CLINICAL

 CHEMISTRY     1  
 
3. Hydrolase  –  catalyze  the  hydrolysis  of  compound  with  introduction  of  water  
ENZYMES   into  the  structure  
  4. Lyases  –  removal  of  one  group  from  the  substrate  without  hydrolysis,  leaving  
Enzymes   double  bonds  in  the  molecular  structure  of  the  products  
  -­‐considered  as  biochemical  catalysts  (speed  up  chemical  reaction)   5. Isomerase  –  catalyzes  intramolecular  rearrangement  of  the  substrate  
  -­‐protein  in  nature     compound  
  Isoenzyme     6. Ligases  –  catalyze  the  joining  together  of  two  substrate  molecules  with  a  
  Apoenzyme.   simultaneous  breakdown  of  pyrophosphate  bond  in  ATP.  
  Holoenzyme-­‐    
   
Components:   Measurement:  
a. active  site   1. Measurement  of  Enzyme  Activity  
________________________________________________________________________________.   -­‐ based  on  Michaelis  –Menten  Kinetics    
b. allosteric  site    
____________________________________________________________________________.     Saturation  Point    =  up  to  the  substrate  concentration  when  enzyme  is  fully  saturated  
Characteristics:   with  substrate  
1. Highly  specific   -­‐ also    called    V  max  :  the  rate  of  reaction  when  all  the  things  are  
2. Measured  by  its  activity  rather  than  its  concentration.    Normally  secreted  in   equal  varies  only  with  the  enzyme  concentration.  
minute  concentration.    
3. Require  substrate   3  indications  of  reaction:  
4. Require  activators  or  metallic  ions  that  are  loose  bound  to  the  enzymes  and   a. use  of  excess  substrate    to  determine  enzyme  
help  activate  the  enzyme.   concentration.  
5. Affected  by  pH  and  temperature   b. Measurement  of  reaction  products    like  NAD  or  NADH  
6. Secreted  by  cells  and  tissues   NADH  is  measured  by  its  Use    of    a  coupled  enzyme  
  assay    if  the  reaction  do  not  utilize  NAD  /NADH.  
Factors  that  affect  enzyme  reaction:    
1. Substrate  –  molecules  or  substances  that  attached  with  enzymes  (highly   Example  of  COUPLED  ENZYME  ASSAY      :    (measurement  of  disappearance  of  excess  
specific)   NADH)    
2. Temperature    
3. pH   Aspartate  +  a-­‐ketoglutarate    AST  (addition  –  no  utilization  of  NADH)  -­‐>  
4. Activators/Cofactors   oxaloacetate(OAA)  +  glutamate  +NADH    (MD  +  excess      a-­‐ketoglutarate    +  NADH)    -­‐-­‐-­‐à  
5. Coenzyme     malate  +  NAD  
6. Inhibitors      
  Other  examples  of  enzymes  not  utilizing  NAD/NADH:  
Enzyme  nomenclature:   a. ALP  –  use  excess  p-­‐nitrophenyl    phosphate  at  pH  10.  (absorbance  of  p-­‐
1. Name  of  the  substance  or  group  on  which  the  enzyme  acts  plus  suffix  “ase”   nitrophenol  at  405nm).    
2. Type  of  reaction  involved   b. ACP  –  use  excess  p-­‐nitorphenyl  phosphate  at  pH  5.0  
3. Combination  of  the  1st  and  2nd.    
4. International  Unit  of  Biochemistry  (IUB)   2. Measurement  of  Enzyme  Antigen    Concentration    
  -­‐  quantity  of  enzyme  is  proportional  to  enzyme  activity  
  a. Usually  by  immunoassay    
Classes  of  Enzyme:   If    quantity  of  enzyme    do  not  agree  with  enzyme  activity,  it  maybe  
1. Oxidoreductase  –  catalyze  oxidation-­‐reduction  reaction   due  to:  
2. Transferase  –  catalyze  the  transfer  of  a  chemical  or  functional  group  from  one   1. presence  of  serum  enzyme  inhibitors  
substance  to  another   2. deficiency  of  a  necessary  cofactor  
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3. macroenzymes   Reaction  Catalyzed:  transfer  of  an  amino  group  in  aspartic  acid  for  an  alpha-­‐keto  group  
4. defective  enzyme   in  alpha-­‐ketoglutaric  acid  forming  oxaloacetateand  glutamate.  
5. proteolytically  inactivated  enzymes    
    Tissue  Sources:    
a. organic     -­‐ present  in  cardiac  muscle  ,  liver  ,  skeletal  muscle  ,  kidney,  brain  ,  
b. inorganic  or  coenzymes     lung  and  pancreas  (in  decreasing  water)  
Other  enzymes  subtypes:   Laboratory  Methods:  
1. Macroenzyme       1.Karmen  method  –  incorporates  a  coupled  enzymatic  reaction  using  MD  as  
2. Defective  Enzyme:   indicator  enzyme  and  monitors  the  change  in  absorbance  at  340  nm.  
Type  of  Enzyme  Inhibition   a. NADH  –strongly  absorbs  at  340  nm  
1. Uninhibited    enzyme:  plotting  of  1/V  vs.  1  /[S]  resulting  into  a  straight  line   b. MD  is  used  to  reduce  oxaloacetate  to  
which  is  called  a  Lineweaver-­‐Burke  Plot.  Wherein  y-­‐intercept  equals  1/V  max   malate  
and  x-­‐intercept  is  equal  to  -­‐1/Km.   2.Reaction  with  DNPH:  Reitman  –Frankel  
    -­‐ketoacids  formed  after  the  catalyzed  reaction  are  reacted  with  2,4  
2.  Noncompetitive  inhibition  :  due  to  an  inhibitor  that  binds  with  the  away   DNPH  to  form  ketoacid  hydrazones  which  produce  intense  brown  color  in  the  
from  the  substrate  binding  site.   presence  of  NaOH  measured  at  505nm.  
   
3. Competitve  inhibition  :  inhibitor  and  enzyme  substrate  compete  for  the   3.Coupling  with  Diazonnium  Salts  
same  binding  site.   ketoacid  +  diazo  compound  -­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐diazonium  
  derivative  
4. Uncompetitive  inhibition  :  substance  that  binds  the  enzyme-­‐substrate(ES)    
complex  and  stabilizes  it.    
  II.  ALT/  SGPT  
FIRST  Order  Kinetics   Reaction  Catalyzed:    transfer  of  an  amino  group  of  alanine  for  an  alpha  keto  group  in  
__________________________________________________________________________________________.   alpha  ketoglutaric  acid  forming  pyruvate  and  glutamate.  
ZERO  order  kinetics   Tissue  Source:  Liver  
__________________________________________________________________________________________   Laboratory  Methods:  
  a.  Coupled  Enzyme  Reaction  
Fixed  Time  vs  Continuous  :       Substrate:  ____________________.  
__________________________________________________________________________________________.   Indicator  Reaction:  LD  as  indicator  enzyme  catalyzes  reduction  of  
  pyruvate    to  lactate  with  simultaneous  oxidation  monitored  at  340  
  nm.    
  b.Reaction  with  DNPH  –  keto-­‐acid  formation  
    c.Coupling  with  Diazonium  Salts  
Unit  of  Enzyme  Measurement:        
1. International  Unit  (IU)  :  amount  of  enzyme  that  catalyzes  the  conversion  of  1   Clinical  Significance:  
micromole  of  substrate  per  minute   Increased:    hepatic  parenchymal  disease,  viral  hepatitis,  obstructive  
2. Katal    (1  katal)  :  mount  of  enzyme  that  catalyzes  the  conversion  of  1  mole  of   jaundice,  Reye’s  Syndrome,  Heart  failure  or  AMI,  Infectious  
substrate  per  second.   Mononucleosis,  Muscular  Dystrophy  
3. 1  IU  =  16.7  nanokatals      
  Decreased:  Not  significant  
  NOTE:  
  Intra-­‐individual  variation  is  more  significant  in  ALT  than  AST  with  marked  diurnal  
 I.AST/SGOT     variation  (highest  in  the  afternoon)  and  day  to  day  variation  of  30%.  
 
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III.  Lactate  Dehydrogenase       Skeletal  Muscle  Disease:  muscular  dystrophy  
Reaction  Catalyzed:  oxidation  of  L-­‐lactate  to  pyruvate  with  the  mediation  of  NAD  or       Brain  and  CNS  disease:  CVA  
hydrogen  receptor  (reversible  reaction)    
  VI.  Alkaline  Phosphatase:  
Tissue  source:  liver,  heart,  skeletal  muscle  ,  kidney,  erythrocytes   Reaction  Catalyzed:  hydrolysis  of  organic  phosphate  esters  with  formation  of  alcohol  
Laboratory  Methods:   and  phosphate  ion  at  alkaline  pH  
a. Wacker  Method  :      
b. Wroblewski  LaDue  Method.   Tissue  Sources:  bone,  liver,  intestine  kidney,  placenta,  carcinoplacental  ALP  (Regan  –
Other  Methods:   Lung  CA,  Nagao  –  adenocarcinoma  ,  Kasahara-­‐  gastrointestinal  cancer)  
  a.  Heat  Denaturation    
Isoenzymes:   Laboratory  Methods:    
  LD1  –  HHHH:  cardiac  muscle,  RBC,  kidney   1.bessey-­‐Lowry-­‐Brock:  p-­‐nitrophenylphosphate  
  LD2-­‐  HHHM:  cardiac  muscle,  kidney,  RBC   2.  Bowers-­‐McComb:  p-­‐nitrophenylphosphate  
  LD3  –HHMM:  spleen,  kidneys,  lungs  ,  RBC   3.  King-­‐Armstrong  :  phenylphosphate  
  LD4  –HMMM:  spleen,  lungs,  kidney   4.  Sinowara-­‐Jones-­‐Reinhart:  B-­‐glycerophosphate  
  LD5  –  MMMM:  liver,  skeletal  muscle    
   
Clinical  Significance:   Isoenzyme  Differentiation:  
  Increased:   a.Phenylalanine  inhibits  intestinal  (75%)  and  placental  (80%)  
      Cardiac  Muscle:  AMI,  CHF,  Myocarditis     b.  Electrophoresis:  Liver  ALP  migrates  fastest  followed  by  bone,  placental  and  
      Skeletal  Muscle  Diseases:  muscular  dystrophy  ,  muscle   intestinal  fractions  
trauma     c.Urea(2M)  inactivates  bone  (90%)  more  than  liver  (60%)    fraction  
      Hepatic  Parenchymal  Diseases:  Viral  Hepatitis,  Cirrhosis,   d.  Heating  to  56C  for  15  mins  =  bone  and  liver  ALP  fraction  loses  activity,  
Obstructive  Jaundice  ,     placental  ALP  most  is  the  most  stable  can  resist  Heat  Denaturation  at  60C  for  
        Infectious  Mononucleosis   10  mins.  
      Others:  megaloblastic  and  pernicious  anemia    
  Decreased:  not  clinically  significant    
  Clinical  Significance:  
NOTE:  Elevated  LD1  and  LD5  :  due  to  AMI  complicated  by  liver  congestion  and  chronic    
alcoholism  complicated  by  liver  damage  and  megaloblastoc  anemia   Increased:  obstructive  jaundice,  cholestasis,  viral  hepatitis,  alcoholic  cirrhosis,  hepatic  
  malignancy  ,  hyperparathyroidism  ,  bone  tumors  ,  rickets  ,  osteomalacia,  osteitic  
V.  Creatine  Kinase  (2.7.3.2  Transferase)   deformans  (Paget’s  Disease),  pregnancy  (3rd  trimester)  
Reaction  Catalyzed:    reversible  phosphorylation  of  Creatine  by  ATP  in  the  presence  of    
magnesium  ions.   Decreased:  not  significant  
Tissue  source:  skeletal  muscle,  myocardium  (cardiac  muscle)  ,  brain    
  VII.  Acid  Phosphatase  
Laboratory  Methods:   Reaction  Catalyzed:  hydrolysis  of  organic  phosphate  esters  with  formation  of  alcohol  
1.Tanzer  Gilvarg  Assay   and  phosphate  ion  at  an  acid  pH.  
    Types:  
2.Oliver-­‐Rosalki  Assay   a.Red  Cell  Acid  Phosphatase  
      -­‐  distuinguished  form  other  acid  phospahatss  
Isoenzymes:  CK-­‐BB  –brain,  CK-­‐MM  muscle,  CK-­‐MB-­‐  Heart       b.  prostatic  Acid  Phosphatase  
Clinical  Significance:    
  Increased:     Tissue  Source:  prostate  gland  ,  non-­‐prostatic  source:  RBC,  platelets,  liver,  spleen  ,  
Cardiac  Muscle:  AMI     kidney  ,  bone  marrow  
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Laboratory  Methods:   Laboratory  Methods:  
1. Bodansky  –  B-­‐glycerophosphate   1.Turbidimetric  Enzyme  Reaction  
2. Gutman,  King  Armstrong  –phenylphosphate   Substrate:  olive  oil  or  triolein  
3. Babson  and  Reed  –  a-­‐  naphthylphosphate   Indicator  Reaction:  decreased  turbidity  as  LPS  hydrolyzes  the  turbid  substrate  
4. Roy-­‐thymolphthalein  monophosphate     fat  emulsion  
  2.Titiration  :  Cherry-­‐Crandal  Method  (classic  Method)  
      uses  olive  oil  substrate  and  measure  liberated  fatty  acid  by  titration  
  after  24  incubation.  
   
  Clinical  Significance:  
Chemical  Inhibition  by  tartrate:  PAP  fraction  is  inhibited  by  tartrate   Increased:  acute  pancreatitis,  pancreatic  cyst  or  pseudocyst,  obstructive  jaundice,  
Total  ACP  –ACP  activity  after  tartrate  inhibition  =  prostatic  ACP   peritonitis,  intetsinal  obstruction  
  RBC  ACP   Prostatic  ACP   Decreased:  pancreatic  insufficiency.  
 
Copper       Other  Enzymes:  
Tartrate  ion       1. Cholinesterase  
2. Glucose-­‐6-­‐phosphate  Dehydrogenase    
  3. Aldolase  
  4. Ornithine  Carbamoyl  Transferase    
Clinical  Significance:   5. Leucine  Aminopeptidase    
Increased:  metastatic  carcinoma  of  the  prostate,  bone  disease  :  osteoporosis,    
multiple  myeloma,  Paget’s  disease,  Gaucher’s  Disease    
  Decreased:  not  clinically  significant    
   
VII.  Amylase    
Reaction  Catalyzed:  hydrolysis  of  polysaccharides  such  as  amylase,  amylopectin,    
glycogen  .    
Tissue  Sources:  pancreas,  salivary  gland    
   
Laboratory  Methods:  Calcium  and  Chloride  are  both  activators    
1. Amyloclastic  –  time  required  for  the  disappearance  of  colored  starch  iodine    
complex  upon  hydrolysis  of  amylase  (+)  blue  color  disappears    
2. Saccharogenic  –  measure  the  amount  of  reducing  sugars  formed  after    
hydrolysis  .    
3. Chromogenic  –uses  chromogen    
4. Coupled  enzyme  reaction  test      
   
Clinical  Significance:    
Increased:    acute  non-­‐hemorrhagic  pancreatitis,  bacterial  parotitis    
Decreased:  pancreatic  insufficiency    
   
VIII.  Lipase    
Reaction  Catalyzed:  hydrolysis  of  fats  into  fatty  acids  and  monoglycerides    
Tissue  Sources:  pancreas,  stomach  ,  small  intestine    
   
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MAJOR DETERMINANT OF PLASMA OSMOLALITY?______
FLUIDS and ELECTROLYTES
Osmolaility of body fluids includes: _________________
Body Water
-osmolalilty is determined by particle number not the nature or weight of the
-bulk of the body mass is water
solute.
-can vary from 40%- 70% of the total body weight depending on the amount of fat
-measure specific gravity in urine to measure osmolality.
contained in the tissues.
Urine :Range in normal individuals:
Importance:
Plasma :
– it constitutes the medium by which solutes are dissolved
Ratio of urine to plasma:
– By which metabolic reactions take place
FORMULA:__________________________
Normal Reference values
NOTE: Increase pure water loss = increase ECF osmolality
` Venous -INCREASED in ECF osmolality triggers the ff physiological responses:
Sodium 135-148 mEq/L – Antidiuretic hormone/vasopressin release via hypothalamic
Potassium 3.5-5.3 mEq/L osmoreceptors
Chloride 98-106 mEq/L – Stimulation of the hypothalamic thirst center
Bicarbonate 19-25 mEq/L – Redistribution of water from the ICF compartment
Anion Gap 12-18 mEq/L
Serum Osmolality 285-310 mOsm/kg H2O
b.ECF volume
Obtained from: -directly dependent on the sodium content.
1.diet • Maintained by the ff:
-drink-1L – Regulation of renal excretion of sodium or glomerular filtration rate
-food -1-1.2 L – Aldosterone via the RAA system
-fat metabolism -100ml/100g DISORDERS OF WATER BALANCE
-protein metabolism -44ml/100g a. Dehydration
-carbohydrate metabolism-60ml/100g b. Overhydration
2. oxidation of food
ELECTROLYTES
Water Excretion:
1.skin
2.lungs Cations – ions w/ positive charge
3.GI tract Anions – ions w/negative charge
4. Kidneys -readily absorbed in the GIT into the circulation
-initially filtered at the glomerulus since they are very small and readily pass through
Distributed in 2 compartments: membrane pores.
1.) Intracellular
2.) Extracellular 2 processes:
a. Intravascular a.reabsorption
b. Interstitial b.excretion
2 properties of ECF
a. ECF osmolality FUNCTIONS:
• -Regulated by the levels of sodium and associated anions, ________________________________________________________
glucose, urea and proteins ____________________.
OSMOLALITY -___________________

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Hormonal Regulation
Two Major hormone involved: Laboratory Determination.
1.Antidiuretic hormone (ADH) 1.Flame Emission Photometry
2.Ion-selective Electrode.
2.Renin-angiotensin aldosterone system 3. Colorimetric method:
– Sodium + zinc uranyl acetate = sodium uranyl acetate precipitate
ANION GAP – sodium uranyl acetate precipitate + water = yellow solution
• -Difference between the sums of the concentrations of the principal cations
and of the principal anions
• Represents the unmeasured net negative charge on plasma proteins POTASSIUM
Anion gap_________________________________ • Major intracellular cation
INCREASED in: Concentration:
• Uremia – CELL - Inside (20x greater) > Outside
• Ketoacidosis – 90% free or exchangeable; 10% bound to RBC, bone and brain
• Methanol & aspirin poisoning tissues
• Severe dehydration • Kidney - primary that controls extracellular K+
• Lactic acidosis • Proximal tubule
DECREASED in: • Distal tubule
• Multiple myeloma • Secreted in the gastric juice and reabsorbed by the small intestines
• Protein error • Influenced by pH
• Instrument error • ACIDOSIS
SODIUM • ALKALOSIS
• Most abundant cation in the ECF /chief base of the blood. • Normal value:
• Main function are water pull Function:
– Osmotic activity of ECF a. nueromuscular excitability, contraction of the heart. Intracellular fluid
– Blood volume regulation volume and hydrogen ion concentration.
– Neuromuscular excitability Clinical Implication:
Levels are regulated by: 1. Hyperkalemia/Hyperpotassemia –inc. K levels
– Diet -inadequate excretion (renal failure)
++
– Kidney: renal threshold for Na is 110 - 130 mmol/L -cell damages (burns, accidents, surgery, chemotherapy)
– RAA system -acidosis
– Atrial natriuretic factor 2.Hypokalemia/ Hypopotassemia-dec. K levels
Normal value: ________________L -GI loss associated w/ diarrhea , severe vomiting , starvation ,
malabsorption
Clinical Implication; -Increased secretion of adrenal steroids primarily aldosterone
1.)Hypernatremia -severe burns
a.severe dehydration -insulin treatment
b.Cushing’s Syndrome (hyperadrenalism) – Laboratory Examinations:
c.Diabetic coma after insulin treatment 1.Colorimetric Method- K is determined in a specifically prepared mixture of sodium
d.Diabetes insipidus(def. of ADH) tetraphenylboron producing a colloidal suspension whose turbidity is proportional to
2)Hyponatremia –dec. sodium levels the potassium concentration in the sample.
a.severe burns, severe diarrhea • Lockhead and Purcell
b.Addison’s disease 2. FES
c.Diabetic acidosis 3. ISE
d.Renal Tubular Disease a.glass that is permeable selectively to sodium

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 CLINICAL  CHEMISTRY     7  
 
b. membrane impregnated w/ valinomycin ( has a charged activity just the Laboratory Determinations:
right size to admit K and exclude others. 1.)ISE method.
4.AAS 2.) Coulometric-amperometric method
3.) Colorimetric Method
ISE for Na and K • Zall color reaction
• Based on the activity of the ion Colorimetric method
– Its dissociated or completely ionized fraction per unit volume of Result:
water Schales and Schales
+
• Na : glass electrode – Mercuric nitrate titration method
+: - + +
• K liquid ion-exchange membrane electrode, incorporating the antibiotic – Cl + Hg (mercuric nitrate) = Mercuric chloride + Hg (mercuric
valinomycin nitrate) = colorless or faint pink to violet

2 methods: CALCIUM
1. DIRECT METHOD • Most abundant cation in the body
2. INDIRECT METHOD • 99% bound to the skeleton
++
• Bone: Ca + phosphates = hydroxyapatite crystals; to provide strength to
REMEMBER:_____________________________ the bone
-impt. activator of the coagulation system.
CHLORIDE --skeletal and cardiac muscle contractility
• Major extracellular anion ,exist as NaCl or HCl -neuromuscular conduction and activation.
• Functions:
– Maintenance of electrolyte balance Reference range (serum): 9-11 mg/dl or 4.5 -5.5 mEq/L
– Hydration 3 forms:
– Maintenance of osmotic pressure 1.) bound
– Only known anion to serve as an enzyme activator (stimulating the 2.) Ionized
starch hydrolysis reaction catalyzed by the enzyme amylase 3.) Complexed
– Has the reciprocal power of increasing or decreasing in
concentration whenever changes occur in the concantration of Factors Affecting Calcium Levels
other anions. 1.Parathyroid Hormone – mobilizes calcium from the bones in the circulation, acts on
– Ex. metabolic acidosis –inc. Cl :HCO3 dec. the kidney inhibiting the tubular reabsorption of phosphate while enhancing the
• Normal value reabsorption of calcium and magnesium and stimulating the formation of a vitamin D
Clinical Implication: derivative
1.)Hyperchloridemia
a.dehydration 2.Vit D3 /Calcitriol
b.Cushing’s syndrome 3.Calcitonin – peptide hormone produced by specific cells in the thyroid gland
c.Hyperventilation(respiratory alkalosis)
d.anemia Clinical Implications:
e.Cardiac decompensation 1.Hypercalcemia
2.)Hypochloridemia
a.severe vomiting, severe diarrhea , severe burns 2.Hypocalcemia
b.heat exhaustion
c.Diabetic Acidosis LABORATORY DETERMINATION:
d.acute infection(pneumonia) 1. Formation of colored complexes between Ca++ and a variety of dyes
e.Diuretics
* Followed by colorimetric method

 K.B.R   7  
 
 8    CLINICAL  CHEMISTRY    
 
-phosphorus in the form of inorganic phosphates is allowed to react with -one of the buffering system
molybdic acid producing a phosphomolybdate complex in the presence of a reducing -reported as mg/dl
agent.
a.Fiske –Subbarow Function?
b.Gomori MOdificatio
2.ISE QUESTION? Why is there a need to avoid opening tubes used for ionized calcium?
3.AAS .
4.FES IRON
5.Precipitation of Ca++ as an insoluble compound using • 70% in the RBC and 25% in the RES, incorporated with ferritin and
hemosiderin as stored iron
• After precipitation it is followed by titration or colorimetric • cofactors for enzymes
method • 2 forms in the body:
• c. Ferrous iron -
6. Removal of calcium from colored complex by titration with a chelating agent d. Ferric iron Ferritin = iron storing protein(soluble)
– EDTA Transferrin
– EGTA Haptoglobin
• Endpoint is reached by recovery of the original color of the dye or the Hemopexin
disappearance of the fluorescence of the calcium-dye complex Hemosidirin)
CLINICAL IMPLICATION
MAGNESIUM 1.)Iron Overload
• 4th most abundant cation in the body
• Essential activator of several enzymes
• Therapeutic agent and anti-convulsant, laxative and antacid effects 2,) Iron deficiency
• Involved in protein synthesis and DNA metabolism
REFERENCE RANGE:______________________ Laboratory assays:
• Serum Iron
CLINICAL IMPLICATION: • Total Iron Binding Capacity
1.)Hypermagnesia • Transferrin Saturation

2.)Hypomagnesia %Saturation=Serum Fe/TIBC x 100

• TIBC = 260 - 440 ug/dL
Laboratory Determination: • % saturation = 20 - 50%
1. AAS or ISE
2.Fluorometric analysis: Nephelometric Assay for Transferrin
3.Colorimetric methods: a.IRMA and enzyme liked systems

Examples of dyes  
a.Calgamite -  
b.Methylthymol blue  
c.Titan yellow  
d..Formazan Dye  
 
PHOSPHORUS  
-has an inverse relationship with Calcium  
-measured in body fluids as a mixture of the phosphates HPO4 and H2PO4.  

8    K.B.R  
 
 CLINICAL  CHEMISTRY     9  
 
    -­‐Proteins   are   amphoteric   ,   carrying   both   acidic   and   basic   charge   and   in   this   way  

  are  able  to  find  or  release  excess  hydrogen  as  required.  
• Imidazole  groups  of  Histidine  are  present  in  plasma  proteins  which  
Acid  –Base    Disorders     are  negative  in  charge  and  capable  of  binding  with  H+.  
 
Definition  of  Terms:  
   
a.Acid  –  substance  that  can  yield  a  hydrogen  ion  (H+)  or  Hydronium  Ion  when    
dissolved  in  water.   3.  Phosphate  Buffer  System  
b.  Base  –  substance  that  can  yield    a  hydroxyl  ions  (OH-­‐).     -­‐Excess  H+  combines  in  renal  tubules  with  Na2PO4    
    -­‐Sodium  is  reabsorbed  and  H+  is  passed  into  urine.  
c.    K  value    or  ionization  constant  –  describes  the  relative  strength  of  an  acid   -­‐ plays  a  role  in  plasma  and  RBC  which  is  involved  in  the  
and  a  base.  It  also  describes  their  ability  to  dissociate(separate)  in  water.   exchange  of  sodium  ion  in  the  urine  H+  filtrate.  
  -­‐  
d.  pKa  –  defined  as  the  negative  log  of  the  ionization  constant  (level  of   4.  Hemoglobin  –Oxyhemoglobin  Buffer  System  
concentration  for  protonated  and  unprotonated  are  equal).     -­‐   Venous   content   has   higher   CO2   content   and   bicarbonate     ion   concentration   than  
Ex.  strong  acid  –  less  than  pKa  3.0  (  if  the  pH  becomes  more  than  the   areterial  blood.  The    pH  is  the  same  since  oxyhemoglobin  (acid)  in  RBC  has  taken  over  some  
pKa  it  will  cause  the  acid  to  dissociate  and  yield  H+)   anion  function  which  was  provided  by  excess  bicarbonate  venous  plasma.  
Ex.  strong  base  –  greater  than  pKa    9.0  (if  the  pH  becomes  less  than    
the  pKa  it  will  cause  release  of  OH-­‐).    
  ACID  BASE  BALANCE  
e.  Buffer  -­‐    combination  of  a  weak  acid  and  weak  base  and  its  salt.  It  prevents     Maintenance  of  H+  
changes  in  the  pH.       -­‐Reference  Range  :  34  –  44  nmol/L    (  pH  7.34  –  7.44)  
  -­‐    Principal  Buffer  system  :  Bicarbonate-­‐Carbonic  Acid  System  (pKa  of  6.1)       -­‐  major  role  in  maintaining  pH  thru  the  lungs  and  kidneys.  
    H2CO3  ß-­‐-­‐-­‐-­‐à  HCO3-­‐  +  H+       Formula  to  Compute  pH  when  H+  is  given:    
  Reference  value  :  pH  of  7.40    or  H+  of  40  nmol/L(arterial  blood)       pH  =  log  1  /  H+  =  -­‐log  H+    (pH  is  the  negative  log  of  H+)  
   
Major  Buffer  Systems:   TAKE  NOTE!    
    Since  pH  if  the  negative  log  of  H+:  
1.Bicarbonate  –Carbonic  Acid  Buffer  System   -­‐ Increase  in  H+  concentration  ____________the  pH  (<  pH  7.34  –
It  is  the  principal  buffer  system  of  the  body.  When  a  strong  acid  such  as  HCl  enters   acidosis)  
the   body,   H+   combines   with   HCO3   ions   of   NaHCO3     yielding   carbonic   acid   and   -­‐ Decrease  in  H+  concentration  ___________  the  pH  (>  pH  7.44  –  
neutral  salt.   alkalosis)  
     
HCL  +  NAHCO3                          H2CO3  +  NACl    
    The  Bicarbonate  –Carbonic  Acid  system  (HCO3-­‐  and  H2CO3)  
  Weak  acid  like  H2CO3  does  not  release  H+  as  readily    as  strong  acid  like  HCl  ,  thus   -­‐ main  role  is  to  regulate  H+  
ionizes   effectively   .   When   a   strong   base   such   as   NaOH   is   added   to   the   system,   it   is   -­‐ H2CO3  –  is  a  weak  acid  ,  do  not  dissociate  easily  into  H+  and  
neutralized  by  carbonic  acid  yielding  water  and  HCO3  from  a  salt.   HCO3-­‐  
 
   
Functions:  
  In   cases   of   imbalance,   before   Renal   and   Pulmonary     compensatory   mechanisms  
1. H2CO3  dissociates  into  CO2  an  H2O  so  CO2  can  be  eliminated  by  
the    lungs  alter  the  ratio  of  HCO3    to  denominator  H2CO3      by  blowing  off  CO2.  
the  Lungs  and  H+  as  water.  
  2. Respiration  or  Ventilation  Rate  is  affected    by  changes  in  CO2  
2.  Protein  Buffer  System   3. HCO3  can  be  altered  in  the  kidneys  

 K.B.R   9  
 
 10    CLINICAL  CHEMISTRY    
 
4. Buffering  system  immediately  counters    the  effects  of  fixed  non-­‐
volatile  acids  (H+  A-­‐)  by  binding  the  dissociated  hydrogen  ion  
(H+A-­‐  +  HCO3-­‐  =  H2CO3  +  A-­‐)  
5. The  resultant  H2CO3  dissociates  and  H+    neutralized  by  the  
buffering  capacity  of  hemoglobin.  
 
2  components:  
a. HCO3  :    HCO3  +  H-­‐  -­‐>  H2CO3    
b. H2CO3:  H2CO3  +  OH  -­‐>  H2O  +  HCO3  
 

 
1. CO2  (by  product  of  aerobic  metabolism)  diffuses  in  tissue  
2. CO2  combines  with  H20  forming  H2CO3  then  dissociates  to  HCO3  +  H  by  
carbonic  anhydrase  found  in  RBC.  
3. HCO3  diffuses  in  plasma  
4. H+  is  increased  and  Cl-­‐  is    diffuses  in  the  cell  (Chloride  shift  ,  this  is  to  maintain  
electroneutrality  or  maintaining  same  number  of  +  and  –  charged  ions)  
5. Plasma  Proteins  and  plasma  buffers  also  binds  with  free  H+  to  maintain  stable  
pH.  
 
  LUNGS  (net  effect  is  minimal  change  in  H+  concentration  in  venous  and  
Regulation  of    Acid-­‐Base  Balance  by  Lungs  and  Kidneys   arterial  blood).  
-­‐ depicted  by  the  Henderson  –Hasselbach  Equation   1. Inspired  O2  binds  with  Hgb  forming  O2Hgb.  
o pH  =  pKa  +  log  A/  HA  or  HCO3/  pCO2  (H2CO3)   2. H+  from  reduced  Hgb  in  venous  blood  combines  with  HCO3-­‐  forming  
-­‐ LUNGS:  regulate  pH  by  retention  or  elimination  of  CO2  by   H2CO3  which  dissociates  again  to  H2O  and  CO2  .  CO2  diffuses  in  alveoli  
changing  the  rate  and  volume  of  ventilation   and  eliminated  by  ventilation/expiration.  
o Represented  by  pCO2  (H2CO3)   2  conditions:  
§ Denotes  Lung  Function      
-­‐ KIDNEYS:  regulate  pH  by  excreting  acid  ,  primarily  in  Ammonium   a. Increase  H+  /  decreased  pH  
ion  and  reclaiming  HCO3  from  the  glomerular  filtrate.   § lungs  do  not  remove  CO2  or  decreased  
o Represented  by  HCO3   ventilation  
§ Denotes  Kidney  Function   § Hypoventilation  
b. Decrease  H+/  increased  pH  
§ CO2  removal  is  increased  or  
hyperventilation.  
§ Hyperventilation  
 
10    K.B.R  
 
 CLINICAL  CHEMISTRY     11  
 
NOTE:  if  the  change  in  H+  is  non-­‐respiratory  origin,  lungs  compensate  by  altering   -­‐ The  remaining  H+  combines  with  HPO4(2-­‐)  or  monohydrogen  
ventilation  and  regulating  the  pH.  (first  line  of  defense  in  acid-­‐base  status   phosphate  and  (NH3)  ammonia.  
  -­‐ HPO4  (2-­‐)  becomes  H2PO4(-­‐)  and  NH3  becomes  NH4  which  is  
  *LUNGS  MAINTAIN  BALANCE  BY  ALTERING  VENTILATION   excreted.  Remember  daily  excretion  of  H+  is  mainly  influenced  
  by  the  amount  of  NH4+  formed  this  is  due  to  capability  of  renal    
  KIDNEYS   tubular  cells  to  generate  NH3  from  glutamine  and  other  amino  
-­‐ main  role  is  to  reclaim  HCO3-­‐  from  the  glomerular  filtrate.   acid.  
-­‐ Main  site  for  HCO3-­‐  reabsorption  is  Proximal  Tubules   *  Excretion  of  H+    in  urine  depends    on  the  amount  of  NH4+  
-­‐ Transport  of  HCO3  in  tubules  is  indirect  by  exchanging  one   formed.  
molecule  of  H+  for    Na+.     *  Concentration  of  NH3  will  increase  in  response  to  a  decreased  
-­‐ The  H+  combines  with  HCO3-­‐  to  form  H2CO3  which    dissociates   blood  pH.  
to  H2O  and  CO2  (  by  carbonic  anhydrase)  .  The  CO2  diffuses  into     Decrease  pH  =  Increase  NH3  
the  tubule  and  reacts  with  H2O    to  reform  H2CO3  then    
dissociates  to  HCO3-­‐  and  H+.  HCO3-­‐  formed  is  reabsorbed  into   -­‐ LUNGS  –  regulate  CO2  (hyperventilation  or  hypoventilation)  
the  blood  together  with  sodium.     -­‐ KIDNEYS  –regulate  HCO3-­‐  (reabsorption  or  
2  conditions:   excretion/secretion)  
a. Increased  HCO3-­‐  ,  Increased  pH    
b. Decreased  HCO3  ,  Decreased  pH   Assessment  of    Acid  -­‐Base  Homeostasis  
   
other  factors  affecting  HCO3-­‐  reabsorption:     Use:  Henderson-­‐Hasselbalch  Equation  
1. when  HCO3-­‐  is  higher  than  26-­‐  30  mmol/L.      
2. Exception  to  this  compensatory  mechanism    
(retention  of  HCO3-­‐  even  when  it  is  increased    
is  when  the  condition  is  chronic  lung   Reference  Range:  
disease.)   Parameter   Normal  Range  at  37C  
Increased  levels  of  HCO3:   pH   7.35-­‐7.45  
1.      Increased  HCO3  maybe  due  to  IV  infusion  of  lactate  ,  acetate  and  HCO3-­‐.   pCO2  (mmHg)   35-­‐45  
2.Increased  HCO3    may  be    due  to  excess  loss  of  Chloride  (  sweating  ,  vomiting,   HCO3-­‐  (mmol/L)   22-­‐  26  
prolonged  nasogastric  suction)  .  HCO3  is  retained  in  the  tubules  to  preserve   Total  CO2  content  mmol/L   23-­‐27  
electroneutrality.   pO2  (mmol/L)   80-­‐110  
Decreased  levels  of  HCO3:   SO2  (%)   >95  
1. use  of  diuretics   O2Hb   >95  
2. excessive  loss  of  cations  
 
3. kidney  dysfunction  like  chronic  nephritis    or  infections  (HCO3-­‐  
*lungs  –  control  blood  pH  by  Hyper  or  Hypoventilation  
reabsorption  is  impaired).  
*  kidneys  –  control  HCO3  concentration.  
 
 
Important  terms:  (determines  the  pH)  
 
a. Reabsorption  and  Reclamation  –  process  of  re-­‐entering  the  blood.  
ACID  –BASE  Disorders  :    Acidosis  and  Alkalosis  
b. Secretion  or  Excretion  –  happens  in  the  tubules  by  removing  substances  
 
from  the  filtrate.  
2  conditions:  
 
a. Acidemia  -­‐  <pH  ,  excess  acid  concentration  or  H+  concentration  
Notes:   § Primary  Respiratory  Acidosis  –  change  in  pCO2  
-­‐ Normal  Next  excess  of  H+  :  50-­‐100  mmol/L  (this  must  be  
excreted  because  minimum  pH  is  4.5)  

 K.B.R   11  
 
 12    CLINICAL  CHEMISTRY    
 
o Increased  PCO2  (decrease  alveolar  elimination    or   § Secondary  compensation  occurs  when  the  original  organ  
hypoventilation  leading  to  decreased  elimination  of   with  problem    begins  to  correct  the  ratio  by  retaining  
CO2  by  the  lungs)   bicarbonate.  
o Decreased  pH    
o Less  than  20:1    ratio   b. Alkalemia  -­‐  >pH  ,  excess  base  concentration  .  
  § Primary  Respiratory  Alkalosis  –  change  in  pCO2  
  o Due  to  excessive  elimination  of  CO2  
Cause:   o Decrease  pCO2  
-­‐ COPD  –  desctruction  of  airways  and  alveolar  wall  increase  the   o Increase  pH  
size  of  alveolar  air  spaces  resulting  to  the  reduction  of  lung   o Increase  20:1  ratio  
surface  area  available  for  gas  exchange.  This  leads  to  retention    
of  CO2  causing  hypercarbia  (elevated  pCO2).   Cause:  
-­‐ Bronchopneumonia  –  impeded  gas  exchange    because  of   ü -­‐hypoxia  
secretions  such  as  WBC  ,  bacteria  and  fibrin  in  the  alveoli  wall   ü -­‐chemical  stimulation  by  salicyates  
-­‐ Use  of  Barbiturates  ,  morphine  ,alcohol  –  promotes   ü -­‐increase  environmental  temperature  
hypoventilation  increasing  blood  pCO2   ü -­‐fever  
-­‐ Mechanical  Obstruction  or  Asphyxiation  (strangulation  or   ü -­‐hysteria  (hyperventilation)  
aspiration)   ü -­‐pulmonary  emboli  and  fibrosis  
-­‐ Congestive  Heart  Failure  –  less  blood  being  presented  to  the        
lungs  for  gas  exchange  increasing  pCO2.   Compensatory  Organ:  Kidneys  (  excretion  of  HCO33-­‐)  in  the  urine  and  
  reclaiming  H+  in  the  blood.  
Compensatory  Organ:  Kidneys      
  -­‐  Increase  excretion  of  H+  and  increase  reabsorption  og   Treatment:  In  hysterical  hyperventialtion  –breathing  into  a  paper  
HCO3-­‐   bag    
   
§ Primary  Non-­‐Respiratory  Acidosis  /Metabolic  /  Renal     § Primary  Non-­‐Respiratory  Alkalosis/Metabolic/Renal  
Function  –  change  in  HCO3-­‐   Function  –  change  in  HCO3-­‐  
o Decrease  HCO3  (<  24  mmol/L)    
o Decreased  pH   o Increase  HCO3-­‐  
o Less  than  20:1  ratio   o Increase  pH  
Cause:   o Increase  20:1  ratio  
• Administration  of  acid-­‐producing  substance  like  ammonium    
chloride  and  calcium  chloride   Cause:  
• Excessive  formation  of    organic  acids  common  in  diabetic   -­‐ excess  administration  of    sodium  bicarbonate    
ketoacidosis  and  starvation.   -­‐ ingestion  of    bicarbonate  producing  salts  such  as  sodium  lactate,  
• Reduced  excretion  of  acids  like  in  renal  tubular  acidosis   citrate  and  acetate  
• Excessive  loss  of  Bicarbonate  due  to  diarrhea  ,  drainage  from   -­‐ Loss  of  acid    through  vomiting  ,  nasogastric  suctioning    or  
biliary  ,  pancreatic  or  intestinal  fistula.   prolonged  use  of  diuretics  
   
Compensatory  Organ:  Lungs  ,  Hypervantilation   Compensatory  Organ:  Lungs  –  hypoventilation  or  retention  of  CO2  
§ increase  rate  or  depth  of  breathing    
§ Blowing  off  CO2    
 
 
 
12    K.B.R  
 
 CLINICAL  CHEMISTRY     13  
 
  5. Adequate  hemoglobin  
*compensation  –  body  accomplishes  by  altering    the  factor  NOT  primarily  affected  by   6. Adequate  transport  (cardiac  output)    
the  pathologic  process  to  restore  acid-­‐base  homeostasis.   7. Release  of  O2  into  the  tissue  
   
REMEMBER:   Notes:  
  If  the  imbalance  is  nonrespiratory  origin  the  body  compensates  by  altering   -­‐ *any  alteration  will  cause  poor  tissue  oxygenation  
ventilation.  For  disturbances  of  the  respiratory  component  ,  the  kidneys  compensate  by   • Amount  of  Oxygen  available  in  atmospheric  air  depends  on  the  Barometric  
selectively  excreting    or  reabsorbing  anions  and  cations.  The  lungs  can  compensate   pressure  
immediately  but  the  response  is  short  term  and  incomplete.  The  kidneys  are  slower  to   • Dalton’s  Law  states  that  total  atmospheric  pressure  is  the  sum  of  individual  
respond  (2-­‐4  days)  but  the  response  is  long  term  and  potentially  complete.     gas  pressures.  
  -­‐ One  Atmosphere  (760  mmHg  pressure)  contains:  
o Fully  Compensated  –  pH  has  returned  to  normal  range   -­‐ O2  –  20.93%  
(20:1  range)   -­‐ CO2  –  0.03%  
o Partially  Compensated  –  pH  has  not  yet  returned  to  normal   -­‐ Nitrogen  –  78.1%  
  -­‐ Inert  gases  –  approximately  1%  
Summary  of  Acid-­‐Base  Disorders:   • Partial  Pressure  =  Barometric  
  Pressure  at  a  particular  altitude  X  
4 Major categories of acid-base disorders appropriate  percentage  for  each  
1. Respiratory acidosis gas.  
• Vapor  Pressure  of  water    (47  mmHg  
2. Respiratory alkalosis at  37C)    is  used  to  calculate  partial  
pressure.  
3.Metabolic Acidosis Ex.  Partial  pressure  of  Oxygen  at  Sea  Level  (in  the  body  )  
  =  (760  mmHg  –  47  mm  Hg  )  x  20  .93%  
  =  149  mm  Hg  (at  37C)  
4. Metabolic Alkalosis
 
 
             Partial  Pressure  of    CO2  at  sea  level    (in  the  body)  
Oxygen  and  Gas  Exchange  
  =  (760  mm  Hg  -­‐47  mm  Hg)    x0.  03%  
 Role  of  Oxygen:  inside  the  mitochondria  after  oxidation  of  NADH  and  FADH2  ,  electron  
  =  2  mm  Hg  (at  37  C)  
pairs  are  transferred  to  molecular  oxygen    causing  release  of  the  energy  used  to  
 
synthesize  ATP  from  phosphorylation  of  ADP.  
Factors  that  influence  amount  of  Oxygen  moving  in  the  alveoli  into  the  blood  and  
 
into  the  tissue.  
What  is  measured?  
1. Destruction  of  alveoli  –  decrease  surface  area  leading  to  inadequate  amount  of  
  pO2,  pCO2  and  pH  
Oxygen  moving  into  the  blood  
 
2. Pulmonary  Edema  –  there  is  a  barrier  in  the  diffusion  of  gas  between  the  
 
alveoli  and  capillary  wall  
 
3. Airway  Blockage  –  prevention  of  air  from  reaching  the  alveoli  like  in  Asthma  
 
and  Bronchitis  
 
4. Inadequate  Blood  Supply  –  not  enough  blood  to  carry  oxygen  in  the  tissues  
 
like  in  pulmonary  embolism  ,  pulmonary  hypertension  and  heart  failure  
Seven  Conditions  Necessary  for  Adequate  Tissue  Oxygenation:  
5. Diffusion  of  CO2  and  O2-­‐  decrease  O2  diffusion  
1. available  atmospheric  oxygen    
 
2. adequate  ventilation  
Oxygen  Transport  
3. gas  exchange  between  lungs  and  arterial  blood  
-­‐ Oxygen  is  primarily  transported  in  the  tissue  by  Hemoglobin  
4. loading  of  O2  in  Hgb  
 K.B.R   13  
 
 14    CLINICAL  CHEMISTRY    
 
-­‐ One  Adult  Hemoglobin  can  be  filled  up  by  Four  Molecules  of   1.Blood  gas  analysis  routinely  made  @  37C  
Oxygen.  (reversible  )   2.  for  each  grade  of  fever  in  the  patinet,  PO2  will  fall  by  7%  and  CO2  will  rise  3%.  
o Binding  is  affected  by:    
§ Availability  of  oxygen    
§ Concentration  and  type  of  Hemoglobin   Measure  by  blood  gas  instrument:  
present   a.  pH    
§ Presence  of  interfering  substances  such  as   b.  pCO2    
CO,  pH,  Temperature  ,  pCO2  and  2,3-­‐DPG.   c.  pO2  
§ Increase  levels  of  Oxygen  when  hemoglobin    
is  fully  saturated  is  toxic.    
§ 4  forms  of  hemoglobin:   NOTE:   HCO3   and   CO2   content   can   be   obtained   by   nomogram   after   pH   +   pCO2  
• Oxyhemoglobin  –  O2  bound  to  HgB  -­‐ measurement  or  as  a  direct  readout  from    a  calculation  programmed  in  the  instrument.  
reversible    
• Deoxyhemoglobin  –  Reduced   Total  CO2  Content:  
Hemoglobin  (not  bound)  -­‐reversible    
• Carboxyhemoglobin  –  CO2  bound  to   A.  Automated  Enzymatic  Method    
Hgb  –reversible   All  forms  of  CO2  present  in  serum  are  converted    
• Methemoglobin  –  Do  not  bind  with    HCOs   by   the   addition   of   a   base.   The   HCO3   is   then   converted   to   oxaloacetic   acid   by  
O2  because  Fe3+  /  oxidized    rather   phosphoenolpyruvate   carboxylase.   The   extent   of   oxaloacetic   acid   formation   can   be  
than  reduced  binds  with  Hgb.   monitored   spectrophotomterically   by   measuring   its   conversion   to   malate   by   malate  
Methemoglobin  reductase  can   dehydrogenase  with  a  corresponding  consumption  of  NADH,  a  UV  light  chromogen.  
reduce  Fe3+  which  is  found  in  RBC.    
  B.  Automated  Colorimetric  Method  
Methods  of  Measurement  of  Acid-­‐Base  Balance   The   CO2   appearing   in   serum   as   HCO3   ,   H2CO3   or   carbaminbound   CO2   is   released   by  
a.requires  arterial  blood  sample  (pO2  testing)   addition   of   acid.   The   gaseous   CO2   is   dialyzed   through   a   silicone-­‐rubber   gas   dialysis  
b.   venous   blood   maybe   taken   for   pH   and   CO2   provided   it   is   drawn   without   stasis   (no   membrane   into   a   buffer   solution   of   cresol   res   at   pH   9.2   .   The   CO2   diffuses   through   the  
torniquet)  and  without  patient  clenching  the  fist.   membrane    and  lowers  the  pH  of  buffered  cresol  red  solution.  The  decrease  in  color  
  intensity  is  proportional  to  the  CO2  content  and  is  measured  in  a  spectrophotometer  
b.   Arterialized   venous   blood   maybe   obtained   by   heating   the   hand   or   forearm   in   water   at   at   430   nm.   Other   continuous   flow   methods   have   used   phenolphthalein   as   the  
indicator.  
45C  for  5  minutes  then  drawing  blood  from  dilated  veins  on  the  back  of  the  hand.  
 
 
 
c.  Capillary  blood  is  arterialized  by  warming  the  ear,  finger  or  heel  at  45C  before  taking  the  
 
sample.    
 
   
d.   Dead   space   in   the   needle   should   be   filled   with   a   needle   with   sterile   anticoagulant   to    
prevent  formation  of  air  bubbles.  (  maintain  anaerobic  environment)    
   
e.  Samples  are  placed  in  a  tray  if  ice  for  analysis  in  the  laboratory.      
 
Specimen  &  Patient  Consideration:    
§ most  desirable  specimen  is  arterial  blood  (  it  reflects  the  status  of  gas      
§ ________________________________________.    
§ ________________________________________.    
For  Patient:    
14    K.B.R  
 
 CLINICAL  CHEMISTRY     15  
 
  MERCURY  
TRACE    and  TOXIC  ELEMENTS    
  Manganese  
§ Levels  varies  based  on:  Absorption,  Transport  ,        
Distribution,  Metabolism  and  Elimination.   Molybdenum  
§ Deficiency  maybe  due  to:      
o Decreased  Intake   SELENIUM  
o Impaired  Absorption    
o Increased  Excretion   Zinc  
o Genetic  Abnormality    
  2  types:   Questions:  
1. Essential   1. Discuss  the  disorders  associated  with  the  excess  and  deficiency  of  each  trace  
a. Associated  with  cofactors  such  as  Metalloenzyme   element/metal.  
(enzyme)  and  Metalloprotein  (protein)  as  cofactors.   2. Determine  the  specimen  collection  and  preparation  in  the  measurement  of  
2. Non-­‐Essential   each  trace  element  and  metal.  
a. Usually  toxic     3. Enumerate  the  different  laboratory    tests  used  in  the  measurement  of  each  
Laboratory  Determination:   trace  element/metal.  
Specimen:  Serum  ,  Plasma  and  Urine     4. Discuss  the  absorption,  transport  and  excretion/elimination  of  each  trace  
_____________________________________________________________________________________________________ element/metal.  
____________________    
INSTRUMENTATION    
Methods  of  Instrumentation    
1. AAS    
2. AES  (Atomic  Emission  Spectroscopy)    
3. FAAS  (Flame  Atomic  Absorption  Spectroscopy)    
4. GFAAS  (  graphite  furnace  atomic  absorption  spectroscopy)    
5. ICP-­‐AES  (Inductively  Coupled  Plasma  Atomic  Emission  Spectroscopy)    
6. ICP-­‐  MS  (Inductively  Coupled  Plasma  Mass  Spectroscopy)    
   
Trace    and  Toxic  Elements    
   
ALUMINUM    
   
ARSENIC    
   
CADMIUM    
   
Chromium    
   
COPPER    
     
IRON    
   
LEAD    

 K.B.R   15  
 
 16    CLINICAL  CHEMISTRY    
 
5. Epidermal  growth  factor  receptor  (EGFR)  
TUMOR  MARKERS   • also  known  as  HER1  
 
• a  receptor  found  on  cells  that  helps  them  grow  
AFP    (a-­‐fetoprotein)  
  • used  to  guide  treatment  and  predict  outcomes  of  non-­‐small  
cell  lung,  head  and  neck,  colon,  pancreas,  or  breast  cancers  
Cancer  Antigen  125  
  6. S-­‐100    
Carcinoembryonic  Antigen   • protein  found  in  most  melanoma  cells  
  • elevated  in  most  patients  with  metastatic  melanoma  
Human  Chorionic  Gonadotropin    
   
Prostate-­‐Specific  Antigen    
   
CA  125    
   
CA  19-­‐9    
   
   
OTHER  TUMOR  MARKERS    
1.  Bcr-­‐abl  -­‐      abnormal  gene  ,  increased  in  chronic  myeloid  leukemia    
§ Philadelphia  chromosome  or  Philadelphia  translocation  –    
defect  in  chromosome  22  (reciprocal  translocation  between    
chromosome  9  and  chromosome  22.  –  t  (9;22)  (q34;q11)-­‐      
common  in  CML    
§ Breakpoitn  cluster  region-­‐Abl  1  gene    or  a  fusion  gene    
2.Beta-­‐2-­‐microglobulin  (B2M)    
• Elevated  in  multiple  myeloma  and  chronic  lymphocytic    
leukemia  
• Increased  in  kidney  disease  and  hepatitis  
1. Bladder  tumor  antigen  (BTA)      
• found  in  the  urine  of  many  patients  with  bladder  cancer  
2. CA  27.29  
• used  to  follow  patients  with  breast  cancer  during  or  after  
treatment  
3. CA  72-­‐4      
• ovarian  and  pancreatic  cancer  
•  cancers  starting  in  the  digestive  tract,  especially  stomach  
cancer  
4. CALCITONIN  
• Produced  by  parafollicular  cells  
• In  medullary  thyroid  carcinoma  (MTC)  
 
 
 
 
16    K.B.R