Liver Function

• Synthesis
• Excretory
• Detoxification
• Proteins
• Coagulation factors
• Ammonia
• Carbohydrates
• Fat
• Ketones
• Vitamin A
• Enzymes

• Detoxification and drug metabolism

• Primary site in the body for the synthesis of the waste product (e.g. urea)
• conjugation of hormones
• bilirubin to water-insoluble forms
• conversion of drugs and metabolites for excretion in urine or stool.
Jaundice (icterus)

• Yellow discoloration that

• occurs when the bilirubin concentration in the blood rises (> 2- 3 mg/dL)
• bilirubin is deposited
o skin and sclera of the eyes
Kernicterus

• Elevated bilirubin deposits in brain tissue of infants,

• affecting the central nervous system
o resulting in mental retardation
Classification of Causes of Jaundice

Pre-hepatic Jaundice Hepatic Jaundice Post-hepatic Jaundice

Organs affected • Before Liver • Liver / hepatocytes • Small intestines
• Bile duct
Elevated • Unconjugated • Conjugated • Excretions
• Unconjugated
• Can be both
Pre-hepatic Jaundice

• Occurs in excessive erythrocytes destruction

o hemolytic anemias
o spherocytosis
o toxic conditions
 o hemolytic disease of the newborn caused Rh or ABO incompatibility, and so on
• Increased level of unconjugated bilirubin in the serum
Hepatic Jaundice
Occurs when the liver cells malfunction and cannot take up, conjugate, or secrete bilirubin

Gilbert Crigler-Najjar Dubin-Johnson Neonatal Intrahepatic

Syndrome disease syndrome PHYSIOLOGICAL cholestasis
jaundice
transport partial or complete impaired transport in UDP- caused by
problem of deficiency of UDP- the hepatocyte of glycuronyltransferase is hepatocyte
bilirubin from glycuronyltransferase conjugated bilirubin low at birth injury
sinusoidal from micosomal cirrhosis, bile
membrane to region to the bile duct such as
the microsomal canaliculi Rotor
region; syndrome,
neoplasms

mild increase in little, if any, characterized by causes increased serum

serum level of conjugated bilirubin increased serum level level of unconjugated
unconjugated formed, which of conjugated bilirubin bilirubin
bilirubin causes increased with mild increased in
serum level of unconjugated bilirubin
unconjugated
bilirubin

1.5 – 3.0 mg/dL (moderate to

extremely elevated)
Post-hepatic Jaundice

• Occurs when an obstruction blocks the flow of bile into the intestines; referred to as the extrahepatic
cholestasis
o and may be caused by gallstones obstructing the common bile duct, neoplasms
▪ such as carcinoma, neoplasms, and inflammatory conditions
• Characterized by a significantly increased level of conjugated bilirubin in serum, increased level of
unconjugated bilirubin in serum, increased conjugated bilirubin in urine, decreased urine and fecal
urobilinogen, and stool that appears pale in color.
Other Disorders of the Liver

• Cirrhosis – result of chronic scarring of liver tissue turning it into nodules

• Tumors (hepatocellular carcinoma or hepatoma)
• Reye syndrome – encephalopathy, neurologic abnormalities; occurs mainly in children; cause is
unknown
• Drug-related disorders
• Acute & chronic hepatitis
Serum Enzymes Used to Assess Liver Function

Markers for hepatocellular necrosis Markers that reflect cholestasis

• ALT (alanine transaminase or transferase) • Alkaline phosphatase
o most specific • Gamma-glutamyl transferase (specific for
• AST (aspartate transaminase or transferase) alcoholism)
• LDH (lactate dehydrogenase)
Test Methodology for Bilirubin

• 1883 Erlich – bilirubin + diazotized sulfanilic acid colored product (urine as sample); known as the
“classic diazo reaction”
• 1913 van den Bergh – application to serum samples with the addition of an accelerator (solubilizer)
Malloy and Evelyn

• Total bilirubin – bilirubin + diazotized sulfanilic acid + 50% methanol (accelerator) red – purple
azobilirubin (pH 1.2); absorption at 560nm
• Conjugated (direct) bilirubin – bilirubin + diazotized sulfanilic acid azobilirubin
• Unconjugated (indirect) bilirubin – total bilirubin – conjugated (direct) bilirubin
Jendrassik-Grof
 • Total bilirubin – bilirubin + diazotized sulfanilic acid + caffeine-benzoate-acetate (accelerator) + alkaline
tartrate solution green-blue-colored product; absorption at 600nm
• Conjugated (direct) bilirubin – bilirubin + diazotized sulfanilic acid azobilirubin
• Unconjugated (indirect) bilirubin – total bilirubin – conjugated (direct) bilirubin

Malloy and Evelyn Jendrassik-Grof

Accelerator 50% methanol caffeine-benzoate-acetate

Colored product red – purple green-blue-colored product
Absorption 560nm 600nm
Additional Notes: alkaline tartrate solution
Sources of Error

• Hemolysis
• Lipemia
• Exposure to light
Reference Ranges
Infants: Total bilirubin – 2 to 6 mg/dL
Adults:

• Total bilirubin 0.2 – 1.0 mg/dL

• Indirect bilirubin 0.2 – 0.8 mg/dL
• Direct bilirubin 0.0 – 0.2 mg/dL
Test Methodology for Urobilinogen
Urobilinogen Assay

• Urobilinogen is the collective term for stercobilinogen, mesobilinogen, and urobilinogen

• Urobilinogen + pdab (paradimethyl amino benzaldehyde) red colored complex
• Oxidation will occur if urine is allow to stand; other compounds react such as porphobilinogen
 CLINICAL CHEMISTRY 2
which reacts with a reagent to
generate a product.
ENZYMOLOGY PART 1
• Molecules where enzyme
I. Introduction catalyzes a reaction.
• Enzymes are specific biologic • These are the components
proteins that catalyze consumed in the reaction.
biochemical reactions without
altering the equilibrium point of IV. Enzyme Structure
the reaction or being consumed
or changed in composition. The
other substances in the reaction
are converted to products.
• The catalyzed reactions are
frequently specific and essential
to physiologic functions, such as
the hydration of carbon dioxide,
nerve conduction, muscle
contraction, nutrient
degradation, and energy use.

II. Enzyme
• Found in all body tissue, but
enzymes frequently appear in
the serum following cellular
injury or, sometimes, in smaller
amounts, from degraded cells.
• Lowers the activation energy
(energy required before the
reaction takes place) of a
i. ACTIVE SITE
chemical reaction.
• It is the region of an
• Acts as facilitators of chemical
enzyme where
reactions.
substrate molecules
• Present in low concentrations in
bind and undergo a
the blood.
chemical reaction
• Serves as biological markers for
• Consists of amino acid
specific organs with injury.
residues that form
III. Substrate temporary bonds with
• A reactant in a chemical reaction the substrate (binding
is called a substrate when acted site).
upon by an enzyme. It is typically • Also consists of residues
the chemical species being that catalyze a reaction
observed in a chemical reaction, of the substrate
(catalytic site).

PALADA, TJG
 CLINICAL CHEMISTRY 2

ii. ALLOSTERIC SITE

• Referred to as a cavity
other than the active
site may bind regulator
molecules and, thereby,
be significant to the
basic enzyme structure.
• It allows molecules to
either activate or
inhibit, or turn off,
enzyme activity.
iii. ISOENZYMES
• group of enzymes with
different form and
efficiencies but
catalyzes similar
reactions.
iv. COFACTORS
• nonprotein molecule
attached to an enzyme, v. HOLOENZYME
completing its active • It is a catalytically active
site enzyme consisting of an
• Cofactors can either be apoenzyme combined
ions, such as zinc and with its cofactor.
iron ions, or organic • Examples of
molecules, such as holoenzymes include
• vitamins or vitamin- DNA polymerase and
derived molecules. RNA polymerase which
• It assists in enzyme contain multiple protein
activity. subunits.
• Can substitute • It is also referred as a
substrates. complete and active
• Additional catalyzing system.
requirements for certain
enzyme activations.
• inorganic cofactors are
called and classified as
"Activators".
• Organic cofactors are
referred to as
“Coenzymes”.

PALADA, TJG
 CLINICAL CHEMISTRY 2
(isoenzymes), which alters rates
and specificity suitable for
vi. PROENZYME (ZYMOGEN)
selective cellular homeostasis.
• Also known as the
• Controlled by the binding of
"inactive form of an
small molecules that cause
Enzyme”.
conformational change in the
• Identified as substances
enzyme’s structure.
which is metabolized
• Enzymes do not affect the value
into an enzyme.
of equilibrium constant between
reactants and the product.
V. Enzyme Specificity
• Enzyme specificity is essential to VII. Enzyme-Substrate(ES)
function, not only to maintain
Complex
the faithful reproduction of
• The enzyme substrate complex
metabolic pathways but also to
is a temporary molecule formed
prevent unwanted side
when an enzyme comes into
reactions at a particular active
perfect contact with its
site.
substrate.
• An adduct (product of an
addition reaction) is formed by
THE THREE (3) CLASSIFICATIONS OF ENZYME
the physical adsorption of the
SPECIFICITY
substrate to the active site.
• Binding Specificity - refers to the
interaction where an enzyme 2 ENZYME-SUBSTRATE MODELS
reacts to a specific substrate or a • Lock-and-key Model
substrate with a similar ▪ The lock and key model
composition. also called Fisher's
• Reaction Specificity - refers to theory is one of two
the interaction where an models which describe
enzyme catalyzes a unique the enzyme-substrate
chemical reaction, with no interaction. The lock and
minor byproduct key model assumes that
formed(absolute). the active site of the
• Stereoselective - refers to the enzyme and the
interaction where an enzyme substrate equal shaped.
recognizes only one
enantiomeric form of the
substrate.

VI. Enzyme activity

• Different tissues contain
isoforms of the same enzymes

PALADA, TJG
 CLINICAL CHEMISTRY 2
• Induced Fit Model enzyme called lactic acid
▪ It describes that only the dehydrogenase.
proper substrate is
capable of inducing the
proper alignment of the • Each enzyme has an EC numerical code –
active site that will 4 digits separated by decimal points.
enable the enzyme to ▪ First digit refers to the class of
perform its catalytic the enzyme.
function. ▪ Second and third digits refers to
the subclass and sub subclass of
the enzyme.
▪ Final number is the serial
number specific to the enzyme.
▪ In addition to naming enzymes,
the IUB system identifies each
enzyme by an EC numerical code
containing four digits separated
by decimal points. The first digit
places the enzyme in one of the
VIII. Classification and following six classes:
nomenclature
• To standardize enzyme
nomenclature, Enzyme
Commission (EC) of
International Union of
Biochemistry (IUB) assigns a
systematic name to each
enzyme, defining the substrate
acted on, the reaction catalyzed,
and, possibly, the name of any
coenzyme involved in the IX. REFERENCES
reaction. Bishop, M., et. al. (2013). Clinical chemistry:
• Enzymes are named according principles, techniques, and correlations 7th
to the substrate being catalyzed edition. Philadelphia
followed by the suffix -ase or
also includes the type of Lippincott Williams & Wilkins McPherson, RA.,
reaction catalyzed sometimes. Pincus, MR. (2022)Henry's Clinical Diagnosis and
• Examples: Management by Laboratory Methods 24th
▪ RNA is hydrolyzed by an edition. Philadelphia: Elsevier Inc.
enzyme called
ribonuclease.
▪ Lactic acid is oxidized to
pyruvic acid by an

PALADA, TJG
 CLINICAL CHEMISTRY 2

PALADA, TJG
 ENZYMOLOGY

HEPATIC ENZYMES
ENZYMES REFERENCE VALUE CLINICAL SIGNIFICANCE DISTRIBUTION
Alanine Aminotransferase • 4-36 U/L • Sensitive and more specific test of Main Source Other sources
(ALT) • Whole Blood hepatocellular disease • Liver • Kidney
Serum Glutamic Pyruvic • Monitors the course of hepatitis treatment and • Skeletal muscle
Transaminase (SGPT) effects of drug therapy. • Heart
• Sensitive screening test for post transfusion • Pancreas
hepatitis and toxic exposure • Lungs
• Liver-specific enzyme, more than AST • RBC

Aspartate Aminotransferase • 5-35 U/L • Evaluation of hepatic disorders and skeletal Highest concentration Other sources
(AST) • Serum muscle involvement.
Serum Glutamic Oxaloacetic AMI (AST LEVELS) • Heart • Kidney
Transaminase (SGOT) Rise 6-8 hrs • Liver • Pancreas
Peak 24 hrs • Skeletal muscle • RBC
Normalize within 5 days.
• Higher activity seen in alcoholic hepatitis,
hepatic cirrhosis, liver neoplasia and chronic
NOTES TO REMEMBER:
liver disorders compared to ALT.
• Pyridoxal-5-phosphate functions as a coenzyme for
• Increased in progressive muscular dystrophy
transferases and serves as a true prosthetic group.
and dermatomyositis
• Acute hepatitis – highest transaminases elevation.
• Moderate increase in hemolytic diseases.
• Severe viral/toxic hepatitis – increased up to 20- fold the normal
• It is commonly referred to as a transaminase
limit
and is involved in the transfer of an amino group
• De Ritis ratio – ratio between ALT and AST, useful indicator for
between aspartate and α-keto acids
hepatitis etiology.
Conditions with increase transaminases
o Viral hepatitis: <1.0
• Toxic hepatitis
o Acute hepatitis: >1.0
• Wolff-Parkinson white syndrome o Alcoholic hepatitis: >2.0
• Chronis alcoholism • Moderate elevation in chronic hepatitis, hepatic carcinoma, and
• Hepatic carcinoma infectious mononucleosis
• Reye’s syndrome • In end stage cirrhosis, both of the enzymes are not elevated
• Viral hepatitis because of massive tissue damage
• Acute myocardial Infarction
• Trichinosis
• Dermatomyositis
• Muscular dystrophy
• Acute pancreatitis
 NOTE: Both enzymes may reach up to as 100times
the ULN, but usually seen 10- 40 fold elevations

Alkaline Phosphatase (ALP) 4-15 y: 54 - 369 U/L • Optimal pH for its reaction is 9.0-10.0 Highest activity
20-50y: • Requires divalent ions as an activator: • Liver (microvilli of the bile canaliculi),
• Males: 53 - 128 U/L • Mg2+, Co2+, Mn2+; Zn2+ is a part of the • Bone
• Females: 42 - 98 U/L enzyme. • Intestine
• The ALP family of enzymes are zinc • Kidney
metalloenzymes • Placenta.
o widely distributed in all tissues.
• Evaluate hepatobiliary and bone disorders THINGS TO REMEMBER:
• In biliary tract obstruction, ALP levels range • Heat stability test - Total ALP is measured before and after
from 3 to 10 times the ULN due to cholelithiasis. incubation of a sample at 56° C for 10 minutes.
• In bone disorders, • Phenylalanine – inhibits placental and intestinal ALP
o highest ALP elevation • 3M urea – inhibits one ALP
▪ Paget’s disease (Osteitis • Levamisole – inhibits liver and bone ALP
deformans): 10 to 20 times the ULN
• Serves as a tumor marker (Carcinoplacental
ALP):
o Regan ALP
▪ lung, breast, ovarian, and colon;
bone ALP co-migrator;
▪ Most heat stable (65°C for 30 min);
▪ inhibited by phenylalanine
o Nagao ALP
▪ Metastatic pleural carcinoma,
adeno carcinoma of pancreas and
bile ducts
▪ variant of Regan;
▪ inhibited by phenylalanine and L-
leucine
γ-glutamyl transferase (GGT) • Males: 6-45 U/L • Detection of hepatobiliary disorders (elevated) • Kidney Highest
• Females: 5-30 U/L • Used to differentiate the cause of elevated ALP. • Brain,
• Most sensitive indicator of alcoholism • Prostate
• Catalyzes the transfer of γ glutamyl residue • Pancreas
from γ glutamyl peptides to amino acids, H2O, • Liver
and other small peptides.
5’-nucleotidase • 0-1.6 Units • Phosphatase that acts only on Nucleoside- Ubiquitous distribution; marker of hepatobiliary diseases and
5′-phosphates, such as adenosine-5′- infiltrative lesions of the liver
phosphate (AMP) releasing inorganic
phosphate
 • Measured together with total ALP of
patients suspected of liver disease.
• NO CLINICAL SIGNIFICANCE
MUSCLE ENZYMES
ENZYMES REFERENCE VALUE CLINICAL SIGNIFICANCE DISTRIBUTION
Creatine Kinase (CK) Total CK • Evaluates cardiac and skeletal muscle Main Sources Other sources
• Male: disorders. Skeletal muscle (CK-MM), • Bladder
o 46-171 U/L • Catalyzes a reversible reaction; transfers a Heart (CK-MB), • Placenta
• Female: phosphate group between creatine Brain tissue (CK-BB). • GI tract
o 34-145 U/L phosphate and adenosine diphosphate. • Thyroid
• Most sensitive enzyme marker for AMI • Uterus
(CK-MB) • Kidney
• Highest elevation of total CK is in • Lung
Duchenne muscular dystrophy (50- 100x • Prostate
ULN) • Spleen
• Markedly elevated after trauma to skeletal • Liver
muscle and crush injury • Pancreas
ISOENZYME Composition Present
CK-1 BB Brain
CK-2 MB Myocardium,
heart
CK-3 MM Skeletal
Muscle,
Myocardium
Lactate Dehydrogenase (LD) • 24 mo-12y: 180-360 U/L • LD is an enzyme that catalyzes the Isoenzyme Location
• 12-60: 125-220 U/L interconversion of lactic and pyruvic acids LD 1 and 2 Heart, RBC, Kidneys,
• Highest levels of total LD are seen in
pernicious anemia and hemolytic disorders. LD 3 Lungs, Pancreas, Spleen
• Intramedullary destruction of erythroblasts
causes elevation. LD 4 and 5 Skeletal muscle, Liver, Intestine
• Slight elevation in liver disorders
o (eg. Viral hepatitis and cirrhosis with 2-3
times the ULN)
• AMI and pulmonary infarct (2-3x ULN) Isoenzyme Composition Present Elevated in
• LD2, LD3, LD4: markers for cancer
o leukemia, germ cell tumor, breast and LDH 1 H4 MI
lung cancers. HHHH Myocardium
• LD flipped pattern (LD-1 > LD-2): suggestive of LDH 2 H3M1 RBC
AMI HHHM
 o LD1>LD2>LD3>LD4>LD5 LDH 3 H2M2 Kidney
• Order of isoenzyme concentration HHMM Skeletal
o LD2>LD1>LD3>LD4>LD5 LDH 4 H1M3 Muscle
HMMM
LDH 5 M4 Skeletal Skeletal
MMMM Muscle Muscle
Liver & Liver
diseases
PANCREATIC ENZYMES
ENZYMES REFERENCE VALUE CLINICAL SIGNIFICANCE DISTRIBUTION
Amylase (AMY) • Serum amylase: • Hydrolase that catalyzes the breakdown of Main Sources Other sources
o 28-100 U/L starch (amylose and amylopectin) and • Acinar cells of pancreas (p- • Adipose tissue
• Urine amylase: glycogen. type) • Skeletal muscle
o 1-15 U/h • Smallest physiologic enzyme: filtered in the • Salivary glands (s-type) • Small intestine
glomerulus and appears in the urine. • Fallopian tube
• Requires calcium and chloride ions for its
activation
• Earliest pancreatic marker – in acute
pancreatitis
• Both urine and serum sample are used to
differential diagnosis of pancreatitis.
• In AP, both blood and urine AMS is elevated
• Direct measurement of P-AMY instead of total
enzyme activity is used for the differential
diagnosis of patients with acute abdominal pain
ACUTE PANCREATITIS (AMY LEVELS)
Rise 5-8 hours
Peak 24 hours
Normalize 3-5 days
Lipase (LPS) • <38L • Hydrolyzes the ester linkages of fats to produce Major source: Pancreas
alcohols and fatty acids.
• Catalyzes partial hydrolysis of dietary TAG in
the intestine to the 2-monoglyceride
intermediate, with the production of long chain
fatty acids.
• Most specific pancreatic marker
• LPS measurements are confined almost
exclusively to the diagnosis of acute
pancreatitis (3 times ULN)
 • In contrast to AMY levels, LPS levels are
normal in conditions of salivary gland
involvement.
LPS LEVELS (ACUTE PANCREATITIS)
Rise 4 to 8 hours
Peak 24 hours,
Normalize 7 to 14 days
PROSTATIC ENZYME
ENZYMES REFERENCE VALUE CLINICAL SIGNIFICANCE DISTRIBUTION
Acid phosphatase (ACP) • Prostatic ACP • Detection of prostatic carcinoma, particularly • Tissue source: prostate (major source)
o 0.2-3.5 U/L metastatic carcinoma of the prostate. • Bone
• Used in forensic examinations for possible • Liver
victims of rape – vaginal washing are examined • Spleen
for seminal fluid-acid phosphatase (ACP) • Kidney
activity, which can persists for up to 4 days • Erythrocytes
• Platelets.
OTHER CLINICALLY SIGNIFICANT ENZYMES
ENZYMES REFERENCE VALUE CLINICAL SIGNIFICANCE DISTRIBUTION
Cholinesterase (CHS) • 6,000- 12,000 U/L • Used to monitor muscle relaxants after surgery Acetylcholinesterase Butyrylcholinesterase
• Marker for organophosphate poisoning
(pesticide poisoning – primarily affects liver) True cholinesterase (involved in Pseudocholinesterase (has no
• Hydrolyzes ester with acetylcholine to choline the transfer of nerve impulses) known function)
and acetic acid
• Index of parenchymal function; secreted by the • RBC • Serum
liver • neurons (primary location) • Pancreas
• Considered as functional enzyme as it • brain • Liver
participates in important metabolic processes • heart
• Most unique enzyme because during pathologic • white matter of CNS
events, it decreases
Angiotensin-converting • Possible indicator of neuronal dysfunction (eg. • Major sources:
enzyme (ACE) Alzheimer’s disease) o Macrophages and epithelioid cells
• Increased in sarcoidosis, acute and chronic
bronchitis, and leprosy (causative agent: M.
leprae)
• ACE2 is the receptor for coronaviruses
including the COVID SARS virus and the
COVID-19 virus that cause pandemic.
Glucose-6-phosphate • 10-15 U/g Hgb • Primary function: Maintains NADPH in the • Major sources:
dehydrogenase (G6PD) • 1,200- 2,000 mU/mL reduced form in the erythrocyte o Adrenal cortex
packed RBC • increased in MI, megaloblastic anemia o Spleen
• Make hemoglobin in its functional form always o RBC
• It is a screen test for newborn (paper blot) o Lymph nodes
• Deficiency of this enzyme may cause drug-
induced hemolytic anemia (RBCs: bite cell
appearance)
• Considered as functional enzyme as it is
involved in various metabolic processes
Order of Tube Stopper Additive No. of Lab Section / Tests Liquid Part after
Draw Color Inversion Department Centrifuge

1 Yellow Sodium 8 -10x Microbiology • Blood Culture

Polyethanol
Sulfonate (SPS) Plasma
2 Light Blue / Sodium Citrate 3x Hematology • PT
Blue (Coagulation Studies) • APTT
• D-Dimer
3 Red (Plain) No Additive None Routine Chemistry / • ALT Serum
Serology • AST
• ALP
• GGT
• CK-MB
• BUN
• BUA
• Lipid Panel
• Amylase
• Lipase
• Electrolytes
• Total Protein
• Albumin
• FBS
• Kidney Function
Test
• Thyroid Panel
4 Green Heparin STAT Chemistry • Blood Gas
Analysis
5 Lavender Ethylenediamine Hematology • CBC
tetracetic acid 8 -10x • ESR
(EDTA) • HBA1c Plasma
6 Gray Sodium Fluoride Chemistry • Lactic Acid
• Glucose
Determination
Mnemonics
You Better Remember Girls Lav Gray
 Electrolytes
INTRODUCTION
• Electrolytes play an important role in numerous physiologic processes such as regulating the fluid levels
in the body. These body function requires a certain level of electrolyte ranges; thus, the body has complex
systems to regulate and maintain these electrolytes to its proper levels
• Ions capable of carrying an electric charge
• Fluids always contain equal numbers of cation and anions
o Cations = (+) charged
o Anions = (-) charged
• Dissociation of solutes into charged particles depends on the chemical composition of the compound and
on the concentration of other charged particles in the medium
DISTRIBUTION
WATER / BODY FLUIDS
• 60% of the body’s water is inside the cells, rest: bloodstream / tissue fluids
• Retention of 3L of fluids will result to Edema
• Vasopressin deficiency caused 10-20L excreted daily.
• Normal plasma
o Water content: higher than blood
o 93% water
o 7% solutes
▪ Glucose, lipids, proteins, NPN, Amino acids, Ions
• Responsible for transporting nutrients to cells
• Determining cell volume by its transport into and out of cells, removal of waste products by way of urine,
acting as the body's coolant by way of sweatingdetermining cell volume by its transport into and out of
cells, removal of waste products by way of urine, acting as the body's coolant by way of sweating
• The average water content of the human body varies from 40% to 75% of total body weight (declining with
age and especially with obesity) the average water content of the human body varies from 40% to 75% of
total body weight (declining with age and especially with obesity)
• Water is located in intracellular and extracellular compartments
• Intracellular fluid (icf) is the fluid inside the cells and accounts; two thirds of total body water, 24 l (60%)
• Extracellular fluid (ecf) subdivided into the intravascular ecf (plasma) and the interstitial cell fluid; one-third
of total body water, 16 l (40%)
o Note
▪ Intracellular fluid (ICF) = two thirds of total body water, 24 L (60 %)
▪ Extracellular fluid (ECF) = one-third of total body water, 16 L (40%)
• The concentrations of ions within cells and in plasma are maintained both active transport processes and
passive transport processes.
• Active transport is a mechanism that requires energy to move ions across cellular membranes. (Na, K
pump)
• Diffusion is the passive movement of ions across a membrane.
• The concentration of ions and proteins on either side of the membrane will influence the flow of water
across a membrane (an osmoregulator)
OSMOLALITY
• Physical property of a solution that is based on the concentration of solutes (expressed as
millimoles) per kilogram of solvent (w/w) while osmolarity is reported in milliosmoles per liter (w/v)
Osmolality Osmolarity
(expressed as millimoles) per kilogram of solvent milliosmoles per liter (w/v)
(w/w)
• Clinical Significance
o Parameter to which the hypothalamus responds.
o Increase in ECF osmolality triggers the following physiological responses:
Compiled by: Virgildo Fonzy Jake A. Aguillon
 ▪ Antidiuretic hormone/ vasopressin release via hypothalamic osmoreceptors.
▪ Stimulation of thirst center
▪ Redistribution of water from the ICF compartment
▪ Renal water excretion is more important in controlling water excess, whereas thirst is more
important in preventing water deficit or dehydration.
• Determination of osmolality
o Specimen: Serum or urine.
o Plasma use is not recommended because osmotically active substances may be introduced into
the specimen from the anticoagulant.
o The methods for determining osmolality are based on properties of a solution that are related to
the number of molecules of solute per kilogram of solvent (Colligative properties).
o Osmometers that operate by freezing point depression are standardized using sodium chloride
reference solutions.
o Osmolal gap is the difference between the measured osmolality and the calculated osmolality.

REFERENCE RANGES
Serum 275 - 295 mOsm/kg
Urine (24 hours) 300 – 900 mOsm/kg
Urine / Serum Ratio 1.0 – 3.0 mOsm/kg
Random Urine 50 – 1200 mOsm/kg
Osmolal Gap 5-10 mOsm/kg
REGULATION OF BLOOD VOLUME
▪ The renin–angiotensin– aldosterone system (RAAS) responds primarily to a decreased blood volume.

Simplified Explanation:
RAAS is activated due to low blood pressure or low blood volume. The first organ to be stimulated is the kidney
releasing the substance called Renin. This substance will stimulate the liver to release the protein
Angiotensinogen, whose main purpose is to help in the production of Angiotensin I. Angiotensin I is an inactive
protein and requires an enzyme to be activated, particularly the enzyme Angiotensin-converting enzyme (ACE)
which is produced / released by the lungs, converting the inactive protein into its activated form called
Angiotensin II. Angiotensin II will stimulate the adrenal gland to produce the hormone Aldosterone to increase
the blood volume and blood pressure. Firstly, Aldosterone reabsorbs water and sodium inside the kidneys,
retaining the sodium or water inside, thus, blood volume and pressure gradually increases. Secondly,
Vasoconstriction, it signals the blood vessels to tighten, increasing blood volume and blood pressure. Lastly,

Compiled by: Virgildo Fonzy Jake A. Aguillon

 stimulate / signal the release of the Anti-Diuretic hormone / Vasopressin from the pituitary gland, which aids
in inhibiting the excretion of water, thus retaining the water inside the kidneys, allowing an increase in blood
volume and blood pressure.

Explanation / Transcript sa yawyaw ni sir

▪ This mechanism is used for the regulation of blood volume or blood pressure. It will be activated due to
low blood pressure or low blood volume.
▪ blood pressure and blood volume are directly proportional to one another.
▪ The first organ to be stimulated is the kidney, which will release the substance called Renin and will
stimulate the liver to release the protein Angiotensinogen. The purpose of the protein will help in the
production of Angiotensin I.
▪ Angiotensin I is an inactive protein and requires an enzyme to be activated, particularly the enzyme
Angiotensin-converting enzyme (ACE) which is produced / released by the lungs.
▪ Angiotensin-converting enzyme aids in converting Angiotensin I into its active form Angiotensin II
▪ Angiotensin II will help in the production of Aldosterone, which help in the vasoconstriction and production
of ADH
o First: help in stimulating / signaling the adrenal gland to produce the hormone, Aldosterone
▪ Function of Aldosterone: reabsorbing water and sodium inside the kidneys.
▪ Retain the sodium or water inside the kidneys, the blood volume will increase
o Second: Vasoconstriction
▪ Signals the blood vessels to tighten up, increasing blood volume and blood pressure.
o Third: stimulate / signal the pituitary gland to release the hormone, ADH (Anti-Diuretic Hormone /
Vasopressin)
▪ Diuresis: Promoting the release of water through urine
▪ Alcoholic Drinks promote the excretion of water through urine and is a form of Diuretics
▪ ADH (Anti-Diuretic Hormone / Vasopressin)
• Inhibit the excretion of water
• Retains water inside the kidneys, increasing blood volume and blood pressure
Main GOAL of RAAS: INCREASE BLOOD VOLUME AND BLOOD PRESSURE
Summary
PRIMARY CATIONS DESCRIPTION PRIMARY ANIONS DESCRIPTION
Sodium • Major extracellular cation Chloride • Major extracellular anion
(90%) o chief counterion of
• Also known as “natrium” sodium in ECF
• Major contributor to plasma • Maintains osmolality, blood
osmolality volume, and electric
neutrality.
• Only anion to serve as an
enzyme activator
(Amylase)
Potassium • Also known as “kalium” Bicarbonate • Second most abundant
• Major intracellular cation anion in the ECF
• The single most important • Accounts for 90% of the
analyte in terms of an total Carbon Dioxide at
abnormality being physiologic pH
immediately life threatening. • Composed of undisclosed
NaHCO3 carbonate and
carbamate
• It buffers excess hydrogen
ion by combining with acid
• Maintenance of high
plasma bicarbonate
concentration occurs in
Compiled by: Virgildo Fonzy Jake A. Aguillon
 advanced renal failure /
renal threshold for
bicarbonate is increased
Calcium • Most abundant ions in the Phosphate • Omnipresent in its
body distribution
• present almost exclusively in o 85% in the bones
the plasma o 15% in the ECF in
• Third most abundant cation in the form of
the blood. inorganic
phosphate (Pi).
• Inversely related to calcium
• Maximally absorbed in the
jejunum.
• Essential for the insulin
Magnesium • Fourth most abundant cation Sulfate
in the body
• Second most abundant
intracellular ion
• An essential cofactor of more
than 300 enzymes
Reference Values
PRIMARY SAMPLE UNIT PRIMARY ANIONS SAMPLE UNIT
CATIONS
Serum 135-145 mmol/L or Plasma / 98 – 107
Sodium mEq/L Chloride Serum mmol/L
CSF 136-150 mmol/L Urine (24 110 -250
hours) mmol/d
Urine 40-220 mmol/d Bicarbonate Venous blood 21 – 28
(plasma or mEq/L
serum)
Potassium Serum 3.5-5.1mmol/L Serum / 2.7 – 4.5
Heparinized mg/dL
Plasma
Phosphate (Adult)
Plasma 3.5- 4.5mmol/L Serum / 4.5-5.5
Heparinized mg/dL
Plasma
(Child)
Total 8.6-10 mg/dL
Calcium
(adult)
Total 8.8- 10.8 mg/dL
Calcium
(Child)
Ionized : 4.6- 5.3 mg/dL
Calcium Calcium
(adult)
Ionized 4.8- 5.5 mg/dL
Calcium
(child)
Conversion 0.25
Factor

Compiled by: Virgildo Fonzy Jake A. Aguillon

 Serum / 0.63 –1.0 mmol/L (1.26
Magnesium Colorimetric – 2.10 mmol/L)
Rodriguez 1.2 – 2.1 mEq/L
(book)
Clinical Significance
Primary Cations
Sodium
HYPERNATREMIA HYPONATREMIA
EXCESS WATER LOSS EXCESS WATER LOSS
Diabetes Insipidus Hypoadrenalism
Renal Tubular Disorder Potassium deficiency
Prolonged Diarrhea Diuretic Use
Profuse Sweating Ketonuria
Severe Burns Salt-losing nephropathy
Prolonged vomiting or diarrhea
Severe burns
INCREASED WATER INTAKE / RETENTION INCREASED WATER RETENTION
Hyperaldosteronism (Conn’s disease) Renal failure
Sodium Bicarbonate excess Nephrotic syndrome
Dialysis Fluid excess Hepatic cirrhosis
Ingestion of Sea Water Congestive heart failure
Increased oral or IV intake of NaCl
DECREASED WATER INTAKE WATER IMBALANCE
Older Persons Excess water intake
Infants SIADH
Mental Impairment Pseudohyponatermia

POTASSIUM
HYPERKALEMIA HYPOKALEMIA
>5.2 mmol/L <3.5 mmol/L
DECREASED RENAL EXCRETION GASTROINTESTINAL LOSS
Acute / Chronic Renal failure (GFR <20mL/min) Vomiting
Hypoaldosteronism Diarrhea
Addison’s disease Gastric Suction
Diuretics Intestinal tumor
Malabsorption
Cancer therapy: chemotherapy, radiation therapy
Large doses of laxatives
CELLULAR SHIFT
Acidosis Diuretics- thiazides, mineralocorticoids
Muscle/Cellular injury Nephritis
Chemotherapy Renal tubular acidosis
Leukemia Hyperaldosteronism
Hemolysis Cushing’s syndrome
Hypomagnesemia
Acute Leukemia
INCREASED INTAKE DECREASED INTAKE
Oral or intravenous potassium replacement therapy
ARTIFICIAL RENAL LOSS
Sample hemolysis Alkalosis
Thrombocytosis Insulin Overdose

Compiled by: Virgildo Fonzy Jake A. Aguillon

Prolonged tourniquet or Excessive fist clenching
CALCIUM
HYPERCALCEMIA HYPOCALCEMIA
CHIMPS CHARD
Cancer (Lung and Mammary) Calcitonin
Hyperthyroidism Hypoparathyroidism (primary and secondary)
Iatrogenic causes Alkalosis
Multiple myeloma Renal failure
Hyperparathyroidism (primary): main cause Vitamin D deficit
Sarcoidosis Others
Others Acute pancreatitis
Vitamin D excess Hypomagnesemia
Prolonged immobilization Malabsorption Syndrome
Thiazide diuretics Renal tubular Failure
Malignancy Hypermagnesemia
Benign familial hypocalciuria Hypoalbuminemia
Rhabdomyolysis
Pseudohypoparathyroidism
MAGNESIUM
HYPERMAGNESEMIA HYPOMAGNESEMIA
DECREASED EXCRETION DECREASED ABSORPTION
Acute or chronic renal failure Malabsorption syndrome
Hypothyroidism Surgical resection of small intestine
Hypoaldosteronism Nasogastric suction
Hypopituitarism (decreased growth hormone) Pancreatitis
Vomiting Diarrhea
Laxative abuse
Neonatal
Primary
Congenital
INCREASED INTAKE REDUCED INTAKE
Antacids Poor diet/ Starvation
Enemas Prolonged Magnesium-deficient intravenous therapy
Cathartics
Therapeutics
Eclampsia
cardiac arrhythmia
MISCELLANEOUS INCREASED EXCRETION-RENAL
Dehydration Tubular disorder
Bone Carcinoma Glomerulonephritis
Bone Metastases Pyelonephritis
INCREASED EXCRETION-ENDOCRINE
Hyperparathyroidism
Hyperaldosteronism
Hyperthyroidism
Hypercalcemia
Diabetic ketoacidosis
INCREASED EXCRETION- DRUG INDUCED
Diuretics
Antibiotics
Cyclosporin
Digitalis
MISCELLANEOUS
Excess lactation
Compiled by: Virgildo Fonzy Jake A. Aguillon
 Pregnancy
Primary Anions
CHLORIDE
HYPERCHLOREMIA HYPOCHLOREMIA
Renal tubular acidosis Prolonged committing
Diabetes Insipidus Aldosterone Deficiency
Salicylate Intoxication Metabolic alkalosis
Primary hyperparathyroidism Salt-losing nephritis
Metabolic acidosis
Prolonged diarrhea
PHOSPHATE
HYPERPHOSPHATEMIA HYPOPHOSPHATEMIA
Hypoparathyroidism, Transcellular shift – major cause
Renal failure (tubular failure) Alcohol abuse – most common cause
Lymphoblastic leukemia Primary hyperparathyroidism
Hypervitaminosis Avitaminosis D
Myxedema
Methods
PRIMARY CATIONS PRIMARY ANIONS
Sodium • Ion Selective Electrode (ISE) Chloride • Mercuric Titration (Schales & Schales)
• Emission Flame photometry o Diphenylcarbazone = indicator
• Albanese-Lein (Colorimetry) o HgCl2 (blue violet) = end product
• Atomic Absorption • Spectrophotometric Methods
Spectrophotometry o Mercuric Thiocyanate (Whitehorn
Titration Method) = reddish complex
o Ferric Perchlorate = colored complex
• Coulometric Amperometric Titration:
Cotlove Chloridometer (Ampirometric)
• Ion Selective Electrode: using ion exchange
membrane (tri-n-octylpropylammonium
chloride decanol);
o most commonly used method; AgCl -
AgS
Potassium • Ion Selective Electrode (ISE) Bicarbonate • Ion Selective Electrode (using pCO2
o Valinomycin Gel electrode)
• Emission Flame photometry • Enzymatic (phsphoenolpyruvate
• Lockhead and Purcell carboxylase and dehydrogenase)
(Colorimetry)
• Atomic Absorption
Spectrophotometry
Calcium • Precipitation and Redox Phosphate • Fiske and Subarrow Method
Titration o Most commonly used method to
Clark Collip Ferro Ham measure serum inorganic phosphate
Precipitation Chloranilic o Most common reducing agent: Pictol
Acid (Amino Naphthol Sulfonic Acid)
Precipitation o Others:
End product: End product: ▪ Elon (methyl amino phenol)
Oxalic acid Chloranilic acid ▪ Ascorbic acid
(purple color) (purple color) ▪ Senidine (N-phenyl-p-
• Colorimetric Method phenylene diamine
hydrochloride)

Compiled by: Virgildo Fonzy Jake A. Aguillon

 o Ortho-Cresolpthalein o Endproduct: ammonium molybdate
Comlexone Dyes complex (unstable)
o Dye: Arsene III o Unreduced complex at 340nm is the
o Mg inhibitor: 8- most accurate measurement of
hydroxyquinoline inorganic phosphorus in serum
• EDTA Titration Method (Bachra, o pH must be maintained in acid range.
Dawer and Sobel) ▪ Alkaline: reduction in complex
• Ion Selective Electrode (Liquid o Reduced form: blue color; determined
Membrane) between 600-700nm
• Atomic Abosrption
Spectrophotometry
o reference method
• Emission Flame Photometry
Magnesium • Atomic Absorption
Spectrophotometry
o Reference method
• Colorimetric Method
o Camalgite Method: (+)
reddish-violet complex
o Formazen Dye Method: (+)
colored complex
o Magnesium Thymol Blue
Method = (+) colored
complex
• Ion Selective Electrode: Ionized
Magnesium
• Dye-Lake Method- Titan Yellow
Dye
o Clayton Yellow or Thiazol
Yellow
Interfering Substances
PRIMARY CATIONS PRIMARY ANIONS
Sodium • Aldosterone Chloride • Bromide
• Atrial Natriuretic Factor (ANF) • Cyanine
• Cysteine
Potassium • Bicarbonate •
Calcium • 1,25 Dihydroxycholecalciferol Phosphate • Parathyroid hormone
[1,23-(OH)2- D3] • Calcitonin
• Parathyroid hormone • Growth hormone
• Calcitonin
Magnesium • Parathyroid hormone
• Aldosterone and Thyroxine

Functions
FUNCTION ELECTROLYTE/S INVOLVED
Volume and osmotic regulation • Sodium
• Chloride
• Potassium
Myocardial rhythm and contractility and • Potassium
neuromuscular excitability:
Compiled by: Virgildo Fonzy Jake A. Aguillon
 • Magnesium
• Calcium
Cofactors in enzyme activation: • Magnesium
• Calcium
• Zinc
• Chloride
Blood coagulation • Calcium
• Magnesium
Production and use of ATP from glucose • Magnesium
• Phosphorous
Maintenance of acid-base balance • Bicarbonate
• Chloride
• Potassium
Regulation of ATPase-ion pump: • Magnesium
Compare and Contrast
SODIUM
HYPERNATREMIA HYPONATREMIA
Diabetes Insipidus SIADH
• Syndrome of Inappropriate
secretion of Anti-Diuretic
Hormone
• Syndrome of Inappropriate
Arginine Vasopressin Hormone
Secretion
Vasopressin / ATH MAIN HORMONE Vasopressin / ATH
Retain water inside the kidney Retain water inside the kidney
Hyposecretion of vasopressin Characterized Hypersecretion of vasopressin
• Total loss of water Description • Retain the water inside the
• Pxs experiences 3Ps kidney
o Polyuria: increase loss • Cause: hemodilution
of water; excessive • Dilute ang blood: Nagababa
urination ang Sodium
o Polydipsia: excessive • Pxs experiences
thirst • Polyguria: di maka secrete ng
o Dehydration water
o Concentrated ang
blood: increase ang
Sodium
POTASSIUM
HYPERKALEMIA Sodium and Potassium are HYPOKALEMIA
>5.2 mmol/L inversely proportional to one <3.5 mmol/L
another
Addison’s disease
Cause of hypoaldosteronism MAIN HORMONE
Hormone responsible for
reabsorbing water and sodium
inside the kidneys
Low secretion of aldosterone Characterized
Excessive Potassium retention
kasi walang masayadong
Aldosterone

Compiled by: Virgildo Fonzy Jake A. Aguillon

 •
Sodium •
SIADH
Pseudohyponatermia
HYPERNATREMIA
REFERENCE VALUES
• Increased Na concentration >145 mmol/L
SAMPLE UNIT
• Caused by loss of water, gain of Na, or both.
Serum 135-145 mmol/L or
mEq/L • Perspiration and breathing – loss of 1L of
CSF 136-150 mmol/L water everyday
Urine 40-220 mmol/d • Thirst is the major defense for hyperosmolarity
and hypernatremia.
RENAL THRESHOLD
110-130mmol/L • Sodium level of 150- 160 mmol/L is an
indicative of moderate water deficit.
METHODS
• >165 mmol/L is severe water deficit.
• Ion Selective Electrode (ISE)
• Drinking 20mL/kg of water in 15 minutes
• Emission Flame photometry
reduced arterial serum sodium by about
• Albanese-Lein (Colorimetry)
• 8 mmol/L resulting to rapid diuresis
• Atomic Absorption Spectrophotometry
• Chronic hypernatremia in alert patient is
OVERVIEW indicative of hypothalamic disease
• Major extracellular cation (90%) CAUSES OF HYPERNATREMIA
• Major contributor to plasma osmolality EXCESS WATER LOSS
• Sodium’s entry to the cell is controlled by • Diabetes Insipidus
ATPase ion pump, an active transport system • Renal Tubular Disorder
• Draws out water from the cell to prevent • Prolonged Diarrhea
osmotic rupture • Profuse Sweating
CLINICAL SIGNIFICANCE • Severe Burns
HYPONATREMIA DECREASED WATER INTAKE
• Most common electrolyte disorders • Older Persons
• Decreased Na concentration • Infants
• Clinical concern arises when it reaches • Mental Impairment
• In renal failure, the kidneys ultimately fail to INCREASED WATER INTAKE / RETENTION
concentrate the urine, resulting to • Hyperaldosteronism (Conn’s disease)
hyponatremia
• Sodium Bicarbonate excess
• If urine sodium is more than 20 mmol/day,
• Dialysis Fluid excess
there is ongoing renal loss of sodium and
• Ingestion of Sea Water
water
• Increased oral or IV intake of NaCl
• For every 100 mg/dL increase in blood
PSEUDOHYPONATREMIA
glucose, serum sodium decreases by 1.6
mmol/L – glucose is osmotically active and • Reduction in serum sodium concentration
induces flow of water from cells to ECF caused by a systematic error in measurement
CAUSES OF HYPONATREMIA • Most common, yet not widely known, cause is
INCREASED SODIUM LOSS in vitro hemolysis, a well-known cause of
• Hypoadrenalism pseudohyperkalemia
• Potassium deficiency • Marked hemolysis: cause decreased of
sodium levels due to dilutional effect
• Diuretic Use
• Hemoglobin released from RBCs cause
• Ketonuria
additional reduction in serum Na+, as in
• Salt-losing nephropathy
hyperproteinemia, caused because hgb, is
• Prolonged vomiting or diarrhea mostly a protein and has the same effect as
• Severe burns hyperproteinemia in displacing plasma water.
INCREASED WATER RETENTION • Artificial hyponatremia is also associated with
• Renal failure hyperlipidemia or hyperproteinemia: decrease
• Nephrotic syndrome sodium is due to excess retention of water in
• Hepatic cirrhosis the collecting ducts
• Congestive heart failure INTERFERING SUBSTANCES
WATER IMBALANCE • Aldosterone
• Excess water intake
Compiled by: Virgildo Fonzy Jake A. Aguillon
 o Promotes absorption of sodium in • Diet rich in fats may lead to elevated serum
distal tubule potassium.
o Promotes sodium retention and SPECIMEN CONSIDERATION
potassium excretion • Hemolysis of 0.5% RBCS can increase levels
• Atrial Natriuretic Factor (ANF) by 0.5 mmol/L (30% increase in gross
o It is an endogenous antihypertensive hemolysis)
agent secreted from the cardiac atria • Plasma levels are lower (0.1-0.7 mmol/L)
o It blocks aldosterone and renin compare to serum levels because of the
secretion, and inhibits the action of release of platelets into serum or clot
angiotensin II and vasopressin formation
o It causes natriuresis • Muscular activity like exercise and prolonged
Potassium standing (10-20% increase)
o Mild to moderate exercise:
REFERENCE VALUES ▪ 0.3-1.2 mmol/L (↑)
SAMPLE UNIT o Vigorous exercise; fist clenching:
Serum 3.5-5.1mmol/L ▪ 2-3mmol/L (↑)
Plasma 3.5- 4.5mmol/L • Prolonged contact of serum and RBC
THRESHOLD CRITICAL VALUES • Prolonged application of tourniquet
Hyperkalemia 6.5 mmol/L CLINICAL SIGNIFICANCE
Hypokalemia 2.5 mmol/L HYPERKALEMIA >5.2 mmol/L
FUNCTIONS • Almost always due to impaired renal excretion
• Heart contraction • 3 major mechanisms of diminished renal K
• Neuromuscular excitability excretion
o Reduced aldosterone / aldosterone
• ICF volume regulation and hydrogen ion
responsiveness
concentration
▪ Most common cause of chronic
METHODS
hyperkalemia due to impaired
• Ion Selective Electrode (ISE) renal excretion of potassium is
o Valinomycin Gel hyporeninemic
• Emission Flame photometry hypoaldosteronism caused by
• Lockhead and Purcell (Colorimetry) chronic renal insufficiency of
• Atomic Absorption Spectrophotometry primarily tubulointerstitial
OVERVIEW disease
• Also known as “kalium” ▪ Hyporeninemic
• Major intracellular cation hypoaldosteronism: common
o 2% of body’s total K circulates in cause of all aldosterone
plasma deficiency
• 20x higher inside the cells • Most common cause of
• The single most important analyte in terms of chronic hyperkalemia
an abnormality being immediately life among nondialysis
threatening. patients
• Concentration in RBCs: 105 mmol/L (23x its o Renal failure
concentration in plasma) ▪ Reduced CFR and decreased
• Filtered in the glomeruli and is mostly (70- tubular secretion causes: K
80%) reabsorbed by active and passive accumulation (inc. Mg and P) in
mechanism in the proximal tubule plasma
• Ascending limb of Henle’s loop: reabsorbed o Reduced distal delivery of sodium
together with Na+ and Cl- by sodium • Effects of hyperkalemia to Cardiac Muscle
potassium chloride cotransporter o Decreases resting membrane potential
• Heparinized plasma is preferred over serum of cell
due to potassium released during blood o Severe: can ultimately cause a lack of
clotting muscle excitability (8mmol/L)
• Platelets contain K that is released into serum o Plasma K levels: 6-7mmol/L: may alter
on clot formation ECG

Compiled by: Virgildo Fonzy Jake A. Aguillon

 o Plasma K levels: 10mmol/L: fatal ECG changes are rare in chronic
(cardiac arrest) hyperkalemia.
• pH Imbalance (Acidosis) and Drugs HYPOKALEMIA <3.5 mmol/L
o Acidosis: K levels increases • Plasma K levels: 3.0-3.4 mmol/L (mild
o Low insulin levels = cause high serum hypokalemia)
K • Hypomagnesemia leads to hypokalemia by
o Therapeutic K administration: most promoting urinary loss of potassium
common cause of hyperkalemia • If plasma K levels are low: retained and NH4
among hospitalized individuals ions will be secreted if balancing cations are
o Digitalis inhibits the Sodium and needed
Potassium (ATPase Pump) • Impaired renal function/ Renal loss
CAUSES o Most common cause of hypokalemia
DECREASED RENAL EXCRETION o Increased renal wasting of potassium
• Acute / Chronic Renal failure (GFR can be attributed to increased activity
<20mL/min) of aldosterone or other
• Hypoaldosteronism mineralocorticoids
• Addison’s disease o Primary and secondary
• Diuretics hyperaldosteronism are other causes
CELLULAR SHIFT • Extra renal loss
• Acidosis o Diarrhea (low urine anion gap) most
• Muscle/Cellular injury common cause of extra renal loss of
• Chemotherapy potassium
• Leukemia o Causes direct K loss in stool, but in
• Hemolysis vomiting, hypokalemia is mainly the
INCREASED INTAKE result of K loss in urine,
• Oral or intravenous potassium replacement ▪ Vomiting: causes metabolic
therapy alkalosis and subsequent renal
ARTIFICIAL excretion of bicarbonate leads
• Sample hemolysis to renal K wasting
• Thrombocytosis • Effects of hypokalemia to Cardiac Muscle
o Decreases cell excitability by
• Prolonged tourniquet or Excessive fist
increasing RP, resulting in arrhythmia
clenching
and paralysis
PSEUDOHYPERKALEMIA
o Heart may experience cessation of
CAUSES
contraction in either hyperkalemia /
• Sample hemolysis
hypokalemia
• Thrombocytosis o Heart failure does not lead to
• Prolonged tourniquet application hypokalemia despite secondary
• Fist clenching hyperaldosteronism, unless distal
• Blood stored in ice delivery of Na is increased by diuretic
• IV Fluid and high blast counts in acute or therapy
accelerated phase leukemias (blast may lyse • pH Imbalance (Acidosis) and hormones
during standard phlebotomy releasing K) o Alkalosis: plasma K decreases
• Thrombocytosis and Leukocytosis falsely o Alkalemia promotes intracellular loss
decrease K+ by WBC uptake of the of hydrogen
electrolyte. o pH balance due to increased
• Pseudohyperkalemia (cause: thrombocytosis) concentration of bicarbonate and
o Serum and plasma K should be pCO2, leads to movement of K to cells
obtained simultaneously o accumulation of bicarbonate in cell
• Recentrifugation of SST has been associated must be accompanied by K and Na
with Pseudohyperkalemia. o Chronic metabolic acidosis,
• ECG abnormalities of hyperkalemia are hypokalemia develops
absent in Pseudohyperkalemia, absence of ▪ Reduced proximal
ECG does not rule out true hyperkalemia as reabsorption of NaCl allows

Compiled by: Virgildo Fonzy Jake A. Aguillon

 increased delivery of NaCl to • Low serum values are observed in conditions
the distal nephron. with high HCO3 levels
o Insulin and catecholamines influence METHODS
the distribution of K between cells and • Mercuric Titration (Schales & Schales)
ECF. o Diphenylcarbazone = indicator
CAUSES o HgCl2 (blue violet) = end product
GASTROINTESTINAL LOSS • Spectrophotometric Methods
• Vomiting o Mercuric Thiocyanate (Whitehorn
• Diarrhea Titration Method) = reddish complex
• Gastric Suction o Ferric Perchlorate = colored complex
• Intestinal tumor • Coulometric Amperometric Titration:
• Malabsorption Cotlove Chloridometer (Ampirometric)
• Cancer therapy: chemotherapy, radiation • Ion Selective Electrode: using ion exchange
therapy membrane (tri-n-octylpropylammonium
• Large doses of laxatives chloride decanol);
RENAL LOSS o most commonly used method;
• Diuretics- thiazides, mineralocorticoids o AgCl -AgS
• Nephritis INTERFERENCES
• Renal tubular acidosis • Bromide
• Hyperaldosteronism • Cyanide
• Cushing’s syndrome • Cysteine (chemical test and coulometry)
• Hypomagnesemia • Methods for chloride also measure bromide
• Acute Leukemia CLINICAL SIGNIFICANCE
CELLULAR SHIFT HYPERCHLOREMIA
• Alkalosis • Renal tubular acidosis
• Insulin Overdose • Diabetes Insipidus
DECREASED INTAKE • Salicylate Intoxication
• Primary hyperparathyroidism
•
Chloride •
Metabolic acidosis
Prolonged diarrhea
HYPOCHLOREMIA
REFERENCE VALUES
• Prolonged committing
SAMPLE UNIT
• Aldosterone Deficiency
Plasma / Serum 98 – 107 mmol/L
Urine (24 hours) 110 -250 mmol/d • Metabolic alkalosis
OVERVIEW • Salt-losing nephritis
CYSTIC FIBROSIS
• Major extracellular anion – chief counterion of
sodium in ECF • Inherited disorder of the exocrine glands,
causing glands to produce abnormally thick
• Promotes maintenance of water balance and
secretions of mucus, elevation of sweat
osmotic pressure in conjunction with sodium.
electrolytes, increased organic and enzymatic
• Only anion to serve as an enzyme activator constituents of saliva, and overactivity of the
(amylase)
autonomic nervous system
• Excess Cl- excreted in urine and sweat
• Increased in electrolytes is due to defective
• Disorders of chloride are the same as sodium gene and protein known as the cystic fibrosis
since they are both extracellular cations. transmembranous conductance regulator,
FUNCTION located on chromosome 7.
• Maintains osmolality • Sweat inducer: Pilocarpine
• Blood volume • Diagnostic test: Sweat test
• Electric neutrality o increases sodium and chloride
SPECIMEN CONSIDERATIONS REFERENCE METHOD
• Marked hemolysis may caused decreased • Gibson and Cooke Pilocarpine Iontophoresis
levels of chloride due to dilutional effect o (>50 mg of sweat (sample) collected
• Slightly lower values are observed in post within 30 mins)
prandial specimen NORMAL VALUES
Compiled by: Virgildo Fonzy Jake A. Aguillon
• 5-40 mmol/L, >65 mmol/L of sweat Bones 53%
electrolytes (+ result) Muscles and soft 46%
SIGNS tissues
• Chronic cough Serum and RBC <1%
• Frequent foul-smelling stool • Essential cofactor of more than 300 enzymes
• Persistent URT infection. including those important in:
AFFECTED ORGANS AND GLANDS o Glycolysis
• Pancreas o Transcellular ion transport
• Respiratory system o Neuromuscular transmission
• Sweat glands o Synthesis of
TEST REQUIREMENTS: ▪ carbohydrates
• 48 h of age (newborn) ▪ proteins
▪ lipids
Bicarbonate ▪ nucleic acids
o Release of and response to certain
REFERENCE VALUES hormones
SAMPLE UNIT • Vasodilator and cause decrease uterine
Venous blood (plasma 21 – 28 mEq/L hyperactivity in eclampsic states and increase
or serum) uterine blood flow
OVERVIEW • Life threatening conditions occur if serum level
• Second most abundant anion in the ECF reach 5mmol/L
• Accounts for 90% of the total Carbon Dioxide • Magnesium loss leads to decreased
at physiologic pH intracellular K levels.
• Composed of undisclosed NaHCO3 FORMS
carbonate and carbamate Free/ Ionized 55%
• It buffers excess hydrogen ion by combining (physiologically
with acid active)
• Maintenance of high plasma bicarbonate Protein -bound 30%
concentration occurs in advanced renal failure Ion Complexed 15%
/ renal threshold for bicarbonate is increased METHODS
FUNCTION • Atomic Absorption Spectrophotometry
• Major component of the buffering system in o Reference method
blood • Colorimetric Method
SPECIMEN CONSIDERATION o Camalgite Method: (+) reddish-violet
• Blood, anaerobically collected complex
METHODS o Formazen Dye Method: (+) colored
complex
• Ion Selective Electrode (using pCO2
o Magnesium Thymol Blue Method = (+)
electrode)
colored complex
• Enzymatic (phsphoenolpyruvate carboxylase
• Ion Selective Electrode: Ionized Magnesium
and dehydrogenase)
• Dye-Lake Method- Titan Yellow Dye
Magnesium o Clayton Yellow or Thiazol Yellow
FUNCTIONS
REFERENCE VALUES • Important in maintaining the structures of
SAMPLE UNIT DNA, RNA, and Ribosomes
Serum / Colorimetric 0.63 –1.0 mmol/L (1.26 • Synthesis of CHO, CHONS and Lipids
– 2.10 mmol/L) • Neuromuscular transmission
Rodriguez (book) 1.2 – 2.1 mEq/L • Cofactor
OVERVIEW • Regulates movement of potassium across
• Intracellular Cation second in abundance to myocardium
potassium INTERFERING SUBSTANCES
• Fourth most abundant cation in the body; • Parathyroid hormone
Enzyme activator. o Increases renal reabsorption of
• Stored in bones and muscles magnesium
Compiled by: Virgildo Fonzy Jake A. Aguillon
 o Increases intestinal absorption of HEMOSTATIC
magnesium • Decreased thrombin generation
• Aldosterone and Thyroxine • Decreased platelet adhesion
o Increases renal excretion of HYPOMAGNESEMIA
magnesium • Hypomagnesemia is most frequently
CLINICAL SIGNIFICANCE observed in hospitalized individuals in
HYPERMAGNESEMIA intensive care units (ICUs) or those receiving
• Hypermagnesemia is observed less frequently diuretic therapy or digitalis therapy.
than hypomagnesemia CAUSES
• The most severe elevations are usually a REDUCED INTAKE
result of the combined effects of decreased • Poor diet/ Starvation
renal function • Prolonged Magnesium-deficient intravenous
• increased intake of commonly prescribed therapy
Mg2+ - containing medications, DECREASED ABSORPTION
o such as antacids, enemas, or • Malabsorption syndrome
cathartics • Surgical resection of small intestine
CAUSES • Nasogastric suction
DECREASED EXCRETION • Pancreatitis
• Acute or chronic renal failure • Vomiting Diarrhea
• Hypothyroidism • Laxative abuse
• Hypoaldosteronism • Neonatal
• Hypopituitarism (decreased growth hormone) • Primary
INCREASED INTAKE • Congenital
• Antacids INCREASED EXCRETION-RENAL
• Enemas • Tubular disorder
• Cathartics • Glomerulonephritis
• Therapeutics • Pyelonephritis
o Eclampsia INCREASED EXCRETION-ENDOCRINE
o cardiac arrhythmia • Hyperparathyroidism
MISCELLANEOUS • Hyperaldosteronism
• Dehydration • Hyperthyroidism
• Bone Carcinoma • Hypercalcemia
• Bone Metastases • Diabetic ketoacidosis
SYMPTOMS INCREASED EXCRETION- DRUG INDUCED
CARDIOVASCULAR • Diuretics
• Hypotension • Antibiotics
• Bradycardia • Cyclosporin
• Heart block • Digitalis
DERMATOLOGIC MISCELLANEOUS
• Flushing • Excess lactation
• Warm Skin • Pregnancy
GASTROINTESTINAL SYMPTOMS
• Nausea CARDIOVASCULAR
• Vomiting • Arrhythmia
NEUROLOGIC • Hypertension
• Lethargy • Digitalis toxicity
• Coma NEUROMUSCULAR
NEUROMUSCULAR • Weakness
• Decreased reflexes • Cramps
• Dysarthria • Tremor
• Respiratory Depression • Seizure
• Paralysis • Tetany
METABOLIC
• Paralysis
• Hypocalcemia
Compiled by: Virgildo Fonzy Jake A. Aguillon
• Coma o Hypocalcemia can be a
PSYCHIATRIC consequence of reduced plasma
• Depression albumin
• Agitation METHODS
• Psychosis • Precipitation and Redox Titration
METABOLIC Clark Collip Ferro Ham
• Hypokalemia Precipitation Chloranilic Acid
• Hypocalcemia Precipitation
• Hypophosphatemia End product: Oxalic End product:
• Hyponatremia acid (purple color) Chloranilic acid
(purple color)
Calcium • Colorimetric Method
o Ortho-Cresolpthalein Comlexone
REFERENCE VALUES Dyes
SAMPLE UNITS o Dye: Arsene III
Total Calcium (adult) 8.6-10 mg/dL o Mg inhibitor: 8-hydroxyquinoline
Total Calcium (Child) 8.8- 10.8 mg/dL • EDTA Titration Method (Bachra, Dawer and
Ionized Calcium (adult) : 4.6- 5.3 mg/dL Sobel)
Ionized Calcium (child) 4.8- 5.5 mg/dL • Ion Selective Electrode (Liquid Membrane)
Conversion Factor 0.25 • Atomic Abosrption Spectrophotometry
OVERVIEW o reference method
• Most abundant ions in the body • Emission Flame Photometry
• present almost exclusively in the plasma FACTORS INHIBITING PLASMA CALCIUM
• Third most abundant cation in the blood LEVELS
• Maximally absorbed in the duodenum – the • 1,25 Dihydroxycholecalciferol [1,23-(OH)2-
absorption is favored at an acidic pH D3 ]
• 99% of Ca2+ is in bone and 1% is in ECF o Increases intestinal absorption of
FUNCTION calcium
• Blood coagulation o Increase reabsorption in the kidneys
• Enzyme activity o Increases mobilization of calcium from
• Excitability of skeletal and cardiac muscle bones
• Maintenance of blood pressure • Parathyroid hormone
SPECIMEN CONSIDERATION o Conserves calcium by increasing
reabsorption in the kidneys
• Serum is the specimen of choice for analysis
o Increases the level by mobilizing bone
• Decrease in plasma protein concentration will
calcium
result in decrease total Calcium
o Activates the process of bone
• Avoid prolonged contact of serum with cell resorption
clot: decrease Ca2 o Suppresses urinary loss of calcium
• Recumbent posture: decrease Calcium o Stimulates the conversion of inactive
• Venous occlusion: Increased Calcium vitamin D to active vitamin D3 in
• Decrease pH of the reagent (acidification) kidneys
results to liberation of calcium from albumin • Calcitonin
FORMS o Thyroid hormone; secreted by the
Ionized (active) 50% parafollicular C cells of the thyroid
calcium gland
Protein-bound 40% o Inhibits PTH and vitamin D3:
Complexed with 10% hypocalcemic hormone
anions o Inhibits bone resorption
• Ionized calcium is a sensitive and specific o Promotes urinary excretion of calcium
marker for calcium disorders CLINICAL SIGNIFICANCE
• For every 1 g/dL serum albumin decrease, HYPERCALCEMIA
there is 0.8 mg/dl decrease in total calcium CHIMPS
• Cancer (Lung and Mammary)
• Hyperthyroidism
Compiled by: Virgildo Fonzy Jake A. Aguillon
• Iatrogenic causes • True hypocalcemia frequently develops as a
• Multiple myeloma serious medical emergency in pancreatitis due
• Hyperparathyroidism (primary): main cause to sequestration of ionized calcium in the
• Sarcoidosis damaged tissue of the surrounding fluid
Others
• vitamin D excess
Phosphorus
• prolonged immobilization REFERENCE VALUES
• Thiazide diuretics SAMPLE UNITS
• Malignancy Serum / Heparinized Plasma 2.7 – 4.5 mg/dL
• Benign familial hypocalciuria (Adult)
HYPOCALCEMIA Serum / Heparinized Plasma 4.5-5.5 mg/dL
CHARD (Child)
• Calcitonin OVERVIEW
• Hypoparathyroidism (primary and secondary) • Omnipresent in its distribution; 85% in the
• Alkalosis bones and 15% in the ECF in the form of
• Renal failure inorganic phosphate (Pi).
• Vitamin D deficit • Inversely related to calcium.
Others • Maximally absorbed in the jejunum
• Acute pancreatitis • Phosphate is essential for the insulin-
• Hypomagnesemia mediated entry of glucose into cells by a
• Malabsorption Syndrome process involving phosphorylation of
• Renal tubular Failure theglucose and the co-entry of K +.
• Hypermagnesemia • Most important reservoir of energy-like: ATP,
• Hypoalbuminemia creatine PO4, PEP
• Rhabdomyolysis • Exists as organic phosphate or inorganic
• Pseudohypoparathyroidism phosphate esters
ADDITIONAL NOTES Organic phosphate Inorganic phosphate
• Ionized calcium: decreased in Secondary principal anion within part of the blood
hyperparathyroidism cells buffer
• Acidosis: promotes leaching of calcium from FORMS
bones & elevation of hydrogen ions; displace Free / Unbound form 55%
calcium from proteins Complexed with 35%
• Alkalosis: promotes deposition of calcium in ions
bones Protein-bound 10%
o Cause plasma proteins to have a SPECIMEN CONSIDERATION
greater negative charge that in turn • Specimen: serum/ heparinized plasma
binds more ionized calcium = • Fasting is required: high cholesterol diet can
hypocalcemia result to decrease levels
• Parathyroid hormone-related protein (pthrp): • Separate the serum from the red cells
increased in hypercalcemia associated with immediately after clotting is completed
malignancy • Blood collection is affected by circadian
• Dehydration / hemoconcentration may elevate rhythm – high levels in late morning and low
serum albumin, resulting in a falsely elevated levels in evening
total serum calcium • Avoid prolonged contact of serum with RBC
• Rate of fall (ionized calcium) initiates tetany FACTORS AFFECTING PHOSPHATE
• Estrogen deficiency reduces formation of CONCENTRATION
active vitamin D • Parathyroid hormone
• Primary hypocalcemia (low pth) is due to o Decreases phosphate by renal
parathyroid gland disease exretion
• Secondary hypocalcemia (high pth) is sdue to • Calcitonin
renal falilre o Inhibits bone resorption
• Severe hypocalcemia = total calcium level • Growth hormone
<7.5 mg/dL (1.88 mmo/L) o Increases phosphate renal absorption

Compiled by: Virgildo Fonzy Jake A. Aguillon

 METHODS
• Fiske and Subarrow Method
o Most commonly used method to
measure serum inorganic phosphate
o Most common reducing agent: Pictol
(Amino Naphthol Sulfonic Acid)
o Others:
▪ Elon (methyl amino phenol)
▪ Ascorbic acid
▪ Senidine (N-phenyl-p-
phenylene diamine
hydrochloride)
o Endproduct: ammonium molybdate
complex (unstable)
o Unreduced complex at 340nm is the
most accurate measurement of
inorganic phosphorus in serum
o pH must be maintained in acid range.
▪ Alkaline: reduction in complex
o Reduced form: blue color; determined
between 600-700nm
HYPERPHOSPHATEMIA
• Hypoparathyroidism,
• Renal failure (tubular failure)
• Lymphoblastic leukemia
• Hypervitaminosis
HYPOPHOSPHATEMIA
• Transcellular shift – major cause
• Alcohol abuse – most common cause
• Primary hyperparathyroidism
• Avitaminosis D
• Myxedema
ADDITIONAL NOTES
• Deficiency can lead to ATP depletion
• Transcellular shift; increase shift of phosphate
into cells can deplete blood phosphate.
• Equilibrium: determined largely by carb
metabolism and blood pH
• Increased serum phosphate causes serum
calcium to diminish

Compiled by: Virgildo Fonzy Jake A. Aguillon

Compiled by: Virgildo Fonzy Jake A. Aguillon
Compiled by: Virgildo Fonzy Jake A. Aguillon
Compiled by: Virgildo Fonzy Jake A. Aguillon
ACID-BASE BALANCE • BASE
▪ - is a substance that can
I. INTRODUCTION
accept hydrogen ions.
Maintaining the homeostasis
▪ -yield OH-, associated
of acid and base concentration
with ↑HCO3-
in the body is vital since most
• BUFFER
of the physiologic activities
▪ Combination of a
and reactions are pH
weak acid or weak
dependent. Slight alteration of
base and its salt, is a
these pH levels may bring
system that resists
detriment to the patient, if not
changes in pH.
taken care immediately. The
▪ In plasma, the
parameters for the evaluation
bicarbonate–carbonic
of acid-base balance and
acid system, is one of
blood gas homeostasis are
the principal buffers:
interrelated and usually tested
in panels rather than individual
testing.

There are the factors and

parameters utilized by ▪ Buffers consist of a
the body to maintain pH weak acid, such as
homeostasis. These will carbonic acid
include the blood gas (H2CO3), and a salt of
exchange and the body’s its conjugate base,
action to maintain acid-base such as bicarbonate
balance. These test (HCO3–), which
parameters can be calculated, forms the
analyzed, and bicarbonate–carbonic
interpreted, to help us in acid buffer system.
identifying the cause of an H2CO3 is a weak acid
acid-base imbalance. because it does not
completely dissociate
II. DEFINITION into H+ and HCO3–,
• ACID whereas a strong
▪ is a substance that can acid, such as HCl,
donate hydrogen ions completely
(H+) when dissolved in dissociates into H+
water. and Cl– in solution.
▪ Yield H+, H3O;
associated with ↑CO2

1
PALADA,TJG.
 • ACIDEMIA IV. ORGANS INVOLVED IN
▪ arterial blood pH ACID- BASE BALANCE
<7.35 • The lungs and kidneys play
• ALKALEMIA important roles in
▪ arterial blood pH extracellular fluid pH
>7.45 homeostasis. The
• pKa interrelationship of the
▪ Negative log of the lungs and kidneys in
ionization constant; maintaining pH is depicted
protonated and by the Henderson-
unprotonated forms Hasselbalch equation. The
are present in equal Henderson- Hasselbalch
concentrations. equation expresses acid–
▪ Decrease in one pH base relationships in a
unit represents a 10- mathematical formula:
fold
increase in H+
concentration.

1. LUNGS
• Respiratory control of CO2
III. pH REGULATION IN THE elimination for rapid
BODY adjustment of blood pH.
• CO2 combines with H2O to • H2CO3 dissociates into
form H2CO3, which quickly CO2 and H2O, allowing
dissociates into H+ and CO2 to be eliminated by
HCO3−. This process is the lungs and H+ as water
accelerated by carbonic through ventilation.
anhydrase. The
• Elimination of CO2 resist
dissociation of H2CO3
accumulation of H+
causes the HCO3-
• Chloride shift
concentration to increase
2. KIDNEYS
in the red cells and diffuse
• The kidneys regulate the
into the plasma. Through
excretion of both acid and
exquisite mechanisms that
base, making them an
involve the lungs and
important player in the
kidneys, the body controls
regulation of acid–base
and excretes H+ in order to
balance. Specifically, the
maintain pH homeostasis.
kidney's main role is to
reabsorb bicarbonate ion,
HCO3–, from the

2
PALADA,TJG.
 glomerular filtrate in the b. Mainly used in
proximal tubules. pulmonology and critical-
▪ Metabolic care medicine to determine
reclamation of gas exchange
HCO3 from the across the alveolar-
glomerular filtrate capillary membrane.
and excretion of H+. c. This will help physician to
▪ H+ is excreted as determine how well the
NH4+ (indirect patient’s lungs and kidneys
disposal) and are working.
titratable acid (direct d. Specimen:
disposal). ▪ Arterial blood
▪ Kidneys excrete anticoagulated with
considerable heparin (0.05mL/mL
amounts of acid and of blood)
base for acid-base e. Methods:
regulation. ▪ Gasometer: Van
▪ Bicarbonate Slyke, Natelson
reabsorption ▪ Electrodes for pH
(potentiometry)
V. BUFFERS YSTEMS
• Bicarbonate-carbonic acid B. PARAMETERS
– principal buffers with pKa a. pH – Evaluates blood pH.
of 6.1 b. pCO2 – Evaluate the
• Plasma proteins ventilation (lungs),
• Hemoglobin efficiency of gas exchange.
• Phosphate buffer – c. HCO3 – Evaluate the
important IC buffer metabolic
process(kidneys).
VI. ASSESSMENT OF ACID- d. pO2– Evaluate the degree
BASE BALANCE of oxygenation and
availability of gas in the
In assessing acid–base homeostasis, blood.
components of the bicarbonate buffering
system are measured and calculated.
Inferences can be made from these
results about the systems produce,
retain, and excrete the acids and bases.
A. Arterial Blood Gas (ABG) analysis
a. Measures the amounts of
arterial gases, such as
oxygen and carbon
dioxide.

3
PALADA,TJG.
 VII. CALCULATIONS • To get the cdCO2 using the
given PCO2, we need to multipy
The pH of plasma is dependent on the
the PCO2 to a factor a:
partial CO2 (Respiratory function) and
HCO3- concentration (Metabolic
function).
The acid-base balance relationship uses
these components and calculated using
the Henderson-Hasselbalch equation. where:
PCO2 - partial carbon
dioxide
A. Henderson-Hasselbalch
Equation

B. Alternate Formulas
• The total CO2 is the sum of the
bicarbonate and carbonic acid,
given the formula:

where The average normal ratio of HCO3- to

pCO2 is 20:1. • If the given is only the TCO2,
PCO2, and carbonic acid use
: pK' - this is the pKa (negative log of the formula:
the ionization constant where acid
and base are equal)
where:

• We can subtract the to TCO2 to

yield the bicarbonate and use to
• When carbonic acid is not given yield the carbonic acid as
and partial CO2 is given, we shown below:
need to use the cdCO2 instead
of carbonic acid. Hence, given
the formula:

The average normal ratio of HCO3- to

pCO2 is 20:1.
Where:

4
PALADA,TJG.
 SAMPLE PROBLEM:
elimination of CO2 by the
What is the blood pH when partial lungs.
pressure of carbon dioxide is 60 mm Hg
and the bicarbonate level is 18 mmol/L? Respiratory acidosis may be caused
by the following reasons:
Given:
• Ineffective removal of CO2 from
▪ pCO2 : 60 mm Hg
the blood as seen in lung disease.
▪ HCO3- (bicarbonate) : 18 mmol/L
• Airway obstruction as seen in
Formula: chronic obstructive pulmonary
disease (COPD) such as chronic
hypercarbia (elevated pCO2 ).
• Drugs such as barbiturates,
morphine, and alcohol will cause
hypoventilation which
VIII. Acid-Base Imbalances subsequently increase blood
• Acid–base disorders result from pCO2 levels.
imbalances in the acid base • Decreased cardiac output, as
equilibrium. When blood pH is less observed with congestive heart
than the reference range (7.35 to failure, will result in less blood
7.45), it is termed acidemia. being presented to the lungs for
Similarly, a pH greater than the gas exchange and, therefore, an
reference range is termed elevated pCO2 .
alkalemia.
• A disorder caused by ventilatory B. Respiratory Alkalosis
dysfunction (a change in the • Decrease in CO2 due to
pCO2, the respiratory component) excessive respiration
is termed primary respiratory (Hyperventilation)
acidosis or alkalosis.
• An increased rate of
• A disorder resulting from a change alveolar ventilation causes
in the bicarbonate level (a renal or excessive elimination of
metabolic function) is termed a CO2 by the lungs.
non-respiratory or metabolic
disorder. The causes of respiratory alkalosis
include:
A. Respiratory acidosis
• Hypoxemia- and hysteria-induced
• Increase in CO2 due to
hyperventilation.
ineffective respiration
• Chemical stimulation of the
(hypoventilation).
respiratory center by drugs, such
• results from a decrease in
as salicylates and nicotine that
alveolar ventilation
cause hyperventilation.
(hypoventilation), causing
a decreased

5
PALADA,TJG.
 • Pulmonary emboli or pulmonary Metabolic alkalosis maybe caused by
fibrosis in which pulmonary the following reasons:
oxygen exchange is impaired.
• Excess administration of sodium
bicarbonate or through ingestion
C. Metabolic Acidosis
of bicarbonate-producing salts,
• HCO3- deficiency
such as sodium lactate, citrate,
• The amount of acid
and acetate.
exceeds the capacity of the
• Excessive loss of acid through
buffer systems, and there is
vomiting, nasogastric suctioning,
a decrease in bicarbonate
or prolonged use of diuretics that
to less than 24 mmol/L.
augment renal excretion of H+ can
Metabolic acidosis may be caused by produce an apparent increase in
the following reasons: HCO3 – .
• Hypokalemia and chloride deficit
• Direct administration or stimulate the reabsorption of
ingestion of acid- HCO3 – in the distal tubules.
producing substances (i.e.,
ammonium chloride, IX. Mixed Acid-base disorders
calcium chloride,
• Due to excessive
salicylates, ethanol).
compensation pCO2
• Production of organic acids
and HCO3- is in
as seen with diabetic
opposite direction
ketoacidosis (increased
• Arise from the presence
levels of acetoacetic acid
of more than one
and β-hydroxybutyric acid
process or
and lactic acid in lactic
compensatory
acidosis).
mechanism in response
• Reduced excretion of acids
to the primary disorder.
as seen in renal tubular
acidosis.
• Excessive loss of
bicarbonate from diarrhea
or drainage from a biliary,
pancreatic, or intestinal
fistula.

D. Metabolic Alkalosis
Normal Ranges
• HCO3- excess
• Results from a gain in • pH : 7.35 - 7.45
HCO3 – , causing an • pCO2 : 35 - 45 mm Hg
increase in the pH. • H+ : 50 - 100 mmol/L
• HCO3- : 22 -26 mmol/L

6
PALADA,TJG.
 A. EVALUATION OF ACID-BASE ➢ Uncompensated
IMBALANCES • the body is not yet working
to bring the pH back to
normal.
• pH is abnormal (<7.35 or
>7.45)
• PaCO2 or HCO3 is
abnormal, but not both.
• The cause of the disorder is
out of range but the other
value is not yet out of
range, indicating
B. Compensatory Mechanism compensation is not yet
• The response to maintain occurring.
acid–base homeostasis is
termed compensation and
is accomplished by altering
the factor not associated
with the primary process.
• The lungs can immediately
compensate by retaining or
expelling carbon dioxide;
however, this response is
short term and often REFERENCES
incomplete, whereas the • Ashwood E., D. Bruns and C.
kidneys are slower to Burtis(2007). Tietz’s Fundamentals
respond (2 to 4 days), but ofClinical Chemistry 6th ed.
the response is long term Philadelphia:W.B. Saunders Co.
and sustained.
➢ Fully compensated status • Bishop, M., et. al. (2013). Clinical
• Implies that the pH has chemistry: principles, techniques, and
returned to the normal correlations 7th edition. Philadelphia:
range (the ratio of HCO3 –
to H2CO3 of 20:1 has been • Lippincott Williams & Wilkins
restored). McPherson, RA., Pincus, MR. (2022).
➢ Partially compensated Henry's Clinical Diagnosis and
• Implies that the pH is Management by Laboratory Methods
approaching normal; 24th edition. Philadelphia: Elsevier Inc.
parameters are trying to
compensate with the origin • Rodriguez, M.T. (2012). Clinical
of imbalance. Chemistry Review Handbook for
Medical Technologists.
Sampaloc,Manila: Cattleya

7
PALADA,TJG.
TUMOR MARKERS solid benign (non-cancer)
mass.
I. INTRODUCTION
• Oncogene - Encodes a
protein that, when mutated,
Cancer is a broad term used to
promotes uncontrolled cell
describe more than 200 different
growth.
malignancies that affect more than 50
• Tumor Suppressor Gene -
tissue types. Accounting for more
Encodes a protein to protect
than 2.7 million deaths annually,
cell from unregulated growth.
although cancer mortality has
• Malignant Transformation -
decreased over the past seventy
Due to deletion or mutation of
years by about 21%.
TSG, healthy cell undergoes
differentiation and mutate to
Biologically, cancer refers to the
malignant cell.
uncontrolled growth of cells that often
forms a solid mass or tumor • Oncofetal Antigen -
(neoplasm) and spreads to other Substances which are
areas of the body. A complex produced by tumors and also
combination of inherited and by fetal tissues but they are
acquired genetic mutations lead to produced in much lower
tumor formation (tumorigenesis) and concentration by adult
spreading (metastasis). tissues.

Prostate cancer was the leader

among men, and breast cancer was
the leader in women, followed by
cancer o the lung, colon-rectum, and
bladder (men) or uterine corpus
(women). With the discovery of
cancer biomarkers with high
sensitivity and specificity allowed
early cancer detection, effective
treatment, and decreased mortality.

II. COMMON CANCER -ASSOCIATED

TERMINOLOGIES
• Angiogenesis -
Development of new blood
vessels.
• Apoptosis - Programmed III. TYPES OF TUMOR MARKERS
cell death.
Cancer can be detected and monitored using
• Cell Cycle - Phases of cell
biologically relevant tumor markers. Tumor
activity (G, S, and M).
markers are produced either directly by the
• Neoplasm/Tumor -
tumor or as an effect of the tumor on healthy
Uncontrolled tissue growth:
tissue (host).Tumor markers encompass an
can be malignant (cancer)
array of diverse molecules such as serum
that may metastasize or a
proteins, oncofetal antigens, hormones,
metabolites, receptors, and enzymes. • In hematologic malignancies such as
multiple myeloma, immunoglobulins
provide a relatively specific measure of
• Enzymes – correlate with tumor plasma cell production of monoclonal
burden; useful for monitoring the proteins.
success of therapy. • In endocrine malignancies, hormones
• Immunoglobulins – more specific and hormone metabolites are widely
measure of plasma cell production of used as specific markers of secreting
monoclonal proteins observed in tumors.
hematologic malignancies such as • Hormones can be valuable in diagnosing
multiple myeloma. neuroblastomas, as well as pituitary and
• Hormones and hormone adrenal adenomas.
metabolites – specific markers of • Oncofetal antigens such as
secreting tumors; valuable in carcinoembryonic antigen (CEA) and
diagnosing neuroblastomas, pituitary, α-fetoprotein (AFP) are expressed
and adrenal adenomas. transiently during normal development
• Oncofetal antigens – proteins that and are then turned on again in the
are expressed in fetal tissue during formation of tumors.
development but are not normally • Antibodies are directed toward specific
found in the tissues of adults but carbohydrate or cancer antigens and are
turned on again in the formation of best used for monitoring treatment of
tumors. tumors that secrete these epitopes.
• Carbohydrate or cancer antigens –
identified by monoclonal antibody
made against tumor cell lines and IV. CHARACTERISTICS OF IDEAL
extract; best used for monitoring TUMOR MARKERS
treatment of tumors (tissue source) ✓ Tumor specific
that secrete these epitopes. ✓ Absent in healthy individuals
• Receptors – are used to classify ✓ Readily detectable in body
tumors for therapy (e.g., ER, PR). fluids
✓ Are used in combination with
clinical signs, symptoms, and
Notes: histology to facilitate clinical
decision making.
• β2-Microglobulin is found on
✓ Elevated in serum of patients
the surface of all nucleated
with malignant tumors only.
cells and can, therefore, be
✓ Elevated in early stages for
used as a nonspecific marker
early detection and initiation
of the high cell turnover
of proper therapy.
common in tumors.
✓ A high enough specificity and
sensitivity to be used on a
targeted basis for aiding
diagnosis, prognosis,
detection of recurrence, and
monitoring the response to
treatment.
 CANCER PATHOGENESIS VI. CLINICAL APPLICATIONS
• Tumor markers are used in
combination with clinical
signs, symptoms, and
histology to facilitate clinical
decision-making.
• No tumor marker identified to
date can be used to
effectively screen
asymptomatic populations
except PSA and most tumor
markers are also found in
normal cell.
• Therefore, screening
asymptomatic populations will
lead to false positive.
• Tumor markers are not tissue
specific and also be
expressed in diseases other
than cancer.
• The clinical value of any given
tumor marker will depend on
its specificity and sensitivity,
as well as its intended clinical
use. PSA is tissue specific but
not cancer specific.

❖ TNM STAGING SYSTEM

V. PROGNOSIS OF TUMOR • T- Tumor size and
MARKERS involvement/invasion
Tumor marker concentration of nearby tissue.
generally increases with tumor • N- regional lymph
progression, reaching their highest node involvement.
levels when tumors metastasize. • M- metastasis; extent
Serum tumor marker levels at of tumor spreading
diagnosis can reflect the from one tissue to
aggressiveness of a tumor. High another.
concentrations of a serum tumor ❖ THERAPY MONITORING
marker at diagnosis might indicate • Effective therapy results in
the presence of malignancy and a dramatic decrease or
possible metastasis, which is disappearance of the
associated with a poorer prognosis. tumor marker; appearance
In other instances, the mere of circulating tumor
presence or absence of a particular markers can then be used
marker may be valuable. as a highly sensitive
marker of recurrence.
 immunoassay, but the added
VII. LABORATORY DETERMINATION value is the ability to
✓ Immunoassays determine whether the
▪ Immunoassays are the most antigen in question is in a
commonly used method to particular cell type (such as a
measure tumor markers. tumor), in the specific
There are many advantages subcellular location.
to this method, such as the ✓ Enzyme Assays
ability to automate testing ▪ Enzyme activity assays are
and relative ease of use. used to quantify all of these
Many tumor markers are enzymes, with the exception
amenable to automation and of PSA, which is measured
relatively rapid analysis using by immunoassay. When cells
large immunoassay or die (autolysis/necrosis) or
integrated chemistry test undergo changes in
platforms. membrane permeability,
✓ High-Performance Liquid enzymes are released from
Chromatography intracellular pools into
▪ High-performance liquid circulation where they are
chromatography (HPLC) is readily detected.
commonly used to detect
small molecules, such as VIII. ENZYMES SERVING AS TUMOR
endocrine metabolites. With MARKERS
respect to tumor markers, ➢ Alkaline phosphatase -
HPLC is used to detect (bone, liver, leukemia, and
catecholamine metabolites in sarcoma)
plasma and urine. Generally, ➢ Creatine kinase–BB -
there is an extraction (prostate, small cell lung,
process, by which the breast, colon, and ovarian)
analytes of interest are ➢ Lactate dehydrogenase -
separated from either plasma (liver, lymphomas, leukemia,
or urine. Extractions are and others)
applied to a column where
they are separated by their IX. FREQUENTLY ORDERED TUMOR
physical characteristics MARKERS
(charge, size, and polarity). ➢ α-Fetoprotein
✓ Immunohistochemistry and • AFP is an abundant serum
Immunofluorescence protein normally
▪ Specific antibodies (and the synthesized by the fetal
proper control antibodies) liver that is reexpressed in
are incubated with tissue certain types of tumors.
sections to detect the This reexpression during
presence (or absence) of malignancy classifies AFP
antigens using colorimetric or as a carcinoembryonic
fluorescent secondary protein. AFP is often
antibodies. In many ways, elevated in patients with
this is similar to detection by hepatocellular carcinoma
 (HCC) and germ cell Some types of tumor
tumors. invasion are actually
➢ Cancer Antigen 125 (CA 125) similar to uterine
• Cancer antigen 125 (CA- implantation, except that
125) was first defined by a implantation in pregnancy
murine monoclonal is regulated and limited.
antibody raised against a hCG is elevated in
serous ovarian carcinoma trophoblastic tumors,
cell line. 10 CA-125 may mainly choriocarcinoma,
be useful for detecting and germ cell tumors of the
ovarian tumors at an early ovary and testis.
stage and for monitoring ➢ Prostate-Specific Antigen
treatments without surgical (PSA)
restaging. • PSA is a 28-kD
➢ Carcinoembryonic Antigen glycoprotein produced in
(CEA) the epithelial cells of the
• It is expressed during acini and ducts of the
development and then prostatic ducts in the
reexpressed in tumors. prostate. It is a serine
CEA is the most widely protease of the kallikrein
used tumor marker for gene family. It functionally
colorectal cancer and is regulates seminal fluid
also frequently elevated in viscosity and is
lung, breast, and instrumental in dissolving
gastrointestinal tumors. the cervical mucus cap,
CEA can be used to aid in allowing sperm to enter.
the diagnosis, prognosis,
and therapy monitoring of REFERENCES
colorectal cancer. Although
high levels of CEA (>10 • Ashwood E., D. Bruns and C. Burtis(2007).
ng/mL) are frequently Tietz’s Fundamentals ofClinical Chemistry
associated with 6th ed. Philadelphia:W.B. Saunders Co.
malignancy, high levels of
CEA are not specific for • Bishop, M., et. al. (2013). Clinical
colorectal cancer, and chemistry: principles, techniques, and
therefore, CEA is not used correlations 7th edition. Philadelphia:
for screening.
➢ Human Chorionic • Lippincott Williams & Wilkins McPherson,
Gonadotropin (hCG) RA., Pincus, MR. (2022). Henry's Clinical
• hCG is a dimeric hormone Diagnosis and Management by Laboratory
normally secreted by Methods 24th edition. Philadelphia:
trophoblasts to promote
Elsevier Inc.
implantation of the
blastocyst and the
placenta to maintain the • Rodriguez, M.T. (2012). Clinical Chemistry
corpus luteum through the Review Handbook for Medical
first trimester of pregnancy. Technologists. Sampaloc,Manila: Cattleya
TUMOR MARKERS