CLINICAL CHEMISTRY 09/06/25

Midterms
SEMINAR 1
Lecturer: Dr. Renz Jethro M. Ortega, RMT, ASCPI (MLS), MD Trans #1
[Name of Lecturer]
[TRANS] UNIT 1: WEEK 1
[Name of Lecturer]

[SUBJECT]
QUALITY CONTROL
[Name of that
• A system Lecturer]
identifies error
•
[Name of Lecturer]
To identify a possible error, for our result to be accurate and precise for a
long period of time
• RA 5527: Medical Technology is a branch of laboratory medicine that
[Name of Lecturer]
deals with the examination of blood, body fluid and tissues. Purpose: To
aid the doctor in diagnosis, treatment, and maintenance of the disease.
[Name of chemistry
By doing Lecturer] tests, by doing quality control on those tests, we are
ensuring that our results will help the doctor in the maintenance, treatment
and even diagnosis on the disease of the patient.
Terms Definition MM/DD/YYYY
Ability of the analytical method to measure the smallest

Sensitivity
concentration of the analyte of interest
• Example: Creatinine level is .1 Shifting #
• Talks about quantity. We can detect the smallest quantity of
•
•
•
Patient with disease + Positive = TP
Patient without disease + Negative = TN
Patient without disease + Positive = FP

Trans #
analyte present • Patient with disease + Negative = FN
Ability of the analytical method to measure on the analyte
Specificity of interest ACCURACY VS PRECISION
• Talks about quality
Accuracy Nearness or closeness of the assayed value to the true
or target value
Ability of the method to give repeated results on the same

[SUBJECT]
Precision sample that agree with one another
• Repeatability
Degree by which a method is easily repeated
Practicability • Increase TAT if the test is practical
• Practical = more tests done
Ability of the method to maintain accuracy and precision
Reliability over a period of time
• “Maasahan ka”

• Gold standard test is the test with the highest sensitivity, specificity, BEQ

[SUBJECT]
accuracy, precision, practicability, and reliability.

DIAGNOSTIC SENSITIVITY
• Same color, same value
• Target value is always the middle one
DEFINITION OF THE FIGURE ABOVE
• It is the ability of the analytical method to detect the proportion of Individuals
with the disease. • Inaccurate but precise
→ Rule out the condition (SnOUT) • Inaccurate but imprecise
→ A screening test should be highly sensitive • Accurate and precise
• Inaccurate and imprecise
DIAGNOSTIC SPECIFICITY
• It is the ability of the analytical method to detect the proportion of individuals • T-test – compares two means
without the disease. • F-test – compares two SDs
→ Specificity use to rule in a condition (SpIN) • Analysis of Variance (ANOVA) – compares three or more variables

APPLICATION IN CC QUALITY CONTROL

• If your sugar is 300 mg/dL in a glucometer, it does not mean that you have • It involves the process of monitoring the characteristics of the analytical
diabetes already. There is just a possibility that you can have a diabetes processes and detects analytical errors during testing, and ultimately prevent
since a glucometer is for monitoring and not for confirmatory. If it is high the reporting of inaccurate patient test results.
on Hexokinase coupled with G6PD, you have diabetes. → We want to identify the possible errors.
APPLICATION IN MICROBIOLOGY OBJECTIVES OF QUALITY CONTROL
• Tests for Syphilis – RPR 1. To check the stability of the machine
• Confirmatory tests for Syphilis – TPHA or FTA-ABS • We do QC before the start of the next shift
• If you are positive in RPR, you do not have syphilis, but if you are positive • Major hospitals: 1 in MN (applicable for AM shift) and 1 in PM (applicable for
in TPHA or FTA-ABS, you have syphilis. PM shift)
→ Machines are only borrowed
APPLICATION IN STATISTICS
• Stand alone laboratory: Usually done once: before the start of the AM shift
• Two by two table
• Med Tech performs laboratory tests. Rules out positive or negative. BEQ
• Old name for Vitros: Kodak
2. To check quality of the reagents
• Done when opening a new reagent. Calibrate first then control.
3. To check technical errors
• Do delta check
• Check QC

IDEAL QC MATERIAL IS...

Clinical Chemistry - Seminar 1 JDS 1 of 7

1. Similar to human sample Gives the earliest indication of systematic error
• QC material for CC: Frozen and Yellow. Youden/Twin Plot Compares results from different laboratories
• Serum like sample BEQ Most widely used in the laboratories
2. Inexpensive and stable Shewhart Lewey- • Most commonly used laboratory chart
3. Safe to handle Jennings Chart A representation of the acceptable limits of
4. Known analyte concentration variation in the results of analytical methods
• QC materials: Westgard Control Used to evaluate Shewhart Levey-Jennings
→ Level 1: Low, Level 2: Normal, Level:3 High Rules Chart
5. No matrix effects • Categorized to Systematic and Random Errors
• No interference in the sample MEAN, MEDIAN, AND MODE CALCULATION
6. Convenient Given Data: 85, 91, 91, 97, 96, 101
• In CC when a test is special, QC material is powdered or Lyophilized.
Mean – average
Reconstituted by adding distilled water
• Sum of all values = 85 + 91 + 91 + 97 + 96 + 101 = 561
Internal/Intralab QC External/Interlab QC • Number of values = 6
Daily monitoring of accuracy and Daily monitoring of accuracy and • Mean = 561 / 6 = 93.5
precision precision
If MN: Valid for AM shift Median – middle value
Short term accuracy Long term accuracy • Arrange the data in ascending order: 85, 91, 91, 96, 97, 101
• For an even number of data (6), median is the average of the 3rd and 4th
• External/Interlab QC – known as proficiency testing.
values:
→ National External Quality Assessment Scheme (NEQAS) in the
• (91 + 96) / 2 = 93.5
Philippines

• NRL for Chemistry – Lung Center of the Philippines Mode

→ Prepares samples to be sent to different laboratories; the results will • The mode is the value that appears most often.
be forwarded to the NRL to determine whether you passed or failed • 91 appears twice, while all other numbers appear once.
to continue operating. If you fail, you will be given a second chance • Mode = 91
to take the test.
→ NRL for Histopath (Lungs) Final Answer:
• NRL for STID – San Lazaro Hospital • Mean = 93.5
→ STI AIDS Cooperative Central Laboratory • Median = 93.5
• NRL for Histopath, Hematology, Blood Bank, Immunosero – NKTI • Mode = 91
• NRL for Toxicology, Water Analysis, and Drug Testing – East Avenue Westgard Control Rules
Medical Center
Systematic error Random error
• NRL for infectious diseases – RITM
22s 12s
• NRL for Histopath (Heart) – Philippine Heart Center Warning rule that has an impending error
• NRL for Newborn Screening – National Institute for Health 41s 13s
Random error 10x R4s
Systematic error Chance Error
• 2 – Number of QC result
Unpreventable/Unpredictable
Deterioration of reagents Error in pipetting • 2s – Standard deviation
Check when all results are weird • Remember: Even (2, 4, 10) in Systematic error and 1 or R in Random
Contaminated solution Mislabeling Error
Wash buffer – if reconstituted incorrectly in Mortal sin of MT
the machine
Unstable sample
Bilirubin is affected by light
BEQ: Jendrassik Grof method is not Dirty optics
affected by or can compensate light for
bilirubin

Diminishing lamp power Fluctuations

Light source can affect the results if the BEQ: Circuit braker – prevent fluctuations
light is going out of electricity

• Power unit or System unit – prevention in fluctuations in electricity

Quality Control Description
Charts
Obtained by plotting values from multiple
analyses of a sample.
Occurs when the data set can be accurately
described by the SD and the mean
• Perfect bell shaped curve is achieved when x̅ = Median
= Mode
• Quality Control limit in all laboratories: ± 2 SD or 95%
→ In 100 controls run, 5 are rejected
Gaussian Curve (Bell-
shaped curve)

• R4S – two consecutive results that has more than 4 SDs difference

Cumulative Sum Calculates the difference between QC results

Graph (CUSUM) and the target means

Clinical Chemistry – Seminar 1 Week 1 2 of 7

 → Splits the light into different color
→ Then isolates specific wavelength
• Exit Slit
→ Allows entry of specific wavelength
→ Prevents entry of stray light
• Cuvette
→ Sample holder
• Detector
→ Collects light energy
6 or more consecutive control values distribute themselves on
Shift one side or either side of the mean but maintain a constant • Meter
level → Converts light energy to electrical energy
• At least 6 results on one side of the chart. Either positive or negative • Electromagnetic Spectrum:
6 consecutive control values continue to either increase or → >400 nm: Ultraviolet
Trend decrease → <700 nm: Infrared
• Ugly results pattern
• Visible Light: light between 400-700 nm
Outliers Control values are far from the main set of values
• Day 13: Abnormal result then back to normal
→ VIBGYOR
Light Source
QUALITY ASSURANCE
Ultraviolet lamps Infrared lamps
• A system for the benefit of the patient Mercury arc (+ visible) Tungsten lamp (+ visible)
• All systematic actions necessary to provide adequate confidence that lab Minimata’s disease – mercury poisoning
services will satisfy the given medical needs for patient care Deuterium lamp Merst glower
→ Patient satisfaction – Surveys Hydrogen lamp Globar (Si Carbide)
→ Cost efficiency Xenon Lamp
→ Turnaround time – STAT (Short TAT) for DOH; STAT (immediately) for
books BEER’S LAW/BEER LAMBERT’S LAW
→ Quality Control • Concentration of the unknown substance is directly proportional to the
absorbed light and inversely proportional to the amount of transmitted light
SIX SIGMA → Principle of spectrophotometer
• New technique → Imagine a cuvette containing a sample. A specific wavelength of light is
• A program based on improvement by eliminating processes that slows absorbed by creatinine. The higher the creatinine concentration, the
down or hinders work more light is absorbed, and the less light is transmitted. If small light is
• Sigma – symbol for SD absorbed, more light is transmitted and less analyte is present.
• Visible error in the naked eye is seen in the standard deviation Conversely, if more light is absorbed, less light is transmitted, and more
analyte is present.
STEPS OF SIX SIGMA:
DMAIC KINDS OF MONOCHROMATOR
1. Define 1. Prism
• Slow TAT 2. Diffraction Gratings
• “Breakfast club” • Most commonly used monochromator
2. Measure 3. Filters
• Hard to extract patients. Example: Spinal injury
3. Analyze KINDS OF CUVETTE
• Barcode system 1. Alumina silica glass
4. Improve • Most commonly used
• Memo, different trays for different tops 2. Quartz/plastic
5. Control 3. Borosilicate
• After 1 week, TAT is improved 4. Soft glass

• Pre-analytics – majority of error in the laboratory made by human KINDS OF DETECTORS

1. Barrier layer/ Photocell Photovoltaic cell
ANALYTICAL METHODS 2. Phototube
3. Photomultiplier tube
Methods Description • Most commonly used
Involves measurement of light transmitted by a • Most sensitive
solution to determine the concentration of the light 4. Photodiode
Spectrophotometer absorbing substance
• Most commonly used instrument in chemistry Methods Description
• Wavelength: measure of light energy Measures light emitted by a single atom burned in
a flame
PARTS OF A SPECTROPHOTOMETER • Light source and cuvette: Flame

Flame Emission
Photometry
DEFINITION OF THE FIGURE ABOVE
• Light source
→ Source of light
• Entrance slit
→ Allows certain wavelength of light enter the machine
→ Prevents the entry of stray light
• Monochromator • Lithium – bipolar disease

Clinical Chemistry – Seminar 1 Week 1 3 of 7

 Measures light absorbed by atoms dissociated by • Calibrator for timer: Stopwatch
Atomic Absorption heat
Spectrophotometry Light source: Hollow-cathode lamp CARBOHYDRATES
(AAS) • Reference method for: Calcium and Magnesium
• CHO
• Tetany – hypocalcemia; Tetani – C. tetani
Turbidimetry Determines the amount if light blocked by a • Monosaccharides (single molecule): glucose, fructose (grape sugar), and
particulate matter in a solution galactose
Nephelometry Determines the amount of scattered light by a • Disaccharides (two molecules):
particulate matter in a solution → Maltose
Migration of charged particles in an electric field ▪ Glucose and Glucose
• Cation – positive ion; Anion – negative ion → Sucrose (table sugar)
Electrophoresis • Cation migrates to cathode (negative pole) ▪ Only non-reducing sugar
• Anion migrates to anode (positive pole) → Lactose (milk sugar)
• Zwitterion – an ion that is either positive or negative
▪ Glucose and Galactose
Determines the amount of light emitted by a ▪ Adult: Lactose; Children: Galactose
Fluorometry molecule after excitation by EM radiation • Polysaccharides (less than 10 molecules)
Fluorometer – uses two Disadvantage: quenching (pH, UVL, and
or more monochromator • Oligosaccharides: More than 10 molecules
temperature changes, chemical contaminants

SUPPORT MATERIALS FOR ELECTROPHORESIS CARBOHYDRATE METABOLISM

• Chemistry: HPLC, Serum Protein Electrophoresis, TPAG • Glycolysis
1. Agarose gel: electric charge → Breakdown of glucose
• Cathode anode migration → Also known as Embden Meyerhof Pathway
2. Cellulose acetate: molecular size ▪ Nangingimay – anaerobic glycolysis
3. Polyacrylamide gel: charge and size • Gluconeogenesis
→ Formation of glucose from non-carbohydrate sources
Methods Description → Lipids, proteins, and amino acids
Volumetric The unknown sample is made to react with a ▪ Ketogenic diet
(Titrimetric) known solution in the presence of an indicator • Glycogenesis
Potentiometry Measurement of electrical potential due to the → Formation of glycogen
activity of free ions (Nerst equation) → Muscle – the organ composed of most amount of glycogen; Liver – most
Coulometry Measurement of the amount of electricity at fixed concentrated and storage form
potential • Glycogenolysis
Amperometry Measurement of the current flow produced by an → Breakdown of glycogen to form glucose
oxidation-reduction
Voltammetry Measurement of current after which a potential is BIOCHEMICAL THEORY AND PHYSIOLOGY
applied to an electromechanical cell
Separation of soluble components in a solution by • Fasting glucose in whole blood is 15% lower than serum or in plasma.
Chromatography specific differences in physical-chemical → Whole blood contains RBCs and other cells, which will continuously
characteristics of the different constituents consume glucose
• Venous blood glucose is 7 mg/dL lower than capillary blood and capillary is
FORMS OF CHROMATOGRAPHY equal to arterial blood glucose.
1. Paper chromatography → Arteriole → Capillary → Venules
• Simple sugars and amino acids → Site of exchange: Capillary
2. Thin layer Chromatography • CSF glucose is 60% of the plasma concentration (100 mg/dL)
• For screening test for drugs: MET and THC → BEQ: Plasma concentration: 50% up to 2/3 or 70%
3. Gas chromatography (with Mass Spectrometry) • Peritoneal fluid (Ascites) glucose is the same as plasma glucose.
• Gold Standard/Confirmatory test for drug testing • Serum or plasma must be separated from the cells within 1 hour to prevent
• Driving under influence of alcohol – using Breath analyzers loss of glucose.
4. Liquid Chromatography → Allowed in red top
• Usually used for HBA1C → Yellow top gel: Thixotropic gel
→ Preferred method for HBA1C – Affinity Chromatography ▪ Additive: Clot activator
• At room temperature, glycolysis decreases glucose by 5-7%/hr (5-10 mg/dL)
in normal uncentrifuged coagulated blood.
AUTOMATION • At refrigerator temperature, glucose is metabolized at the rate of 1-2
mg/dL/hr.
Approaches Description
Uses continuous tubing system where sample • Fasting for Glucose: 6-8 hrs
flows through a common reaction vessel or • Glucose only test: Gray tops (Old) – not used anymore according to
Continuous Flow pathway Henry’s
Analyzer Air bubbles serve as separating and cleaning → Gray tops does not stop glycolysis
media ▪ Potassium oxalate – anticoagulant
• Coils are used for mixing ▪ Sodium chloride – anticoagulative agent that prevents
Uses the force generated by centrifugation to glycolysis
Centrifugal transfer specimen and reagents in separate
Analyzer cuvettes Glucagon
Uses acceleration and deceleration of the rotor ACTH
Most popular and versatile Growth hormone
Discrete Analyzer Have a random-access capability for STAT Cortisol
samples HPL
Hyperglycemic hormones • Causes glucose to spike when
SIDE NOTES (GAGCHET) pregnant
• Types of Centrifuges: Increases blood glucose Epinephrine
→ Fixed angle: 45° • Adrenaline
→ Swinging bucket – tube is not moving: vertical; tube is moving: Thyroxine
horizontal • T4
• Thyroid hormone causes increase in
• Disinfect: Weekly metabolism, so T4 produces more
• Calibrator: Strobe light/tachometer glucose to compensate.

Clinical Chemistry – Seminar 1 Week 1 4 of 7

 Hypoglycemic hormone Insulin
Method Reducing Agent Oxidizing Agent
• Master gland for glucose control: Pancreas (Vitamin C) (Detergent)
• Pancreas produces lipase and amylase Cu red  
→ Amylase – earliest marker of pancreatitis Glu Ox  
▪ Salivary – S-type (Ptyalin)
• Benedict’s test – example of copper reduction test. Brick red positive result
− Mumps in children
• Glucose oxidase – commonly applied to machines and dipstick
▪ Pancreatic – P-type (Amylopsin)
→ Lipase – most specific marker of pancreatitis B. Polarographic glucose oxidase
• GA-BI (Glucose) • Principle of glucometer
→ Glucagon • Glucometer’s result is only valid if HCT of the patient is normal. If anemic or
→ Alpha cell leukemic, invalid.
→ Beta cell • Wipe the first drop of blood then collect
→ Insulin
▪ Alpha and Beta Cells are located in Islet of Langerhans C. Hexokinase coupled with G6PD
− Also have Delta cell – that produces somatostatin • G6PD deficiency – one of the tests detected in NBS
• BEQ: Beta Cells produces Pro-insulin → converted to Insulin → By- • Conversion of NAD to NADH
product of conversion: C-peptide • Most specific method for glucose
→ C-peptide: production of insulin in the body • Hemolysis falsely decreases the value
→ Type 2 DM – C-peptide

METHODOLOGIES
CHEMICAL METHODS
• Colorimetric method
• End color: Formation of color
• Chemical or name-based

A. Oxidation Reduction Methods – Redox (Reduction Oxidation)

i. Alkaline Copper Reduction Method • Glutathione is an antioxidant, and one of its side effects is skin lightening.
• Cu2+ = Cupric It binds to free radicals, protecting cells from damage. When you have
• Cu+ = Cuprous plenty of glutathione, it neutralizes free radicals that contribute to aging.
• Cupric turns to Cuprous Once bound to free radicals, glutathione becomes oxidized glutathione,
→ Glucose is responsible for the conversion of cupric to cuprous which can be recycled back to its active form with the help of NADPH.
Free radicals are neutralized by glutathione, and NADPH helps regenerate
Folin Wu Cuprous ions + phosphomolybdate → glutathione in its reduced form and bind to free radicals
phosphomolybdenum blue
Nelson-Somogyi Cuprous ions + arsenomolybdate → • G6PD deficiency means your cells can’t neutralize free radicals effectively.
arsenomolybdenum blue • Red blood cells (RBCs) are the most affected.
Neocuprine Cuprous ions + neocuproine → Cuprous- • Babies with G6PD deficiency should avoid oxidative stress—such as
Method neocuproine complex (yellow) crying for prolonged periods or eating fava beans—as these can trigger
hemolysis.
ii. Alkaline Ferric Reduction Methods (Hagedorn Jensen)
• Fe2+ = Ferrous LABORATORY TESTS
→ More important in the body SCREENING TESTS
→ Ferrous Sulphate + Folic Acid = for pregnancy; good development for the 1. Random Blood Sugar/ Random Blood Glucose
baby • Snapshot of the level of the glucose of the human body
• Fe3+ = Ferric • Insulin monitoring – if the patient received the correct dose
→ Ferric is converted to Ferrous • Sticker glucose (the ones on TikTok)
• Blood glucose taken anytime of the day
• Stain for Ferric – Prussian Blue
• Requested during insulin shock, hyperglycemic ketonic coma
• Stain for Ferrous - Turnbull’s blue
2. Fasting Blood Sugar
• Hagedorn Jensen is also known as inverse colorimetry • Most commonly used screening test
→ End product is disappearance of color • Taken after 6-8 hours of fasting
→ NPO
B. Condensation Method (DuBowski Method/ Ortho-toluidine method) • Gives the best indication of overall homeostasis
• We use Schiff’s reagent 3. 2-Hour PBBS
ENZYMATIC METHODS • Evaluates hyperglycemia and hypoglycemia
• Plasma glucose is evaluated two hours after giving a glucose load (usually 75
• Ends with -ase
grams)
A. Glucose Oxidase Method
DIAGNOSIS OF PRE-DIABETIS AND DIABETIS MELLITUS
• Measures B-D-glucose (65%)
Fasting Plasma 2-Hour Plasma Glucose HbA
→ 35% - A-D-glucose
Glucose after 75 g OGTT 1c
▪ Converted to B-D-glucose by Mutarotase
(mg/dL) (mmol/ (mg/dL) (mmol/L) (%)
• Measures CSF glucose
L)
• Interference: Bilirubin, uric acid, and ascorbate causes false decreased result
Normal <100 <5.6 <140 <7.8 —
→ Ascorbate or Vitamin C is a reducing agent
Pre-
▪ Oxidation (+) + Reducing Agent (-) = False Decrease
diabetes
Impaired 100–125 5.6–6.9 — — 5.7–
fasting 6.4
glucose
Impaired — — 140–199 7.8–11.0 5.7–
glucose 6.4
tolerance
Diabetes ≥126 ≥7.0 ≥200 ≥11.1 ≥6.5
• Measures the colored chromogen mellitus

Clinical Chemistry – Seminar 1 Week 1 5 of 7

CONFIRMATORY TEST TRIVIA
1. OGTT or Oral Glucose Tolerance Test • Whipple’s Triad – diagnostic to hypoglycemia
• Multiple blood sugar tests
• Used to determine how well the body metabolizes glucose over a given period
REQUIREMENTS FOR OGTT
1. Fasting of at least 8 hours up to 14 hours
2. No eating, no drinking, no vomiting during the test
3. Minimum amount of 150g of carbohydrates per day for 3 days
→ No restrictions
4. No smoking or other strenuous activity during the test

GLUCOSE LOADS:
1. 75g for adults
2. 100g for pregnant individuals
3. 1.75g/kg for kids
→ > 50kg children = 75g glucose loads

OGTT Characteristics of Type 1 and Type 2 Diabetes Mellitus

• Adult – 3 hrs Type 1 diabetes Type 2 diabetes
→ 0°, 1°, 2° Frequency 5%-10% 90%-95%
• Pregnant - 4 hrs Any, but most common More common with
→ 0°, 1°, 2°, 3° Age of onset in children and young advancing age, but
adults can occur in children
MONITORING TEST and adolescents
1. Fructosamine Genetic, autoimmune, Genetic, obesity,
• Short term glucose control environmental sedentary lifestyle,
→ 2-3 weeks race/ethnicity,
• Used in monitoring diabetic individuals with chronic hemolytic anemias hypertension,
2. HbA1c dyslipidemia,
polycystic ovarian
• Also known as Glycosylated Hemoglobin/Glycated Hemoglobin
Risk factors syndrome
• Glucose molecule attached to one or both N-terminus valines of the beta • Lifestyle disease
polypeptide chains of a normal adult hemoglobin • PCOS – metformin
• Used for long term glucose monitoring lowers blood sugar
levels
1. Long term - 2-3 months • Obesity – Normal BMI:
2. Specimen for HbA1c - EDTA whole blood <25. >25 or 30 =
3. Hemolyzed specimen will give a false decrease result overweight or obese
4. Unit for HbA1c: % Destruction of No autoimmunity
5. 1% = 35 mg/dL Pathogenesis pancreatic beta cells, Insulin resistance and
6. Cut off value: 6.5%; >10% = prolong hyperglycemia usually autoimmune progressive insulin
• Autoimmune disease deficiency
• Diagnosis of Diabetes in books: FBS, OGTT, and HBA1c C-peptide levels Very low or Detectable
→ High HBA1c means you have diabetes due to prolong hyperglycemia undetectable
→ Adult: 2/3 tests are high, you have diabetes Autoantibodies Autoantibodies absent
Glutamic Acid • Acanthosis nigricans
→ FBS needs two samples – diagnostic to HBA1c
Decarboxylase
▪ If one test only, ask 3Ps: Polyphagia, polydipsia, and polyuria.
(GAD65), Anti-Beta
Cell (IA-2), Anti-Islet
• Diagnosis of Diabetes in books: FBS, OGTT, and HBA1c Pre-diabetes Cell (IAA)) may be
→ High HBA1c means you have diabetes due to prolong hyperglycemia present.
• IAA – anti islet of
→ Adult: If 2/3 tests are high, you have diabetes Langerhans
→ FBS needs two samples – diagnostic to HBA1c • IA-2 – beta makes
▪ If one test only, ask 3Ps: Polyphagia, polydipsia, and polyuria insulin
• GAD65 – required
• Hypoglycemia - low sugar production of insulin
• Hyperglycemia – high sugar Insulin absolutely Oral agents
→ Dependent on what test is done. If FBS, hyperglycemia is 1.6; necessary, multiple • Metformin
hypoglycemia is 70. daily injections or Insulin commonly
→ Hyperglycemia is more dangerous Medication therapy insulin pump needed
• No production of insulin
→ Hypoglycemia is fatal. Prolong hyperglycemia is detrimental to the
• C-peptide is low or
brain undetectable
• Injection of insulin when
positive
None known Lifestyle (weight loss
Therapy to prevent Clinical trials in and increased physical
or delay onset of progress activity) Oral
diabetes medications
(metformin, acarbose)
may be helpful.

• Normal value Glucose/FBS (Henry’s) : >100

→ 100-125: Pre-diabetes/Impaired Fasting
→ >126: Diabetes Mellitus
• Normal value 2-hr PBBS or after glucose load: >140
→ 140-189: Impaired Fasting
→ ≤200: Diagnosis for Diabetes Mellitus

Clinical Chemistry – Seminar 1 Week 1 6 of 7

 • HBA1c: 6.5% 3. This is an analyte used to detect the presence of endogenous production of
• Nocturia insulin.
→ Waking up in the middle of the night twice to urinate a. ketones
→ Also, a symptom for Diabetes b. c-peptide
• Enuresis – peeing in the bed c. insulin
d. proinsulin
Type I DM
Blood Sugar >250 mg/dl
4. FBS = 120 mg/dL. Interpret.
Acetone breath Ketones in urine
a. Normal
pH < 7.35
Diabetic Ketoacidosis (DKA) Kussmaul's respirations b. Impaired FBS
Develops quickly c. Hyperglycemia
Nausea d. T2 DM
Vomiting
Abdominal pain 5. The preferred method for testing glycosylated hemoglobin:
Type II DM a. HPLC
Blood Sugar > 600 mg/d b. TLC
No fruity smell c. GC
Hyperosmolar Hyperglycemic Minimal or no ketones d. AC
State (HHS) Normal pH, no acidosis
Shallow breaths 6. Jane Doe, 35F, went to her doctor for consult of prolonged polydipsia and
Develops slowly
polyuria. Upon testing an FBS, her result was 211 mg/dL. Interpret.
Severely altered LOC
a. Requires further testing
Profound dehydration
b. T1 DM
BEQ: DKA (Type 1), HHS (Type 2) c. T2 DM
• DKA: A child was playing sports when he suddenly fainted. At the ER, he d. None of the above
had a fruity odor on his breath, and his blood glucose was markedly
elevated.
• HHS: A diabetic patient forgot to take their medication and fainted. At the
hospital, they were found to be severely dehydrated. Remember: high
glucose makes the blood hyperosmotic. Because glucose has high
osmolar properties, it pulls water out of tissues and causes dehydration.
Diabetics often experience polydipsia because their blood glucose is high
and their blood becomes concentrated, so they feel the need to drink more
water.
Glycogen Storage Disease
Type Name Deficient Enzyme
I Von-Gierke Glucose-6-phosphatase
II Pompe Lysosomal a 1,4-glucosidase
III Cori Debranching Enzyme
IV Anderson Branching enzyme
V McArdle Muscle phosphorylase
VI Hers Liver phosphofructokinase
VII Tarui Phosphofructokinase
MNEMONIC
• VPCAMHT – Vice President CAM HenTai
• I – Gierke – G
• II – Pom – “som”
• III – CD
• IV – AB
• V – Mc – Muscle
• VI – Her – “LiveHer”
• VII – T - PK

• Von-Gierke
→ You can’t use the glycogen in the liver or cant return back to glucose.
The glycogen just accumulates in the liver
→ Hepatomegaly – enlargement of liver
→ Splenomegaly – enlargement of spleen

QUESTIONS
1. A researcher studying on a possible vaccine for CoVid-19 will use a statistical
test in order to compare two mean values. This test is known as:
a. t-test
b. f-test
c. chi square
d. ANOVA

2. The most commonly used photodetector in spectrophotometric analysis is:

a. phototube
b. photodiode
c. photovoltaic cell
d. photomultiplier tube

Clinical Chemistry – Seminar 1 Week 1 7 of 7

CLINICAL CHEMISTRY 09/20/25

Midterms
SEMINAR 1
Lecturer: Dr. Renz Jethro M. Ortega, RMT, ASCPI (MLS), MD Trans #2
[Name of Lecturer]
[TRANS] UNIT 1: WEEK 2

These notes are intended solely for personal study use. They are shared with • Linear chains of C-H bonds that terminate with a carboxyl group

[SUBJECT]
[Name of Lecturer]
you in confidence and must not be copied, reproduced, or distributed without • The substrate for gluconeogenesis (conversion of other sources to glucose)
[Name of Lecturer]
my prior permission. → Ketogenic diet – fats are the source of energy
- Nelly
Other side notes are not included due to my slow net connection. LIPOPROTEINS
[Name of Lecturer] STUDY AT YOUR OWN RISK • Most important
[Name of Lecturer] • Large macromolecular complexes of lipid used to transport triglyceride and
LIPIDS cholesterol
• Lipids are fat
[Name of Lecturer] APOLIPOPROTEINS

PHOSPHOLIPID
TYPES OF LIPIDS
MM/DD/YYYY • Makes lipid soluble in the blood
• Helps to keep the lipids in solution during circulation through the blood stream

Shifting #
• Most abundant lipid in the body
• Formed by conjugation of two fatty acids and a phosphorylated glycerol METHODOLOGIES
(amphipathic) CHOLESTEROL
→ Two fatty acid tails and 1 glycerol head A. Chemical Methods

are hydrophobic Trans #

→ Glycerol head is hydrophilic meaning it loves water, while Fatty acid tails
Liebermann Burchardt Cholestadienyl monosulfonic acid
Green
• Histology: Cell membrane is lined by a phospholipid bilayer Salkowski Cholestadienyl disulfonic acid
Red
THREE TYPES OF PHOSPHOLIPIDS
1. Lecithin: 70% of the phospholipid in the body MNEMONIC

[SUBJECT]
• Also known as phosphatidylcholine
• Amniotic Fluid: L:S ratio - ≥ 2.0 for Fetal Lung Maturity. Assesses the
maturity of the lungs by determining the level of lecithin
• LMG
• SDR

→ Done in premature babies because lungs are not mature. One-step method Pearson, Stern and Colorimetry
→ If the L:S ratio is normal, Corticosteroids is given to make the lungs Mac Gavack
mature Two-step method Bloor's Colorimetry+
• Lecithin is a lung surfactant Extraction
→ Basic unit of the lungs: Alveoli is like a balloon. Easy to inflate if Abell-Kendall Colorimetry+
there’s air already inside. Three-step method Most commonly used Extraction +

[SUBJECT]
→ Maintains the surface tension so that there’s still air in the alveoli.
Lungs are easy to expand
2. Sphingomyelin: 20% Four-step method
Schaenheimer,
Sperry, Parekh and
Saponification
Colorimetry +
Extraction +
3. Cephalin: 10% Jung Saponification +
Precipitation
• Alter fluid surface tension acting as surfactants
B. Enzymatic Method
CE hydrolase
CHOLESTEROL
Cholesterol ester → Cholesterol + Fatty acid
• Unsaturated steroid alcohol containing four rings, and it has a single C-H side
chain (amphipathic) Cholesterol
• Exclusively synthesized by animals Oxidase
• Precursor of steroids hormones Most commonly
→ Ends with -ol, one, -en used
▪ Calciferol, testosterone, estrogen, progesterone, cortisol, Cholesterol O2 → Cholest-4-en-3-one + H2O2
aldosterone
Peroxidase
→ Men are more prone to heart attack due to stress
▪ Menstruation in women is productive in the body due to the H2O2 + 4-AP + Phenol → 2H2O + Quinone-imine
regulation of estrogen. Stress goes in the estrogen
▪ In men, wherein testosterone is constant, Cholesterol deposits in → Absorbance of Quinonimine at 510 nm is directly proportional to the
other parts of the body: Arteries or Heart concentration of cholesterol in serum
− Menopause = men
• Hydrolase hydrolyses cholesterol and fatty acids attached to it
• As the patient age, cholesterol increases by 2 mg/dL per year after 50 years
→ In measuring certain analytes, we must test in free form. Meaning
old
there’s no other compound attach to it.
→ Naturally increases
→ In Cholesterol ester, Cholesterol is the free form
TRIGLYCERIDE C. CDC Reference Method: Abell, Levy, Brodie
• Also knows as TAG Step 1: Hydrolysis/saponification (Alc. KOH)
→ Triacylglycerol Step 2: Hexane extraction
▪ One glycerol head with three fatty acids Step 3: Colorimetry (Liebermann-Burchardt)
− Common name of glycerol is neutral fat
• Contains three molecules of fatty acid and one molecule of glycerol TRIGLYCERIDE
• Main storage lipid in man A. Chemical Method
→ Love handles are made of TAG
→ Excess sugar → glycogen → TAG Colorimetric Van Handel & Chromotropic acid; (+)
Zilversmith blue
FATTY ACID

Clinical Chemistry - Seminar 1 JDS 1 of 13

 Fluorometric Hantzsch Diacetyl acetone; (+) → Good for you even if it’s high
Condensation Diacetyl lutidine → Inverse risk for atherosclerosis
Step 1: Alkaline → Salmon, avocado, and olive oil are high in HDL
hydrolysis (S)
CDC Reference Modified Van Handel Step 2: Chloroform MINOR LIPOPROTEINS
Method & Zilversmith extraction (E) • Lp (a)
Gold standard Step 3: Color reaction → Sinking lipoprotein
with chromotropic acid → Independent risk factor for Atherosclerosis
(C)
• IDL Intermediate Density Lipoprotein
B. Enzymatic Method → Always in the middle
i. Glycerol kinase method
MISCELLANEOUS LIPOPROTEINS
BEQ: What does the machine measures? Glycerol head • B-VLDL
• The machine cannot measure TAG directly → Floating Lipoprotein
• Why glycerol head? Easier to count than fatty acids • LpX
MNENOMIC FOR THE METHODS OF CHOLESTEROL AND MNEMONIC FOR LP X
TRIGLYCERIDE LOCA
SCAL | TVH • LCAT deficiency – enzyme needed for the metabolism of lipoproteins
• Salkowski • Obstructive jaundice
→S • Cholestasis
→ Disulfonic • Apo C/Albumin
→ Red
• Cholesterol ULTRACENTRIFUGATION
• Abell, Levy, Brodie
• LB
→L
→ Mono
→ Green
• TAG
• VHZ (Modified)
• Hantzsch Method – Condensation methos

• Reference method
• KBr (1.063)
• Done for 24 hrs
• Svedberg unit
• HDL (heaviest) → LDL→ VLDL → Chylomicron (lightest)
• Chylomicrons – cream layer in EDTA samples
• Turbid plasma/serum – VLDL
→ That’s why we fast for 8-12 hours, so that our TAG will not have a high
result. That includes chylomicrons
• Lipemia

ELECTROPHORESIS

CM – apoB48; VLDL – apoB100 LDL– apoB100

LIPOPROTEINS • Fastest to migrate from origin: α-lipo (HDL), pre-β (VLDL), β (IDL), CM
MAJOR LIPOPROTEINS • Friedrickson's Classification of Hyperlipidemia
• Chylomicron • Medium for electrophoresis: Agarose gel (most sensitive media)
→ Transporter of exogenous (from the food that we eat)
→ Predominant lipid: TG Friedrickson's Classification of Hyperlipidemia
Phenotype Name Elevated Elevated Lipid Frequency
• VLDL Lipoproteins Levels (%)
→ Transporter of endogenous TAG from the liver I Primary CM TAG <1
→ Predominant lipid: TG Hyperchylomicronemia
• LDL lla Famillal LDL Cholesterol 10
→ Predominant lipid: CE Hypercholesterolemia
→ Bad cholesterol transporter llb Familial Mixed LDL, Cholesterol, 40
→ Direct risk for the development of Atherosclerosis Hyperlipidemia VLDL TAG
• HDL III Familial IDL Cholesterol, <1
→ Predominant lipid: CE dysbetalipoproteinemia TAG
→ Good cholesterol transporter

Clinical Chemistry – Seminar I Week 2 2 of 13

 IV Hypertriglyceridemia VLDL TAG, 45
Cholesterol
V Mixed CM, VLDL TAG, 5
Hypertriglyceridemia Cholesterol

• Hematology: Acanthocytes are seen in Abetalipoproteinemia

→ No LDL • Niemann-Pick – macrophage are called foam cells
• Tangier’s Disease → Foamy cytoplasm
→ No HDL • Gaucher – crumpled cytoplasm
→ Tonsils are color orange
PROTEINS
Lipid Profile (in mg/dL)
• Proteins means of prime importance
Desirable Borderline High
Triglycerides <150 150-199 200-499
HDL-C 40 n/a n/a
LDL-C <130 130-159 160-189
Total Cholesterol <200 200-239 ≥240

• We only do fasting for TAG in lipid profile

Stratified Risk Factors for CHO
Age (in years) Moderate risk (mg/dL) High risk (mg/dL)
2-19 >170 >185
20-29 >200 >220
30-39 >220 >240
Protein Structures
40-above >240 >260
Primary Amino acid sequence
• Not affected by fasting Structure
• Prolong diet Secondary Winding of polypeptide chain
Structure Specific 3-D conformations:
Formula for LDL Cholesterol alpha-helix, beta-pleated sheath, bend for
Friedewald De Long Tertiary Actual 3-D configuration
Not applicable when TAG Most accurate and most Structure • Myoglobin
is >400 used Association of 2 or more polypeptide chains → protein
mg/dL 5 6.5 Quaternary • Hemoglobin
mmol/L 2.175 2.825 Structure → A1 – 2A, 2B
→ A2 – 2A, 2D
𝑇𝐴𝐺 → F – 2A, 2G
𝐿𝐷𝐿 = 𝑇𝐶 − 𝐻𝐷𝐿 −
𝑋
BEQ: What structure protein is resistant to denaturation? Primary
Denaturation
Types of Proteins
Fibrous
Hydrolysis will yield • Feather-like
Simple Proteins amino acids • Fibrinogen, troponin
Globular
• Hb, plasma proteins
Metalloproteins
• Ferritin (storage form
of protein,
ceruplasmin (tranport
Lipid Storage Disease carrier of Cu)
Protein (apoprotein) Lipoproteins
Disease Deficient Enzyme Major Storage Product Conjugated Proteins + nonprotein moiety • CM, VLDL, LDL, HDL
Tay-Sachs Hexosaminidase GM2 ganglioside (prosthetic group)
B-Glucosidase Glucocerebroside Glycoproteins
Gaucher's • Haptoglobin, AAT
Fabry's a-Galactosidase Ceramide trihexoside Mucoproteins
Krabbe's Galactocerebrosidase Ceramide trihexoside • Mucin
Niemann-Pick Sphingomyelinase Galactocerebroside Nucleoproteins
• Chromatin

Clinical Chemistry – Seminar I Week 2 3 of 13

 SERUM PROTEIN ELECTROPHORESIS • A1 chymotrypsin
• Most common media: Cellulose acetate • A1 acid glycoprotein or orosomucoid
→ pH: 8.6
ALPHA-2
→ All proteins are negatively charge
CHA
STEPS IN SPE • Ceruloplasmin
1. Electrophoresis → Transporter of Cu
2. Staining ▪  Cu – Wilson’s Disease
3. Densitometry − Kayser Fleischer Ring
▪  Cu – Menke’s disease
− Kinky hair
• Haptoglobin
→ Transporter of free Hb
• A2-macroglobulin
→ Nephrotic syndrome - A2
• High A1 and A2 – inflammation and  albumin

GAMMA
• Immunoglobulins
• IgG – anamnestic response
→ Secondary responder
• IgA - secretions
• 1 – Albumin
• IgM – first responder
• IgD - receptor
• IgE – allergy/parasites
• Monoclonal gammopathy
→ Multiple Myeloma
• Polyclonal gammopathy
→ All increase
• 2 to 5 – Globulin
BETA
• All proteins that are not mentioned
→ Transferrin
→ Complement
• TPAG – 1 to 5 → Fibrinogen
→ Hemopexin
*The illustration is in the last page*
• At pH 8.6, all proteins are negative charge to they will go to positive pole
(anode) • Beta-Gamma bridging
→ Most common cause: Liver cirrhosis
PRE-ALBUMIN →  IgA
• Is also known as transthyretin • Sharp peak between B and G – Fibronogen
→ Transporter of thyroxin and retinol → Used plasma instead of serum
→ Abundant or increased in CSF
ELCTROENDOSMOSIS/ENDOSMOSIS
ALBUMIN • Negative proteins migrate to negative charge pole
TWO MAJOR FUNCTIONS:
1. Oncotic pressure SAMPLE QUESTION
• Low albumin = Edema; Problem in the liver can result to edema
• Hyperalbuminemia -  albumin
→ Dehydrated
• Hypoalbuminemia -  albumin
→ Malnutrition
→ Pregnancy
→ Inflammation
▪ Albumin is a negative Acute Phase Reactant
▪ CRP –  APR
→ Burns
▪ Uses albumin to recover
• Bisalbuminemia – two peaks
• Analbuminemia – no albumin
2. Transport carrier
• Stains:
→ Bromcreol green (BCG) – most commonly used
→ Bromcresol purple – most sensitive
→ Methyl Orange
→ HABA

ALPHA-1
• A1 antitrypsin
→ 90% of the A1 region
→ If depressed, deficiency of A1-antitrypsin, seen in pulmonary
emphysema
▪ Cigarette users
▪ Inherited

Clinical Chemistry – Seminar I Week 2 4 of 13

 MYOCARDIAL INFARCTION
• Infarction: Ischemia + necrosis
→ No blood supply that leads to necrosis

Aminoacidopathies
MNEMONIC Isovaleric acidemia Sweaty feet
My TropICAL MSUD Maple Syrup
• Myoglobin – first protein to be elevated Methionine malabsorption Cabbage/Coleslaw
• Troponin I – most sensitive marker Phenylketonuria Mousy/Musty
• CKMB – first enzyme to be elevated Trimethyl aminuria Rotten egg/Fish
→ Marker of reinfarction Tyrosinemia Rancid butter
• AST – 2nd enzyme • Aminoacidopathies – amino acids that are not properly metabolized in the
• LDH – 3rd enzyme body. Excreted in urine
→ Newborn Screening – detects aminoacidopathies
Acute Myocardial Infarction Markers ▪ Done in the 2nd to 3rd day
Myoglo Troponin Troponi CK-MB AST LD
bin T nI MNEMONIC
Rise 1-3 h 3-4 h 3-6 h 4-8 h 6-8 h • I Saw
48-72 • My Mom
Peak 5-12 h 10-24h 12-18 h 12-24 h 24h h
• Making Cake
Norm 10-14 • Papaya Melon
alize 18-30 h 7 d (10-14 d) 5-10 d 48-72 h 5d d • Tri Ro
• Tyr Ra
OTHER PROTEINS Total Proteins
• Myoglobin Name Description Reagent End
→ First protein elevated in MI Product
→ Nonspecific Reference method
→  Myoglobin = muscle injury since myoglobin is found in the muscle Measurement of
→ It doesn’t tell you what muscle has a problem nitrogen content
• Troponin
→ I - Myocardial infarction Kjeldahl 1 g N2 = 6.54 grams Sulfuric acid Ammonia
(Digestion) of protein
→ T – inflammation in the heart or Myocarditis
1
→ C - Calcium
5.1-16.8% =
• BNP (Brain Natriuretic Factor) nitrogen content of
→ When our BP is high, the brain senses it. Through our heart, it will release CHON
BNP, for you to excrete sodium in urine Most widely used Alkaline
→ “Where Na goes, H2O follows” (IFCC) Cu2SO4, BEQ:
• Cystatin C Biuret Rochelle Violet (545
→ GFR Requires at least 2 salt (NaK nm)
• Amyloid peptide bonds Tartrate);
→ Abnormal proteins seen in conditions such as T1 DM and Alzheimer’s NaOH; KI
disease Highest analytical Phenol; Deep blue
Folin-Ciocalteu sensitivity Oxidation Biuret color
• Stains for amyloid
of phenolic
→ Congo red compounds
→ Methyl violet – Crystal violet Lowry Folin-Ciocalteu +
→ Gram’s iodine Biuret method
• Bence Jones Proteins Proteins absorb light
→ Immunoglobulin light chains at 280 nm and 210
▪ Kappa or lambda nm
▪ Seen in the urine in patients with Multiple Myeloma UV Absorption
→ Test of choice: Immunofixation/Immunoelectrophoresis 280 nm tryptophan,
▪ Heat solubility testing – most common tyrosine and
phenylalanine
− BJB is soluble in100°C, recoagulates in 40°C-60°C
• Multiple myeloma Alternative test
→ Malignancy of plasma cell Refractometry
→ Manifested with CRAB Measurement of RI
▪ Calcium in increased in blood of solutes in serum
▪ Renal Failure Globulins are
▪ Anemia separated from Sodium
▪ Bone pains Salt fractionation albumin by salting- sulfate salt
out procedures
using sodium salts

Clinical Chemistry – Seminar I Week 2 5 of 13

 Characterizes 3. Loop of Henle
abnormal bands by • Major site of solute concentration
adding specific • DWAS
antisera to each → Descending Loop - Water
sample cell → Ascending Loop – Sodium (Na) and Cl
Used in the 4. Distal Convoluted Tubule
Immunofixation diagnosis and • Site of secretion (blood to urine)
Electrophoresis monitor Multiple
Myeloma (IgG) 5. Collecting duct
and Waldenstrom • Site of final water concentration
Macroglobulinemia → ADH prevents urination
(IgM) → ANP/VNP promotes urination
Has higher GLOMERULAR FILTRATION RATE
analytical sensitivity
than conventional • Creatinine clearance is collected by 24 hr urine
electrophoresis → Starts and end with an empty bladder
→ 6PM – discard, after that collect all the urine
• Refractive Index – the ratio of the speed of light in a vacuum over a
medium of greater density → 6PM the next day – collect
• Received in a cooler
KIDNEY FUNCTION TESTS • Measure the total volume upon receiving the 24 hr sample, and use a big
graduated cylinder
• Kidneys
→ Bean-shaped organs located at the top of adrenal glands
FUNCTION OF THE KIDNEYS 𝒎𝑳
𝑼𝒄𝒓 𝒙 𝑽𝒖𝒓 ( 𝒉𝒓𝒔) 𝟏. 𝟕𝟑
𝟐𝟒
1. Elimination of waste products 𝑪𝒓𝒆𝒂𝒕𝒊𝒏𝒊𝒏𝒆 𝑪𝒍𝒆𝒂𝒓𝒂𝒏𝒄𝒆 =
𝟏, 𝟒𝟒𝟎
𝒙
𝑷𝒄𝒓 𝒙 𝒉𝒓𝒔 𝑷𝒙 𝑩𝑺𝑨
2. Maintenance of blood volume 𝟐𝟒
3. Maintenance of electrolyte balance
4. Maintenance of acid-base balance Ucr = Urine creatinine
5. Endocrine function Vur = Urine volume
Pcr = Plasma creatinine
1440 = Constant. 60 x 24
1.73 = Average BSA (constant)
BSA = Body Surface Area

• If there’s no BSA given, only use the left equation.

SAMPLE PROBLEM
Urine crea: 120 mg/dL
Serum crea: 3.4 mg/dL
Volume in 24 hr: 1. 3L

Step 1: Convert urine volume to flow rate

Given:
Total urine volume in 24 hr = 1.3 L = 1300 mL
• EPO - Hormone that is released in the kidneys leading to the production Minutes in 24 hr = 1440 min
of RBCs
1300
• Nephron – basic functional and structural unit of the kidney 𝑉= = 0.9028 𝑚𝐿/𝑚𝑖𝑛
1440

Step 2: Plug values into formula

𝑚𝑔 𝑚𝐿
(120 ) 𝑥 (0.9028 )
𝐶𝐶𝑟 = 𝑑𝐿 min = 31.86 𝑚𝐿/𝑚𝑖𝑛
3.4 𝑚𝑔/𝑑𝐿
KDIGO Definition of Acute Kidney injury
Stage Creatinine Criteria Urine Output Criteria

1 Cr 1.5-1.9 times baseline, OR < 0.5 ml/kg/hr x 6-12 hours

Cr increase 0.3 mg/dL
2 Cr 2-2.9x baseline < 0.5 ml/kg/hr for > 12 hours
• Nephron – basic structural and functional unit of the kidney
Cr > 3x baseline, OR < 0.3 ml/kg/hr for > 24 hours,
1. Glomerulus (Renal Corpuscle) 3 Cr > 4mg /dL OR OR Anuria 12 hours
• Major site of filtration Initiation of dialysis
• Acts as a sieve or filter Patients are staged based on the single most concerning feature.

2. Proximal Convoluted Tubule NON-PROTEIN NITROGENOUS COMPOUNDS (NPNS)

• Major site of reabsorption (urine back to blood) 1. Urea
→ SAGUW – reabsorbed in the PCT • Major end product (45%) of protein and amino acid catabolism
▪ Sodium • 10-20:1 (BUN: Creatinine ratio)
▪ Amino acid • BUN is not urea
▪ Glucose → BUN is the nitrogen of urea
▪ Urea • BUN x 2.14 = Urea
▪ Water

Clinical Chemistry – Seminar I Week 2 6 of 13

• Marker of hydration status → Fuller’s earth: Aluminum Magnesium Silicate
→ Dehydration -  Urea
• Marker of nitrogen intake B. Enzymatic Method
→ If Vegetarian -  Urea i. Creatinine Aminohydrolase - CK Method
• 1st to increase in kidney injury ii. Creatininase Hydrogen Peroxide Method
• Ornithine/Kreb’s Henselet Cycle iii. Creatininase - Creatine Aminohydrolase Method

2. Creatinine BLOOD URIC ACID

• End product of muscle metabolism derived from creatine A. Chemical Method
• Produced by three amino acids: methionine, arginine and lysine i. Reduction-Oxidation Reaction
• Generation remains fairly constant • NaCN: Folin
• Most commonly test analyte to monitor kidney injury/renal function → Toxic
• From the muscle • NaCO3: Caraway
• Amino acid: Methionine, arginine, lysine
• Diet can only affect if you eat red meat if  renal function B. Enzymatic Method
i. Uricase Method
3. Blood Uric Acid • Simplest and most specific method
• Major product of purine catabolism
• Purine: Adenine and guanine C. Isotope Dilution Mass Spectrometry (IDMS)
• Final breakdown of nucleic acid catabolism in humans • For research purposes only
→ Beaten up = damage cells = damage myelocytes = nucleic acid = BUA
→ Chemotherapy – destroys normal and abnormal cells = nucleus will be DISEASE CORRELATION
destroyed or degraded = purines will be converted to UA 1. AZOTEMIA
• Tophi
• BUN, Creatinine, and UA is 
• Lesch Nyhan Syndrome
• Laboratory term
→ Deficiency of HGPRT (Hypoxanthine Phosphoribosyl Transferase)
• Elevated level of nitrogenous substances like urea and creatinine in the blood
→ Amino acid is not being recycled and deposited in other parts of the body
→ Reason: Unknown
▪ If deposited in the brain, it can cause a self-mutating disease,
wherein the baby bites their mouth, tongue, or hand

METHODOLOGIES Azotemia
BLOOD UREA NITROGEN (BUN) Pre-renal Renal Post Renal
Tissue damage
A. Chemical Method The damage is the
i. Diacetyl Monoxime Method kidney itself
• Colorimetric
• End product: Color yellow Decreased GFR
Hypoperfusion Obstruction
B. Enzymatic Method No blood flow in the kidney
Striking BUN level
but slowly rising
i. Urease method Decreased GFR
Dehydration (marathon), creatinine value
• Derived by jack beans as a source of urease Diabetic nephropathy
• We don’t allow additional test for urea using gray tops since Sodium fluoride shock (septic and Drinks antifreeze Nephrolithiasis,
in gray tops inhibits urease hypovolemic shock) , CHF Anything toxic to the cancer or tumors of
• Most commonly used method Increased: BUN kidney can lead to GUT
intrinsic damage S. haematobium –
ii. Coupled Urease/ Glutamate Dehydrogenase Method-UV Enzymatic Method
Normal: Creatinine malignancy on the veins
BUN ≥ 100 mg/dL of the urinary bladder
C. Isotope Dilution Mass Spectrometry BUN: Crea > 20:1
plexus
• Reference method Creatinine ≥ 220
• Not commonly used mg/dL. Creatinine normal or
• Used in research purposes slightly increased
Uric acid ≥ 12 mg/dL
BUN: Crea ≥ 20:1
CREATININE
• Product of muscle metabolism BUN: Crea < 1
A. Jaffe Method – commonly used method before 2. UREMIA
• Jaffe A • Clinical term – scales on the skin, can’t sleep, always crosses legs, kuyakoy,
→ Saturated picric acid – yellow and itchiness
• Jaffe B • Clinical syndrome comprised of marked elevation in plasma urea and other
→ 10% NaOH – colorless nitrogenous waste products, accompanied by acidemia and electrolyte
• A + B = Alkaline Picrate Solution (APS) imbalance of renal failure.
→ APS + Serum = Red-orange complex (Red tautomer)
• Modified Jaffe Method
→ Lloyd’s reagent: Na Aluminum Silicate

Clinical Chemistry – Seminar I Week 2 7 of 13

 OSMOLALITY • Bilirubin will be B1
• An expression of concentration in terms of the total number of solute particles • In the bloodstream, Bilirubin will bind to albumin
per kilogram of solvent. • Indirect bilirubin will roam inside the body until it reaches the liver
• Measured using the colligative property of sample • In the liver, it will be conjugated by (UDGPT) Uridine Diphosphate
→ Freezing point Glucouronyl Transferase
• Reference range: → Enzyme responsible for the conjugation of B1 to B2
→ Serum: 280-295 mOsm/kg • It will go to the intestine in the biliary tract where gallbladder is.
→ 24-hour urine: 300-900 mOsm/kg • It will be excreted in the bile.
→ Random urine: 50-1200 mOsm/kg → 80% - excreted in stercobilin
→ 2% - excreted in urobilin
→ 18% - will go back to the liver
𝐵𝑈𝑁 𝐺𝑙𝑢
𝑂𝑠𝑚𝑜𝑙𝑎𝑙𝑖𝑡𝑦 = 1.86 + + Bilirubin 1 Bilirubin 2
2.8 18 Always have prefix
Unconjugated bilirubin Conjugated bilirubin
Water insoluble Water soluble
BIOMARKERS OF KIDNEY INJURY Non-polar bilirubin Polar bilirubin
1. Kidney injury molecule-1 (KIM-1) Indirect acting Direct acting
• Expressed in proximal tubular cells injured by ischemia or nephrotoxins • Hemobilirubin Cholebilirubin
2. Neutrophil gelatinase associated lipocalin (NGAL)
• Aka lipocalin-2 or siderocalin • B1 + B2 = Total Bilirubin
• Inflammation of kidney parenchyma and in kidney injury • Delta bilirubin – bilirubin covalently bonded to albumin
3. Insulin-like GF binding protein 7 (IGFB7) → In the bloodstream, Bilirubin will bind to albumin, once it goes to liver,
Albumin must separate. If not separated, it is called Delta Bilirubin.
• Not commonly used
4. Tissue inhibitor metalloproteinase-2 (TIMP-2) Direct Bilirubin Indirect Bilirubin
• Not commonly used • Diazo Rgt • Needs Accelerator since it doesn’t
Reacts immediately to bilirubin react to Diazo rgt alone
LIVER FUNCTION TESTS Diazo Rgt + Accelerator = Total Bilirubin
• Liver is the largest internal organ IBil = TBil - DBil
• Right upper quadrant Increased
•  B1 – Hemolysis
LIVER FUNCTIONS •  B2 – Obstructive jaundice
1. Synthetic function → Gall stones
• Proteins are synthesized in the liver •  B1 + B2 – Liver disease
• Only protein does not synthesize in the liver: Immunoglobulins – produced in • Yellow sclera – icteric sclera
the plasma cells found in the bone marrow • Yellow skin – jaundice
2. Conjugation function • Yellow sample – icteric
• What’s being conjugated in the liver: Bilirubin • Bilirubin deposited in the brain – kernicterus
3. Detoxification and Drug Metabolism
4. Excretory and Secretory Function Methods of pH Color Accelerator
5. Storage Function Bilirubin Assay
Methanol
Methanol is toxic
BILIRUBIN If ingested, it will
Evelyn Malloy Acid Pink/Purple
“Girl” be converted to
Formaldehyde in
the liver
Caffeine
Jendrassik Grof sodium
“Boy” Basic Blue/Green benzoate
Compensate for
sunlight’s exposure

DERANGEMENTS IN BILIRUBIN METABOLISM

1. Gilbert's Syndrome
• Transport of bilirubin
• GT: Game of Thrones
• End product of hemoglobin metabolism and the principal pigment in bile 2. Crigler-Najjar Syndrome
• Color reaction: Van den Bergh
• Conjugation of bilirubin
• Color reagent: Diazo reagent
• CC: Candy Crush
• Product: Azobilirubin 3. Dubin Johnson Syndrome
• Excretion of bilirubin
• EJ: Elton John
• Contains a dark liver
4. Rotor Syndrome
• Excretion
5. Lucey-Driscoll Syndrome
• Circulating inhibitor against bilirubin conjugation

BILIRUBIN PATHWAY
• In the RTE, RBCs are degraded which leads to the release of Hgb. Heme
is further metabolized where the globin is recycled.
• Heme is further metabolized to B1

Clinical Chemistry – Seminar I Week 2 8 of 13

 • Nonprotein portion
→ Coenzyme
→ Activator

3. HOLOENZYME
• Apoenzyme + Cofactor = Whole enzyme (Holoenzyme)
MNEMONIC
• Certain Animal Cl Ams
• Must Care Mg CK
• Coz Accordingly Ca ALP and ACP
• Zoo Loses Zn LDH
• Being Animal lovers B6 AST ALT
• Prehepatic – associated with hemolysis • Cl, Mg, Ca, Vit B6 - activators
• Hepatic – problem is the liver itself → Inorganic cofactors meaning no carbon
• Post hepatic – all related to conditions in the liver • Vitamin B6 (Pyridoxine) – inorganic compounds
Types of Pre hepatic Hepatic Post hepatic → Coenzymes are organic compounds
Jaundice 4. INHIBITOR
Bilirubin increased B1 B1 + B2 B2
• Interferes with the reaction
Urine urobilinogen Increased +/- Absent
Urine color Normal Dark Dark
Stool color Dark brown Normal Clay colored
AST and ALT Normal Very high Increased
ALP Normal 2-3x 10-12x

• B2 in the blood goes to the urine since it is water soluble

• Post hepatic – there is a blockage in the liver to the intestine resulting B2
to the blood
→ Competitive inhibitor – binds to active site
• Post hepatic (Obstructive jaundice) -  ALP and GGT → Non-competitive inhibitor – binds to allosteric site
→ Uncompetitive inhibitor – substrate + enzyme + inhibitor
AMMONIA
• Toxic in the blood 5. ISOENZYME
• Detoxify by Urea cycle
• Arises from deamination of amino acid
• Metabolized in the liver via the urea cycle
• Increased in cirrhosis, hepatitis, Reye's syndrome, chronic renal disease,
acetaminophen poisoning
• The kid receives Aspirin/Aspilet (Salicylate) as medication. Liver is then
damage. Ammonia is not being converted and accumulated resulting to
Reye’s Syndrome. • Performs same function reaction but have different structure
• Ammonia deposited in the brain: Hepatic encephalopathy
• Preferred sample: fresh arterial blood 6. ACTIVE SITE
• Sample requirement: heparin or EDTA plasma in ice water • Holoenzymes contains a cavity
→ Usually, heparin is used instead of EDTA • Substrate is like an ingredient for a chemical reaction
• Common method: glutamate dehydrogenase • Where substrates bind
• Major interference: hemolysis, smoking • “Front door”

ENZYMES 7. ALLOSTERIC SITE

• Binds to other sites
ENZYMES • “Back door”
• Biological catalysts
→ Speeds up the reaction 8. PROENZYME (ZYMOGENS)
• Lowers the activation energy level that the substrate must reach in order for
the reaction to occur.

OTHER TERMINOLOGIES

• Inactive enzymes

CLASSIFICATION OF ENZYMES

Class Examples
1 Oxidoreductase LDH, MDH, G6PD
1. APOENZYME 2 Transferases CK, AST, ALT
• Protein portion of the enzyme
3 Esterases - ACP, ALP, CHS,
2. COFACTOR LPS
• Nonprotein entities that must bind to particular enzyme before the reaction Hydrolases Peptidases – Trypsin, Pepsin
occurs

Clinical Chemistry – Seminar I Week 2 9 of 13

 Glycosidases – AMS, Inhibitors of ACP Isoenzymes
Galactosidase Prostatic ACP L-tartrate
4 Glutamate decarboxylase, RBC ACP Cupric sulfate and formaldehyde
Lyases Pyruvate decarboxylase, ions
Aldolase
5 Isomerase Glucose phosphate isomerase, ASPARTATE AMINOTRANSFERASE (AST/SGOT)
Ribose phosphate isomerase • Transfer of amino group between aspartate and a-keto acids with the
6 Ligases Enzymes with ligase in its formation of oxaloacetate and glutamate
name • Tissue sources: Heart, Liver, Skeletal Muscle

ENZYME UNITS ALANINE AMINOTRANSFERASE (ALT/SGPT)

• Katal Unit • Transfer of amino group between alanine and a-ketoglutarate with the
formation of pyruvate and glutamate
→ Mole/s
• Liver specific
• International Unit (IU)
→ Micromole/min
• AST and ALT are both markers of liver injury
MODELS OF SUBSTRATE-ACTIVE SITE BINDING Elevations of AST and ALT
Slight Hepatic cirrhosis, alcoholic hepatitis, obstructive jaundice
Moderate Chronic hepatitis, hepatic cancer and infectious
mononucleosis
Markedly Acute/viral hepatitis or mechanical damage to the liver
• Acute/Viral - Liver is still healthy and can produce a lot of transferases
• Lock-and-Key – “real key” • De Ritis Ratio – (ALT:AST)
• Induced-Fit – “duplicate key” → ALT:AST >1.0 – Acute hepatitis
TYPES OF ENZYMATIC REACTIONS AMYLASE
Zero-order reaction First-order reaction
• Catalyzes the breakdown of starch and glycogen
Reaction rate depends only on Reaction rate is directly
• Smallest enzyme
enzyme concentration proportional to substrate
concentration • Earliest marker of pancreatitis
Independent of substrate Independent of enzyme • Two isoenzymes:
concentration concentration → Salivary – S-type (Ptyalin)
→ Pancreatic – P-type (Amylopsin)
MAJOR CLINICAL ENZYMES
• Remember: Method and highest elevation LIPASE
• Hydrolyzes the ester linkages of fats to produce alcohol and fatty acid
ALKALINE PHOSPHATASE • Most specific marker to the pancreas
• Liberates inorganic phosphate from an organic phosphate ester with the
concomitant production of alcohol at an alkaline pH 9.0-10.0 • Amy and Lip are both markers of pancreatitis
• Highest elevation is seen in Paget’s disease/Osteitis deformans Acute Pancreatitis Markers
• ALP isoenzymes: placenta, intestine, liver, bone Amylase Lipase
1. Heat stability (56°C) Rise 2-12 h 6h
• Placenta – most heat stable Peak 24 h 24 h
• Intestine Normalize 3-5 7d
• Liver LACTATE DEHYDROGENASE
• Bone – most heat labile
• Catalyzes the interconversion of lactic and pyruvic acids
• Highest elevation is seen in Pernicious/Hemolytic anemia
2. Electrophoresis (Anodal) - quantitate
• Liver LDH Isoenzymes Location Component
• Bone 1 Heart, HHHH
• Placenta 2 RBC HHHM
• Intestine 3 Pancreas, lungs HHMM
4 Liver, HMMM
• Carcinoplacental isoenzymes: Regan, Nagao, Kasahara
5 muscles MMMM
• Ragan is associated with placental cancer 6 Alcohol dehydrogenase
• Nagao is associated with pancreatic cancer Special only Asian flush or hangover
• Kasahara is associated with intestinal cancer CREATINE KINASE
• Methods: • Catalyzes the transfer of a phosphate group between creatine phosphate and
a. Heat Fractionation/ Stability Test: P-I-L-B adenosine diphosphate
b. Electrophoresis: L-B-P-I • Highest elevation is seen in Duchenne’s muscular dystrophy
c. Chemical Inhibition
CK Isoenzyme Composition Location
Inhibitors of ALP Isoenzymes 1 BB Brain
Phenylalanine Regan, Placental and intestinal 2 MB Heart
L-leucine Nagao 3 MM Muscles
Levamisole Liver and bone
3M Urea Bone ALDOLASE
• Splits fructose-1,6-diphosphate into two triose phosphate molecules in the
ACID PHOSPHATASE metabolism of glucose
• Liberates inorganic phosphate from an organic phosphate ester with the • Associated with muscles
concomitant production of alcohol at an acidic pH 5.0-6.0
• ACP isoenzyme: prostate, RBCs, platelets, liver and bone
• Suspected Heterosexual Rape cases – ACP, but it is also related to bleeding,
PSA or microscopical exam to detect the presence or semen

Clinical Chemistry – Seminar I Week 2 10 of 13

GAMMA GLUTAMYL TRANSFERASE (GGT) BEQ: ALP
• Mediates the transfer of glutamyl groups between peptides or amino acids Bowers Reference
through linkage at a gamma carboxyl group. McComb Method
• Sensitive indicator of alcoholism
Bessy Lowry ALP Kinetic, P-nitrophenylphosphate (PNPP)
PSEUDOCHOLINESTERASE Brock Rapid or
Endpoint
• Used to monitor the effect of muscle relaxants (succinylcholine) after
surgery Hudson ACP Rapid
• Marker of insecticide/ pesticide poisoning (organophosphate)
Roy Prostatic ACP Thymolphthalein monophosphate
Acetylcholinesterase Butyrylcholinesterase ACP
Description True cholinesterase Pseudocholinesterase Reitz-Guilbalt Fluorescent 4-methylumbelliferonephosphate
Diagnostic
significance in Chronic exposure Acute exposure
organophosphate MNEMONIC
poisoning • CTO – CK → Tanzer and Oliver
Sample EDTA whole blood Serum • LaWAWro – LD → Wacker and Wroblewski
• Karmen → Her son SInchan AST
GLUCOSE-6-PHOSPHATE DEHYDROGENASE
• Used to maintain, NADPH in the reduced form QUESTIONS
ANGIOTENSIN-CONVERTING ENZYME (ACE) 1. In the most commonly used technique for measuring TAG, the analyte being
detected is:
• Aka peptidyl-dipeptidase or kininase II
a. TAG
• Converts angiotensin I to angiotensin II in the lungs
b. Fatty acid
• ACE2 in the cellular receptor of SARS and SARS-CoV2
c. Glycerol
→ If infected with COVID: Pneumonia
d. Cholesterol ester
→ Ends with “-Pryl” medications – side effects: cough since its mechanism
is ACE2 inhibitor making the lungs irritated
• Major tissue source: lungs and kidney 2. Corticosteroid is used as an artificial surfactant for premature babies with
underdeveloped lungs.
Summary of Enzymatic Methods This chemical is used as a substitute to the natural surfactant of the lungs
Name Enzyme Description which is
CK, PK, LDH a. Lecithin
Tanzer Gilvarg CK Forward Creatine to Creatine Phosphate b. Sphingomyelin
NAD c. Albumin
CK Reverse CK, HK, G6PD d. Fatty acids
Oliver Rosalki Faster than Tanzer Creatine Phosphate to Creatine
NADPH
3. Troponin I (+); CK-MB is normal. Interpret
Wacker LD Forward LDH at pH 7.1-7.4
a. AMI
Lactate to NADH pyruvate
Wroblewski LDH at pH 8.3 to 8.9 b. Reinfarction MI
Ladue LD Reverse Pyruvate to NAD lactate c. Normal
d. Previous MI
DNPH to ketoacid hydrazone +
Reitman ALT Colorimetric NaOH to intense brown color 4. Identify what region does complement protein migrates to in SPE.
Frankel read at 505 nm a. Alpha 1 region
b. Alpha 2 region
AST Coupled AST, MOH c. Beta region
Karmen Enzymatic Aspartate to NAD malate d. Gamma region

AMS Starch + iodine to decrease in 5. Biuret for protein detection uses copper sulfate as one of its reagents.
Amyloclastic Colorimetric color Identify the form of copper used:
a. Copper (I)
Starch chromogenic dye to b. Cupric
Chromogenic AMS insoluble dye-substrate solution to
c. Copper (III)
Colorimetric increase in color
d. Cuprous
AMS Reference Somogyi
Saccharogenic Method Starch substrate 6. A laboratory term for, the elevation of kidney waste products such as
creatinine and urea
Continuous or AMS, a-glucosidase, HK, G6PD at a. Uremia
Coupled AMS Enzymatic pH 6.9 b. Azotemia
Enzymatic Maltopentose to NADH c. Both
50% Olive Oil/Triolein to Oleic d. Neither
Cherry LPS Titration acid
Crandall Phenolphthalein (pink) 7. This additive In blood collection tube Inhibits the enzyme used In the o say
of urea.
50% Olive oil/ Triolein to Oleic a. NaF
Tietz LPS Titration acid Thymolphthalein and Veronal b. EDIA
(blue) c. K Oxalate
Turbidimetric Estimated Rate of clearing of fats in the d. Na Citrate
Activity of LPS solution
LPS Coupled
7. The yellow color of the reagent used in the detection of creatinine is
Colorimetric with Enzyme: Oxidation: POD
POD/ Glycerol Phosphorylation. GK attributed tor
Kinase a. Lloyd’s reagent
b. Fuller's earth

Clinical Chemistry – Seminar I Week 2 11 of 13

c. 10% NoOH
d. Saturated picric acid

8. Drug toxicity screening of la 6-year old sial has an increased presence of

acetaminophen. What test/s would be done next?
a. Albumin
b. Bilirubin tests
c. AST and ALT
d. Clotting factors

9. Compute for the indirect bilirubin.

Direct bilirubin = 1.2 mg/dL; Total bilirubin = 4.9 mg/dL; Della bilirubin = 0.1
mg/dL.
a. 6.1 mg/dL
b. 6.2 mg/dL
c. 3.7 mg/dL
d. 3.6 mg/dL

10. An increased level of urobilinogen lo the urine is associated with this

condition
a. Blackwater fever
b. Hepatitis B
c. Hepatocellular CA
d. Cholecystitis

11. This enzyme reacts with phenol at pH 9.6

a. ALP
b. ACP
c. AST
d. ALT

12. The marker used to confirm organophosphate poisoning is

pseudocholinesterase which will demonstrate ____ value in positive cases.
a. elevated
b. depressed
c. both
d. neither

13. The forward method for LDH determination is otherwise known as:
a. Tanzer-Gilvarg
b. Oliver Rosalki
c. Wacker
d. Wroblewski Ladue

Clinical Chemistry – Seminar I Week 2 12 of 13

Clinical Chemistry – Seminar I Week 2 13 of 13
CLINICAL CHEMISTRY 09/27/25

Midterms
SEMINAR 1
Lecturer: Dr. Renz Jethro M. Ortega, RMT, ASCPI (MLS), MD Trans #3
[Name of Lecturer]
[TRANS] WEEK 3

• Women physiologically has more fat than men since men have more water

[SUBJECT]
[Name of are
These notes Lecturer]
intended solely for personal study use. They are shared with
that women.
[Name of Lecturer]
you in confidence and must not be copied, reproduced, or distributed without
my prior permission.
- Nelly
IMPORTANT ELECTROLYTES

[Name
Otherof Lecturer]
side notes are not included due to my slow net connection. SODIUM
[Name of Lecturer] STUDY AT YOUR OWN RISK
• Major extracellular and major contributor of osmolarity or osmolality
CONTENT ELECTROLYTES → Major positive ion outside the cell
FUNCTION OF ELECTROLYTES
[Name of Lecturer]
• Each function corresponds to a specific electrolyte
• For volume and osmotic regulation
→ Na+
MM/DD/YYYY 𝑶𝒔𝒎𝒐𝒍𝒂𝒍𝒊𝒕𝒚 = 1.86𝑁𝑎 +
𝐵𝑈𝑁 𝐺𝑙𝑢
2.8
+
18

Shifting #
• In this formula, we are safe to assume that Na is the major contributor of
→ General rule: Water follows Na
osmolarity in the human body
• For myocardial rhythm and contractility
→ K+ • Principal osmotic particle outside the cell

heartbeat (arrythmia)
• Important cofactors in enzyme activation
Trans #
→ K+ (Hyperkalemia) or  K+ (Hypokalemia) can lead to an irregular → Water follows Na+
• Most abundant electrolyte in the body
• For every 100 mg/dL increase in blood glucose, serum sodium decreases by
→ Cl+, Mg+, and Ca+ 1.6 mmol/L
• For regulation of ATPase ion pumps →  glucose,  Na+
→ Mg+ • Major hormones affecting plasma Na levels
• For neuromuscular excitability → Increases Na: Aldosterone, angiotensin II, catecholamines

[SUBJECT]
→ Ca+
• For the production and use of ATP from glucose
→ Mg+
▪ Aldosterone from the RAAS system – Na reabsorption
▪ Angiotensin II – triggers the release of aldosterone which in return,
increases Na reabsorption
• Maintenance of acid base balance → Decreases Na: ANF (Atrial Natriuretic Factor/Peptide), urodilantin
→ Mg+ ▪ ANF (Atrial Natriuretic Factor/Peptide) - The heart releases ANF →
• Replication of DNA and the translation of mRNA kidneys push Na+ out in urine → water follows → blood pressure
→ Mg+ goes down.
Increased retention/ Hyperaldosteronism

[SUBJECT]
ELECTROLYTE DISTRIBUTION IN THE BODY Na in body  Na+ reabsorption

DI, diarrhea, profuse

Hypernatremia sweating, burns
Increase Na+ Excess water loss DI – water instead of urine
Profuse sweating – Cl is
more abundant
Reduced water intake Inability to drink water
Concentrates blood
Increased water Renal failure,
retention nephrotic syndrome,
stress
Hyponatremia Increased Na loss Diuretic use, saline
Decrease Na+ infusion
• Outside the cells, you would see the presence of the predominant SIADH, excess water
electrolyte which is Na+. Inside the cell, the predominant electrolyte is the Water imbalance intake
K+.
Most common cause is in vitro hemolysis
MNEMONIC • If the blood sample is hemolyzed, extracellular fluid will
• PISO come out making Na diluted
Artifactual hyponatremia: Increase proteins and
→ Potassium
Pseudohyponatremia lipids in the blood
→ Inside •  Proteins and  Lipids in the body makes your sample
Falsely decrease Na+
→ Sodium turbid
→ Outside → Interfere in the detection of the machine
• PICASO (Modified) • Remedy: Use Direct Ion Selective Electrode
→ A method of ISE that uses no dilution
→ Potassium
→ Inside POTASSIUM
→ Calcium • Major intracellular cation
→ Sodium • Functions for neuromuscular excitability, heart contraction, ICF volume and
→ Outside hydrogen ion concentration
WATER DISTRIBUTION IN THE BODY → K+ (Hyperkalemia) or  K+ (Hypokalemia) can lead to an irregular
heartbeat (arrythmia)
• 60% of the body is composed of water • Preferred specimen: Lithium heparinized blood
• 40% is found intracellularly → Not recommended since it only determines electrolytes and no other
• 20% is found extracellularly chemistry tests
→ 15% is interstitial fluid – in between cells • BEQ: Insulin: Lowers potassium level
→ 5% plasma • Banana is rich in K+

Clinical Chemistry - Seminar 1 JDS 1 of 13

 → Uncomfortable feeling on your skin that makes you want to scratch
Renal failure, resulting to a white flaky skin
Decreased renal excretion dehydration, → Seen in Dialysis patients
Addison's disease
Extracellular shift Acidosis, cell injury,
MAGNESIUM
Hyperkalemia exercise
Increased K+ Tacrolimus, Sirolimus, • Intracellular cation second in abundance to potassium
Drugs Trimethoprim • Vital for neuromuscular excitability, enzyme activation, uterine vasodilation
Tacrolimus and Sirolimus and cofactor in Taq DNA polymerase
are immunosuppressants • Magnesium loss leads to decreased intracellular potassium
Increased intake Oral or IV infusion → Mg is directly proportional to K. As Mg decreases, K also decreases, and
GI loss Gastric suction and vice versa
laxative use
Intracellular shift Alkalosis, insulin BICARBONATE
Hypokalemia • Primarily CO2
Decreased K+ Diuretics, → CO2 that transforms into another form is Bicarbonate
Extrarenal loss Hyperaldosteronism, • Accounts for 90% of the total carbon dioxide at physiologic pH
Cushing syndrome • Major component of buffering system in the blood
Decreased intake --- → Bicarbonate carbonic acid
• K in FES – violet ▪ Normal ratio: 20:1
• Na in FES - yellow • Part of chloride shift or Hamburger effect
→ Chloride shift - Cl changes its position with bicarbonate to maintain
CHLORIDE electrical neutrality of the cell
• Major extracellular anion ▪ They change position by Cl goes inside the cell, and bicarbonate
→ Negative ion found outside the cell outside the cell
• Chief counterion of sodium
→ Na is + IRON
• Only anion that is an enzyme activator • Common metallic element needed for the synthesis of hemoglobin
→ Amylase is activated by chloride → Ferrous is an important form of Fe+ in the body
→ Ferrous sulfate is taken by women
CALCIUM STAINS
• 99% present in the bones, the rest is in ECF • Ferric – Prussian blue
• Involved in blood coagulation, enzyme activity, excitability of skeletal and • Ferrous – Turnbull’s blue
cardiac muscle, and maintenance of blood pressure
• Factor IV in blood coagulation
→ ALP and ACP are activated by calcium
• Absorbed in duodenum at acidic pH
→ Drink milk after waking up and before sleeping, but not immediately after
eating
→ After 2 hours, the stomach is empty, which leads to higher calcium
absorption
• "For every 1 g/dL serum albumin decrease, 0.8 mg/dL decreases in total
calcium level
→ Albumin and Ca are directly proportional. As Albumin decreases, Ca also
decreases, and vice versa
• Forms of calcium in the body
→ 50% - ionized • Iron deficiency anemia -  Fe,  TIBC
▪ Active form of calcium in the body → TIBC is the ability of transferrin to bind iron
▪ The active form is always the free form • Thalassemia - TIBC,  Fe
→ 40% - protein bound
→ Fe is not used properly
▪ Bounded with albumin
• Anemia of Chronic Disease -  Fe, TIBC
→ 10% - complexed with anion
→ All Fe is in transferrin since Fe is not excreted/released. If Fe is
• Hormones affecting calcium
release, bacteria will multiply especially if you have an infection.
→ Vitamin D – increases Ca reabsorption in the intestine
→ PTH – increases Ca levels, increase bone resorption, decrease urine ANION GAP
excretion of Ca, and further activates Vitamin D
▪ Other name of Vitamin d: Calciferol • It is the difference between the unmeasured cation and unmeasured anions
▪ Main source of Vitamin D in humans: Sunlight • A form of quality control for the analyzer used to measure electrolytes
− Noon is when Vitamin D levels are highest, but morning • Formula and reference range:
exposure is preferred since noon is extremely hot and radiation → Na - (CI + HCO3) = 8-12 mmol/L
levels are high ▪ Most used
→ Calcitonin → (Na + K) - (CI+ HCO3) = 12-16 mmol/L
▪ Misnomer since it lowers Ca levels ▪ Because K is negligible
• If you compute the anion gap and it is high, that indicates metabolic
PHOSPHOROUS acidosis.
• Organic phosphate is the principal anion within cells
→ Inside the cell • America – Acetaminophen
• Inorganic phosphate is part of the blood buffer system • Philippines – Paracetamol
→ Blood buffer
TRIVIA
▪ A system that maintains and regulates blood pH
• Maximally absorbed in the duodenum • Isoniazid – medication for Tuberculosis
• Green leafy vegetables are high in phosphorus • Lactic acidosis – de quatro or cross legs (nangingimay)
→ Malunggay, Kangkong, and Talbos ng Kamote are examples → Glycolysis takes over because there is no oxygen supply. Blood flow
• High phosphorus: Pruritus is impeded

Clinical Chemistry – Seminar I Week 3 2 of 13

 • BEQ: Diabetic Ketoacidosis in HAGMA
HAGMA – High Anion Gap Metabolic Acidosis

BEQ: ISE Reference Electrodes

Sodium Glass Aluminum Silicate
Potassium Valinomycin
• Antibiotic as a reference electrode
Chloride Ion exchange Membrane
Calcium Liquid Membrane
Summary of Electrolyte Methods
Name Enzyme Description
AlbaneSe Lein Sodium Colorimetry
Lockhead and Potassium Colorimetry
Purcell
Diphenyl carbazone
SCHales and Schales Chloride Titration measuring excess
mercury (blue violet)
Whiterhorn Titration Chloride Titration Mercuric thiocyanate
(reddish complex)
NAGMA – Normal Anion Gap Metabolic Acidosis Clark Collip Calcium Precipitation (+) Oxalic acid
Method
Arzeno III dye
8-hydroxyquinoline
BEQ: Ortho-Cresol (inhibits Mg)
phthalein Calcium Colorimetry By inhibiting Mg, what we
COMplexone are detecting is just Ca
since Mg and Ca have
almost the same valence in
the periodic table.
Phosphorus (+)
Fiske Subbarow (Ammonium Phosphomolybdenum
molybdate method) blue
Magnesium Dye-lake Uses Clayton or
Titan Yellow Method Thiazole yellow)

ION-SELECTIVE ELECTRODE

• Electrode

CYSTIC FIBROSIS
• Analytical method used to determine the activity of ions in an aqueous • Mutation on a gene on Ch 7
• solution by measuring electrical potential → CFTR gene: Cystic Fibrosis Transmembrane Regulatory Protein
• Consists of a thin membrane across which only the intended ion can be → All secretions become viscous if you have a mutation on this gene
transported • Most common manifestation: Salty sweat due to the elevated Cl
• Types of ISE • Test:
→ Direct – no dilution → Gibson and Cooke Pilocarpine Iontophoresis
→ Indirect – with dilution ▪ Pilocarpine: induces sweat formation and release
▪ Measuring sweat chloride
− > 60 Cl: Diagnosis to CF
− 30-59 Cl: Indeterminate
− < 30 Cl: Negative for CF
• CF is a disease of Caucasians so it’s not common in Blacks and Asians
• RA 9928 or Newborn Screening Act: Detects CF

Clinical Chemistry – Seminar I Week 3 3 of 13

 ACID-BASE BALANCE PH
• We are measuring directly the pH
• Potentiometry
→ Silver-silver chloride electrode (Reference electrode)
→ Calomel electrode (Reference electrode)

PCO2
• We are measuring directly the pCO2
• Severing Haus electrode (potentiometry)

PO2
• We are measuring directly the pO2
• Clark electrode (polarography-amperometry)
• RTs are now responsible for ABG, but historically MT performs it.
• To collect ABG, you will aspirate heparin into the syringe, then blow it out.
Leave 0.1 mL in the syringe. Insert the needle into the artery, then aspirate
nor the blood will rise on its own because of arterial pressure
• BEQ: Slurry or iced water – used for the transportation of ABG sample.
→ If you place it directly on ice, the RBCs will freeze. When thawed, the
sample will hemolyze.
• Our diet is composed of proteins, carbohydrates, and fats, which are used
by the body for metabolism. As metabolism ensues, it produces hydrogen pH PCO2 pO2
and CO2. Delayed Testing   
• Hydrogen can be converted to ammonia, but the regulator of hydrogen is Tube is Closed
bicarbonate.
• In terms of bicarbonate, this is the kidney Delayed Testing   
• In terms of CO2, is lungs Open System
BEQ • Closed system/Tube is closed = Continuous metabolism,  pO2. The
• pH: 7.35 -7.45 byproduct is PCO2 but since the tube is closed, pCO2 will not evaporate.
• Correction: pCO2: 35-45 mmHg Also, pH will become acidic.
• pO2: 75-100 • That’s why when collecting an ABG sample, you should avoid
→ O2 is not commonly used probing/searching. If you do, it will act like an open system. Bubbles
→ Pulse oximeter is used to assess oxygen level because PO2 needs a should also be avoided, since they introduce air into the sample.
special machine
• HCO3: 22-26 ACID BASE BALANCE DISORDERS

• CO2 in the body exists in two forms, either bicarbonate or carbonic acid
• Carbonic acid in the formula: 0.03 PCO2

HENDERSON-HASSELBALCH EQUATION
BEQ: Formula of Henderson-Hasselbalch Equation

STEPS
1. Normal value
• pH: 7.35-7.45
• pCO2: 35-45
• HCO3: 22-26

2. Principle of ROME
• Respiratory: Lungs
• Henderson-Hasselbalch Equation – used to compute for Ph • Opposite:  pCO2  pH or  pCO2  pH
• Weak acids always start at Hydrogen (HA)
• Metabolic: Kidneys
• Blood
• Equal:  HCO3 =  pH or  HCO3 =  pH

BLOOD BUFFERS
• Blood buffers are substances that maintains pH

1. Bicarbonate and carbonic acid

• Important blood buffer
• Bicarbonate and carbonic acid: 20:1
• Carbonic acid to bicarbonate: 1:20
2. Plasma proteins
3. Hemoglobin
4. Inorganic phosphate

BLOOD GASES AND PH ELECTRODES

Clinical Chemistry – Seminar I Week 3 4 of 13

3. To determine if its Acidosis or Alkalotic, go back to the pH ACIDOSIS
•  pH - acidosis
•  pH – alkalotic

3.1
• pH: 7.49 , HCO3: 31  - Metabolic alkalosis
3.2
• pH: 7.32 , PCO2: 49  – Respiratory acidosis
3.3
• pH: 7.48 , HCO3: 32 , PCO2 (N) – Uncompensated metabolic
alkalosis
3.4
• pH: 7.47 , PCO2: 26 , HCO3: 18  - Partially Compensated
respiratory alkalosis
3.5
• pH: 7.35 (N but on the lower limit), PCO2: 33  , HCO3: 20  - Fully
Compensated Metabolic acidosis
PRACTICE TESTS
1. pH: 7.46  , PCO2: 23  - Respiratory Alkalosis
2. pH: 7.23  , HCO3: 11 - Metabolic Acidosis
3. pH: 7.5  , PCO2: 29 , HCO3: 24 (N) - Uncompensated Respiratory
Alkalosis RESPIRATORY ACIDOSIS
4. pH: 7.3  , PCO2: 30  , HCO3:18  - Partially Compensated Metabolic • In COPD, the airways are obstructed, so CO₂ cannot be exhaled and it
Alkalosis accumulates in the body.
5. pH: 7.37 (N but on the lower limit) , PCO2: 47  , HCO3: 30  - Fully • Chest trauma – airways are damaged, CO2 can’t pass thru
Compensated Respiratory Acidosis
METABOLIC ACIDOSIS
• This method is called Eyeballing or estimation. In practice or in a hospital • HAGMA and NAGMA
setting, we compute to know if its fully or partially compensated
• Common: DKA and Renal Failure
• If the result is it’s unmatched, not opposite or equal, or abnormal:
→ Renal Failure is uremia. If the patient is uremic, there is a chance of
→ Example pH:  , PCO2:  , HCO3:  developing metabolic acidosis or DKA
▪ Mixed status – if ROME is not applicable
PaO2 [mmHg] SaO2 [%]
ALKALOSIS Normal 97 to ≥ 80 97 to ≥ 95
< 80 < 95
Hypoxia O2 supplementation is
given
Mild 60-79 90-94
Moderate 40-59 75-89
Severe < 40 < 75
Metabolic MUDPILES CAT, HARD UPS
acidosis
Metabolic Vomiting
alkalosis
Respiratory COPD, myasthenia gravis, drug overdose, CNS
acidosis disease, acute asthma
Respiratory Anxiety, severe pain, trauma, hepatic cirrhosis,
alkalosis pulmonary embolism

ENDOCRINOLOGY
ENDOCRINE SYSTEM

RESPIRATORY ALKALOSIS
• Use a paper bag if the patient is hyperventilating, so that the CO₂ they
exhaled can be inhaled again.
→ CO2 will not decrease
• When you climb a mountain, the oxygen becomes thinner

METABOLIC ALKALOSIS
• Kremil S and Gaviscon can cause metabolic alkalosis

• Series of glands of the body

• Prostate and Testis collectively called Gonads
• The Endocrine system produces hormones. Each gland produces hormones

PATHOLOGIES IN ENDOCRINOLOGY
1. Excessive hormone production
• Anything excessive is harmful
2. Decrease to no hormone production
• Anything insufficient is harmful
3. Resistance to hormones
• The hormone is present, but the receptors are defective

Clinical Chemistry – Seminar I Week 3 5 of 13

 Luteinizing
Hormone
HORMONES
TSH Stimulates the thyroid gland to produce T3 and T4
• Chemical signals produced by specialized cells secreted into the blood stream Thyroid-Stimulating
and carried to a target tissue Hormone
→ The gland produces a hormone. The hormone is released into the blood. ACTH
Through the blood, it flows throughout the body until it reaches the target Adrenocorticotropic Stimulus for the production of cortisol
Hormone
organ
Milk production
• Major function: maintain constancy of chemical composition of extracellular
Prolactin • Prolactinoma - If a man has gynecomastia and milk comes out,
and intracellular fluids; controls metabolism, growth, fertility, and responses he has a tumor in the brain. Most likely its cancer
to stress
→ The function of hormones corresponds to its name Hormones Stored in the Posterior Pituitary Gland Description
▪ Example: Hormones Description
− Growth hormone for growth development Oxytocin Milk ejection; uterine contraction
− Thyroid hormones for metabolism • Important during childbirth
− Cortisol for stress response ADH
BEQ: Also
Types of Examples known as
Arginine
Hormones Vasopressin Conservation of water
FSH, hCG, TSH, LH • Antidiuretic prevents urination
Glycoproteins • All 4 have the same alpha subunit What amino
• Identity: Beta subunit acid is
→ Example in PT, we don’t detect a-hCG, we detect B-hCG important in
• Chains of amino acid vasopressin?
ACTH, ADH, GH, angiotensin, calcitonin, CCK, Arginine
Polypeptides
gastrin, glucagons, insulin, MSH, oxytocin, PTH, PRL,
• Posterior Pituitary Gland does not produce any hormone. It’s just a
somatostatin
storage for Oxytocin and ADH
Precursor: cholesterol; aldosterone, cortisol, estrogen,
Steroids progesterone, testosterone, vitamin D
• Ends with -one and -ol
• Made up of amino acids
Amines • T3 and T4’s amino acid: Tyrosine
• The amino acid involved here is tyrosine

HYPOTHALAMUS
• Not really a part of the endocrine system
• The one that controls the pituitary gland
• Connected to the posterior pituitary gland by the infundibulum
• Releases TRH, GnRH, GH-IH, GH-RH, PIH
→ Ends with -RH: Releasing Hormones
→ Ends with -IH: Inhibiting hormones
→ Except Oxytocin and ADH/Vasopressin
▪ POSA
− Paraventricular Nuclei
− Oxytocin
− Supraoptic nuclei
− ADH
→ These hormones are triggers for the pituitary gland to release hormones
DIABETES INSIPIDUS
PITUITARY GLAND •  ADH

TWO TYPES OF DI
• Central
→ No production of ADH
• Nephrogenic/Peripheral
→ Faulty receptor for ADH

SYNDROME OF INAPPROPRIATE ANTIDIURETIC HORMONE

SECRETION
•  ADH
• Edema is more prominent
• Master gland
• Located in the sella turcica
TWO PARTS OF PITUITARY GLAND
• Anterior: Adenohypophysis
• Posterior: Neurohypophysis
Hormones Produced in the Anterior Pituitary Gland
Hormones Description
Growth Most abundant of all hormones
Hormone For growth and development
FSH Egg cell: Oogenesis and Sperm cell:
Follicle-stimulating spermatogenesis
hormone
LH Helps in the synthesis of sex hormones
• Release production of estrogen, progesterone, and testosterone

Clinical Chemistry – Seminar I Week 3 6 of 13

 THYROID GLAND
• GnRH triggers pituitary gland to produce FSH/LH targeting your gonads
• TRH triggers pituitary gland to produce TSH targeting thyroid gland in
return to produce T3 and T4
• ADH and Oxytocin are produced in the hypothalamus just stored in the
pituitary gland. ADH targets the kidney. Oxytocin targets the mammary
gland and uterus

GROWTH HORMONE
• Butterfly shaped organ which functions for metabolism
• 2 lobes connected by isthmus
→ Isthmus connects the right and left lobe
• Produces T3, T4 and calcitonin
• Goiter – enlargement of neck
• Iodine – an important element for the production of thyroid hormone
→ The ultimate source: Seafoods

• Decreased GH: Dwarfism

• Increased GH
→ In children: Gigantism
▪ If you notice when children grow, they grow vertically — they get
taller. If a child has overproduction of growth hormone, they will
grow excessively tall, but when you look at them, their height still
seems proportional to their body.
→ In Adults: Acromegaly
▪ For us adults, if we take Cherifer, we won’t grow taller anymore
because our growth plates (physes) are already closed. If our
growth hormone increases, we won’t grow taller — instead, our
bones will become thicker, and our tissues will enlarge.

PRODUCTION OF T3 AND T4
• Hypothalamus produces TRH triggers pituitary gland to produce TSH
which in return to produce T3 and T4.
• Calcitonin is different. It is for calcium regulation
→ Lowers the Ca
• BEQ: TBG or Thyroxine Binding Globulin – major transport carrier of the
thyroid hormone
• If pregnant, TBGs
→ If you are pregnant, you can develop hyperthyroidism.
→ You can develop pseudo hypothyroidism — your thyroid gland itself
is not really the problem. It’s just that you have too much TBG, so
your total T4 is high in the body.

GH DEFICIENCY TESTS
a. Physical activity test - screening test
b. Insulin tolerance test – gold standard
• T3 and T4’s major function is for metabolism
• Growth hormone is a hyperglycemic hormone
→ T3 and T4 is high – fast metabolism
• If I give you insulin, your glucose will drop. When your glucose drops, that
→ T3 and T4 is low – slow metabolism
normally triggers the release of growth hormone. However, if you have
dwarfism, even if your glucose goes down, growth hormone will not • BEQ: What is the relationship of T3 and T4 with TAG and Cholesterol?
compensate because you are deficient in it. → When metabolism is fast, fats are metabolized quickly. This leads to
a decrease in TAG and cholesterol.
TESTS FOR ACROMEGALY → When metabolism is slow, fats are metabolized slowly. This leads to
a. Somatomedin C (Insulin-like growth factor) - screening test an increase in TAG and cholesterol
b. OGTT (75 g) - confirmatory test - gold standard
• Total T3 and T4: Overall Concentration
• If I give you a glucose load, your blood sugar will rise. When your sugar is • Free T3 and T4: Active form
high, that signals the brain to stop producing growth hormone. However, • T3: Most active thyroid hormone
in gigantism or acromegaly, no matter how high your sugar is, growth • T4: Secretory hormone
hormone production will not stop.
• TSH: single most important thyroid function test
• Another clue that a hormone is produced by the pituitary gland is the suffix → TSH > T4 > T3
-SH. When you see -SH, it stands for stimulating hormone. Stimulating
hormones are produced in the pituitary gland — specifically, the anterior • T3 and T4: Produced in the Follicular cells of the thyroid
pituitary gland. • Calcitonin: Produced in the Parafollicular cells

Clinical Chemistry – Seminar I Week 3 7 of 13

 • When the explosion happened at the Chernobyl power plant, the nuclear
plant released radiation. The most commonly affected organ was the
thyroid

PARATHYROID GLAND

• When T3 and T4 are low, it is called hypothyroidism. All the signs and
symptoms of hypothyroidism points to slow metabolism
• Hypo: Always feels cold

• If your thyroid is removed, your parathyroid glands will also be removed

• Known: Chief cells
• Parathyroid produce PTH (Parathyroid Hormone)
• Smallest endocrine gland
• Functions in the maintenance of calcium level in the body

• All the signs and symptoms of hyperthyroidism point to a fast metabolism

• Hyper: Always feels hot
BEQ
• Primary: The problem is the organ of interest
• Secondary: The problem is the pituitary gland
• Tertiary: The problem is the hypothalamus
T3 T4 TSH
Primary Hypothyroidism   
Secondary Hypothyroidism   
Tertiary Hypothyroidism   
Primary Hyperthyroidism   
Secondary Hyperthyroidism   
Tertiary Hyperthyroidism   

• In Primary Hypothyroidism, when T3 and T4 are low, the problem is in the

thyroid gland. The pituitary gland will try to compensate by increasing
WHAT DOES THE PARATHYROID HORMONE DO
TSH. But the root of the problem is still the thyroid.
• In Primary Hyperthyroidism, when your T3 and T4 production is high, the • Causes elevation of Ca in the blood
brain senses it and lowers TSH. But if T3 and T4 remain high despite low • Activates Vitamin D leading to increase Ca absorption in the intestine
TSH, the problem is in the thyroid. • Increase Ca reabsorption in kidney tubule
• Increase bone resorption
AUTOIMMUNE DISEASES OF THE THYROID GLAND → All to which increase Ca
1. Grave's disease: Hyperthyroidism
• Grabe grabe ADRENAL GLAND
• Anti-TSH receptor antibody – if you have this, your thyroid is always
activated, continuously producing T3 and T4
2. Hashimoto's Thyroiditis: Hypothyroidism
• You have antibodies attacking the thyroid
• Anti-thyroglobulin
• Anti-thyroid peroxidase
• Anti-microsomal antibody
3. Reidel's Thyroiditis
• Lymphocytic infiltration of the thyroid gland
• Above the kidney
• Stony wood appearance of the thyroid
• Pyramid-shaped organ found above the kidneys

Clinical Chemistry – Seminar I Week 3 8 of 13

• Has two major parts: adrenal cortex and adrenal medulla Major site of steroid • The more aldosterone you produce, the more sodium is
and catecholamine production reabsorbed, which results in high blood pressure.
• Adrenal cortex Old Methods for Certain Steroids
→ Zona Glomerulosa – Salt Aldosterone Name Analyte Measured Description
→ Zona Fasciculata – Sugar Cortisol Rgt: DNPH in
→ Zona Reticularis – Spice Sex hormones Porter-Silber Method 17-hydroxycorticosteroids H2SO+Alcohol
• Adrenal medulla: Catecholamines (+) Yellow
→ Epinephrine or Adrenaline Rgt: m-
→ Norepinephrine Zimmerman Reaction 17-ketogenic steroids dinitrobenzene
→ Dopamine (+) Reddish
• Pheochromocytoma – tumor of the adrenal medulla purple
→ Dx: 24 hr urine metanephrine or normetanephrine or Vanillylmandelic Pisano Method Metanephrine and
acid (VMA) Normetanephrine
Rgt: H2SO4 +
• Urinary preservative for hormones: HCl Kober's Reaction Estrogen hydroquinone (+)
Reddish brown
color
Tests for Cushing’s
1. 24-hour urine free
cortisol test
• Detects cortisol level
2. Overnight
dexamethasone Screening tests for
suppression tests = Cushing's
Most widely used
(1mg)
3. Salivary cortisol
test.
1. Low-dose
dexamethasone
suppression test
(0.5mg) Confirmatory tests for
2. Midnight plasma Cushing's
cortisol
3. CRH stimulation
test
ACTH Stimulation test Tests for Addison's
(Cosyntropin disease (decrease cortisol)
stimulation test)

CONGENITAL ADRENAL HYPERPLASIA (CAH)

• RA 9928: Newborn Screening Act

→ Detect CAH
1. 21-hydroxylase – most common
2. 11-β-hydroxylase – followed by this
3. 3β -hydroxysteroid dehydrogenase-isomerase
4. 17α-hydroxylase

• CAH is like Primary Hypoadrenolism

→ Low cortisol
→ High ACTH

REPRODUCTIVE HORMONES
• Testosterone
→ Most potent and active sex hormone
• Dehydroepiandrosterone (DHEA)
→ Precursor of the sex hormone
• Estrogen
→ E1 – Estrone: Post menopausal women
▪ Tanders na or iniwan
→ E2 – Estradiol: Women in reproductive years
▪ Dalagang may shota
High cortisol because of a pituitary problem → E3 – Estriol: Pregnant
• Cortisol is a hyperglycemic hormone, we expect
hyperglycemia. ▪ Tatlo na kayo
Cushing's disease
• We also expect other manifestation such as
gynecomastia, fat deposits (bulldog face), and violet • E3 used to assess the fetoplacental unit
stretch marks. • Quad marker for Down Syndrome
High cortisol in the body regardless of the • Trisomy 21 is Down Syndrome
Cushing's syndrome cause • How do we diagnose down syndrome? We get the amniotic fluid, and we
• Example: You inject steroids, which causes your cortisol check for 4 markers.
levels to rise → Increased: HI
Addison's disease Low cortisol ▪ hCG
• Expect hypoglycemia
▪ Inhibin A
Adrenal Aldosteronoma – tumor in the adrenal → Decreased:
Conn's disease producing more testosterone ▪ Estriol
•  Aldosterone

Clinical Chemistry – Seminar I Week 3 9 of 13

 ▪ AFP → In TV: A spoon is placed in the mouth to prevent biting the tongue
− This pattern is diagnostic for Down Syndrome • Petit mal: Silent seizure
→ Eyelid stye (tumirik mata ng bata)
• AFP – increased; screening test for neural tube defects
→ Spina Bifida, Meningocele, Myelomeningocele • Phenobarbital – first line drug for seizure
• Acetylcholinesterase - confirmatory test for NTDs • Ethosuximide – used for petit mal
• Carbamazepene – used for grand mal
• Progesterone • Valproic acid – used for grand mal and petit mal
→ Hormone that sustains pregnancy
ANTIBIOTICS
THERAPEUTIC DRUG MONITORING
• In CC, you need to know the complication of the drug
• Vancomycin – used for MRSA
→ Red man syndrome – allergic reaction to vancomycin
▪ Vancomycin should be administered slowly through IV
• Chloramphenicol
→ Gray baby syndrome – the baby’s liver is not yet mature leading to this
complication
• Side effects of Chloramphenicol in Hematology: Aplastic anemia
→ The bone marrow becomes empty
• Aminoglycoside
→ Ototoxicity: Ears
PHARMACOKINETICS
→ Nephrotoxicity: Kidney
• Relationship between drug dose and the drug blood level
• What the body does to the drug
PSYCHOACTIVE DRUGS
FIVE MAJOR PHARMACOKINETIC PROCESSES • Lithium
1. Liberation → Drug of choice for bipolar disorder or Manic depressive disorder
• When you take a capsule, and it dissolves
2. Absorption TRIVIA
• From the stomach or intestine going to the blood • Bipolar 1 – has more severe manifestations
3. Distribution • Bipolar 2
• Circulation in the human body going to the target organ
4. Metabolism BRONCHODILATOR
• Happens in the target organ • Theophylline
5. Excretion → Commonly used for COPD
• Excreted when metabolized
IMNUNO SUPPRESSANT
PHARMACODYNAMICS • Used to prevent organ transplant rejection
• Relationship between drug concentration at the target site and response of
the tissue • Autograph – from you to you
• What the drug does to the body • Isograph – from identical twin to you
• Allograph – from others to you
DRUG LEVELS • Xenograph – from an animal to you
• Peak – highest level of the drug • Cyclosporine
→ 30 to 45 mins after drug introduction (if orally) • Tacrolimus
→ If thru an IV, it will take 5 minutes only • Sirolimus
• Trough level – lowest drug level
→ Right before giving the next dose ANTI-INFLAMMATORY/ ANALGESICS
• Salicylates
→ Aspirin: Trinder’s assay – test for aspirin or salicylate
• Acetaminophen
→ Paracetamol

TOXICOLOGY
• Alcohol - Most common toxic agent that human consume
• The manifestation differs depending on alcohol concentration

CARDIOACTIVE DRUGS CLASSES Alcohols Common CNS depressants

• Class I Rapid sodium channel blockers (%w/v)
0.01-0.05 No obvious impairment, some changes observable on
• Class II Beta blockers
performance testing
→ Common
0.03-0.12 Mild euphoria, decrease inhibitions, some impairment
→ Drugs ending in -olol
of motor skills
▪ Propranolol, Atenolol, Metoprolol, Esmolol, Timolol, Bisoprolol,
0.09-0.25 Decreased inhibitions, loss of critical judgment,
Nadolol
memory impairment, decreased reaction time
• Class III Potassium channel blockers
0.18-0.30 Mental confusion, dizziness, strongly impaired motor
• Class IV Calcium channel blocker
skills (slurred speech)
0.27-0.40 Unable to stand/walk, vomiting, impaired
ANTISEIZURE DRUGS consciousness
0.35-0.50 Coma and possible death
TYPES OF SEIZURE
≥ 0.10 Legally intoxicated alcohol level
• Grand mal: Tonic clonic seizure • When driving, DIU (Driving Under the Influence)
→ Telenovela seizure

Clinical Chemistry – Seminar I Week 3 10 of 13

 COMMON TOXIC AGENTS CS 1972: Protein C,
Protein S, Factor X, Factor
• Carbon monoxide (CO) IX, Factor VII, and Factor II
→ Colorless and odorless Water Soluble Vitamins (Ta Ra Na Pa Pa Boy Friend Co)
→ Blood: Cherry red; RCS: Tomato red Vitamin C Ascorbic acid Scurvy
→ CO has 214x affinity to Hgb than O2 (1x affinity) Vitamin B1 Thiamine Beriberi
• Cyanide Vitamin B2 Riboflavin Stomatitis, cheilitis
→ Odor: Bitter almond Pellagra
• Arsenic Vitamin B3 Niacin Manifested with 3Ds:
Diarrhea
→ Odor: Garlic Dementia
• Cadmium Dermatitis
→ Environmental pollutant Vitamin B5 Panthotenic acid Depressed immune
→ Commonly found in batteries system
→ Associated with prostate and liver cancer Vitamin B6 Pyridoxine Facial seborrhea
• Lead Vitamin B7 Biotin Dermatitis
→ Inhibits heme synthesis Vitamin B9 Folate Megaloblastic anemia
Vitamin B12 Cyanocobalamin Megaloblastic anemia
• Appearance of RBCs in PBS: Basophilic stippling Brain involvement
• Lead inhibits Ferrochelatase and ALA dehydrase in heme synthesis
LABORATORY MATHEMATICS

Formula Example
Two mL of distilled water is
added to 4 g of a powdered drug.
% weight per volume The final volume is % weight per
volume 3 mL. Find the %w/v of
𝑤 𝑔𝑟𝑎𝑚𝑠 𝑜𝑓 𝑠𝑜𝑙𝑢𝑡𝑒 𝑥 100 the solution.
% =
𝑣 𝑡𝑜𝑡𝑎𝑙 𝑣𝑜𝑙𝑢𝑚𝑒
𝑣 4𝑔
% = 𝑥 100 = 𝟏𝟑𝟑%
𝑣 3 𝑚𝐿
• Mercury
Find the percentage strength of Z
→ Binds to your bone % weight per weight if 300 g of a mixture contains 90 g
→ Minamata’s disease – mercury poisoning/excess mercury when brain is of Z.
affected already 𝑤 𝑔𝑟𝑎𝑚𝑠 𝑜𝑓 𝑠𝑜𝑙𝑢𝑡𝑒 𝑥 100
% = 𝑤 90 𝑔
𝑤 𝑡𝑜𝑡𝑎𝑙 𝑔𝑟𝑎𝑚𝑠 𝑑𝑒𝑠𝑖𝑟𝑒𝑑
DRUG TESTING METHODS % = 𝑥 100 = 𝟑𝟎%
𝑣 300 𝑔
1. Immunoassay – rapid diagnostic kits
2. Chromatographic techniques Find the percentage strength of Z
a. Thin layer chromatography (TLC) – screening test % volume per volume if 225 mL of a mixture contains 15
b. Mass spectrophotometry (MS) mL of Z.
c. Gas chromatography-mass spectrophotometry (GC-MS) – gold 𝑣 𝑚𝑙 𝑜𝑓 𝑠𝑜𝑙𝑢𝑡𝑒 𝑥 100
% = 𝑣 15 𝑚𝐿
standard 𝑣 𝑡𝑜𝑡𝑎𝑙 𝑣𝑜𝑙𝑢𝑚𝑒 𝑑𝑒𝑠𝑖𝑟𝑒𝑑 % = 𝑥 100 = 𝟔. 𝟔𝟕%
𝑣 225 𝑚𝐿

COMMON DRUGS OF ABUSE

• Morphine Moles
→ Powerful painkiller
𝑤𝑒𝑖𝑔ℎ𝑡 𝑖𝑛 𝑔𝑟𝑎𝑚𝑠
• Cocaine 𝑀𝑜𝑙 =
→ BEQ: Metabolite: Benzoylecgonine 𝐺𝑀𝑊
• Amphetamines
What is the molarity of a solution
→ Shabu
formed from 6.75 g of NaCl
→ Poor man’s cocaine dissolved in water Molarity to
• Cannabinoids make a solution with a total
→ Marijuana volume of 452 mL? (MW of NaCl-
→ BEQ: Metabolite: Delta 9 tetrahydrocannabinol (THC) 58.4)
• Lysergic acid
→ Side effect: Bad trip 452 mL = 0.452 L
• Phencyclidine
→ Angel dust 6.75
𝑀= = 𝟎. 𝟐𝟔 𝑴
58.4 𝑥 0.452 𝐿
• In the Philippines, common drug testing kits are MET for Molarity
Methamphetamine e and THC for Cannabinoids. How to make 1L of a 5M solution
→ MET for Shabu and THC for Marijuana 𝑔𝑟𝑎𝑚𝑠 𝑜𝑓 𝑠𝑜𝑙𝑢𝑡𝑒 of a substance with a molecular
𝑀= weight of 75g/mol. How many
𝐺𝑀𝑊 𝑥 𝑣𝑜𝑙𝑢𝑚𝑒 𝑖𝑛 𝑙𝑖𝑡𝑒𝑟𝑠
VITAMINS grams of the solute should be
weight out?
Vitamins Common Name Deficiency
Fat Soluble Vitamins (ADEK sa taba) g=?
Vitamin A Retinol Night blindness V=1L
Vitamin D Calciferol Rickets (young); MW = 75
Osteomalacia (adults) M=
Vitamin E Tocopherol Hemolytic anemia 5 𝑥
𝑔= 𝑥
Hemorrhage 1 1 𝑥 75
Vitamin K Quinones Vitamin K Dependent
Factors: x = 5 x 1 x 75 = 375g

Clinical Chemistry – Seminar I Week 3 11 of 13

 What is the normality of a solution Iron μg/dL μmol/L 0.179
Normality prepared by dissolving 25 g of Uric Acid mg/dL μmol/L 59.48
HCI in enough Normality water to Bilirubin mg/dL μmol/L 17.1
𝑔𝑟𝑎𝑚𝑠 𝑜𝑓 𝑠𝑜𝑙𝑢𝑡𝑒 make 150 mL of solution? (MW of (Total/Direct)
𝑁=
𝐸𝑊 𝑥 𝑣𝑜𝑙𝑢𝑚𝑒 𝑖𝑛 𝑙𝑖𝑡𝑒𝑟𝑠 HCL=36.5) Albumin g/dL g/L 10
Total Protein g/dL g/L 10
𝑀𝑊 V = 0.15 L
𝐸𝑊 = Hemoglobin g/dL g/L 10
𝑉𝑎𝑙𝑒𝑛𝑐𝑒 G = 25 Ammonia μg/dL μmol/L 0.588
Valence – number of electrons in the Lactate mg/dL mmol/L 0.111
outermost shell of an atom
36.5
𝐸𝑊 = = 36.5
1 QUESTIONS
Remember:
HCl = 1 25 𝑔 1. In a laboratory report, you have noticed that all electrolytes are normal except
H2SO4 = 2 𝑁= = 𝟒. 𝟓𝟕 𝑵 for a depressed sodium. To confirm, this is best performed using:
KOH = 1 36.5 𝑥 0.15 a. Manual sodium testing
NaOH = 1 b. Direct ISE
Acid: Number of hydrogens c. Indirect ISE
Base: Number of hydroxides d. Release the report

Two drops of picric acid is mixed 2. (+) result is the presence of phosphomolybdenum blue
with 3 drops of water. Find the a. Schales and Schales
Dilution dilution. b. Fiske Subarrow
c. Albanese Lein
𝑠𝑎𝑚𝑝𝑙𝑒 2 2 𝟏 d. Lockhead and Purcell
𝐷𝑖𝑙𝑢𝑡𝑖𝑜𝑛 = 𝐷= = =
𝑠𝑎𝑚𝑝𝑙𝑒 + 𝑑𝑖𝑙𝑢𝑒𝑛𝑡 2 + 3 5 𝟐. 𝟓
3. The function of insulin is to allow passage of glucose from the blood into the
cell During this process, this electrolyte is also taken inside the cell.
Two drops of picric acid is mixed a. Sodium
with 3 drops of water. He further b. Calcium
diluted the Compound Dilution C. Potassium
sample by getting a drop of the d. Chloride
mixture and combining this again
Compound Dilution with 3 drops of water. Find the 4. An ISE test for the detection of carbon dioxide measures this analyte:
dilution. a. Carbon dioxide
1𝑠𝑡 𝑑𝑖𝑙𝑢𝑡𝑖𝑜𝑛 𝑥 2𝑛𝑑 𝑑𝑖𝑙𝑢𝑡𝑖𝑜𝑛 … b. Carbonic acid
1 1 c. Bicarbonate
= d. All of the above
1+3 4
1 1 𝟏 5. Diabetes ketoacidosis (DKA) is associated with what acid-base balance
𝑥 = 𝒐𝒓 𝟏: 𝟏𝟎
2.5 4 𝟏𝟎 disturbance?
a. Metabolic acidosis
How much volume of a 5M b. Metabolic alkalosis
solution of NaCl do you need in c. Respiratory acidosis
order to make 100 Diluting d. Respiratory alkalosis
Solutions mL of 0.5M of the same
solution. 6.
ABG: pH 7.21 / pCO2 32 / pO2 98
Diluting Solutions C1 = 5 98% 02 Sat on Room Air
V1 = ? Electrolytes: Na 145 mEq/L, K 4.5 mEq/1, CI 105 mEq/L, HCO3 25 mEq/L
𝐶1𝑉1 = 𝐶2𝑉2 C2 = 0.5
V2 =100

5 x V1 = 0.5 x 100

5𝑉1 50
= = 𝟏𝟎 𝒎𝑳
5 5

CONVERSION FACTOR

Analyte Conventional SI Unit Multiply Anion Gap: 19.5 elevated

Unit Conventional ABG: Mixed Acid Base Status
by:
Glucose mg/dL mmol/L 0.0555 7. A patient with soft goiter tested for a decreased TSH. What is the best next
Blood Urea mg/dL mmol/L 0.357 test to be performed?
Nitrogen (BUN) a. FTS
Creatinine mg/dL μmol/L 88.4 b. FT4
Cholesterol mg/dL mmol/L 0.0259 c. TRH
Triglycerides mg/dL mmol/L 0.0113 d. Anti-microsomal antibody
Calcium mg/dL mmol/L 0.25
Phosphate mg/dL mmol/L 0.323 8. A patient was rushed to the ER due to suspected steroid overdose. This
(Phosphorus) substance is known to be the most common exogenous cause of
Magnesium mg/dL mmol/L 0.411 a. Cushing's disease
Sodium mEq/L mmol/L 1 b. Cushing syndrome
Potassium mEq/L mmol/L 1 c. Addison's disease
Chloride mEq/L mmol/L 1 d. Conn's syndrome
Bicarbonate mEq/L mmol/L 1
(HCO3+) 9. High calcium; normal PTH. Interpret
a. Hypercalcemia

Clinical Chemistry – Seminar I Week 3 12 of 13

b. Metastatic calcinosis
a. Dysmorphic calcinosis
d. Hyperparathyroidism

10. John Doe was chosen to be part of a random drug testing. He has been
using cannabinoids for quite a while. What analyte would be detected in his urine
sample?
a. Benzoylecgonine
b. NAPA
c. Delta-9-THC
d. Cannabinoids

11. This marker of carcinoid tumor is detected by measuring the metabolite ___
a. Serotonin – not detected in the human body because it has a short half-life
b. Dopamine
c. 5-HIAA (Hydroxy Indole Acetic Acid) – metabolite of serotonin
d. VMA

12. Which of the following coenzyme is used for the assay of AST and ALT?
a. Vitamin B1
b. Vitamin B2
c. Vitamin B6
d. Vitamin B9

Clinical Chemistry – Seminar I Week 3 13 of 13