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Quality Control
Practicability Method is easily repeated
Reliability Maintain accuracy and precision
Intralab/Interlab QC Daily monitoring of accuracy and precision
Interlab/External QC Proficiency testing (Reference lab)
Long-term accuracy
Difference of >2: not in agreement w/ other lab
QC materials Available for a min. of 1 yr
Bovine control materials Preferred (Human: biohazard)
Not for immunochem, dye-binding and bilirubin
Matrix effect Improper product manufacturing
Unpurified analyte
Altered protein
Precision study First step in method evaluation
Nonlab. personnel 29% of errors (lab results)
SD Dispersion of values from the mean
CV (coefficient of variation) Index of precision
Relative magnitude of variability (%)
Variance SD2
Measure of variability
Inferential statistics Compare means or SD of 2 groups of data
T-test Means of 2 groups of data
F-test SD of 2 groups of data
Cumulative Sum Graph V-mask
(CUSUM) Earliest indication of systematic errors (trend)
Youden/Twin Plot Compare results obtained from diff. lab
Shewhart Levey-Jennings Graphic representation of the acceptable limits of variation
Chart
Trend Gradual loss of reliability
Cause: Deterioration of reagents (Systematic error)
Shift Values: one side or either side of the mean
Cause: Improper calibration (Systematic error)
Outliers Values: far from the main set of values
Highly deviating values
Random or systematic errors
Kurtosis Degree of flatness or sharpness
Precision Random error
Accuracy Systematic error
Random error Causes:
(Imprecision; -Mislabeling
Indeterminate) -Pipetting error
-Improper mixing of sample and reagents
-Voltage/Temperature fluctuation
-Dirty optics
Parameters: SD and CV
Systematic error Causes:
(Inaccuracy/Determinate) -Improper calibration
-Deterioration of reagents
-Contaminated solution
-Sample instability/unstable reagent blanks
-Diminishing lamp power
-Incorrect sample and reagent volume
Parameter: Mean
Multirule Shewhart procedure Control rules + Control chart
Test method Westgard: at least 40 samples
Reference method Westgard: preferably 100 samples
Analytical Run Control and patient specimens assayed, evaluated, and report
together
Physiologic Limit Referred to as absurd value
POCT Performed by nonlab personnel
(Point of Care Testing)
Quality Assurance Tripod: #PAQ
Program development
Assessment and monitoring
Quality improvement
Quality Patient Care Test request forms, clear instruction for patient prep.,
specimen handling…
Reference Range/ Interval At least 120 individuals should be tested in each age and sex
Range/ Reference Values category
Analytical Methods
Wavelength Distance bet 2 successive peaks (nm)
Lower frequency = Longer wavelength (Ex. Red)
Higher frequency = Shorter wavelength (Ex. Violet)
Spectrophotometric meas. Meas. light intensity in a narrower wavelength
Photometric measurement Meas. light intensity w/o consideration of wavelength
Multiple wavelength (uses filter only)
LASER Light Amplification by Stimulated Emission of Radiation
Light source for spectrophotometry
Visible region Tungsten light bulb
Mercury arc
UV Deuterium lamp
Mercury arc
Xenon lamp
Hydrogen lamp
IR Merst glower
Globar (Silicone carbide)
Stray light Wavelength outside the band
Most common cause of loss of linearity
Diffraction gratings Most commonly used monochromator
Cutting grooves
Prisms Rotatable
Nickel sulfate Prevents stray light
Cutoff filter Anti-stray light
Bandpass ½ peak transmittance
Alumina silica glass cuvet Most commonly used cuvet
Quartz/plastic cuvet UV
Borosilicate glass cuvet Strong bases
Photodetector Converts transmitted light into photoelectric energy
Barrier layer cell/ photocell/ Simplest detector
photovoltaic cell No external voltage
For filter photometers
Phototube Contains anode and cathode
Req external voltage
Photomultiplier tube Most common type
Most sensitive
UV and visible region
Galvanometer/Ammeter Meter or read-out device
Absorbance A = abc (a = absorptivity; b = length of light (1cm); c =
concentration)
A = 2 – log%T
Double beam spectro. Splits monochromatic light into two components:
One beam sample
One beam reference soln or blank (corrects for variation in
light source intensity)
Double-beam in space 2 photodetectors (sample beam and reference beam)
Double-beam in time 1 photodetector
Monochromatic light sample cuvet and reference cuvet
Dydimium filter 600 nm
Holmium oxide filter 360 nm
Reagent blank Color of reagents
Sample blank Optical interference (Hgb)
FEP Meas. light emitted by a single atom burned in a flame
Principle: Excitation
Lt. source and cuvette: Flame
For excited ions (Na+, K+)
Cesium and Lithium Internal standards (FEP)
Correct variations in flame
Lithium Preferred internal std
Potent antidepressant
AAS Meas. light absorbed by atoms dissociated by heat
Principle: Dissociation (unionized, unexcited, ground
state)
Lt. source: Hollow-cathode lamp
For unexcited trace metals (Ca++ and Mg++)
More sensitive than FEP
Atomizer (nebulizer) Convert ions atoms
Chopper Modulate the light source
Lanthanum/Strontium Complex with phosphate
chloride Avoid calcium interference
Volumetric (Titrimetric) Unknown sample is made to react with a known solution in
the presence of an indicator
Turbidimetry Light blocked
Meas. abundant large particles (Proteins)
Depend on specimen concentration and particle size
Nephelometry Meas. amt of Ag-Ab complexes
Scattered light
Depends on wavelength and particle size
Electrophoresis Migration of charged particles in an electric field
Iontophoresis Migration of small charged ions
Zone electrophoresis Migration of charged macromolecules
Endosmosis Movement of buffer ions and solvent relative to the fixed
support
Ex: gamma globulins
Cellulose acetate Molecular size
Agarose gel Electrical charge
Polyacrylamide gel Charge and molecular size
20 fractions (ex. isoenzymes)
Electrophoretic mobility Directly proportional to net charge
Inversely proportional to molecular size & viscosity of the
supporting medium
Isoelectric focusing Molecules migrate through a pH gradient
pH = pI
For isoenzymes: same size, different charge
Densitometry Scan & quantitate electrophoretic pattern
Capillary electrophoresis Electro-osmotic flow
Southern blot DNA
Northern blot RNA
Western blot Proteins
Chromatography Separation by specific differences in physical-chemical
characteristics of the different constituents
Paper chromatography Fractionation of sugar and amino acid
Sorbent: Whatman paper
TLC Screening: Drugs
Retention factor (Rf) value Relative distance of migration from the point of application
Rf = Distance leading edge of component moves
Total distance solvent front moves
Gas chromatography Separation of steroids, barbiturates, blood, alcohol, and lipids
Volatile compounds
Specimens vaporized
Mobile phase: Inert gases
Gas Solid chromatography Differences in absorption at the solid phase surfaces
Gas Liquid chromatography Differences in solute partitioning between the gaseous
mobile phase and the liquid stationary phase
Mass Spectrometry Fragmentation and ionization
GC-MS Gold standard for drug testing
MS/MS Detect 20 inborn errors of metabolism from a single
blood spot
HPLC Most widely used liquid chromatography
Fractionation of drugs, hormones, lipids, carbohydrates and
proteins
Hydrophilic gel Gel filtration
Separation of enzymes, antibodies and proteins
Ex: Dextran and agarose
Hydrophobic gel Gel permeation
Separation of triglyceride and fatty acid
Ex: Sephadex
Ion exchange chromatography Separation depends on the sign and ionic charge density
Partition chromatography Based on relative solubility in an organic solvent (nonpolar)
and an aqueous solvent (polar)
Affinity chromatography For lipoproteins, CHO and glycated hemoglobins
Adsorption chromatography Based on differences between the adsorption and desorption
of solutes at the surfaces of a solid particle
Fluorometry/Molecular Det. amt. of lt. emitted by a molecule after excitation by
Luminescence Spectro. electromagnetic radiation
Lt. sources: Mercury arc and Xenon lamp (UV)
Lt. detector: Photomultiplier tubes
2 monochromators:
Primary filter – selects wavelength absorbed by the solution
to be measured
Secondary filter – prevents incident light from striking the
photodetector
Sensitivity: 1000x than spectro
Quenching Major disadvantage of fluorometry
pH and temperature changes, chemical contaminants, UVL
changes
Instrumentation
Borosilicate glasswares For heating and sterilization
Ex: Pyrex and Kimax
Boron-free/Soft glasswares High resistance to alkali
Corex (Corning) Special alumina-silicate glass
Strengthened chemically than thermally
6x stronger than borosilicate
Vycor (Corning) For high thermal, drastic heat and shock
Can be heated to 900OC
Flint glass Soda-lime glass + Calcium, Silicon, Sodium oxides
Easy to melt
For making disposable glasswares
TD: To deliver Exact amount
TC: To contain Does not disperse the exact volume
Blowout w/ etched rings on top of pipet
Self-draining w/ o etched rings
Drain by gravity
Transfer pipet Volumetric: for non-viscous fluid; self-draining
Ostwald folin: for viscous fluid; w/ etched ring
Pasteur: w/o consideration of a specific volume
Automatic macro-/micropipets
Graduated or measuring pipet Serological: w/ graduations to the tip (blowout)
Mohr: w/o graduations to the tip (self-draining)
Bacteriologic
Ball, Kolmer and Kahn
Micropipettes: <1 mL
Micropipettes TC pipets:
Sahli-Hellige pipet
Lang-Levy pipet
RBC and WBC pipets
Kirk and Overflow pipets
Air displacement pipet Piston: suction
Disposable tip
Positive displacement pipet Piston barrel (like a hypodermic syringe)
Dispenser/Dilutor pipet Liquid: common reservoir dispense repeatedly
Distilled H2O Calibrating medium for TD pipettes
Mercury Calibrating medium for TC pipettes
Acid dichromate Cleaning solution for glasswares
(H2SO4 + K2Cr2O4)
Continuous flow analyzer Common reaction vessel
Air bubbles: separates and cleans
Glass coil: mix
Examples: “STS”
Simultaneous Multiple Analyzer (SMA)
Technicon Autoanalyzer II
SMAC
Centrifugal analyzer Acceleration and deceleration of the rotor
Advantage: Batch analysis
Examples: “RICC”
Cobas-Bio (Roche)
IL Monarch
CentrifiChem
RotoChem
Discrete Analyzer Most popular
Req. vol: 2-6 μL
Uses positive-displacement pipets
Run multiple-tests-one-sample-at-a-time
Random access capability (STAT)
Examples:
Vitros
Dimension Dade
Beckman ASTRA System (4 & 8)
Hitachi
Bayer Advia
Roche Cobas Integra 800
Roche Analytics P Module
Automated Clinical Analyzer (ACA) Star (Dade)
Dupont ACA
Abbott ABA-100 Bichromatic Analyzer
ABA-200
VP Analyzer
American Monitor KDA
Olympus Demand
Thin-Film Analyzers 4 or 5 layers:
(Dry slide technology) -Spreading layer
-Scavenger layer - Ascorbate Oxidase
-Reagent layer
-Indicator layer
-Support layer
Colored reaction Reflectance spectrophotometry
Examples: “KV2(75)”
Kodak Ektachem
Vitros 750XRC
Vitros 550XRC
Carry over Transport of quantity of analyte or rgt from one specimen
rxn into another, and contaminating a subsequent one
Batch testing All samples loaded at the same time
Single test is conducted on each sample
Parallel testing One specimen
More than one test is analyzed
Random access testing Any sample
Any test
Any sequence
STAT
Sequential testing Multiple tests analyzed one after another on a given
specimen
Open reagent system System other than manufacturer’s reagents can be utilized
for measurement
Closed reagent system The operator can only use the manufacturer’s reagents
Patient Preparation
Exercise Increased: GU2FT C2L3A5P2
GH
Urea
Urinary protein (Proteinuria)
Fatty acid
Testosterone
CPK (muscle)
Creatinine (muscle)
Lactate
LH
LD (muscle)
ACP
Aldolase (muscle)
AST
ALT
Ammonia
Pyruvate
Prolactin
Decreased:
Glucose
Fist clenching Increased: “LPP”
Lactate
Potassium
Phosphate
Fasting 8-16 hours:
Glucose
Lipids
Lipoproteins
Increased:
Bilirubin (48 hours)
Triglyceride (72 hours)
Basal state collection Glucose
Cholesterol
Triglyceride
Electrolytes
Diet Increased: “GLUC2H”
Glucose
Lipids
Urea (High protein diet)
Caffeine: increases glucose
Catecholamines
5-HIAA (From Serotonin)
Turbidity/Lactescence Triglyceride >400mg/dL
Icterisia Bilirubin: 25.2 mg/dL
Icteric samples Interfere with: "TACGu”
Total Protein
Albumin
Cholesterol
Glucose
Upright/supine (lying) Preferred position
position Patient should be seated/supine at least 20 mins before
blood collection to prevent hemodilution or
hemoconcentration
Supine Sitting/Standing Vasoconstriction Reduced plasma volume
Increased: “ECA”
Enzymes
Calcium
Albumin
Sitting Supine Hemoconcentration
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. Hemoconcentration
Anaerobiosis
Increased: “C2LEA2K”
Calcium
Cholesterol
Lactate
Enzymes
Ammonia
Albumin
K+
Tobacco smoking (Nicotine) Increased: “TUNG2C3”
Triglycerides
Urea
Nonesterified fatty acid
Glucose
GH
Catecholamines
Cortisol
Cholesterol
Alcohol ingestion Increased: “THUG”
Triglycerides
Hypoglycemia (chronic alcoholism)
Uric acid/Urates
GGT
Ammonia Increases by 100-200μg/L/cigar
Stress (anxiety) Increased: “LAGIC”
Lactate
Albumin
Glucose
Insulin
Cholesterol
Drugs Medications affecting plasma volume can affect protein, BUN,
iron, calcium
Hepatotoxic drugs: increased liver function enzymes
Diuretics: decreased sodium and potassium
Diurnal variation "CA3PI2TG”
Cortisol
ACTH
ACP
Aldosterone
Prolactin
Iron
Insulin
Thyroxine
GH
Specimen Collection and Handling
Sleeping patients Must be awakened before blood collection
Unconscious patients Ask nurse or relative
Identification bracelet
Venipuncture Median Cubital (1st) Cephalic (2nd) Basilic (3rd)
Tourniquet Velcro or Seraket type
3-4 inches above the site
Not exceed 1 minute
Needle Bevel up
15-30O angle
Length: 1 or 1.5 inch (Butterfly needle: ½ to ¾ inch)
After blood collection Cotton site
Apply pressure for 3-5 minutes
BP cuff as tourniquet Inflate to 60 mmHg
Benzalkonium chloride Disinfectant for ethanol testing
(Zephiran) Dilution – 1:750
IV line on both arms Discontinue IV for 2 minutes
Collect sample below the IV site
Initial sample (5mL) discard
IV fluid contamination Increased:
Glucose (10% contam. w/ 5% dextrose increased bld glucose
by 500 mg/dL)
Chloride
Potassium
Sodium
Decreased:
Urea
Creatinine
Renin blood level Collected after a 3-day diet, from a peripheral vein
Basal state collection Early morning blood collection
12 hours after the last ingestion of food
Lancet 1.75mm: preferred length to avoid penetrating the bone
Incision (Skin puncture) <2.0mm (infants and children)
2-3mm (adults)
1.5-2.4mm Distance from the skin surface to bone or cartilage
(middle finger)
Arterialized capillary blood Earlobe: Preferred site
Lateral plantar heel surface: most commonly used site
Flea 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
Indwelling umbilical artery Best site for blood gas analysis (newborns)
1000-3000 RCF for 10 mins Centrifugation requirement
Hemolysis Increased:
“KLA6MP ITC2”
-K+
-LDH (150x)
-ACP
-ALP
-Aldolase
-ALT
-AST
-Albumin
-Mg2+
-Phosphorus
-Iron
-Total protein
Affects bilirubin levels
Inhibits lipase
Refrigeration/Chilling Required for: “ABCGLRP2”
(Low temp) Ammonia
Blood gases
Catecholamines
Gastrin
Lactic acid
Renin
PTH
Pyruvate
Decreased:
LD 4 and 5
Increased:
ALP
Photosensitive analytes Bilirubin
Beta-carotene
Folate
Porphyrins
Vitamins A and B6
Oxalate Insoluble salt
1-2 mg/mL blood
Citrate Non-ionized form
3.2-3.8 g/dL (1:9 ratio)
EDTA Chelation
1-2 mg/mL blood
Versene: disodium salt
Sequestrene: Dipotassium salt
Fluoride Weakly dissociated calcium component
2 mg/mL blood: anti-glycolytic
10 mg/mL blood: anticoagulant
Heparin A.k.a. Mucoitin polysulfuric acid
Universal anticoagulant
Antithrombin
0.2 mg/mL blood
Lithium heparin For glucose, BUN, ionized calcium, electrolyte studies (K+:
best) and creatinine
Orange top tube Additive: Thrombin
Royal blue top tube Additives:
None;
Na2EDTA
Sodium heparin
Brown top tube Lead testing
Tan top tube Lead testing
Black top tube Additive: Buffered sodium citrate
For ESR
Respinning gel tubes Increases potassium
Thixotropic gel Gel separator (SG: 1.04)
Serum: (SG: 1.03)
RBC: (SG: 1.05)
Laboratory Mathematics
% w/v Grams of solute = % solution desired x total volume desired
100
% v/v mL of solute = % solution desired x total volume desired
100
% w/w Grams of solute = % solution desired x grams of the total
solution
100
Molarity M= _grams of solute_______
GMW x volume of solution
Moles Mol = weight (grams)
GMW
To prepare a molar solution Grams of solute = Molarity x GMW of the solute x Volume (L)
desired
To convert % w/v to Molarity M = % w/v 10
GMW
Normality N = _Grams of solute_
EW x volume (L)
Equivalent weight (EW) EW = __MW___
Valence
To prepare a normal solution Grams of solute = Normality x EW x Volume (L)
of solids
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
Cortisol
Human Placental Lactogen
Epinephrine
Thyroxine
Hyperglycemia Electrolyte Imbalance:
(≥126 mg/dL) Decreased: Sodium, Bicarbonate
Increased: Potassium
Hypoglycemia 50-55 mg/dL = Symptoms
≤50 mg/dL = Diagnostic
Whipple’s triad Low blood glucose concentration
(Hypoglycemia) Typical symptoms
Symptoms alleviated by glucose administration
6:1 Ratio of BHA to AA in severe DM
(Normal = 1:1)
Type 1 DM IDDM
Juvenile Onset
Brittle
Ketosis-prone
80-90% reduction of beta-cells Symptomatic Type 1 DM
HLA-DR3 and DR4
(+) Glutamic acid decarboxylase (GAD65): prediabetes
marker!
(+) Insulin autoantibodies (IAA) : prediabetes marker!
(+) Microalbuminuria: 50-200 mg/24 hours = Diabetic
nephropathy
(-) C-peptide
Complications of Type I DM Microvascular disorders:
Nephropathy (microalbuminuria of 50-200 mg/day)
Neuropathy
Retinopathy
Type 2 NIDDM
Adult type/Maturity Onset
Stable
Ketosis-resistant
Receptor-deficient
Insulin resistance: relative insulin deficiency
Strong genetic predisposition
Geneticist’s nightmare
If untreated glucose: >500 mg/dL nonketotic hyperosmolar
coma
Gestational DM Screening: 1hr GCT (50g) – bet. 24 and 28 weeks of
gestation
Confirmatory: 3-hr GTT (100g)
Infants: at risk for respiratory distress syndrome,
hypocalcemia, hyperbilirubinemia
After giving birth, evaluate 6-12 weeks postpartum
Converts to DM w/in 10 years in 30-40% of cases
OGTT (GDM) 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
Impaired fasting glucose FBS = 100-125 mg/dL
(Pre-diabetes)
Impaired glucose tolerance FBS = <126 mg/dL
2-Hr OGTT = 140-199 mg/dL
FBS WB = 15% lower than in serum or plasma
VB = 7 mg/dL lower than capillary and arterial blood
CSF glucose 60-70% of the plasma glucose
Peritoneal fluid glucose Same with plasma glucose
Plasma glucose increases w/ Fasting: 2 mg/dL/decade
age Postprandial: 4 mg/dL/decade
Glucose challenge: 8-13 mg/dL/decade
w/in 1 hour Separate serum/plasma from the cells
(Preferably w/in 30 mins)
5-7mg/hr Glycolysis at room temperature
1-2 mg/hr Glycolysis at refrigerated temperature
Copper reduction methods Cupric Cuprous Cuprous oxide
Folin Wu Cuprous ions + phosphomolybdate phosphomolybdenum
blue
Nelson-Somogyi Cuprous ions + arsenomolybdate arsenomolybdenum
blue
Neocuproine method Cuprous ions + neocuproine Cuprous-neocuproine
complex (yellow)
Benedict’s method Reducing substances in blood and urine
Alkaline Ferric Reduction Ferricyanide ---(Glucose)--> Ferrocyanide
method (Hagedorn-Jensen) (Yellow) (Colorless)
Ortho-toluidine Schiff’s base
(Dubowski method)
Glucose oxidase Measures beta-D-glucose (65%)
Mutarotase Converts alpha-D-glucose (35%) to beta-D-glucose
(65%)
NADH/NADPH Absorbance at 340nm
Polarographic glucose oxidase Consumption of oxygen on an oxygen-sensing electrode
O2 consumption α glucose concentration
Hexokinase method Most specific method
Reference method
Uses G-6-PD
G-6-PD Most specific enzyme rgt for glucose testing
Interfering substances False-decreased
(Glucose oxidase) Bilirubin
Uric acid
Ascorbate
Hemolysis (>0.5 g/dL Hgb) Major interfering substance in hexokinase method
(false-decreased)
Dextrostics Cellular strip
Strip w/ glucose oxidase, peroxidase and chromogen
OGTT Janney-Isaacson method (Single dose) = most common
Exton Rose (Double dose)
Drink the glucose load within 5 mins
IVGTT For patients with gastrointestinal disorders (malabsorption)
Glucose: 0.5 g/kg body weight
Given w/in 3 mins
1st blood collection: after 5 mins of IV glucose
Requirements for OGTT Ambulatory
Fasting: 8-14 hours
Unrestricted diet of 150g CHO/day for 3 days
Do not smoke or drink alcohol
Glucose load 75 g = adult (WHO std)
100 g = pregnant
1.75 g glucose/kg BW = children
HbA1c For the past 2-3 months (monitoring of treatment)
Glucose = beta-chain of HbA1
1% increase in HbA1c = 35 mg/dL increase in plasma
glucose
18-20% = prolonged hyperglycemia
7% = cutoff
Specimen: EDTA whole blood
Test: Affinity chromatography (preferred)
IDA and older RBCs High HbA1c
RBC lifespan disorders Low HbA1c
Fructosamine For the past 2-3 weeks (monitoring of treatment)
(Glycosylated albumin/ Useful for patients w/ hemolytic anemias and Hgb variants
plasma protein ketoamine) Not used in cases of low albumin
Specimen: Serum
Galactosemia Congenital deficiency of 1 of 3 enzymes in galactose
metabolism
Galactose-1-phosphate uridyl transferase (most common)
Galactokinase
Uridine diphosphate galactose-4-epimerase
Essential fructosuria Autosomal recessive
Fructokinase deficiency
Hereditary fructose Defective fructose-1,6-biphosphate aldolase B activity
intolerance
Fructose-1,6-biphosphate Failure of hepatic glucose generation by gluconeogenic
deficiency precursors such as lactate and glycerol
Glycogen Storage Disease Autosomal recessive
Defective glycogen metabolism
Test: IVGTT (Type I GSD)
Ia = Von Gierke Glucose-6-Phosphatase deficiency (most common
worldwide)
II = Pompe Alpha-1,4-glucosidase deficiency (most common in the
Philippines)
III = Cori Forbes Debrancher enzyme deficiency
IV = Andersen Brancher enzyme deficiency
V = McArdle Muscle phosphorylase deficiency
VI = Hers Liver phosphorylase deficiency
VII = Tarui Phosphofructokinase deficiency
XII = Fanconi-Bickel Glucose transporter 2 deficiency
CSF glucose Collect blood glucose at least 60 mins (to 2 hrs) before the
lumbar puncture
(Because of the lag in CSF glucose equilibrium time)
< 0.5 Normal CSF : serum glucose ratio
C-peptide Formed during conversion of pro-insulin to insulin
5:1 to 15:1 Normal C-peptide : insulin ratio
D-xylose absorption test Differentiate pancreatic insufficiency from malabsorption
(low blood or urine xylose)
Gerhardt’s ferric chloride test Acetoacetate
Nitroprusside test 10x more sensitive to acetoacetate than to acetone
Acetest tablets Acetoacetate and acetone
Ketostix Detects acetoacetate better than acetone
KetoSite assay Detects beta-hydroxybutyrate but not widely used
Normal Values RBS = <140 mg/dL
(Carbohydrates) 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
1-Hr = 20-50 mg/dL above fasting
2-Hr = 5-15 mg/dL above fasting
3-Hr = fasting level or below
Lipids
• Phospholipids Most abundant lipid
Amphipathic: polar (hydrophilic head) and nonpolar
(hydrophobic side chain)
Sphingomyelin Reference material during 3rd trimester of pregnancy
Concentration is constant as opposed to lecithin
Not derived from glycerol but from sphingosine (amino
alcohol)
Forms of phospholipids 70% Lecithin/Phosphatidyl choline
20% Sphingomyelin
10% Cephalin
TLC + Densitometric Method for L/S ratio
quantitation
Microviscosity Measured by fluorescence polarization
• Cholesterol Not a source of fuel
Not affected by fasting
70% Cholesterol ester (plasma/serum)
30% Free cholesterol (plasma/serum and RBC)
LCAT Esterification of cholesterol
Apo A-1 Activator of LCAT
Cholesterol increases after the 2 mg/dL/year between 50 and 60 years old
age of 50
Liebermann Burchardt Cholestadienyl Monosulfonic acid
Green end color
Salkowski Cholestadienyl Disulfonic acid
Red end color
Color developer mixture Glacial acetic acid
(Cholesterol) Acetic anhydride
Conc. H2SO4
One-step method Colorimetry (Pearson, Stern and Mac Gavack) C
Two-step method Color. + Extraction (Bloor’s) CE
Three-step method Color. + Extract. + Saponification (Abell-Kendall) CES
Four-step method Color. +Extract. + Sapon. + Precipitation
(Schaenheimer Sperry, Parekh and Jung) CESP
Abell, Levy and Brodie mtd CDC reference method for cholesterol:
(Chemical method) -Hydrolysis/saponification (Alc. KOH)
-Hexane extraction
-Colorimetry (Liebermann-Burchardt)
• Triglycerides Most insoluble lipid
Main storage lipid in man (adipose tissue) – 95%
Fasting: 12 hours
Triglyceride increases after 2 mg/dL/year between 50 and 60 years old
the age of 50
Van Handel & Zilversmith Chromotropic acid
(Colorimetric) (+) Blue color compound
Hantzsch Condensation Diacetyl acetone
(Fluorometric) (+) Diacetyl lutidine compound
Modified Van Handel and CDC reference method for triglycerides:
Zilversmith -Alkaline hydrolysis
(Chemical method) -Chloroform extraction extract treated w/ silicic acid
-Color reaction w/ chromotropic acid – meas. HCHO
(+) Pink colored
• Fatty acids Short chain = 4-6 C atoms
Medium chain = 8-12 C atoms
Long chain = >12 C atoms
Saturated = w/o double bonds
Unsaturated = w/ double bonds
Substrate for gluconeogenesis
Most is bound to albumin
Palmitic acid 16:0
Stearic acid 18:0
Oleic acid 18:1
Linoleic acid 18:2
Arachidonic acid 20:4
Lipoprotein lipase Hydrolyzes TAG in lipoproteins, releasing fatty acid and
(Lipemia clearing factor) glycerol
Hepatic lipase Hydrolyzes TAG and phospholipids from HDL
Hydrolyzes lipids on VLDL and IDL
Endothelial lipase Hydrolyzes phospholipids and TAG in HDL
Apolipoprotein Protein component of lipoprotein
Amphipathic helix – ability of proteins to bind to lipids
• Chylomicrons Largest and least dense
Produced by the intestine
SG: <0.95
80-95% TAG (exogenous)
Apo B-48 (Major)
EP: Origin
• VLDL Secreted by the liver
SG: 0.95-1.006
65% TAG (endogenous)
Apo B-100 (Major)
EP: pre-beta
• LDL Synthesized by the liver
SG: 1.006-1.063
50% CE
Apo B-100 (Major)
EP: beta
Cholesterol transport: LiverTissues
Target of cholesterol lowering therapy
Better marker for CHD risk
• HDL Smallest but dense
SG: 1.063-1.21
45-55% protein
26-32% phospholipid
Apo A-1 (Major)
EP: alpha
Produced by the liver and intestine
Reverse cholesterol transport: TissueLiver
• IDL (intermediate Product of VLDL catabolism
density LPP) **converted to LDL (presence is abnormal)
Seen in Type 3 hyperlipoproteinemia (Apo E-III def.; beta-
VLDL)
SG: 1.006-1.019
• Lpp(a) [lipoprotein a] Sinking pre-beta lipoprotein
SG: 1.045-1.080
Apo B-100
EP: pre-beta (VLDL)
UC: like LDL
Independent risk factor for atherosclerosis
• LpX Found in obstructive jaundice (cholestasis) and LCAT
deficiency
90% FC and PL
Apo C and albumin
• Beta-VLDL Floating beta-lipoprotein
SG: <1.006
EP: beta (LDL)
UC: like VLDL
Found in type 3 hyperlipoproteinemia (Apo E-III def; IDL)
Rich in cholesterol content than VLDL
Lipoprotein methodologies Specimen: sample from serum separator tubes
(preferred)
EDTA plasma: choice for research studies of LPP fractions
Fasting state: TAG VLDL
Nonfasting state: TAG CM
Ultracentrifugation Reference method for LPP quantitation
Reagent: Potassium bromide (SG: 1.063)
Ultracentrifugation of plasma for 24 hours
Expressed in Svedberg units
Electrophoresis Electrophoretic pattern:
(+) HDL VLDL LDL CM (Origin) (-)
Agarose gel: sensitive medium
VLDL: migrates w/ alpha2-globulin (pre-beta)
Chemical precipitation Uses polyanions (heparin and divalent cations) and
polyethylene glycol
Dextran sulfate-Mg2+
Heparin-Mn2+
3-step procedure: CDC Reference method for HDL
Ultracentrifugation
Precipitation
Abell-Kendall assay
Beta quantification + Method for LDL
Ultracentrifugation + Sample: EDTA plasma
Chemical precipitation
Immunoturbidimetric assay Measures Lipoprotein (a)
LDL – Cholesterol = Total Cholesterol – HDL – VLDL
Friedewald method Most commonly used
VLDL = TAG/2.175 (mmol/L)
VLDL = TAG/5 (mg/dL)
Not applicable if TAG is >400 mg/dL
De Long method VLDL = TAG/2.825 (mmol/L)
VLDL = TAG/6.5 (mg/dL)
Apo A-1 Activates LCAT
Apo B-100 LDL LDL receptor
Apo B-48 CM (major)
Not recognized by LDL receptor
Apo C-II Activates LPL
Apo D Activates LCAT
Apo E Apo E-4: associated w/ high LDL, higher risk of CHD and
Alzheimer’s disease
Apo(a) Lp(a)
Homologous to plasminogen
Abetalipoproteinemia Autosomal recessive
(Basses-Kornzweig syn.) Defective apo B synthesis
Deficient fat soluble vitamins
Niemann-Pick disease Sphingomyelinase deficiency
Tangier’s disease Deficiency of HDL (1-2 mg/dL)
Defects in the gene for the ABCA1 transporter
LPL deficiency TAG = 10,000 mg/dL
(Chylomicronemia) Do not develop premature coronary disease (CM are not
atherogenic)
Abdominal pain and pancreatitis
LCAT deficiency Fish-eye disease
Low HDL
LpX
Tay-Sachs disease Hexosaminidase A deficiency
Fredrickson Classification
Type 1 LPL deficiency (Chylomicronemia)
Increased: CM (TAG)
Type 2a Familial hypercholesterolemia
Increased: LDL (cholesterol)
Type 2b Combined hyperlipidemia (most common primary
hyperlipidemia)
Increased: LDL (cholesterol), VLDL (TAG)
Type 3 Dysbetalipoproteinemia
Increased: IDL, (+) beta-VLDL
(+) Apo E-II
(+) Eruptive and palmar xanthomas
Type 4 Hypertriglyceridemia
Increased: VLDL (TAG)
Type 5 Increased: VLDL (Endo.TAG), CM (Exo.TAG)
Normal Values Cholesterol:
(Lipids) Desirable = <200 mg/dL
Borderline high = 200-239 mg/dL
High = >240 mg/dL
Triglycerides:
Desirable = <150 mg/dL
Borderline high = 150-199 mg/dL
High = 200-499
Very high = >500 mg/dL
HDL:
Low = <40 mg/dL (Cutoff)
High = >60 mg/dL
LDL:
Optimal = <100 mg/dL
Near/above optimal = 100-129 mg/dL
Borderline high = 130-159 mg/dL
High = 160-189 mg/dL
Very high = >190 mg/dL
Proteins
Proteis First rank of importance
Proteins Amphoteric: positive and negative charges
Effective blood buffers
Synthesized by the liver except immunoglobulins
(plasma cells)
Provide 12-20% of total daily body energy requirement
Composed of 50-70% of the cell’s dry weight
Test for Detoxification Enzyme tests: ALP, AST, ALT, 5’NT, GGT, OCT, LAP, LDH
Function Ammonia:
-Kjeldahl (Digestion) method
-Nesslerization reaction
-Berthelot reaction
Plasma protein 0.2-0.4 g/dL higher than serum due to fibrinogen
Kjeldahl (Digestion) mtd Standard reference method
Measurement of nitrogen content
Serum + Tungstic acid PFF
1g N2 = 6.54g protein
15.1-16.8% = N2 content of proteins
Rgt: H2SO4
End product: NH3
Biuret method Most widely used method (IFCC recommended)
Req. at least 2 peptide bonds and an alkaline medium
Rgts:
Alkaline CuSO4
Rochelle salt (NaK Tartrate)
NaOH
KI
End product: Violet color (545nm)
Folin-Ciocalteu (Lowry) Highest analytical sensitivity
method Oxidation of phenolic compounds (tyrosine, tryptophan,
histidine)
Rgts:
Phenol (or phosphotungstic-molybdic acid)
Biuret (color enhancer)
End product: Blue color
Electrophoresis MI: elevated APRs (AAT, HPG, a1-x)
Gamma-spike Monoclonal gammopathy (multiple myeloma)
Beta-gamma bridging In serum: Hepatic cirrhosis (IgA)
In plasma: normal (fibrinogen)
Alpha2-globulin band spike Nephrotic syndrome
Alpha1-globulin flat curve Juvenile cirrhosis (AAT deficiency)
Alpha1, alpha2, beta-globulin Inflammation
band spikes
Polyclonal gammopathy Chronic inflammation (RA, malignancy)
Small spikes in beta region IDA (transferrin)
Free hemoglobin “Blip” in the late alpha2 or early beta region
Refractometry Refractive index
Turbidimetric and SSA
nephelometric methods TCA
Salt fractionation Salt: Sodium sulfate
Albumin Soluble:
Water
Moderately concentrated salt solution
Concentrated salt solution
Insoluble:
Hydrocarbon solvents
Highly concentrated salt solution
Saturated salt solution
Globulin Soluble:
Hydrocarbon solvents
Weak salt solution
Insoluble:
Water
Saturated salt solution
Concentrated salt solution
Prothrombin time Differentiates intrahepatic disorder (prolonged PT) from
extrahepatic obstructive liver disease (normal PT)
Albumin Inversely proportional to the severity of the liver disease
Hepatic cirrhosis Low total protein + low albumin
Bromcresol green Most commonly used dye for albumin
Bromcresol purple Most specific dye for albumin
Other dyes for albumin Hydroxyazobenzene benzoic acid (HABA)
Methyl orange (MO)
Nephrotic syndrome Albumin excretion: 20-30 g/day
Analbuminemia (-) albumin
Bisalbuminemia EP: 2 albumin bands
Therapeutic drugs in serum
Inverted A/G ratio Hepatic cirrhosis (IgA)
Multiple Myeloma (IgG)
Waldenström’s macroglobulinemia (IgM)
Chronic inflammation
Bilirubin Derived from hemoglobin myoglobin, catalase and
cytochrome oxidase
Heme oxygenase Protoporphyrin Biliverdin
Biliverdin reductase Biliverdin B1
Urobilinogen Deconjugated bilirubin
Bilirubin 1 Non-polar bilirubin
Free/Slow bilirubin
Bilirubin 2 Polar bilirubin
One-minute/prompt bilirubin
Regurgitative bilirubin
Delta bilirubin Bilirubin tightly bound to albumin
Delta bilirubin = TB-DB+IB
Jaundice Bilirubin >2 or 3 mg/dL
Pre-hepatic jaundice Hemolytic
B1 = increased
B2 = normal
UG = increased
UB = negative
Hepatic jaundice Hepatocellular
B1 = increased
B2 = increased
UG = increased
UB = positive
ALT = increased
AST = increased
Post-hepatic jaundice Obstructive
B1 = normal
B2 = increased
UG = decreased/negative
UB = positive
ALP = increased
GGT = increased
Cholesterol = increased
Gilbert’s syndrome Bilirubin transport deficit (uptake)
B1 = increased
B2 = decreased
Crigler-Najjar syndrome Conjugation deficit
Type I = total UDPGT deficiency
Type II = partial UDPGT deficiency
B1 = increased
B2 = decreased
Danger: Kernicterus
Bile is colorless
Dubin-Johnson syndrome & Bilirubin excretion deficit
Rotor syndrome Blockade of excretion into the canaliculi
TB = increased
B2 = increased
Lucey-Driscoll syndrome Circulating inhibitor of bilirubin conjugation
B1 = increased
Methods (Bilirubin) Free from hemolysis and lipemia
Store in the dark
Measured ASAP or w/in 2-3 hours
Van den Berg reaction Diazotization of bilirubin
Evelyn and Malloy method Accelerator: Methanol
Diazo rgts:
Diazo A (0.1% Sulfanilic acid + HCl)
Diazo B (0.5% Sodium nitrite)
Diazo blank (1.5% HCl)
(+) pink to purple azobilirubin
Affected by hemolysis
Jendrassik and Grof Candidate reference method
Accelerator: Caffeine sodium benzoate
Buffer: Sodium acetate
Ascorbic acid: terminates the initial reaction and destroys the
excess diazo rgt
Not falsely elevated by hemolysis
Total bilirubin is measured 15 minutes after adding methanol
or caffeine soln
Bilirubin Absorbs light maximally at 450nm
Rosenthal White method Double collection method
Collection:
-After 5 mins (50% dye retention)
-After 30 mins (0% dye retention)
Mac Donald method Single collection method
Collection:
-After 45 mins (+/- 5% dye retention)
Ammonia From deamination of amino acids
Elevated levels are neurotoxic and often associated w/
encephalopathy and acetaminophen poisoning
Diagnosis of hepatic failure and Reye’s syndrome
In severe liver disorder: NH3 circulation brain (conv. to
glutamine) increases pH compromise the Kreb’s cycle Coma
due to lack of ATP for the brain
Methods 1. Gasometer
(Blood gases & pH) a. Van Slyke
b. Natelson
-Mercury: produce vacuum
-Caprylic alcohol: anti-foam reagent
-Lactic acid
-NaOH
-NaHSO3
2. Electrodes
a. pH = potentiometry
-Silver-silver chloride electrode (Reference electrode)
-Calomel electrode [Hg2Cl2] (Reference electrode)
b. pCO2 = Severinghaus electrode (potentiometry)
c. pO2 = Clark electrode (polarography-amperometry)
Whole blood total CO2 Dissolved CO2 + H2CO3 + HCO3-
Transcutaneous electrodes Continuous monitoring of pO2
Directly placed on the skin
Blood gas QC Min. requirement:
-1 sample every 8 hours
-3 levels of control (acidosis, normal, alkalosis) every 24
hours
Normal Values pH = 7.35-7.45
(Blood gases and pH) pCO2 = 35-45 mmHg
Total CO2:
WB arterial = 19-24 mmol/L
WB venous = 22-26 mmol/L
HCO3- = 21-28 mEq/L
pO2 = 81-100 mmHg
[Hypoxemia:]
-Mild (61-80 mmHg)
-Moderate (41-60 mmHg)
-Severe (40 mmHg or less)
O2 saturation = 94-100%
Endocrinology
Endocrine Hormone blood circulation specific receptor
Paracrine Hormone interstitial space adjacent cell
Autocrine Hormone self-regulation
Juxtacrine Hormone direct cell-to-cell contact
Exocrine Hormone gut
Neurocrine Hormone neurons extracellular space
Neuroendocrine Hormone neurons nerve endings
Glycoproteins FSH, hCG, TSH, LH
Polypeptides ACTH, ADH, GH, angiotensin, calcitonin, CCK, gastrin,
glucagons, insulin, MSH, oxytocin, PTH, PRL, somatostatin
Steroids Precursor: cholesterol
Aldosterone, cortisol, estrogen, progesterone, testosterone,
vitamin D
Amines Derived from amino acids
Catecholamines, T3, T4
Hypothalamus Connected to the posterior pituitary by the infundibulum
stalk
Hypophyseal hormones: TRH, GnRH, GH-IH, GH-RH, PIF
Pineal gland Melatonin: decreases pigmentation of the skin
Pituitary gland Master Gland
Located in the sella turcica or Turkish saddle
Anterior Pituitary True endocrine gland
(Adenohypophysis) Hormones: PRL, GH, FSH, LH, TSH, MSH, ACTH
GH (Somatotropin) Most abundant of all pituitary hormones
Structurally similar to PRL and HPL
Markedly elevated during deep sleep
Dwarfism Decreased GH
Acromegaly Increased GH
GH deficiency tests 1. Insulin tolerance test = Gold standard (Confirmatory test)
2. Arginine stimulation test = 2nd confirmatory test
Tests for Acromegaly 1. Somatomedin C or insulin-like growth factor I (Screening)
-Increased: Acromegaly
-Decreased: GH deficiency
2. OGTT (Confirmatory)
-75g glucose
FSH Spermatogenesis
LH Helps Leydig cells to produce testosterone (male)
Ovulation (female)
Synthesis of androgens, estrogens, and progesterone
TSH (Thyrotropin) Stimulates thyroid gland to produce T3 and T4
Increased: 1’ hypothyroidism, 2’ hyperthyroidism
Decreased: 1’ hyperthyroidism, 2’ hypothyroidism, 3’
hypothyroidism
ACTH (Corticotropin) Highest: 6-8 AM
Lowest: 6-11 PM
Not allowed to have contact with glass because it adheres to
glass surface
Collect blood in plastic tubes
Prolactin Initiation and maintenance of lactation
Inhibited by Dopamine
Highest: 4AM and 8AM, and 8PM and 10PM
Increased: Menstrual irregularity, infertility, amenorrhea,
galactorrhea
Panhypopituitarism From pituitary tumor (adenoma) or Ischemia
Pituitary ischemia Hemorrhage or shock in a pregnant female at the time of
(Shechan’s) deliver
Posterior pituitary Release but not produce oxytocin and vasopressin
(Neurohypophysis)
Oxytocin Uterine contraction and milk ejection
ADH/AVP (Arginine H2O reabsorption (DCT and CD)
vasopressin) Stimulus: Increased plasma osmolality (>295 mOsm/kg),
decreased blood vol.
Promotes factor VII and vWF release
Overnight water deprivation Diagnostic test for ADH
test (Conc. test)
Neurogenic DI True Diabetes Insipidus
Failure of the pituitary gland to secrete ADH
Nephrogenic DI Failure of the kidneys to respond to normal or elevated ADH
SIADH Syndrome of inappropriate ADH
Sustained production of ADH
Decreased urine volume
Low plasma osmolality
Low serum electrolytes
Thyroid Gland Butterfly-shaped
2 lobes = connected by the isthmus
Follicle Fundamental structural unit of the thyroid gland
Follicular cells Secrete T3 and T4
Parafollicular or C cells Secrete calcitonin
Thyroglobulin Preformed matrix containing tyrosyl groups
Stored in the follicular colloid of the thyroid gland
Thyroid hormone 1. Trapping of Iodine
Biosynthesis 2. Iodination: I2 Tyrosine ring MIT and DIT
3. Condensation: MIT+DIT=T3 / DIT+DIT=T4
4. Release: T3/T4 Blood circulation
5. Transport of T3/T4 by proteins
Protein-bound hormones Metabolically inactive
Biologically inert
Do not enter cells
Storage sites
Free hormones (FT3/FT4) Physiologically active
Readily enters cells
Reverse T3 (rT3) From removal of one iodine from T4 (product of T4
metabolism)
Metabolically inactive
I2 intake <50 μg/day Deficiency of hormone secretion
T3 3,5,3’-Triiodothyronine
Most active thyroid hormonal activity
75-80% is produced from the tissue deiodination of T4
Diagnosis of T3 thyrotoxicosis
T4 3,5,3’5’-Tetraiodothyronine
Principal secretory product
All originated in the thyroid gland
TBG Transports 70-75 of TT4, and majority of T3
TBPA (Transthyretin) Transports 15-20% of TT4
No affinity for T3
TBA Transports T3 and 10% of T4
Thyroid autoantigens TPO
Tg
TSHR
Thyroid disorders Screening is recommended when a person reaches 35 yrs old
and every 5 yrs thereafter
Primary hyperthyroidism T3 and T4
TSH
Secondary hyperthyroidism T3 and T4
TSH
T3 Thyrotoxicosis (Plummer’s T3
disease) N-T4
TSH
Graves’ disease 1’ Hyperthyroidism
(Diffuse toxic goiter) Most common cause of thyrotoxicosis (autoimmune)
Women > Men
Anti-TSH receptor
Riedel’s thyroiditis Thyroid woody or stony-hard mass
Subclinical hyperthyroidism No symptoms
N-T3 and T4
TSH
Subacute granulomatous/ Hyperthyroidism
Subacute nonsuppurative/ De Painful thyroiditis
Quervain’s thyroditis Neck pain, low-grade fever
(-) anti-TPO, ESR and Tg
Hypothyroidism Treatment: Levothyroxine
Primary hypothyroidism T3 and T4
TSH
Hashimoto’s disease (Chronic Most common cause of 1’ hypothyroidism
autoimmune thyroiditis) Thyroid is replaced by a nest of lymphoid tissue (T cells)
Goiter
(+) anti-TPO
TSH
Myxedema coma Severe form of 1’ hypothyroidism
Peculiar nonpitting swelling of the skin
Skin is infiltrated by mucopolysaccharides
“Puffy” face, thin eyebrows
Secondary hypothyroidism T3 and T4
TSH
Tertiary hypothyroidism T3 and T4
TSH
TRH
Congenital hypothyroidism Mental retardation (child)
(Cretinism) Screening: T4
Confirmatory: TSH
Subclinical hypothyroidism N-T3 and T4
TSH
TRH stimulation test Most specific and sensitive test for diagnosing thyroid
disease
Confirm borderline cases and euthyroid Graves’ disease
: 1’ hypothyroidism
: Hyperthyroidism
Radioactive Iodine Uptake Measure the ability of the thyroid gland to trap iodine
(RAIU)
Thyroglobulin (Tg) assay Postoperative marker of thyroid cancer
: Untreated and metastatic differentiated thyroid cancer,
hyperthyroidism
: Hypothyroidism, thyrotoxicosis factitia
rT3 Assess borderline or conflicting laboratory results
Free Thyroxine Index (FT4I) Indirectly assesses the level of FT4 in blood
Equilibrium relationship of bound T4 and FT4
Reference method: Equilibrium dialysis
FT4I = TT4 x T3U(%) or TT4 x THBR
100
TT3, FT3, FT4 FT4 test: differentiates drug induced TSH elevation and
hypothyroidism
TT3 or FT3: confirm hyperthyroidism
Reference method (FT4): Equilibrium dialysis
T3 Uptake test Measures the number of available binding sites of the
thyroxine binding proteins (TBG)
TBG = T3U
TBG = T3U
TBG test Confirm results of FT3 or FT4 or abnormalities in the
relationship of TT4 and THBR test
Estrogen: TBG
Androgen: TBG
Fine-needle aspiration Most accurate tool in the evaluation of thyroid nodules
Recombinant Human TSH Test patients w/ thyroid cancers for the presence of residual
or recurrent dis.
Tanned Erythrocyte Test for anti-Tg disorders
Hemagglutination method
Serum calcitonin test Marker for familial medullary thyroid carcinoma
FT4 and TSH Best indicators of thyroid status
FT3 and FT4 More specific indicators of thyroid function than meas. of
total hormone
Not affected by TBG
Euthyroid sick syndrome Acutely ill but without thyroid disease
T3 and T4
N/ TSH
rT3
Parathyroid gland 4 parathyroid glands
Smalles endocrine gland
PTH Hypercalcemic hormone
Ca2+ (bone resorption and renal reabsorption) and Mg2+
iPO4
1’ hyperparathyroidism Defective: Parathyroid gland
Most common cause of hypercalcemia
Parathyroid adenoma
PTH and iCa2+
Hypercalciuria
Phosphaturia Hypophosphatemia
If goes undetected severe demineralization (osteitis fibrosa
cystica)
2’ hyperparathyroidism In response to Ca2+
Hyperplasia of all 4 glands
Causes: Vit. D deficiency and chronic renal failure
PTH
Ca2+
3’ hyperparathyroidism Occurs w/ 2’ hyperparathyroidism ( Ca2+)
Autonomous function of hyperplastic PT glands or PT
adenoma
PO4
Calcium phosphates precipitate in soft tissues
Hypoparathyroidism Accidental injury of the PT glands (neck) during surgery
Autoimmune parathyroid destruction
PTH = Ca2+
Hyperparathyroidism Acidosis
Hypoparathyroidism Alkalosis
Adrenal glands Pyramid-shaped
Above the kidneys
Adrenal cortex = outer (yellow)
Adrenal medulla = inner (dark mahogany)
Has prime effects on blood pressure
Adrenal cortex Major site of steroid hormone production
G cells: convert cholesterol pregnenolone
CPPP ring 17-carbon skeleton derived from cholesterol
3 layers (Adrenal cortex) 1. Zona Glomerulosa = Mineralocorticoids (Aldosterone)
2. Zona Fasciculata = Glucocorticoids (Cortisol)
3. Zona Reticularis = Weak androgens (androstenedione,
DHEA)
Cortisol 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