CLS_A_Bottomline_Approach_5e CC Chemistry PDF

IOJ CHEMISTRY by Larry Broussard and Mary Muslow * Sample Collection and Handling 1. Serum (r ed top) for most chemistry tes...

IOJ CHEMISTRY by Larry Broussard and Mary Muslow * Sample Collection and Handling 1. Serum (r ed top) for most chemistry tests 2. Plasma - H eparin better th an oxalate, EDTA, citrate REMEMBER! 3. H ep arin (on ice) - ammonia, blood ga ses, lactic acid Hemolysis... as the cell bursts, 4. Sodium fluoride (gray top) a. Glucose (slows glycolysis) help (c)KLAMP the leak! b. NOT for BUN (inhihits urease) K x+,t.. 5. Acid Phosphatase must be stabilized or L W♦ tpH A Aldolase (ALD +) 6. EDTA Acid Phosphatase (ACP ♦) a. NOT for Na+ or K+ (EDTA contains Na+ and K+) M Mg++,+.. b. Not for Ca++ since calcium is ch elated in E DTA ( will cau,.-,e a false t ) p P04 ,t.. ,t.. Hemoglobin = Protein Electrophoresis May Sb.ow Extra Band ,t.Fe++ But, Bilirubin t or ♦ (Depending on hemoglobin and bilirubin concentrations) Carbohydrates : Glucose 2. Sp ecin1en c ollection and handling I. Digestion , metabolism, r egulation a. Glucose levels decr ease a. End product of car bohydrate approximately 10 mg/dL per hour digestion in the intestine in whole blood (7%) b. Blood glucose is maintained at a b. R efrigerated serum is fairly stable fairly constant level b y hormones c. Sodium fluoride (anticoagulant) (Insulin t ; all other s ,I.; see table on slows glycolysis (gray top tube) page 102) d. Fasting reference range for serum c. Provides ener gy for life p rocesses or plasma is 70-99 mg/dL e. Arterial and capilla ry values are 2- 3 mg/dL higher f. "Normal" CSF values are two- thirds (approximately 60-65%) of plasma l evels Relationship Between CSF and Plasma Glucose LevelJJ "Original contribution by Melanie S. Chapman 102 HORMONAL ACTIVITY AFFECTING SERUM GLUCOSE LEVELS HORMONE SOURCE ACTION Insulin beta cells of Islets of t serum glucose Langerhens of pancreas Stimulates glucose uptake by cells Glucagon alpha cells of ,t. glucose pancreas Stimulates glycogenolysis (breakdown of glycogen ➔ glucose) ACTH anterior pituitary ,t. glucose Insulin antagonist Growth Hormone anterior pituitary ,t. glucose Insulin antagonist Acromegaly = hyperglycemia Cortisol adrenal cortex ,t. glucose Stimulates gluconeogenesis (glucose from non-carbohydrate sources) Human Placental placenta ,t. glucose Lactogen Insulin antagonist Epinephrine adrenal medulla ,t. glucose Stimulates glycogenolysis Pheochromocytoma-tumor of adrenal medulla ➔ hyperglycemia T3 &T4 thyroid gland ,t. glucose Stimulates glycogenolysis REMEMBER! REMEMBER! Fido the GAG CHET Diabetic Dog Glucagon Cause:+ or No Insulin Production ACTH Growth Hormone SYMPTOMS: Tired 1,1-l ~)§) Polyuria Cortisol + Thirst & Hunger Human Placental Lactogen Weight Loss Poor Wound Healing Epinephrine T 3&T4 58@3 All cause an increase in serum glucose LAB TESTS: + Glucose (serum & urine), + AlC May Have + Cholesterol Diabetic Acidosis: t' Na+ + K+ Hormones affectmgtflllll t' Cl- gl.ucose - those that it vs. + Ketones (blood & urine) i.n.sulin wbich it  103 TEST INTERPRETATION TO DIAGNOSE DIABETES MELLITUS TEST STAGE Fasting plasma Casual plasma glucose Oral glucose tolerance A1c glucose (FPG) test (OGTT) * Normal FPG 100 mg/dL CHO ~ 100 mg/dL Diet from Notional Cholesterol Education Prag-am 106 ❖ Bran ched chain k etoaciduria (maple syrup urine disease) - branched chain aJni.no acids J. in blood and urine b. Renal-normal plasma level but Specimen Collection for decreased r enal threshold or Li.pid Analysis reahsorption ❖ Cystinuria.+ cystine, lysine, ornitbine, arginine in urine Calculate LDL and VLDL METHODS 1. Scr eening Tests (Initial Diagnosis) a. Thin la yer chromatography with ninhydrin Lipid Cut-OHAction Levels b. U rine color tests c. Guthrie bacterial inhibition assays F or PKU: positive when phenylalanine Cardiac Risk Factors m etabolites in blood overcome 1. Positive Risk Factors inhibition in agar and B. subtillis grows. a. Age >45 years men, >55 years women 2. Quantitative Tests b. Family history of premature CHD a. fon-excbange chromatography c. Current cigarette smoking b. High performance liquid d. H ypertension systolic hp >120 chromatography (HPLC) e. HDLc 35 mgldL ❖ Tritdycerides < 150 mgldL 1. Most proteins are synthesized a nd ❖ LDLc < 100 mgldl catabolized in the liver c. Follow-up testing if levels outside 2. Basic unit - amino acids linked together goals by amide bonds to form protein ❖ 12 hour fasting sample ❖ Lipoprotein analysis 3. Prot ein breakdown in the body cl. Begin treatment b ased on LDLc produces urea and ammonia ; urea r esults ( see page 105) and other risk prod uced in liver and eliminated in factors (see above) urine b y kidneys METHODS : SERUM TOTAL PROTEIN Amino Acids 1. Kjeldabl GENERAL a. Reference method 1. Arninoacidurias b. Principle - measures nitrogen a. Overflow-plasma level above renal c,o ntent threshold as result of metabolic c. Acid digestion converts nitrogen in disorder protein to ammonium ion (NH4+) ❖ PKU - enzyme defi.ciencies cause which i s mea sured l- of phenylalanine in hlood and d. Difficult to p erform , infrequently j phenyl compounds in urine used  107 2. Biuret reaction 6. Relative concentration of each band a. Used most frequently determined by densitometry b. Depends on presence of z2 peptide bonds which react to form a purple 7. Specimen collection and handling complex with copper salts in a. Plasma samples (mistaken as serum) alkaline solution result in fibrinogen peak migrating METHODS : URINE AND CSF TOTAL PROTEIN between gamma and beta fractions b. Recollect and repeat to verify that 1. Dye - Coomassie brilliant blue peaks not fibrinogen 2. Turbi dimetric methods CLINICAL SIGNIFICANCE a. Acid (sulfosalicylic acid or 1. Plasma proteins - albumin and trichloroacetic acid) precipitates globulins protein a. Liver produces albumin, alpha-I, b. Measured spectrophotometrically or alpha-2 and beta globulins visually b. RE system produces gamma METHODS : SPECIFIC SERUM PROTEINS globulin (antibodies secreted by plasma cells) 1. Dye-binding methods for albumin a. Bromcresol green (BCG) 2. Prealbumin b. HABA (2- [4' - H ydroxyazobenzene) a. Appears as a faint band on serum - benzoic acid) electrophoresis b. Used clinically to assess nut ritional 2. ImmumochemicaI methods for specific status proteins other than allmmin MAJOR SERUM PROTEIN ELECTROPHORESIS FRACTIONS PROTEIN ELECTROPHORESIS 1. Albumin 1. Direction of migration of proteins in an a. Largest plasma protein fraction (52- electrical field determined by 62%) surface charge of protein b. Regulator of osmotic p ressure a. Protein at pH higher than its c. Transport protein because of ease isoelectric point is negatively of binding with blood components charged and mii:,rrates toward anode d. Causes oft values (positive charge) ❖ t synthesis (liver impairment) b. Albumin (smallest M. W.) has largest ❖ t associated with edema, number of free negative charges and decreased osmotic pressure migrates most rapidly traveling ❖ Ma/absorption or malnutrition grea test distance from application ❖ Nepbrotic syndrome (renal loss) point ❖ Severe burns c. Urine protein electrophoresis same e. ,t. values generally have no clinical a s serum except it must be significance (hemoconcentration, concentrated before application dehydration) 2. Electroendosmosis causes gamma 2. Alpha-I-globulins globulins to migrate toward the cathode a. Alpha-1-antitrypsin (AAT) even though they ar e slightly negatively ❖ + in acute phase and pregnancy ❖ t associated with emphysema in charged ( due to electrical charge on support medium) neonates 3. At pH 8.6, in order of migration, the 5 major bands are albumin, alpha-!, alpha-2, beta and gamma 4. Support media include cellulose acetate, agarose gel, and starch gel 5. Stains include Amido Black, P onceau S and Coomassie Brilliant Blue Basic Tests for Protein 108 b. Alph a fetoprotein (AFP) b. ,t- in: ❖ ,t- in amniotic fluid and maternal ❖ Elevated beta lipoprotein (LDL) serum in neural tube defects ❖ Iron deficiency anemia (spina bifida) ❖ liver cancer marker 5. Gamma globulin ❖ t in maternal senun during a. ,t- in: p1·egnancy associated with Down's ❖ Chronic inflammation syndrome ❖ Cirrhosis or viral hepatitis ❖ Collagen diseases 3. Alpha-2-globulins ❖ Pai-aproteins (monoclonal b ands, a. Haptoglobin gammopathies) ❖ Binds free hemoglobin b. t in congenital or acquired ❖ ,t- in acute phase and nephrotic immuno-deficien cy syndrome ❖ 't seen in transfusion reactions ❖ t i.J1 hemolysis and liver disease b. Ceruloplasmin ❖ Transports copper REMEMBER! ❖ ,t- iu acute phase and pregnancy Protein ❖ t Wilson's disease Electrophoresis 4. Beta globu]in a. Carrier proteins for iron Abbie Albumin is attracted to (transferri11) and lipids (lipoproteins) Andy Anode because of his _ , _..__..ositive attitude. 0 Some Common Protein Electrophoresis Patterns Beta Gamma Bridge =.E N "EE " E :, ,L -a." -a." co"s E < < < " 0 " 0 + Normal + + Monoclonal Gammopathy normal = normal= '® = Point of Application \ ', N ' ".c ' E- < --L....l.'-lo~-_;::....,_;;...._-,c;. + + Hypogammaglo bulinemia normal = Graphs Adapted with Permission from Helena Labo,atories' Electrophoresis Reference Chart  109 Total CK (Creatine Kinase) 1. ,t. in muscle, cardiac or brain damage 2. Higher reference ranges in males due to greater muscle mass and physical activity CK Jsoenzymes 1. Different molecular forms of CK Co,nditions Associated with enzyme AFP increase or decrease a. 2 subunits - M and B ❖ CKl = CK-BB - 2 B chains ❖ CK2 = CK-MB - 1 M & 1 B chain Protein.ARsociatea with ❖ CK3 = CK-MM - 2 M chains Copper Transport b. Cardiac muscle= CK-MM and CK- MB c. Skeletal muscle = CK-MM d. Brain, GI, colon, prostate, uterus = Enzymes CK-BB GENERAL e. Trauma to skeletal muscle causes ,t. 1. Organic catalysts responsible for most in total CK and MB isoenzyme, but reactions in the body % activity MB is < 3% (> 6% in MO 2. Enzyme reactions in laboratory measurements affected by: a. Concentrations of reactants b. pH (optimum pH varies with each enzyme) c. Temperature ❖ Optimum 37°C ❖ Rate doubles every ,i. 10 degrees d. Ionic strength e. Cofactors and coenzymes LD (Lactate Dehydrogenase) 3. Enzyme inhibition by substances that can reduce the rate of the enzyme 1. in: reaction a. Myocardial infarction (MI) a. Competitive inhibitor- binds free h. Liver disease enzyme at the active site c. Muscle trauma b. Noncompetitive inhibitor- hinds at a d. R enal infarct site other than the active site e. Hemolytic diseases c. Uncompetitive inhillitor- binds only f. Pernicious anemia to the enzyme substrate complex 2. Sources of error 4. Measurement a. H emolyzed specimens a. Zero-order-kinetics - Large excess b. Prolonged contact of serum to cells of substrate so that the amount of 3. Spectrophotometric method enzyme activity is only rate-limiting a. LD converts pyruvate to lactate factor while oxidizing NADH to NAD b. Catalytic activity rate (not mass or b. Rate of decrease in absorbance of concentration) is directly measured NADH at 340 nm is proportional to c. One international unit ( U or JU) = LD activity amount of enzyme that will cause utilization of substrate or 4. LD isoenzymes production of product at the rate of a. 2 chains (Mand H) 1 µM/ minute b. 4 subunits c. 5 forms (tissue-specific) 110 AST (Aspartate transaminase) c. Disorder s of hepatic biliary tree 1. Found in cardiac muscle, liver, RBCs (obstructive Jaundice due to and other tissues gallstones or malignancy) d. Third trimester of pregnancy 2. ,t.. in MI, liver disease (hepatocellula1· (placenta) damage, cirrhosis, carcinoma), muscle trauma, renal infarct, hemolysis 5. Methods a. Spectrophotometric ALT (Alanine transaminase) ❖ ALP converts p-nitrophenyl 1. ,t.. in liver disease (hepatocellular phosphate to phosphate and P- damage, cirrhosis, carcinoma) nitrophenylate which is measured at 404-410 nm 2. More hver-specific than AST b. Immunoassay for bone isoenzyme GGT (Gamma-glutamyl transferase) 5'NT (5'-Nucleotidase) 1. ,t.. in liver disease (liighest in biliary 1. ,t.. in liver but NOT hone disease obstruction and cirrhosis) 2. ,t.. ALP+ Normal S'NT = bone disease 2. Often ♦ after alcohol intake 3. ,t- ALP +.f- S'NT = liver disease 3. Spectrophotometric method - measure nitroaniline released when Amylase GGT acts on substrate gamma- 1. Produced in salivary and pancreatic glutamyl-p-nitroanilide glands ALP (Alkaline Phosphatase) 2. Requires Ca++ and c1- (dilute elevated ]. Optimum pH= 10; Mg++ activation samples with saline not water) 2. Found in hone, intestinal mucosa , renal 3. Only common enzyme normally tubule cells, biliary tree (liver) , excreted in urine leukocytes, placenta, some tumors 4. Highest elevations seen in pancreatitis 3. Isoenzyme separation: acrylamide gel, and obstruction to pancreatic ducts electrophoresis, chemical or heat (malignancy) (56°C; 10 minutes): Heat Stability: a. Regan (cancer)= rare, most heat 5. Lower elevations seen in obstruction of stable salivary glands (mumps) b. Placental = most heat-stable of 4 6. Methods most common a. Amyloclastic - measure c. Intestinal = inhibited by disappearance of starch substrate L-phenylalanine b. Saccharogenic - measure reducing d. Liver= highest concentrations sugars (glucose and maltose) e. Bone= most heat-labile produced by enzymatic action 4. ,t- in: c. Chromolytic (dye) - measure a. Bone disorders with osteoblastic ahsorbance of soluble dye split from activity insoluble amylase-dye substrate ❖ Paget's (highest ALP values) 7. Urinary amylase remains elevated ❖ Osteoblastic tumors longer than serum in pancreatitis ❖ Rickets ❖ Hyperparathyroidism 8. Opiates (Ex. morphine} cause elevation b. Growing children - rapid skeletal growth (bone) Higbly Elevated ALP & G Various Diseases Biliary Obstruction  11 l Lipase ❖Add tartrate buffer: 1. + in pancreatitis ~ Prostatic ACP inhibited by tartrate 2. Remains elevated longer than amylase I@' RBC ACP not inhibited by tartrate 3. More specific for acute pancreatitis c. Immunoassay for prostatic ACP 4. Methods: 4. Specimen Collection and Handling a. Turbidimetric b. Older method: olive oil substrate; a. Hemolysis results in falsely + results measure fatty acids product b. Storage at room temperature results in loss of enzyme activity; must TE$ remove serum from cells ASAP and stabilize (add disodium citrate t monohydrate or pH to 5.4 with acetic acid) Clinical Significance ofan bicre1JSed Amylase Test Most SpeciJic for Acute Pancreatitis Specimen Handling for Acid Phosphatase Determination ACP (Acid Phosphatase) 1. Sources: primarily prostate; other Cholinesterase tissues: erythrocytes, bone, liver, 1. Erythrocyte acetylcholinesterase and spleen, kidney, platelets plasma pseudocholinesterase 2. Clinical significance 2. Destroys acetylcholine after nerve a. Highest elevations seen in impulse transmission metastasizing carcinoma of prostate; now use PSA instead 3. Severe t results in serious b. + in bone disease or cancers that neuromuscular effects; one of few enzymes in which t is clinically metastasize to hone and in metastasizing breast cancer significant c. Tartrate-resistant portion elevated in hairy cell. leukemia 4. t cholinesterase: organophosphate poisoning and genetic susceptibility to d. Presence in seminal fluid useful in certain anesthetic agents forensic medicine for rape cases; now use PSA instead 3. Methods: a. Spectrophotometric for Total ACP ❖ Phosphate substrate (Ex. p-.nitrophenyl phosphate) Test Helpful in Determining cleaved by ACP to give colored Pesticide Poisoning product (Ex. p-nitrophenol after OH- added; yellow, read at 410nm) Cardiac Markers to Evaluate Possible Acute b. Spectrophotometric for Prostatic Myocardial lnfardion (AMI or Ml) ACP: 1. Myoglobin ❖ Use substrates more specific for a. Produced by muscles including prostatic ACP (Ex. h eart thymolphthalein monophosphate b..+ in muscle damage including AMI and alpha naphthyl phosphate) c. + in renal damage 112 d. Rises within 30 minutes of AMI; g. If BNP given as medication peaks within 4-10 hours and returns (Natreco~) to t blood pressure, to normal within 24 hours must u se NT pro-BNP to monitor e. Absence rules out AMI but ,+. does ventricular BNP release not diagnose AMI because may be h. Also used for risk stratification due to other muscle trauma other Cardiac Risk Assessment Markers 2. CK2 ( CK-MB) 1. hsCRP a. Immunoassays: mass CK2 a ssays a. Sensitive marker for chronic measure concentration rather than inflammation activity b. Pa6ent must b e free of other b. Rises within 6-10 hours of AMI; inflammatory processes (trauma , peaks within 24 hours; returns to rheumatoid arthritis, infection, normal in 2-3 days etc.) c. Replaced by Troponin for detection c. Elevated levels potential risk factor of AMI 2. Homocysteine 3. Troponin a. Amino acid associated with vitamin a. Single best test for diagnosis of AMI B6, Bl2 and folic acid b. Troponin (Tn) is complex of 3 b. Elevated levels potential risk factor muscle fiber proteins: troponin T (Tn1), troponin I (Tnl) and troponin C (Tn C) c. l soforms cTnT and cTnl are very specific to cardiac muscle and either may be u sed for detection of AMI d. cTnT and cTnl often called TnT and Tnl or simply Tn e. Rises 4-8 hours after AMI; peaks at approximately 12-14 hours; r em ains elevated for up to 10 days Liver Markers f. Also used for cardiac risk stratification 1. AST - highest valu es in hepatitis Cardiac Markers to Assess 2. ALT - highest values in hepatitis, liver Congestive Heart Failure sp ecific 1. B-type Natriuretic Peptide (BNP) and 3. LD - found in many tissues other than N-Terminal pro-BNP (NT pro-BNP) liver (ex., h eart, skeletal muscle) a. BNP and NT pro-BNP levels ,+. in congestive heart failure ( CHF) 4. ALP - biliary obstruction; may be ❖ Levels correlate to classification of slightly elevated in hepatitis stages of CHF h. Released by ventricular walls in 5. 5 1 NT - biliary obstruction response to hypertension and volume overload 6. GGT - liver-specific; highest + from c. Pre-pro-BNP cleaved to BNP biliary ob struction or after alcohol (active) and T pro-BNP (inactive) ingestion d. Natriuretic because BNP ,t. Na+ and water excr etion and causes vasodilation to t blood pressure REMEMBER! e. BNP antagonist to renin- Elevated Liver En~mes angiotensin-aldosterone system are as Easy as AB c; (RAAS) which,+. blood pressure by vasoconstriction and r etention of A,lcoholism Na+ and water f. NT pro-BNP cleared b y kidneys so §.iliary Obstruction affected by renal function ~irrhosis  113 REMEMBER! REMEMBER! Hepatitis vs. Muscle Man Obstruction M u AST Adapte 60 mM/L - cystic fibrosis d. Renal failure e. Addison's disease 9. Chloride Shift a. Buffering system of the blood (for 8. Method: Ion-selective electrode acid-base balance) a. Valinom cin membrane selectively b. HC03 pulled out of erythrocytes binds K 4 and CJ· moves into erythrocytes, t resulting in serum ci-  115 6. +Anion gap a.+in concentration of unmeasured anions ❖ Ethanol ❖ Ketones ❖ Lactic acid b. tin unmeasured cations ❖ Low serum Mg++ ❖ Low serum Ca++ Reasents Used m Sweat Chloride 7. t Anion gap a. tin unmeasured anions- albumin loss Definition. of Chloride Shiite b. +in unmeasured cations ❖ High serum Mg++ ❖ High serum Ca++ CO2 (TOTAL CARBON DIOXIDE) ❖ Lithium therapy c. Hemodilution 1. CO2 + HCO3 + H 2CO3 = total CO2 OSMOl..ALITY 2. Reflects bicarbonate (HCO3) 1. Measure of total concentration concentration (n umber) of dissolved particles in a solution (molecular weight, size, 3. Methods: density or typ e of particle does not a. Volumetric matter) b. Manometric c. Colorimetric 2. Can be measured directly - practical d. pCO2 electrode measures change in methods are freezing point depression internal pH due to CO2 (most precise) and vapor pressure ANION GAP depression - 2 colligative properties 1. Calculation that r eflects differences between unmeasured cation s and 3. One equation (there are others that anions; u sed as analytical QC for give similar results) Calculated Osmolality = measuring all electrolytes 2Na + Glucose + BUN a. If abnormal gaps for multiple 18 2.8 patients, suspect problem with electrolyte measurements 4. Can compare calculated osmolality to measured osmolality; measured 2. Major unmeasured cations a. K+ osmolality > 10 higher than calculated b. ca++ osmolality indica tes presence of c. Mg++ exogenous unmeasured anions (methanol, ethanol , k etone bodies, etc.) 3. Major unmeasured anions a. Albumin b. Sulfate c. Phosphate 4. Two calculations (with or w:ithout K+): a. [(Na+) +(K+)] - [(Cr) +(HC03)] b. (Na+) - [(Cr)+ (HC03)] 5. Reference ran ge a. 10-20 mM/L (using equation 4a Ev.aluate Anion Gap and above) Talre Cornetive Action b. 7-16 mM/L (using equation 4b above) 116 5. Methods a. Atomic absorption spectroscopy - ·· REMEMBER! Conditions Causing ,t.. in reference method b. Colorimetric method - most common Unmeasured Anions ❖ Ca++ reacts wi.th o- (ethanol, ketones, etc.) ucsolphthalein to form r eddish S alicylate intoxication complex L actic acidosis ❖ 8-hydroxyquinoline is added to Unmeasured ions remove Mg++ Methanol P olyethylene glycol c. ISE - measures ionized Ca++ ❖ pH dep endent Ethanol D iabetic Ketoacidosis ❖ Collection - anaerobically to prevent CO2 loss ( ,t- pH) MAGNESIUM (MG++) d. Most methods measure total Ca++ 1. Ca++ channel blocking agent ( affects including protein-bound Ca++ heart) ( ,t- protein causes ♦ Ca++; ISE avoids problem) 2. i in r enal failure e. Falsel y t if using EDTA (purple top) 3. tin: or oxalate; due to binding Ca++ a. Cardiac disorder s b. Diabetes mellitus c. Diuretics, alcohol and other drugs 4. Methods a. Atomic absorption b. Colorimetric method - calmagite, @REMEMBER! formazen or methylthymol blue, or magon In Cases of Tetany, suspect CALCIUM (Ca~ ca++ first, then Mg++ or K+ 1. Combines with phosphate in bone 2. Controlled by 3 hormones: PHOSPHOROUS a. PTH (parathyroid) ,t- Ca++ 1. Majority of phosphate in body b. Calcitonin inhibits bone expressed as phosphorous; laboratory reabsorption ( t Ca++) measures inorganic phosphorous (PO,i) c. Vitamin D causes ,t- absorption in only intestines(+ ca++) 2. Inverse r elationship with Ca++ (when 3. Hyper calcemia ( ♦ Ca++) - muscle ca++ is ♦, P04 is f and vice vei-sa) weakness, disorientation a. Hyperparathyroidism 3. ,t- PO4 b. Cancer with bone metastasis a. H ypoparathyroidism c. Multiple myeloma b. Chronic renal failure d. Renal failure c. Excess vitamin D 4. Hypocalcemia (t ca++) - tetany 4. t PO4 a. Hypoparathyroidism a. H yperparathyroidism b. t serum albumin (1 mg/dL ca++ b. Impaired r en al absorption p_er 1 gldL t albumin) 5. Methods c. t vitamin D (malabso1ption, a. Spectrophotometric methods use inadequate diet) - impaired bone molybdate to combine with PO4 ions release, impaired renal r eabsorption b. Molybdenum blue is formed by the reduction of phosphomolybdate  117 REGULATORS OF CALCIUM AND PHOSPHORUS LEVELS ❖ Stimulation of renal hydroxylation of 25-(OH)D to 1. Vitamin D l ,25-(OH)2D a. Functions more like a prohormone than a vitamin c. Intraoperative PTH monitoring: b. Exists in 2 forms: ❖ Rapid (POCT) assaying of PTH ❖ D2 (ergocalciferol) dieta1-y form d111·ing surgery- use to determine found in fl.sh, plants, and fungus ii' abnormal PTH producing tissue ❖ D3 (cholecalciferol), most has been removed produced by photosynthesis in ❖ Baseline plasma PTH and then at skin from exposure to simlight but 5 and 10 minute intervals after also found in dietary animal removal of the parathyroid tissue products ❖ Look for >50% decline in PTH c. Both forms metabolized to more from O to 5 min postexcision active dihydroxy forms (l,25- (OH)2D) in a 2-step process 3. Procalcitonin (PCT) occurring first in liver (producing a. Normally made in thyroid and 25 hydroxyvitamin D) and then in converted to calcitonin which the kidneys causes T blood Ca++ d. 1,25-Dihydroxyvitamin D causes ,t.. b. In bacterial infection elevated levels blood calcium and phosphorus by (greater than 2.0 ng/mL) marker of increasing intestinal Ca and PO4 high risk of sepsis absorption and renal reabsorption IRON and increasing mineralization during bone formation 1. Over 65% of total body iron is in e. Deficiency causes: hemoglobin - 0 2 transport ❖ Rickets: childhood disease 2. Transported by transferrin, characterized hy softening and haptoglobin and hemopexin weakening ofbones ❖ Osteopenia and osteoporosis 3. Stored as ferritin and hemosiderin ❖ Linked to other conditions such as hypertension, obesity, diabetes, 4. Methods cardiovascular disease, multiple a. Serum iron - colorimetric - avoid sclerosis, cancer (colon and hemolysis breast), autism, systemic lupus b. TIBC (total iron-binding capacity) erythematosus (SLE), and other ❖ Reflects transferrin lel'els autoimmune diseases ❖ Excess ferric salts are added to f. Appropriate test for assessing serum to saturate binding sites on vitamin D stores: transferrin ❖ serum 25-hydroxyvitamin D (25- ❖ Unbound iron precipitated with 0II D2 & D3) magnesium carbonate g. Methods: ❖ After centrifugation, supe1·natant ❖ Immunoassay analyzed for iron ❖ Liquid cbromatography (high- c. Direct methods for transferrin are pPrfnrm:mce liquid immunochemical (nephelometry) chrnmatography [HPLC] and d. Ferritin liquid chromatography tandem ❖ A.ssess iron storage mass spectrometry [LCMSMS]) ❖ Immunoassay methods ❖ Sensitive for detection ofiron 2. PTH (.Parathyroid Hormone) deficiency a. Synthesis by parathyroid glands ❖ +in infection, inflammation, stimulated by low Ca, suppressed chronic diseases by high Ca concentrations b. Causes ♦blood calcium by ❖ Bone resorption ❖ Renal tubula1· reabso1ption of calcium but 1,25-(0H)2 vit. D most active form 118 Laboratory Assessment of Iron DISEASE SERUM IRON TRANSFERRIN TIBC SERUM (µg/dL) SATURATION {%) (µg/dL) FERRITIN (µg/dL) Normal 65-175 (M) 20-55 250-425 20-250 (M) 50-170 (F) 10-120 (F) Storage Iron Depletion (No Anemia) N N N t Iron Deficiency Anemia t t + t Anemia of Chronic Disease (Inflammation) t t t + Thalassemia Hemochromatosis ,t. + ,t. + t t + Sideroblastic Anemia + + N + Acid-Base Balance METABOLIC ACIDOSIS HENDERSON-HASSELBALCH EQUATION 1. Primary bicarbonate deficit (t HCOj 1. Definition - logarithmic expression of a. Diabetic ketoacidosis ( acid + ionization constant equation of a weak production) acid b. Renal disease ( t J-J+ excretion; decreased readsorption of HCOj) 2. Formula c. Prolonged diarrhea (excessive a. pH = pKa + log [HC0 3-) HC0 3 loss) d. Late salicylate poisoning [H 2C03] 2. Compensatory mechanism s want this ratio to be 20 a. Primarily respiratory 1 ❖ Hyperventilation ❖ t pC02 b. pH p roportional to: b. Some r enal (ilkidney fun ction ❖ log HC03- normal) pC02 ❖ +excretion of JI+ ❖ kidney ❖ Reahsorption of HC03 lungs ❖ metabolic 3. Lah Findings respiratory a. t pH, H CO3, CO2 and pCO2 b. Acid urine SAMPLE COLLECTION AND HANDLING METABOUC ALKALOSIS 1. Anticoagulant - sodium heparinate (heparin) 1. Primary H CO3 excess ( HCOj} + 2. Seen in: 2. Must use anaerobic collection for pH a. NaHCO3 infusion and blood gas studies b. Citrate (anticoagulant in blood transfusions) 3. If blood is exposed to air (bubbles in c. Antacids (contain HCOj) syringe; uncapped tube): d. Vomiting (HCJ loss; prolonged a. CO2 and pCO2 t vomitingjeads to alkalosis due to GI h. pH ♦ loss of FI ) c. pO2 ,t. e. K+ depletion 4. If testing prolonged (> 15 minutes) blood f. Diuretic therapy should be k ept in cracked ice to prevent g. Cushing's Syndrome glycolysis , which leads to: (+ mineralocorticosteroids) a. CO2 and pC02 + 3. Compensatory mechanisms b. pHt a. Primarily respiratory C. pO2 t ❖ Hypoventilation ❖ ,t- retention of CO2  119 b. Some renal - 5. Primary respiratory dysfunction ❖ t excretion of H+ results in change in pCO2 (~eesaw); ❖ +excretion of HCO'j main compensation is HCO3 (metabolic) 4. Lab Findings - ,t. pH, HCO3, CO2 and pCO2 6. Primary metabolic dysfunction results RESPIRATORY ACIDOSIS in change in HCO3_ (swing); main + 1. Primary CO2 excess ( pC02) compensation is pCO2 (respiratory) BASE EXCESS / DEFICIT 2. Seen in: 1. Defined as amount (dose) of acid or a. Emphysema alkali needed to return pH to normal b. Pneumonia c. Rebreathing air (paper hag) 2. Calculated using pH and pCO2 3. Compensatory mechanisms 3. Assess metabolic compon ent of acid- a. Mainly renal - base disorder ❖ ,t. H+ excretion a. Positive value (base excess) = ❖ HCO3reabsorption metabolic alkalosis b. Some respiratory (if defect is not in b. Negative value (base deficit) = the respiratory center) metabolic acidosis 4. Lab findings - t pH and ,t.. HCO3, CO2 and pCO2 Blood Gas Reference Ranges RESPIRATORY ALKALOSIS 1. Primary CO2 deficit (t pC02) PARAMETER DEFINITION "NORMAL" 2. Seen in: pH Negative Log of H+ 7.35-7.45 a. Hyperventilation (blowing off too pCO2 P.:irtiol Pressure or Tension 35-~5 mm Hg much CO?) of CO2 in Blood b. Early salicylate poisoning HCO3 Bicarbonate - Calculated 22-26 mM/L 3. Compensatory mechanisms a. Mainly renal pO2 Ox~gen Tension - Partial 85-1 05 mm Hg ❖ t H+ excretion ressure of Oxygen 4. Lab findings - ,t.. pH and HCO3, t pCO2 and CO 2 EVALUATING ACID-BASE DISORDERS 1. Look at pH; determine if acidosis or alkalosis REMEMBER! Blood Gas 2. Compare pCO2 and HCO3 to 11normals 11 a. pCO.J going opposite to pH = "Normals" respiratory b. HCO3 going same direction as pH = I like my oxygen at 100, metabolic p02 but 90 will do. 3. If pH normal, full compensation occurred 1/2 (90) = 45 4. If main compensatory mechanism nco- 3 kicked in, but pH still out of normal 1/2 (45) ~ 23 (a little >1/2) range, partial compensation has occurred pH 1/3 22.5 ~ 7.4 a little >1/3 120 Factors Affecting Blood Gas Analysis pH pC02 p02 Bubbles in Syringe Sample Sitting MoreThan 30 Minutes (Not on Ice) t + t + t REMEMBER! Factors Affecting Blood Gases Let me introduce the characters who will help you remember blood gases: Phonetia (pH), Carbo (Bicarbonate - HCO3), and Paco (pCO2) Phonetia flies through the air but... Paco falls from the air.. but rises , = after sitting. 1 I' I (Air bubbles in syringe ,i.. pH, prolonged I sitting at roomtemperature t pH) I \ / / / ~~ =------ (Air bubbles in syringe t pC02; prolonged sitting at room temperature ,i.. pC02) 0 2 is simple: Exposure to air(oxygen) causes ♦ in pO2 ; prolonged sitting causes loss of air, at in pO2. Compensatory Mechanisms Resp. Acidosis Renal ♦ HC01 Resp. Alkalosis Renal t Hco~ Metabolic Acidosis Lung t pC02 Metabolic Alkalosis Lung ,t. pC02  121 REMEMBER! Acid-Base Status To determine acid base status (respiratory or metabolic) picture yourself in Rome. You are on a playground with Phonetia (pH), Carbo (HC03), and Paco (pC02)- Phonctia and Paco h op on the seesaw and begin to play. Up and down , up and down. When the pH and pC02 are in opposite R Respiratory directions from "normal," the sta tus is r espiratory (respiratory = opposite). 0 Opposite Phoentia tires of playing with Paco and runs off to join Carbo who i s on a swing. Both go up and both M Metabolic go down, always together. When pH and HC03 are either both ,t. or both t , the status is metabolic (metabolic = equal). E Equal pH > 7.45 = alkalosis pH< 7.35 = acidosis Compensation occurs in respiratory situations when Carbo gets mad at Phonetia for playing with Paco and hops on Paco's side of the seesaw! pH (Plwentia) goes up, pC02 and HCO3 (Paco and Carbo) go down. pH comes down, pC02 and HC03 go up. Compensation occurs in metabolic situations when Paco decides to crash the swinging twosome and hops on with Phonetia and Carbo. Now all go up or all go down. Hey who needs Henderson or Hasselbalch !! ! 122 ACID-BASE PROBLEMS Hemoglobin Derivatives Determine the acid-base status in each of 1. Hemoglobin (Hb) breakdown products the following examples: ind ude porphyrins, bilirubin and 1. urobilinogen pH= 7.24 pC02 = 44 LABORATORY ANALYSIS OF PORPHYRINS AND HC03=18 RELATED COMPOUNDS Answer: Metabolic Acidosis 1. Urines with large amounts of ( uncompensated); Phonetia and Carbo porphyrins sh ow a red or "port wine" are swinging down. pH< 7.35 color 2. 2. Chromatography (HPLC, ion- pH= 7.52 exchange) to separate. All porphyrins pC02 = 44 h ave a characteristic pink fluorescence HC03= 39 (can be quantitated using a UV spectrophotometer or flurometer) Answer: Metabolic Alkalosis ( uncompensated); Phonetia and Carbo 3. Watson-Schwartz test are swinging up. pH> 7.45 a. Porphobilinogen (PBG) will react with Ehrlich's reagent, p-dimethyl- 3. aminobenzaldehyde, to form r ed pH= 7.26 color pC02 = 56 b. Add chloroform to separate PBG HC03= 24 from interfering compounds including urobilinogen (UBG) Answer: Respiratory Acidosis ❖ Color in chloroform top layer= (uncompen sated); Phonetia and Paco UBG and other interfering are on the seesaw. pH< 7.35 compounds ❖ Color in aqueous bottom layer = 4. PBG pH= 7.52 pC02 = 28 LABORATORY ANALYSIS OF BILIRUBIN HC03= 21 1. Diazotization methods Answer: Partially compensated respiratory alkalosis. Phonetia and Paco are seesawing. Carbo joins Paco to compensate. Correlate Porpbyrin 5. Reaults with Disease pH= 7.39 (tiee Bematology cbapwr) pC02 = 25 HC03= 15 a. Classic method ❖ Bilirubin + diazotized sulfanili.c Answer: Completely compensated metabolic acidosis or completely acid ~ azobilirubin (purple) ❖ Total bilirubin (conjugated+ compen sated respiratory alkalosis. For unconjugated) reacts slowly with these situations, look at the pH. If it is diazo reagent on the low side of normal, choose ❖ Conjugated biliruhin (direct) acidosis. If it is on the high side of normal, choose alkalosis. In a like reacts rapidly with diazo reauent manner, completely compensated in water Jendrassik-Grof m:thod metabolic alkalosis cannot be uses caffeine-benzoate as accelerator distinguished from fully compensated c, Direct= conjugated= water soluble respiratory acidosis. The Phonetia, d. Indirect = unconjugated = r elatively Paco and Carbo story will work > 90% of the time in solving acid-base insoluble in water problems.  123 2. Direct Spectrophotometric method 3. Posthepatic ( obstructive) jaundice a. Newborns only; they Jack a. Conjugated and unconjugated interfering compounds bilirubin cannot be metabolized Rroperly; " back-up" into plasma 3. Sp ecimen collection and handling b. t urobilinogen (due to Mockage) a. Bilirubin is light sen sitive, ther efor e prevents conjugated hilirubin from sample should h e stored in d ark entering intestine to be broken (amber-colored) glass down into urobilinogen b. Lipemia - falsely ,t. r esults c. Stool may become clay colored c. Hemolysis - falsely tor~ results depending on hemoglobin & bilirubin concentration GENERAL INFORMATION 1. When unconjugated bilirubin is ,t., there will be a ;+.. in urine urobilinogen + (due to a.mount reabsorbed from intestine and filtered by kidney) 2. When conjugated hilirubin (wa ter soluble) is ,t. , it will appear in urine CONDITIONS 1. P re-hepatic jaundice (i.e. hemolytic anemia) a. ,t. red cell destruction ➔ + unconjugated bilirubin MA1ERNAL Af'O tEW80RN TESTING DURING PREGNANCY b. Liver function is normal; conjuga tion occurs at normal rate 1. Maternal Serum prenatal testing at 16 ➔ normal conjuga ted bilirubin weeks gestation and no bilirubin in urine a. Detection of n eural tube defects c. ,t. unconjugated bilirubin ➔ ,t. (such as spina hifida) urine urobilinogen ,t. alpha fctoprotcin (AFP) h. Detection of Down' s Svndrome 2. Hepatic jaundice (i. e. viral hepatitis, ❖ Triple (HCG, AFP, ~nconjugated cirrhosis) estriol) or Quad (add Inhihin A) a. ,t. unconjugated bilirubin, ,t. screen conjugated biliruhin and ,t. t AFP urobilinogen due to liver t estriol dysfunction ,t. H CG b. ,+.: conjugated hilirubin ➔ ,t. urine Quad: (,t. Inhibin A) biliruhin c. ,t. urine urobilinogen Bilirubin and Disedse states Plasma/Serum Urine DISEASE UNCONJUGATED CONJUGATED BILIRUBIN UROBILINOGEN BILIRUBIN BILIRUBIN Prehepatic Jaundice (hemolytic anemia) + N 0 + Hepatic (cirrhosis, viral hepatitis) + + Oor+ + Posthepatic (obstructive jaundice) N + + t 124 2. Premature labor or premature rupture Toxicology of membranes (PROM) METHODS a. Premature Delivery - Fetal fibronectin (ffN) 1. Immunoassay ❖ Vagi.nal swab specimen ❖ Protein secreted at boundary of 2. Chromatographic Techniques amniotic sac and uterus a. Thin-Layer Chromatography (TLC) ❖ Negative test indicates preterm ❖ Separates drugs for identification delivery will not occur thus ❖ Urine best specimen for detecting sparing preventative measures drugs (MgSO4) with side effects ❖ Limited sensitivity b. Premature rupture of membranes ❖ Results should be confirmed with (PROM) another method ❖ Vaginal swab specimen b. Mass Spectrophotemtry (MS) as ❖ AmniSure TM detects amniotic fluid detector ❖ After separation & quantitation of PAMG-1 present in cen rico- vagi.nal secretions after rupture of drugs & metabolites by high fetal membranes performance liq. chrom. (HPLC or LC) or Gas Chrumatog. (GC) 3. Fetal newborn screening c. Gas Chromatography-Mass a. Dried blood spot specimen Spectrophotometry ( GC-MS) ❖ 11 b. Tandem mass spectrometry used to Gold-standard 11 technique for screen for >25 genetic diseases (ex. confirmation of SCI'eening methods PKU, congenital hypothyroidism, ❖ Highly sensitive and reliable cystic fibrosis, sickle cell disease. ACUTE POISONING other metabolic diseases) - 1. Substances a. Cyanide REMEMBER! h. Carbon monoxide- forms carhoxyhemoglohin ( affinity for ~ Hgb is 200 times the affinity for 0 2) c , Alcohols - Ethanol most common, Hemolytic Disease. of enzymatic - alcohol dehydrogenase d. Heavy meta]s (arsenic, mercury and the Newborn ( HDN). lead) Sin 60 ml/min IMMUNOSUPPRESSANTS 6. Urine Albumin 1. Generic names a. Use with eGFR to stage and monitor a. Cyclosporine chronic Kidney disease ( CKD) b. Tacrolirrms c. Sirolimus CREATININE d. Mycophenolic Acid (MPA) 1. From cr e atine in muscle 2. Suppress rejection after organ 2. Can also be measured to evaluate renal transplants function; NOT as sen sitive as GFR 3. Often u sed in combination 3. Classic meth od is the Jaffe reaction a. Creatinine reacts with picric acid in 4. Whole blood specimen of choice except alkaline solution to form a red- for MPA (serum or plasma) orange complex that absorbs light at 5. May need multiple samples instead of 490-540 nm trough collection- area under b. Interferents (non-creatinine time/concentration curve r eflects drug chrom agens) include glucose, exposure acetoacetate and ascorbic acid BLOOD UREA NITROGEN (BUN) Renal Function 1. ,+. in impaired renal function GENERAL INFORMATION 2. ,+. in high protein diet 1. All non-protein nitrogens (urea, creatinine, uric acid and ammonia) are ,+. 3. Rises more r apidly than serum creatinine in plasma in r enal impairment; 4. Methods: referred to a s azotemia a. Colorimetric method: urea reacts 2. Best laboratory evaluation when renal with diacetyl monoxime to form a impairment is suspected is glomerular colored complex filtration rate ( GFR) b. Enzymatic method: Urease hydr olyzes urea into ammonia which 3. Creatinine clearance evaluates GFR is mea sured spectrophotometically (more sensitive than BUN or creatinine) or ·with an I SE ❖ Inhibited by the anticoagulant, sodium fluoride  127 ❖ DO NOT use this anticoagulant ❖ Cirrhosis for any enzyme analysis- may ❖ Viral hepatitis inhibit activity b. Impaired renal function ❖ Blood urea is ♦ (,t- excretion into 5. BUN/creatinine ratio is normally about intestine, site of conversion to 10:1-20: 1 ammonia) CYSTATIN C 1. Serum marker for GFR 5. Causes of false ,t. due to specimen collection and handling 2. Small protein produced by most a. Failure to place sample on ice, nucleated cells in a consistent manner, centrifuge and analyze immediately unaffected. by inflammation, gender, (nitrogenous constituents will age, eating habits, or nutritional status metabolize to ammonia) 3. Method= immunoassay b. Poor venipuncture technique URINE ALBUMIN (probing) c. Incompletely filling collection tube 1. Units a. 24 hr collection: mg albumin/24 hrs b. Random sample: mg albumin/ gram creatinine 2. Alhuminuria categories Category Urine albumin Term Specimen Collection for mg/24hr or mg/g creat. Ammonia Analysis A1 < 30 N to mild,+.. A2 30-300 Moderate ,+.. Endocrinology A3 > 300 Severely ,t.. GENERAL 1. Hypothalmus / Pituitary / End Organ URIC ACID System- Hypothalmus produces 1. End product of purine metabolism releasing hormone which stimulates pituitary to produce stimulating 2. ♦ in gout, renal failure, leukemia, and hormone that causes end organ to chemotherapy treatment produce hormones or initiate a process 3. Colorimetric method (see table page 128) a. Uric acid reduces phosphotungstic 2. Hyper and hypo conditions: end acid to tungsten blue measured product hormone is ♦ (hyper) or t spectrophotometrically (hypo) b. Interferents include lipids and a. Primary caused by end organ several drugs problem b. Secondary caused by pituitary 4. Enzymatic assays are based on the problem uricase reaction in which allantoin and c. T ertiary caused by hypothalmic H 2O2 are produced and H 2O2 is problem coupled to give a colored product AMMONIA 3. Regulation - end organ product or process feeds back to hypothalmus and 1. Derived from action of bacteria on pituitary to stop production of contents of colon r eleasing and stimulating hormones 2. Metabolized by liver normally THYROID HORMONES 1. Stimulate metabolic processes; 3. ,t. plasma ammonia toxic to the CNS necessary for normal growth and 4. Hyperammonemia ( ♦ ammonia) development a. Advanced liver disease (most 2. In the tissues T 4 is converted to T 3 common cause) (physiologically active product): T4 ❖ R eye~syndrome concentration much higher than T3 128 a. 99.97% of T 4 hound to thyroxine- d. Hashimoto's Thyroiditis binding globulin (TBG) ~thyroxine- ❖ Thyroid aut·oantibodies binding prealbumin (TBPA) and ❖ Lab findings aUmrnin; 0.03% is free 1& t T3 and T4 b. T3 is 99.5% bound and 0.5% free 1& ,t.. TSH 3. Only free fractions metabolically active; 6. Tests for Thyroid Function bound is for storage and transport a. TSH ❖ Ultra-sensitive immunoassay 4. Primary hyperthyroidism (t TSH; ❖ Single best thyroid fu11ction test -t- T4andTy b. Total thyroxine (T,i) a. Symptoms include weight loss, heat c. Free T4 intolerance, hair loss , nervousness, d. (Direct) T 3 measures tachycardia and tremor b. The most common cause is Grave's triiodothyrinine (T3) disease e. T3 uptake ❖ Autoimmune disorder ❖ Indirect measuremfmt nf TRG ❖ Antibodies to thyroid-stimulating ❖ No longer recommended hormone (TSH) receptors ADRENAL CORTEX HORMONES ❖ Causes thyroid hyperactivity and 1. Hypothahnus produces CRH that suppression of TSH stimulates pituitary to produce ACTH ❖ Lab findings that stimulates adrenal cortex to i& Normal or ,t.. T 3 and ,t.. T4 produce steroid hormones made from i& t TSH cholesterol c. Pregnancy 2. 3 classes of steroids produced ❖ TSH first trimester a. Mineralcorticoids ❖ TBG due to estrogen ❖ Aldosterone ❖ FT4 and FT3 t second and third b. Glucocorticoids trimesters ❖ Cortisol ❖ Total T4 and T3 ,t.. c. Sex hormones 5. Primary hypothyroidism ( t T 4 and T3. ❖ Androgens: testosterone ♦ TSH) ' ❖ Estrogens: estradiol a. Symptoms include fatigue, weight 3. Regulation - cortisol feedback to gain, decreased mental and physical hypothalmus and pituitary to stop output, cold intolerance production of CRH and ACTH b. Cretinism - congenital ALDOSTERONE c. Myxedema - sever e thyroid deficiency in adults 1. Maintains blood pressure, promotes sodium r eah sorption and potassium secretion in distal tubles and collecting ducts of the nephron HYPOTHALMUS / PITUITARY/ END ORGAN SYSTEM HYPOTHALMUS PITUITARY END ORGAN PRODUCT/ ACTION TRH TSH Thyroid T4 andT3 (thyrotropin releasing hormone) (thyroid stimulating hormone) CRH ACTH Adrenal Cortex cortisol, aldosterone, (corticotropin releasing (adrenocorticotropic releasing estrogens, testosterone hormone) hormone) GnRH LH Ovaries ovulation (gonadotropin releasing (leutinizing hormone) m OR hormone) AND Testes sperma togenesi s FSH (follicle stimulating hormone)  129 REMEMBER! The Thyroid Sisters Morbid Matilda Everything __ Myxedema is racing (,I. T3 & T4) Everything is EXCEPT low (t T3 and my TSH (t) T4 ) except my TSH (+) 2. Regulation of secretion through renin- and hypertension angiotensin system b. Truncal obesity, facial hair, a. Renin converts angiotensinogen to 11 buffalo hump 11 , osteoporosis, scant angiotensin I which is rapidly menses converted to angiotensin II which stimulates cortex to produce 3. t cortisol - Addison1s disease (see aldosterone Aldosterone) 3. Hyperaldosteronism (,t. aldosterone) - ANDROGENS Conn's Disease 1. Male sex hormones, secondary sexual a. ,t. Na+ characteristics b. t K+ c. Hypertension 2. Secreted by testes, adrenals and ovaries 4. Hypoaldosteronism (t aldosterone) - Addison's disease 3. ,t. testosterone - precocious puberty in a. tNa+ and c1- boys , testicular tumors; masculinization in females b. tcortisol c. t hemoglobin 4. t in hypogonadism d. t urinary steroids 5. 17-ketosteroids (17-KS) e. ,t. ACTH when primary a. Metabolites of androgens hypoaldosteronism (adrenal cortex b. Zimmermann reaction problem) ❖ 17-KS react with metadinitro- f. t ACTH if secondary (pituitary) or benzene in alcoholic alkali tertiary (hypothalamus) problems ❖ Produces red-purple color ESTROGENS CORTISOL 1. Functions 1. Female sex hormones a. Causes ,t. glucose through 2. Secreted by ovaries gluconeogenesis and decreased a. Estradiol - secondary sexual carbohydrate use characteristics b. Inhibits protein synthesis b. Estrone - metabolite of estradiol c. Immunosuppressive and anti- c. Estriol inflammatory ❖ ,t. during fetal development in 2. ,t. cortisol ( without diurnal variation) - pregnancy ❖ Steady increase should occur in Cushing1s syndrome t a. Diabetes mellitus, plasma protein the third trimester 130 ❖ 24-hour urinary maternal estriol 3. Aldosterone monitors integrity of feto- a. ,t.. in upright position. placental unit ❖ Decline or sudden change 4. Renin indicates a complication of the a. Produced in kidneys; may draw from either renal vein pregnancy b. Tests 3. ,t. estrogen - precocious puberty in ❖ Renin activity (angioten sin I girls, feminization in males, pregnancy, generation) oral contraceptives, polycystic ovary ❖ Direct renin (immunoassay for disease renin molecule) c. Very unstable (sample must b e TESTS FOR ADRENAL CORTEX FUNCTION frozen immediately) 1. Cortisol d. ,t.. in upright position a. Diurnal variation (highest in e. t in Conn's morning) b. Can measure free (unbound) or 5. ACTH total in serum, plasma or urine a. Distinguishes between primary and secondary hyperaldosteronism 2. Dexamethasone suppression a. Give dexamethasone to suppresses 6. Testosterone cortisol production a. H ypothalmus / Pituitary / T estes b. Measure cortisol and/or Adrenal Cortex c. Interpretation b. Used for infertility testing ❖ Cortisol t (s uppressed) = normal ❖ Males: t causes infertility ❖ Cortisol ,t.. (not suppressed) = ❖ Females: ,t.. causes infertility, Cushing's birsutism , masculinization ❖ Cortisol partially suppressed = 7. Estrogens depression , obesity, pregnancy, a. Measure estradiol and/or estriol in stress, infection serum and urine REMEMBER! The Steroid Brother Cushy Carl C_g_shy's (Cushing's Disease) problem is everything is Anemic Addison yp: (Addison's Disease) ,t. cortisol, ,t. glucose Addison's problem is (Twinkies™ ), everthing is down: tcortisol ,t. Na+ (chips) t cortisol, turinary ,t. urinary t Na+ and c1- (need