Lab methods

7105307
Introduction to clinical biochemistry and laboratory test
performance
Introduction
• This course dives into the world of laboratory medicine, a cornerstone of
modern medical diagnosis and treatment.
Beyond Techniques
• While we will explore some laboratory methods and techniques used for
various tests, our primary focus will be on understanding the clinical
significance of these tests.
Why it Matters?
• By learning how laboratory tests work, you'll gain a deeper appreciation for
their role in Diagnosing and screening diseases and health risks,
monitoring treatment, disease prognosis, and research
This course equips you to interpret laboratory results within the context of a
patient's clinical presentation. You'll learn to:
• Correlate lab findings with patient symptoms and history.
• Evaluate the limitations of different tests.
• Apply your knowledge to real-world clinical scenarios.
The Clinical Laboratory
The Diagnostic Powerhouse
• A clinical laboratory is a specialized facility within a healthcare system where
tests are performed on biological samples (blood, urine, tissue, etc.) to obtain
information about a patient's health.
A Network of Expertise
• Clinical laboratories encompass various sections, each focusing on specific
analyses:
• Hematology: Studies blood cells and blood disorders.
• Microbiology: Identifies infectious agents like bacteria and viruses.
• Immunology: Evaluates the immune system function.
• Clinical Chemistry (Chemical Pathology): Analyzes body fluids for
chemical imbalances and abnormalities.
• Blood Banking: Ensures safe blood transfusions.
• Histology: Examines tissues for diagnosis of diseases.
• Cytogenetic and molecular biology lab: studies chromosomes, genes,
and hereditary abnormalities
Why Focus on Clinical Biochemistry?
• This course will focus on Clinical Biochemistry for several compelling
reasons:
• Widespread impact: Biochemical tests are fundamental in diagnosing
and monitoring a vast array of diseases. Clinical biochemical tests
comprise over one third of all hospital laboratory investigations.
• Chemical insights: By analyzing the body's chemical makeup, we
gain valuable clues about organ function, metabolic processes, and
potential abnormalities.
• Versatility of tests: Clinical biochemistry offers a broad spectrum of
tests, making it highly adaptable to various clinical situations.
• Foundation for other disciplines: Understanding clinical biochemistry
lays a strong foundation for interpreting tests from other laboratory
sections, as many diseases manifest through both cellular and
chemical changes.
• Throughout this course, we will explore the world of clinical
biochemistry, equipping you to utilize its power in effectively
diagnosing and managing patients.
Why Order a Lab Test? Legitimate Reasons for Clinical
Investigations
A test with a purpose.
• Clinical laboratory tests are powerful tools, but not without careful
consideration. Here are the key reasons a healthcare professional might
order a lab test:
1. Diagnosis: To confirm or rule out a suspected illness. Lab results can
provide objective evidence to support a diagnosis, guiding appropriate
treatment decisions. Example: Detecting elevated blood sugar levels to
diagnose diabetes.
2. Monitoring: Tracking Progress and to assess the effectiveness of a
treatment plan for existing conditions. Lab results can indicate how well a
patient is responding to medication or other interventions.
Example: Monitoring kidney function during treatment for a urinary tract
infection.
3. Screening: Early Detection is Key: To identify potential health risks before
symptoms arise. Screening tests can lead to earlier interventions and
improved patient outcomes. Example: Cholesterol testing to identify
individuals at risk for heart disease.
Why Order a Lab Test? Legitimate Reasons for Clinical
Investigations
4. Prognosis: Predicting the Future: To assess the potential course of a
disease and guide treatment strategies. Lab results can provide information
about disease severity and potential complications. Example: Evaluating
liver function to predict the risk of liver failure in a patient with chronic
hepatitis.
5. Research: To advance medical knowledge and develop new diagnostic
tools and treatment approaches. Laboratory testing plays a crucial role in
clinical research trials. Example: Investigating new biomarkers for early
detection of cancer.
• Remember: Ordering a test should be a well-informed decision based on the
patient's specific needs and clinical context.
The place of clinical biochemistry in
medicine
• Diagnosis begins with a physician collecting
information from the patient's history and
performing a clinical examination.
• Frequently, a confident diagnosis can be
made on the basis of the history combined
with the findings on examination. Failing
this, it is usually possible to formulate a
differential diagnosis, in effect a short list
of possible diagnoses.
• Diagnostic services can then be employed
to distinguish between them and confirm a
diagnosis. Clinical biochemistry is one type of
laboratory service used in this process.
The clinical biochemistry repertoire
• Clinical biochemistry itself isn't an
emergency service, but it plays a
crucial role in emergency medicine by
providing rapid diagnostic testing.
• Core biochemistry: common and
frequently requested tests
• Specialized tests: less common
tests, sometimes for rare diseases,
large labs as referral centers
Test request priorities
• Lab tests should be ordered according to the critical need for the result based
on the patient’s clinical condition. Priority must be determined by the
attending physician.
• Following these guidelines will ensure that lab tests are available to each
individual according to their needs.
STAT:
• "STAT" comes from the Latin word "statim," meaning "immediately“.
• Collect and process results immediately after order received.
• Reserved for those situations of life- or limb-threatening medical
emergencies.
• Test results are vital for immediate patient management in these
emergencies;
• STAT orders will be given priority over all other test requests
• Results will be available within 60 minutes of ordering
Test request priorities
When are STAT Orders Used in Clinical Biochemistry?
• Emergency situations where rapid diagnosis is crucial, such as:
• Suspected heart attack: Cardiac markers are ordered STAT to assess
heart muscle damage.
• Diabetic emergencies: Blood sugar levels are checked STAT to guide
treatment decisions.
• Electrolyte imbalances: Electrolyte levels are sometimes measured STAT
to ensure proper nerve and muscle function.
• Severely ill patients: Kidney and liver function tests can be ordered STAT
to assess organ function and guide treatment.
Benefits of STAT Orders:
• Faster diagnosis and treatment initiation in critical situations.
• Improved patient outcomes by facilitating timely interventions.
Challenges of STAT Orders:
• Increased lab workload and potential delays in non-STAT tests.
• Potential for errors due to the rushed nature of STAT processing.
Test request priorities
Urgent: (ASAP – (As Soon As Possible))
• High priority, but less critical than STAT: Require faster processing
compared to routine tests.
• Used for situations where a delay in results may impact patient care (i.e.
potentially serious conditions), but isn't immediately life-threatening.
• Collection as soon as possible after order received.
• Requests are processed as soon as possible upon receipt of the order in
the lab
• Results are required sooner than the Routine priority for the efficient
provision of patient management;
• Results will be available within 3 hours of ordering
• Does not have to be done immediately and requires that laboratory
personnel hasten its completion, but NOT to the detriment of other tests.
(Processed after STAT and before Routine testing)
Test request priorities
Timed:
• “Timed" requests refer to tests where the sample collection needs to occur at a
specific time point or interval to obtain accurate results.
• Physicians clearly specify the desired time for sample collection on the test
requisition form.
Why Timed Tests?
• Certain biochemical markers or analytes fluctuate throughout the day due to
biological processes or external factors like meals.
• Timed tests ensure sample collection happens at the optimal time window to
reflect a true representation of the analyte's concentration.
Examples:
• Cortisol: Highest in the morning (Insufficiency) vs lowest at midnight (Cushing)
• Oral Glucose Tolerance Test: Measures blood sugar levels over time following
a sugary drink.
• Medication Monitoring: Certain medications have peak concentration times, so
timed blood draws are needed to assess effectiveness.
Test request priorities
Routine:
• “Routine" requests refer to test orders that don't require expedited
processing.
• These tests are typically used for general health screening, monitoring
chronic conditions, or following up on initial diagnoses
• Turnaround times: Routine tests have turnaround times ranging from a few
hours to a day or two, depending on the specific test and lab workload.
• Scheduling: No specific time constraints for sample collection or analysis
exist.
• Workflow: Routine tests are integrated into the overall laboratory workflow
and processed alongside other non-urgent requests.
• Inpatient specimens will be collected during a regular collection round.
• Requested when the priority does not meet the STAT, Urgent or TIMED
definition.
Specimen collection
Blood specimens: One of three different blood specimens may be used:
Whole blood, serum or plasma

Whole-blood specimen:
• Contains both cells and plasma, like blood in the body.
• As with plasma, it must be collected in an anticoagulant tube to keep it from
clotting.
• Must be analyzed within limited time:
• Over time, cells will lyse in whole-blood which will change the
concentration of some analytes such as potassium, phosphate and
lactate dehydrogenase.
• Some cellular metabolic processes will continue which will alter analytes
concentration like glucose and lactate.
Serum:
• Serum is normally a clear, pale yellow fluid (non-fasting serum can be
cloudy due to lipids) separated from clotted blood by centrifugation.
• Forms if blood is collected into a plain tube and allowed to clot, after
centrifugation a serum specimen is obtained
Blood specimens:
Plasma:
• Plasma is normally a clear to slightly hazy, pale yellow fluid that separates from
the cells when blood in an anticoagulant tube is centrifuged.
Serum vs Plasma:
• Serum is the same as plasma except it doesn't contain clotting factors (as
fibrin).
• Plasma contains all clotting factors.
• So, serum and plasma all has the same contents of electrolytes, enzymes
proteins, hormones except clotting factors
• Serum is mainly use in chemistry lab & serology.

Blood collection tubes:

Two major types of blood collecting tubes:
• Serum tubes
• Plasma tubes
Serum tubes
Top Color Additives Principle Uses

Red (plastic) containing a clot Enhancing the formation of - Serology

activator but no blood clot - Antibodies
anticoagulants, - Hormones
preservatives, or - Drugs
separator material - Virology
- Chemistry
Gold clot activator and Serum separating from the - Serology
serum gel separator blood through the gel in the - Chemistry
tube
Plasma tubes
Top Color Additives Principle Uses

Lavender EDTA - The strongest anti-coagulant - Hematology

- Ca+2 chelating agent - Blood bank (ABO)
- To preserve blood cells components - CBC
- HbA1C
Light Sodium Citrate Ca+2 chelating agent - PT: Prothrombin Time
Blue - PTT: Partial Thromboplastin
Time
Green Sodium Heparin or Heparin binds to and activates antithrombin, Enzymes
Lithium Heparin which inhibits the thrombin step in the Hormones
coagulation cascade Electrolytes (Na+, K+, Mg2+, Ca2+
Cl-
Black Buffered Sodium Ca+2 chelating agent ESR ( Erythrocyte
Citrate Sedimentation Rate)
Gray -Sodium Fluoride Glycolysis inhibitor Glucose, lactate, alcohol
-Potassium Oxalate Anti-Coagulant (Ca+2 chelating agent)
Royal Heparin Anti-Coagulant. Tube should not be Toxicology
Blue Na-EDTA contaminated with metals Trace Elements and metals
Yellow ACD ( Acid-Citrate Anti-Coagulant DNA Studies
Dextrose) Paternity Test
HLA Tissue Typing
(Human Leukocyte Antigen)
Blood sampling errors
Errors that arise when the clinician first obtains specimens from the patient.
• Insufficient specimen. It may prove to be impossible for the laboratory to
measure everything requested on a small volume.
• Prolonged stasis during venipuncture. Plasma water diffuses into the
interstitial space and the serum or plasma sample obtained will be
concentrated. Proteins and protein-bound components of plasma, such as
calcium or thyroxine, will be falsely elevated.
• Inappropriate sampling site. Blood samples should not be taken
‘downstream’ from an intravenous drip. It is not unheard of for the laboratory
to receive a blood glucose request on a specimen taken from the same arm
into which 5% glucose is being infused. Usually the results are biochemically
incredible but it is just possible that they may be acted upon with disastrous
consequences for the patient.
Blood sampling errors
• Blood sampling technique. Needle too small, pulling too hard on plunger of
syringe or expelling blood vigorously into a tube may lead to hemolysis with
consequent release of potassium and other red cell constituents.
• Incorrect specimen container. the blood must be collected into a container
with right content (anticoagulant and/or preservative). For example,
• Samples for glucose should be collected into container containing fluoride,
which inhibits glycolysis;
• Blood that has been exposed, even briefly, to EDTA will have a markedly
reduced calcium concentration, approaching zero, along with an
artefactually high K+ concentration. (EDTA chelates Ca2+and is present as
its K+ salt.)
Case
The laboratory staff were concerned when a serum specimen from an outpatient
due to attend the diabetic clinic was analyzed and the following results were
found:
Investigation (serum) Result Normal range
Potassium 12.2 mEq/L 3.5-5.5 mEq/L
Sodium 140 mEq/L 135-145 mE/L
Creatinine 84 µmol/L 53 to 97.2 µmol/L
Calcium 0.34 mmol/L 2.2 to 2.6 mmol/L
phosphate 1.22 mmol/L 0.97-1.45 mmol/L

Comment The potassium and calcium concentrations are not compatible with
life. Investigation disclosed that a locum phlebotomist who had taken the blood
had collected the original specimen into a tube containing (potassium) fluoride
and oxalate, the correct container for an accurate blood glucose measurement,
but had then concealed his error by transferring the sample to a plain tube.
Oxalate acts as an anticoagulant by binding to calcium ions (cofactors in several
of the reactions in the clotting cascade) to form insoluble calcium oxalate.
Urine specimens
• Urine specimen containers may include a preservative to inhibit bacterial
growth, or acid to stabilize certain metabolites.
• Timed Collection: Urine collected over a specific period (e.g., 24 hours) to
measure total volume and analyte excretion. They need to be large enough to
hold a full 24-hour collection.
• Random urine samples: collected at any time of the day into small
‘universal’ containers, suitable for routine screening.
• First Morning Sample: Preferred for some tests as it's usually the most
concentrated.
• Midstream Clean Catch: Preferred method to minimize contamination with
bacteria from the genitals.

Other specimen types

• For some tests, specific body fluids or tissue may be required (Arterial
blood, feces, saliva, CSF, etc. There will be specific protocols for the
handling and transport of these samples to the laboratory. Consult the local
lab for advice.
Performance of a diagnostic test
• In biomedical studies, diagnostic tests are used to determine the presence
or absence of diseases in study subjects. For example testing for invasive
carcinoma.
• A diagnostic test is validated by comparing test results against a gold
standard that establishes the true status of the subject.
• Test validation is an evaluation method used to determine the fitness of a
test for a particular use and through it, one can assess how good the test
is at identifying subjects with and without a disease or condition.
• Validation involves calculating four objective measures of test
performance, namely, sensitivity (Se), specificity (Sp), positive predictive
value (PPV) and negative predictive value (NPV).
• These calculations gives us an answer to the following question:
• "How well this test discriminates between certain two conditions of
interest (health and disease; two stages of a disease etc.)?".
• The ideal diagnostic test would correctly identify subjects with and without
the disease with 100% accuracy.
Performance of a test
• Calculations of the test performance parameters are based on a four-fold
table, where a set of individuals is divided into a group of healthy and
diseased individuals based on a definitive method (gold standard), and
the individuals have been examined by the tested laboratory test.
• The gold standard is the most reliable and definitive method used
to diagnose a particular disease or condition. It's the benchmark
against which all other diagnostic tests are compared.
• Not Always a Perfect Test: While considered the most reliable, a gold
standard test isn't necessarily perfect. It may have limitations or
drawbacks, such as being invasive, expensive, or time-consuming.
• Varies depending on the disease. For instance:
• Biopsy: Removing a tissue sample for microscopic examination is the gold
standard for diagnosing many cancers.
• Angiography: X-ray imaging of blood vessels using a contrast dye is the
gold standard for diagnosing certain vascular diseases.
• Autopsy: Examination of organs and tissues after death can be the gold
standard for confirming some diagnoses.
Sensitivity and specificity concept
• Thus, by that gold standard test, each person taking the new test either
has (sick) or does not have the disease (healthy).
• On the other hand, the new test outcome can be positive (classifying the
person as having the disease) or negative (classifying the person as not
having the disease).
• The test results for each subject may or may not match the subject's actual
status determined by the gold standard.
• In that setting:
• True positive (TP): Sick people correctly identified as sick
• False positive (FP): Healthy people incorrectly identified as sick
• True negative (TN): Healthy people correctly identified as healthy
• False negative (FN): Sick people incorrectly identified as healthy
In other words
Actual disease status
Sick Healthy

+ TP FP
Test result
- FN TN
Sensitivity of a test
• Ability of a test to identify correctly affected
individuals
• proportion of people testing positive among affected
individuals
Actual disease status
Sensitivity (Se) = Sick Healthy
TP / ( TP + FN )
+ TP FP
Test result

- FN TN
Specificity of a test
• Ability of test to identify correctly non-affected
individuals
• proportion of people testing negative among non-
affected individuals
Actual disease status
Specificity (Sp) = Sick Healthy
TN / ( TN + FP )
+ TP FP
Test result

- FN TN
FOBT performance in colon CA
Colon CA
+ - Total
+ 350 1900 2250
FOBT
- 150 7600 7750
Total 500 9500 10000
• Sensitivity = 350 / 500 = 0.7= 70 %
• Specificity = 7600 / 9500 =0.8 = 80 %
A NEW test performance in colon CA
Colon CA
+ - Total
NEW + 470 850 1320
test - 30 8650 8680
Total 500 9500 10000
• Sensitivity = 470 / 500 = 0.94= 94 %
• Specificity= 8650 / 9500 =0.911 = 91.1 %
• From the previous data it seems that NEW test
has a better performance than the fecal occult
blood test
• When aiming to identify the true positives, NEW test
establishes the diagnosis in 94% of the sick individuals
(Se = 94%, Error (False negative rate) = 6%). Compere
that to the FOBT.
• When aiming to identify the true negatives, CNEW test
rules out the disease in 91.1 % of the healthy
individuals (Sp = 91.1%, Error (False positive rate) = 8.9
%). Compere that to the FOBT.
Distribution of quantitative test results
• In the previous example, the test have only two possible
results +ve or –ve, Another example of such tests is
qualitative urine pregnancy test
• Many tests on the other hand show results that are
continuous and have an infinite number of possible
results, Example: WBC count, blood glucose level.
• As you will see in the next slides, this type of test requires
the definition of “threshold for positive results”. Above
that threshold, the test result is considered positive.
• Notice also the reference interval for what is considered
a normal reading.
 Distribution of quantitative test results
among affected and non-affected people
(ideal case) Non-affected:
Affected:
Threshold for
positive result
Number of people tested

TN TP

0 5 10 15 20 25 30

Reference Quantitative result of the test

interval
 Distribution of quantitative results
among affected and non-affected people
(Realistic case) Threshold for Non-affected:
positive result Affected:
Number of people tested

TN TP

FN FP
0 5 10 15 20 25 30
Reference
interval Quantitative result of the test
Effect of Decreasing the Threshold
Effect of Increasing the Threshold
Lessons learned
• Different threshold points yield different
sensitivities and specificities for a quantitative test
• The threshold determines how many subjects will
be considered as having the disease
• The threshold that identifies more true negatives
will also identify more false negatives
• The threshold that identifies more true positives
will also identify more false positives
Where to draw the threshold?
Balance the severity of the consequences of false positives against the
severity of the consequences of false negatives:

• When FP is worse than FN

• Example scenarios: Burden on follow-up services (further testing is
expensive or invasive), or labeling effect (HIV and STDs) and the stress
associated with it (Cancer and screening for fetal anomalies)
• In this case minimize false positive, i.e. use a threshold that results in high
specificity (increase the threshold)
• When FN is worse than FP
• If the penalty for missing a case is high (e.g., the disease is fatal or serous
and treatment exists, or disease easily spreads; (Failure to intervene)
• In this case maximize true positives, i.e. use a threshold that results in high
sensitivity (decrease the threshold)
Test efficiency

• The efficiency of a test is the number of correct results

divided by the total number of tests. Thus efficiency is
given by:
TP + TN
Efficiency = X 100%
Total Number of tests

• When sensitivity and specificity are equally important, the

test with the greatest efficiency should be used.
Positive and Negative Predictive Values
• Positive predictive value (PPV)
• The proportion of patients with positive test results that
actually have the disease to the total individuals who
tested positive
• PPV = TP/ (TP + FP)
• Negative predictive value (NPV)
• The proportion of individuals with negative test results
and actually are free of the disease to the total
individuals who tested negative
• NPV = TN / (TN + FN)
 Positive and Negative Predictive Values
• PPV and NPV are affected by the Prevalence of the
disease
• Prevalence1 is the proportion of persons in a
population who have a particular disease at a
specified point in time or over a specified period of
time.
Prv = Persons with the disease
X 100 %
Total population
1Prevalence differs from Incidence which refers to the occurrence of new cases
of disease or injury in a population over a specified period of time. Although
some epidemiologists use incidence to mean the number of new cases in a
community, others use incidence to mean the number of new cases per unit of
population.
PPV and NPV calculation (Community A)
Se = 70 % Colon CA
Sp = 80 %
Prv= 5 % + - Total
+ 350 1900 2250
FOBT
- 150 7600 7750
Total 500 9500 10000

• PPV = TP/ (TP + FP)

= 350 / 2250 = 0.156= 15.6 %
• NPV = TN / (TN + FN)
= 7600 / 7750 =0.981 = 98.10 %
PPV and NPV calculation (Community B)
Se = 70 % Colon CA
Sp = 80 %
Prv= 10 % + - Total
+ 700 1800 2500
FOBT
- 300 7200 7500
Total 1000 9000 10000

• PPV = TP/ (TP + FP)

= 700 / 2500 = 0.28 = 28 %
• NPV = TN / (TN + FN)
= 7200/ 7500 =0.96 = 96 %
When thinking about predictive value of a
test….
• The sensitivity and specificity are properties of the test.
• The positive and negative predictive values are properties of both
the test and the population you test.
• If you use a test in two populations with different disease prevalence,
the predictive values will be different.
• A high PPV indicates a strong chance that a person with a positive
test has the disease whereas a low PPV is usually found in
populations with low prevalence of the condition being examined.
• A high NPV means that a negative test in effect rules out the
disease.

How to remember?
• PPV: “I just got a positive test result back on my patient. What is the
chance that my patient actually has the disease?”

• NPV: “I just got a negative test result back on my patient. What is the
chance that my patient actually doesn't have the disease?”
Effect of population prevalence on the values of positive
and negative predictive values, using a test with a
sensitivity and specificity of 85%.
 Lab Methods
Self Reading Topic 1: Likelihood
Ratios
Likelihood ratio (LR) for a test result
• Likelihood ratio for a test result is the probability of obtaining this test
result in those with the disease divided by the probability of obtaining
the same result in those without the disease.
• Positive Likelihood Ratio (LR+) is the probability of obtaining a
positive result in those with the disease divided by the probability of
obtaining a positive result in those without the disease. In other
words: TPR/FPR

• Higher LR+ values strengthen suspicion of disease. (i.e. increases

the probability of the disease given a positive result)
Likelihood ratio (LR) for a test result
• Negative Likelihood Ratio (LR-) is the probability of obtaining a
negative result in those with the disease divided by the probability of
obtaining a negative result in those without the disease. In other
words: FNR/TNR

• Lower LR− values reduce suspicion of disease. (i.e. decreases the

probability of the disease given a negative result)

• Similar to sensitivity and specificity, likelihood ratios do not change

when we change the population we are testing, unlike PPV and NPV,
which do.
Impact of LR Strength
LR+ Range Effect on Post-Test Probability
>10 Large increase: Dramatic shift in probability
Moderate increase: Meaningful but not definitive change in
5–10
probability.
Small increase: Clinically relevant but limited impact on
2–5
probability.
1–2 Negligible: Minimal or no meaningful diagnostic value.

LR- Range Effect on Post-Test Probability

<0.1 Large increase: Dramatic shift in probability
Moderate increase: Meaningful but not definitive change in
0.1–0.2
probability.
Small increase: Clinically relevant but limited impact on
0.2–0.5
probability.
0.5–1 Negligible: Minimal or no meaningful diagnostic value.
LH+ and LH- calculation

Se = 70 % Colon CA
Sp = 80 %
Prv= 5 % Sick Healthy Total
+ 350 1900 2250
FOBT
- 150 7600 7750
Total 500 9500 10000

• LH+= Se / (1-Sp) = 0.7/ (1-0.8) = 3.5 (i.e. a positive

result makes disease 3.5 times more likely (=LH+))
• LH- = (1-Se) / Sp = (1-0.7) / 0.8 = 0.375 (i.e. a
negative result makes disease 2.67 times less likely .
(i.e. (1/LH-) times less likely )
FLUIDS AND
ELECTROLYTES
Importance
• Understanding fluid and electrolyte balance is fundamental in
clinical biochemistry.
• These parameters are tightly regulated to maintain cellular function
and overall body homeostasis.
• Even subtle imbalances can have profound clinical consequences,
making their assessment and management critical in patient care.

Example Imbalance Clinical Consequences

Hyponatremia (↓Na⁺) Confusion, seizures, coma

Hyperkalemia (↑K⁺) Muscle weakness, fatal arrhythmias

Hypovolemia Shock, organ failure

Edema Tissue swelling, impaired organ function

Water distribution
• Water is most abundant body compound
• Water accounts for about 80% of body weight in newborn, about
60% in adult males; and about 55% in adult females
• Two Major Compartments
• Intracellular Fluid (ICF, ~66% of Total Body Water
(TBW)): Metabolic reactions, cell integrity.
• Extracellular Fluid (ECF, ~33% of TBW): Transport medium
(nutrients/wastes), cell environment.
• Plasma (8% TBW): Central circulation.
• Interstitial Fluid (25% TBW): Local cell bathing.
Water Movement Between Compartments
• Between ICF & ECF: Governed by OSMOSIS
• Driven by osmolality (Total solute particles/kg water (mOsm/kg)).
• Primary Ions: ECF (Na⁺), ICF (K⁺) (See next slide for details)
• Normally, the ICF and ECF have equal osmolality (≈ 290
mOsm/kg (Isotonic))
• Ion gradients are actively maintained by: Na⁺/K⁺-ATPase.
• Changes in the osmolality of a compartment drives water
movement across cell membranes to restore isotonicity.
• ↓ ECF osmolality (as in some cases of true hyponatremia) →
water shifts into cells → cellular swelling
• ↑ ECF osmolality (as in cases of hyperglycemia or mannitol
treatment) → water shifts out of cells → cellular dehydration
ECF and ICF Osmolality Key Players
Extracellular Fluid (ECF):
• Main contributors: Na+ and its associated counter ions (Cl- and HCO3-)
• Other factors: Glucose and urea (smaller contribution).
• Plasma proteins (e.g., albumin) contribute minimally to osmolality due to high
molecular weight, but their molar concentration is ~1 mmol/L.
Intracellular Fluid (ICF):
• Main contributors: K+ and its associated counter ions (phosphates, proteins)
Colloid Osmotic Pressure:
• Protein concentration in plasma is much higher than interstitial fluid.
• Capillaries are relatively impermeable to proteins.
• This difference creates an osmotic pressure drawing water into the
bloodstream, known as colloid osmotic pressure or oncotic pressure.
Note: Although protein concentration in plasma is high, its contribution to
overall ECF osmolality is minor due to the impact of molecular weight on
osmolality calculations.
Water Movement Between Compartments
• Between Plasma and Interstitium (Within ECF): Governed by
STARLING FORCES
• Hydrostatic Pressure: Blood pressure in capillaries (Pushes water
out)
• Colloid Osmotic (Oncotic) Pressure: Plasma proteins, mainly
albumin (Pulls water in)
• Net Fluid Movement = [Hydrostatic Pressure - Oncotic Pressure]
• Arterial End (↑Hydrostatic): Net filtration → fluid enters
interstitium.
• Venous End (↓Hydrostatic): Net reabsorption → fluid returns to
plasma.
• Lymphatics: Drains excess filtrate.
• EDEMA = Imbalanced Starling Forces
This diagram illustrates the
approximate distribution of water,
sodium, and potassium a healthy, non-
obese 70 kg man. The figure highlights
the selective distribution of major
cations: K⁺ predominates in the ICF,
while Na⁺ is the primary cation in the
ECF. Water moves freely across the
cell membrane between the ICF and
ECF compartments, driven primarily by
osmotic forces. Across the capillary
membrane within the ECF, water and
small solutes (like Na⁺) move freely,
maintaining overall osmotic equilibrium
between plasma and interstitial fluid.
However, plasma proteins (e.g.,
albumin) are largely confined to the
plasma compartment due to their size
and the selective permeability of the capillary endothelium. This confinement creates
a selective osmotic gradient due to the protein concentration difference. This
gradient generates oncotic pressure – a key component of the Starling forces that,
opposing hydrostatic pressure, governs the net movement of fluid between plasma
and interstitial fluid.
Water Movement Between Compartments
EDEMA = Imbalanced Starling Forces:

Cause Examples

↑ Venous Pressure → ↑ Capillary Hydrostatic

Heart failure, DVT
P → Blocks Venous Reabsorption

↓ Plasma Oncotic Pressure (↓ Albumin) Nephrotic syndrome, Liver cirrhosis

↑ Capillary Permeability Sepsis, Burns, Anaphylaxis, Trauma

Lymphatic obstruction Cancer metastasis, surgery

Water Balance: Intake vs. Output

• Our bodies normally balance water intake

and loss over time.
• Water comes from: Diet & Metabolism
• Water is lost through: Kidneys, Skin,
Lungs and Gut
• Kidneys filter massive amounts (170
L/day) and reabsorb most of it.
• Minimum urine output for waste removal:
500 mL/day
• Minimum daily water intake necessary for the maintenance of water
balance is 1100 mL (although context dependent, e.g. hot vs cold
weather)
• Increased water loss (sweating, diarrhea) requires more intake
• Healthy individuals consume more than the minimum and excrete the
excess through urine.
Vasopressin (AVP): Central Regulator of Water
Balance
• ECF osmolality tightly controlled: 282–295 mmol/kg.
• When ECF osmolality increases: e.g., dehydration or non-
diffusible solute (a solute that does not cross cellular membranes):
• Water shifts from ICF → ECF trying to restore isotonicty.
Nonetheless, it will not be restored completely allowing for:
• Vasopressin release → concentrated urine → water
conservation (small urine volume)
• Stimulation of hypothalamic thirst center → water intake
• Note: If a diffusible solute like urea increases ECF osmolality, it
also enters cells → no stimulation of vasopressin release.
• When ECF osmolality decreases (e.g., overhydration):
• Vasopressin release is suppressed → dilute urine → water
excretion (large urine volume)
Vasopressin & Volume Status: Modifying the
Response
Volume Status Modulates Osmotic Stimulus: The relationship
between plasma osmolality and AVP secretion is profoundly
influenced by ECF volume:
During Euvolemic state:
• AVP release follows a standard curve,
increasing with rising osmolality.
• At a normal osmolality of 282
mmol/kg, vasopressin release is
minimal.
• When osmolality goes above 282
mmol/kg, vasopressin secretion
increases sharply, leading to renal
water conservation and
concentrated urine.
Vasopressin & Volume Status: Modifying the
Response
During hypovolemic state (Low blood volume): Volume depletion
intensifies the vasopressin response.
• The osmolality threshold for AVP release is lowered (AVP is released
at lower osmolalities).
• AVP secretion increases more steeply for a given osmotic stimulus.
During hypervolemic state (High blood volume): Increased volume
suppresses AVP release.
• The osmolality threshold for AVP release is elevated.
• AVP secretion is blunted for a given osmotic stimulus.
Vasopressin & hypotension
Hypotension:
• Interestingly, vasopressin response to blood
pressure drops is exponential.
• Small decreases have minimal effect, but larger
drops trigger a massive vasopressin surge.
• This emphasizes the body's priority to maintain
blood volume, pressure and tissue perfusion
over a perfectly adjusted osmolality
• Hypovolemia and hypotension together intensify the vasopressin
response. (They not only lower the threshold for vasopressin release
but also increase its sensitivity to rising osmolality)
• These changes in vasopressin release/response are mediated by:
• Angiotensin II
• Baroreceptors (blood vessel sensors for pressure changes)
• Volume receptors (detect blood volume)
More Than Osmolality: Factors Influencing
Vasopressin

Factors affecting vasopressin secretion. ECF osmolality

is normally the most important of these.
Types of fluid loss

Feature Pure Water (Hypotonic) Loss Isotonic Fluid Loss

Insufficient intake or Insufficient
Primary Cause Vomiting, diarrhea, bleeding, burns with
intake with Diabetes Insipidus,
Examples inadequate correct replacement
fever, hyperventilation, sweating
ECF Osmolality ↑↑ Usually remains normal
ECF Volume ↓ ↓↓↓
Key Lab Change ↑ Serum Sodium (>145 mmol/L) Normal Sodium (135-145 mmol/L)
Water Shift ICF → ECF (Cells dehydrate) Minimal ICF shift (Cells unaffected)
Thirst, Neurological (confusion,
Dominant Symptoms Hypotension, tachycardia, oliguria
seizures)
Primary
RAAS ↑↑ (Aldosterone ↑), ADH ↑ (via
Compensatory ADH ↑, Thirst ↑↑
volume)
Mechanism
Urine Osmolality High (>600 mOsm/kg) Variable (Depend on ADH levels)
Treatment Goal Replace WATER (PO/IV D5W) Replace ISOTONIC FLUID (NS, LR)
Sodium in the Body: Balance
Total Body Sodium:
• ~4000 mmol (adult male); 70% exchangeable while the remaining 30% is
stored in bones.
Sodium Distribution:
• Most exchangeable sodium is found in the extracellular fluid (ECF)
• Normal ECF sodium concentration: 135-145 mmol/L.
• ICF sodium concentration is much lower: 4-10 mmol/L.
• Cell membranes limit sodium entry, but some leaks occur.
• Na+/K+-ATPase actively pumps sodium out of ICF, maintaining the gradient.
Sodium Balance:
• Daily Intake: 100–200 mmol (Western diet; often exceeds needs).
• Excretion:
• Obligatory Loss: <20 mmol/day (skin, gut, kidneys).
• Excess: Excreted via kidneys.
• Chronic high intake → Risk hypertension.
Sodium in the Body: Balance
Massive Internal Sodium Movement:
• Gut: Secretes/reabsorbs 1,000 mmol/day (digestive processes).
• Kidneys: Filter 25,000 mmol/day → reabsorb >99% (critical for balance).
• Disrupted reabsorption (e.g., diarrhea, kidney disease) → imbalances.
Renal Regulation
• Key Role: Kidneys adjust excretion to match intake.
• Process:
• Filtered Na⁺ is mostly reabsorbed (proximal tubules).
• Fine-tuned in distal nephron (aldosterone-dependent).

ECF Volume Depends on Sodium:

• The volume of the ECF is directly linked to total body sodium content.
• Since sodium is the major contributor to ECF osmolality and is largely
confined to the ECF, its content dictates ECF volume.
The Kidneys: Fine-Tuning Sodium Excretion
Distal Control for Fine-Tuning:
• Although most reabsorption happens earlier, the distal convoluted tubules
(DCTs) and collecting ducts are crucial.
• Precise adjustment of Na⁺ excretion (final "fine-tuning").
• Primarily controlled by aldosterone (key regulator)
Aldosterone:
• Binds receptors in DCT/collecting ducts → ↑ ENaC channels and Na⁺/K⁺-
ATPase → ↑ Na⁺ reabsorption.
• Without aldosterone, these segments cannot fine-tune Na⁺.
• Aldosterone is released in response to the renin-angiotensin system
activation, which is triggered primarily by a decrease in effective
circulating volume (ECV).
Effective circulating volume (ECV) in Renal Sodium
Regulation
• ECV is the volume of arterial blood that effectively perfuses tissue (delivers
oxygen and nutrients to the tissues)
• It's important to note that ECV is a dynamic concept, not a physically
measurable compartment within the body.
• ECV is not the same as total blood volume.
• It's influenced by cardiac output, vascular tone, plasma oncotic
pressure.
• Example: Heart failure → normal/high total blood volume but ↓ ECV
(poor cardiac output).
ECV as a RAAS Trigger
• ↓ ECV (e.g., dehydration, heart failure, hypoalbuminemia) → ↓ Renal
perfusion → Renin release → RAAS activation → Aldosterone →
Na⁺/water retention → restores ECV.
Physiological responses to a decrease in ECV
Summary
• ECV is the functional
signal for blood volume
status.
• RAAS adjusts
sodium/water retention
based on ECV, not total
blood volume.
• By monitoring ECV, the
kidneys can adjust sodium
excretion and ultimately
influence blood volume to
maintain a healthy
balance.
Natriuretic Peptides Role in Sodium Excretion
Atrial Natriuretic Peptide (ANP):
• ANP is secreted by the heart in response to high blood volume or pressure.
• Mechanisms of action:
• Directly inhibits sodium reabsorption in the DCTs.
• Suppresses renin secretion, leading to lower aldosterone and less sodium
reabsorption.
• Counteracts the blood pressure-raising effects of norepinephrine and
angiotensin II.
• May increase GFR.
• Relaxes blood vessels (vasodilatory effect).
Brain Natriuretic Peptide (BNP)
• Structurally similar and shares similar properties with ANP in regulating sodium
excretion, is secreted by the heart ventricles in response to stretching.
ANP/BNP act as emergency brakes against fluid overload, promoting
sodium/water excretion and vasodilation when blood volume/pressure
rises.
Laboratory assessment of water and sodium
status
1. Plasma Sodium Concentration [Na⁺]:
• What It Reflects:
• Ratio of Na⁺ to Water in plasma.
• Does NOT accurately indicate:
• Total body Na⁺ content.
• Sodium depletion/excess as this requires clinical context and other tests
• Interpretation Pitfalls:
• ↑ [Na⁺]: Can occur with Na⁺ depletion if water loss > Na⁺ loss.
• ↓ [Na⁺]: Can be due to water retention diluting Na⁺, but can occur due to
Na⁺ loss > water loss. (see hyponatremia topic later in this chapter)
• Normal [Na⁺]: Possible with isotonic fluid loss (e.g., hemorrhage).
• When to Measure:
• Dehydration/excessive fluid loss.
• Patients on parenteral fluids (comatose, elderly, infants).
• Unexplained CNS symptoms (confusion, irritability).
Laboratory assessment of water and sodium
status
2. Urinary Sodium tests

Test Normal Range Key Notes

24-hour U-Na⁺ 40–220 mmol/day Reflects total daily sodium excretion.
Spot U-Na⁺ context-dependent Approximates renal sodium handling.
• Low urine sodium concentration indicates not only intact reabsorptive
function but also the presence of a stimulus to conserve sodium,
• High urine sodium concentration may signify salt wasting etiologies.
• Clinical Utility:
• Differentiate prerenal vs. renal causes of acute kidney injury (AKI).
• Determine some causes of hyponatremia
• Caution
• Diuretics ↑ U-Na⁺ (avoid testing until diuretics are paused).
• Chronic kidney disease may blunt urinary Na⁺ response.
• Context Matters: Spot U-Na⁺ thresholds vary (e.g., >40 mmol/L in
SIADH).
Laboratory assessment of water and sodium
status
3. Plasma Osmolality :
• Osmolality refers to the total concentration of all solutes dissolved
plasma (mOsm) per unit of water (Kg)
• While sodium is a major player in osmolality, other solutes like
glucose, urea, and proteins also contribute.
• Clinical Uses of plasma osmolality test:
• Diagnostic approach to hyponatremia
• Water deprivation tests (diagnose diabetes insipidus).
• Detect toxic ingestions (ethanol, ethylene glycol).
• Advantage Over [Na⁺] Alone:
• Accounts for non-Na⁺ solutes (e.g., glucose in hyperglycemia).
• Gives more comprehensive picture of fluid balance.
 Laboratory assessment of water and sodium
status
• Measured vs. Calculated Osmolality

Measured Osmolality Calculated Osmolarity

Parameter
(mOsm/kg) (mOsm/L)
Lab-measured total Formula-based estimate of solute
Definition
solute concentration. concentration.
Osmometer (freezing Formula: 2×([Na⁺] + [K⁺]) + [Glucose] +
Method
point depression). [BUN] (all in mmol/L).
- Glucose (mg/dL → mmol/L): divide by
Key
18.
Conversions
- BUN (mg/dL → mmol/L): divide by 2.8.

Plasma Osmol Gap = Measured Osmolality – Calculated Osmolarity

• Must be from the same sample
• Normal: <10 mOsm/L.
• Elevated (>10): Unmeasured solutes (e.g., toxins, mannitol, alcohols).
Conditions Altering Plasma Osmolality
Increased Osmolality

With Normal Gap With Elevated Gap

- Hyperglycemia (DKA, HHS).
- Hypernatremia due to excessive NaCl or - Toxins (ethanol,
NaHCO3intake methanol, ethylene
- Hypernatremia due to dehydration: when fluid glycol, etc.).
intake is insufficient or losses are excessive - Mannitol administration.
(diarrhea, vomiting, sweating, diabetes insipidus).

Decreased Osmolality
• Seen in cases of Hypotonic hyponatremias (True Hyponatremias) which are
classified into:
Hypovolemic: Normovolemic: Hypervolemic:
- Diarrhea, vomiting. - - SIADH.
- Diuretic overuse. - Hypothyroidism. - CHF, cirrhosis,
- Adrenal - Psychogenic nephrotic syndrome.
insufficiency. polydipsia.
Laboratory assessment of water and sodium
status
4. Urine Osmolality (U-Osm)
• Measures: Total solute concentration in urine (normal: 50–1,200 mOsm/kg).
• Reflects kidney’s ability to concentrate/dilute urine.
• Baseline (Normal Sodium/Fluid Intake):
• 24-hour urine osmolality: 500–850 mOsm/kg.
• Random urine osmolality: 300–900 mOsm/kg.
• Fluid Restriction (12–14 hours): U-Osm should exceed 800
mOsm/kg (kidneys concentrate urine).
• Excess Fluid Intake: U-Osm can drop to 40–80 mOsm/kg (maximal
dilution).
Clinical Uses:
• Hyponatremia Evaluation
• Hypernatremia evaluation
• Dehydration Assessment
• Assessment of abnormal plasma osmolality
Laboratory assessment of water and sodium
status
5. Urine-to-Plasma (U/P) Osmolality Ratio
• Normal Ratio: 1.0–3.0.
• High U/P osmolality ratio (>3.0): This indicates that the kidneys are
concentrating urine effectively. It suggests that the body is conserving water,
which might be due to dehydration, fluid restriction, or conditions like SIADH.
• Low U/P osmolality ratio (<1.0): This suggests that the kidneys are diluting
urine, meaning the body is trying to get rid of excess water (excessive fluid
intake) or is unable to preserve water (diabetes insipidus,, or certain kidney
diseases)
Hyponatremia
• Serum sodium <135 mmol/L
• A very common disorder, occurring in up to 22% of hospitalized
patients.
• It is essentially a secondary phenomenon that merely reflects the
presence of disease; treatment should be directed at the underlying
cause and not at the hyponatremia.
• Hyponatremia itself may warrant primary treatment, but usually only
when it is severe or associated with clinical features of water
intoxication
• It has been emphasized that plasma sodium concentration depends
on the amounts of both sodium and water in the plasma, and so a low
sodium concentration does not necessarily imply sodium depletion.
Isotonic hyponatremia (Pseudohyponatremia)
• very rare
• Hyponatremia with normal plasma osmolarity (isotonicity)
• Causes:
• Severe hypertriglyceridemia (triglyceride concentrations in the
thousands of mg/dl)
• Severe hyperproteinemia, as may occur in multiple myeloma
(plasma protein concentration > 10 gm/dl)
• Sodium is confined to the aqueous phase but its concentration is
expressed in terms of total volume of plasma (i.e. water plus lipid or
proteins). In this situation plasma osmolality is normal and treatment
of hyponatremia is unnecessary
Hypertonic hyponatremias
• Hyponatremia with increased plasma osmolarity due to osmoles other than
sodium for example: glucose (in diabetes), mannitol, sorbitol, radiocontrast
agents
• Hyponatremia because of water shifting out of the cells, but both tonicity and
measured plasma osmolality are very high.
• In absence of insulin, glucose becomes an effective extracellular osmole, this
causes water movement from the intracellular compartment to the
extracellular compartment reducing the extracellular sodium concentration.
• Consequently, the sodium concentration decreases, even though the tonicity
of the ECF is increased.
• The sodium concentration falls by approximately 1.6 mEq/L for every
increase of 100 mg/dl in glucose concentration above 100 mg/dl. To make the
diagnosis of hyponatremia with hypertonicity, measured osmolality must be
clearly elevated by the hyperglycemia.
Hypotonic (True) Hyponatremias
• Hyponatremias + Decreased plasma osmolarity (hypotonicity)
• Excess total body water relative to total body sodium (i.e., sodium
depletion or sodium dilution or both)
• True hyponatremia is usually the result of an increase in circulating
ADH and/or increased renal sensitivity to ADH, combined with an
intake of free water; a notable exception is hyponatremia due to
low solute intake.
• True hyponatremias is subdivided diagnostically into three groups,
depending on clinical history and volume status, i.e.,
1. Hypovolemic hyponatremia: a decrease in body sodium
greater than the decrease in body water
2. Hypervolemic hyponatremia: an increase in total body water
that exceeds the increase in total body sodium
3. Normovolemic hyponatremia: an increase in body water with
little or no change in body sodium
Hypotonic (True) Hyponatremias
• All three forms are associated with a failure to fully dilute the urine
and mount a water diuresis in the face of hypotonic hyponatremia.
However, the disorders with which they are associated and the types
of salt and water imbalance that result differ.
• Raised values of ADH are present in the majority of patients with
hyponatremia, irrespective of the cause.
• For determining the cause of hyponatremia it is important to assess:
• Patient extracellular volume status: to do determine water
change (loss, gain, or no change)
• Urinary sodium concentration: to have an idea about the renal
function (sodium preservation or wasting)
Abnormalities of Extracellular Volume
Increased Extracellular volume:
• Extracellular Volume expansion is the result of either kidney increased
sodium (and hence water) reabsorption or impaired sodium and water
excretion.
Causes (Etiologies):
• Congestive cardiac failure, nephrotic syndrome and cirrhosis: they can
often lead to decreased effective circulating volume (CHF, nephrotic
syndrome, and cirrhosis) and decreased plasma oncotic pressure (cirrhosis
and nephrotic syndrome), which trigger compensatory mechanisms that can
indirectly contribute to fluid retention within extracellular space.
• Sodium retention:
• Renal impairment where there is a reduction in renal capacity to excrete
sodium e.g. chronic renal failure and nephritic syndrome
• Drugs: mineralocorticoids, NSAIDs
Abnormalities of Extracellular Volume
Clinical features:
• Depend on the distribution of extracellular water:
• E.g. hypoalbuminemia: interstitial volume overload
• Cardiac failure: expansion of both intravascular and interstitial
compartments
• Interstitial volume overload: pitting edema, pulmonary edema, pleural
effusion and ascites
• Intravascular volume overload: raised jugular venous pressure,
cardiomegaly and a raised arterial pressure in some cases

Pitting edema Jugular venous distension

Abnormalities of Extracellular Volume
Decreased extracellular volume
• Maybe due to loss of sodium and water, plasma or blood
Causes (Aetiology):
• Volume depletion occurs in hemorrhage, plasma loss in excessive burns, loss
of salt and water from kidneys, gastrointestinal tract or skin
Clinical features:
• Symptoms include: thirst, nausea, postural dizziness (due to hypotension)
• Interstitial fluid loss causes loss of skin elasticity “turgor”
• Loss of circulating volume causes peripheral
vasoconstriction and tachycardia, low
jugular venous pressure and postural
hypotension.
• Severe depletion of circulating volume
causes hypotension which may impair
cerebral perfusion resulting in confusion
and eventual coma
Abnormalities of Extracellular Volume
Investigations:
• Clinical diagnosis mainly
• Plasma urea (BUN) and Creatinine
• Urinary sodium
• Serum electrolytes
• Plasma and urine osmolality
• Complete blood count
Hypovolemic hypotonic hyponatremia
• Total body water ↓
• Total body sodium ↓↓
• Effective circulating blood volume is low
• Causes of Na+ losses can be classified into:
Extra-renal causes:
• Causes include:
• GI loss (e.g., vomiting (late phase), diarrhea
• Insensible loss (sweating, burns)
• Random Urine Na+ concentration is typically <20 mmole/L
Renal losses:
• Random Urine Na+ concentration is typically >20 mmol/L
• Causes include:
• Diuretic excess: Thiazide diuretics
• Mineralocorticoid deficiency: hyperkalemia and hyponatremia in a
hypotensive and/or hypovolemic patient with high urine Na+ concentration
(much greater than 20 mmol/L) should strongly suggest this diagnosis
Hypovolemic hypotonic hyponatremia
• Salt wasting nephropathy: e.g. interstitial nephropathies, recovery
phase of acute tubular necrosis
• Increased excretion of an osmotically active nonreabsorbable or
poorly reabsorbable solute e.g. glycosuria, ketonuria (e.g., in
starvation or in diabetic ketoacidosis)
• Bicarbonaturia: e.g., in renal tubular acidosis or metabolic alkalosis
(example: vomiting in early phase, 1-3 days), where the associated
bicarbonaturia leads to loss of Na+
Hypervolemic hypotonic hyponatremia
• Total body water ↑↑
• Total body sodium ↑
(i.e. dilutional hyponatremia)
• Causes can be separated by the effect on urine Na+ concentration:
• Acute or chronic renal failure
• uniquely associated with an increase in urine Na+ concentration.
• renal insufficiency can reduce the ability to excrete free water
• Random Urine Na+ concentration is >20 mmol/L
• Sodium-avid edematous disorders:
• Causes are congestive heart failure, cirrhosis, and nephrotic syndrome
• Pathophysiology is similar to that in hypovolemic hyponatremia, except that
Effective circulating blood volume is decreased due to the specific etiologic
factors (e.g., cardiac dysfunction in CHF, peripheral vasodilation snd
hypolbuminemia in cirrhosis, hypoalbuminemia in nephrotic syndrome)
while in hypovolemic hyponatremia it’s a real volume loss
• Usually clinically obvious and no further investigation is necessary.
• Radom Urine Na+ concentration is <20 mmol/L (typically very low, i.e., <10
mmol/L), this state may be obscured by diuretic therapy.
Normovolemic hypotonic hyponatremia
• Total body water ↑
• Total body sodium

↑
↑
• Normovolemic (Euvolemic) hyponatremia is due mainly to expansion of total
body water caused by excessive intake in the face of a failure to dilute the
urine in response to excessive water intake.
• The impaired dilution of urine is usually caused by a defect in the osmotic
suppression of ADH that can have either of two causes:
• A nonhemodynamic stimulus such as nausea or a cortisol deficiency; seen
in secondary adrenal insufficiency (low cortisol and high CRH increase
ADH secretion), which often presenting with a 'SIADH-like’ picture. Or,
• A primary defect in osmoregulation caused by another disorder such as
malignancy, stroke, or pneumonia commonly known as Syndrome of
inappropriate secretion of ADH (SIADH)
The syndrome of inappropriate secretion
of ADH (SIADH)
• The syndrome of inappropriate secretion of ADH (SIADH)
• Defined by hyponatremia and low plasma osmolality resulting from
inappropriate, continued secretion or action of ADH which results in
impaired water excretion despite low plasma osmolality
• The most frequent cause of Normovolemic Hyponatremia
• SIADH is essentially a diagnosis of exclusion and it is important to rule out
other causes of hyponatremia before confirming SIADH. (It is frequently
diagnosed on insufficient evidence without regard to other possible causes
of hyponatremia)
• Edema is NOT a feature of SIADH: the excess of water is distributed
throughout both the ICF and the ECF and the effect on ECF volume is
insufficient to cause edema.
The syndrome of inappropriate secretion
of ADH (SIADH)
• The syndrome of inappropriate secretion of ADH (SIADH)
• Ingestion of water is an essential prerequisite to the development of the
syndrome. Regardless of cause, hyponatremia does not occur if water
intake is severely restricted.
• The key to understanding the pathophysiology, signs, symptoms, and
treatment of SIADH is the awareness that the hyponatremia results from
an excess of water rather than a deficiency of sodium.
• Measurement of ADH concentration is seldom helpful in differential
diagnosis: raised values are present in the majority of patients with
hyponatremia, irrespective of the cause.
• Causes are classified into either: ectopic secretion or inappropriate
secretion
The syndrome of inappropriate secretion
of ADH (SIADH)
The syndrome of inappropriate secretion
of ADH (SIADH)
Diagnostic features: of SIADH can be summarized as follows :
• Hyponatremia
• Decreased plasma osmolality
• Inappropriately concentrated urine (it is sometimes said that the osmolality of
the urine should be greater than that of the plasma but it is sufficient that it is
not maximally dilute; urine osmolality > 100 mOsm/L)
• Continued natriuresis (urinary sodium >40 mmol/L)
• No clinical evidence of fluid depletion or overload
• Normal renal function
• Normal adrenal function
• Clinical and biochemical response to fluid restriction (i.e. Correction of
hyponatremia by fluid restriction)
• Absence of other causes of hyponatremia
Clinical Features of true Hyponatremia
• Hyponatremia induces generalized cellular swelling, a consequence of
water movement down the osmotic gradient from the hypotonic ECF to the
ICF.
• The symptoms of hyponatremia are primarily neurologic, reflecting the
development of cerebral edema within a rigid skull.
• Acute hyponatremic
encephalopathy ensues when
the brain is overwhelmed by a
rapid decrease in tonicity,
resulting in acute cerebral
edema. Early symptoms can
include nausea, headache, and
vomiting. However, severe
complications can rapidly evolve,
including seizure activity,
brainstem herniation, coma,
and death.
Clinical Features of true Hyponatremia
• Persistent, chronic hyponatremia results in an efflux of organic
osmolytes (creatine, glutamate, myoinositol, and taurine) from brain
cells; this response reduces intracellular osmolality and the osmotic
gradient favoring water entry. This reduction in intracellular osmolytes is
largely complete within 48 h, the time period that clinically defines
chronic hyponatremia;
• The cellular response to chronic hyponatremia does not fully protect
patients from symptoms, which can include vomiting, nausea,
confusion, and seizures, usually at plasma Na+ concentration <125
mmole/L.
• Even patients who are judged “asymptomatic” can manifest subtle gait
and cognitive defects that reverse with correction of hyponatremia
Hypernatremia
• Serum sodium > 145 mmol/L
• results from water loss in excess of sodium in addition to impaired
thirst/intake.
• More rarely it is caused by excess administration of sodium (iatrogenic)
• Insufficient fluid intake is most often elderly, neonates or unconscious
patients when access to water is denied or confusion or coma eliminates
normal response to thirst.
Clinical features:
• Altered mental status is the most frequent manifestation, ranging from mild
confusion and lethargy to deep coma.
• Anorexia, restlessness, nausea, and vomiting occur early.
• Hypernatremic rhabdomyolysis due to osmotic damage to muscle
membranes
• Symptoms suggestive of fluid loss and clinical signs of dehydration
Hypernatremia Causes
Hypernatremia from extra-renal water loss
• The most common causes of hypernatremia from extra-renal water loss
include:
• fever, profuse sweating, hyperventilation, including mechanical ventilation,
and severe diarrhea.
• Patients with those causes often have decreased ECFVs as well, indicating
deficits in total body sodium as well as water.
• The proportionally greater deficiency of water than of sodium leads to the
increase in the serum sodium concentration.

Hypernatremia from Renal Water Loss

• The hallmark of marked renal water loss is polyuria, defined as a urine
volume greater than 3 L/24 hours.
• The common defect in all cases of renal water loss is an inability of the
kidney to conserve water appropriately.
• There are several important causes of renal water loss.
 Causes of hypernatremia
Category Specific Causes
• Insensible losses (fever, tachypnea, mechanical ventilation)
Extrarenal
• Sweat losses in hot environment
Water Loss
• GI losses: osmotic diarrhea, acute infectious diarrhea
Osmotic Diuresis (Urine Osm excretion >750 mOsm/day):
• Glucose
• Urea (e.g., enteral tube feedings)
• Mannitol
Central DI (Inadequate ADH):
• Head trauma, post-neurosurgery
Renal Water • Neoplasms, sarcoidosis, Langerhans cell histiocytosis (LCH)
Loss • Meningitis/encephalitis, idiopathic
Nephrogenic DI (Renal ADH Resistance):
• Electrolyte disorders (hypercalcemia, hypokalemia)
• Drugs (lithium, demeclocycline)
• Recovery phase of acute renal failure
• Post urinary obstruction
• Chronic renal disease
Iatrogenic • Administration of hypertonic sodium solutions
The diagnostic approach to hypernatremia
Diabetes insipidus (DI)
• Is defined as the passage of large volumes (> 3 L/24 hr) of dilute urine (< 300
mOsm/kg).
• Causes are classified into (See slide about the causes of hypernatremia):
• Central: decreased secretion of ADH
• Nephrogenic, inability to concentrate urine because of resistance to ADH
action in the kidney
• Polyuria, polydipsia, and nocturia are the predominant manifestations of
diabetes insipidus
Laboratory tests
• 24-hour urine collection for determination of urine volume is required.
• Serum electrolytes and glucose
• Urinary specific gravity
• Simultaneous plasma and urinary osmolality
• Plasma antidiuretic hormone (ADH) level
• What test setup would you advice to differentiate between central and
nephrogenic DI?
Potassium in the Body: Balance and Importance
Location
• Potassium is the predominant intracellular cation (ICF).
• 90% of total body potassium is free. The rest is bound in red blood cells,
bones, and brain tissue.
• Only a tiny fraction (2%, 50-60 mmol) is found outside cells (ECF).
• However, ECF potassium is crucial for nerve and muscle function.
• Normal serum level 3.5-5.5 mmol/L (mEq/L)
Measuring Potassium:
• ECF potassium is easily measured but doesn't reflect total stores.
• Plasma potassium levels are NOT a perfect indicator of overall potassium
status.
Concentration Gradients:
• Potassium naturally wants to flow from high (ICF) to low (ECF) concentrations.
• The Na+/K+-ATPase pump works against this gradient, actively pushing
potassium into cells.
Regulation of Potassium
Distribution between body fluids:
• Potassium distribution across cell membranes is influenced by numerous
factors e.g. Hormones, principally insulin and Catecholamines, acid‐base
status and extracellular tonicity.
• Entry into cells is increased by: Insulin, Aldosterone, b2 adrenoceptor
agonists, Alkalosis, a Adrenoceptor antagonists
• Exit from cells is increased by: Acidosis, b2 adrenoceptor antagonists, a
Adrenoceptor agonists, Increased osmolality (as in Hyperglycemia),
Aldosterone deficiency
Total body potassium
• Aldosterone is the major regulator of body stores of potassium.
• Aldosterone stimulates potassium excretion in the distal renal tubules.
• Aldosterone secretion is subject to feedback control by potassium,
independently of the effect of renin; hyperkalemia stimulates it, hypokalemia
inhibits it
Hyperkalemia
• K+ > 5.5 mmol/L
• Dangerous due to potential for fatal dysrhythmias, cardiac arrest
• Major cause is renal disease
• Pseudohyperkalemia (an artefactual increase in serum K+ due
to the release of K+ during or after venipuncture) should be
excluded.
• It can occur in the setting of in vitro hemolysis, excessive
muscle activity during venipuncture (e.g., fist clenching), and a
marked increase in cellular elements (thrombocytosis,
leukocytosis, and/or erythrocytosis) with in vitro efflux of K+.
• Hereditary (familial) pseudohyperkalemia, caused by mutations
that increases the passive K+ permeability of erythrocytes
Hyperkalemia
Redistribution Hyperkalemia
• Redistribution hyperkalemia is caused by potassium transiently
leaving cells, thereby raising the serum potassium concentration.

Hyperkalemia Secondary to Impaired Potassium Excretion

• The majority of cases of hyperkalemia secondary to true excess of
total body potassium are due to a defect in renal potassium
excretion in the presence of ongoing potassium intake. The
impaired renal potassium excretion is due to one or both of the
following:
• Aldosterone deficiency or tubular unresponsiveness to
aldosterone
• Renal insufficiency (reduced GFR)
Causes of Hyperkalemia
Category Specific Causes
• Hemolysis during blood draw
• Excessive fist clenching
Pseudohyperkalemia • Thrombocytosis (>1M platelets/μL)
• Leukocytosis (>200K WBC/μL)
• familial pseudohyperkalemia
• Acidosis (metabolic/respiratory)
Redistribution (K⁺ Shift Out) • Hypertonic states
• Digitalis overdose
Excessive tissue breakdown eg, rhabdomyolysis, tumor lysis syndrome, or massive hemolysis
• Primary adrenal failure (autoimmune, TB, hemorrhage)
• Syndrome of hypereinemic hypoaldosteronism (SHH)
- Accounts for many cases of unexplained hyperkalemia
- GFR is generally >20%
Aldosterone - May have an associated normal anion gap metabolic acidosis
Deficiency/unresponsiveness - Caused by a variety of interstitial renal diseases
- Diabetes is the most common cause
• Tubular unresponsiveness to aldosterone
- Caused by a variety of interstitial renal diseases
- Very similar to SHH but does not respond to fludrocortisone
Stage 4/5 CKD (GFR <10-20%) • Especially with Exogenous K⁺ intake

K⁺ Sources: IV K⁺, K⁺-penicillin, salt substitutes

Redistribution: β2-blockers, succinylcholine, digitalis, hypertonic mannitol. Arginine
Drug-Induced Hyperkalemia
and lysine (HCl)
Aldosterone Deficiency/unresponsiveness : NSAIDs, ACE inhibitors, ARBs
Clinical Features of Hyperkalemia
• Severe hyperkalemia may be a medical emergency requiring immediate
treatment, depending upon the nature of any ECG abnormalities.
• Clinical manifestations of hyperkalemia usually occur when the potassium
concentration is > 6.5 mEq/L and include:
• Neuromuscular signs (weakness, ascending paralysis, and respiratory
failure)
• Typical progressive ECG changes with increasing potassium
concentration: peaked T waves, flattened P waves, prolonged PR interval.
• The cardiac changes may occur suddenly and without warning.
HYPOKALEMIA
• K+ < 3.5 mmol/L
• A common type of electrolyte imbalance
• Major cause is increased renal loss most often associated with diuretics
• Causes are classified into:
• Spurious hypokalemia
• In spurious hypokalemia, the potassium concentration is not really
low. Marked leukocytosis (> 100,000) rarely may produce spurious
hypokalemia if the blood tube is allowed to sit at room temperature.
White cells may simply take up the potassium in the blood
specimen.
• Redistribution hypokalemia
• Redistribution hypokalemia is caused by the entry of potassium into
cells.
• A dose of insulin right before blood drawing could cause temporary
movement of potassium into cells in the blood tube and falsely lower
the serum potassium. The magnitude of the fall in potassium is
generally small (around 0.3 mEq/L).
HYPOKALEMIA
• Extra-renal loss
• urine potassium >20 mEq/24 hours in a patient with hypokalemia
• GI and sweat losses
• Renal loss
• urine potassium >20 mEq/24 hours in a patient with hypokalemia
• Many of the disorders causing renal potassium loss are also
associated with acid-base disorders. Therefore, it is customary to
classify the numerous causes of renal potassium loss according to
whether they typically occur together with:
• Metabolic acidosis
• Metabolic alkalosis
• No specific acid-base disorder
Causes of hypokalemia
Category Specific Causes
Spurious • Marked leukocytosis (>100K WBC/μL)
• Insulin administration
Redistribution (K⁺ Shifts • Alkalemia
Into cells) • β₂-agonists, theophylline toxicity
• Factor replacement in megaloblastic anemia
• Diarrhea, laxative abuse
Extrarenal Loss (Urine
• Villous adenoma of the recto-sigmoid colon
K⁺ <20 mEq/24h)
• Sweat losses, fasting/inadequate intake
With Metabolic Acidosis:
• Renal tubular acidosis (I/II)
• Carbonic anhydrase inhibitors
• DKA,
• Ureterosigmoidostomy
With Metabolic Alkalosis:
• Vomiting/NG suction
Renal Loss (Urine K⁺ • Diuretic therapy
>20 mEq/24h) • Mineralocorticoid excess syndromes
• Gitelman/Bartter syndromes
No Acid-Base Disorder:
• Recovery phase of acute kidney injury
• Post urinary obstruction
• Osmotic diuresis
• Magnesium depletion
• High doses of penicillin-related antibiotics
Bartter syndrome vs. Gitelman syndrome
Bartter Syndrome (BS)
• Caused by mutations in genes related to regulated Na+, K+, and Cl– transport by the
TALH.
• Symptoms: polyuria, polydipsia,
• Hypokalemia, hypomagnesemia (20% of cases), hypercalciuria, and metabolic
alkalosis
• Severe antenatal forms: electrolyte wasting, polyhydramnios, hypercalciuria with
nephrocalcinosis
Gitelman Syndrome (GS)
• Caused by mutations in a single gene related loss-of-function mutations in the thiazide-
sensitive Na+-Cl– cotransporter of the DCT.
• Symptoms: muscle weakness, fatigue, and cramps
• Hypokalemia, consistent hypomagnesemia, hypocalciuria (opposite of BS) and
metabolic alkalosis
• Milder condition than BS, but can cause chondrocalcinosis (calcium deposits in joint
cartilage)
Key Difference:
• Urinary calcium excretion: High in BS, Low in GS
Other cause of hypokalemia
• Ureterosigmoidostomy: This surgery diverts urine into the sigmoid colon instead of
the bladder. Chronic exposure of the colon to urine can lead to hyperchloremic (normal
anion gap) metabolic acidosis. Colon cells actively exchange chloride ions (Cl-) for
bicarbonate ions (HCO3-) which is lost from the body. Associated electrolyte
abnormalities may include hypokalemia, hypocalcaemia, and hypomagnesaemia.
Hypokalemia is caused by both intestinal loss (secretion) and by renal wasting.
• Magnesium depletion: Inhibits muscle Na+/K+-ATPase activity and secondary
kaliuresis
• High doses of penicillin-related antibiotics: increase obligatory K+ excretion by
acting as non-reabsorbable anions in the distal nephron
Clinical Features of Hypokalemia
• The clinical consequences of
significant hypokalemia include:
• Neuromuscular manifestations
(weakness, fatigue, paralysis,
respiratory muscle dysfunction,
rhabdomyolysis)
• Gastrointestinal manifestations
(constipation, ileus)
• Nephrogenic diabetes insipidus
• ECG changes (prominent U
waves, Shallow (flat) T wave, ST
segment changes) and cardiac
arrhythmias (especially with
concurrent digitalis)
CALCIUM, PHOSPHATE
AND MAGNESIUM
BALANCE
Calcium
• Most abundant mineral in the human body
• Involved in important processes: Muscle contraction, coagulation,
neural transmission, bone metabolism
• Nearly most of it is extracellular (~99% in hard tissues as
hydroxyapatite Ca10(PO4)6(OH)2)

Calcium in blood
• Present in three forms:
• Bound to protein: ~ 46% (80% of the amount bound to protein
is bound to albumin):
• Complexed with small diffusible ligands (citrate and
phosphate): ~ 7%
• Free ionized calcium (iCA) (Only this form is physiologically
active, and it is that is maintained by homoeostatic
mechanisms): ~ 47%
• Concentrations are well controlled
Calcium in blood
• Calcium binds to the negatively charged sites of proteins,
especially albumin. Therefore, this binding is pH-
dependent.
• Alkalemia: leads to increased protein ionization,
increased negative charge and calcium binding, and,
consequently, decrease in free ionized calcium. This
may be sufficient to produce clinical manifestations of
hypocalcaemia, although total plasma calcium
concentration is unchanged.
• Acidemia: has the opposite effects.
Measurement of plasma calcium
concentration
• Total Calcium
• Most common method (easier, cost-effective).
• Satisfactory for routine clinical use.
• Limitations:
• Affected by albumin levels (does not reflect free calcium).
• Misleading in abnormal protein states (e.g., multiple myeloma,
hypoalbuminemia).
• Ionized Calcium (Gold Standard)
• Directly measures free, biologically active calcium (ion-selective electrode).
• Faster results; critical for rapid calcium changes (e.g., surgery, transfusions).
• Handling Requirements:
• Use whole blood and analyze immediately to prevent pH shifts or anion
chelation.
• Green-top heparin tubes are fine for total calcium but not ideal for
ionized calcium. Always confirm with your lab’s protocol for ionized
calcium testing (Syringe type and collection tube)
Corrected total calcium calculations
• Formulas exist to estimate "normal" total calcium based on albumin.
• Adjusts for albumin deviations from a normal reference, often applied
clinically when plasma albumin is below 4 g/dL or above 4.5 g/dL.
• Corrected Calcium (mg/dL) = Measured Ca (mg/dL) + 0.8 × (4.0 −
Patient’s Albumin (g/dL))
• Corrected Calcium (mmol/L) = Measured Ca + 0.2 × (4.0 −
Patient’s Albumin (g/dL))
• Note: formula assumes albumin units in g/dL.
• Limitations:
• Unreliable with abnormal pH or non-albumin protein disorders.
• Direct ionized calcium measurement preferred in these cases.
Factors affecting total calcium
measurements:
• Venous Stasis:
• Tourniquet use → falsely ↑ total calcium (avoid during blood draw).
• Protein Levels:
• High Albumin: ↑ Total calcium (no effect on ionized).
• Multiple Myeloma:
• High gamma globulins ↑ total calcium (artifact).
• True hypercalcemia may coexist (bone resorption by tumor cells).
• Hypoalbuminemia: Most common cause of pseudohypocalcemia (low
total Ca, normal ionized Ca).
Systemic control of calcium balance
• Two major hormones and one minor hormone are responsible for
calcium homeostasis
• Parathyroid Hormone - PTH
• 1,25-dihydroxy-vitamin D
• Calcitonin: lowers serum calcium by stimulating bone accretion
(suppressing osteoclast activity)
–minor physiological role: thyroidectomy has no adverse affect on
bone strength or density
PARATHYROID HORMONE (PTH)
• A polypeptide secreted from the parathyroid glands in response to a decrease
in the plasma concentration of ionized Ca2+ .
• PTH release is controlled by a cell signaling pathway that starts with cell
membrane receptor called calcium-sensing receptor (CaSR) which
senses extracellular calcium concentration.
• CaSR is a GPCR type receptor found in the PTH glands, kidneys and
brain
• In parathyroid gland cells: High plasma calcium concentrations
activate CaSR which inhibits the release of PTH, and vice versa
• In kidneys: Found in renal tubules and regulates calcium
reabsorption. High calcium levels lead to CaSR activation, decreased
calcium reabsorption and increased calcium excretion in urine, and
vice versa
• In brain: May be involved in various functions, but the exact role is still
being explored.
• CaSR is affected by Magnesium and Magnesium disorders may affect
the production of PTH.
PTH effects on plasma calcium and phosphate
PTH acts to increase the plasma Ca2+ concentration in three ways:
• It stimulates bone resorption, resulting in the release of calcium phosphate.
• It enhances intestinal Ca2+ and phosphate absorption by promoting the
formation within the kidney of 1,25 dihydroxy Vitamin D3
• It increases active renal Ca2+ reabsorption.
PTH also influences phosphate balance, although its actions may be
offsetting
• It tends to increase phosphate entry into the extracellular fluid by its effects
on bone and intestinal absorption.
• However, PTH also reduces proximal tubular phosphate reabsorption,
resulting in enhanced excretion.
• The urinary effect usually predominates in patients with relatively normal
renal function, as PTH tends to lower the plasma phosphate concentration.

• High levels of 1,25 dihydroxyvitamin D3 inhibit PTH transcription

How Calcium and Magnesium affect PTH release
• Both these divalent cations act on the same negative feedback receptor
on parathyroid cells.
• Extracellular magnesium is a direct agonist of the CaSR with a potency of
2-3 times less than that of calcium.
• Increased Magnesium and calcium leads to increased binding of these
cations with CaSR which activates the G-alpha subunit leading to PTH
release inhibition.

Hypermagnesemia suppresses PTH

release
• CaSR perceives high Magnesium levels
as high calcium levels
• Has no significant impact on PTH
resistance
• Leads to hypocalcemia
Effect of hypomagnesemia on PTH release
Mild hypomagnesemia increases PTH release:
• Seen in magnesium level as low as 1.2 mg/dL (normal: 1.7-2.2 mg/dl)
• Decrease in extracellular Magnesium leads to decreased CaSR activation.
• This leads to decreased feedback inhibition of PTH and hence, increased PTH
secretion.
Severe hypomagnesemia decreases PTH release:
• Seen in magnesium level < 1.2 mg/dL.
• Severe hypomagnesemia results in the depletion of intracellular magnesium in
PTH gland cells.
• Intracellular magnesium depletion leads to decreased magnesium binding to
G-alpha subunit associated with CaSR.
• This leads to disinhibition of G-alpha subunit which mimics CaSR activation.
• This leads to decreased PTH release (not decreased PTH synthesis).
• This effect is called paradoxical block of PTH secretion.
Effect of hypomagnesemia on PTH release
• Hypomagnesemia also results in target tissue resistance to the effects of PTH,
in particular, in the renal tubules and in bone. Several findings suggest that
PTH resistance may be of greater importance than diminished secretion in
most patients.
• In any case, hypomagnesemia (mild or severe) leads to hypocalcemia because
of this resistance issue
PTH homeostasis
Plasma Ca2+

PTH

Bone Kidneys

Resorption

Phosphate Calcium Active Vit D

Release of Ca2+ reabsorption formation
secretion
and phosphate

Effect of parathyroid hormone (PTH) on calcium and Intestinal

phosphate metabolism. The net effect is an increase in CaHPO4
the plasma calcium concentration with no change or a absorption
decrease in the plasma phosphate concentration.
VITAMIN D
• Vitamin D3 (Cholecalciferol) a fat-soluble vitamin, which is present in the diet
and also can be synthesized in the skin from 7-dehydrocholesterol in the
presence of ultraviolet light.
• In the liver, Vitamin D3 is hydroxylated by the enzyme 25–hydroxylase
resulting in the formation of 25-hydroxy vitamin D3 (25-
hydroxycholecalciferol; calcidiol)
• In the kidney, 25-hydroxyl vitamin D3 is further hydroxylated tubular by the
enzyme 1-alpha-hydroxylase producing 1,25-dihydroxy Vitamin D3, the most
active form of vitamin D (1,25-dihydroxycholecalciferol; calcitriol)
• The formation of calcitriol is primarily stimulated by PTH and
hypophosphatemia (Phosphate depletion tends to raise renal calcitriol
production and phosphate loading tends to lower renal calcitriol production)
 UV light
Skin
7-dehydrocholesterol Vitamin D3 Diet
(Cholecalciferol)

Liver
25-Hydroxy vitamin D3
Vitamin D
(25-Hydroxy Cholecalciferol; calcidiol)
metabolism
Kidneys
PTH
Hypophosphatemia
1,25-Diydroxy vitamin D3 24,25-Diydroxy Metabolic activation of
vitamin D3 vitamin D to calcitriol
(1,25-Dihydroxycholecalciferol; calcitriol)
and its effects on
(inactive)
calcium and phosphate
homeostasis. The
result is an increase in
Intestine Bone Kidneys the serum calcium and
phosphate
concentrations.

CaHPO4 CaHPO4 Ca2+ and phosphate

absorption release excretion
 Plasma Ca2+
Hormonal response
PTH
to hypocalcemia

Calcitriol

Ca2+ from Ca2+ from Phosphate from Phosphate

bone intestine bone and intestine excretion in urine

Increased serum calcium Plasma phosphate unchanged

If hypocalcemia occur, there is a direct stimulus to PTH secretion and the
subsequent formation of calcitriol. PTH increases calcium phosphate release
from bone and urinary phosphate excretion, whereas calcitriol increases
intestinal calcium phosphate absorption. Both hormones also reduce urinary
Ca2+ excretion. The net effect is an increase in the plasma Ca2+
concentration with little change in the plasma phosphate concentration. This
sequence is reversed with hypercalcemia or a high Ca2+ diet as both PTH
secretion and calcitriol production are diminished.
 Plasma PO43-
Hormonal response
Calcitriol to hypophosphatemia

Ca2+ from PTH

intestine

Ca2+ from Phosphate Phosphate from

Bone excretion in urine intestine

Plasma calcium slightly Plasma phosphate increased

increased

Physiologic sequence of events following the stimulation of calcitriol formation

by hypophosphatemia. The net effect is an increase in the plasma phosphate
concentration with only a slight increase in the plasma calcium concentration.
Both the latter change and the direct inhibitory effect of Calcitriol formation
contribute to the decline in PTH release in this setting.
HYPERCALCEMIA
• Hypercalcemia from any cause can result in fatigue, depression,
mental confusion, anorexia, nausea, constipation, renal tubular
defects, polyuria, bradycardia, AV block, and short QT interval.
• CNS and GI symptoms can occur at levels of serum calcium >11.5
mg/dL, and nephrocalcinosis and impairment of renal function occur
when serum calcium is >13 mg/dL.
• Severe hypercalcemia, usually defined as >15 mg/dL, can be a
medical emergency, leading to coma and cardiac arrest.
• With long-standing hyperparathyroidism, patients may present with
bone pain or pathologic fractures.
• Two conditions account for up to 90% of cases of hypercalcemia:
primary hyperparathyroidism and malignancy. Causes are listed in the
next slide
 Primary Hyperparathyroidism
• Hyperparathyroidism is an increased parathyroid hormone
(PTH) levels in the blood (See later for other types)
• The disorder is characterized by hypercalcemia,
hypercalcuria, hypophosphatemia, and hyperphosphaturia
• Most common complication are renal stones made of
calcium phosphate and oxalate
• Most serious complication is the deposition of calcium in
the kidney tubules resulting in impaired renal function
(nephrocalcinosis)
• Osteopenia, osteoporosis.
• Peptic ulcer disease, pancreatitis
• Psychiatric manifestations such as psychosis, coma,
depression, anxiety, fatigue
Familial Hypocalciuric Hypercalcemia (FHH)
• Inherited autosomal dominant condition causing hypercalcemia.
• Three main types; of which FHH type 1 is the most common caused
by mutations in CaSR itself.
• Mutations impair CaSR in parathyroid and kidneys and lower the
capacity of the sensor to bind calcium. The mutant receptors function
as though blood calcium levels were low, leading to
• Inappropriate PTH secretion
• Increased calcium reabsorption from kidneys
• Hypercalcemia
• Mild hypermagnesemia
• Most cases of FHH are asymptomatic. This is because the body
somewhat adapts to the chronically elevated blood calcium levels.
HYPERCALCEMIA: Diagnosis
• Serum: Ca2+, PTH, calcitriol and parathyroid hormone
related protein (PTHrp), urine calcium
HYPERCALCEMIA: Diagnosis
• Primary hyperparathyroidism is confirmed by
demonstration of an inappropriately high PTH level for the
degree of hypercalcemia.
• Hypercalciuria helps to distinguish this disorder from
FHH, in which PTH levels are usually in the normal
range (inappropriately normal or even increased
secretion of PTH) and the urine calcium level is low.
• A Ca/Cr clearance ratio (calculated as urine Ca/serum
Ca divided by urine Cr/serum Cr) of <0.01 is suggestive
of FHH, particularly when there is a family history of
mild, asymptomatic hypercalcemia.
• Levels of PTH are low in hypercalcemia of malignancy
Secondary and tertiary hyperparathyroidism

Secondary Hyperparathyroidism:
• Occurs in chronic kidney disease and vitamin D deficiency.
• Caused by decreased calcitriol production leading to low blood calcium.
• Body responds by raising PTH to increase calcium levels (appropriate
response).
• PTH may not fully normalize calcium due to resistance in bones without
enough calcitriol.
Tertiary Hyperparathyroidism:
• Rare complication in end-stage renal failure patients who receive a kidney
transplant.
• Long-term low calcium stimulates parathyroid glands to become overactive
(autonomous PTH secretion).
• After transplant, normal calcitriol production can lead to hypercalcemia due
to excessive PTH.
Renal disease and secondary
hyperparathyroidism
Case 1
• A 60-year-old man with end-stage renal disease receives a kidney
transplant. He previously had hypocalcemia due to his kidney
problems.
• New Development: After the transplant, the patient develops
hypercalcemia.
• Explanation: Long-standing hypocalcemia can lead to secondary
hyperparathyroidism (overactive parathyroid glands). After the
transplant, with improved kidney function and normal vitamin D
metabolism, the parathyroid glands may continue to be overactive,
causing hypercalcemia despite adequate calcium levels. This is called
tertiary hyperparathyroidism.
• Learning Point: Chronic hypocalcemia can have long-term
consequences on parathyroid function. In some cases, even after the
underlying cause is addressed, hyperparathyroidism may persist.
 Case 2
A 20-year-old man is hospitalized after sustaining a pelvic fracture in an
automobile accident. One month into his hospitalization, the patient notes nausea
and anorexia. Before the injury, he was in good health and took no medications.
Family history is unremarkable. Current medications are enoxaparin and
hydromorphone.
Physical examination reveals an alert, oriented, and thin patient with normal vital
signs. Thyroid examination reveals no goiter, and the lungs are clear to
auscultation. The patient is immobilized in bed and a pelvic external fixation device
is in place. Neurologic examination findings are unremarkable.
Laboratory studies show: normal albumin, high calcium, high creatinine, normal
phosphate, low parathyroid hormone, normal calcidiol, low calcitriol, and normal
endocrine panel.
Which of the following is the most likely cause of his hypercalcemia?
A. Acute kidney injury
B. Familial hypocalciuric hypercalcemia
C. Humoral hypercalcemia of malignancy
D. Hypercalcemia of immobilization
HYPOCALCEMIA
• Serum total calcium concentrations below the reference
interval for the appropriate age and sex reflect a
hypocalcemic status.
• Mildly low levels that develop slowly often have no
symptoms.
• Otherwise symptoms may include numbness, muscle
spasms, seizures, confusion, or cardiac arrest
Clinical manifestations of hypocalcemia
Acute Chronic
Neuromuscular irritability (Tetany) Ectopic calcification (basal ganglia)
Paresthesias (peri-oral, extremities) Extrapyramidal signs
Muscle twitching Parkinsonism
Carpopedal spasm Dementia
Trousseau's sign Subcapsular cataracts
Chvostek's sign Abnormal dentition
Seizures Dry skin
Laryngospasm (causes stridor)
Bronchospasm (causes wheezing)
Cardiac
Prolonged QT interval
Hypotension
Heart failure
Arrhythmia
Papilledema
• Prolongation of the Q-T interval (ST-segment portion) is typical of
hypocalcemia. Hypercalcemia may cause abbreviation of the ST
segment and shortening of the QT interval.
Etiologies of Hypocalcemia
Low PTH (primary hypoparathyroidism)
Genetic disorders
Destruction of parathyroid glands: Post-surgical, Autoimmune, Infiltration of the parathyroid gland,
Radiation
Severe hypomagnesemia (involved in PTH resistance also), Hypermagnesemia
Hungry bone syndrome (post parathyroidectomy)
High PTH (secondary hyperparathyroidism in response to hypocalcemia)
Vitamin D deficiency or resistance
Parathyroid hormone resistance
- Pseudohypoparathyroidism
- Mild hypomagnesemia
Renal disease (See previously)
Loss of calcium from the circulation (Hyperphosphatemia, Tumor lysis, Acute pancreatitis, Acute
respiratory alkalosis)
Drugs
Inhibitors of bone resorption (bisphosphonates, calcitonin), especially in vitamin D deficiency
Cinacalcet: calcimimetic that activates CaSR causeing PTH secretion inhibition
Calcium chelators (EDTA, citrate, phosphate)
Foscarnet (antiviral, due to intravascular complexing with calcium)
Phenytoin (due to conversion of vitamin D to inactive metabolites)
Disorders of magnesium metabolism
Hypomagnesemia causes PTH resistance with reduced or increased PTH secretion
Hypermagnesemia reduces PTH secretion
Hypocalcemia: Signs and Symptoms
• Trousseau's sign: Trousseau's sign is the induction of
carpopedal spasm by inflation of a sphygmomanometer
above systolic blood pressure for three minutes.
Carpopedal spasm is characterized by adduction of the
thumb, flexion of the metacarpophalangeal joints,
extension of the interphalangeal joints, and flexion of the
wrist. It may also be induced by voluntary
hyperventilation for one to two minutes after release of
the cuff.
• Chvostek's sign: Chvostek's sign is contraction of the
ipsilateral facial muscles elicited by tapping the facial
nerve just anterior to the ear. The response ranges from
twitching of the lip to spasm of all facial muscles and
depends upon the severity of the hypocalcemia.
Chvostek's sign occurs in about 10 percent of normal
subjects
Hypocalcemia: Diagnostic approach
• Serum total and ionized calcium concentration
• Liver function tests, Albumin, and coagulation parameters should be
obtained to assess liver dysfunction and hypoalbuminemia.
• Kidney function tests: Blood urea nitrogen (BUN) and serum creatinine
should be measured, as elevated levels may indicate renal dysfunction.
• Serum Electrolytes:
• A combination of hypocalcemia and elevated phosphorus levels typically
suggests hypoparathyroidism or pseudohypoparathyroidism.
• Patients with renal failure and hypocalcemia usually present with
hyperphosphatemia and high PTH levels. Hypophosphatemia develops in
patients with vitamin D deficiency and hungry bone disease.
• Occasionally, inadequate dietary magnesium intake leads to
hypomagnesemia and hypocalcemia. Thus, the serum magnesium level
should always be checked to determine its potential contribution to the
hypocalcemia, as hypomagnesemia impairs both PTH secretion and action.
Hypocalcemia: Diagnostic approach
• Parathyroid Hormone
• The parathyroid hormone level should be checked as early as possible.
Low-to-normal PTH levels occur in patients with hereditary or acquired
hypoparathyroidism and in patients with severe hypomagnesemia.
• Patients with ineffective PTH have elevated PTH levels (This elevation is a
result of hypocalcemia)
• Vitamin D Metabolites
• If vitamin D deficiency is suspected, measurements of calcidiol and calcitriol
should be performed.
• A low calcidiol level suggests vitamin D deficiency from poor nutritional
intake, lack of sunlight, or malabsorption.
• Low levels of calcitriol in association with high PTH suggest ineffective
PTH from a lack of vitamin D, as observed in patients with chronic renal
failure and pseudohypoparathyroidism.
Hypophosphatemia
• Serum phosphate level of less than 2.5 mg/dL in adults
• Mild hypophosphatemia (ie, 2-2.5 mg/dL), is generally
asymptomatic.
• In severe hypophosphatemia, patients may have:
• Muscle weakness, numbness, paresthesia, and
confusion.
• Rhabdomyolysis may develop during rapidly
progressive hypophosphatemia.
• Respiratory insufficiency can result from diaphragm
muscle weakness.
Hypophosphatemia
The causes of hypophosphatemia include:
• Decreased intake/intestinal absorption: vitamin D deficiency,
phosphorus-binding antacids, malabsorption, alcoholism
• Urinary losses: Primary hyperparathyroidism, secondary
hyperparathyroidism (vitamin D deficiency, calcium starvation), PTHrP-
dependent hypercalcemia of malignancy, FHH, hyperglycemic states,
diuretics, X-linked hypophosphatemic rickets, alcoholism, intrinsic renal
diseases (Fanconi syndrome(s)), oncogenic osteomalacia (FGF23),
• Shifts of phosphorus from extracellular to intracellular
compartments: administration of insulin in diabetic ketoacidosis or
refeeding in a malnourished patient with inadequate phosphate (e.g.
refeeding hospitalized alcoholics), acute respiratory alkalosis, rapid
cellular proliferation
• Accelerated net bone formation: After parathyroidectomy, treatment
of vitamin D deficiency
Case 3
• A 70-year-old woman, presents to her doctor for a routine check-up.
She complains of vague fatigue and generalized bone aches for the
past few months. She denies any recent falls or injuries. She has a
history of long-term use of diuretics for high blood pressure. Physical
Examination: Vital signs are normal. There are no signs of
tenderness or fractures on bone examination. Laboratory Findings:
Blood tests reveal normal blood sugar levels and electrolytes except
phosphorus 2.2 mg/dL (2.5-4.5 mg/dL) with normal serum calcium
levels. X-ray shows early signs of bone loss (osteopenia).
• Diagnosis: Chronic hypophosphatemia, possibly due to long-term
diuretic use.
• Explanation: Diuretics can increase urinary phosphate excretion,
leading to gradual depletion of phosphate stores over time. This
chronic deficiency can contribute to bone weakness and pain, even
before fractures occur.
Case 4
• Presenting Complaint: A 47-year-old man with a history of
alcoholism is hospitalized for abdominal pain, nausea, and vomiting.
He has lost weight due to poor diet and alcohol consumption.
• Laboratory Findings: Electrolyte imbalances including hypokalemia
and borderline hypophosphatemia.
• Learning Point: Alcoholism is a risk factor for electrolyte imbalances,
including hypokalemia and hypophosphatemia. Chronic malnutrition
and poor diet can further contribute to these deficiencies.
Hyperphosphatemia: Causes
• In adults, hyperphosphatemia is defined as a level >5.5 mg/dL.
• Asymptomatic unless hypocalcemia occurs due to precipitation of insoluble
Ca-P complexes and decreased calcitriol synthesis
• The clinical consequences of acute, severe hyperphosphatemia are due
mainly to the formation of widespread calcium phosphate precipitates and
resulting hypocalcemia. Thus, tetany, seizures, accelerated nephrocalcinosis
(with renal failure, hyperkalemia, hyperuricemia, and metabolic acidosis), and
pulmonary or cardiac calcifications may occur.
• Chronic hyperphosphatemia in renal failure is associated with vascular
calcification and increased mortality
• The most common causes are acute and chronic renal failure, but it may also
be seen in excessive intake/administration, hypoparathyroidism,
pseudohypoparathyroidism, vitamin D intoxication, severe hypermagnesemia,
hypomagnesemia (Note: hypomagnesemia is listed as a cause of both hypo-
and hyperphosmatemia in Harrison’s Medicine 20th edition), acidosis,
rhabdomyolysis, hemolysis, and tumor lysis syndrome.
Magnesium
• Total body Mg approximates 25g; it is the fourth most abundant cation
extracellularly, and the second most abundant cation intracellularly.
• Bone contains about 60% of total body Mg. The normal serum Mg is 1.7-2.2
mg/dl (0.7 to 0.9 mmol/L)
• The kidney is the major organ controlling Mg excretion.
• Urinary magnesium excretion is increased by ECF volume expansion,
hypercalcemia and hypermagnesemia, and decreased in the opposite of
these states.
• There is no one specific homoeostatic mechanism for magnesium. Various
hormones, including PTH and aldosterone, affect the renal handling of
magnesium; the effects of aldosterone, which increases the clearance and
excretion of magnesium are probably secondary to changes in ECF volume
but PTH, which increases the tubular reabsorption of filtered magnesium,
appears to act directly.
Hypomagnesemia
• Hypomagnesemia usually indicates significant whole body magnesium depletion.
• Asymptomatic when serum magnesium concentrations are > 1.2 mg/dL (normal 1.7-2.2
mg/dL), although the severity of symptoms may not correlate with serum magnesium
levels.
• Hypomagnesemia may cause generalized alterations in neuromuscular function,
including tetany, tremor, seizures, muscle weakness, ataxia, nystagmus, vertigo,
apathy, depression, irritability, delirium, and psychosis.
• ECG abnormalities may include prolonged PR or QT intervals, T-wave flattening or
inversion, and ST straightening and cardiac arrhythmias.
• Hypocalcemia (with hypocalciuria): Magnesium is important for effective PTH
secretion as well as the renal and skeletal responsiveness to PTH. Therefore,
hypomagnesemia is often associated with hypocalcemia.
• Hypokalemia
• Electrolyte disturbances may not be easily corrected unless magnesium is
administered as well.
• Hypomagnesemia generally results from a derangement in renal or intestinal handling
of magnesium and is classified as primary (hereditary) or secondary (acquired).
Secondary causes are much more common
Causes of Hypomagnesemia
I. Impaired intestinal absorption: Malabsorption syndromes, Vitamin D
deficiency, Proton pump inhibitors
II. Increased intestinal losses: Protracted vomiting/diarrhea
III. Impaired renal tubular reabsorption
A. Genetic magnesium-wasting syndromes: Gitelman’s syndrome, Bartter’s
syndrome
B. Acquired renal disease: Tubulointerstitial disease, ATN (diuretic phase)
C. Drugs and toxins: Ethanol, Diuretics (loop, thiazide, osmotic), Cisplatin,
Cyclosporine, Aminoglycosides, amphotericin B
D. Other: Extracellular fluid volume expansion, Hyperaldosteronism, SIADH,
Diabetes mellitus, Hypercalcemia, Metabolic acidosis, Hyperthyroidism
IV. Intracellular shifts
A. Recovery from diabetic ketoacidosis, refeeding syndrome (insulin effects)
B. Accelerated bone formation: Post-parathyroidectomy, Treatment of vitamin D
deficiency
IV. Other
A. Other: Pancreatitis, excessive sweating, pregnancy (third trimester) and
lactation
Hypermagnesemia
• Hypermagnesemia is rarely seen in the absence of renal
insufficiency, as normal kidneys can excrete large
amounts of magnesium.
• Clinical manifestations depend on Mg++ level:
1. Mild: Often asymptomatic (2.2–4 mg/dL) or mild
symptoms of weakness, nausea, dizziness, confusion
(4–7 mg/dL)
2. Moderate (7–12 mg/dL): Neuromuscular: hypoactive
tendon reflexes, drowsiness, bladder paralysis.
Cardiovascular: Mild hypotension, vasodilation,
bradycardia. Other: Flushing, headache,
gastrointestinal hypomotility, constipation, blurred vision.
3. Severe (>12 mg/dL): Life-threatening manifestations: Muscle paralysis,
respiratory depression, paralytic ileus. ECG changes: (↑ PR/QRS, AV block),
coma. Cardiac arrest (>15 mg/dL).
• Hypermagnesemia, acting via the CaSR, causes hypocalcemia and hypercalciuria
due to both parathyroid suppression and impaired calcium reabsorption.