent antidepressant))6 Meas+ light absorbed by atoms dissociated by heatPrinciple' Dissociation unionied1 unexcited1 ground state!"t+ source' .ollo(#cathode lamp3or unexcited trace metals Caand Mg!More sensiti*e than 3EP

)tomier nebulier! Con*ert ions atomsChopper Modulate the light source"anthanum/6trontiumchloride

Complex (ith phosphate)*oid calcium interference

7olumetric 8itrimetric! 2n:no(n sample is made to react (ith a :no(n solution in thepresence of an indicator

8urbidimetry "ight bloc:edMeas+ abundant large particles Proteins!Depend on specimen concentration and particle sie

0ephelometry Meas+ amt of )g#)b complexes6cattered lightDepends on (a*elength and particle sie

Electrophoresis Migration of charged particles in an electric eldIontophoresis Migration of small charged ionsNone electrophoresis Migration of charged macromoleculesEndosmosis Mo*ement of bu$er ions and sol*ent relati*e to the xed support

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Ex' gamma globulinsCellulose acetate Molecular sie)garose gel Electrical chargePolyacrylamide gel Charge and molecular sie

&A fractions ex+ isoenymes!Electrophoretic mobility Directly proportional to net charge

In*ersely proportional to molecular sie O *iscosity of thesupporting medium

Isoelectric focusing Molecules migrate through a p. gradientp. H pI3or isoenymes' same sie1 di$erent charge

Densitometry 6can O Fuantitate electrophoretic patternCapillaryelectrophoresis

Electro#osmotic ?o(

6outhern blot D0)0orthern blot R0)estern blot ProteinsChromatography 6eparation by specic di$erences in physical#chemical

characteristics of the di$erent constituents

Paper chromatography 3ractionation of sugar and amino acid6orbent' hatman paper

8"C 6creening' DrugsRetention factor Rf!*alue

Relati*e distance of migration from the point of applicationRfH Distance leading edge of component mo*es 8otal distance sol*ent front mo*es

9as chromatography 6eparation of steroids1 barbiturates1 blood1 alcohol1 and lipids7olatile compounds6pecimens *aporiedMobile phase' Inert gases

9as 6olid

chromatography

Di$erences in absorption at the solid phase surfaces

9as "iFuidchromatography

Di$erences in solute partitioning bet(een the gaseous mobilephase and the liFuid stationary phase

Mass 6pectrometry 3ragmentation and ioniation9C#M6 9old standard for drug testingM6/M6 Detect &A inborn errors of metabolism from a single blood spot.P"C Most (idely used liFuid chromatography

3ractionation of drugs1 hormones1 lipids1 carbohydrates andproteins

.ydrophilic gel 9el ltration6eparation of enymes1 antibodies and proteinsEx' Dextran and agarose

.ydrophobic gel 9el permeation6eparation of triglyceride and fatty acidEx' 6ephadex

Ion exchangechromatography

6eparation depends on the sign and ionic charge density

Partitionchromatography

-ased on relati*e solubility in an organic sol*ent nonpolar! and anaFueous sol*ent polar!

)nitychromatography

3or lipoproteins1 C.= and glycated hemoglobins

)dsorption -ased on di$erences bet(een the adsorption and desorption of

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chromatography solutes at the surfaces of a solid particle3luorometry/Molecular"uminescence 6pectro+

Det+ amt+ of lt+ emitted by a molecule after excitation byelectromagnetic radiation"t+ sources' Mercury arc and enon lamp 27!"t+ detector' Photomultiplier tubes& monochromators'Primary lter K selects (a*elength absorbed by the solution to bemeasured

6econdary lter K pre*ents incident light from stri:ing thephotodetector6ensiti*ity' ,AAAx than spectro

Quenching Maor disad*antage of ?uorometryp. and temperature changes1 chemical contaminants1 27"changes

I$'#rume$#!#io$-orosilicate glass(ares 3or heating and steriliation

Ex' Pyrex and >imax-oron#free/6oft

glass(ares

.igh resistance to al:ali

Corex Corning! 6pecial alumina#silicate glass6trengthened chemically than thermallyLx stronger than borosilicate

7ycor Corning! 3or high thermal1 drastic heat and shoc:Can be heated to 4AA=C

3lint glass 6oda#lime glass Calcium1 6ilicon1 6odium oxidesEasy to melt3or ma:ing disposable glass(ares

8D' 8o deli*er Exact amount8C' 8o contain Does not disperse the exact *olume-lo(out (/ etched rings on top of pipet6elf#draining (/ o etched rings

Drain by gra*ity8ransfer pipet 7olumetric' for non#*iscous ?uid@ self#draining

=st(ald folin' for *iscous ?uid@ (/ etched ringPasteur' (/o consideration of a specic *olume)utomatic macro#/micropipets

9raduated ormeasuring pipet

6erological' (/ graduations to the tip blo(out!Mohr' (/o graduations to the tip self#draining!-acteriologic-all1 >olmer and >ahnMicropipettes' , m"

Micropipettes 8C pipets'6ahli#.ellige pipet"ang#"e*y pipetR-C and -C pipets>ir: and =*er?o( pipets

)ir displacement pipet Piston' suctionDisposable tip

Positi*e displacementpipet

Piston barrel li:e a hypodermic syringe!

Dispenser/Dilutor pipet "iFuid' common reser*oir dispense repeatedly

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Distilled .&= Calibrating medium for 8D pipettesMercury Calibrating medium for 8C pipettes)cid dichromate.&6=B >&Cr&=B!

Cleaning solution for glass(ares

Continuous ?o(analyer

Common reaction *essel)ir bubbles' separates and cleans9lass coil' mix

Examples' T686U

6imultaneous Multiple )nalyer 6M)!8echnicon )utoanalyer II6M)C

Centrifugal analyer )cceleration and deceleration of the rotor)d*antage' -atch analysis

Examples' TRICCUCobas#-io Roche!I" MonarchCentriChemRotoChem

Discrete )nalyer Most popular

ReF+ *ol' L V"2ses positi*e#displacement pipetsRun multiple#tests#one#sample#at#a#timeRandom access capability 68)8!

Examples'7itrosDimension Dade-ec:man )68R) 6ystem B O W!.itachi-ayer )d*iaRoche Cobas Integra WAA

Roche )nalytics P Module)utomated Clinical )nalyer )C)! 6tar Dade!Dupont )C))bbott )-)#,AA -ichromatic )nalyer)-)#&AA7P )nalyer)merican Monitor >D)=lympus Demand

8hin#3ilm )nalyersDry slide technology!

B or S layers'#6preading layer#6ca*enger layer # )scorbate =xidase#Reagent layer

#Indicator layer#6upport layerColored reaction Re?ectance spectrophotometry

Examples' T>7&XS!U>oda: E:tachem7itros XSARC7itros SSARC

Carry o*er 8ransport of Fuantity of analyte or rgt from one specimen rxn intoanother1 and contaminating a subseFuent one

-atch testing )ll samples loaded at the same time

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6ingle test is conducted on each sampleParallel testing =ne specimen

More than one test is analyedRandom access testing )ny sample

)ny test)ny seFuence68)8

6eFuential testing Multiple tests analyed one after another on a gi*en specimen

=pen reagent system 6ystem other than manufacturerYs reagents can be utilied formeasurement

Closed reagent system 8he operator can only use the manufacturerYs reagents!#ie$# re!r!#io$

Exercise Increased' 92&38 C&")SP&9.2rea2rinary protein Proteinuria!3atty acid

8estosteroneCP> muscle!

Creatinine muscle!"actate"."D muscle!)CP)ldolase muscle!)68)"8)mmoniaPyru*ateProlactin

Decreased'9lucose

3ist clenching Increased' T"PPU"actatePotassiumPhosphate

3asting W#,L hours'9lucose"ipids"ipoproteinsIncreased'-ilirubin BW hours!

8riglyceride X& hours!-asal state collection 9lucose

Cholesterol8riglycerideElectrolytes

Diet Increased' T9"2C&.U9lucose"ipids2rea .igh protein diet!Ca$eine' increases glucoseCatecholamines

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S#.I)) 3rom 6erotonin!8urbidity/"actescence 8riglyceride %BAAmg/d"Icterisia -ilirubin' &S+& mg/d"Icteric samples Interfere (ith' Z8)C9uU

8otal Protein)lbuminCholesterol9lucose

2pright/supine lying!position

Preferred positionPatient should be seated/supine at least &A mins before bloodcollection to pre*ent hemodilution or hemoconcentration

6upine 6itting/6tanding

7asoconstrictionReduced plasma *olumeIncreased' TEC)UEnymesCalcium)lbumin

6itting 6upine .emoconcentrationIncreased' TPu!-"ICUProteins

-20"ipidsIronCalcium

6tanding 6upine .emodilutionDecreased' T8"CU

8riglycerides"ipoproteinsCholesterol

Prolonged standing Increased' > muscles!Prolonged bedrest Decreased' )lbumin 3luid retention!

8ourniFuet Recommended' , minute applicationProlonged tourniFuetapp+

.emoconcentration)naerobiosisIncreased' TC&"E)&>UCalciumCholesterol"actateEnymes)mmonia)lbumin>

8obacco smo:ing

0icotine!

Increased' T8209&CU

8riglycerides2rea0onesteried fatty acid9lucose9.CatecholaminesCortisolCholesterol

)lcohol ingestion Increased' T8.29U8riglycerides.ypoglycemia chronic alcoholism!

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2ric acid/2rates998

)mmonia Increases by ,AA#&AAVg/"/cigar6tress anxiety! Increased' T")9ICU

"actate)lbumin9lucoseInsulin

CholesterolDrugs Medications a$ecting plasma *olume can a$ect protein1 -201 iron1

calcium.epatotoxic drugs' increased li*er function enymesDiuretics' decreased sodium and potassium

Diurnal *ariation ZC)PI&89UCortisol)C8.)CP)ldosteroneProlactin

IronInsulin8hyroxine9.

Se%ime$ Co""e%#io$ !$d H!$d"i$g6leeping patients Must be a(a:ened before blood collection2nconscious patients )s: nurse or relati*e

Identication bracelet7enipuncture Median Cubital ,st! Cephalic &nd! -asilic rd!

8ourniFuet 7elcro or 6era:et type#B inches abo*e the site0ot exceed , minute

0eedle -e*el up,S#A=angle"ength' , or ,+S inch -utter?y needle' J to [ inch!

)fter blood collection Cotton site)pply pressure for #S minutes

-P cu$ as tourniFuet In?ate to LA mm.g-enal:onium chlorideNephiran!

Disinfectant for ethanol testingDilution K ,'XSA

I7 line on both arms Discontinue I7 for & minutesCollect sample belo( the I7 siteInitial sample Sm"! discard

I7 ?uid contamination Increased'9lucose ,A5 contam+ (/ S5 dextrose increased bld glucose bySAA mg/d"!ChloridePotassium6odiumDecreased'2reaCreatinine

Renin blood le*el Collected after a #day diet1 from a peripheral *ein-asal state collection Early morning blood collection

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,& hours after the last ingestion of food"ancet ,+XSmm' preferred length to a*oid penetrating the boneIncision 6:in puncture! &+Amm infants and children!

mm adults!,+S#&+Bmm Distance from the s:in surface to bone or cartilage middle nger!)rterialied capillaryblood

Earlobe' Preferred site"ateral plantar heel surface' most commonly used site

3lea Minute metal lling (hich may be inserted into the capillary tube

before collecting blood to help mix the specimen (hile the blood isentering the tube

Ind(elling umbilicalartery

-est site for blood gas analysis ne(borns!

,AAA#AAA RC3 for ,Amins

Centrifugation reFuirement

.emolysis Increased'T>")LMP I8C&U#>

#"D. ,SAx!#)CP

#)"P#)ldolase#)"8#)68#)lbumin#Mg&

#Phosphorus#Iron#8otal protein)$ects bilirubin le*elsInhibits lipase

Refrigeration/Chilling"o( temp!

ReFuired for' T)-C9"RP&U)mmonia-lood gasesCatecholamines9astrin"actic acidReninP8.Pyru*ateDecreased'"D B and SIncreased'

)"PPhotosensiti*e analytes -ilirubin

-eta#carotene3olatePorphyrins7itamins ) and -L

=xalate Insoluble salt,#& mg/m" blood

Citrate 0on#ionied form++W g/d" ,'4 ratio!

ED8) Chelation

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,#& mg/m" blood7ersene' disodium salt6eFuestrene' Dipotassium salt

3luoride ea:ly dissociated calcium component& mg/m" blood' anti#glycolytic,A mg/m" blood' anticoagulant

.eparin )+:+a+ Mucoitin polysulfuric acid2ni*ersal anticoagulant

)ntithrombinA+& mg/m" blood

"ithium heparin 3or glucose1 -201 ionied calcium1 electrolyte studies >' best!and creatinine

=range top tube )dditi*e' 8hrombinRoyal blue top tube )dditi*es'

0one@0a&ED8)6odium heparin

-ro(n top tube "ead testing8an top tube "ead testing

-lac: top tube )dditi*e' -u$ered sodium citrate3or E6RRespinning gel tubes Increases potassium

8hixotropic gel 9el separator 69' ,+AB!6erum' 69' ,+A!R-C' 69' ,+AS!

L!bor!#ory M!#&em!#i%'5 (/* 9rams of solute H 5 solution desired x total *olume desired

,AA5 */* m" of solute H 5 solution desired x total *olume desired

,AA

5 (/( 9rams of solute H 5 solution desired x grams of the total solution ,AAMolarity M H \grams of solute\\\\\\\

9M x *olume of solutionMoles Mol H (eight grams!

9M8o prepare a molarsolution

9rams of solute H Molarity x 9M of the solute x 7olume "!desired

8o con*ert 5 (/* toMolarity

M H 5 (/* ,A 9M

0ormality 0 H \9rams of solute\ E x *olume "!

EFui*alent (eight E! E H \\M\\\ *alence

8o prepare a normalsolution of solids

9rams of solute H 0ormality x E x 7olume "!

8o con*ert 5 (/* to0ormality

0 H (/* ,A E

0ormality 0 H Molarity x 7alenceMolarity M H 0ormality

*alence

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Molality m H 9rams of solute\\ M x :g of sol*ent

MillieFui*alents mEF/" H mg/d" ,A *alence M

Millimoles mmol/" H mg/d" ,A M

Ratio Ratio H \7olume of solute\ 7olume of sol*ent

Dilution Dilution H \\7olume of solute\\ 7olume of solution

A+,X4 Con*ersion factor for iron mg/d" Vmol/"!A+A, Con*ersion factor for phospholipid g/d" to g/"!&+&X Con*ersion factor for folate)nalytical reagent )R!grade

3or Fualitati*e and Fuantitati*e analyses3or accuracyEstablished by )merican Chemical 6ociety )C6!2ses' 8race metal analysis and preparation of standard solutions

2ltrapure reagents )dditional purication stepsEx' 6pectrograde1 nanograde1 .P"C grade

2ses' Chromatography1 atomic absorption1 immunoassaysChemically Pure CP! orPure 9rade

Indicates that the impurity limitations are not statedPurity is deli*ered by meas+ of melting point or boiling point

8echnical/Commercialgrade

In manufacturing0e*er used in clin+ lab+ testing

2nited 6tatesPharmacopoeia 26P!and 0ational 3ormulery03!

3or human consumption0ot applicable for lab+ analysisPurpose' 3or drug manufacturing

Preparation of reagentgrade (ater

3iltration ,st! Distillation1 Ion exchange1 Re*erse =smosis

8ype I Rgt ater Min+ interferenceMax+ (ater purity2sed immediately3or ultramicrochemical analyses1 measurements of nanogram orsubnanogram concentrations1 tissue or cell methods microscopy!and preparation of standard solutions2ses' 3EP1 ))61 blood gases and p.1 enyme studies1 electrolytetesting1 .P"C1 trace metal and iron studies

8ype II Rgt ater 3or clinical laboratory use hematology1 microbiology1 immunology1chemistry!3or prep+ of rgts and QC materials

8ype III 3or (ashing glass(ares

3or urinalysis1 parasitology and histologyDistilled (ater Puried to remo*e almost all organic materialsDeionied (ater 3ree from mineral salts@ remo*ed by ion exchange processes

=rganic material may still be present=ccupational 6afetyand .ealth )ct =6.)!

ReF+ manuf+ to indicate lot no+1 physical or biological health haardof the chem++ rgts1 and precautions for safe use and storage

College of )mericanPathologists C)P!

Recommends that a lab+ document culture gro(th1 p. and specic(ater resistance on reagent grade (ater

8ests for (ater purity Microbiological content

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p.Resisti*ityChemical oxygen demand)mmoniaIonsMetals

Detergent#contaminated (ater

)l:aline p.

.ard (ater Contains calcium1 iron and other dissol*ed elements0CC"6 0o(' Clinical and "aboratory 6tandards Institute C"6I!Dilute solution Relati*ely little soluteConcentrated solution "arge Fuantity of solute in solution6aturated solution Excess of undissol*ed solute particles6uper saturatedsolution

9reater concentration of undissol*ed solute particles than does asaturated solution of the same substance

Primary standardI2P)C!

.ighly puriedMeasured directly to produce a substance of exact :no(nconcentration

6econdary standard "o( purity

Concentration is determined by comparison (/ a primary standardL!bor!#ory S!*e#y

N!#io$!" Fire ro#e%#io$ A''o%i!#io$ (NFA) C"!''i+%!#io$ o* Fire'Class ) re =rdinary combustibles' paper1 cloth1 rubbish1 plastics1 (ood

Extinguisher' ater )!1 Dry chemical )-C!1 loaded steamClass - re 3lammable liFuids' grease1 gasoline1 paints1 oil

Extinguisher' Dry chemical )-C!1 carbon dioxide -C!1 halon foam-C!

Class C re Electrical eFuipment and motor s(itchesExtinguisher' Dry chemical )-C!1 Carbon dioxide -C!1 halon -C!

Class D re 3lammable metals' mercury1 magnesium1 sodium1 lithium

Extinguisher' Metal 3ought be re ghters onlyClass E re Detonation )rsenal re!

)llo(ed to burn out and nearby materials protectedS#!$d!rd H!z!rd' Ide$#i+%!#io$ Sy'#em (,i!mo$d-'&!ed %o"or %oded 'ymbo")-lue Fuadrant .ealth haardRed Fuadrant 3lammable haard

;ello( Fuadrant Reacti*ity/6tability haardhite Fuadrant =ther special informationChemical spills ,ststep' assist/e*acuate personnel,',A dilution of chlorinebleach ,A5!

8o disinfect and clean bench topsIn contact (ith the area for at least &A minutes.-7' ,A minutes.I7' & minutes

Poisonous *apors ChloroformMethanolCarbon tetrachloride-romide)mmonia3ormaldehydeMercury

3lammable and )cetone

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combustible sol*ents Ethanol8olueneMethanolylene-eneneIsopropanol.eptane

3lammable liFuids 3lash point belo( X+W=C

Combustible liFuids 3lash point at or abo*e X+W=

C6trong acids or bases 0eutralied before disposal

ater should 0E7ER be added to concentrated acidEther Deteriorate o*er time haardous

3orms explosi*e peroxides-enidine >no(n carcinogen3umehoods 7entilation' *elocity of ,AA#,&A ft/min6afety sho(ers Deli*er A#SA gal/min of .&= at &A#SA psi

C!rbo&ydr!#e'9lycol aldehyde 8he simplest carbohydrate6ucrose Most common nunreducing sugar

Pancreas Exocrine' Enymes )M61 "P6!Endocrine' .ormones Insulin1 glucagon1 somatostatin!

.yperglycemic

.ormonesT9)9 C.E8U9lucagon)C8.9.Cortisol.uman Placental "actogenEpinephrine

8hyroxine.yperglycemia],&L mg/d"!

Electrolyte Imbalance'Decreased' 6odium1 -icarbonateIncreased' Potassium

.ypoglycemia SA#SS mg/d" H 6ymptoms^SA mg/d" H Diagnostic

hippleYs triad.ypoglycemia!

"o( blood glucose concentration8ypical symptoms6ymptoms alle*iated by glucose administration

L', Ratio of -.) to )) in se*ere DM0ormal H ,',!

8ype , DM IDDMetosis#proneWA#4A5 reduction of beta#cells 6ymptomatic 8ype , DM.")#DR and DRB! 9lutamic acid decarboxylase 9)DLS!! Insulin autoantibodies! Microalbuminuria' SA#&AA mg/&B hours H Diabetic nephropathy#! C#peptide

Complications of 8ype IDM

Micro*ascular disorders'0ephropathy0europathy

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Retinopathy8ype & 0IDDM

)dult type/Maturity =nset6table>etosis#resistantReceptor#decientInsulin resistance' relati*e insulin deciency6trong genetic predisposition

9eneticistYs nightmareIf untreated glucose' %SAA mg/d" non:etotic hyperosmolarcoma

9estational DM 6creening' ,hr 9C8 SAg! K bet+ &B and &W (ee:s of gestationConrmatory' #hr 988 ,AAg!Infants' at ris: for respiratory distress syndrome1 hypocalcemia1hyperbilirubinemia)fter gi*ing birth1 e*aluate L#,& (ee:s postpartumCon*erts to DM (/in ,A years in A#BA5 of cases

=988 9DM! 3-6 H ]4S mg/d",#.r H ] ,WA mg/d"

.r H ] ,SS mg/d"#.r H ] ,BA mg/d"9DM H & plasma *alues of the abo*e glucose le*els are exceeded

Impaired fastingglucose Pre#diabetes!

3-6 H ,AA#,&S mg/d"

Impaired glucosetolerance

3-6 H ,&L mg/d".r =988 H ,BA#,44 mg/d"

3-6 - H ,S5 lo(er than in serum or plasma7- H X mg/d" lo(er than capillary and arterial blood

C63 glucose LA#XA5 of the plasma glucosePeritoneal ?uid glucose 6ame (ith plasma glucosePlasma glucoseincreases (/ age

3asting' & mg/d"/decadePostprandial' B mg/d"/decade9lucose challenge' W#, mg/d"/decade

(/in , hourPreferably (/in Amins!

6eparate serum/plasma from the cells

S#X5/hr 9lycolysis at room temperature,#& mg5/hr 9lycolysis at refrigerated temperatureCopper reductionmethods

Cupric Cuprous Cuprous oxide

3olin u Cuprous ions phosphomolybdate phosphomolybdenum blue0elson#6omogyi Cuprous ions arsenomolybdate arsenomolybdenum blue

0eocuproine method Cuprous ions neocuproine Cuprous#neocuproine complexyello(!

-enedictYs method Reducing substances in blood and urine)l:aline 3erricReduction method.agedorn#


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0)D./0)DP. )bsorbance at BAnmPolarographic glucoseoxidase

Consumption of oxygen on an oxygen#sensing electrode=&consumption glucose concentration

.exo:inase method Most specic methodReference method2ses 9#L#PD

9#L#PD Most specic enyme rgt for glucose testingInterfering substances

9lucose oxidase!

3alse#decreased

-ilirubin2ric acid)scorbate

.emolysis %A+S g/d"

.gb!Maor interfering substance in hexo:inase method false#decreased!

Dextrostics Cellular strip6trip (/ glucose oxidase1 peroxidase and chromogen

=988


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9lycogen 6torageDisease

)utosomal recessi*eDefecti*e glycogen metabolism

8est' I7988 8ype I 96D!Ia H 7on 9ier:e 9lucose#L#Phosphatase deciency most common (orld(ide!II H Pompe )lpha#,1B#glucosidase deciency most common in the Philippines!III H Cori 3orbes Debrancher enyme deciencyI7 H )ndersen -rancher enyme deciency7 H Mc)rdle Muscle phosphorylase deciency

7I H .ers "i*er phosphorylase deciency7II H 8arui Phosphofructo:inase deciencyII H 3anconi#-ic:el 9lucose transporter & deciencyC63 glucose Collect blood glucose at least LA mins to & hrs! before the lumbar

puncture-ecause of the lag in C63 glucose eFuilibrium time!

A+S 0ormal C63 ' serum glucose ratioC#peptide 3ormed during con*ersion of pro#insulin to insulinS', to ,S', 0ormal C#peptide ' insulin ratioD#xylose absorptiontest

Di$erentiate pancreatic insuciency from malabsorption lo(blood or urine xylose!

9erhardtYs ferricchloride test

)cetoacetate

0itroprusside test ,Ax more sensiti*e to acetoacetate than to acetone)cetest tablets )cetoacetate and acetone>etostix Detects acetoacetate better than acetone>eto6ite assay Detects beta#hydroxybutyrate but not (idely used0ormal 7aluesCarbohydrates!

R-6 H ,BA mg/d"3-6 H XA#,AA mg/d".b),cH #L53ructosamine H &AS#&WS Vmol/".r PP-6 H ,BA mg/d"

988'A mins H A#LA mg/d" abo*e fasting,#.r H &A#SA mg/d" abo*e fasting.r H S#,S mg/d" abo*e fasting#.r H fasting le*el or belo(

Liid'Phospholipids Most abundant lipid

)mphipathic' polar hydrophilic head! and nonpolar hydrophobicside chain!

6phingomyelin Reference material during rdtrimester of pregnancyConcentration is constant as opposed to lecithin0ot deri*ed from glycerol but from sphingosine amino alcohol!

3orms of phospholipids XA5 "ecithin/Phosphatidyl choline&A5 6phingomyelin,A5 Cephalin

8"C DensitometricFuantitation

Method for "/6 ratio

Micro*iscosity Measured by ?uorescence polariationCholesterol 0ot a source of fuel

0ot a$ected by fastingXA5 Cholesterol ester plasma/serum!A5 3ree cholesterol plasma/serum and R-C!

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18/56

"C)8 Esterication of cholesterol)po )#, )cti*ator of "C)8Cholesterol increasesafter the age of SA

& mg/d"/year bet(een SA and LA years old

"iebermann -urchardt Cholestadienyl Monosulfonic acid9reen end color

6al:o(s:i Cholestadienyl Disulfonic acidRed end color

Color de*elopermixture Cholesterol!

9lacial acetic acid)cetic anhydrideConc+ .&6=B

=ne#step method Colorimetry Pearson1 6tern and Mac 9a*ac:!8(o#step method Color+ Extraction -loorYs!8hree#step method Color+ Extract+ 6aponication )bell#>endall!3our#step method Color+ Extract+ 6apon+ Precipitation

6chaenheimer 6perry1 Pare:h and


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Endothelial lipase .ydrolyes phospholipids and 8)9 in .D")polipoprotein Protein component of lipoprotein

)mphipathic helix K ability of proteins to bind to lipidsChylomicrons "argest and least dense

Produced by the intestine69' A+4SWA#4S5 8)9 exogenous!)po -#BW Maor!

EP' =rigin7"D" 6ecreted by the li*er

69' A+4S#,+AALLS5 8)9 endogenous!)po -#,AA Maor!EP' pre#beta

"D" 6ynthesied by the li*er69' ,+AAL#,+ALSA5 CE)po -#,AA Maor!EP' beta

Cholesterol transport' "i*er

8issues8arget of cholesterol lo(ering therapy-etter mar:er for C.D ris:

.D" 6mallest but dense69' ,+AL#,+&,BS#SS5 protein&L#&5 phospholipid)po )#, Maor!EP' alphaProduced by the li*er and intestineRe*erse cholesterol transport' 8issue"i*er

ID" Product of 7"D" catabolism

6een in 8ype hyperlipoproteinemia )po E#III def+@ beta#7"D"!69' ,+AAL#,+A,4

"pa! 6in:ing pre#beta lipoprotein69' ,+ABS#,+AWA)po -#,AAEP' pre#beta 7"D"!2C' li:e "D"Independent ris: factor for atherosclerosis

"p 3ound in obstructi*e aundice cholestasis! and "C)8 deciency4A5 3C and P")po C and albumin

-eta#7"D" 3loating beta#lipoprotein69' ,+AALEP' beta "D"!2C' li:e 7"D"3ound in type hyperlipoproteinemia )po E#III def@ ID"!Rich in cholesterol content than 7"D"

"ipoproteinmethodologies

6pecimen' sample from serum separator tubes preferred!ED8) plasma' choice for research studies of "PP fractions3asting state' 8)9 7"D"0onfasting state' 8)9 CM

2ltracentrifugation Reference method for "PP Fuantitation

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Reagent' Potassium bromide 69' ,+AL!2ltracentrifugation of plasma for &B hoursExpressed in 6*edberg units

Electrophoresis Electrophoretic pattern'! .D" 7"D" "D" CM =rigin! #!)garose gel' sensiti*e medium7"D"' migrates (/ alphaglobulin pre#beta!

Chemical precipitation 2ses polyanions heparin and di*alent cations! and polyethylene

glycolDextran sulfate#Mg&

.eparin#Mn&

#step procedure'2ltracentrifugationPrecipitation)bell#>endall assay

CDC Reference method for .D"

-eta Fuantication 2ltracentrifugation Chemical precipitation

Method for "D"6ample' ED8) plasma

Immunoturbidimetric

assay

Measures "ipoprotein a!

"D" Cholesterol 8otal Cholesterol K .D" K 7"D"3riede(ald method Most commonly used

7"D" H 8)9/&+,XS mmol/"!7"D" H 8)9/S mg/d"!0ot applicable if 8)9 is %BAA mg/d"

De "ong method 7"D" H 8)9/&+W&S mmol/"!7D" H 8)9/L+S mg/d"!

)po )#, )cti*ates "C)8)po -#,AA "D" "D" receptor)po -#BW CM maor!

0ot recognied by "D" receptor)po C#II )cti*ates "P")po D )cti*ates "C)8)po E )po E#B' associated (/ high "D"1 higher ris: of C.D and

)lheimerYs disease)poa! "pa!

.omologous to plasminogen)betalipoproteinemia-asses#>orn(eigsyn+!

)utosomal recessi*eDefecti*e apo - synthesisDecient fat soluble *itamins

0iemann#Pic: disease 6phingomyelinase deciency8angierYs disease Deciency of .D" ,#& mg/d"!

Defects in the gene for the )-C), transporter"P" deciencyChylomicronemia!

8)9 H ,A1AAA mg/d"Do not de*elop premature coronary disease CM are notatherogenic!)bdominal pain and pancreatitis

"C)8 deciency 3ish#eye disease"o( .D"

8ay#6achs disease .exosaminidase ) deciencyFredri%.'o$ C"!''i+%!#io$

8ype , "P" deciency Chylomicronemia!

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Increased' CM 8)9!8ype &a 3amilial hypercholesterolemia

Increased'"D" cholesterol!8ype &b Combined hyperlipidemia most common primary hyperlipidemia!

Increased' "D" cholesterol!1 7"D" 8)9!8ype Dysbetalipoproteinemia

Increased' ID"1 ! beta#7"D"! )po E#II

! Erupti*e and palmar xanthomas8ype B .ypertriglyceridemia

Increased' 7"D" 8)9!8ype S Increased' 7"D" Endo+8)9!1 CM Exo+8)9!0ormal 7alues"ipids!

Cholesterol'Desirable H &AA mg/d"-orderline high H &AA#&4 mg/d".igh H %&BA mg/d"

8riglycerides'Desirable H ,SA mg/d"-orderline high H ,SA#,44 mg/d"

.igh H &AA#B447ery high H %SAA mg/d"

.D"'"o( H BA mg/d" Cuto$!.igh H %LA mg/d""D"'=ptimal H ,AA mg/d"0ear/abo*e optimal H ,AA#,&4 mg/d"-orderline high H ,A#,S4 mg/d".igh H ,LA#,W4 mg/d"7ery high H %,4A mg/d"

ro#ei$'

Proteis 3irst ran: of importanceProteins )mphoteric' positi*e and negati*e charges

E$ecti*e blood bu$ers6ynthesied by the li*er except immunoglobulins plasma cells!Pro*ide ,&A5 of total daily body energy reFuirementComposed of SA#XA5 of the cellYs dry (eight

Primary structure )mino acid seFuenceDet+ the identity of protein1 molecular structure1 function bindingcapacity1 recognition ability

6econdary structure inding of polypeptide chain

6pecic #D conformations' alpha#helix1 beta#pleated sheath1 bendform

8ertiary structure )ctual #D conguration3olding patternPhysical and chemical properties of proteins

Quarternary structure )ssociation of & or more polypeptide chains protein)lbumin 0o Fuarternary structure9lucogenic amino acids )lanine pyru*ate!

)rginine alpha#:etoglutarate!)spartate oxaloacetate!

>etogenic amino acids Degraded to acetyl#Co)

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"eucine"ysine

6imple proteins .ydrolysis )mino acids3ibrous' brinogen1 troponins1 collagen9lobular' hemoglobin1 plasma proteins1 enymes1 peptidehormones

Conugated proteins Protein apoprotein! nonprotein moiety prosthetic group!Metalloproteins' ferritin1 ceruloplasmin1 hemoglobin1 ?a*oproteins

"ipoproteins' 7"D"1 .D"1 "D"1 CM9lycoproteins' haptoglobin1 alpha,#antitrypsin ,A#BA5 C.=!Mucoproteins or proteoglycans' Mucin C.= % C.=0!0ucleoproteins' Chromatin combined (/ nucleic acids!

0itrogen balance -alance bet+ anabolism and catabolism0egati*e nitrogenbalance

Catabolism % anabolismExcessi*e tissue destruction

Positi*e nitrogenbalance

)nabolism % catabolism9ro(th and repair processes

Prealbumin8ransthyretin!

8ransports thyroxine and retinol 7it+ )!"andmar: to conrm that the specimen is really C63

)lbumin Maintains osmotic pressure0egati*e acute phase reactant)lpha,#antitrypsin )cute phase reactant

Maor inhibitor of protease acti*ity4A5 of alpha,#globulin band

)lpha,#fetoprotein 9estational mar:er8umor mar:er' hepatic and gonodal cancers6creening test for fetal conditions 6px' maternal serum!)mniotic ?uid' conrmatory testIncreased' .epatoma1 spina bida1 neural tube defectsDecreased' Do(n 6yndrome 8risomy &,!

)lpha,#acidglycoprotein/orosomucoid

"o( pI &+X!0egati*ely charged e*en in acid solution

)lpha,#antichymotrypsin

)cute phase reactant-inds and inacti*ates P6)Increased' )lheimerYs disease1 )MI1 infection1 malignancy1 burns

.aptoglobin alpha&! )cute phase reactant-inds free hemoglobin alpha chain!

Ceruloplasmin alpha&! Copper binding L#W atoms of copper are attached to it!.as enymatic acti*itiesDecreased' ilsonYs disease copper s:in1 li*er1 brain1 cornea_>ayser#3leisher rings`!

)lphamacroglobulin "arges maor nonimmunoglobulin proteinIncreased' 0ephrotic syndrome ,Ax!3orms a complex (/ P6)

9roup#speciccomponent 9c!#globulin bet+ alpha,and alpha&!

)nity (/ *itamin D and actin

.emopexin beta! -inds free heme-etamicroglobulin .")

3iltered by glomeruli but reabsorbed

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8ransferrin/6iderophilinbeta!

0egati*e acute phase reactantMaor component of betaglobulin fractionPseudoparaproteinemia in se*ere ID)Increased' .emochromatosis brone#s:in!1 ID)

Complement beta! C' maor3ibrinogen bet+ betaand gamma!

)cute phase reactant-et(een beta and gamma globulins

CRP gamma! 9eneral sca*enger molecule

2ndetectable in healthy indi*idualshsCRP' (arning test to persons at ris: of C)D

Immunoglobulinsgamma!

6ynthesied by the plasma cellsIg9%Ig)%IgM%IgD%IgE

Myoglobin Mar:er' Ischemic muscle cells1 chest pain angina!1 )MI8roponins Most important mar:er for )MI8n8 8ropomyosin#binding subunit!

6pecic for heart muscleDet+ unstable angina angina at rest!

8nI Inhibitory subunitor )ctin#binding unit!

=nly found in the myocardium9reater cardiac specicity than 8n8.ighly specic for )MI

,x more abundant in the myocardium than C>#M-7ery sensiti*e indicator of e*en minor amount of cardiac necrosis8nC -inds calcium ions and regulate muscle contractions9lomerular proteinuria Most common and serious type

=ften called albuminuria8ubular proteinuria Defecti*e reabsorption

6lightly increased albumin excretion=*erload proteinuria .emoglobinuria

Myoglobinuria-ence#


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6creen' Modied 9uthrie test )ntagonist' B#aaleucine!Diagnostic' )mino acid analysis .P"C!

P>2 Deciency of tetrahydrobiopterin -.B! ele*ated bloodphenylalanine

0ormal 7aluesProteins!

8otal protein H L+S#W+ g/d")lbumin H +S#S+A g/d"9lobulin H &+#+S g/d"

Kid$ey Fu$%#io$ Te'#'

8ests for 93R Clearance'#Inulin clearance#Creatinine clearance#2rea clearancePhenolsulfonphthalein dye testCystatin C

8ests for Renal -lood3lo(

-20Creatinine2ric acid

8ests Measuring 8ubular3unction

Excretion'#Para#amino hippurate test Diodrast test!

#Phenolsulfonphthalein dye testConcentration'#6pecic gra*ity#=smolality

93R Decreases by ,+A m"/min/year after age &A#A years,SA " of glomerular ltrate is produced daily

Inulin clearance Reference methodCreatinine clearance -est alternati*e method

Measure of the completeness of a &B#hour urine collectionExcretion' ,+,+S g creatinine/day

2rea clearance Demonstrate progression of renal disease or response to therapyCystatin C "o( M protease inhibitor

3iltered0ot secretedCompletely reabsorbed PC8!Indirect estimates of 93RIts presence in urine denotes damage to PC8

-20 6ynthesied from =rnithine or >rebYs .enseleit cycle3irst metabolite to ele*ate in :idney diseases-etter indicator of nitrogen inta:e and state of hydration

&+,B -20 2rea mg/d"!3luoride or citrate Inhibit urease

8hiosemicarbaide3erric ions

Enhance color de*elopment -20 mtd!

Diacetyl monoxime

method

;ello( diaine deri*ati*e

2rease method Routinely used2rease' prepared from ac: beans2rea ###2rease!##% 0.B -erthelot reagent Measure ammonia!

Coupled urease 9lutamate dehydrogenase method27 enymatic method

Isotope dilution massspectrometry

Reference method3or research purposes

0P0 BS5 2rea&A5 )mino acid

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&A5 2ric acidS5 Creatinine,#&5 CreatineA+&5 )mmonia

Creatinine Deri*ed from alpha#methyl guanidoacetic acid creatine!Produced by amino acids methionine1 arginine1 lysine!Most commonly used to monitor renal function

Enymatic methods

Creatinine!

Creatinine )minohydrolase K C> method

Creatinase#.ydrogen Peroxide method K benoFuinonemine dyered!Creatininase a+:+a+ creatinine aminohydrolase!

Direct


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polycythemia1 hemolytic and megaloblastic anemia! K 8x')llopurinol#Chronic renal disease#"esch#0yhan syndrome .9PR8 deciency!

.ypouricemia 3anconiYs syndromeilsonYs disease.odg:inYs disease

Methods 2ric acid! 6table for days

Potassium oxalate cannot be usedMaor interferences' )scorbate and bilirubin

Phosphotungstic acidmtd

2ric acid Phosphotungstic acid ###0aC0/0aC=!##% 8ungsten blue )llantoin

0aC0 3olin0e(ton-ro(n-enedict

0aC= )rchibald.enryCara(ay

"agphase Incubation period after the addition of an al:ali to inacti*ate non#uric acid reactants2ricase method 6implest and most specic method

Candidate reference method2ric acid )bsorbance at &4nm! ###_2ricase`##% )llantoin 0oabsorbance!Decrease in absorbance uric acid concentration

Para#amino hippuratetest

Measures renal plasma ?o(Reference method for tubular function

Phenolsulfonphthaleindye test

Measures excretion of dye proportional to renal tubular massL mg of P6P is administered I7

Concentration tests Collecting tubules and loops of .enle6pecimen' ,stmorning urine

6pecic gra*ity )$ected by solute number and mass69 %,+ASA' #ray dye and mannitol,+A,A H 69 of ultraltrate in -o(manYs space

=smolality 8otal number solute particles present/:g of sol*ent moles/:gsol*ent!)$ectted only by number of solutes present2rine osmolality H due to urea6erum osmolality H due to sodium and chlorideDet+ by Colligati*e properties'3reeing point incr+ osm+ H decr+ 3P!

7apor pressure incr+ osm+ H decr+ 7P!=smotic pressure incr+ osm+ H incr+ =P!-oiling point incr+ osm+ H incr+ -P!

Direct methods=smolality!

3reeing point osmometry H popular method7apor pressure osmometry 6eebec: e$ect!

Incr+ plasma osmolality Incr+ *asopressin .&= reabsorption! decr+ plasma osmolality8ubular failure Increased' -201 creatinine1 calcium

Decreased' Phosphate=smolal gap Di$erence bet(een measured and calculated osmolality

6ensiti*e indicator of alcohol or drug o*erdose=smolal gap' %,& D>)

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m=sm/:g Drug o*erdoseRenal failure

0ormal 7alues>idney 3unction 8ests!

Creatinine Clearance'Male H WS#,&S m"/min3emale H XS#,,& m"/min-20 H W#& mg/d"Creatinine H A+S#,+S mg/d"2ric acid'

Male H +S#X+& mg/d"3emale H &+L#L+A mg/d"Renal plasma ?o( P).! H LAA#XAA m"/minRenal blood ?o( P6P! H ,&AA m"/min69 H ,+AAS#,+AA=smolality'6erum H &XS#&4S m=sm/:g2rine &B#hr! H AA#4AA m=sm/:g_&4A m=sm/:g H :idney damage`2rine osmolality' 6erum osmolality H ,', to ',_%,', H 9lomerular disease`_,+&', H loss of renal concentrating ability`_,', H Diabetes Insipidus`

Li/er Fu$%#io$ Te'#'"i*er Recei*es ,S m" of blood per minute

"obule' anatomic unit6ynthetic function Proteins1 C.=1 lipids1 "PP1 clotting factors1 :etone bodies1 enymes

)lbumin' ,&g/dayConugation function -ilirubin metabolism

-ilirubin' &AAmg/dayDetoxication and Drugmetabolism

Drugs)mmonia 2rea Excreted

Excretory and

6ecretory functions

-ile acids' cholic acid and chenodeoxycholic acid

-ile salts' bile acids amino acids glycine and taurine!6torage function 7itamins

9lycogen8est measuring the.epatic 6ynthetic)bility

8otal Protein Determination'#>eldahl method#-iuret method#3olin#Ciocalteu "o(ry! method#27 absorption method#Electrophoresis#Refractometry#8urbidimetric and 0ephelometric methods

#6alt fractionationProthrombin 8ime 7itamin > Response 8est!

8est measuringConugation/Excretion3unction

-ilirubin )ssay'#E*elyn and Malloy method#eldahl Digestion! method#0essleriation reaction

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#-erthelot reactionPlasma protein A+A+B g/d" higher than serum due to brinogen>eldahl Digestion!mtd

6tandard reference methodMeasurement of nitrogen content6erum 8ungstic acid P33,g 0&H L+SBg protein,S+,#,L+W5 H 0&content of proteinsRgt' .&6=B

End product' 0.-iuret method Most (idely used method I3CC recommended!

ReF+ at least & peptide bonds and an al:aline mediumRgts')l:aline Cu6=BRochelle salt 0a> 8artrate!0a=.>IEnd product' 7iolet color SBSnm!

3olin#Ciocalteu "o(ry!method

.ighest analytical sensiti*ity=xidation of phenolic compounds tyrosine1 tryptophan1 histidine!

Rgts'Phenol or phosphotungstic#molybdic acid!-iuret color enhancer!End product' -lue color

Electrophoresis MI' ele*ated )PRs ))81 .P91 a,#x!9amma#spi:e Monoclonal gammopathy multiple myeloma!-eta#gamma bridging In serum' .epatic cirrhosis Ig)!

In plasma' normal brinogen!)lphaglobulin bandspi:e

0ephrotic syndrome

)lpha,#globulin ?atcur*e


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.ydrocarbon sol*entsea: salt solutionInsoluble'ater6aturated salt solutionConcentrated salt solution

Prothrombin time Di$erentiates intrahepatic disorder prolonged P8! fromextrahepatic obstructi*e li*er disease normal P8!

)lbumin In*ersely proportional to the se*erity of the li*er disease.epatic cirrhosis "o( total protein lo( albumin-romcresol green Most commonly used dye for albumin-romcresol purple Most specic dye for albumin=ther dyes for albumin .ydroxyaobenene benoic acid .)-)!

Methyl orange M=!0ephrotic syndrome )lbumin excretion' &A#A g/day)nalbuminemia #! albumin-isalbuminemia EP' & albumin bands

8herapeutic drugs in serumIn*erted )/9 ratio .epatic cirrhosis Ig)!

Multiple Myeloma Ig9!aldenstrmYs macroglobulinemia IgM!Chronic in?ammation

-ilirubin Deri*ed from hemoglobin myoglobin1 catalase and cytochromeoxidase

.eme oxygenase Protoporphyrin -ili*erdin-ili*erdin reductase -ili*erdin -,2robilinogen Deconugated bilirubin-ilirubin , 0on#polar bilirubin

3ree/6lo( bilirubin-ilirubin & Polar bilirubin

=ne#minute/prompt bilirubinRegurgitati*e bilirubinDelta bilirubin -ilirubin tightly bound to albumin

Delta bilirubin H 8-#D-I-


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)"P H increased998 H increasedCholesterol H increased

9ilbertYs syndrome -ilirubin transport decit upta:e!-, H increased-& H decreased

Crigler#0aar syndrome Conugation decit8ype I H total 2DP98 deciency

8ype II H partial 2DP98 deciency-, H increased-& H decreasedDanger' >ernicterus-ile is colorless

Dubin#


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Methods )mmonia! 6pecimen' .eparin or ED8) plasma3asting is reFuired)*oid smo:ingProlonged standing of specimen' increased 0.due to deaminationPlace on iced (ater immediately)*oid hemolysis

>eldahl Digestion!

method

6pecimen P33

0#########hot conc+ .&6=B Cu6=B .g 6elenium!##########% 0.0essleriation ofammonia

0. >&.g&I#########9um 9hatti!##########% 0.&.g&I&End color'

;ello( lo( to moderate 0&!=range bro(n high 0&!

-erthelot reaction 0. Phenol .ypochlorite #####0a 0itroprusside!#####%Indophenol blue

0ormal 7alues"i*er 3unction 8ests!

8otal protein H L+S#W+ g/d")lbumin H +S#S+A g/d"9lobulin H &+#+S g/d"1-globulin = 0.1-0.3 g/dL

2-globulin = 0.6-1.0 g/dL#globulin H A+X#,+, g/d"#globulin H A+W#,+L g/d"

8otal bilirubin H A+,+A mg/d"Indirect bilirubin H A+A+W mg/d"Direct bilirubin H A#A+& mg/d"2robilinogen'2rine H A+,#,+A Ehrlich units/&hrs or A+SB Ehrlich units/day!6tool H XS#&XS Ehrlich units/,AAg feces or XS#BAA Ehrlichunits/&Bhrs!)mmonia H ,4#LA Vg/d"

E$zyme'

Enyme concentration 6erumEnyme concentration H reaction rate

6ubstrateconcentration

ReagentIf enyme % substrate1 substrate H reaction rate

6aturation :inetics hen substrate concentration reaches a maximal *alue1 higherconcentration of substrate no longer results in increased rate ofreaction

Cofactors 0onprotein entitiesCoenymes =rganic compound

Ex+ 0)DPCoenyme H 7elocity

)cti*ators Inorganic ions)lters spatial conguration of the enyme for proper substratebindingEx+ Ca&, acti*ator!1 Nn&"D.!1 Cl# )M6!1 Mg&C>1 )"P!

Metalloenymes Inorganic ion attached to a moleculeEx+ Catalase1 cytochrome oxidase

Inhibitors Interferes (ith the enymatic reactionsCompetiti*e inhibitor -inds to the acti*e site of an enyme

Re*ersible 6ubstrate % Inhibitor!0oncompetiti*einhibitor

-inds to the allosteric site cofactor site!Irre*ersible

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2ncompetiti*e inhibitor -inds to the enyme#substrate complex6ubstrate H E6 H Inhibition

Isoenymes 6ame catalytic reactions but slightly di$erent molecular structures3ractionation of isoenymes

8emperature XYC H optimum temperature for enyme acti*ity8emperature HReaction rate mo*ement of molecules!

BA#SAYC Denaturation of enymesLA#LSYC Inacti*ation of enymes

8emperature coecientQ,A!

3or e*ery ,A=C increase in temperature1 there (ill be a t(o#foldincrease in enyme acti*ity

p. Most physiologic reactions occur in the p. range of X#W6torage Enymes' #&AYC H for longer period of time

6ubstrate and Coenymes' WYC"D. "DB O S!' Room temperature

.emolysis Mostly increases enyme concentration"actescence or mil:yspecimen

Decreases enyme concentration

Enyme nomenclature ,stdigit' classication&ndand rddigits' subclass

Bth

digits!' serial numberEnyme classication T=8."I"U

=xidoreductases8ransferases.ydrolases"yasesIsomerases"igases

=xidoreductases Redox reactionDehydrogenases'#Cytochrome oxidase#"D.#MD.#Isocitrate dehydrogenase#9#L#PD

8ransferases 8ransfer of a chemical group other than hydrogen from , substrateto another>inases1 8ransaminases1 )minotransferases'#C>#998#)68#)"8#=C8

.ydrolases .ydrolysis/splitting by addition of (aterEsterases'#)CP#)"P#C.6#"P6Peptidases'#8rypsin#Pepsin#")P9lycosidases'

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#)M6#9alactosidases

"yases Remo*al of groups (/o hydrolysis product contains double bonds!)ldolaseDecarboxylases'#9lutamate decarboxylase#Pyru*ate decarboxylase#8ryptophan decarboxylase

Isomerases Intramolecular arrangements9lucose phosphate isomeraseRibose phosphate isomerase

"igases


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&+ -essy1 "o(ry and -roc: P0PP!+ -odans:y1 6hino(ara1 ing and )rmstrong H PP phenylphosphate!S+ >lein1 -abson O Read H -u$ered PPP phenolphthaleinphosphate!L+ .uggins and 8alalay H PPDP phenolphthalein diphosphate!X+ Moss H )0P alpha naphthol phosphate!

Increased )"P 6prue.yperparathyroidismRic:ets children! and osteomalacia adults!

)cid Phosphatase p. H S+SBASnm6ources' Prostate maor!1 R-C1 platelets1 bone

Prostatic )CP Inhibited by "#tartrate ionsR-C )CP Inhibited by cupric and formaldehyde ionsMethods )CP! Room temperature ,#& hrs! H decreased )CP

8hymolphthalein monophosphate H specic substrate1 substrate ofchoice endpoint!

)lpha#naphthyl phosphate H preferred for continuous monitoringmethods,+ 9utman and 9utman H PP&+ 6hino(ara H P0PP+ -absonm Read and Phillips H )0P continuous monitoring!B+ Roy and .illman H 8hymolphthalein monophosphate endpoint!

)spartate)minotransferase)68/69=8!

p. X+SBAnm6ources' Cardiac tissue % "i*er % 6:eletal muscle % >idney1pancreas1 R-Cs

)lanine)minotransferase

)"8/69P8!

p. X+SBAnm

Maor 6ource' "i*erMethods )68 and )"8! ,+ >armen method H >inetic

&+ Reitman and 3ran:el H Endpoint#Color de*eloper' D0P.#Color intensier' A+B0 0a=.

Increased8ransaminases

DeRitis ratio )"8')68! %,+A H )cute hepatitis .ighest!&Ax H *iral or toxic hepatitisModerate ele*ation H chronic hepatitis1 hepatic cancer1 IM6light ele*ation H .epatic cirrhosis1 alcoholic hepatitis1 obstructi*e

aundice)mylase 6mallest enyme appears in urine!

Earliest pancreatic mar:erP' most predominant pancreatic )M6 isoenyme in )PIsoenymes'6#type ptyalin!' anodalP#type amylopsin!' cathodal

Methods )M6! 6amples (/ high acti*ity of )M6 should be diluted (/ 0aCl to pre*+inacti*ation6ali*ary )M6 H inhibited by (heat germ lectin6ubstrate' 6tarch

6accharogenic Reducing sugars producedClassic reference method 62!

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)myloclastic Degradation of starchChromogenic Increase in color intensityCoupled#enyme Continuous#monitoring techniFue"ipase "ate mar:er )P!

Most specic pancreatic mar:erMethods "P6! 6ubstrate' =li*e oil/8riolein

,+ Cherry Crandal Reference method!&+ 8iet and 3ierec:

+ Peroxidase coupling most commonly used method!"actate dehydrogenase "ac:s specicity

R-C' ,SAx "D. than in serum6ources'"D,#.-D! and "D&H .eart1 R-C1 >idneys"DH pancreas1 lungs1 spleen"DBan "DSH li*er and muscle"DLH alcohol dehydrogenase

Methods "D.! ,+ ac:er method for(ard/direct! H p. W+W1 BA nm1 mostcommonly used&+ robleus:i "aDue re*erse/indirect! H p. X+&1 &x faster

+ robleus:i CabaudB+ -erger -roida,A#fold increase "D.! .epatic carcinoma and toxic hepatitis 2R" 7iral hepatitis and cirrhosisCreatine >inase Isoenymes'

C>#-- H most anodal1 brainC>#M- H myocardium &A5!C>#MM H least anodal1 s:eletal and smooth muscles Maor1 4B#,AA5!

DuchenneYs musculardystrophy

8otal C>' SAx 2R" highest!

C>#M- Most specic indicator of myocardial damage )MI!0ot ele*ated in angina

Methods C>! ,+ 8aner#9ilbarg for(ard/direct! H p. 4+A1 BAnm&+ =li*er#Rosal:i/ Rosal:i O .ess re*erse/indirect! H mostcommonly used method1 faster reaction@ p. L+W1 BAnm

)denylate :inase Inside R-CsInterferes (/ C> assayInhibited by adenosine monophosphate

0#acetylcysteine )cti*ate C> "i*er cells and R-C Do not contain C>ClelandYs reagent andglutathione

Partially restore lost acti*ity of C>

Electrophoresis Reference method for C> C> relati*e index C>I! C>I 5! H C>#M-/8otal C> x ,AA)ldolase Isoenymes'

)ldolase ) H 6:eletal muscles)ldolase - H -C1 li*er1 :idney)ldolase C H brain tissue

SY 0ucleotidase Mar:er for hepatobiliary diseases and inltrati*e lesions of the li*erMethods',+ Dixon and Purdon&+ Campbell1 -eleld and 9oldberg

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998 "ocated in the canaliculi of the hepatic cellsDi$erentates the source of an ele*ated )"P le*el6ensiti*e indicator of occult alcoholismIncreased'=bstructi*e aundice)lcoholic hepatitis most sensiti*e!

Methods 998! 6ubstrate' gamma#glutamyl#p#nitroanilide,+ 6ass

&+ Rosal:i and 8arro(+ =rlo(s:i

Cholinesterase/Pseudocholinesterase

Monitor e$ects of relaxants succinylcholine! after surgeryMar:er for organophosphate poisoning "o( C.6!Methods',+ Ellman technic&+ Potentiometric

)ngiotensin#Con*ertingEnyme

)+:+a+ peptidyldipeptidase ) or >ininase IICon*erts angiotensin I angiotensin II lungs!Indicator of neuronal dysfunction )lheimerYs disease K C63!

Ceruloplasmin 3errooxidase enyme=rnithine carbamoyltransferase

3or hepatobiliary diseases

9#L#PD Drug induced hemolytic anemia primaFuine1 antimalarial drug!0ormal 7aluesEnymes!

)"P H A#4A 2/")CP'

8otal )CP male! H &+S#,,+X 2/"Prostatic )CP H A#+S ng/m")68 H S#X 2/")"8 H L#X 2/")M6 H LA#,WA 62/d" 4S#&4A 2/"!"P6 H A#,+A 2/m"

"D.'3or(ard H ,AA#&&S 2/"Re*erse H WA#&WA 2/"A%u#e Myo%!rdi!" I$*!r%#io$ M!r.er'

Myoglobin 8roponin 8 8roponin I C>#M- )68 "DRise ,# h #B h #L h B#W h L#W h ,&B hPea: S#,& h ,A#&B h ,,W h ,&B h &B h BW#X& h0ormalie ,W#A h X d ,A#,B

d!S#,A d BW#X& h S d ,A#,B d

A%u#e !$%re!#i#i' M!r.er')mylase "ipase

Rise ,& h L hPea: &B h &B h0ormalie #S d X d

E"e%#ro"y#e'Electroneutrality EFual no+ of cations and anions

-alance of chargesBA#XS5 )*erage (ater content of the human bodyEC3 ,/ of total body (aterIC3 &/ of total body (ater0ormal plasma 45 (ater Plasma' ,5 % hole blood!

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X5 solutes' Increased in dehydration!#Proteins#9lucose#0P0#"ipids#Ions

7asopressin deciency Excretion of ,A#&A" .&= e*eryday7olume and =smotic

regulation

6odium

PotassiumChloride

Electrolytes EC H 0a% Cl#% .C=#% Ca&Sth! % iP=BIC H >% Mg&Bth!

Myocardial rhythm andcontractility0euromuscularexcitability

PotassiumCalciumMagnesium

Cofactors enyme! CalciumMagnesium C>!Ninc

Chloride )M6!Potassium)8Pase ion pump MagnesiumProduction and use of)8P from glucose

MagnesiumPhosphate

)cid#base balance -icarbonateReplication of D0) andtranslation of mR0)

Magnesium

6odium Maor contributor of osmolality 4&51 together (/ Chloride and-icarbonate!,AA mg/d" glucose H ,+L mmol/" sodium

)ldosterone 6odiumPotassium H Magnesium

)trial natriuretic factor 6odium.ypernatremia Excess (ater loss

Decreased (ater inta:e.yperaldosteronism ConnYs disease!.ypothalamic disease Chronic hypernatremia!

.yponatremia Renal failure6I)D. increased (ater retention!Mar:ed hemolysis dilutional e$ect!,&S mmol/" H se*ere neuropsychiatric symptoms

8hirst Maor defense against hyperosmolality and hypernatremia

,#&5 (ater decit H se*ere thirst,SA#,LA mEF/" 0aH Moderate decit of (ater%,LS mEF/" 0aH 6e*ere (ater decit

Pseudohyponatremiaartifactual!

.yperlipidemia turbidity!

.yperproteinemiaMethods 0a! ,+ 3EP

&+ ))6+ I6E H 9lass aluminum silicateB+ Colorimetry H )lbanese "ein

Potassium Concentration in R-C is ,AS mmol/"

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Reciprocal relationship (ith .

6pecimenConsiderations >!

A+S5 hemolysis H A+S mmol/"9ross hemolysis H A56erum >% Plasma >by A+,#A+X mmol/" because of plateletsclot!,A#&A5 in muscle acti*ityA+#,+& mmol/" H mild to moderate exercise mmol/" H *igorous exercise@ st clenching

.yper:alemia Decreased resting membrane potential incr+ contractility lac:of muscle excitabilityDecreased renal excretion Dehydration1 renal failure1 )ddisonYsdisease!)cidosis DM!Muscle inury6pironolactone

.ypo:alemia Increased resting membrane potential arrhythmia"eads to hypomagnesemia7omiting

DiureticsCushingYs syndrome)l:alosisInsulin o*erdose

p. and > p. by A+, H >by A+,+X mmol/"Methods >! "ithium heparin plasma H preferred

,+ 3EP&+ ))6+ I6E H 7alinomycin gelB+ Colorimetry H "oc:head and Purcell

Chloride Chief counter ion of sodium in EC36pecimen

Considerations Cl#!

Chloride methods measure bromide and iodideCl#H .C=#

Methods Cl#! ,+ 6chales and 6chales'#Mercurimetric titration#Diphenylcarbaone#Excess .g

#! -lue *iolet&+ hiterhorn 8itration method#Mercuric thiocyanate#Reddish complex+ 3erric perchlorateB+ Cotlo*e chloridometer

#Coulometric amperometric titration#Excess )g

S+ I6E#Ion exchange membrane#8ri#n#octylpropylammonium chloride decanol

.yperchloremia Renal tubular acidosisMetabolic acidosisDiabetes insipidus Dehydration!Prolonged diarrhea

.ypochloremia Prolonged *omiting .Cl!)ldosterone deciency 0aH Cl#H >!

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Metabolic al:alosis .C=#H Cl#!Mar:ed hemolysis dilutional e$ect!

Calcium 445 -ones,5 EC3)bsorbed in the duodenum)bsorption is fa*ored at an acidic p.

3orms of Calcium SA5 H 3ree/Ionied/2nbound/)cti*e CalciumBA5 H Protein#bound )lbumin!

,A5 H Complexed (ith anions7itamin D Ca& H absorption intestine! and reabsorption :idney!P8. Ca& Hresorption bone! and reabsorption :idney!Calcitonin Ca& H urinary excretion maor net loss of calcium!Practical considerationsCa&!

6erum H specimen of choice)lbumin ,g/d"! H Ca&A+W mg/d"!

.ypercalcemia )cidosis Ca&' from -ones -lood!Cancer.yperthyroidismMil:#al:ali syndrome

.ypocalcemia 8etany)l:alosis Ca&' from -lood -ones!)cute pancreatitis Ca&' binds to damage pancreatic tissues!

Primary hypocalcemia "o( P8.Parathyroid gland disease

6econdaryhypocalcemia

.igh P8.Renal failure excretion!

Methods Ca&! ,+ Clar: Collip precipitation method#! =xalic acid#Renal calculi&+ 3erro .am Chloranilic acid precipitation method#!Chloranilic acid+ Colorimetric H =rtho#Cresolphthalein complexone dyes#Dye' )reno III#W#hydroxyFuinoline H chelates inhibits! Mg&

B+ ED8) titration method -achra1 Da(er and 6obel!S+ ))6 H Reference methodL+ I6E H "iFuid membraneX+ 3EP

Inorganic Phosphorus WS5 -ones,S5 EC3 iP=B!Maximally absorbed in the eunum Ca&' duodenum!

8rancellular shift' =nce absorbed inside cells1 it no longer comes

out used for energy productionDirunal *ariation' late morning1 e*ening=rganic phosphate H principal anion (ithin cellsInorganic phosphate H part of the blood bu$er Measured in theclin+lab+!

3orms of InorganicPhosphorus

SS5 H 3reeS5 H Complexed (ith ions,A5 H Protein#bound

P8. P=BH Ca&

Calcitonin P=BH Ca&

9ro(th hormone P=Brenal reabsorption!

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Practical considerations 3asting is reFuired 0onfasting' P=B!.yperphosphatemia .ypoparathyroidism

Renal failure.yper*itaminosis D

.ypophosphatemia )lcohol abuse H most common causePrimary hyperparathyroidism)*itaminosis D Ric:ets1 =steomalacia!

Methods iP=B! Most accurate' unreduced phosphomolybdate formation BAnm!

,+ 3is:e 6ubbaro( Method )mmonium molybdate method!#Reducing agents' Pictol1 Elon1 6enidine1 )scorbic acid#! Phosphomolybdenum blue

Magnesium S5 -onesBL5 Muscles and soft tissues,5 6erum and R-C7asodilator

3orms of Magnesium SS5 H 3ree/Ionied/Physiologically acti*eA5 H Protein#bound,A5 H Complexed (ith ions

P8. Mg&H Ca&H P=B

)ldosterone O8hyroxine! Mg&

H >

H 0a

.ypermagnesemia )ddisonYs diseaseChronic renal failure

.ypomagnesemia )cute renal failureChronic alcoholism

Methods Mg&! ,+ Calmagite#! Reddish#*iolet complex&+ 3ormaen dye method#! Colored complex+ Magnesium 8hymol blue method#! Colored complexB+ ))6 H reference methodS+ Dye#la:e Method#8itan ;ello( dye Clayton ;ello( or 8hiaole yello(!

-icarbonate 4A5 of the total C=&Chloride shift .C=#di$uses out of the cell in exchange for Cl#to maintain ionic

charge neutrality (/in the cell)nion 9ap Di$erence bet(een unmeasured anions and unmeasured cations

QC for I6EIncreased )9 2remia/renal failure

>etoacidosis"actic acidosis

Methanol poisoningEthanol poisoningEthylene glycol poisoning6alicylate poisoning

Decreased )9 .ypoalbuminemia.ypercalcemia.yperlipidemiaMultiple myeloma

Cystic 3ibrosisMuco*iscidosis!

Defecti*e gene' Cystic brosis transmembranous conductanceregulator Chromosome X!Miconeum ileus Infants!

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3oul#smelling stool2R8 infection0aand Cl#

Pilocarpine 6(eat inducer9ibson O Coo:epilocarpineiontophoresis

Reference method 6(eat sodium and chloride!

Iron Prooxidant

#Sg H 8otal body iron3errous H .gb3erric H 8ransferrin and 3erritin

Methods Iron! ,+ Colorimetric H .Cl and 3erroine#! -lue color&+ )nodic stripping *oltammetry

Increased iron .emochromatosis7iral hepatitis0on#ID)

Decreased iron ID)MalnutritionChronic infection

8I-C 2I-C 6erum IronIncreased' ID)1 hepatitis1 iron#supplemented pregnancyDecreased' 0on#ID)1 nephrosis

2I-C 8I-C K 6erum ironMeasure of reser*e iron binding capacity of transferrin

5 8ransferrin6aturation

Index of iron storageIncreased' Iron o*erdose1 hemochromatosis1 sideroblastic anemiaDecreased' ID) lo(est!1 malignancy1 chronic infection

8ransferrin 8I-C Vg/d"! x A+XA H mg/d"0ote 6odium ,/Potassium

Potassium ,/.ydrogen ionPotassium MagnesiumMagnesium CalciumCalcium ,/Inorganic phosphateChloride ,/ Bicarbonate

0ormal 7aluesElectrolytes!

6odium'6erum H ,S#,BS mmol/"_Critical' ,LA mmol/" and ,&A mmol/"`C63 H ,L#,SA mmol/"Potassium'

6erum H +S#S+& mmol/"_Critical' L+S mmol/" and &+S mmol/"`Chloride'6erum H 4W#,AX mmol/"6(eat H S#BA mmol/" _Critical' %LS mmol/"`Calcium'

8otal H W+L#,A mg/d" adult! and W+W#,A+W mg/d" child!Ionied H B+L#S+ mg/d" adult! and B+W#S+S mg/d" child!_Critical' X+S mg/d"`Inorganic Phosphate')dult H &+X#B+S mg/d"

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Child H B+S#S+S mg/d"Magnesium'6erum H ,+&+, mEF/")nion 9ap'(/ >H ,A#&A mmol/"(/o >H X#,L mmol/"Iron'Male H SA#,LA Vg/d"

3emale H BS#,SA Vg/d"8I-C')dult H &BS#B&S Vg/d"%BA y+o+ H ,A#&SA Vg/d"0- and Child H ,AA#&AA Vg/d"5 8ransferrin 6aturation H &A#SA5

0"ood 1!'e' !$d HRegulation of )cid#-asebalance

"ungs and >idneysC=& .&= ##Carbonic anhydrase!##% .&C=.&C=#######Carbonic anhydrase!##% . .C=#

&A', .C=#' .&C=ratioB', .P=B' .&P=BratioExpanded .enderson#.asselbalch eFuation

p. H L+, log _8otal C=&K pC=&x A+A!` pC=&x A+A

Chloride#isohydric shift -u$ering e$ect of hemoglobinpC=& Index of eciency of gas exchange

Increased' -arbiturates1 morphine1 alcohol1 heparin ,,S5!p=& Re?ects the a*ailability of the gas in blood but not its content

Excessi*e =&supply acidosisMetabolic )cidosis Causes'

#-icarbonate deciency#D>) normochloremic acidosis!#Renal failure#Diarrhea .C=#!Compensation' .yper*entilationCompensated' .C=# pC=& p. X+B

Metabolic )l:alosis Causes'#-icarbonate excess#7omiting Cl#!#.ypochloremia#.ypo:alemiaCompensation' .ypo*entilation

Compensated' .C=# pC=& p. %X+BRespiratory )cidosis Causes'

#C=&excess .ypo*entilation!#C=PD#Drug o*erdose morphine1 barbiturates1 opiates!Compensation' -icarbonate retentionCompensated' .C=# pC=& p. X+B

Respiratory )l:alosis Causes#C=&loss .yper*entilation!Compensation' -icarbonate excretionCompensated' .C=# pC=& p. %X+B

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3ull compensation p. normal rangePartial compensation p. near normal-u$er base )ll forms of base that (ill titrate hydrogen ionsMethods for -lood9ases and p.

6pecimen' )rterial blood-lood gas analyers' meas+ p.1 pC=&1 p=&

3actors a$ecting -loodgases O p.measurements

3or e*ery ,=C abo*e X= C'p. by A+A,Sp=&by X5

pC=&by 5-acterial contamination' consume =&p=&!Excess heparin acid MP6! H p.)ir exposure bubbles!'p=&H B mm.g/&minspC=&H B mm.g/&mins

Methods-lood gases O p.!

,+ 9asometera+ 7an 6ly:eb+ 0atelson#Mercury' produce *acuum

#Caprylic alcohol' anti#foam reagent#"actic acid#0a=.#0a.6=&+ Electrodesa+ p. H potentiometry#6il*er#sil*er chloride electrode Reference electrode!#Calomel electrode _.g&Cl&` Reference electrode!b+ pC=&H 6e*eringhaus electrode potentiometry!c+ p=&H Clar: electrode polarography#amperometry!

hole blood total C=& Dissol*ed C=& .&C= .C=#

8ranscutaneous

electrodes

Continuous monitoring of p=&Directly placed on the s:in

-lood gas QC Min+ reFuirement'#, sample e*ery W hours# le*els of control acidosis1 normal1 al:alosis! e*ery &B hours

0ormal 7alues-lood gases and p.!

p. H X+S#X+BSpC=&H S#BS mm.g

8otal C=&'- arterial H ,4#&B mmol/"- *enous H &&L mmol/".C=# H &,#&W mEF/"p=&H W,#,AA mm.g

_.ypoxemia'`#Mild L,#WA mm.g!#Moderate B,#LA mm.g!#6e*ere BA mm.g or less!=&saturation H 4B#,AA5

E$do%ri$o"ogyEndocrine .ormone blood circulation specic receptorParacrine .ormone interstitial space adacent cell)utocrine .ormone self#regulation


44/56

0eurocrine .ormone neurons extracellular space0euroendocrine .ormone neurons ner*e endings9lycoproteins 36.1 hC91 86.1 ".Polypeptides )C8.1 )D.1 9.1 angiotensin1 calcitonin1 CC>1 gastrin1 glucagons1

insulin1 M6.1 oxytocin1 P8.1 PR"1 somatostatin6teroids Precursor' cholesterol

)ldosterone1 cortisol1 estrogen1 progesterone1 testosterone1*itamin D

)mines Deri*ed from amino acidsCatecholamines1 81 8B

.ypothalamus Connected to the posterior pituitary by the infundibulum stal:.ypophyseal hormones' 8R.1 9nR.1 9.#I.1 9.#R.1 PI3

Pineal gland Melatonin' decreases pigmentation of the s:inPituitary gland Master 9land

"ocated in the sella turcica or 8ur:ish saddle)nterior Pituitary)denohypophysis!

8rue endocrine gland.ormones' PR"1 9.1 36.1 ".1 86.1 M6.1 )C8.

9. 6omatotropin! Most abundant of all pituitary hormones6tructurally similar to PR" and .P"

Mar:edly ele*ated during deep sleepD(arsm Decreased 9.)cromegaly Increased 9.9. deciency tests ,+ Insulin tolerance test H 9old standard Conrmatory test!

&+ )rginine stimulation test H &ndconrmatory test8ests for )cromegaly ,+ 6omatomedin C or insulin#li:e gro(th factor I 6creening!

#Increased' )cromegaly#Decreased' 9. deciency&+ =988 Conrmatory!#XSg glucose

36. 6permatogenesis

". .elps "eydig cells to produce testosterone male!=*ulation female!6ynthesis of androgens1 estrogens1 and progesterone

86. 8hyrotropin! 6timulates thyroid gland to produce 8 and 8BIncreased' ,Y hypothyroidism1 &Y hyperthyroidismDecreased' ,Y hyperthyroidism1 &Y hypothyroidism1 Yhypothyroidism

)C8. Corticotropin! .ighest' L#W )M"o(est' L#,, PM0ot allo(ed to ha*e contact (ith glass because it adheres to glasssurfaceCollect blood in plastic tubes

Prolactin Initiation and maintenance of lactationInhibited by Dopamine.ighest' B)M and W)M1 and WPM and ,APMIncreased' Menstrual irregularity1 infertility1 amenorrhea1galactorrhea

Panhypopituitarism 3rom pituitary tumor adenoma! or IschemiaPituitary ischemia6hechanYs!

.emorrhage or shoc: in a pregnant female at the time of deli*er

Posterior pituitary0eurohypophysis!

Release but not produce oxytocin and *asopressin

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=xytocin 2terine contraction and mil: eection)D./)7P )rginine*asopressin!

.&= reabsorption DC8 and CD!6timulus' Increased plasma osmolality %&4S m=sm/:g!1decreased blood *ol+Promotes factor 7II and *3 release

=*ernight (aterdepri*ation test Conc+test!

Diagnostic test for )D.

0eurogenic DI 8rue Diabetes Insipidus3ailure of the pituitary gland to secrete )D.

0ephrogenic DI 3ailure of the :idneys to respond to normal or ele*ated )D.6I)D. 6yndrome of inappropriate )D.

6ustained production of )D.Decreased urine *olume"o( plasma osmolality"o( serum electrolytes

8hyroid 9land -utter?y#shaped& lobes H connected by the isthmus

3ollicle 3undamental structural unit of the thyroid gland

3ollicular cells 6ecrete 8 and 8BParafollicular or C cells 6ecrete calcitonin8hyroglobulin Preformed matrix containing tyrosyl groups

6tored in the follicular colloid of the thyroid gland8hyroid hormone-iosynthesis

,+ 8rapping of Iodine&+ Iodination' I&8yrosine ring MI8 and DI8+ Condensation' MI8DI8H8 / DI8DI8H8BB+ Release' 8/8B -lood circulationS+ 8ransport of 8/8B by proteins

Protein#boundhormones

Metabolically inacti*e-iologically inertDo not enter cells6torage sites

3ree hormones38/38B!

Physiologically acti*eReadily enters cells

Re*erse 8 r8! 3rom remo*al of one iodine from 8B product of 8B metabolism!Metabolically inacti*e

I&inta:e SA Vg/day Deciency of hormone secretion8 1S1Y#8riiodothyronine

Most acti*e thyroid hormonal acti*ityXS#WA5 is produced from the tissue deiodination of 8BDiagnosis of 8 thyrotoxicosis

8B 1S1YSY#8etraiodothyronine

Principal secretory product)ll originated in the thyroid gland

8-9 8ransports XA#XS of 88B1 and maority of 88-P) 8ransthyretin! 8ransports ,S#&A5 of 88B

0o anity for 88-) 8ransports 8 and ,A5 of 8B8hyroid autoantigens 8P=

8g86.R

8hyroid disorders 6creening is recommended (hen a person reaches S yrs old and

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e*ery S yrs thereafterPrimaryhyperthyroidism

8 and 8B86.

6econdaryhyperthyroidism

8 and 8B86.

8 8hyrotoxicosisPlummerYs disease!

80#8B86.

9ra*esY diseaseDi$use toxic goiter!

,Y .yperthyroidismMost common cause of thyrotoxicosis autoimmune!omen % Men)nti#86. receptor

RiedelYs thyroiditis 8hyroid (oody or stony#hard mass6ubclinicalhyperthyroidism

0o symptoms0#8 and 8B86.

6ubacutegranulomatous/6ubacute

nonsuppurati*e/ DeQuer*ainYs thyroditis

.yperthyroidismPainful thyroiditis0ec: pain1 lo(#grade fe*er

#! anti#8P=1 E6R and 8g

.ypothyroidism 8reatment' "e*othyroxinePrimary hypothyroidism 8 and 8B

86..ashimotoYs diseaseChronic autoimmunethyroiditis!

Most common cause of ,Y hypothyroidism8hyroid is replaced by a nest of lymphoid tissue 8 cells!9oiter! anti#8P=86.

Myxedema coma 6e*ere form of ,Y hypothyroidismPeculiar nonpitting s(elling of the s:in6:in is inltrated by mucopolysaccharidesTPu$yU face1 thin eyebro(s

6econdaryhypothyroidism

8 and 8B86.

8ertiary hypothyroidism 8 and 8B86.8R.

CongenitalhypothyroidismCretinism!

Mental retardation child!6creening'8BConrmatory' 86.

6ubclinical

hypothyroidism

0#8 and 8B

86.8R. stimulation test Most specic and sensiti*e test for diagnosing thyroid disease

Conrm borderline cases and euthyroid 9ra*esY disease' ,Y hypothyroidism' .yperthyroidism

Radioacti*e Iodine2pta:e R)I2!

Measure the ability of the thyroid gland to trap iodine

8hyroglobulin 8g!assay

Postoperati*e mar:er of thyroid cancer' 2ntreated and metastatic di$erentiated thyroid cancer1hyperthyroidism

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' .ypothyroidism1 thyrotoxicosis factitiar8 )ssess borderline or con?icting laboratory results3ree 8hyroxine Index38BI!

Indirectly assesses the le*el of 38B in bloodEFuilibrium relationship of bound 8B and 38BReference method' EFuilibrium dialysis38BI H 88B x 825! or 88B x 8.-R ,AA

881 381 38B 38B test' di$erentiates drug induced 86. ele*ation and

hypothyroidism88 or 38' conrm hyperthyroidismReference method 38B!' EFuilibrium dialysis

8 2pta:e test Measures the number of a*ailable binding sites of the thyroxinebinding proteins 8-9!8-9 H 828-9 H 82

8-9 test Conrm results of 38 or 38B or abnormalities in the relationship of88B and 8.-R testEstrogen'8-9)ndrogen' 8-9

3ine#needle aspiration Most accurate tool in the e*aluation of thyroid nodulesRecombinant .uman86.

8est patients (/ thyroid cancers for the presence of residual orrecurrent dis+

8anned Erythrocyte.emagglutinationmethod

8est for anti#8g disorders

6erum calcitonin test Mar:er for familial medullary thyroid carcinoma38B and 86. -est indicators of thyroid status38 and 38B More specic indicators of thyroid function than meas+ of total

hormone0ot a$ected by 8-9

Euthyroid sic:syndrome

)cutely ill but (ithout thyroid disease8 and 8B0/86.r8

Parathyroid gland B parathyroid glands6malles endocrine gland

P8. .ypercalcemic hormoneCa&bone resorption and renal reabsorption! and Mg&

iP=B,Y hyperparathyroidism Defecti*e' Parathyroid gland

Most common cause of hypercalcemiaParathyroid adenoma

P8. and iCa&

.ypercalciuriaPhosphaturia .ypophosphatemiaIf goes undetected se*ere demineraliation osteitis brosacystica!

&Y hyperparathyroidism In response toCa&

.yperplasia of all B glandsCauses' 7it+ D deciency and chronic renal failureP8.Ca&

Y hyperparathyroidism =ccurs (/ &Y hyperparathyroidism Ca&!

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)utonomous function of hyperplastic P8 glands or P8 adenomaP=BCalcium phosphates precipitate in soft tissues

.ypoparathyroidism )ccidental inury of the P8 glands nec:! during surgery)utoimmune parathyroid destructionP8. H Ca&

.yperparathyroidism )cidosis

.ypoparathyroidism )l:alosis

)drenal glands Pyramid#shaped)bo*e the :idneys)drenal cortex H outer yello(!)drenal medulla H inner dar: mahogany!.as prime e$ects on blood pressure

)drenal cortex Maor site of steroid hormone production9 cells' con*ert cholesterol pregnenolone

CPPP ring ,X#carbon s:eleton deri*ed from cholesterol layers )drenalcortex!

,+ Nona 9lomerulosa H Mineralocorticoids )ldosterone!&+ Nona 3asciculata H 9lucocorticoids Cortisol!+ Nona Reticularis H ea: androgens androstenedione1 D.E)!

Cortisol 9luconeogenesis hyperglycemia8he only adrenal hormone that inhibit the secretion of )C8.)nti#in?ammatory and immunosuppressi*eDiurnal' L#W)M / ,APM#,&)M2rinary metabolites' ,X#=.C6 and ,X#>96

Porter#6ilber method Meas+ ,X#=.C6Rgt' D0P. in .&6=B )lcohol! ;ello(

Nimmerman reaction Meas+ ,X#>96Rgt' m#dinitrobenene! Reddish purple=xidation procedure' 0orymbers:i 0abismuthate!

Pisano method 3or Fuantitating metanephrines and normetanephrines>ober reaction 3or estrogen

Rgt' .&6=B hydroFuinone! Reddish bro(n color

CushingYs syndrome.ypercortisolism!

Excessi*e production of cortisol and )C8.=*eruse of corticosteroids-u$alo hump.yperglycemia.ypertension

.ypercholesterolemia"ymphocytes

6creening testsCushingYs!

,+ &B#hour urine free cortisol test&+ =*ernight dexamethasone suppression tests H Most (idely used,mg!+ 6ali*ary cortisol test

Conrmatory testsCushingYs!

,+ "o(#dose dexamethasone suppression test A+Smg!&+ Midnight plasma cortisol+ CR. stimulation test

)ddisonYs disease,Y .ypocorticolism!

Primary adrenal insuciencyCortisol and aldosterone

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)C8.! .yperpigmentation6creen' )C8. 6timulation 8est

&Y .ypocorticolism 6econdary adrenal insuciency.ypothalamic#pituitary insuciency)C8.

8est' )C8. 6timulation test)C8. 6timulation test

Corsyntropinstimulation test!

Corsyntropin' synthetic coritsol and aldosterone stimulator

Di$erentiates'&Y adrenal insuciency )C8.! fromY adrenal insuciency )C8.!

Metyrapone test Metyrapone' inhibitor of ,, #hydroxylaseMeasures the ability of the pituitary gland to respond to decliningle*els of circulating cortisol1 thereby secrete )C8.)lternati*e diagnostic or conrmatory test for &Y or Y adrenalinsuciency!' )C8.

&B#hour urine freecortisol

Most sensiti*e and specic screening test for excess cortisolproduction because plasma cortisol is a$ected by diurnal *ariation

Methods' .P"C or 9C#M6.P"C#M6 Reference method for measuring urinary free cortisolI88 Insulin tolerancetest!

9old standard for &Y and Y hypocorticolismConrms borderline response to )C8. stimulation test

6erum )C8. Di$erentiates'CushingYs disease )C8.!CushingYs syndrome A#)C8.!

)C8. ,X#=.C6 and ,X#>6Congenital )drenal.yperplasia

Enyme deciencies',+! &,#hydroxylase H most common&+! ,, #hydroxylase H &ndmost common+! #hydroxysteroid dehydrogenase#isomeraseB+! C#,X1&A#lyase/,X#hydroxylaseCortisol)C8.)ndrogens hirsutism1 *iriliation1 amenorrhea1pseudohermaphroditism!

)ldosterone )ldo! Electro#regulating hormone0aand Cl#

>and .

at night,W#hydroxysteroid dehydrogenase' enyme needed for aldosteronesynthesis

ConnYs disease,Y hyperaldosteronism!

)ldosterone#secreting adrenal adenoma6creen' Plasma )ldo conc+/Plasma renin acti*ity ratio P)C/PR)ratio!#!' %SA ratioConrm' 6aline suppression test#!' %S ng/d" aldosterone

&Y .yperaldosteronism Excessi*e production of renin"iddleYs syndrome Pseudohyperaldosteronism

Resembles ,Y aldosteronism clinically)ldosterone#! .ypertension

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-artterYs syndrome -umetanide#sensiti*e chloride channel mutation)ldosterone and Renin

9itelmanYs syndrome 8hiaide#sensiti*e transporter mutation)ldosterone

.ypoaldosteronism Destruction of the adrenal glands9lucocorticoid deciency&,#hydroxylase deciency

Postural stimulation

test

8est for aldosterone

3lorinef 6ynthetic mineralocorticoidea: androgens Precursors for the production of more potent androgens and

estrogensPrecursors' Pregnenolone and ,X#=. pregnenoloneExamples' D.E) and androstenedione-ound to steroid hormone binding globulin 6.-9!' 7iriliation pseudohermaphroditism!

D.E)Dehydroepiandrosterone!

Principal adrenal androgenCon*erted to estrone

)drenal medulla Chroman cells' secrete catecholaminesPrecursor' "#tyrosine0orepinephrine/Epinephrine ###Monoamine oxidase and Catechol#A#methyl#transferase!###% Metanephrines and 7M)

4', 0orepinephrine' Epinephrine ratio0orepinephrine Primary amine

in C06Metabolites'##methoxy#B#hydroxyphenylglycol M.P9! H Maor metabolite#7M)

Epinephrine 6econdary amineMost abundant medullary hormoneT3light or ght hormoneUMetabolites'#7anillylmandelic acid 7M)! H Maor metabolite#Metanephrines#0ormetanephrines#.7)

Dopamine Primary amine3rom the decarboxylation of 1B#Dihydroxyphenylalanine D=P)!Maor metabolite' .omo*anillic acid .7)!

Pheochromocytoma 8umors of the adrenal medullaCatecholamines

Classic T6pellsU' tachycardia1 headache1 chest tightness1 s(eating1hypertension

Clonidine test Di$erentiates'Pheochromocytoma Catecholamines not suppressed! from0eurogenic hypertension SA5 decreased in catecholamines!

0euroblastoma 0orepinephrine Children!urinary .7)1 7M) or both and dopamine

MethodsCatecholamines!

6pecimen' &B#hr urine and plasma,+ Chromatography' .P"C or 9C#M6&+ RI)' sensiti*e screening test#%&AAApg/m" H diagnostic for pheochromocytoma

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Estrogens Estrone H Postmenopausal (omenEstradiol H Premenopausal (omen most potent1 secreted by theo*ary!Estriol H Pregnancy placenta!

Mar:ers for Do(n6yndrome

)3P2nconugated EstriolhC9Inhibin )

>aryotyping or 3I6.typing

8est for Do(n syndrome amniotic ?uid!

Progesterone Produced mainly by the corpus luteumDet+ (hether o*ulation has occurred"uteal phase

8ests for menstrualcycle dysfunction andano*ulation

EstrogenProgesterone36.".

8ests for femaleinfertility

hC9PR"

38B86.36.".EstradiolProgesterone

Pancreas Exocrine! Digesti*e enymes )M61 "P6!)cinus' functional secretory unit

Pancreas Endocrine! .ormones')lpha cells &A#A5! H glucagon-eta cells LA#XA5! H insulinDelta cells W5! H somatostatin

hC9 Produced by the syncytiotrophoblasts placenta!Maintain progesterone production by the corpus luteum

.uman placentallactogen .P"!

6timulates de*elopment of mammary glandIncreases maternal plasma glucose le*elsDiagnosis of intrauterine gro(th retardation

9astrin 6ecreted by 9 cells stomach!6timulates parietal cells to secrete .Cl6timulus' )mino acidNollinger#Ellison syndrome

Pernicious anemia6erotoninS#hydroxytryptamine!

6ynthesied by argentan cells 9I8!Metabolite' S#.I))

S#.I)) Diagnostic mar:er for carcinoid syndrome8est' EhrlichYs aldehyde test H ! purple color

6omatostatin )+:+a+ 9.#I.Inhibitor of 9.1 glucagon and insulin

,Y amenorrhea Menstruation ha*ing ne*er occurred&Y amenorrhea )bsence of menses for L monthsCushingYs disease )bnormal increased secretion of )C8.CushingYs syndrome Chronic excessi*e production of cortisol by the adrenal cortex

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#"arge doses of glucocorticoids#Pituitary tumor )C8.! H most common cause

9ynecomastia De*elopment of breast tissue in males.irsutism Excessi*e hair gro(th (/ a male distribution pattern in a female

Most common endocrine disorder in (omenMullerian agenesis Congenital malformation or absence of the fallopian tubes1 uterus

or *agina0#36.1 ". and testosterone

0onthyroidal illness Illness that do not directly in*ol*e the thyroid gland6ipples syndrome ME0II!

Medullary carcinoma of the thyroidPheochromocytomaParathyroid adenoma

6tein#"e*enthalsyndrome

Mild hirsutism (/ normal menses to excessi*e hirsutism (/amenorrhea

8hyroid stones )+:+a+ thyroid crisis"ife#threatening2ncontrolled thyrotoxicosis

0ormal 7aluesEndocrinology!

8')dult H WA#&AA ng/d"

Children ,#,B y+o+ H ,AS#&,S ng/d"8B')dult H S+S#,&+S Vg/d"0eonate H ,,+W#&&+L Vg/d"

82 H &S#S5T&er!eu#i% ,rug Mo$i#ori$g

Mixed function oxidaseM3=! system

-iochemical path(ay responsible for the greatest portion of drugmetabolism

Intra*enous route ,AA5 bioa*ailability"iberation Drug Release)bsorption Drug -lood most' by passi*e di$usion!

Distribution Drug

8issuesMetabolism Drug Chemical modicationExcretion Drug metabolites excreted-ioa*ailable fraction f! 3raction of the dose that reaches the blood7dof a drug Dilution of the drug after it has been distributed in the body3irst#pass hepaticmetabolism

Drugs "i*er Decreased bioa*ailability

3irst order elimination "inear relationship bet+ the a

clinical chemistry reviewer by mtr

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