UNIT 4

Basic Clinical Chemistry Tests

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 Basic Clinical chemistry tests

• Learning objective: At the end of the lessen, students will

be able to:
• Describe the clinical significant of basic clinical
chemistry tests
• Identify common interferences in test results

• Interpret the test results based on the reference value

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 Clinical Chemistry
• Clinical chemistry is an area in laboratory sciences that deals
with chemical (biochemical) analysis of body fluids such as
blood, urine, spinal fluid as well as feces, tissue, calculi and
other material

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 Basic Clinical chemistry tests

1. Carbohydrate metabolic disorder test

2. Lipid profile tests
3. Renal function test
4. Liver function tests
5. Common enzyme tests
6. Common electrolyte tests
7. Cardiac marker

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 Specimen types and collection

Majority of clinical chemistry tests are done on blood : whole

blood, serum or plasma
Blood for analysis may be obtained from veins, arteries or
capillaries
Specimen can be

-Random specimen

-Fasting specimen

-Timed specimen
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 Specimen Collection precautions

 Do not shake the blood but gently mix it with the

anticoagulant.
Using clean dry glass tubes or bottles
Centrifuging blood samples for a minimum period of time.
Not storing whole blood samples in, or next to, the freezing
compartment of a refrigerator.

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Common specimen factors affecting test results

Hemolysis and lipemia may be considered

as common factors affecting test result

hemolysis
• Hemolysis causes physiological and chemical interference
to the tests
• Serum shows visual evidence of hemolysis when
hemoglobin conc exceeds 20 mg/dl

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common specimen factors affecting the result

Lipemia:
 milky white color – results from collecting blood from the
patient too soon after a meal
 lots of fats and proteinemia (lots of protein)
– Causes serum or plasma to become turbid
– Also can cause a dilution effect. Fats and proteins are
large and displace water in plasma.

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 Basic Clinical chemistry tests
1. GLUCOSE TEST: The main reason to perform plasma or
serum glucose analysis is to screen and diagnose
hyperglycemia, usually caused by diabetes mellitus (Glucose
metabolism disorder)
- Glucose is commonly determined from plasma and serum and
rarely from CSF and urine
- There are different test methods for glucose determination
 random blood sugar
 fasting blood sugar
 2hr post prandial
 glucose tolerance test

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 Interpretation of Results

Reference
• Fasting blood glucose
– Serum---------------------------70-110mg/dl
– whole blood------------------- 65 -95 mg/dl
– CSF----------------------------- 40-70 mg/dl
• 2-hour postprandial: less than 140 mg/dl
• Random: less than 126 mg/dl

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 What affect the glucose test ?

• Consuming food or drink less than 12 hour before testing will

affect FBS test result
• Medication that can raise blood glucose level
• Medication that can lower blood glucose level
• illness or emotional stress, smoking
• Inappropriate collection, storage and processing

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 Diabetes Mellitus(DM)
 Chronic hyperglycemia with disturbance of CHO, fat, & protein
metabolism
Cause: defects in insulin secretion, action or both.
Symptoms
• polyuria, polyphagia & polydipsia , blurring of vision & weight loss.
• in sever case ketoacidosis or ketomia
 coma & death.
Classification of Diabetes Mellitus
1. Type I(IDDM)
Caused by:- damage of  -cell of pancreas (Autoantibody)
2. Type II (NIDDM)
Insulin resistance( receptor or in structure change).
3. Gestational diabetes mellitus (GDM)
Normal pregnancy is associated with increased insulin resistance
Risk factor for GDM
• Obesity , advanced maternal age , glucosuria & familial history of DM 12
..

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 2. Renal function test

Function of the kidney

• Removal of excess body water

• Elimination of waste products of metabolism

• Excretion of foreign substances like drugs .

• Retention of sub/es necessary for normal body fun.

• Regulation of electrolyte balance and osmotic pressure of

the body fluids .
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 Renal function tests

Kidneys act to excrete metabolic waste into urine

Amino acids
Ammonia
Blood urea nitrogen (BUN)
Creatinine
Uric acid

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 UREA

• Synthesized in the liver from CO2 and the ammonia from

the deamination of amino acids in the reactions of the
urea cycle.
• Major excretory product of protein metabolism

• Readily filtered from the plasma by the glomerulus

– 40% is reabsorbed by passive diffusion

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 UREA

• Plasma concentration depends on:

– Renal function and perfusion

– Protein content of the diet

– The amount of protein catabolism

– Liver function

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 Urea and BUN

• U= Urea
• Blood Urea Nitrogen = BUN
• Urea contains 2 nitrogen atoms: 28 g nitrogen/mole of urea
• BUN x 2.14 = urea

28 mg N / mmol urea
BUN mg / dL  urea (mg / L)  10 dL / L
60 mg urea / mmol
60 mg urea / mmol
Urea mg / L  BUN (mg / dL)  0.1L / dL
28 mg N / mmol urea

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 Disease Correlations

•Azotemia - an elevated concentration of urea in the blood.

•Uremia or Uremic syndrome- a very high plasma urea concentration

accompanied by renal failure
•Conditions causing elevations of plasma urea are classified according
to cause into three main categories:
– Prerenal

– Renal

– Postrenal
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 Disease Correlations
• Pre renal azotemia is caused by:

– Reduced renal blood flow

– CHF

– Shock

– Hemorrhage

– Dehydration

– Protein metabolism

• A high-protein diet

• Increased protein catabolism

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 Disease Correlations
 Renal causes
Acute and Chronic renal failure
Glomerular nephritis
Tubular necrosis, and other intrinsic renal disease
Postrenal azotemia
Obstruction of the urine flow in the UT by renal calculi
Tumors of the bladder or prostate, or
Severe infection.
The major causes of decreased plasma urea
Decreased protein intake and severe liver disease
 Increased protein synthesis- during late pregnancy and infancy

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 Blood Urea N (BUN)

Reference Range:
• For adults (Serum/plasma)……………….. 6-20 mg/dl
• New borne up to one week( Serum/plasma)
– 3- 25mg/dl
• Adult over 60 (Serum/plasma)
– 8-23mg/dl
• Urine: 12-20 g/24hrs

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 Creatinine

• Creatinine is a non-protein waste product of creatine phosphate

metabolism by skeletal muscle tissue.
• Renal dysfunction diminishes the ability to filter creatinine and
the serum creatinine rises.
• The serum creatinine is a better indicator of renal function than
either that of BUN or uric acid, because creatinine
– Is released into the circulation at a relatively constant rate
proportional to an individual's muscle mass.
– Removed from the circulation by glomerular filtration and
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excreted in the urine.
 Creatinine

• Plasma creatinine concentration depends on:

– Relative muscle mass

– Rate of creatine turnover

– Renal function

• Concentration in the blood is reasonably stable and constant

– Determination of creatinine excretion can be used as a

measure of the completeness of 24-hour urine collections in
a given individual
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 Increased serum creatinine

• Impaired renal function

• Chronic nephritis
• Urinary tract obstruction
• Muscle diseases
• Congestive heart failure (CHF)
• Shock

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 Decreased creatinine

the elderly, persons with small stature, decreased muscle mass,

or inadequate dietary protein.
Muscle atrophy can also result in decreased serum creatinine
level. If muscle atrophy is suspected, assessment of serum
creatine kinase, an important enzyme necessary for normal
muscle function, is done.

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 Reference values for serum creatinine

• Adult males: 0.8 - 1.4 mg/dl

• Adult females: 0.6 - 1.1 mg/dl

• Children: 0.2 - 1.0 mg/dl: slight increases with age because

values are proportional to body mass
• A panic value for creatinine is 10 mg/dl in non dialysis patients.

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 Uric acid

•Uric acid is the final breakdown product of purine metabolism

•Transported in the plasma from the liver to the kidney

– Increased uric acid

• Gout
• Increased breakdown of nucleic acids
• Renal disease
– Decreased uric acid
• Severe liver disease

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 Reference Range:

• Serum Adult male: 3.5-7.2 mg/dl

Adult female: 2.6-6.0 mg/dl
Child: 2.2-5.5 mg/dl

• Urine 250-750 mg/24 hr

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 3. Liver Function Test

Functions of liver
① Excretory function: bile pigments, bile salts and cholesterol are
excreted in bile into intestine.
② Metabolic function: liver actively participates in carbohydrate, lipid,
protein, mineral and vitamin metabolisms.
③ Hematological function: liver also produces clotting factors like factor
V, VII. Fibrinogen involved in blood coagulation are also synthesized in
liver. It is also used to synthesize plasma proteins
④ Storage functions: glycogen, vitamins A, D and B12,and trace element
iron are stored in liver.
⑤ Protective functions and detoxification: Ammonia is detoxified to urea.
kupffer cells of liver perform phagocytosis to eliminate foreign
compounds.

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 What is Purpose of LFTs?

 LFTs alone do not give the Physician full information, but used in
combination with a Careful History, Physical Examination (particularly
Ultrasound and CT Scanning), can contribute to making an accurate
diagnosis of the Specific Liver Disorder.
 Different tests will show abnormalities in response to
 liver inflammation
 liver injury due to drugs, alcohol, toxins, viruses
 Liver malfunction due to blockage of the flow of bile
 Liver cancers

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 Liver Function Test
Liver chemistry test Clinical implication of abnormality
ALT( Alanine Hepatocellular damage
Transaminase)
AST ( Aspartate Amino Hepatocellular damage
Transferase )
Bilurubin Cholestasis, impair conjugation, or biliary
obstruction
ALP Cholestasis or biliary obstruction
PT( protrombin time) Synthetic function
Albumin Synthetic function
GGT Cholestasis or biliary obstruction
Bile acids Cholestasis or biliary obstruction
5`-nucleotidase Cholestasis or biliary obstruction
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 Liver Function Test

• Classified in 3 groups:

•synthetic function : albumin, PT

•hepatocyte injury : AST, ALT

•metabolic activity: bilirubin

cholestasis : ALP, Gamma Gultamyl Transferase
(GGT) and bilurubin.

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 Diagnostic Significance(AST)

•Mainly used for the evaluation of hepatocellular disorders

and skeletal muscle
•Pronounced liver disease

•In Acute Myocardial Infraction (AMI), levels begin to rise

within 6-8 hours, peak at 24 hours, and return to normal
within 5 days.
•Highest in acute hepatocellular disorders
•Viral hepatitis - may reach 100 times ULN
•Cirrhosis - 4 times ULN
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 Diagnostic Significance(ALT)

• Evaluation of hepatic disorders

• Liver specific

• Elevates in hepatocellular disorders than extrahepatic or

Intrahepatic obstructive disorders
• Stays longer and higher than AST

• Historically compared with the AST to detect the source of an

elevated AST

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 Reference Ranges of AST

Serum or plasma reference ranges vary with method

• Reference range:
• Adult male <35 U/L
• Adult female <31 U/L

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 Reference Values of ALT

Serum or plasma reference ranges vary with method

• Reference ranges reflect the normal amount in serum or
plasma:
• Adult male <45 U/L
• Adult female <34 U/L

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 Serum albumin (35-45g/L)

• Major synthetic protein product of liver, maintains plasma

osmotic pressure & acts as carrier for low MW substances in
blood
• Depends on nutrition, hepatic synthesis & loses

• ↓ albumin may be due to chronic liver disease; also ↓ in

malnutrition, oedema/ascite

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 Alkaline phosphatase (ALP)

• Enzyme localized to biliary & sinusoidal membranes of

hepatocytes (also found in bone, intestine & placenta)
isoenzymes give specificity

• ↑ ALP in : Biliary disease (esp. cholestatic disorders), hepatic

infiltrative diseases, pregnancy, Paget’s, bone tumor

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 Diagnostic Significance

• Hepatobiliary

– Predominant in obstructive conditions than in hepatocellular

disorders - 3 to 10 X ULN
– Hepatocellular disorders - <3 X ULN.

• Increased with bone diseases of osteoblastic activity

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 Cholestasis and ALP

Cholestasis is a condition where bile can not flow from

the liver to the duodenum
• Release of ALP into the circulation

• Cholestasis may cause ALP increased 3-10 X the normal levels

• Serum total and direct bilurubin are increased

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 Interpretation of Alkaline Phosphatase

Reference ranges vary with method used:

• 53 -128 U/L
• 2x or more increases in serum or plasma:
• Bone cancer, bone disease (such as Paget’s)
• Hepatobiliary disease such as cholestasis, cholelithiasis

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 Bilirubin (BIL)

• Normal Range: Total = 0.2 to 1.2 mg/dL

• Normal Range: Direct = 0 to 0.3 mg/dL

• Increased levels of Total Bilirubin associated with liver

disease and hemolytic disorders.
• Increased levels of conjugated Bilirubin (Direct Bilirubin)
associated with biliary obstruction and hepatocellular disease.

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 Cardiac marker
• Troponin
• CK-MB
• LDH

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 Lipid profile tests
• Total cholesterol
• HDL-C
• LDL-C
• VLDL-C
• TG

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 Electrolyte tests

• Na
• K
• Cl
• Ca

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 Quiz-1

1.Writes two main common specimen

factors which affect clinical chemistry
test?
2. Writes at least 4 symptoms of
diabetes mellitus?
3. Lists 5 liver function tests with their
clinical implication?
4. Lists at least 3 renal function tests? 47