CCHM 2 LECTURE ❖ Through mechanisms that involve the lungs and kidneys, the body

controls and excretes H+ in order to maintain pH homeostasis.

BLOOD GASSES Imbalances between the rate of acid formation and excretion can occur
and can lead to alterations in consciousness, neuromuscular irritability,
tetany, coma, and death.
KEY TERMS
ACID A substance that can yield a
hydrogen ion or hydronium ion Regulation of Acid-Base Balance
o Strong acids – Pka when dissolved in water.
less than 3.0 ❖ To achieve the homeostasis in the body the pH should be
BASE a substance that can yield bet. the range of 7.35 – 7.45
hydroxyl ion when dissolved in
o Strong bases – pKa water. pH – power of hydrogens
greater than 9.0 ❖ Relative strengths of acids
and bases, their ability to Acidic – more hydrogen ions
disassociate in water are
describe by their Alkaline – more hydroxide ions
disassociation constant or
ionization constant value Lungs
(pka)
❖ Pka – negative log of the ➢ Help maintain acid-base balance through gas exchange or
ionization constant respiration
BUFFER - the combination of a ➢ Rapid and short-term compensation
weak acid or weak base ➢ Analytes controlled: oxygen and carbon dioxide
and its salt, is a system ❖ In-charge of regulating carbon dioxide
that resist changes in ❖ Increase in CO2 makes the body more acidic → participates in
pH carbonic acid (H2CO3)
RESPIRATION - Process to supply cells ❖ By exhaling it lessen the acidity of the body
with oxygen for ❖ Excessive exhaling → alkaline
metabolic processes
and remove the carbon
dioxide produced during
metabolism Kidneys
PARTIAL PRESSURE - In a mixture of gases,
partial pressure is the ➢ Help maintain acid-base balance through reabsorption or
amount of pressure excretion of bicarbonate
contributed by each gas ➢ Slow but long-term compensation
to the total pressure ➢ Analyte controlled: -bicarbonate
exerted by the mixture ❖ Regulate hydrogen ions and bicarbonate
ACIDEMIA - occurs when arterial
❖ More hydrogen ions make the body more acidic
blood pH <7.35
❖ Once kidneys release more hydrogen ions in the urine → body
ALKALEMIA - occurs when arterial will be more alkaline
blood pH >7.45
❖ Reference value for arterial
blood plasma pH: 7.4
HYPERCAPNIA is increased blood PCO2 Buffer system: Regulation of H+

HYPOCAPNIA is decreased blood PCO2 Bicarbonate-carbonic acid buffer system:

- All buffers consists of a weak acid (carbonic acid – regulated

PARTIAL PRESSURE OF Measured in blood as mmHg by lungs), and its salt or conjugate base (bicarbonate –
CARBON DIOXIDE (PCO2) regulated by kidneys).
CONCENTRATION OF Includes undissociated carbonic
DISSOLVED CARBON acid (H2CO3) and carbon dioxide - Bicarbonate-carbonic ratio must be 20:1 in order to maintain
DIOXIDE (cdCO2) dissolved in blood (represented by normal pH
PCO2)
CONCENTRATION OF Includes bicarbonate (primary
TOTAL CARBON DIOXIDE component), carbamino-bound Different buffer system:
(ctCO2) CO2, carbonic acid, and dissolved
carbon dioxide ❖ Phosphate buffer system
❖ Protein buffer system
❖ Oxyhemoglobin buffer system
❖ Carbonic-bicarbonate buffer system – most important
buffer system in the body (Principal mammalian buffer
Acid-Base Balance
system)
- Bodies first line of defense against in extreme changes in
• Important in order to maintain the pH within the normal range
Hydrogen ion concentration
(7.35 – 7.45)
- Carbonic acid dissociates into carbon dioxide and water,
• Increase in H+ decreases the pH
allowing carbon dioxide to be eliminated by the lungs and
• Decrease in H+ increases the pH
hydrogen ions as water
❖ Through metabolism, the body produces approximately 150 g of H+
- Changes in carbon dioxide modified the ventilation rate or
each day.
the respiratory rate
❖ Yet the concentration of H+ in the extracellular body fluids is
- Bicarbonate concentration may be altered by kidneys
maintained within a narrow range from 36 to 44 nmol/L (pH 7.35 to
H2CO3 – carbonic acid (lungs)
7.45).
 HCO3 – bicarbonate (kidneys)

HENDERSON-HASSELBALCH EQUATION

❖ Describes the relationship between blood pH and the

components of bicarbonate-carbonic buffer system
❖ Qualitative description acid-base physiology allows the
metabolic components to be separated from the respiratory
components of acid base balance
• States the relationship between lungs, kidneys and pH
• pK = 6.1
• Bicarbonate– total carbon dioxide minus carbonic acid **reference range (HCO3) – 22-29 mEq/L
• Carbonic acid – partial pressure of carbon dioxide x 0.0307
pH
*0.0307 = combination of the solubility constant for pCO2 and the
factor to convert mm Hg to millimoles Common Causes Common Mechanism

Formula:

pH = 6.1 + log HCO3 Respiratory acidosis Inability to exhale Renal compensation:

H2CO3 CO2: Excretion of H+ in urine
Emphysema, *ventilation
• pH is directly proportional to bicarbonate - an increase in pulmonary edema, ❖ Bicarbonate
bicarbonate causes an increase the pH and vice versa Airway obstruction, reabsorption
• pH is indirectly proportional to partial pressure of carbon COPD, pneumonia
dioxide – an increase in pCO2 causes a decrease in pH and
vice versa Respiratory alkalosis Low CO2: Renal compensation:
Hyperventilation, Excretion of OH- in urine
Pulmonary disease, ❖ Bicarbonate
Psychogenic, Sever excretion in
ACID-BASE DISORDERS anxiety, Panic attack, urine
Pain, Aspirin ❖ ** the
Acidosis and Alkalosis (Salicylate) overdose compensation
of the kidney is
• Changes in pH can be caused by: somewhat slow/
- either defect in the lungs (respiratory) or long-term
- defect in the kidneys (metabolic) - Compensation
• Because the body’s cellular and metabolic activities are pH can happen
after a day
dependent, the body tries to restore acid-base homeostasis
whenever imbalance occurs.
*breathe into a paper bag
❖ Blood pH below 7.35 → Acidosis
❖ Blood pH above 7.45 → Alkalosis Metabolic acidosis Loss HCO3: Respiratory
• This action by the body is termed compensation. The body Severe diarrhea, compensation:
accomplishes this by altering the factor not primarily affected failure to excrete H+, Hyperventilation
by the pathologic process renal failure Excess ❖ Lungs will
acid: Diabetic compensate
ketoacidosis, Lactic ❖ Fast/ short-term
acidosis and renal compensation
failure
Classification of Acid-Base Imbalance
Metabolic alkalosis Loss of stomach acid Respiratory
METABOLIC – DEFECT IN KIDNEYS (vomiting), compensation:
Bicarbonate excess: Hypoventilation
RESPIRATORY – DEFECT IN LUNGS excessive intake of
antacid, diuretics,
• METABOLIC ALKALOSIS severe hydration
• METABOLIC ACIDOSIS
• RESPIRATORY ALKALOSIS
• RESPIRATORY ACIDOSIS
Metabolic Acidosis

Primary Bicarbonate Deficit

A. In metabolic acidosis, the bicarbonate concentration

decreases, causing a decrease in the 20:1 ratio between
cHCO3 and cdCO2, which results in a decrease in the blood
pH
❖ Production of increase amount of acid
Ex. Diabetic ketoacidosis, lactic acidosis or
alcoholism, renal failure and diarrhea →
compensation: hyperventilation
 ❖ Seen in hyperkalemia and hyperchloremia pneumonia, congestive heart failure, salicylate overdose,
B. Metabolic acidosis may be caused by organic acid and so on.
production or when ingestion exceeds the excretion rate. ❖ Anxiety, severe pain, aspirin overdose and hepatic
Disorders include diabetic ketoacidosis cirrhosis → decreased reabsorption of bicarbonate
❖ Vomiting with the loss of chloride in stomach → ❖ Bicarbonate fall 2 mmEq/L for each 10mmHg fall
hypoventilation in pCo2
❖ For every 10 mEq/L in bicarbonate, the pco2 ❖ (+) hypokalemia
rise by 6mmHg
❖ The pco2 drops 1-1.3 mmHg per mmEq/L fall in
bicarbonate
ACID-BASE DISORDERS: Acidosis and Alkalosis

➢ When the lungs have problem, the kidneys will compensate.

Metabolic Alkalosis When the kidneys have problem, the lungs will compensate.
➢ Fully compensated implies that the pH has returned to the
Primary Bicarbonate Excess normal range (20:1).
➢ Partially compensated implies that the pH is approaching
A. In metabolic alkalosis, the bicarbonate concentration normal
increases, causing the increase in the 20:1 ratio between
cHCO3 and cdCO2, which results in the increase in the
blood pH.
❖ Vomiting with the loss of chloride in stomach →
hypoventilation
❖ For every 10 mEq/L in bicarbonate, the pco2 rise by
6mmHg
❖ The pco2 drops 1-1.3 mmHg per mmEq/L fall in
bicarbonate
❖ Seen in hypokalemia and hypochloremia

B. Metabolic alkalosis may be caused by ingestion of excess

base, decreased elimination of base, or loss of acidic fluids.

Respiratory Acidosis

Primary cdCO2 excess expressed as increase in PCO2

(Hypercapnia)
Oxygen Metabolism
A. Inability of a person to exhale CO2 through the lungs
(hypoventilation causes an increase of'PCO2. The increased ➢ Oxygen is transported bound to hemoglobin present in red
PCO2 causes an increase in the concentration of dissolved blood cells and in a physically dissolved state.
carbon dioxide, which forms carbonic acid in the blood. This
decreases the 20:1 ratio between cHCO2 and cdCO2 which ➢ Three factors control oxygen transport:
decreases the blood pH. • PO2
❖ Chronic obstructive pulmonary disease, • free diffusion of oxygen across the alveolar
myasthenia gravis, CNS disease, drug overdose membrane
(morphine, barbiturates and opiates) and • affinity of hemoglobin for oxygen.
pneumonia → retention of bicarbonates
❖ Bicarbonate rises 1 mmEq/L for each 10 mmHg
rise in partial pressure of carbon dioxide
B. Respiratory acidosis may be caused by chronic obstructive ➢ Release of oxygen to the tissues is facilitated by an increase
pulmonary disease, such as chronic bronchitis and in H+ concentration and PCO2 levels at the tissue level.
emphysema ingestion of narcotic and barbiturates, and
severe infections of the central nervous system such as ➢ Under normal circumstances, the saturation of hemoglobin
meningitis with oxygen is 95%. When the PO2 is >110 mm Hg, greater
than 98% of hemoglobin binds to oxygen.

Respiratory Alkalosis
➢ When a person's oxygen saturation falls below 95%, either
Primary cdCO2 deficit expressed as decrease in PCO2 the individual is not getting enough oxygen or does not have
(Hypocapnia) enough functional hemoglobin available to transport the
oxygen.
A. Decreased PCO2 results from an accelerated rate or depth
of respiration or a combination of both. Excessive exhalation ❖ Hypoxemia
of carbon dioxide (hyperventilation) reduces the PCO2,
causing a decrease in the concentration of dissolved carbon ➢ The amount of functional hemoglobin available in the blood
dioxide, which forms less carbonic acid in the blood (i.e., less can be altered due to decreased red blood cells or presence
hydrogen ions). This increases the 20:1 ratio between of nonfunctional hemoglobin
cHCO3 and cdCO2, which increases the blood pH.
B. Respiratory alkalosis may be caused by hypoxia, anxiety,
nervousness, excessive crying, pulmonary embolism,
Blood Collection For Blood Gas and pH Analysis
 ➢ Arterial whole blood using heparin as the anticoagulant
❖ Arterial blood is most preferred specimen (pulse)
- Brachial artery, radial artery, femoral artery and inguinal
artery
❖ ABG syringe – syringe coated with heparin inside
(80-120 gauge for brachial artery 45-60 degrees
angle)

➢ Venous blood usually 0.03 pH units lower than arterial blood

- Venous and capillary blood can also be used for
analysis, provided that they undergo arterialization
- Arterialization
• Immerse the puncture site in an 45˚C water bath
• Wrap the puncture site with a prewarmed towel
wetted with water of 45˚C

➢ Syringe with rubber stopper; specimen should be Sealed.

• Heparinized plastic syringe: Disadvantage –
leaking gases through plastic
• Glass syringe pretreated with heparin Advantage –
reusable, most accurate results obtainable, lesser
tendency for bubble formation
• Do not use vacutainer tube Disadvantage – ❖ ABG is considered as POCT (Point of Care testing) can be
oxygen contamination increases pO2 by the done bedside
residual O2 present in the nitrogen-filled
vacutainer tube
• Place specimen on ice water or ice bath METHODOLOGY:
• 3 hours - This prevents O2 consumption by the
RBC and release of acidic metabolites - This will ▪ pH – glass electrode connected to a reference electrode
also stabilize the pH and pCO2 up to 3 hours (calomel electrode, mercury-mercuric chloride)
• No to clot, hemolysis or bubbles ✓ principle: based on Polarographic principle – uses
pH meters (Calomel electrode and Mercury-
Mercuric Chloride)
▪ pCO2 –Severinghaus electrode – a modified pH electrode;
➢ SPECIMEN WAS EXPOSED TO ROOM AIR glass electrode with weak bicarbonate solution enclosed in
Increase in oxygen, decrease in carbon dioxide, silicone membrane
decrease in pH ✓ Principle: based on pH measurement of a
stationary sodium bicarbonate solution w/c is in
➢ SEALED SPECIMEN WAS LEFT AT ROOM equilibrium with the test solution and the test via a
TEMPERATURE carbon dioxide permeable membrane
decrease in oxygen, Increased in carbon dioxide, ✓ Measurement: Voltage flow
decrease in pH ▪ pO2 – amperometric/polarographic; Clark electrode –
❖ Changes are due to the presence of blood cells composed of oxygen permeable membrane with electrode
utilizing glucose and oxygen at RT composed of a platinum cathode and silver-silver chloride
❖ Causing the formation of acid products and carbon anode
dioxide ✓ Gasometric analysis – calculation from oxygen
saturation, pH and temperature (standard oxygen
➢ EXCESS HEPARIN dissociation curve) → transcutaneous monitoring,
Heparin is an acid mucopolysaccharide It is often <1ml natholsone micro gasometer; >1ml van’s-like
used at a concentration of 0.2 mg/mL of blood gasometer
Excess heparin leads to acidic pH of blood
specimen

Methodology:
 • must be placed in an ice slurry

Parameters of Interest

Evaluate the pH (normal pH = 7.35-7.45)

< 7.35 – acidosis
> 7.45 – alkalosis

Evaluate the ventilation (Lungs) pCO2 = 35-45 mmHg

< 35 – respiratory alkalosis
> 45 – respiratory acidosis

Evaluate the metabolic process (Kidneys) HCO3 = 22-29 meq/L

< 22 – metabolic acidosis
> 29 – metabolic alkalosis
Clark electrode: measurement of pO2- Amperometric → amount of
Determine which is the primary and compensating disorder
current flow is an indication of oxygen present
Determine the degree of compensation
Severinghaus electrode: pCO2 and pH measurement are
Non-compensation
potentiometric in which a change in the voltage indicates the activity of
Partial compensation
each analyte
Complete compensation
Reference electrode

▪ Silver-silver chloride reference electrode

▪ Cuvette

pH electrode: measures the pH uses silver-silver electrode and

Calomel electrode

reference electrode:

▪ Silver-silver chloride
▪ Potassium-chloride solution

7.31-7.34 – acidosis
▪ Bicarbonate and Carbon dioxide content – nomogram 7.46-7.49 – alkalosis
from blood gas analyzers
▪ CO2 content – consists of bicarbonate; undissociated
carbonic acid, dissolved carbon dioxide and carbamino-
bound carbon dioxide

Continuous flow analyzer for Blood Gas Analysis:

▪ Caprylic alcohol- prevent foaming

▪ Mercury- separate the sample and other reagent
▪ Lactic acid 10% - releases CO2 from HCO3
▪ 12% NAOH - for collecting CO2
▪ Na2CO3- for releasing O2

Alternative Method:

➢ Involves the release of C02 gas when the sample is added to

H2S04 (sulfuric acid) with subsequent monitoring of this Evaluate the degree of oxygenation
release with a pair of pCO2 electrodes (reference and
sample electrodes). The rate of change in pH of the buffer pO2 = 80-110 mmHg (adequate oxygenation)
inside the pCO2 electrodes is a measure of the
concentration of its CO2 In the Sample HYPOXEMIA:

Mild = 61-80
Moderate = 41-60
Conditions for Analysis: Severe = 40 or less

• All procedures should be considered “STAT” Final interpretation

o If delayed 20-30 mins: pH lowers by 0.01 Degree of compensation
o Avoid glycolysis Primary disorder
• Specimen must be kept at anaerobic condition Degree of oxygenation
• Specimen w/c cannot be analyzed immediately
Examples:

A 71-year-old woman walking home from attending church mass

suddenly faints and falls. The medics were called and upon arrival, find
her with an oxygen saturation of 88% on room air and pinpoint pupils
on exam. She is brought into the FUMC ER where an arterial blood
gas (ABG) was performed and revealed the following:

pH = 7.25 → acidic (decreased)

pCO2= 60mmHg → increased

pO2= 65 → decreased (mild hypoxemia)

HCO3 = 26mmolL → within the range

Answer: Uncompensated Respiratory Acidosis with Mild

Hypoxemia

Examples:

**pH and pCO2 are opposite = respiratory problem

**pH and pCO2 are equal = metabolic

pH: Acidic

pCO2: Increased

pO2: below (Mild Hypoxemia)

HCO2: Increased

Answer: Partially Compensated Respiratory Acidosis with Mild

Hypoxemia
CCHM 2 LEC ➢ Early detection is critical to cancer prevention in
general to high risk families in particular
TUMOR MARKES ➢ Well differentiated and composed of cells resembling
the nature of normal cells from the tissue of origin of
the neoplasm
Purple – trans

Blue – book
Neoplasia

➢ Involves the possibility of normal cells undergoing

Tumor markers – substances that are usually proteins and are cancerous proliferation
produced by cancer tissue itself ➢ Pathologic hyperplasia
➢ Unregulated and serves no purpose
- Produced by bodies in response to caner growth ➢ Elevation of tumor markers will be a long lasting
phenomenon if not treated
Tumor markers can be detected in the body samples:

- Urine
- Blood
- Tissues

Markers are being used along with other test and procedures
to detect and diagnose types of cancer

- Helps to predict and monitor person’s response to

certain treatment
- Help and detect recurrence of cancers

Major processes involved in Cell growth Malignant

• Proliferation – rapid reproduction of cell or organism ➢ Due to genetic instability of tumor cells.
- Process in which it increases the ➢ Cancerous tumor
cell number ➢ Involves abnormal growth that is uncontrolled and can
• Differentiation – alteration of morphology and function even spread although out the body
of the cell ➢ Often resistant to treatment
➢ It can even reoccur

Tumorigenesis What is Cancer?

➢ Formation of solid mass or tumor ➢ refers to the uncontrolled growth of cells that can
➢ Activation of growth factors (e.g., epidermal growth develop into a solid mass or tumor and spread to
factor [EGF]) Activation of oncogenes (e.g., K-ras), other areas of the body
➢ Inhibition of apoptosis, tumor suppressor, and cell ➢ formation – tumorigenesis/ oncogenesis/
cycle regulation genes (e.g., BRCA1, p53, cyclins) carcinogenesis
➢ spreading – metastasis – caused by a complex
combination of inherited and acquired genetic
Hyperplasia mutations
➢ during tumorigenesis, these mutations an include
➢ Involves the multiplication of cells in an organ or activation of the growth factor and oncogenes
tissue, which may consequently have increased in ➢ inhibition of apoptosis of tumor suppressor and even
volume. ell cycle regulation genes
➢ Serves a useful purpose and is controlled by stimuli
➢ Elevation of tumor markers is transient
Metastasis

Benign ➢ Cause of the most cancer deaths

➢ Due to multiple genetic changes that result to
➢ Tumors remain at the primary site and present a uncontrolled proliferation
smaller risk to the host ➢ Multistep processes involving numerous tumor cell-
➢ At this stage the patient stands a good chance of host cell and cell-matrix interactions.
being successfully treated by the complete removal of ➢ Tumor cells at the primary site →penetrate their
the tumor. adjacent surroundings (epithelial basement
membrane and the interstitial stroma.)
 ➢ →invade blood or lymphatic vessels to distant sites
➢ →venous/capillary beds or solid tissue of a distant
organ.
➢ It is a highly selective process.
➢ Additional changes required:
- Loss of cell adhesion proteins
*adhesion proteins – specific class of
transmembrane glycoproteins that are involved
whenever cells are moving and interacting
*regulate migration of leukocytes into the
sites of inflammation or lymphatic system
* 3 Classes: selectins, integrins and
immunoglobulin family
- Activation of angiogenesis genes

Cancer Progression

➢ Metastasis
➢ Loss of cell adhesion proteins (e.g., β-catenin
Tumor Markers
and E-cadherin)
➢ Activation of angiogenesis genes (e.g.,VEGF) ➢ Produced either directly by the tumor or as an effect
of the tumor on healthy tissue (host)
➢ Used to:
• Differentiate a tumor from normal tissue
• Detect the presence of a tumor based on
measurements in the blood or secretions
➢ Enzymes – tumor markers

Clinical Utilities of tumor markers

Factors Considered in Cancer Severity

➢ Tumor size – the bigger the tumor the severe the

cancer is
➢ Histology
➢ Regional lymph
➢ Node involvement
➢ Presence of metastasis Screening

➢ None of the tumor markers discovered had sufficient

specificity and sensitivity for screening in the general
Cancer Staging population
➢ It is not recommended for most tumor markers,
➢ Four Stages – Roman Numerals I-IV especially in an asymptomatic population
➢ Disease severity ➢ Except AFP and PSA
• higher stages are indicative of significant
spreading and severe systemic disease
➢ Disease Progression
• proliferation and metastasis occur at the Alpha-Fetoprotein (AFP)
expense of normal organ processes → ➢ The screening of primary hepatoma in Asian countries
cause of morbidity and mortality is based on the measurement of serum AFP.
Prostate-Specific Antigen (PSA) and Free PSA ➢ High level of serum tumor markers indicates the
presence of malignancy, possible for metastasis that
➢ First tumor marker recommended for screening for will lead to poor prognosis
prostate cancer in men older than age of 50. ➢ Determination is based on the assessment of tumor
➢ The purpose was to detect prostate cancer at early aggressiveness, which, in turn, determines how a
curable stages, when the tumor is still confined inside patient should be treated.
the organ. ➢ Prognostic factors measured in the clinical laboratory
➢ Two major forms: Free PSA and a PSA–alpha1- also indicate risk and predict the length of a relapse-
antichymotrypsin (PSA-ACT) free, as well as overall, survival period at the time of
➢ Free PSA percentage of free PSA to PSA-ACT ratio the primary therapy.
may help differentiate benign prostate hyperplasia ➢ High levels of serum tumor marker measured during
(BPH) from prostate cancer. diagnosis would indicate the presence of a malignant
or metastatic tumor associated with a poor prognosis.
Susceptibility Genes

➢ Several familial cancers are associated with germline Early Detection

mutations in various genes.
➢ The most prominent are genes for susceptibility to ➢ Detecting the phenotypes in the blood circulation
breast and ovarian cancer, such as BRCA1 and corresponding to early mutations of a cancer allows
BRCA2 are now available to screen these families for the detection of early neoplasm at the curable stage.
the identification of carriers. ➢ Measurement of all mutant phenotypes and risk
➢ APC – Adenomatous Polyposis Coligene – identifying factors in the circulation would help to identify
the germline mutation in patients that may have family individuals at risk for cancer or detect early tumors in
history of this disease benign state.
➢ Can be used as screening for BRCA-1 and BRCA-2 ➢ There are several risk factors that can lead to
and APC tumorigenesis
➢ Can be identify and eliminate with diet adjustment and
lifestyle change
Monitoring Treatment

➢ One of the two most useful applications of tumor Functional Classification of Tumor Markers
markers involves their use in monitoring the course
during treatment of the cancer patient. 1. oncofetal antigens, such as AFP and CEA, which
➢ Measures serum tumor markers during the treatment are normally expressed during fetal development but
➢ Indicates the effectiveness of anti-tumor drug that is do not occur normally in the tissues or sera of children
being used and adults
➢ Provides a guide for the selection of the most effective CEA – Carcino embryonic antigen
drug in each individual 2. proteins occurring in epithelial cells that become
elevated in tissue and serum in adeno and squamous
cell carcinomas, such as the CA 19-9, CA 125, and
CA 15-3 proteins
Detection of recurrence
3. polypeptide hormones, such as the β chain of
➢ Monitoring tumor markers for the detection of the human chorionic gonadotropin (β-hCG), and
recurrence following the surgical removal of the 4. specific enzymes, such as the placental isoform of
tumor. alkaline phosphatase, that become elevated in the
➢ It is desirable to monitor the patient using a highly serum of patients with specific tumors
sensitive tumor marker test to detect recurrence as
early as possible.
*note: the appearance of the most circulating tumor Individual Tumor Markers
markers have a lead time of several months (3-6
months) prior to the stage of which the physical A. α-Fetoprotein (pregnant)
procedures can be used for the detection of the ➢ AFP is a major fetal serum protein and is
cancer also one of the major carcinoembryonic
proteins
➢ Elevated in patients with primary hepatoma
carcinoma cell (HCC) and yolk-sac-derived
Prognosis
germ cell tumors.
➢ Tumor marker concentration generally increased with ➢ Most useful serum marker for diagnosis and
tumor progression management of HCC
➢ Can reach higher levels if the tumors metastasized ➢ Normally synthesized by the fetal liver
➢ Tumor marker levels and diagnosis can reflect by the ➢ Tumor originated from liver
aggressiveness of tumor → can be used to predict the ➢ Due to chronic disease such as hepatitis and
outcome of the patient liver cirrhosis
➢ AFP is not completely specific for HCC
 B. β2-Microglobulin (β2M) Carcinoembryonic Antigen
➢ It is nonspecific tumor marker because it is
elevated, not only in solid tumors but also in ➢ expressed during development of the baby and re-
lymphoproliferative diseases and variety of expressed on alpha-fetoprotein
inflammatory disorders including: RA, SLE, ➢ Most widely used tumor marker for gastrointestinal
Sjogren’s syndrome, and Crohn’s disease. cancer today.
➢ Normal serum level – 0.9-2.5 mg/L ➢ transforming growth factor (TGF)-α, fibroblast growth
factor, and Ras oncoprotein are all increased in
colorectal cancer and decreased after surgical
resection
C. Cancer Antigen 125 (CA125) ➢ mutations of DNA mismatch repair genes (e.g.
➢ Defined first by a murine monoclonal hMSH2, hMLH1 and hMSH6) are shown to be
antibody OC 125 raised against a serous associated with hereditary nonpolyposis colorectal
ovarian carcinoma cell line. cancer
➢ Useful for detecting ovarian tumors at an ➢ elevated in the lung, breast and gastrointestinal
early stage and for monitoring treatments tumors
without surgical restaging. ➢ useful for diagnosis, prognosis and therapy monitoring
➢ Upper normal limit– 35 U/mL of colorectal cancer
➢ Not usually seen on serum
➢ Elevate in px’s with endometriosis
(kumakapal na lining), during the 1st trimester
of pregnancy and during menstruation Calcitonin
➢ CA 125 is the only clinically accepted
➢ one of the circulating peptide hormones that may
serological marker for ovarian cancer
become elevated in patients with increased bone
turnover rate associated with skeletal metastases
➢ ectopically elevated in bronchogenic carcinomas and
D. Cancer Antigen 15-3 (CA 15-3) and CA 27.29 is also elevated in medullary carcinoma of the thyroid.
➢ >25 U/mL are observed in patients with
metastatic breast cancer
➢ More sensitive and specific marker for
Cytokeratin 19 Fragment
monitoring the clinical course of patients with
metastatic breast cancer and is more ➢ (CYFRA21-1)
sensitive marker for metastatic breast cancer ➢ elevated serum CYFRA 21-1 have concentrated on
than CEA. breast cancer and squamous cell carcinoma of the
➢ Observed in px with metastatic breast cancer lung
(CA15-3) ➢ reflect the tumor mass in multiple studies with
correlation to tumor stage, survival, predictive role in
surgical treatment for early stage disease and
E. Cancer Antigen 19-9 (CA19-9) chemotherapy for advanced stage non-small cell lung
➢ The highest sensitivity of CA 19-9 was found cancer
in pancreatic and gastric cancers
➢ CA 19-9 is also related to Lewis blood group
substances. Only serum antigen from cancer Human Chronic Gonadotropin
patients belonging to the Le (α-β+) or Le
(α+β- ) blood group will be CA 19-9-positive ➢ free β-subunit is useful for the detection of recurrence
➢ CA 19-5 and CA50 have also been defined or metastasis for choriocarcinoma when the intact
by monoclonal antibodies that are inly hCG may remain normal
slightly different from CA 19-9 ➢ Seminomatous testicular cancer contains both intact
➢ False-positive may occur in px with hCG and β-hCG or free α subunits in equal amounts
benign liver disease (CA 19-9) ➢ Can also serve as tumor marker
➢ Cholestasis px ➢ HCG are normally secreted by the trophoblast
➢ Can be elevated in trophoblastic tumors,
choriocarcinoma and germ cell tumors of the ovary
and testis
CA 72-4
➢ Diagnostic indicator for testicular cancer
➢ useful marker for the management of patients with ➢ Useful marker for the classification of gestational
gastric and colorectal carcinoma trophoblastic diseases
➢ proposed as a specific marker for tumor occurrence of ➢ Prognostic for ovarian cancer
resectable gastric cancer and a prognostic marker for
survival reported to be an independent prognostic
marker for survival in colorectal in multivariate HER2/ neu (c-erB2) Oncoprotein
analysis together with β-hCG and CEA
 ➢ elevated in the sera of patients with a number of
different epithelial cell cancers, including breast, lung,
colorectal, and ovarian cancers Vanillymandelic Acid (VMA)
➢ also known as CD 340
➢ Useful in detection and monitoring of patients with
➢ protein in human that are encoded in erbB2 gene
pheochromocytoma and diagnosis of neuroblastoma
➢ erbb -erythroblastic oncogene B
in children
➢ gene isolated in the avian genome

Chromogranin A

➢ Itis a useful marker of exocytotic sympathoadrenal

activity in patients with pheochromocytoma.
➢ medullary carcinoma of thyroid, and small-cell lung
carcinoma
➢ increased serum chromogranin A levels are detected
in epithelial cancers with neuroendocrine
differentiation, including prostate, breast, ovary,
pancreas, and colon

Homovanillic Acid

➢ Above normal in tumors originating from neural crest.

➢ Useful in detection and monitoring of patients with
pheochromocytoma and diagnosis of neuroblastoma
in children

Lipid Associated Sialic Acid in Plasma (LASA-P)

➢ Found elevated in various malignant diseases, such

as, in the breast, GI or lungs.
➢ It is also altered in leukemia, lymphoma, Hodgkin’s
disease, and melamona, as well as in nonmalignant
infalammatory diseases.

a. Neuron-Specific Enolase (NSE)

• can be found in tumors originating from the
neuroendocrine cell system, including
glucagonomas and insulinomas.
b. Progesterone receptor(pgR)
• Associated with breast tumors
c. Prostate-Specific Antigen (PSA)
• Major protein in seminal plasma

Squamous Cell Carcinoma Antigen (SCCA)

➢ Useful in monitoring squamous cell carcinomas of the

head and neck, lung, esophagus, and anal canal
CCHM 2 LEC ❖ Positive Feedback
✓ An increase in the product also
ENDOCRINOLOGY (PART 1) increases the activity of the
system and the production rate
✓ The presence of estrogen will not
result to a decrease in the activity
Endocrinology of the system and also the
decrease in the production rate
2 Physiologic Regulatory System rather it will continue
✓ Play an important role in the
• Endocrine system growth and development of an
• Nervous system organism
o Neuroendocrine System – branch of biology
which studies the interaction between the
nervous system and endocrine system
Major Glands of Endocrine System
Types of Glands
• Pituitary Gland
• Endocrine - • Thyroid Gland
• Exocrine – secretes a hormone into a system of ducts • Parathyroid Gland
that lead to the external environment (circulatory system) • Adrenal Gland
• Pancreas
• Reproductive Glands (ovaries & testes)
• Thymus Gland
• Pineal Gland

Hormones

❖ Chemical signals produced by specialized

cells secreted in to the bloodstream and
carried into a target tissue
❖ Serves as free-hormone circulating, can be
Endocrine System carried by transport protein/ carrier protein
• Greek word “hormon” → to set in motion
• consists of ductless glands, which secrete hormone • Intercellular chemical signal transported to act on tissues
directly into the circulatory system at another site of the body to influence their activity
❖ regulated by means of control hormone • Transfer information and instructions from one set of cells
synthesis rather than by degradation to another

Types of Endocrine Control Characteristic of Hormones

• Produced by a specific endocrine gland

• Hormones are released directly from the endocrine gland
to the blood circulation and carried to the site of action as
a free hormone or bound to transport protein
• Acts at a specific site (target site) to induce certain
characteristic, biochemical changes

Functions of Hormones:

• Regulate the chemical composition and volume of the

ECF
• Help regulate metabolism and energy balance
• Help regulate contraction of smooth and cardiac muscles
❖ negative feedback → most common
and secretion of glands
- respond to a change by helping the body
maintain a stable homeostatic condition • Help maintain activities of immune system
• Plays a role in the smooth sequential integration of growth
✓ an increase in the product, decreases and development
the activity of the system and the • Contribute to the basic processes of reproduction, gamete
production rate production, nourishment of the fetus and embryo
• Help maintain homeostasis
✓ hypothalamus (gives signal to) →
hormone A → pituitary gland (releases)
→ hormone B → 3rd endocrine gland (to
release → hormone C Methods of Hormone Delivery:
✓ Presence of Hormone C
send signals to • Endocrine - secreted in one location and release into
hypothalamus and anterior blood circulation
pituitary gland to Stop ❖ Hormone binds to specific receptor to elicit
physiologic response
 • Paracrine - Secreted by endocrine cells and released into Free hormone is transported across cell
interstitial space membrane to interact with intracellular
❖ Hormones binds to specific receptor into receptor; complex binds to chromatin,
adjacent cell producing mRNA; mRNA initiates production
• Autocrine - Secreted in endocrine cells and sometimes of proteins that carry out the function
released into interstitial space attributed to the specific hormone
❖ Binds to specific receptor on cells of origin
❖ Results to self-regulation of its function • Hormone synthesis regulation
• Juxtacrine - Secreted in endocrine cells and remains in Negative Feedback
relation to plasma membrane
❖ Hormones acts on immediately adjacent cell/
Direct cell-to-cell contact
• Exocrine - Secreted in endocrine cells and released into Biogenic Amines (AA)
the lumen of gut; it affects their function
❖ Derived from Amino Acids
❖
❖ Intermediary between the steroid and proteins
• Neurocrine - Secreted in neurons and released into
• tyrosine
extracellular space
❖ Binds to nearby cell and affects its function o Thyroid hormones
▪ T3-triiodothyronine
• Neuroendocrine - Secreted in neurons and released from
▪ T4-thyroxine
nerve endings
o Adrenal hormones
❖ Interacts with receptor cells at distant sites
▪ Epinephrine
▪ Norepinephrine/Cathecholamines
• Mechanism of Action
Functional types of Hormones Epinephrine and norepinephrine do not
bind to carrier proteins and interact with the
• Releasing Hormones: receptor site on the cell membrane.
➢ from hypothalamus; promote secretion of
Anterior Pituitary hormones Thyroxine and triiodothyronine circulate
• Inhibitory Hormones: bound to carrier proteins, with the free
➢ from hypothalamus & GIT; suppress the hormone being transported across the cell
secretion of a particular hormone membrane to interact with the intracellular
• Tropic Hormones: receptor.
➢ stimulate growth & activity of other endocrine • Hormone Synthesis regulation
glands - Nerve stimulation,
• Effector Hormones: - Another hormone (e.g., thyroxine/TSH),
➢ secreted by all endocrine glands & w/ non- - Negative feedback
endocrine cells as targets

Peptides and Proteins

Types of Hormones according to structure
❖ Cleaved as needed
1. Steroids ❖ Cannot cell membrane – large molecular size
2. Biogenic Amines • synthesized by rough ER
3. Peptides and Proteins • hypothalamic releasing and inhibiting hormone
4. Glycoproteins • E.g.
5. Eicosanoids ❖ Water soluble → not bound to carrier protein
o oxytocin
o ADH
o insulin
Steroids o glucagon
o GH
❖ Derived from molecules o calcitonin
❖ Lipid molecules that have a cholesterol as a o PTH
common precursor
❖ Produced by: • Mechanism of Action
▪ Adrenal glands hormones interact with a cell membrane
▪ Ovaries receptor. This activates a second messenger
▪ Testes system to affect the cellular function.
▪ Placenta
• Derived from cholesterol • Hormone synthesis regulation
• transported to blood stream through attachment to Change in the analyte
transport protein Negative Feedback
• E.g.
❖ Water insoluble – Hydrophobic
o aldosterone
o cortisol Glycoproteins
o estrogen
o progesterone • AA derivatives with CHO groups
o testosterone • e.g.
o androgens o TSH
o FSH
• Mechanism of Action o LH
 Pineal Gland

Eicosanoids • Attach to the midbrain

• once dubbed the “third eye”
• Fatty acids • Produces MELATONIN
• with 20 carbon atom fatty acid (arachidonic fatty acid), o decreases the pigmentation of the skin
involved in cellular activity o a "natural" sleep aid
• E.g. o Also regulates circadian rhythm
o Prostaglandin • Secretions are controlled by the nerve stimuli

❖ Elevated at night

Hypothalamus

• Portion of the brain located in the walls and floor of third

ventricle
❖ Serves as a link between the nervous system Pituitary Gland (Hypophysis)
and endocrine system
• Collection of specialized cells located at the central part of Hypophysis - undergrowth
the brain
• Control the pituitary gland by production of chemicals that • small egg-shaped gland located at the base of the brain
stimulate or suppress hormone secretion of pituitary beneath the hypothalamus
❖ Location: small cavity (Sella Turcica/ Turkish
Saddle)
• master gland
Hypothalamic Hormones • divided into 2 lobes: anterior & posterior
❖ anterior – adenohypophysis (pars tuberalis)
❖ immediate – pars intermedia
❖ Posterior – neurohypophysis (pars distalis)

FIVE Types of Cell by immunological test:

1. Somatotroph – GH (growth hormone)

2. Lactotrophs (mammotrophs) – Prolactin
3. Thyrotroph – TSH
4. Gonadotroph – α and β subunits of FSH & LH
5. Corticotroph – Proopiomelanocortin (POMC)
o ACTH
Hormones: o β endorphin & β lipotrophin

• TRH: thyrotropin releasing hormones

• GnRH: gonadotropin releasing hormone
Features that Distinguish the function of Pituitary Gland
• GH-IH: growth hormone inhibiting hormone
• GH-RH: growth hormone releasing hormone
• Feedback Loops
• CRH: corticotropin releasing hormone
• Pulsatile Secretions
• PIF: prolactin inhibiting factor
• Diurnal Rhythms
• Environmental or External Modification of its performance

❖ Oxytoxin – release during childbirth;

stimulates uterine contraction (Positive
Feedback)

Endocrine Feedback Loop

❖ To regulate the secretions of hormones in the

hypothalamic pituitary axis

• Short Feedback Loop- refers to pituitary hormone

providing negative feedback to the hypothalamus,
inhibiting the secretion of the releasing hormone.
• Long Feedback Loop- refers to the hormone that was
released from the peripheral endocrine gland inhibiting
pituitary or hypothalamic secretion of releasing hormone.
• Ultrashort Feedback Loop- hormone inhibits its own
secretion in a paracrine manner
 Anterior Pituitary Gland (true endocrine gland)

❖ regulate the release and production of hormones

❖ peptides or glycoproteins
• Composed of three cell types:
o Chromophobe (50%)
o Acidophilic (40%)
o Basophilic (10%)

❖ Negative feedback • GH, PRL, TSH, FSH, LH, ACTH

o regulates the activity of thyroid, adrenals, and
reproductive glands

Relationship of hormones produced by hypothalamus and • also secretes ENDORPHINS

pituitary gland o acts on the nervous system and reduce
feelings of pain
• open-loop negative feedback system
o they are subject to external modulation and
generally influenced or modified by higher
neural input or other hormones. Adenohypophysis Hormones

Pulsatile Secretion

o a biohemical phenomenon in which chemical

is secreted in a burst-like or episodic manner
rather than constantly

• GnRH
➢ median interpulse interval is 90 to 120 mins.

• LH
➢ median interpulse interval is 55 minutes,
➢ average peak duration is 40 minutes Growth Hormone (Somatotrophin)

❖ exerts major effects on cartilage and growths of long

bones
❖ considered as amphibolic hormone – directly influences
the anabolic and catabolic processes
Cyclic Nature of Hormone Secretion ❖ directly antagonizes effect of insulin
❖ promotes hepatic gluconeogenesis and stimulates
• The nervous system usually regulates this function lipolysis
through external signals, such as light-dark changes or • The somatotrophs comprise over 1/3 of normal pituitary
the ratio of daylight to darkness. weight.
❖ ACTH – lowest secretion at 11 pm – 3 am; peak 6an – • Stimulated by GHRH
9am • secretion is inhibited by somatostatin
• Zeitgeber (“time giver”) - process of entraining or • median interpulse interval is 2 to 3 hours
synchronizing these external cues into the function of • peak occurring at the onset of sleep
internal biologic clocks • structurally related to prolactin and human placental
• pituitary hormones are secreted in different amounts, lactogen
depending on the time of day.

o GH deficiency in children may be accompanied by

Pituitary Hormones hypoglycemia; in adults, hypoglycemia may occur if
both GH and ACTH are deficient.
Tropic Hormones Direct Effectors
✓ TSH • GH
✓ LH • Prolactin
✓ FSH (present in Factors Affecting GH Secretion
male/ female) o act
✓ ACTH directly on
- actions peripheral
are tissue
specific for
another
endocrine
gland
Hormones that influences secretion and metabolic effects of GH: Adrenocorticotropic Hormone (ACTH)
thyroxine, cortisol, estrogen, somatostatin, somatotropin releasing
factor ❖ Produced in response to low serum cortisol
❖ Secretion of cortisol
• acts on the adrenal cortex to stimulate growth and
secretion of corticosteroids
• follows circadian rhythm
• elevated during times of stress
Prolactin (PRL) ❖ zona glomerulosa
❖ zona reticularis
❖ Direct effector hormone
❖ Amino acid structure of prolactin and GH are the same
• A pituitary lactogenic hormone; a stress hormone; also
important for parturition (child birth or during labor)
• Function in the initiation and maintenance of lactation
• Also acts in conjunction with estrogen and progesterone
to promote breast tissue development
• Main inhibitory factor: dopamine

3 Forms of Circulating Prolactin:

1. Non-glycosylated monomer - major form

2. Big prolactin - consists of dimeric and trimeric Summary:
glycosylated form
3. Macro-prolactin – which is less physiologically active for • GH: growth of bone and soft tissues
• PRL: for lactation
• TSH: release of thyroid hormones
• FSH: growth of the follicle (female) and initial wave of
Specimen consideration spermatogenesis (male)
• LH: ovulation and final follicular growth (female) and
• Collect 3-4 hours after the patient awakes production of testosterone (male)
• Highest level: 4-8am; 8-10pm • ACTH: release of cortisol

Thyroid Stimulating Hormone (TSH) thyrotropin

Posterior Pituitary Gland (neurohypophysis)

• Αlpha subunit has the same amino acid sequences of ❖ Synthesized in the supra-optic nuclei and paraventricular
LH, FSH and HCG nuclei of hypothalamus
• ß subunit carries the specific information to the binding
receptors for expression of hormonal activities • Oxytocin or pitocin: for contraction of uterus and
• Main stimulus for the uptake of iodide by the thyroid gland ejection of milk primed with estrogen (Supra-optic)
• It acts to increase the number and size of follicular cells of
follicular cells; it stimulates thyroid hormone synthesis • ADH or arginine vasopressin or pitressin: permeability
of kidney tubules (paraventricular)

Oxytocin

❖ Stimulates muscle contraction during delivery and

Follicle Stimulating Hormone (FSH) and Luteinizing Hormone lactation
(LH) • Major effect: smooth muscle contraction
• Stimulates contraction of the gravid uterus at term
❖ Markers for infertility and menstrual cycle disorder
(fergusson reflex)
• FSH: growth and maturity of ovarian follicles, estrogen
• Contributes directly to uterine contractions during labor on
secretion, promotes endometrial changes,
the myometrium and promotes prostaglandin secretion
spermatogenesis
• Hemostasis at the placental site after delivery
❖ Spermatogenesis in male
• HL: 3-5 minutes
❖ Early folliculogenesis in female

• LH: ovulation and secretion of androgens and

progesterone, initiates secretory phase of mens, Significance
formation of corpus luteum and development of testicular
cells • Useful test in some pregnant women in predicting pre-
❖ Testosterone in male term labor
❖ Final kineme sa babae
• Oat cell carcinoma of the lung and adenocarcinoma of the
pancreas
 Test for GH Deficiency

Arginine Vasopressin • Stimulation tests

o After exercise or during sleep, GH normally
• Maintain osmotic homeostasis by regulating balance increases
• Nonapeptide that acts on the DCT and collecting tubules o Clonidine (potent GH stimulant)
of the kidneys
• Urine/serum /pl asma osmolality and thirst may
stimulate ADH secretion
Growth Hormone Deficiency Test

• Insulin Tolerance Test (Insulin Induced hypoglycemia

test) - Gold standard (confirmatory test)
❖ Fasting serum and complete rest 30mins
before blood collection

• Arginine Stimulation test- 2nd Confirmtory test Failure

of GH to rise > 5 ng/mL (adults) and >10 ng/mL (child) is
abnormal
• GRH and L-arginine
• L-arginine coupled with L-DOPA
• 5-10% drop in blood volume and blood pressure triggers
(baroreceptors) the release ADH
• Responsible for the maintenance of blood volume,
pressure and tonicity GH excess

• Basal plasma vasopressin: 2.3-3.1pg/uL • Over production of GH

• Diagnostic test: Overnight water deprivation test • Gigantism → childhood
• Acromegaly → Adults

Screening test for Acromegaly:

In Relation to Osmolality
SOMATOMEDIN C TEST (Insulin-like growth factor I)
• Principal regulator of ADH secretion: increased
concentration in plasma osmolality ❖ Fasting serum
• ADH secretion is maximally stimulated at a serum ❖ Complete rest
osmolality of > 295 mOsm/kg and suppressed when the
osmolality falls below 284 mOsm/kg

Gigantism

• hypersecretion of GH during childhood

DISEASES ASSOCIATED WITH HORMONES OF THE PITUITARY Acromegaly

GLAND
• hypersecretion of GH during adulthood

features:
Dwarfism (GH deficient)
▪ coarse facial features
• hyposecretion of GH during growth years ▪ soft tissue thickening (lips)
• types: ▪ spade like hands
o Achrondroplasia – disorder of bone growth ▪ protruding jaw (prognathism)
that prevents the changing of cartilage to bone ▪ Sweating
- Inherited autosomal pattern ▪ impaired glucose tolerance or DM
▪ Long bones of Arms and legs

o Hypoachondroplasia – form of short limb

dwarfism

o Spondyloepiphyseal Dysplasia -
involvement of vertebrae and epiphysial
centers
- short trunk disproportionate
dwarfism
Diagnosis of Acromegaly
o Diastrophic dysplasia – joint pain and
• OGTT/ Glucose suppression test (Confirmatory) and GH
deformity
measurement
❖ Blood is collected for every after 30mins for
❖ Children – pituitary dwarfism → retain normal
2hrs
proportions (No intellectual abnormalities)
• Hyperglycemia should suppress GH to <1 ug/L
 • After treatment, failure to suppress GH below 2 ug/L may
cause higher prevalence of DM, heart disease and
hypertension

Galactorrhea

• inappropriate production of breast milk

• due to hypersecretion of PRL (Hyperprolactinemia)
• symptoms: irregular menstruation, menopausal
symptoms, milk discharges, difficulty in getting erection,
breast tenderness and enlargement
Diabetes Insipidus

• Deficient ADH
• Results in severe polyuria (≥ 3 L of urine / day)
• Clinical Pictures include:
o Normoglycemia
o Polyuria with low specific specific gravity
o Polydypsia
o Polyphagia (occasional)

Amenorrhea
True Diabetes Insipidus
• absence of menstrual cycle in females
• due to hypersecretion of PRL • Hypothalamic/neurogenic/cranial/ central diabetes
insipidus
• Deficiency of ADH with normal ADH receptor, due to
hypothalamic or pituitary disease
• Failure of the pituitary gland to secrete ADH
• Large volume of urine is excreted (3-20L/day)

Nephrogenic Diabetic Insipidus

• Normal ADH with normal ADH receptor

Impotence - renal resistance to ADH action
• Failure of the kidneys to respond to normal or elevated
❖ reduced libido ADH levels
• inability to attain penile erection in males • Treatment: Desmopressin (dDAVP)
• due to hypersecretion of PRL • Urine output: >2.5 L
• Diagnostic test: Water deprivation test

Infertility
Syndrome of Inappropriate ADH Secretion (SIADH)
• lack of FSH and LH in both male and female
• inability to conceive after 1 year of unprotected • autonomous sustained production of AVP in the absence
intercourse of known stimuli for its release
• malignancy, CNS diseases, pulmonary disorders drug
therapies
• decreased urine volume, increased sodium concentration
and urine osmolality

Cushing’s Disease

• hypersecretion of ACTH SIADH

• leads to bilateral adrenal hyperplasia and cortisol
overproduction • Occurs when there is uncontrolled secretion of ADH
• Obesity!!! without any known stimulus for such release
• ADH is release even though the blood volume is normal
or increased and plasma osmolality is low

Addison’s Disease

• secondary (ACTH) or tertiary (CRH) adrenal insufficiency • Ectopic tumor production of ADH: small cell carcinoma of
• hyposecretion of glucocorticoids and aldosterone the lung
• CNS disease
• Pulmonary disease
• Administration of certain drugs
• Diagnosis: Water load test
HYPOPITUITARISM o Pregnancy, 3rd tri: 95-473 ng/mL

• Panhypopituitarism – failure of either pituitary or

hypothalamus to secrete hormone
o tumors ACTH Immunoassay
o trauma
o radiation therapy • chemiluminescence and ELISA
o infarction • related test: cortisol
o infection ▫ familial • reacts with intact ACTH and ACTH fragments
o idiopathic o Adults: 5-80 pg/mL (X 0.22= pmol/L)
• Monotropic hormone deficiency – loss of only single o Specimen: P, EDTA
pituitary hormone

Dynamic Function Test

• stimulating or suppressing a particular hormonal axis, and

Laboratory Measurement of Some Hormones Secreted by the observing the appropriate hormonal response
Pituitary Gland o If excess is suspected, conduct a suppression test
o If deficiency is suspected, conduct a stimulation test
o Stimulus: exogenous analogue of a trophic hormone or a
biochemical or physiological stress like hypoglycemia or
exercise

Insulin Stress Test

• done when hypopituitarism is suspected

• also known as Insulin Tolerance Test
• insulin is administered to produce hypoglycemic stress
(<2.2 mmol/L)
• Test the ability of Anterior Pituitary Gland to produce
ACTH and GH
o GH > 6ug/L
o Cortisol >500 nmol/L

TRH Test

Growth Hormone Immunoassay • assesses the adequacy of Anterior Pituitary Reserve, or

to evaluate hypothalamic disease (TSH response to TRH
• uses specific GH antibody is delayed: TSH higher at 60’ than 20’)
• require multiple measurements o Hyperthyroidism: pituitary response to TRH is
o draw specimens every 20-30 minutes over a flat (TSH <2mU/L)
12-24 hours period o Hypothyroidism: exaggerated response (>25
• Insulin tolerance test: to produce hypoglycemia and mU/L)
provoke GH release • TRH is given as an IV bolus
o Basal: 2-5 ng/mL or ug/L • Blood sampling done at 0, 20, and 60 minutes
o Insulin tolerance: >10 ng/mL
o Arginine/L-dopa: >7.5 ng/mL

GnRH Test

hGH-EASIA • assesses hypogonadism

• can be done together with anterior pituitary function test
• solid phase Enzyme Amplified Sensitivity Immunoassay (IST, TRH, GnRH tests)
• Mab 1-hGH-Mab-HRP • Normally,
• absorbance is measured after colorimetric reaction o Adults: GnRH causes marked rise in LH
o Day: <0.2 – 10 uIU/mL (increments of >15 U/L) and smaller rise in
o Night: 30 uIU/mL FSH (>2 U/L)
o Children: GnRH causes marked rise in FSH
and smaller rise in FSH

Prolactin Immunoassay

• homologous competitive binding immunoassay/sandwich ACTH Stimulation Test

technique
• uses two or more antibodies directed at different parts of • cosyntropin test or tetracosactide test
the PRL molecule • small amount of synthetic ACTH is injected, and amount
• 😕 hook effect of cortisol or aldosterone is measured
o Adult male: 3-14.7 ng/mL or ug/L • distinguish whether the cause is adrenal (low cortisol and
o Adult female: 3.8-23 ng/mL or ug/ aldosterone production) or pituitary (low ACTH
production)
 o cortisol should be increased by twofold to
threefold within 60 minutes
o fasting (8 hrs)

LH Ovulation Dipstrip Urine Test

• high estradiol (D3): poor ovarian reserve
• test approximately the same time each day • estradiol rises as follicle matures; useful for measuring
• reduce liquid intake two hours before testing follicular activity
• mature follicles > 200-300 pg/ml of estradiol
• P >15 ng/ml about 7 days after ovulation: corpus luteum
is functioning normally
• low Day 21 P suggests the cycles was anovulatory (no
egg was produced)

Serum FSH Measurement (IRMA)

• measures the amount of follicle stimulating hormone

(FSH) in blood
• Mab1-serum-Mab2125I
• used to assess and manage disorders of the endocrine
glands, including suspected infertility
• related tests: LH, PRL, testosterone, estradiol

Normal Values for serum FSH

• Female, menstruating:
o Follicular phase: 1.4-9.9 mIU/mL (1.4-9.9
IU/L)
o Ovulatory phase: 0.2-17.2 mIU/mL (0.2-17.2
IU/L)
o Luteal phase: 1.1-9.2 mIU/mL (1.1-9.2 IU/L)
• Postmenopausal: 19.3-100.6 IU/L
• Male: 1-15.4 mIU/mL (1-15.4 IU/L)

LH Immunoassay (EIA/IRMA) ADH Measurement

• Mab1-LH-Mab2HRP • measures the amount of antidiuretic hormone, or

o measured using chromogenic reaction vasopressin, in blood
o Absorbance proportional to LH concentration • Related tests: sodium and osmolality
• Mab1-LH-Mab2125I o 270-280 mOsm/kg: <1.5 pg/mL (<1.4pmol/L)
o 280-285 mOsm/kg: <2.5 pg/mL (<2.3 pmol/L)
Fertility test (male) o 285-290 mOsm/kg: 1-5 pg/mL (0.9-4.6
pmol/L)
• Semen analysis o 290-295 mOsm/kg: 2-7 pg/mL (1.9-6.5
o Testosterone 300-1100 ng/dl pmol/L)
o Prolactin 7-18 ng/ml o 295-300 mOsm/kg: 4-12 pg/mL (3.7-11.1
o Luteinizing Hormone (LH) 2-18 mIU/ml pmol/L)
o Follicle Stimulating Hormone (FSH): 2-18 mIU/ml
o Estradiol (Day 3): <50 pg/mL

Fertility test (female)

• FSH: measures your ovarian reserve (ovarian function)

• low levels of FSH & LH: hypogonadotropic hypogonadism
• high LH with a normal FSH level: PCOD (polycystic
ovarian disease)
• high prolactin: hyperprolactinemia
ENDOCRINOLOGY 2
 88

THYROID GLAND
 89

Thyroid Gland
• located in front of the lower neck
• bow tie or butterfly like
• Follicles: structural units of thyroid cells
• Colloid: homogenous viscous fluid
consisting mainly of a glycoprotein
iodine complex called thyroglobin
• secretes T3 and T4 and calcitonin
Types of cells:
• Follicular cells: T3 and T4
▫ control the rate at which cells burn fuels
from food for energy
▫ CNS activity and brain development
▫ cardiovascular stimulation, bone and tissue
growth and development
▫ GI regulation and sexual maturation

• Parafollicular cells (C-cells):

▫ calcitonin
▫ regulation of calcium
 91

T3 and T4
Hormone Bound Free
(Albumin, Prealbumin,
Globulin)
T3 99.8% 0.2%

T4 99.98% 0.02%

• T3: globulin and albumin only

• T4: albumin (10%), pre-albumin (30%:TBPA),
globulin (60%:TBG)
Biosynthesis of Thyroid
Hormones
• Iodine is the most important element in the biosynthesis of
thyroid hormones
• RDI- 150 ug
• Found in seafood, dairy products, iodine-enriched breads, and
vitamins
• The activity of thyroid hormone is dependent on the location
and number of iodine atoms
• Iodination of tyrosine residues in thyroglobulin results in
formation of monoiodothyronine (MIT) and diiodothyronine
(DIT)
Iodothyronine 5-deiodinase
Type 1 Iodothyronine 5-deiodinase
• the most abundant form,
• found mostly in the liver and kidney
• responsible for the largest contribution to the circulating T3
pool.

Type 2 Iodothyronine 5-deiodinase

• found in the brain and pituitary gland
• maintain constant levels of T3 in the central nervous system.
• Its activity is decreased when levels of circulating T4 are high and
increased when levels are low.
Thyroid Hormones Binding Proteins
Thyroxine-Binding Globulin (TBG)
• Transports 70-75% of total T4
• Transports majority of T3

Thyroxine-Binding Prealbumin
• also known as Transthyretin
• Transports 15 to 20% of total T4
• T3 has a very weak or sometimes has no affinity for prealbumin

Thyroxine-Binding Albumin
• Transports the remaining T3
• Transports 10% of T4
Biosynthesis of Thyroid Hormones
• Conversion of T4 to T3 takes place in many tissues, particularly
the liver and the kidney
• Free Hormones (FT3 and FT4)
• physiologically active portions of the thyroid hormones
• Protein bound hormones
• metabolically inactivate
• do not enter cells
• biologically inert
• function as storage site for circulating thyroid hormones
Biosynthesis of Thyroid Hormones
• Hypothalamic-pituitary-thyroid axis
• Iodine intake below 50ug/day = deficiency of hormone
secretion
• Thyroid hormones affect synthesis, degradation,
intermediate metabolism of adipose tissue and circulating
lipids
Functions of Thyroid Hormones
• For tissue growth
• For development of the CNS
• Elevated heat production
• Control of oxygen consumption
• It influences carbohydrate and protein metabolism
• For energy conservation
Major Thyroid Hormones
Triidothyronine (T3)

• Principal application of this hormone is for diagnosing

T3 thyrotoxicosis
• Better indicator of recovery from hyperthyroidism as well as the
recurrence of hyperthyroidism

• Reference values:
• 80 to 200 ng/dL or 1.2 to 3.1 nmol/L (Adults)
• 105 to 245 ng/dL or 1.8 to 3.8 nmol/L (Children)
Major Thyroid Hormones
Tetraiodothyronine (T4)

• Principal secretory product

• A prehormone for T3 production
• The amount of serum T4 is a good indicator of thyroid secretory rate

• Reference values
• 5.5 to 12.5 ug/dL or 71 to 161 nmol/L (adults)
• 11.8 to 22.6 ug/dL or 152 to 292 nmol/L (neonates)
 92

DISEASES ASSOCIATED
WITH HORMONES OF THE
THYROID GLAND
 CLINICAL DISORDERS

HYPERTHYROIDISM HYPOTHYROIDISM
• Thyrotoxicosis • Primary Hypothyroidism
• Grave’s Disease (Diffuse Toxic Goiter) • Hashimoto’s disease
• Myxedema
• Riedel’s Thyroiditis
• Secondary Hypothyroidism
• Subclinical Hyperthyroidism
• Tertiary Hypothyroidism
• Subacute granulomatous/ Subacute
Nonsuppurative Thyroiditis/ De • Congenital Hypothyroidism/
Quervain’s Thyroiditis (painful Cretinism
thyroiditis) • Subclinical Hypothyroidism
Hyperthyroidism
• Primary Hyperthyroidism
• Elevated T3 and T4
• Decreased TSH
• Decreased TRH

• Secondary Hyperthyroidism
• Increased TSH and FT4
• (due to the primary lesion in the pituitary gland)
Hyperthyroidism
Thyrotoxicosis
• Is applied to a group of syndromes caused by high
levels of free thyroid hormones in the circulation
• TSH is low
• FT4 is normal
• Increased FT3
• T3 Thyrotoxicosis / Plummer’s Disease
 97

Grave’s Disease
• hyperthyroidism with peculiar edema behind the
eyes called exolphthalmos which causes the eye to
protrude
• hypersecretion of thyroid stimulating
immunoglobulins (TSIs)
Hyperthyroidism
Riedel’s Thyroiditis
• Thyroid turns into woody or stony hard mass

Subclinical Hyperthyroidism
• No clinical symptoms
• TSH is low
• FT3 and FT4 are normal
Hyperthyroidism
Subacute granulomatous thyroiditis
• Associated with neck pain, low grade fever, and swings in thyroid
function tests
• Thyroidal peroxidase (TPO) antibodies are absent
• ESR and thyroglobulin levels are elevated
Hypothyroidism
• Develops whenever insufficient amounts of thyroid
hormone are available to tissues
• Treated with thyroid hormone replacement therapy
(levothyroxine)
• Signs and Symptoms
• Bradychardia
• Weight Gain
• Coarsened skin
• Cold intolerance
• Mental dullness
Hypothyroidism
Primary Hypothyroidism
• Due to deficiency of elemental iodine
• Decreased T3 and T4, increased TSH
• Caused by destruction or ablation of the thyroid gland
• Other causes:
• Surgical removal of the gland
• Used of radioactive iodine for hyperthyroidism treatment
• Radiation exposure
• Drugs such as lithium
 96

Primary Hypothyroidism
Hashimoto’s disease
• acquired hypothyroidism in later childhood due
to development of autoantibodies to thyroid
tissue components
 95

Primary Hypothyroidism
Myxedema
• hypothyroidism during the adult years
Hypothyroidism
Secondary Hypothyroidism
• Due to pituitary destruction or pituitary adenoma
• T3 and T4 are low
• TSH is low

Tertiary Hypothyroidism
• Due to hypothalamic disease
• T3 and T4 are low
• TSH is low
Hypothyroidism
Congenital Hypothyroidism / Cretinism
• Defects in the development or function of the gland
• Physical and mental development of the child are retarded
• Screening test: T4 (decreased)
• Confirmatory: TSH (increased)

Subclinical Hypothyroidism
• T3 and T4 normal
• TSH is slightly increased
 93

Goiter
• an enlarged thyroid gland which is a symptom of
many thyroid disorders (hypo, hyper, or euthyroid
state)
 98

Laboratory Measurement of
Some Hormones Secreted by the
Thyroid Gland
 99

Serum Free Triiodothyronine

• measures the amount of free triiodothyronine (T3) in

blood
• used to evaluate and manage disorders of the thyroid
gland
• related tests: TSH, FT4
▫ Adults: 1.4-4.4 pg/mL (0.22-6.78 pmol/L)
▫ N>37 weeks (cord blood): 15-391 pg/dL (0.2-6 pmol/L)
▫ Pregnancy, 1st: 211-383 pg/dL (3.2-5.9 pmol/L)
▫ Pregnancy, 2nd: 196-338 pg/dL (3-5.2 pmol/L)
▫ Pregnancy, 3rd: 196-338 pg/dL (3-5.2 pmol/L)
 100

Direct Equilibrium Dialysis

• uses undiluted serum dialyzed for 16-18 hours at 37°C
• dialysate is then analyzed directly using RIA
▫ 2-128 ng/L (2.6 to 165 pmol/L)
 101

Ultracentrifugation
• serum is adjusted to pH of 7.4
• incubated for 20 minutes at 37°C
• ultracentrifuge for 30 minutes at 37°C and 2000 rpm
• ultrafiltrate is analyzed by immunoassay
• J less time consuming than dialysis
 102

Triiodothyronine Measurement

• measures the level of total T3 in blood

• used to evaluate and manage thyroid
dysfunction, including hyperthyroidism
• related tests: FT4, T3 uptake
▫ Adults: 60-181 ng/dL (0.92-2.78 nmol/L)
▫ Pregnancy (last 5 mos): 116-247 ng/dL (1.79-3.8
nmol/L)
 103

Serum Total T4 Competitive Immunoassay

• measures the total amount of thyroxine/T4 (both free and

CHON bound)in blood
• uses barbital buffers (vs TBPA) and 8-anilino-1-
naphthalene-sulfonic acid (vs TBG)
▫ Adults: 4.5-10.9 µg/dL (58-140 nmol/L)
 104

TSH Immunoassay
• measures the amount of thyroid stimulating
hormone (TSH) in blood
• using chemiluminescence w/ low detection limit
• related tests: T3 and T4
▫ Adults: 0.5-4.7 µunits/L
▫ Pregnancy (1st): 0.3-4.5 µunits/L
▫ Pregnancy (2nd): 0.5-4.6 µL
▫ Pregnancy (3rd): 0.8-5.2 µL
TSH Immunoassay
• Second-Generation TSH Immunometric Assays
• with detection limits of 0.1 mU/L
• screen for hyperthyroidism

• Third-generation TSH chemiluminometric assays

• with detection limits of 0.01 mU/L, (euthyroidism and
hyperthyroidism)
• routinely used to monitor and adjust thyroid hormone
replacement therapy
• screen both hyperthyroidism and hypothyroidism.
 Increased TSH Decreased TSH
Primary Hypothyroidism Primary Hyperthyroidism

Secondary and Tertiary

Hashimoto’s Thyroiditis
Hypothyroidism
Thyrotoxicosis due to
Treated Grave’s Disease
Pituitary Tumor

TSH Antibodies Euthyroid Sick Disease

Over Replacement Hormone

Thyroid Hormone Resistance
in Hypothyroidism
 105

Anti-TSH Receptor Autoantibody

• for diagnosis of Grave’s disease
• detects autoantibodies that interfere with the binding
of TSH to TSH receptor
• serum + TSH receptor + I125 labelled TSH tracer
• amount of free tracer is measured
▫ lower than 9 U/L
 106

Thyrotropin Releasing Hormone

(TRH) Stimulation Test
• injection of TRH and measurement of the output
of TSH
• used in the diagnosis of combined pituitary-
thyroid disorders
• differentiates 2° hypothyroidism and 3°
hypothyroidism
 107

Other Laboratory Tests:

• RAI uptake:
▫ based on the ability of the thyroid to concenrate,
convert and release4 I2
• TBI:
▫ based on the thyroid hormone transport system
indirectly measuring the amount of TBG
 108

Other Laboratory Tests:

• PBI:
▫ based on thyroid hormone concentration
representing the organic fraction of blood iodine
that precipitates with serum proteins
• BMR:
▫ based on metabolic response measuring the O2
consumption in the resting fasting state
Summary: Thyroid Function Tests
1. TRH Stimulation Test
2. TSH Test
3. Radioactive Iodine Uptake (RAIU)
4. Thyglobulin (Tg) assay
5. Reverse T3 (rT3)
6. Free Thyroxine Index (FT4I or T7)
7. Total T3 (TT3), FT3, FT4
8. T3 Uptake Test
Summary: Thyroid Function Tests
9. Thyroxine Binding Globulin (TBG) Test
10. Fine Needle Aspiration
11. Recombinant Human TSH
12. Tanned Erythrocyte Hemagglutination Test
13. Serum Calcitonin Test
 Summary of Thyroid Disorders and Lab Tests

Disorders T3 T4 TSH FT4 rT3 Tg TBG

Grave’s Disease N

Primary
/N N
Hypothyroidism /N

Hashimoto Thyroiditis /N /N N/ N/ N

Nonthyroidal illness N/ V V N/ N N

Thyroid Hormone
N/ N
Resistance
 109

PARATHYROID
GLAND
 110

Parathyroid Gland
• four tiny glands attached to the thyroid
• releases PTH
▫ actions directed to bone, kidney and intestines
▫ controls calcium and phosphate metabolism with the
help of calcitonin
 111

Types of cells:
• Chief cells
▫ synthesize and secrete hormone PTH
• Oxyphil cells
▫ non secretory cell
▫ seen only after puberty
 112

DISEASE ASSOCIATED WITH

HORMONES OF THE
PARATHYROID GLAND
Clinical Disorders
1. Hyperparathyroidism
• Primary Hyperparathyroidism
• Secondary Hyperparathyroidism
• Tertiary Hyperparathyroidism

2. Hypoparathyroidism
Primary Hyperparathyroidism
• Physiologic defect lies with the Parathyroid gland
• Most common cause of hypercalcemia
• Is due to the presence of a functioning parathyroid adenoma
• Is accompanied with phosphaturia
• If it goes undetected, severe demineralization may occur
(osteitis fibrosa cystica)
• Lab Results:
• PTH increased
• Ionized Ca increased
• Hypercalciuria
• Hypophosphatemia (fasting state)
Secondary Hyperparathyroidism
• Develops in response to decrease serum calcium
• There is diffuse hyperplasia of all 4 glands
• The patient develops severe bone disease
• Causes: vit. D deficiency and chronic renal failure
• Lab results:
• PTH increased
• Ionized calcium decreased
Tertiary Hyperparathyroidism
• It occurs with secondary hyperparathyroidism
• Develops autonomous function of the hyperplastic parathyroid glands
or of parathyroid adenoma
• The phosphate levels are normal to high; Calcium phosphates
precipitates in soft tissues
Hypoparathyroidism
• Is due to accidental injury to the parathyroid glands (neck) during
surgery- postsurgical cause
• Other cause: autoimmune parathyroid destruction
• Individual are unable to maintain calcium concentration in the blood
without calcium supplementation
• In hypoparathyroidism, the distal convoluted tubules
reabsorbs bicarbonate as well as phosphate resulting in
acidosis
• PTH normally interferes with bicarbonate reabsoption in
the PCT; therefore, the renal tubular bicarbonate
threshold tends to be in increased in hypoparathyroidism
• Low PTH causes elevated bicarbonate reabsorption-
alkalosis
• The best method for PTH measurement involves the use
of antibodies that detect both the amino terminal
fragment and intact PTH
 114

Laboratory method for PTH:

• PTH level measurement:

▫ overnight fasting
– Intact PTH: 10-65 pg/mL
– PTH N-terminal (includes intact PTH): 8-24 pg/mL
– PTH C-terminal (includes C-terminal, intact PTH,
and midmolecule): 50-330 pg/mL
• related tests: Calcium, Phosphorus and
Creatinine
 140

PANCREAS
 141

Pancreas
• lying immediately beneath the stomach
• both an exocrine and an endocrine gland
 142

Pancreas

Types of tissues:
• Acini
▫ secretes digestive juices into the
intestine
• Islets of Langerhans
▫ secretes hormones directly into the blood
143
 144

Hormones
• Glucagon: glycogenolysis and gluconeogenesis
• Insulin: glycogenesis, glycolysis, lipogenesis
• Somatostatin
 145

DISEASES ASSOCIATED
WITH HORMONES OF THE
PANCREAS
 146

Diabetes mellitus
• deficiency of insulin or defects in insulin receptors
 147

Hyperinsulinism
• hypersecretion of insulin
• may be due to a tumor, insulinoma
 148

Glucagonoma
• hypersecretion of glucagon by a tumor
 149

Somatostatinoma
• hypersecretion of somatostatin by a tumor
 150

Laboratory Measurement of some

hormones secreted by the Pancreas
 151

Insulin C-peptide Measurement

• measures the level of a by-product of the hormone
insulin called C-peptide in blood
• used to know how much insulin is being produced in
the body
• fasting specimen
▫ Adults: 0.5 - 2.0 ng/mL (0.17 - 0.66 nmol/L)
 152

Anti-Insulin Antibody Test (RIA)

• measures the amount of antibodies to insulin
• used when insulin resistance in diabetes is
suspected
• determination of the binding of 125I-Tyr-Al4-
insulin to the serum fraction precipitated by PEG
• related test: Insulin C-peptide
▫ <8.2% binding
 153

Glucagon Immunoassay (RIA)

• glucagon competes with 125I tracer for binding sites
• amount of 125I is measured and is inversely proportional
to the concentration of glucagon
▫ Fasting: 60-200 pg/mL
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