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Practicability
Reliability
Intralab/Interlab QC
Interlab/External QC
QC materials
Bovine control materials
Matrix effect
Precision study
Nonlab
...
of 1 yr
Preferred (Human: biohazard)
Not for immunochem, dye-binding and bilirubin
Improper product manufacturing
Unpurified analyte
Altered protein
First step in method evaluation
29% of errors (lab results)
Dispersion of values from the mean
Index of precision
Relative magnitude of variability (%)
SD2
Measure of variability
Compare means or SD of 2 groups of data
Means of 2 groups of data
SD of 2 groups of data
V-mask
Earliest indication of systematic errors (trend)
Compare results obtained from diff
...
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
...
, 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
...
Violet)
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
½ peak transmittance
Most commonly used cuvet
UV
Strong bases
Converts transmitted light into photoelectric energy
Simplest detector
No external voltage
For filter photometers
Contains anode and cathode
Req external voltage
Most common type
lec
...


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
Cellulose acetate
Agarose gel
Polyacrylamide gel
Electrophoretic mobility

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
...
source and cuvette: Flame
For excited ions (Na+, K+)
Internal standards (FEP)
Correct variations in flame
Preferred internal std
Potent antidepressant
Meas
...
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
...
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
Ex: gamma globulins
Molecular size
Electrical charge
Charge and molecular size
20 fractions (ex
...
mt 04 |Page | 3

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
chromatography
Fluorometry/Molecular
Luminescence Spectro
...
amt
...
emitted by a molecule after excitation by electromagnetic
radiation
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
lec
...
mt 04 |Page | 5

Discrete Analyzer

Thin-Film Analyzers
(Dry slide technology)

Carry over
Batch testing
Parallel testing
Random access testing

Sequential testing
Open reagent system
Closed reagent system
Exercise

RotoChem
Most popular
Req
...
mt 04 |Page | 6

Fist clenching

Fasting

Basal state collection

Diet

Turbidity/Lactescence
Icterisia
Icteric samples

Upright/supine (lying)
position
Supine  Sitting/Standing

Sitting  Supine

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
5-HIAA (From Serotonin)
Triglyceride >400mg/dL
Bilirubin: 25
...
mt 04 |Page | 7

Increased: “P(u)BLIC”
Proteins
BUN
Lipids
Iron
Calcium
Standing  Supine
Hemodilution
Decreased: “TLC”
Triglycerides
Lipoproteins
Cholesterol
Prolonged standing
Increased: K+ (muscles)
Prolonged bedrest
Decreased: Albumin (Fluid retention)
Tourniquet
Recommended: 1 minute application
Prolonged tourniquet app
...
mt 04 |Page | 8

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
Lancet
Incision (Skin puncture)
1
...
4mm
Arterialized capillary blood
Flea
Indwelling umbilical artery
1000-3000 RCF for 10 mins
Hemolysis

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
...
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
12 hours after the last ingestion of food
1
...
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
lec
...
2-3
...
k
...
Mucoitin polysulfuric acid
Universal anticoagulant
Antithrombin
0
...
mt 04 |Page | 10

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
Molality
Milliequivalents
Millimoles
Ratio
Dilution
0
...
01
2
...
04)
Serum: (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
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  μmol/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
lec
...
of melting point or boiling point
In manufacturing
Never used in clin
...
testing
For human consumption
Not applicable for lab
...
interference
Max
...
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
...
to indicate lot no
...

rgts, and precautions for safe use and storage
Recommends that a lab
...
mt 04 |Page | 12

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
Ethanol
Toluene
Methanol
Xylene
Benzene
Isopropanol
Heptane
Flammable liquids
Flash point below 37
...
8OC
Strong acids or bases
Neutralized before disposal
Water should NEVER be added to concentrated acid
Ether
Deteriorate over time  hazardous
Forms explosive peroxides
Benzidine
Known carcinogen
Fumehoods
Ventilation: velocity of 100-120 ft/min
Safety showers
Deliver 30-50 gal/min of H2O at 20-50 psi
Carbohydrates
Glycol aldehyde
The simplest carbohydrate
Sucrose
Most common nunreducing sugar
Pancreas
Exocrine: Enzymes (AMS, LPS)
Endocrine: Hormones (Insulin, glucagon, somatostatin)
Hyperglycemic Hormones
“GAG CHET”
Glucagon
ACTH
GH
lec
...
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
lec
...
5 g/dL Hgb)
Dextrostics
OGTT
IVGTT

Requirements for OGTT

Glucose load
HbA1c

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)
Schiff’s base
Measures beta-D-glucose (65%)
Converts alpha-D-glucose (35%) to beta-D-glucose (65%)
Absorbance at 340nm
Consumption of oxygen on an oxygen-sensing electrode
O2 consumption α 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 (false-decreased)
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
...
75 g glucose/kg BW = children
2-3 months
Glucose = beta-chain of HbA1
lec
...
5
C-peptide
5:1 to 15:1
D-xylose absorption test
Gerhardt’s ferric chloride
test
Nitroprusside test
Acetest tablets
Ketostix
KetoSite assay
Normal Values
(Carbohydrates)

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
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 μmol/L
2-Hr PPBS = <140 mg/dL
GTT:
30 mins = 30-60 mg/dL above fasting
lec
...
H2SO4
Colorimetry (Pearson, Stern and Mac Gavack)
Color
...
+ Extract
...
+Extract
...
+ Precipitation
(Schaenheimer Sperry, Parekh and Jung)
CDC reference method for cholesterol:
-Hydrolysis/saponification (Alc
...
HCHO
lec
...
95
80-95% TAG (exogenous)
Apo B-48 (Major)
EP: Origin
Secreted by the liver
SG: 0
...
006
65% TAG (endogenous)
Apo B-100 (Major)
EP: pre-beta
Synthesized by the liver
SG: 1
...
063
50% CE
Apo B-100 (Major)
EP: beta
Cholesterol transport: LiverTissues
Target of cholesterol lowering therapy
Better marker for CHD risk
Smallest but dense
SG: 1
...
21
45-55% protein
26-32% phospholipid
Apo A-1 (Major)
EP: alpha
Produced by the liver and intestine
Reverse cholesterol transport: TissueLiver
Product of VLDL catabolism
Seen in Type 3 hyperlipoproteinemia (Apo E-III def
...
006-1
...
045-1
...
mt 04 |Page | 18

LpX
Beta-VLDL

Lipoprotein methodologies

Ultracentrifugation

Electrophoresis

Chemical precipitation
3-step procedure:
Ultracentrifugation
Precipitation
Abell-Kendall assay
Beta quantification +
Ultracentrifugation +
Chemical precipitation
Immunoturbidimetric assay
LDL Cholesterol
Friedewald method

De Long method
Apo A-1
Apo B-100
Apo B-48
Apo C-II
Apo D
Apo E
Apo(a)

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
...
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
...
825 (mmol/L)
VDL = TAG/6
...
mt 04 |Page | 19

Abetalipoproteinemia
(Basses-Kornzweig syn
...
TAG), CM (Exo
...
mt 04 |Page | 20

Primary structure
Secondary structure
Tertiary structure
Quarternary structure
Albumin
Glucogenic amino acids
Ketogenic amino acids
Simple proteins
Conjugated proteins

Nitrogen balance
Negative nitrogen balance
Positive nitrogen balance
Prealbumin (Transthyretin)
Albumin
Alpha1-antitrypsin
Alpha1-fetoprotein

Alpha1-acid glycoprotein/
orosomucoid
Alpha1-antichymotrypsin
Haptoglobin (alpha2)
Ceruloplasmin (alpha2)

Amino acid sequence
Det
...
anabolism and catabolism
Catabolism > anabolism
Excessive tissue destruction
Anabolism > catabolism
Growth and repair processes
Transports thyroxine and retinol (Vit
...
7)
Negatively charged even in acid solution
Acute phase reactant
Binds and inactivates PSA
Increased: Alzheimer’s disease, AMI, infection, malignancy, burns
Acute phase reactant
Binds free hemoglobin (alpha chain)
Copper binding (6-8 atoms of copper are attached to it)
Has enzymatic activities
lec
...
alpha1
and alpha2)
Hemopexin (beta)
Beta2-microglobulin
Transferrin/Siderophilin
(beta)
Complement (beta)
Fibrinogen (bet
...
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
lec
...
14
Fluoride or citrate
Thiosemicarbazide
Ferric ions
Diacetyl monoxime method
Urease method

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
Screen: Modified Guthrie test (Antagonist: 4-azaleucine)
Diagnostic: Amino acid analysis (HPLC)
Deficiency of tetrahydrobiopterin (BH4)  elevated blood phenylalanine
Total protein = 6
...
3 g/dL
Albumin = 3
...
0 g/dL
Globulin = 2
...
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
...
2-1
...
mt 04 |Page | 23

Coupled urease
Isotope dilution mass
spectrometry
NPN

Creatinine
Enzymatic methods
(Creatinine)
Direct Jaffe method
Interferences (Direct Jaffe)

Folin Wu Method
Lloyd’s or Fuller’s Earth
method
Lloyd’s reagent
Fuller’s earth reagent
Jaffe reagent (Alk
...
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
...
a
...
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
lec
...
plasma osmolality
Tubular failure

Foul breath
Urine-like sweat
From purine (adenine and guanine) catabolism
Excretion: 1g/day
-Gout
-Increased nuclear metabolism (leukemia, lymphoma, MM, polycythemia,
hemolytic and megaloblastic anemia) – Tx: Allopurinol
-Chronic renal disease
-Lesch-Nyhan syndrome (HGPRT deficiency)
Fanconi’s syndrome
Wilson’s disease
Hodgkin’s 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 non-uric acid
reactants
Simplest and most specific method
Candidate reference method
Uric acid (Absorbance at 293nm) ---[Uricase]--> Allantoin (No absorbance)
Decrease in absorbance α 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
...
010 = SG of ultrafiltrate in Bowman’s 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
...
osm
...
FP)
Vapor pressure (incr
...
= decr
...
osm
...
OP)
Boiling point (incr
...
= incr
...
vasopressin (H2O reabsorption)  decr
...
mt 04 |Page | 25

Osmolal gap
Osmolal gap: >12 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

Difference between measured and calculated osmolality
Sensitive indicator of alcohol or drug overdose
DKA
Drug overdose
Renal failure
Creatinine Clearance:
Male = 85-125 mL/min
Female = 75-112 mL/min
BUN = 8-23 mg/dL
Creatinine = 0
...
5 mg/dL
Uric acid:
Male = 3
...
2 mg/dL
Female = 2
...
0 mg/dL
Renal plasma flow (PAH) = 600-700 mL/min
Renal blood flow (PSP) = 1200 mL/min
SG = 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
...
mt 04 |Page | 26

Test for Detoxification
Function

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

Enzyme tests: ALP, AST, ALT, 5’NT, GGT, OCT, LAP, LDH
Ammonia:
-Kjeldahl (Digestion) method
-Nesslerization reaction
-Berthelot reaction
0
...
4 g/dL higher than serum due to fibrinogen
Standard reference method
Measurement of nitrogen content
Serum + Tungstic acid  PFF
1g N2 = 6
...
1-16
...
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

lec
...
mt 04 |Page | 28

Gilbert’s 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
...
5% Sodium nitrite)
Diazo blank (1
...
to glutamine) 
increases pH  compromise the Kreb’s cycle  Coma due to lack of ATP for the
brain
lec
...
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
...
3 g/dL
Albumin = 3
...
0 g/dL
Globulin = 2
...
5 g/dL
α1-globulin = 0
...
3 g/dL
α2-globulin = 0
...
0 g/dL
β-globulin = 0
...
1 g/dL
γ-globulin = 0
...
6 g/dL
Total bilirubin = 0
...
0 mg/dL
Indirect bilirubin = 0
...
8 mg/dL
Direct bilirubin = 0-0
...
1-1
...
54 Ehrlich units/day)
Stool = 75-275 Ehrlich units/100g feces (or 75-400 Ehrlich units/24hrs)
Ammonia = 19-60 μg/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
...
Ca2+ (#1 activator), Zn2+ (LDH), Cl- (AMS), Mg2+ (CK, ALP)
Inorganic ion attached to a molecule
Ex
...
mt 04 |Page | 30

Temperature
40-50’C
60-65’C
Temperature coefficient
(Q10)
pH
Storage
Hemolysis
Lactescence or milky
specimen
Enzyme nomenclature
Enzyme classification

Oxidoreductases

Transferases

Hydrolases

Lyases

37’C = 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: -20’C = for longer period of time
Substrate and Coenzymes: 2-8’C
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:
-AMS
-Galactosidases
Removal of groups w/o hydrolysis (product contains double bonds)
Aldolase
lec
...
5
405nm
Electrophoresis:
(+) Liver  Bone (Regan)  Placenta  Intestine (-)
Heat fractionation:
(Δ Stable) Regan  Placenta  Intestine  Liver  Bone (Δ Labile)
Inhibits Regan, placental and intestinal ALP
Inhibits Nagao ALP
Inhibits liver and bone ALP
Inhibits bone ALP
Low temperature = Increased ALP
1
...
Bessy, Lowry and Brock (PNPP)
3
...
King and Armstrong = PP (phenylphosphate)
5
...
Huggins and Talalay = PPDP (phenolphthalein diphosphate)
lec
...
Moss = ANP (alpha naphthol phosphate)
Increased ALP
Sprue
Hyperparathyroidism
Rickets (children) and osteomalacia (adults)
Acid Phosphatase
pH = 5
...
Gutman and Gutman = PP
2
...
Babsonm Read and Phillips = ANP (continuous monitoring)
4
...
5
(AST/SGOT)
340nm
Sources: Cardiac tissue > Liver > Skeletal muscle > Kidney, pancreas, RBCs
Alanine Aminotransferase
pH 7
...
Karmen method = Kinetic
2
...
4N NaOH
Increased Transaminases
DeRitis ratio (ALT:AST) >1
...
inactivation
Salivary AMS = inhibited by wheat germ lectin
Substrate: Starch
Saccharogenic
Reducing sugars produced
Classic reference method (SU)
Amyloclastic
Degradation of starch
Chromogenic
Increase in color intensity
Coupled-enzyme
Continuous-monitoring technique
Lipase
Late marker (AP)
Most specific pancreatic marker
Methods (LPS)
Substrate: Olive oil/Triolein
1
...
Tietz and Fiereck
3
...
mt 04 |Page | 33

Methods (LDH)

10-fold increase (LDH)
2-3x URL
Creatine Kinase

Duchenne’s muscular
dystrophy
CK-MB
Methods (CK)
Adenylate kinase
N-acetylcysteine
Liver cells and RBC
Cleland’s reagent and
glutathione
Electrophoresis
CK relative index (CKI)
Aldolase

5’ Nucleotidase

GGT

Methods (GGT)

Cholinesterase/

RBC: 150x LDH than in serum
Sources:
LD1 (α-HBD) and LD2 = Heart, RBC, Kidneys
LD3 = pancreas, lungs, spleen
LD4 an LD5 = liver and muscle
LD6 = alcohol dehydrogenase
1
...
8, 340 nm, most commonly used
2
...
2, 2x faster
3
...
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, 94-100%)
Total CK: 50x URL (highest)
Most specific indicator of myocardial damage (AMI)
Not elevated in angina
1
...
0, 340nm
2
...
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
...
Campbell, Belfield and Goldberg
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
...
Rosalki and Tarrow
3
...
mt 04 |Page | 34

Pseudocholinesterase

Angiotensin-Converting
Enzyme
Ceruloplasmin
Ornithine carbamoyl
transferase
G-6-PD
Normal Values (Enzymes)

Rise
Peak
Normalize

Myoglobin
1-3 h
5-12 h
18-30 h

Rise
Peak
Normalize
Electroneutrality
40-75%
ECF
ICF
Normal plasma

Vasopressin deficiency
Volume and Osmotic
regulation
Electrolytes
Myocardial rhythm and

Marker for organophosphate poisoning (Low CHS)
Methods:
1
...
Potentiometric
A
...
a
...
5-11
...
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
...
of cations and anions
Balance of charges
Average water content of the human body
1/3 of total body water
2/3 of total body water
93% water (Plasma: 13% > Whole blood)
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

LD
12-24 h
48-72 h
10-14 d

lec
...
6 mmol/L sodium
Sodium
Potassium =  Magnesium
 Sodium
Excess water loss
Decreased water intake
Hyperaldosteronism (Conn’s 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
...
AAS
3
...
Colorimetry = Albanese Lein
Concentration in RBC is 105 mmol/L
Reciprocal relationship with H+
0
...
5 mmol/L
Gross hemolysis =  30%
Serum K+ > Plasma K+ by 0
...
7 mmol/L because of platelets (clot)
10-20% in muscle activity
0
...
2 mmol/L = mild to moderate exercise
2-3 mmol/L = vigorous exercise; fist clenching
Decreased resting membrane potential  incr
...
mt 04 |Page | 36

Vitamin D3
PTH
Calcitonin
Practical considerations
(Ca2+)

Leads to hypomagnesemia
Vomiting
Diuretics
Cushing’s syndrome
Alkalosis
Insulin overdose
 pH by 0
...
2-1
...
FEP
2
...
ISE = Valinomycin gel
4
...
Schales and Schales:
-Mercurimetric titration
-Diphenylcarbazone
-Excess Hg++
-(+) Blue violet
2
...
Ferric perchlorate
4
...
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+)
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
...
mt 04 |Page | 37

Hypocalcemia
Primary hypocalcemia
Secondary hypocalcemia
Methods (Ca2+)

Inorganic Phosphorus

3 Forms of Inorganic
Phosphorus
PTH
Calcitonin
Growth hormone
Practical considerations
Hyperphosphatemia
Hypophosphatemia
Methods (iPO4)

Magnesium

3 Forms of Magnesium

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
...
Ferro Ham Chloranilic acid precipitation method
-(+)Chloranilic acid
3
...
EDTA titration method (Bachra, Dawer and Sobel)
5
...
ISE = Liquid membrane
7
...
lab
...
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
lec
...
Calmagite
-(+) Reddish-violet complex
2
...
Magnesium Thymol blue method
-(+) Colored complex
4
...
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)
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
...
Anodic stripping voltammetry
Hemochromatosis
lec
...
70 = mg/dL
Sodium 1/α Potassium
Potassium 1/α Hydrogen ion
Potassium α Magnesium
Magnesium α Calcium
Calcium 1/α Inorganic phosphate
Chloride 1/α Bicarbonate
Sodium:
Serum = 135-145 mmol/L
[Critical: 160 mmol/L and 120 mmol/L]
CSF = 136-150 mmol/L
Potassium:
Serum = 3
...
2 mmol/L
[Critical: 6
...
5 mmol/L]
Chloride:
Serum = 98-107 mmol/L
Sweat = 5-40 mmol/L [Critical: >65 mmol/L]
Calcium:
Total = 8
...
8-10
...
6-5
...
8-5
...
5 mg/dL]
Inorganic Phosphate:
Adult = 2
...
5 mg/dL
Child = 4
...
5 mg/dL
Magnesium:
Serum = 1
...
1 mEq/L
Anion Gap:
w/ K+ = 10-20 mmol/L
w/o K+ = 7-16 mmol/L
Iron:
Male = 50-160 μg/dL
Female = 45-150 μg/dL
TIBC:
Adult = 245-425 μg/dL
>40 y
...
= 10-250 μg/dL
NB and Child = 100-200 μg/dL
% Transferrin Saturation = 20-50%
Blood Gases and pH
lec
...
1 + log [Total CO2 – (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:
-CO2 excess (Hypoventilation)
-COPD
-Drug overdose (morphine, barbiturates, opiates)
Compensation: Bicarbonate retention
Compensated:  HCO3- +  pCO2 + pH <7
...
4
pH  normal range
pH  near normal
All forms of base that will titrate hydrogen ions
Specimen: Arterial blood
Blood gas analyzers: meas
...
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
1
...
mt 04 |Page | 41

(Blood gases & pH)

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

a
...
Natelson
-Mercury: produce vacuum
-Caprylic alcohol: anti-foam reagent
-Lactic acid
-NaOH
-NaHSO3
2
...
pH = potentiometry
-Silver-silver chloride electrode (Reference electrode)
-Calomel electrode [Hg2Cl2] (Reference electrode)
b
...
pO2 = Clark electrode (polarography-amperometry)
Dissolved CO2 + H2CO3 + HCO3Continuous monitoring of pO2
Directly placed on the skin
Min
...
35-7
...
mt 04 |Page | 42

(Adenohypophysis)
GH (Somatotropin)
Dwarfism
Acromegaly
GH deficiency tests
Tests for Acromegaly

FSH
LH
TSH (Thyrotropin)
ACTH (Corticotropin)

Prolactin

Panhypopituitarism
Pituitary ischemia
(Shechan’s)
Posterior pituitary
(Neurohypophysis)
Oxytocin
ADH/AVP (Arginine
vasopressin)
Overnight water
deprivation test (Conc
...
Insulin tolerance test = Gold standard (Confirmatory test)
2
...
Somatomedin C or insulin-like growth factor I (Screening)
-Increased: Acromegaly
-Decreased: GH deficiency
2
...

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
lec
...
Trapping of Iodine
2
...
Condensation: MIT+DIT=T3 / DIT+DIT=T4
4
...
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
3,5,3’5’-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 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
lec
...

Test for anti-Tg disorders
Marker for familial medullary thyroid carcinoma
lec
...
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 Mg2+
 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
...
Zona Glomerulosa = Mineralocorticoids (Aldosterone)
2
...
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
...
mt 04 |Page | 46

Zimmerman reaction

Pisano method
Kober reaction
Cushing’s syndrome
(Hypercortisolism)

Screening tests (Cushing’s)
Confirmatory tests
(Cushing’s)
Addison’s disease
(1’ Hypocorticolism)

2’ Hypocorticolism

ACTH Stimulation test
(Corsyntropin stimulation
test)
Metyrapone test

24-hour urine free cortisol
HPLC-MS
ITT (Insulin tolerance test)
Serum ACTH
ACTH
Congenital Adrenal

Rgt: DNPH in H2SO4 + Alcohol
(+) Yellow
Meas
...
24-hour urine free cortisol test
2
...
Salivary cortisol test
1
...
5mg)
2
...
CRH stimulation test
Primary adrenal insufficiency
 Cortisol and aldosterone
 ACTH
(+) Hyperpigmentation
Screen: ACTH Stimulation Test
Secondary adrenal insufficiency
Hypothalamic-pituitary insufficiency
 ACTH
Test: ACTH Stimulation test
Corsyntropin: synthetic coritsol and aldosterone stimulator
Differentiates:
2’ adrenal insufficiency (ACTH) from
3’ adrenal insufficiency ( ACTH)
Metyrapone: inhibitor of 11 β-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
Most sensitive and specific screening test for excess cortisol production
because plasma cortisol is affected by diurnal variation
Methods: HPLC or GC-MS
Reference method for measuring urinary free cortisol
Gold standard for 2’ and 3’ hypocorticolism
Confirms borderline response to ACTH stimulation test
Differentiates:
Cushing’s disease (ACTH)
Cushing’s syndrome (0-ACTH)
17-OHCS and 17-KS
Enzyme deficiencies:
lec
...
) 21-hydroxylase = most common
2
...
) 3β-hydroxysteroid dehydrogenase-isomerase
4
...
/Plasma renin activity ratio (PAC/PRA ratio)
-(+): >50 ratio
Confirm: Saline suppression test
-(+): >5 ng/dL aldosterone
Excessive production of renin
Pseudohyperaldosteronism
Resembles 1’ aldosteronism clinically
 Aldosterone
(-) Hypertension
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 Catechol-0-methyltransferase)---> 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:
lec
...
Chromatography: HPLC or GC-MS
2
...
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
lec
...
k
...
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
-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
...
a
...
o
...
5-12
...
8-22
...
mt 04 |Page | 50

metabolism
First order elimination
Pharmacodynamics
Pharmacokinetics
Pharmacogenomics
Therapeutic index
Trough concentration
Peak concentration
Cardioactive Drugs
Class I
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)

Linear relationship bet
...
of drug eliminated per hour and the blood
level of drug
Relationship bet
...
drug dose and drug blood level
Study of genes that affect the performance of a drug in an individual
Ratio bet
...

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)
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
lec
...
01-0
...
03-0
...
inhibitions, some impairment of motor skills
0
...
25
Decr
...
rxn time
0
...
30
Mental confusion, dizziness, strongly impaired motor skills (slurred speech)
0
...
40
Unable to stand/walk, vomiting, impaired consciousness
0
...
50
Coma and possible death
≥0
...
mt 04 |Page | 52

Carbon Monoxide

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)

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)
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)
lec
...
mt 04 |Page | 54



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