Interpretation Of Clinical Biochemical Tests

Assistant instructor. Jinan Hameed

Source by:-Practical clinical biochemistry
 Part 1: Practical aspects
Part 2: Interpretation of biochemical tests

 Clinical biochemical tests are part of the medical laboratory tests.

 Clinical biochemistry is the application of biochemical knowledge in
diagnosis and management of disease to solve a problem of a single or
individual patient.

 Medical biochemistry involves the study of bimolecular and chemical

changes in human or people in health (metabolic pathways) as well as
any inherited disorders in these pathways where it represents the study
of biochemical disorders.
 Applications of biochemical tests can be listed as the followings;

 Diagnosis: to help differentiate between various possibilities in the differential diagnosis of a

disease.

 Monitoring: to follow the progression or natural history of disease processes, checking any
adverse drug effects (e.g. hypokalaemia with diuretic therapy), or response to therapy (glucose
levels in diabetes mellitus).

 Prognosis: providing information on disease resolution or complications.

 Screening: detection of disease before it is clinically evident, e.g. testing all infants at birth for
a specific inherited disease (phenylketonuria, thyroid deficiency).

 Assessment of risk: e.g. the finding of a high serum cholesterol level is associated with a risk
for atherosclerosis.
 Pre-analytical errors stage:
A. Patient's factors:

1. Physiological factors: which can influence the value of an analyte and may need to be taken into account in
the interpretation of results are the followings:
Factor Example

Age Alkaline phosphatase: elevated in growing children. High serum urea levels are found in the elderly persons.

Gender Levels of sex hormones, also uric acid, urea and creatinine.

Pregnancy Hormone levels and glucose

Posture Albumin: probably the reason why most (recumbent) hospitalized patients have lower albumin values.

Exercise Creatine kinase

Fasting or feeding Glucose and triglyceride levels may be elevated if not fasting.

Time of day Cortisol and iron

 [Link]- physiological factors: which can influence the value of an analyte
and may need to be taken into account in the interpretation of the results as
followings:
Factor Example
Dehydration Urea
Intake of drug TG (β- blockers), uric acid (aspirin and alcohol), potassium (diuretics), creatinine
(some drugs).
Concurrent disease Uric acid (ketoacidosis), creatinine (ketoacidosis).
Clinical procedure PSA: palpation of the prostate by rectal examination may possibly release large
amounts of prostate specific antigen (PSA) into the circulation; the speciously elevated
concentration in blood may persist for several days.
 B. Medical staff factors:

1. Patient identification

 It is important to identify a patient properly. When identifying the patient, have them provide their
full name, address, identification number and age (preferably birth date). An error may cause a
medicolegal disaster.

1. Patient preparation

 Prior to collecting specimens for chemistry, certain patient variables need to be considered. For
certain chemistry analytes such as glucose and lipid profile, patients need to be fasting for at least 8-12
hours respectively prior to venipuncture.
 [Link] collection procedure
Sample collection procedure has many steps, each of which may be associated with
error:
Selecting the site for venipuncture
Site preparation
Tourniquet application and time
Proper venipuncture technique
Order of draw
Proper tube mixing
Correct specimen volume
 3. Sample collection procedure
Sample collection procedure has many steps, each of which may be associated with error:

• Selecting the site for venipuncture:

Selecting the best site for venipuncture can contribute to a better quality sample.
 The best site is the median cubital vein.
 The other is cephalic vein and
 the last choice is basilica vein
 Site preparation: Prior to venipuncture, the site should be cleansed with alcohol and allowed to air
dry. This will help to ensure that the specimen is not contaminated with alcohol which causes
hemolysis.

 Tourniquet application and time:

The tourniquet should be applied approximately 10-15 cm above be venipuncture site and no longer
than one minute. Prolonged tourniquet time can lead to an increase in various chemistry analytes
including serum protein, calcium and cholesterol.
 Proper venipuncture technique:
During phlebotomy, avoid probing to find vein and achieve blood flow. Excessive probing to find a vein
can result in a poor quality sample, including hemolysis.
 Order of draw:
Following the correct order of draw during venipuncture will help to ensure accurate test results. An
example of improper order of draw that can lead to an incorrect chemistry result is drawing in an EDTA
tube prior to plan tube or heparin tube for chemistry testing.
 Proper tube mixing: All tubes with additives need to be inverted to mix well. Usual plastic tubes
should be inverted 5 times. Other additive tubes such as heparin, need to be inverted 8-10 time. Be sure
that tubes are not being shaken vigorously, as this can lead to a hemolyzed sample (hemolysis increases
K, PO4, AST and LDH while lowers ALP).
 Correct specimen volume: All blood collection tubes need to be filled to the correct volume. This will
ensure the proper amount of blood for the amount of additive in the tube.
[Link] tube handling and specimen processing.
Blood specimens need to clot completely prior to centrifugation and
processing. Blood specimens in some tubes should clot for 45-60 minutes,
in others only 30 min.

[Link] handling of blood specimens: Transport of blood

specimens in the proper manner after collection ensures the quality of the sample. Chemistry
analytes will require the tube of blood to be chilled after collection in order to maintain the
stability of the analyte such as in blood gas analysis (otherwise low CO2 and bicarbonate).
Some analytes are photosensitive and the specimen should better be kept in dark. The most
common example of a light-sensitive analyte is bilirubin.
6. Stability of whole blood, serum and plasma: A whole blood specimen that
is going to be spun down should be centrifuged and the serum or plasma
removed from the red blood cells within two hours after the venipuncture (non-
separation of serum will increase K+, PO4, AST and LDH).

 The serum sample will be stable at room temperature for eight hours, and up
to 48 hours at 2-4 ℃. After 48 hours, the serum specimen should be frozen
at -20 ℃.

 Hence, blood samples for urea and electrolytes should not be refrigerated.
Specimen contamination with intravenous (IV) fluid
 Container for blood: Laboratories should accept blood only
in the correct containers
 Sending the specimen to the laboratory
Point-of-care testing
Point-of-care testing (POCT) or near-patient testing or bed-side testing enables clinicians or
patients to perform tests without necessarily using the laboratory directly.

Some possible clinical settings for Point-of-care testing devices;

• Special care baby units and adult intensive care units

One blood test for which POCT is very relevant in the special care
baby units is the determination of bilirubin using POCT
bilirubinometers. In addition, blood gas machines have been
developed. One advantage is the need for only small blood
samples.
 Patient self-testing
 Pregnancy testing is one of the most commonly used forms of POCT that patient can perform
themselves.
 Near-patient testing and diabetes mellitus
 The patient management of diabetes mellitus is one area in medicine in which POCT or self-monitoring
is frequently used. Broadly, this can be considered as involving urinary glucose concentration
determinations, urinary or plasma ketone tests, blood measurements, and urinary microalbumin tests.

 Accident and emergency

A significant number of A and E departments have blood gas machines, blood glucose meters and even
small hand-held analysers for common biochemical tests. One area in A and E where POCT is important is
in the biochemical diagnosis of acute myocardial infarction using troponin T
 Coagulation clinics
A number of devices are available which, using
capillary or venous blood, can measure prothrombin
or activated partial thrombin time. These can be used
in coagulation clinics or by patients on warfarin to
monitor their own treatment.

 Drug addiction and ethanol addiction clinics

Various drugs can be assayed, including opiates,
cocaine, cannabis, benzodiazepines, amphetamines as
well as ethanol.

 General practice, out-patient clinics and wards

Many out-patient clinics and wards as well as general practices use
urine dipstick testing for screening patients, and various urine-
testing strips are available. There are also machines to determine
cholesterol, triglycerides and high-density lipoprotein cholesterol
(HDL-C) concentrations. Some desktop analyzers allow other
parameters to be assayed, for example creatinine, glucose,
bilirubine and heamoglobin.
 Some major advantages of POCT
1. The relative immediacy of results. This may enable prompt treatment, shortened
patient waiting time and reduced number of out-patient a Many POCT devices
require minimal specimen preparation or collection (in some cases using a finger
prick of blood).
2. Some of the modern POCT devices incorporate dry- and solid phase chemistry
reagents. These allow for ease of use and disposal of used reagents.
3. Transcutaneous biosensors allow continuous measurements to be made through the
patient’s skin without the need for blood collection.
4. The reduction in turnaround time may result in a reduction in total costs if patient
episodes are shorter and transport costs are reduced, for example courier costs.
5. Also possible savings of on-call or out-of-hours costs for laboratory staff.
6. Patients can be more involved in their care.
7. There is a possibility of online monitoring of patients.
8. It may offer advantages in remote [Link] and clinical visits for the patient.
 Expression of volumes in clinical chemistry

 1 liter (L) = 1000 milliliter (ml) = 1000000 microliter (µl)

 1L = 1000 ml = 1000000 µl • Units

 1L = 10 dl  Mass concentration (g/dl or g/l) is the most common measurement

 1 ml = 1000 µl unit in the United States. Is usually given with dl (decilitres) or L

(litres).
 1 ml = 1 cubic centimeter (cc)
 Molar concentration (mol/l)
 1 µl = 0.001 ml or 10-3 ml, 1 µl = 10-6 L
 International units (IU) are based on measured biological activity or
 10 µl = 0.01 ml, 100 µl = 0.1 ml, 500 µl = 0.5 ml
effect, or for some substances, a specified equivalent mass.
 1 mol = 1000 mmol (millimoles)
 Enzyme activity (kat)
 1 mmol = (10-3 mol) = 1000 µmol (micromoles)

 1 µmol (10-6 mol) = 1000 nmol (nanomoles)

 1 nmol (10-9 mol) = 1000 pmol (picomoles)

 Conversion from one set of units to another
The unit conversions of substance concentration from the molar to the mass concentration are made
as follows:
mass concentration = molar concentration X molar mass
If a result is expressed in mg/100 ml, then divided by the molecular weight (to convert from mg to
mmol), then multiply by 10 (to convert from 100 ml to a liter) the result will be mmol/L.

𝑚𝑔Τⅆ𝐿
X 10 = mmol/L
𝑚⋅𝑤

As an example the molecular weight of glucose is 180

A glucose concentration of 180 mg/ 100 ml = 10 mmol/L

The molecular weight of urea is 60

A urea concentration of 60 mg/ 100 ml = 10 mmol/L

 Some conversion factors:

To SI units From SI units

Glucose mg / dl / 18 = mmol/L mmol X 18 = mg/dl

Iron µg / dl / 5.6 = µmol/L µmol/L X 5.6 = µg/dl

Urea mg / dl / 6 = mmol/L mmol/L X 6 = mg/dl

Uric acid mg / dl / 17 = mmol/L mmol/L X 17 = mg/dl

Cholesterol mg / dl / 39 = mmol/L mmol/L X 39 = mg/dl

Creatinine mg / dl/0.0113= mmol/L mmol/L X 0.0113=mg/dl

 Part 2: Interpretation of biochemical tests
 Biochemical tests are an essential part of modern medical practice. They have many potential. For
many tests, the ease with they can be requested and performs covers their complexity. They should all
be interpreted through an appreciation of the underlying physiological and pathological principles,
whatever the purpose for which they are to be used.

 Biochemical results can be assessed in relation to various criteria, according to the reasons for
performing the test:

 The reference range for comparable healthy people.

 The range of values expected in a particular condition.

 Cut-off values or action limits, or Results obtained previously in the same individual.
 Post- analytical factors
Analytical factors:

Clerking errors

Clinical laboratory accreditation

Laboratories use of acceptable internal It is a particular risk if results are telephoned as

quality control and external quality assurance may be necessary if they need to be communicated
procedures. to the doctor urgently.

With increasing use of electronic transmission of

results from laboratory to ward or clinic, the risk of
such errors has decreased considerably, but it can
never be entirely eliminated.
Biological variation:-Test results in an individual vary due to non-
analytical factors in addition to those affecting the analysis

Recumbence

Age

Sex

The menstrual cycle

Exercise

Circadian variation

Drug therapy