Renal Function Tests

1.​ Outline the structure of nephron and list functions of kidneys. (C2)

​ A nephron, the functional unit of the kidney, consists of a renal

corpuscle (containing a glomerulus and Bowman’s capsule) at its beginning,
followed by a renal tubule which includes the proximal convoluted tubule, loop
of Henle, distal convoluted tubule, and finally connects to a collecting duct
essentially, it’s a complex network of tubules where blood is filtered and urine
is formed by selectively reabsorbing necessary substances and excreting
waste products.

a.​ Glomerulus: A cluster of tiny blood capillaries where filtration of blood

occurs, allowing small molecules like water and waste products to
pass through into the Bowman's capsule.
b.​ Bowman's capsule: A cup-shaped structure that surrounds the
glomerulus, capturing the filtered fluid.
c.​ Proximal convoluted tubule (PCT): A coiled section where most
reabsorption of important substances like glucose, amino acids, and
electrolytes occurs.
d.​ Loop of Henle: A long, hairpin-shaped loop that further concentrates
the urine by regulating water reabsorption, with a descending limb
permeable to water and an ascending limb actively transporting salts.
e.​ Distal convoluted tubule (DCT): Another coiled section where further
fine-tuning of urine composition takes place, including secretion of
hydrogen ions and potassium.
f.​ Collecting duct: A large tube that receives urine from multiple
nephrons and plays a crucial role in regulating the final concentration
of urine by adjusting water reabsorption.

Functions of kidneys;
(1)​Filtration of Blood: The kidneys filter waste products, excess ions, and water
from the blood to form urine.
(2)​Regulation of Fluid and Electrolyte Balance:They maintain the proper balance
of water, sodium, potassium, and other electrolytes in the body.
(3)​Regulation of Acid-Base Balance:The kidneys help maintain the body's pH by
excreting or reabsorbing hydrogen and bicarbonate ions.
(4)​Excretion of Metabolic Waste Products:They eliminate waste products like
urea, creatinine, and uric acid from the body.
(5)​Regulation of Blood Pressure:The kidneys produce renin, an enzyme that
plays a key role in regulating blood pressure.

(6)​Production of Hormones​ :Erythropoietin: Stimulates red blood cell

production​ ​
: Calcitriol (active vitamin D): Helps regulate
calcium absorption.
(7)​Removal of toxins:The kidneys also filter out many drugs and toxins from the
bloodstream.

2.​ Illustrate the formation of urine. (C2)

​ Urine formation occurs in the kidney through a three-step process: glomerular
filtration (filtering waste products from the blood into the nephron), tubular
reabsorption (reclaiming necessary substances from the filtrate back into the
bloodstream), and tubular secretion (actively adding specific waste products from the
blood into the filtrate) which ultimately produces urine ready for excretion.
1.​ Glomerular filtration
​ Blood enters the nephron at the glomerulus, a network of tiny
capillaries with porous [Link] to high blood pressure, small
molecules like water, urea, glucose, electrolytes, and waste products
are forced through the glomerular walls into the Bowman's capsule,
forming a fluid called [Link] molecules like proteins and blood
cells are too large to pass through and remain in the bloodstream.

2.​ Tubular reabsorption

The filtrate moves through the proximal convoluted tubule, loop

of Henle, and distal convoluted tubule. As the filtrate travels through
the tubules, necessary substances like water, glucose, amino acids,
and electrolytes are actively transported back into the bloodstream via
the peritubular capillaries. The amount of reabsorption is regulated by
hormones like antidiuretic hormone (ADH) which controls water
reabsorption in the collecting duct.

3.​ Tubular secretion

​ Occurs primarily in the proximal convoluted tubule and distal
convoluted tubule. Certain waste products like hydrogen ions,
creatinine, and drugs that were not filtered in the glomerulus are
actively transported from the blood into the filtrate.
3.​ Explain GFR and the factors affecting the rate of filtration. (C2)

GFR is the rate in ml/min at which substances in plasma are filtered through
the glomerulus or a clearance of a substance from the blood. GFR provides the most
useful general index for the assessment of the severity of renal [Link] cannot
be measured directly but estimated from the clearance of a filtration marker.

Factors affecting the rate of filtration

(i)​ Blood Pressure
(ii)​ Oncotic Pressure (Protein Concentration)
(iii)​ Bowman's Capsule Pressure
(iv)​ Glomerular Capillary Permeability and Surface Area
(v)​ Renal Blood Flow:
(vi)​ Age: ​ GFR naturally declines with age.
(vii)​ Sex:​ Men generally have higher GFRs than women.
(viii) ​ Disease States:
Conditions like diabetes, hypertension, and kidney disease
significantly impair GFR.

4.​ Define tubular reabsorption and tubular maximum. (C1)

Tubular reabsorption
​ Tubular reabsorption is the process by which the nephrons in the kidneys
reclaim essential substances from the filtered fluid (filtrate) and return them to the
bloodstream.
This process occurs primarily in the renal tubules, including the proximal
convoluted tubule, the loop of Henle, the distal convoluted tubule, and the collecting
ducts.
Substances reabsorbed include water, glucose, amino acids, ions (like
sodium, potassium, and chloride), and other valuable nutrients.

Tubular maximum
​ The tubular maximum (Tm) represents the maximum rate at which a
substance can be reabsorbed from the renal tubules.
When the concentration of a substance in the filtrate exceeds the Tm, the
excess substance cannot be reabsorbed and is excreted in the urine.

○​ Example:
■​ Normally, all filtered glucose is reabsorbed. However, if blood glucose
levels become too high, the Tm for glucose is exceeded, and glucose
appears in the urine (glycosuria).
5.​ Define renal threshold. (C1)
​ The renal threshold is the blood concentration level at which the kidneys can
no longer effectively reabsorb a particular substance from the filtrate.
When this threshold is exceeded, the substance "spills over" into the urine.
​ For example, normally the kidneys reabsorb all the glucose from the filtrate.
However, if blood glucose levels rise too high, the transport proteins become
saturated, and glucose begins to appear in the urine (glycosuria).

6.​ Classify renal function tests.(C2)

​ They are a group of blood and urine tests to assess renal functions. Tests of
renal function have utility in-
(1)​ Identifying the presence of renal disease (kidney related disorders and renal
failure due to long standing diabetes mellitus, hypertension etc.)
(2)​ Monitoring the response of kidneys to treatment
(3)​ Determining the progression of renal disease

I.​ To screen for kidney disease

-​ Complete urine analysis
-​ Plasma urea and creatinine
-​ Plasma electrolytes
II.​ To assess renal function
a.​ To assess glomerular function
-​ Glomerular filtration rate
-​ Clearance tests
-​ Glomerular permeability
-​ Proteinuria
b.​ To assess tubular function
-​ Reabsorption studies
-​ Secretion tests
-​ Concentration and dilution tests
-​ Renal acidification
III.​ To assess types of renal disease
-​ Renal biopsy
IV.​ To measure renal plasma/blood flow
-​ Para amino hippurate test

7.​ Explain and identify the clinical significance, normal range and methods of
estimation of creatinine. (C3)

Creatinine is the breakdown product of creatine phosphate in muscle, usually

produced at a fairly constant rate by the body depending on muscle mass.
Creatinine is filtered but not reabsorbed in the kidneys.
 Clinical significances

●​ Higher than normal level may indicate

-​ Nephrotic syndrome
-​ Chronic granular nephritis
-​ Acute tubular necrosis
-​ Dehydration
-​ Renal failure
-​ Reduced renal blood flow.
-​ Diabetic nephropathy
-​ Urinary tract obstruction
-​ pyelonephritis
●​ Lower than normal level may indicate:
-​ Muscular dystrophy
-​ Myasthenia gravis

​ Normal range​ : 0.7 - 1.4 mg/dl in male

​ ​ ​ : 0.6 - 1.2 mg/dl in female
​ ​ ​ : 0.8 - 1.8 gm/24 hour in urine

​ Methods of estimation of creatinine

1.​ Jaffe’s method
​ Creatinine in alkaline conditions reacts with picric acid to form alkaline
creatinine picrate. The reddish yellow color is formed and is measured
colorimetrically at 520 nm .

2.​ Enzymatic method

8.​ Explain and identify the clinical significance , normal range and methods of
estimation of urea. (C3)

Urea is a waste product formed in the liver during the breakdown of

proteins
Clinical significance of urea
●​ Greater than normal level may indicate
Prerenal causes
-​ Congestive heart failure
-​ Myocardial infarction
 -​ Excessive protein catabolism
-​ Hypovolemia due to burns , shock or dehydration
​ ​ Renal causes
-​ Acute glomerulonephritis
-​ Chronic nephritis
-​ Nephrotic syndrome

​ ​ Post renal causes

-​ Urinary tract obstruction to urine flow

●​ Lower than normal level may indicate;

-​ Liver failure
-​ Low protein diet
-​ Malnutrition
-​ Overhydration

​ Normal range of urea = 8 - 40 mg/dl

​ ​ ​ ​ BUN : 7 to 21 mg/dl

​ Methods of estimation of urea

1.​ Diacetyl Monoxime (DAM) method
​ Urea reacts with diacetyl monoxime under slightly acidic conditions in
presence of ferric ions and thiosemicarbazide to give a pink colour complex. The
color is measured at a wavelength of 540 nm.

Diacetyl monoxime + H2O + H+ → DIacetyl + hydroxylamine

Diacetyl + Urea + H+ → Diazo Derivative (pink color complex , read at 540 nm)

2.​ Urea - Glutamate Dehydrogenase (GLDH) method

​ Urease hydrolyzes urea to ammonia and CO2. The ammonia formed further
combines with alpha Ketoglutarate and NADH to form Glutamate and NAD. The rate
of oxidation of NADH to NAD is measured as a decrease in absorbance in a fixed
time, which is proportional to the urea concentration in the sample. 340 nm.

​ Urea + H2O + 2H+ + Urease → 2NH4+ + CO2

2NH4+ + 2 alpha ketoglutarate + 2 NADH + GLDH → 2L-glutamate + 2NAD+
​ ​ ​ ​ ​ ​ ​ ​ ​ +​ 2H2O

3.​ Enzymatic method (Berthelot method)

​ The green color complex is formed , measured at 570 nm.

 9.​ Explain and identify the clinical significance , normal range and methods of
estimation of uric acid. (C3)

Clinical significance
Uric acid is the end product of purine metabolism. Uric acid is excreted by the
kidneys.
●​ Increased levels are found in
-​ Gout
-​ Arthritis
-​ Impaired renal functions
-​ Starvation

●​ Decreased levels are found in

-​ Yellow atrophy of the liver
-​ Wilson’s disease
-​ Fanconi's syndrome

​ Normal level ​ : Child : 2-5 mg/dl

​ ​ ​ : Adult male : 3.5 - 7.2 mg/dl
​ ​ ​ : Adult female : 2.6 - 6 mg/dl
​ ​ ​ Urine : 250 -750 mg/24 hour urine

​ Method of estimation
​ Enzymatic method

​ Uric acid + 2H2O + O2 + Uricase → Allantoin + CO2 + H2O2

2H2O2 + 4 Aminoantipyrine + DHBs + Peroxidase → red quinone + H2O + HCl

Where DHBs = 3,5 Dichloro-2-Hydroxybenzenesulfonic acid.

​ The red colour formed is measured at a wavelength of 505 nm.

10.​Define Uremia. (C1)

Uremia is a condition characterized by abnormally high levels of waste
products (urea, creatinine) in the [Link] waste products are normally filtered
out by the kidneys and eliminated in urine. When the kidneys are damaged or failing,
they can't effectively perform this function, leading to a buildup of toxins.

11.​Define and list clearance tests (C1)

​ The volume of blood or plasma completely cleared of a substance per unit
time and is expressed as ml/min. Clearance estimates the amount of plasma that
must have passed through the glomeruli per minute with complete removal of
substance.

Clearance = mg of substance excreted per min / mg of substance per ml of

plasma
 C = UV/P
Where, U - concentration of substance in urine
P - concentration of the substance in plasma/serum
V - ml of urine excreted per min.

(i) Creatinine clearance test

(ii) Urea clearance test
(iii) Inulin clearance test
(iv) Cystatin C clearance test

12.​Explain creatinine clearance test with interpretations. (C2)

​
​ Creatinine clearance is defined as the volume of blood or plasma completely
cleared of creatinine per unit time. Blood samples and 24 hour urine samples are
collected from the patient. It is used to provide an indicator of GFR

​ ​ ​ Creatinine clearance = UV/P

The normal range of creatinine clearance

Male : 97 - 137 ml/min
Female : 88 - 128 ml/min

Factors affecting Creatinine clearance

-​ Muscle mass
-​ Sex and age
-​ Malnutritions
-​ Drugs such as trimethoprim-sulfamethoxazole
-​ Renal disease
-​ Congestive heart failure

​ Procedure
-​ 500ml H2O taken by patient → to promote good urine flow
-​ After 30 minutes, ask to empty the bladder/ discard the urine
-​ After 60 minutes, again avoid the bladder and collect the urine, note the
volume
-​ Take one blood sample. Creatinine in blood and urine is calculated.

​ Interpretation

●​ Decreased is very sensitive indicator of reduced GFR​

●​ Clearance up to 75% of the average normal value may indicate adequate
renal function.
●​ Decrease in older people.
●​ Helpful in long-term monitoring of patients with renal insufficiency (up and
down) under a protein restricted diet.
 13.​Explain urea clearance test with interpretation. (C2)
​
​ The urea clearance measures the efficiency with which the kidneys remove
urea from the blood. It is the ratio of the amount of urea excreted per minute in urine
to the concentration of urea in blood.
​
𝑈𝑢 𝑥 𝑉
​ Urea clearance Cu = 𝑃𝑢
​
​ where ,​ Cu = urea clearance in ml/min
Uu = concentration of urine urea in mg/ml
​ ​ ​ V = volume of urine in ml
​ ​ ​ Pu =concentration of urea in mg/ml of plasma
​
​ Normal value = 60 - 9- ml/min
​
​ Interpretation
○​ Normal range
■​ The normal range for urea clearance varies depending on factors like
age, sex, and muscle mass, but typically falls between 60 - 90 ml/min

○​ Decreased urea clearance

■​ Indicates decreased glomerular filtration rate (GFR) and impaired
renal function. This can be due to conditions like chronic kidney
disease , acute kidney injury or other related disorders

○​ Increased urea clearance

■​ May occur in conditions associated with increased protein metabolism,
such as high - protein diets, or in some cases of liver disease.

​
​
14.​Explain inulin clearance test with interpretation. (C2)

​ Measurement of inulin clearance is the gold standard for assessing GFR.

Inulin is a complex of sugar present in plants and used medically to test kidney
function. It is freely filtered by the glomerulus, is not secreted or reabsorbed in the
tubules and is not synthesized or metabolized by the kidney. Measurement of urinary
clearance requires a constant intravenous infusion to maintain a constant level of
inulin over 3 to 4 hours.

Interpretation

●​ Normal range
○​ For healthy adults, the normal range for inulin clearance is
approximately 90 - 120 ml/min. This indicates normal kidney function.
 ●​ Decreased Inulin Clearance
○​ Indicates a reduced GFR and impaired kidney function. This can be
due to conditions such as chronic kidney disease, acute kidney injury,
or other related disorders.

●​ Increased Inulin Clearance

○​ This is rare and may not have significant clinical importance. It could
occur due to methodological errors or other unusual conditions.

15.​Define microalbuminuria. (C1)

​ Microalbuminuria refers to a small or moderate increase in the amount of

albumin, specifically between 30 and 300 mg per day, a sign that the kidneys might
be starting to have damage.

16.​Define and classify proteinuria. (C2)

​ ​ Presence of abnormal amount of protein in the urine. Normally

proteins are retained in the blood during filtration process in kidneys. When
kidneys are damaged or stressed, protein can lead into the urine leading to
proteinuria.

Classification
1.​ Transient proteinuria
​ This is a temporary increase in protein in the urine.
Causes : Strenuous exercise, Fever, Stress, Exposure to cold,
Dehydration, Pregnancy.

2.​ Orthostatic proteinuria

​ This type of proteinuria occurs when protein appears in the urine
while a person is in an upright position.
It's often absent in urine collected after a period of lying down (e.g.,
first-morning urine).
​ It's most common in adolescents and young adults.

3.​ Persistent proteinuria

​ This is the consistent presence of protein in the urine over time.
It's a significant indicator of potential kidney damage or disease.

Causes:

●​ Diabetic nephropathy
●​ Glomerulonephritis
 ●​ Acute tubular necrosis (ATN)
●​ Multiple myeloma (Bence-Jones proteinuria)
●​ Myoglobinuria (muscle breakdown)
●​ Hemoglobinuria (red blood cell breakdown)

17.​Explain urinalysis for abnormal chemical constituents with their

interpretations. (C2)

Urinalysis is a common and valuable diagnostic tool that examines the

physical, chemical, and microscopic properties of urine.

Protein:

●​ Normal: Negative or trace amounts.

●​ Abnormal: Persistent protein in urine (proteinuria) indicates potential kidney
damage.
●​ Interpretation:
i.​ Glomerular damage (e.g., diabetic nephropathy, glomerulonephritis)
ii.​ Tubular damage
iii.​ Overflow proteinuria (e.g., multiple myeloma)
iv.​ Transient proteinuria (e.g., strenuous exercise, fever)
v.​ Orthostatic proteinuria

Glucose:

●​ Normal: Negative.
●​ Abnormal: Glucose in urine (glucosuria) suggests elevated blood glucose levels.
●​ Interpretation:
1.​ Diabetes mellitus (most common)
2.​ Renal glycosuria (rare; tubules can't reabsorb glucose)
3.​ Pregnancy (sometimes)

Ketones:
●​ Normal: Negative.
●​ Abnormal: Ketones in urine (ketonuria) indicate the body is breaking down fat for
energy.

●​ Interpretation:
1.​ Diabetic ketoacidosis (DKA)
2.​ Starvation or prolonged fasting
3.​ Severe vomiting or diarrhea
4.​ High-protein, low-carbohydrate diets
 Blood (Hemoglobin/Myoglobin):

●​ Normal: Negative.
●​ Abnormal: Blood in urine (hematuria or hemoglobinuria) can be due to various
causes.
●​ Interpretation:
1.​ Kidney stones
2.​ Urinary tract infection (UTI)
3.​ Glomerulonephritis
4.​ Bladder cancer
5.​ Trauma
6.​ Myoglobinuria, caused by muscle damage, can also give a positive result.

Bilirubin:

●​ Normal: Negative.
●​ Abnormal: Bilirubin in urine (bilirubinuria) suggests liver or biliary tract problems.
●​ Interpretation:
1.​ Liver disease (e.g., hepatitis, cirrhosis)
2.​ Biliary obstruction (e.g., gallstones)

Urobilinogen:

●​ Normal: Small amounts.

●​ Abnormal: Increased urobilinogen suggests increased bilirubin breakdown.
Decreases can indicate problems with bile flow.
●​ Interpretation:
○​ Increased: Hemolytic anemia, liver disease.
○​ Decreased: Biliary obstruction.

Nitrite:

●​ Normal: Negative.
●​ Abnormal: Nitrite in urine suggests bacterial infection.
●​ Interpretation:
1.​ Urinary tract infection (UTI)
2.​ Certain bacteria convert nitrate to nitrite.

18.​Explain the concentration tests for renal tubular function. (C2)

A urine concentration test measures the ability of the kidneys to conserve or

excrete water. It is also known as the water loading test.
For this test the specific gravity of urine, urine electrolytes, and , or urine osmolality
are measured.
 Increased urine concentration may be due to
●​ Glucose in the urine
●​ Heart failure
●​ Loss of body fluids from diarrhea or excessive sweating, vomiting.

Decreased urine concentration may be due to

●​ Diabetes insipidus
●​ Kidney failure
●​ Severe kidney infections.

19.​Explain the dilution tests for renal tubular function. (C2)

​ Dilution tests are designed to evaluate the kidneys' ability to dilute urine,
which is a crucial aspect of renal tubular function. These tests assess how well the
kidneys can respond to a water load by excreting excess water.

The most common dilution test is the oral water load test.
Causes of decreased urine dilution
●​ Dehydration
●​ Increased antidiuretic hormone secretion
●​ Reduced renal blood flow

Causes of increased urine dilution

●​ Overhydration
●​ Diabetes insipidus
●​ Hypokalemia and hypercalcemia
●​ Excessive alcohol intake (alcohol suppresses ADH)
​

20.​Explain the test for renal plasma flow. (C2)

The test for renal plasma flow (RPF) measures the volume of plasma that
flows through the kidneys per unit [Link] provides valuable information about the
blood supply to the kidneys and their overall function.

The most common method for measuring RPF involves the use of
para-aminohippuric acid (PAH).

PAH is a substance that is freely filtered by the glomerulus and is also actively
selected by the renal tubules. It is almost entirely cleared from the plasma in a single
pass through the kidneys.

Procedure
​ The patient is injected with or given an intravenous infusion of PAH. Blood
and urine samples are collected at specific intervals to measure the concentration of
PAH
 Calculation
​ The concentration of PAH in the plasma and urine is measured. The rate of
PAH excretion is calculated using the formula,
𝑈 𝑃𝐴𝐻 𝑥 𝑉
Clearance of PAH CPAH = 𝑃 𝑃𝐴𝐻

Normal RPF:
The normal RPF is approximately 600 mL/min.

Decreased RPF:
A decreased RPF indicates reduced blood flow to the kidneys, which can be caused
by:

○​ Renal artery stenosis

○​ Heart failure
○​ Shock
○​ Chronic kidney disease
○​ Conditions that cause a drop in blood pressure.

Tumour Markers
1.​ Define and classify tumor markers. (C2)

A tumor marker is any substance present in or produced by cancer cells, or

other cells of the body in response to cancer or certain benign conditions, that can
provide information about a cancer.

●​ Tumour associated Antigen - CEA, AFP

●​ Carbohydrate Antigen - CA125, CA19-9
●​ Pregnancy associated Ag - beta HCG
●​ Hormones - ACTH
●​ Enzymes and isoenzymes - PSA
●​ Miscellaneous tumor markers - Immunoglobulins steroid receptors

2.​ List tumour markers. (C1)

●​ Oncofetal Antigen - AFP, CEA, beta oncofetal antigens, pancreatic oncofetal

antigens.
●​ Carbohydrate antigen - CA 125, CA 19-9, CA15-3
●​ Prostate specific antigen (PSA)
●​ Prostatic acid phosphatase (PAP)
3.​ List the methods of detection of tumor markers. (C1)

●​ Immunoassay​​ ​ ●​ Fluorescent In Situ

●​ Enzyme assay Hybridization (FISH)
●​ Immunohistochemistry ●​ Polymerase chain reaction
●​ High performance liquid (PCR)
chromatography (HPLC)

4.​ List the characteristics of ideal tumor markers. (C1)

(a)​ Analytical criteria
●​ Should have high sensitivity - can measure even in low concentration
●​ Specificity
●​ Accurate
●​ High precision
●​ Should be simple and easy to measure
●​ Should not be very costly
(b)​ Clinical criteria
●​ Should be disease sensitive
○​ Must be positive in all patient with particular carrier
○​ No false negative result
●​ Should have high disease specificity
○​ Should not be detected in normal healthy people
○​ Should not be associated only with a particular cancer
○​ Stable and not show wide fluctuations

5.​ Give an outline about the oncofetal antigens. (C2)

●​ They are proteins produced during fetal life
●​ Present in high concentration in the serum of the fetus and disappear after
birth.
●​ Reappear in cancer patients.

Including : AFP, CEA, Beta HCG, pancreatic oncofetal antigens

Alpha fetoprotein (AFP)

●​ Glycoprotein, molecular weight of 70000 D and related to albumin

●​ Synthesised by yolk sac in early foetal life. Normal component of serum
protein in human foetus.
●​ Concentration is increased during embryonic and foetal life.
●​ At birth, serum AFP level decreased.
●​ Increased AFP indicates the cancer of liver and germ cells of testis and to
some extent carcinomas of lung, pancreas, ovary and colon.
●​ Increased AFP observed in cirrhosis, hepatitis and pregnancy with fetal
malformations of neural tube.
●​ Measured of AFP provide sensitive index for tumor therapy and detection of
recurrence
 ●​ Most specific and ideal tumor marker for primary carcinoma of liver
●​ AFP and Beta HCG best available tumour marker for germ cell types of
tumors.
●​ Normal - <15 ng/L - in pregnancy little elevate
●​ Above 1000 ng/L → cancer except in pregnancy

​ Carcino embryonic Antigen (CEA)

●​ Glycoprotein, produced by embryonic tissue of liver , gut, pancreas

●​ Molecular weight is 185 kD.
●​ Most common oncofetal antigen
●​ Present only in cancer cells , in the circulation of patients with gastrointestinal
malignancy and in normal epithelial cells of the fetal GI tract.
●​ Increased in colorectal cancer
●​ Aid in diagnosis.
●​ To monitor the response of colorectal cancer to treatment
●​ N → 0-4 ng/ml
●​ Smoker → 0-5 ng/ml

​ Beta Human Chorionic Gonadotropin (Beta HCG)

●​ Synthesized by normal syncytiotrophoblastic cells of placental villi.

●​ Alpha subunit : identical with FSH, TSH, LH
●​ Beta Subunit : specific for HCG
●​ Increased in hydatidiform mole, choriocarcinoma and germ cell tumor
●​ 60% testicular cancer secrete hCG
●​ Help in aiding in the detection of ectopic pregnancy
●​ Increased in CSF → brain metastasis (Used to monitor the therapy of patients
with CNS metastasis)
●​ N - <20 IU/L
●​ Trophoblastic tumor - 10000 IU/L

6.​ Explain the role of Alpha FetoProtein (AFP) as a tumour marker. (C2)

Alpha fetoprotein (AFP)

○​ Glycoprotein, molecular weight of 70000 D and related to albumin

○​ Synthesised by yolk sac in early foetal life. Normal component of serum
protein in human foetus.
○​ Concentration is increased during embryonic and foetal life.
○​ At birth, serum AFP level decreased.
○​ Increased AFP indicates the cancer of liver and germ cells of testis and to
some extent carcinomas of lung, pancreas, ovary and colon.
○​ Increased AFP observed in cirrhosis, hepatitis and pregnancy with fetal
malformations of neural tube.
 ○​ Measured of AFP provide sensitive index for tumor therapy and detection of
recurrence
○​ Most specific and ideal tumor marker for primary carcinoma of liver
○​ AFP and Beta HCG best available tumour marker for germ cell types of
tumors.
○​ Normal - <15 ng/L - in pregnancy little elevate
○​ Above - 1000 ng/L → cancer except in pregnancy

7.​ Explain the function and clinical significance of Carcino Embryonic Antigen.
(CEA). (C2)

​ ​ Carcino embryonic Antigen (CEA)

○​ Glycoprotein, produced by embryonic tissue of liver , gut, pancreas

○​ Molecular weight is 185 kD.
○​ Most common oncofetal antigen
○​ Present only in cancer cells , in the circulation of patients with gastrointestinal
malignancy and in normal epithelial cells of the fetal GI tract.
○​ Increased in colorectal cancer

CEA chiefly present in

○​ GI mucosa, lungs, pancreas

○​ GI tract of foetus, embryonic liver, lung ,pancreas

Clinical significance
●​ Aid in diagnosis
●​ To monitor the response of colorectal cancer for treatment
●​ Prognosis monitoring
●​ In colorectal patient : Stage A - 28%, Stage B - 45 %
●​ 50 % of person with breast cancer, colon, lung, gastric, ovarian,
pancreatic and uterine cancer have increased CEA
●​ N → 0-4 ng/ml
●​ Smoker → 0-5 ng/ml

8.​ Explain the role of the beta chain of Human Chorionic Gonadotropin (beta
HCG) as tumour marker. (C2)

○​ Synthesized by normal syncytiotrophoblastic cells of placental villi.

○​ Alpha subunit : identical with FSH, TSH, LH
○​ Beta Subunit : specific for HCG
○​ Increased in hydatidiform mole, choriocarcinoma and germ cell tumor
○​ 60% testicular cancer secrete hCG
○​ Help in aiding in the detection of ectopic pregnancy
○​ Increased in CSF → brain metastasis (Used to monitor the therapy of patients
with CNS metastasis)
○​ N - <20 IU/L
○​ Trophoblastic tumor - 10000 IU/L
9.​ Explain Prostate Specific Antigen (PSA) with clinical significance and normal
values. (C2)
○​ Produced by secretory epithelium of prostate gland
○​ Normally secreted into seminal fluid
○​ 32 kD glycoprotein
○​ Marker for prostate cancer
○​ Increase in 70% of prostate cancer
○​ Early detection of cancer
-​ Specific for prostate tissue not for prostate cancer
-​ PSA alone will not detect in early stage
●​ For men diagnosed with prostate cancer, PSA levels are used to monitor the
effectiveness of treatment . A decrease in PSA usually indicates that
treatment is working.
●​ Recurrence Detection: After treatment, a rising PSA level can be an early
sign of cancer recurrence.
●​ Normal - <4 ng/L

10.​Explain clinical significance of Prostatic acid Phosphatase. (C2)

○​ Produced by prostate gland
○​ Increased in malignant conditions
i.​ Prostate,
ii.​ Multiple myeloma,
iii.​ Osteogenic sarcoma
○​ Increased in benign conditions;
i.​ Benign prostatic hypertrophy
ii.​ Enlarged prostate

11.​Explain the applications of tumor marker (C2)

○​ Screening population at risk - Not all tumor markers are good screening tools
○​ Diagnosis - use result from markers, imaging, risk factors and symptoms
○​ Prognosis - concentration of the marker determines prognosis.
○​ Detection of recurrent - once tumor is removed, elevations of marker can
indicate regrowth
○​ Monitoring respond to treatment
i.​ decreased level of tumor marker indicate therapy is working
ii.​ Increased level of tumor marker indicate need for a change to therapy

12.​ Explain Ca 125. (C2)

○​ Marker for Ovarian cancer

○​ Glycoprotein, molecular weight : 200 - 1000 kD
○​ Reacted with a monoclonal Ab originally termed as OC125
○​ 75% with ovarian cancer - increased
○​ Increased in approximately of 20% with pancreatic and digestive tract cancer
○​ Normal - <35 U/L
 ACID BASE BALANCE

1.​ Define acids, bases and buffers. (C1)

Acids
​ An acid is a substance that, when dissolved in water, increases the
concentration of hydrogen ions (H+)

Bases
​ A base is a substance that, when dissolved in water, increases the
concentration of hydroxide ions (OH−).

Buffers
​ A buffer solution (or simply a buffer) is an aqueous solution that resists
changes in pH upon the addition of small amounts of acid or base
​
​
2.​ Define buffering capacity. (C1)

The efficiency of a buffer in maintaining a constant pH on the addition of base

or acid.

3.​ List the acid and bases produced in the human body. (C1)
Acid produced in the human body
●​ Carbonic acid - metabolic product of CO2
●​ Lactic acid - anaerobic metabolism
●​ Sulphuric acid - from sulfur containing amino acid
●​ Hydrochloric acid - gastric acid
●​ Amino acid
●​ Fatty acid

​ ​ Basic produced in the human body.

●​ Bicarbonate - metabolism of CO2, metabolism of lactate and citrate
●​ Ammonia NH3 - protein break down
●​ Phosphate

4.​ Explain the mechanism of blood pH regulation by blood buffers. (C2)

​
Blood pH regulation by blood buffers can be classified into three different
mechanisms.
(a)​ Bicarbonate buffer
●​ Predominant buffer system of ECF
●​ It contain NaHCO3 and H2CO3 → ratio 20:1
●​ It is present in high concentration
●​ Very good physiological buffer
●​ First line defense
 ●​ As a chemical buffer it is weak

(b)​Phosphate buffer
●​ The sodium dihydrogen phosphate ions (NaH2PO4) and disodium hydrogen
phosphate (Na2HPO4) ions contribute to the phosphate buffer system. The ratio is
4:2 which is kept constant with the help of kidneys.
●​ It plays a major role mainly as an intracellular buffer and less importance in
plasma due to its lower concentration.
●​ The pKa of a phosphate buffer system is 6.8 which is near to the pH of blood (7.4) →
powerful
●​ Very effective as a chemical buffer
●​ Concentration in blood is low
●​ Less effective as a physiological buffer

(c) Protein buffer

●​ Plasma protein and Hb together constitute
●​ Buffer capacity depend on the pKa of ionizable group of amino acid
●​ Histidine with pKa value of 6.1 most effective
●​ Plasma proteins account for about 2% of total buffer capacity of plasma
●​ Hb of RBC also important buffer
●​ In acidic medium, protein acts as base, NH2 group takes up H+ ,converted into NH3+
and protein becomes positively charged.
●​ In the basic medium, protein acts as acid, COOH part dissociates into H+ and COO-,
H+ bind with OH- and produces H2O and protein becomes negatively charged.
 5. Explain the renal mechanism of blood pH regulation . (C2)
●​ Chemical buffers can tie up excess acids or bases, but they cannot eliminate
them from the body.
●​ Lungs can eliminate carbonic acid by elimination CO2
●​ Only the kidneys can rid the body of metabolic acids and prevent metabolic
acidosis.
●​ Regulate by either excreting acidic urine or basic urine.

Three mechanisms;
(1)​ Bicarbonate

●​ Most important
●​ Conserving or generating new bicarbonate ions
●​ Excreting bicarbonate ions or losing a bicarbonate ion is the same as gaining
as H+
●​ In alkalosis kidney secrete bicarbonate to compensate for an elevated pH
●​ Reabsorption a bicarbonate ion is the same as losing a H+

​ Factors affecting renal bicarbonate reabsorption

●​ Filtered load of bicarbonate
●​ ECF volume
●​ Plasma Chlorine and potassium concentration
●​ Hormones ( mineralocorticoids, glucocorticoids)

(2)​ Phosphate mechanism

●​ Both disodium hydrogen phosphate( Na2HPO4) and sodium dihydrogen
phosphate (NaH2PO4) are present in plasma.
●​ In the acid condition, Na2HPO4 dissociates Na+ and NaHPO42- and
NaHPO42- binds with H+ ion of acid and forms weak acid NaH2PO4.
●​ In the basic condition, NaH2PO4 dissociates NaHPO4- + H+ and H+ bind
with OH- ions of base and forms water and weak base.
 (3)​ Ammonia mechanism
●​ Operates in the distal renal tubule
●​ For the elimination of H+ ion and concentration of Na+ by the production of
NH3 by the renal tubular epithelial cells.

6. Explain the respiratory mechanism of blood pH regulation. (C2)

​ ​
●​ Second line defense against acid base disturbances is the control of CO2 by
the lungs by increasing and decreasing the rate of respiration
●​ The rate of respiration is known to be controlled by the respiration in the
respiratory centre which changes in pH and PCO2 of blood.

Tissue release H+ → in the blood

●​ [H+] increased
●​ [H2CO3] increased
●​ [CO2] dissolved in the blood increased
●​ Presence of CO2 in lungs increased
●​ Exhalation occurs, resting equilibrium
​ ​ Release OH- → in the blood
●​ [H+] decreased
●​ [H2CO3] decreased
●​ [CO2] dissolved in the blood decreased
●​ Presence of CO2 in lungs decreased
●​ Slow breathing, resting equilibrium

7. Explain acid base imbalance. (C2)

There are two abnormalities of acid-base balance:

●​ Acidosis: The blood has too much acid (or) too little base, resulting in a
decrease in blood pH.
○​ Respiratory acidosis
■​ Primary problem is acid-base disturbances ( [H+]) with an
increase in arterial blood PCO2. It is related to the reduction of
amount of air moving out of the lungs
■​ Main causes are
■​ Choking
■​ Bronchopneumonia
■​ Acute exacerbation of asthma
■​ Respiratory center depression by drugs, trauma etc.

○​ Metabolic acidosis
■​ Primary problem is acid-base disturbance ( [H+]) with a
reduction in the bicarbonate concentration of ECF
Main causes are
 ■​ increased production of acids
■​ Ingestion of acidic drugs
■​ Impaired excretion of H+ by the kidneys
●​ Alkalosis: The blood has too much base (or) too little acid, resulting in an
increase in blood pH.
○​ Respiratory alkalosis
■​ Primary problem is acid-base disturbances ( [H+]) with a
decrease in arterial blood PCO2. It is related to the increase of
amount of air moving out of the lungs
■​ Causes
■​ Hysterical overbreathing
■​ Over-ventilation on patient by machine

○​ Metabolic alkalosis
■​ Primary problem is acid-base disturbances ( [H+]) with an
increased bicarbonate concentration of ECF
■​ Main causes are
■​ Loss of hydrogen ion in GI fluid; severe vomiting, chronic
nasogastric suction
■​ Ingestion of alkali: especially sodium bicarbonate
■​ Potassium deficiency: potassium depletion in diuretic therapy

Endocrinology
1.​ List the functions of the endocrine system. (C1)
●​ Regulation of metabolism
●​ Growth and development
●​ Maintenance of homeostasis
●​ Sexula function and reproduction
●​ Mood and emotions
●​ Response to stress and injury

2.​ Classify hormones. (C1)

(a)​ Steroid hormones
(i)​ Sex hormones : testosterone , estrogen, progesterone
(ii)​ Adrenal cortex hormones : cortisol, aldosterone
(iii)​ Calcitriol
(b)​ Amino acid derived hormones
(i)​ Epinephrine
(ii)​ Norepinephrine
(iii)​ Thyroid hormone
(c)​ Peptides and proteins hormones
(i)​ Antidiuretic hormones
(ii)​ Oxytocin
(iii)​ Thyrotropin releasing hormone
 (iv)​ Gonadotropin releasing hormone
(v)​ Calcitonin
(vi)​ Insulin
(vii)​ Glucagon
(viii)​ Growth hormone
(ix)​ Parathyroid hormone

3.​ Explain the mode of action of hormones. (C2)

●​ Steroid and Thyroid Hormones (Lipid-Soluble)

• These hormones can cross the plasma membrane.

• They bind to intracellular receptors, directly influencing gene expression.
• Their effects are longer-lasting compared to water-soluble hormones.
• Example: Cortisol, Estrogen, and Thyroxine (T3, T4) act via this mechanism.

· Process:
Hormone diffuses into the cell.
It binds to a cytoplasmic or nuclear receptor.
The receptor-hormone complex binds to DNA, modifying transcription and
protein synthesis.

●​ Peptide and Protein Hormones (Water-Soluble)

• These hormones cannot pass through the lipid membrane of cells.

• They bind to cell membrane receptors, activating intracellular signaling
pathways.
• Their action involves second messengers like cyclic AMP (cAMP), calcium
ions, or kinase cascades.
• Example: Insulin, Adrenaline, and TSH act via this mechanism.
· Process:
•Hormone binds to a G-protein-coupled receptor (GPCR).
GPCR activates adenylate cyclase, producing cAMP.
CAMP triggers a phosphorylation cascade, altering enzyme activity or gene
expression.

4.​ List the following hormones;

●​ hypophyseal ●​ Suprarenal
hormones hormones
●​ Pituitary hormones ●​ Ovarian and
●​ Thyroid hormones testicular hormones
●​ Pancreatic (C1)
hormones

​ ​ Hypophyseal hormones
The hypophyseal (pituitary) hormones are divided into anterior and
posterior pituitary hormones:
 ●​ Anterior Pituitary Hormones:
○​ Growth Hormone (GH)
○​ Thyroid-Stimulating Hormone (TSH)
○​ Adrenocorticotropic Hormone (ACTH)
○​ Follicle-Stimulating Hormone (FSH)
○​ Luteinizing Hormone(LH)
○​ Prolactin (PRL)

●​ Posterior Pituitary Hormones:

○​ Antidiuretic Hormone (ADH)
○​ Oxytocin

​ ​ Pituitary hormones
​ ​
●​ Anterior Pituitary Hormones:
○​ Growth Hormone (GH)
○​ Thyroid-Stimulating Hormone (TSH)
○​ Adrenocorticotropic Hormone (ACTH)
○​ Follicle-Stimulating Hormone (FSH)
○​ Luteinizing Hormone(LH)
○​ Prolactin (PRL)

●​ Posterior Pituitary Hormones:

○​ Antidiuretic Hormone (ADH)
○​ Oxytocin

​ ​ Thyroid hormones
●​ Thyroxine (T4)
●​ Triiodothyronine (T3)
●​ Calcitonin

​ ​ Pancreatic hormones
●​ Insulin
●​ Glucagon
●​ Somatostatin
●​ Pancreatic polypeptide

​ ​ Suprarenal hormones
●​ Adrenal cortex hormones
○​ Cortisol
○​ Aldosterone
○​ Androgen
●​ Adrenal medulla hormones
○​ Epinephrine
○​ norepinephrine
​ ​ Ovarian and testicular hormones
​ ​ ​ Ovarian hormones
●​ Estrogen
●​ Progesterone
●​ Inhibin
​ ​ ​ Testicular hormones
●​ Testosterone
●​ Inhibin
●​ Androgen

5.​ Explain growth hormone and its disorders. (C2)

Growth hormone (GH) is synthesized and secreted by the

somatotroph cells of the anterior lobe of the pituitary gland. Its actions involve
multiple organs and systems affecting postnatal longitudinal growth, protein,
lipid, and carbohydrate metabolism.
GH is one of many hormones involved in [Link]: Insulin-like
growth factors, thyroxine, cortisol, the sex steroids and insulin are also
involved.

GH hypersecretion results in gigantism or acromegaly, a condition

associated with significant morbidity and mortality.
●​ Gigantism occurs when growth hormone hypersecretion occurs
before the fusion of the long bone epiphysis and is characterized by
tall stature.
●​ Acromegaly occurs when GH hypersecretion occurs after the fusion
of the epiphysis leading to large extremities and characteristic facies.

Growth hormone insufficiency is a rare cause of impaired physical

growth. GH deficiency results in growth retardation in children and the GH
deficiency syndrome in adults.

6.​ Explain anterior pituitary hormone and its disorders. (C2)

The anterior pituitary (adenohypophysis) plays a crucial role in

endocrine regulation by secreting hormones that control various physiological
processes. These hormones are regulated by the hypothalamus and
influence growth, metabolism, reproduction, and stress response.

The anterior pituitary secretes six major hormones:

(a) Growth Hormone (GH)

●​ Stimulates growth, cell regeneration, and metabolism
●​ Promotes protein synthesis and fat utilization while maintaining blood
glucose levels.
Disorders
●​ Gigantism (excess GH before puberty)- Leads to excessive linear
growth.
 ●​ Acromegaly (excess GH in adulthood)- Causes enlarged hands,feet,
and facial features.
●​ Growth Hormone Deficiency - Results in stunted growth or dwarfism.

(b) Thyroid-Stimulating Hormone (TSH)

​ Stimulates thyroid gland function, promoting secretion of T3 and T4.
Essential for metabolism, energy balance, and nervous system activity.
Disorders:
●​ Hypothyroidism (low thyroid hormone levels due to insufficient TSH).
●​ Hyperthyroidism (excess thyroid hormone levels from excessive TSH
production).

(c) Adrenocorticotropic Hormone (ACTH)

Regulates the adrenal cortex, stimulating cortisol release.

Helps in stress response, metabolism, and inflammation control.
· Disorders:
Cushing's Syndrome (excess ACTH → high cortisol)-
Causes obesity, hypertension, and fragile skin.

Adrenal Insufficiency (low ACTH → insufficient cortisol)

Leads to fatigue, weakness, and low blood pressure.

(d) Follicle-Stimulating Hormone (FSH) & Luteinizing Hormone (LH)

• Control reproductive function in males and females.
• FSH stimulates gamete production (sperm in males, ovarian follicle growth
in females).
• LH regulates ovulation in females and testosterone synthesis in males.
· Disorders:
●​ Hypogonadism (low FSH/LH)- Causes infertility, menstrual
disturbances, or sexual dysfunction.
●​ Polycystic Ovary Syndrome (PCOS)- Can involve altered LH/FSH
balance, affecting fertility.

(e) Prolactin (PRL)

• Stimulates milk production in females.
• Plays a minor role in reproductive health in males.
Disorders:
●​ Hyperprolactinemia (excess PRL)- Causes irregular menstrual cycles,
infertility, or galactorrhea.
●​ Prolactin Deficiency - Can lead to inadequate lactation postpartum.

7.​ Explain posterior pituitary hormone and its disorders. (C2)

The posterior pituitary (neurohypophysis) primarily stores and

releases two hormones produced by the hypothalamus: antidiuretic hormone
 (ADH) and oxytocin. These hormones play crucial roles in fluid balance, blood
pressure regulation, and reproductive functions.

(a) Antidiuretic Hormone (ADH)/ Vasopressin

• Regulates water retention in the kidneys by increasing water
reabsorption in the renal collecting ducts.
• Helps maintain blood pressure and osmotic balance.
• Influences vasoconstriction to aid in circulatory stability.
Disorders of ADH:
• Diabetes Insipidus (Dl):
o Caused by inadequate ADH secretion (central DI) or kidney resistance to
ADH (nephrogenic DI).
o Leads to excessive urination (polyuria), dehydration, and extreme thirst
(polydipsia).
• Syndrome of Inappropriate ADH Secretion (SIADH):
o Characterized by excessive ADH release, causing excessive water
retention, low plasma sodium (hyponatremia), and neurological symptoms like
confusion or seizures.

(b) Oxytocin
• Stimulates uterine contractions during labor.
• Promotes milk ejection during breastfeeding
• Plays a role in social bonding and emotional connections.

Disorders of Oxytocin:
· Oxytocin Deficiency:
• May impair milk ejection, causing breastfeeding difficulties.
Excess Oxytocin causes excessive uterine contractions in labor and can lead
to complications like fetal distress.

8.​ Explain thyroid hormone and its disorders .(C2)

●​ Bilobed gland contains many follicle
●​ A follicle is a group of cells encircling a lumen
●​ The lumen contains colloid.
●​ As hormones are produced by the cells, the hormones either released
into the colloid or directly into the blood
●​ There are extra follicular hormone secreting cells, C cells, these are
found between lumina
●​ T3/T4 - non steroid hormones
○​ Increased protein synthesis, promotes glycolysis,
gluconeogenesis, glucose uptake

●​ Calcitonin : calcium metabolism

●​ N T3 :5 -12 microgram / dl
●​ N t4 : 0.8 - 1.8 nanogram/ dl

​ ​ Hyperthyroidism
​ ​ Symptoms
●​ High metabolic rate, hyperactivity, sensitivity to heat, protruding eyes,
nervousness, inability to sleep, weight loss
●​ T3 and T4 increased and TSH is decreased
●​ Grave’s disease

​ ​ Hypothyroidism
​ ​ Symptoms
●​ Decreased basal metabolic rate, sensitivity
●​ T3 and T4 decreased, increased TSH in primary hypothyroidism and
decrease in TSH is seen if hypothyroidism is of 2nd type.
●​ Hushimoto’s disease
●​ Myxedema
●​ Cretinism
●​ Goiter

9.​ Explain parathyroid hormone and its clinical significance. (C2)

10.​Explain hormones of adrenal gland with clinical significance. (C2)
11.​Explain about functions of cortisol and its pathophysiology. (C2)
12.​Explain pancreatic hormone and its clinical significance. (C2)
13.​Explain ovarian and testicular hormones and its clinical significance.
(C2)