ELECTROLYTES, TRACE

ELEMENTS and VITAMINS

Introduction
 Introduction
ELECTROLYTES
Ø Dissociated ions carrying an electrical charge
Ø Cations: positively charged ions; migrates toward the cathode
Ø Anions: negatively charged; migrates toward the anode
Ø Generally, do not need a transport protein
MINERALS
Ø Inorganic homogenous solid substances essential for adequate bodily functions
Ø Classifications:
Ø Macrominerals (major elements): present in the body in quantities greater than 5 grams,
with a daily dietary requirement of 100 mg or more
Ø Microminerals (trace elements): <0.01% of dry body weight; metals except selenium &
halogens
Ø Trace elements: concentrations in mg/L (Iron, Copper, Zinc)
Ø Ultra-trace elements: concentrations in ug/L
 Introduction
VITAMINS
Ø Organic substances essential in minute quantities to the nutrition, acting as
coenzymes (or their precursors) in the regulation of metabolic process
Ø Do not provide energy and or serve as building units
Ø Some are produced by the body; others are present in food
 Introduction
WATER
Ø Solvent of all human body metabolism
Ø 40-75% of total body weight: declines with age, more in males, less in obese
Ø Water levels are maintained by electrolytes as they exert osmotic pressure which
tends to hold water
Ø Functions of water
Ø a.Nutrient transport in the cellular level
Ø b.Removal of waste products
Ø c.Determination of cell volume
Ø d.Body’s coolant
 Introduction
OSMOLALITY!!!!!!!!!
Ø Distribution in the body
Ø a.Intracellular fluid: 2/3 of total water content
Ø b.Extracellular fluid: 1/3
Ø i.Intravascular fluid: 93% of normal plasma
Ø ii.Interstitial fluid
Ø Electrolyte movement through water medium
Ø a.Diffusion
Ø b.Facilitated diffusion
Ø c.Active transport
ELECTROLYTES
 Biochemical Functions
Ø 1.Regulation of volume and osmotic pressure: Na, Cl, K
Ø 2.Water distribution in the body
Ø 3.Cofactors/coenzymes in enzyme activation: Mg, Ca, Zn, Cl
Ø 4.Acid-base balance: HCO3, K, Cl, PO4
Ø 5.Neuromuscular excitability: K, Ca, Mg
Ø 6.Myocardial rhythm and contractions: K, Ca, Mg
Ø 7.ATP production from glucose: Mg, PO4
Ø 8.Regulation of ATPase pumps and oxidative phosphorylation: Mg
Ø 9.Blood coagulation: Ca, Mg
Ø 10.Bone and teeth structure: Ca, PO4
 Sodium
Ø 90% of all ECF cations; Major extracellular cation
Ø Maintains the (a)normal distribution of water, (b)osmotic pressure in body fluids
Ø Normal plasma omolality: 295mmol/L, 270mmol/L is due to sodium and its associated
anions
REGULATION
Ø a.Plasma osmolality: intake of water in response to thirst
Ø b.Blood volume: *RAAS, ANP
Ø c.Kidney response: removal of water *ADH
SPECIMEN CONSIDERATIONS
Ø Serum, plasma (lithium/ammonium heparin or lithium oxalate), urine (24 hour-
collection), sweat
Ø Hemolysis is usually insignificant; marked hemolysis cause decrease
 Sodium
LABORATORY METHODS
Ø a.Colorimetric (Albanese Lein):uses zinc uranylacetate, produces yellow product
Ø b.Ion-selective electrodes: method of choice
Ø Uses glass-ion exchange membrane (AKA glass electrode)
Ø Two types of measurement: Direct and Indirect
Ø c.Flame emission photometry: reference method
Ø Serum is diluted 1:100 or 1:200; Absorbs at 590nm; Emit yellow light
Ø Uses lithium or cesium light as internal standard
Ø d.Atomic absorption spectrophotometry
REFERENCE RANGES
Ø Serum: 135-145 mmol/L
Ø Serum Panic Values: <110 mmol/L, >170 mmol/L
Ø 24-hour urine: 40-220 mmol/day
 Sodium
CAUSES OF HYPONATREMIA HYPONATREMIA CLASSIFICATION BY
Ø Increased Sodium Loss PLASMA/SERUM OSMOLALITY
Ø Hypoadrenalism, Potassium deficiency, Ø With Low Osmolality
Diuretic use (thiazides), Ketonuria,
Salt-losing nephropathy, Prolonged Ø Increased sodium loss, Increased water
vomiting or diarrhea, Severe burns retention
Ø Increased Water Retention Ø With Normal Osmolality
Ø Renal failure, Nephrotic syndrome, Ø Increased nonsodium cations, Lithium excess,
Hepatic cirrhosis, Congestive heart Increased G-globulins—cationic (multiple
failure myeloma), Severe hyperkalemia, Severe
Ø Water Imbalance hypermagnesemia, Severe hypercalcemia,
Ø Chronic excess water intake/Polydipsia, Pseudohyponatremia, Hyperlipidemia,
SIADH, Pseudohyponatremia Hyperproteinemia, Pseudohyperkalemia as a
result of in vitro hemolysis
Ø Others: DM
Ø With High Osmolality
Ø Hyperglycemia, Mannitol infusion
 Sodium
CAUSES OF HYPERNATREMIA
Ø Increased Water Loss
Ø Diabetes insipidus, Renal tubular
disorder (egATN), Prolonged diarrhea,
Profuse sweating, Severe burns
Ø Decreased Water Retention
Ø Older persons, Infants, Mental
impairment, Hypothalamic disease
Ø Water Imbalance
Ø Hyperaldosteronism, Sodium
bicarbonate excess, Dialysis fluid
excess
HYPERNATREMIA CLASSIFICATION
BY URINE OSMOLALITY
Ø <300 mOsm/kg
Ø Diabetes insipidus
Ø 300-700 mOsm/kg
Ø Partial defect in AVP release or response
to AVP, Osmotic diuresis
Ø >700 mOsm/kg
Ø Loss of thirst, Insensible loss of water
(breathing, skin), GI loss of hypotonic fluid,
Excess intake of sodium
 Potassium
Ø Major intracellular cation; only 2% of body K circulates in plasma
Ø Important in (a) Neuromuscular excitability, (b) Cardiac muscle contraction,
Regulation of (c) ICF volume and (d) hydrogen ion concentration
REGULATION
Ø a.NaK ATPase pumps: inhibited by Hypoxia, hypomagnesemia and digoxin
overdose
Ø b.Insulin: inc NaK ATPase pump activity in skeletal muscles&liver cells = entry of K
Ø c.Catecholamines and aspropanolol (Promote and impairs entry, respectively)
SPECIMEN CONSIDERATIONS
Ø Non-hemolyzed serum, plasma (heparin), urine (24-hour collection)
Ø Serum/plasma should be separated from cells right away
Ø Thrombocytosis, prolonged tourniquet application, forearm exercise prior to blood
collection, WB @ ref temperature, hemolysis = false increase
 Potassium
LABORATORY METHODS
Ø a.Colorimetric (Lockhead and Purcell): uses sodium cobaltnitrite and phenol,
produces blue product
Ø b.Ion-selective electrodes: method of choice
Ø Uses valinomycin membrane
Ø c.Flame emission photometry: reference method
Ø d.Atomic absorption spectrophotometry
REFERENCE RANGES
Ø Serum: 3.4-5.1 mmol/L
Ø Serum Panic Values: <2.5 mmol/L, >6.5 mmol/L
Ø 24-hour urine: 25-125 mmol/day
 Potassium
CAUSES OF HYPOKALEMIA
Ø Gastrointestinal Loss
Ø Vomiting, Diarrhea, Gastric suction, Intestinal tumor, Malabsorption, Cancer therapy—
chemotherapy, radiation therapy, Large doses of laxatives, intestinal fistula
Ø Renal Loss
Ø Diuretics (thiazides, mineralocorticoids), Nephritis, Renal tubular acidosis (RTA),
Hyperaldosteronism, Cushing’s syndrome, Hypomagnesemia, Acute leukemia
Ø Cellular Shift
Ø Alkalosis, Insulin overdose, Hypothermia
Ø Decreased Intake
 Potassium
CAUSES OF HYPERKALEMIA
Ø Decreased Renal Excretion
Ø Acute or chronic renal failure (GFR, <20 mL/min), Hypoaldosteronism, Addison’s disease,
Diuretics
Ø Cellular Shift
Ø Acidosis, Muscle/cellular injury, Chemotherapy, Leukemia, Diabetes mellitus, Increased
cellular breakdown (trauma, cytotoxic agent administration, massive ntravascular hemolysis,
tumor lysis, blood transfusions), cardiac bypass
Ø Increased Intake: Oral or IV potassium replacement therapy
Ø Drugs:
Ø Captopril (inhibits angiotensin-converting enzyme), NSAIDS (inhibit aldosterone),
spironolactone (K-sparing diuretic), digoxin (inhibits Na-K pump), cyclosporine (inhibits renal
response to aldosterone), and heparin therapy (inhibits aldosterone secretion)
Ø Artifactual
 Chloride
Ø Major extracellular anion; Precise function not well understood
Ø Involved in (a) Maintaining osmolality, (b) Blood volume and (c) electric neutrality
Ø In most processes, shifts secondarily to a movement of Na or HCO3
Ø Maintains electric neutrality in 2 ways:
Ø Na is reabsorbed along with Cl in the proximal tubules. In effect, Cl acts as the rate-limiting
component, in that Na reabsorption is limited by the amount of Cl available.
Ø Chloride shift: In this process, carbon dioxide (CO2) generated by cellular metabolism
within the tissue diffuses out into both the plasma and the red cell. In the red cell, CO2
forms carbonic acid (H2CO3), which splits into H and HCO3 (bicarbonate).
Deoxyhemoglobin buffers H, whereas the HCO3 diffuses out into the plasma and Cl
diffuses into the red cell to maintain the electric balance ofthe cell.
REGULATION
Ø a. Intestinal tract: Almost completely absorbed
Ø b. Kidneys: Filtered by glomerulus; passively reabsorbed with sodium by PCT
Ø c. Excess chloride: excreted in urine and sweat
 Chloride
SPECIMEN CONSIDERATIONS
Ø Serum, plasma (lithium heparin), urine (24-hour), sweat
Ø Hemolysis is usually insignificant, marked hemolysis = dilutional effect
LABORATORY METHODS
Ø a.Colorimetric (Mercuric thiocyanate)
Ø b.Ion-selective electrodes: most commonly used; Silver wire coated with silver
chloride
Ø c.Amperometric-Coulometric titration: reference method; uses coulometric
generation of silver ions
Ø d.Mercuric titration/Schales and Schales (titrating agent: HgNO3, indicator: S-
phenylcarbazone)
REFERENCE RANGES
Ø Serum: 98-107 mmol/L; Urine: 110-250 mmol/day
 Chloride
CAUSES OF HYPOCHLOREMIA
Ø Excessive loss of Cl
Ø prolonged vomiting, diarrhea, profuse sweating
Ø Diabetic ketoacidosis
Ø Salt-losing renal diseases such as pyelonephritis
Ø Aldosterone deficiency (Addison's disease)
CAUSES OF HYPERCHLOREMIA
Ø Excess loss of HCO3
Ø GI loss of HCO3, dehydration
Ø RTA, metabolic acidosis, respiratory alkalosis
Ø Some endocrine disturbances
Ø Hyperparathyroidism - hypercalcemia
Ø Cystic fibrosis/Mucoviscidosis
 Chloride
SWEAT TESTING
Ø Primarily used to diagnose cystic fibrosis (Mucoviscidosis): an autosomal
recessive metabolic disorder affecting the mucus-secreting glands of the body, as
well as causing pancreatic insufficiency, respiratory distress and intestinal
obstruction
Ø Method of sweat collection: Gibson-Cook Pilocarpine Iontophoresis
Ø Method of testing
Ø Sodium: FEP or ISE
Ø Chloride: Titration
Ø Reference Ranges:
Ø Normal: up to a maximum of 40 mEq/L
Ø Diagnostic of CF: >70 mEq/L *>60 mEq/L
 Bicarbonate
Ø Second major extracellular anion; Total CO2 indicative of HCO3 levels
Ø Major component of the buffering system of the blood
REGULATION
Ø Kidneys: Filtered by glomerulus; 85% reabsorbed by PCT, 15% by the DCT
Ø Alkalosis: with a relative increase in HCO3 compared to CO2, the kidneys increase
excretion of HCO3 into the urine, carrying along a cation such as Na. This loss of HCO3
from the body helps correct pH
Ø Acidosis: the body responds by increased excretion of H into the urine. In addition, HCO3
reabsorption is virtually complete, with 90% of the filtered HCO3 reabsorbed in the
proximal tubule and the remainder in the distal tubule.
SPECIMEN CONSIDERATIONS
Ø Serum, plasma (lithium heparin)
Ø Sample is capped until serum/plasma is separated; should be analyzed immediately
 Bicarbonate
LABORATORY METHODS
Ø 1. Colorimetric: acidifying sample to release CO2 → diffusion into a chamber
containing phenolpthalein → Released gas redissolves, promoting color change
Ø 2. ISE: uses acid reagent to convert all forms of CO2 to gas which is then measured
bythe pCO2 electrode (Severinghaus)
Ø 3. Enzymatic: sample is alkalinized to convert all forms of CO2 to HCO3
Phosphoenolpyruvate + HCO3 ⎯ PEP carboxylase→ Oxaloacetate + H2PO4
Oxaloacetate + NADH + H ⎯ MDH→ Malate + NAD
REFERENCE RANGES
Ø Plasma/Serum (Venous) CO2: 23-29mmol/L
 Magnesium
Ø Fourth most abundant cation; second most abundant intracellular cation
Ø Essential activator/cofactor of more than 300 enzymes, including those important in
glycolysis (e.g. hexokinase, fructokinase), transcellular ion transport, neuromuscular
transmission (e.g. CK), synthesis of carbohydrates, proteins, lipids, and nucleic
acids, and release of and response to certain hormones
Ø Important in the oxidative phosphorylation in the mitochondria
Ø Also has therapeutic effects: anticonvulsant, laxative and antacid effects

DISTRIBUTION
Ø 53% bones and teeth, 46% muscle and other soft tissues and <1% in RBCs and
serum
Ø In the serum: Protein-bound (33%), Free or ionized (61%), Complexed with anions (5%)
 Magnesium
REGULATION
Ø Intestines: absorbs 20-65% of dietary Mg depending on the need and intake
Ø Kidneys: Non-protein bound filtered by glomerulus; 25-30% reabsorbed by PCT, 50-
60% by the ascending limb of Henle's loop; 2-5% by the DCT
Ø Renal threshold for Mg: 0.60-0.85 mmol/L
Ø Magnesium regulation appears to be related to that of Ca and Na
Ø PTH: enhances intestinal absorption and renal reabsorption
Ø Aldosterone and thyroxine: increased renal excretion

SPECIMEN CONSIDERATIONS
Ø Non-hemolyzed serum, plasma (lithium heparin); urine (24-hour, acidified with HCl)
 Magnesium
LABORATORY METHODS
Ø a.Colorimetric: Most methods use “calcium shelter” to remove interference
Ø Calmagite + Mg = reddish-violet complex read at 532 nm
Ø Formazen dye + Mg = colored complex read at 660 nm
Ø Methylthymol blue + Mg = colored complex
Ø b.Atomic absorption spectrophotometry: reference method
Ø c.Ion-selective electrode: rarely used
Ø d.Fluorometry: uses 8-hydroxyquinone orcalcein

REFERENCE RANGES
Ø 0.63–1.0 mmol/L (1.26–2.10 mEq/L)
 Magnesium
CAUSES OF HYPOMAGNESEMIA Ø INCREASED EXCRETION—RENAL
Ø REDUCED INTAKE Ø Tubular disorders, Glomerulonephritis,
Pyelonephritis
Ø Poor diet/starvation
Ø Prolonged magnesium-deficient IV therapy Ø INCREASED EXCRETION—
ENDOCRINE
Ø Chronic alcoholism
Ø Hyperparathyroidism-Hypercalcemia
Ø DECREASED ABSORPTION
Ø Malabsorption syndrome Ø Hyperaldosteronism-Hypernatremia

Ø Surgical resection/bypass intestines Ø Hyperthyroidism

Ø Nasogastric suction Ø Diabetic ketoacidosis
Ø Pancreatitis Ø INCREASED EXCRETION—DRUG
Ø Prolonged vomiting, Diarrhea, Laxative INDUCED
abuse Ø Diuretics (furosemide, thiazide) Antibiotics
Ø Neonatal, Primary, Chronic congenital (gentamicin, cisplatin), Cyclosporine,
Cardiac glycosides (Digoxin, Digitalis)
Ø MISCELLANEOUS
Ø Excess lactation, Pregnancy
 Magnesium
CAUSES OF HYPERMAGNESEMIA INCREASED EXCRETION—ENDOCRINE
Ø DECREASED EXCRETION Ø Dehydration
Ø Acute or chronic renal failure Ø Bone carcinoma
Ø Hypothyroidism
Ø Bone metastases
Ø Hypoaldosteronism
Ø Hypopituitarism
Ø INCREASED INTAKE
Ø Antacids
Ø Enemas
Ø Cathartics
Ø Therapeutic MgSO4—eclampsia, cardiac
arrhythmia, MI
 Calcium
Ø Most abundant electrolyte/mineral found in the body
Ø Has a number of functions
Ø Crystalline portion of the skeleton; Activator of some enzymes; Coagulation factor
Ø Neuromuscular transmission and skeletal and cardiac muscle contraction
Ø Cell Membrane: Regulates ion transport; Stability
Ø Milk production; Cellular secretion (e.g. insulin and amylase)
DISTRIBUTION
Ø 99% of total calcium is in the bones and teeth as hydroxyapatite; 1% in blood/ECF
Ø a.45% free calcium ions AKA ionized calcium: physiologically active form, diffusible
Ø b.40% protein-bound: attached to proteins, mostly albumin
Ø c.~15% complexed: bound to anions (e.g. citrate, bicarbonate, lactate, phosphate)
 Calcium
REGULATION
Intestinal Bone Kidney Overall Effect
Absorption Resorption Reabsorption to Blood Levels
PTH
Vit. D3
Calcitonin
SPECIMEN CONSIDERATIONS
Ø Venous stasis, prolonged tourniquet application, hemolysis = false increase
Ø Total: Serum/Plasma (lithium heparin)
Ø Ionized: Anaerobic collection; heparinized (powdered) WB is preferred; serum may
be used
Ø Urine: 24 hours, acidified with 6M HCl (1 mL acid/100 mL urine)
 Calcium
LABORATORY METHODS
Ø a.Total calcium
Ø i.Colorimetric: Dye binding
Ø Dye used: O-Cresolphtheleincomplexone, Arsenazo III dye, Alizarin, Methylmol blue
Ø Interferences: Proteins (adjust pH/acidify), Magnesium (add 8-hydroxyquinoline), Lipemia (add urea),
Hemoglobin (add ethanol to dec abs blank)
Ø ii. Atomic absorption spectrophotometry: reference method
Ø iii.Chelation with EDTA
Ø iv.Fluorometric: very sensitive; for research/reference lab
Ø v.Titration/Precipitation: Clark-Collip/Kramer-Tisdall
Ø Precipitated (oxalate), washed and redissolved (sulfuric), titrant (Kpermanganate)
Ø b.Ionized calcium: Ion-selective electrode (uses membranes impregnated with
special molecules that selectively, but reversibly, bind Ca ions
 Calcium
REFERENCE RANGES *Conversion Factor: 0.25
Ø Total (Serum, Plasma): 2.15-2.50 mmol/L or 8.6-10.0 mg/dL
Ø Ionized: 1.16-1.32 mmol/L or 4.6-5.3 mg/dL
Ø Total (24-hour urine): 2.50–7.50 mmol/day (100–300 mg/day), varies with diet
 Calcium
CAUSES OF HYPOCALCEMIA
Ø Primary hypoparathyroidism—glandular aplasia, destruction, or removal
Ø Hypomagnesemia / hypermagnesemia
Ø Hypoalbuminemia (total calcium only, ionized not affected)—chronic liver disease,
nephrotic syndrome, malnutrition
Ø Acute pancreatitis
Ø Vitamin D deficiency, malabsorption
Ø Renal (Glomerular) disease
Ø Rhabdomyolysis - major crush injury and muscle damage
Ø Pseudohypoparathyroidism
 Calcium
CAUSES OF HYPOCALCEMIA
Ø Primary hyperparathyroidism—adenoma or glandular hyperplasia
Ø Various malignancies
Ø Hyperthyroidism; Acromegaly
Ø Benign familial hypocalciuria
Ø Malignancy
Ø Multiple myeloma
Ø Increased vitamin D
Ø Thiazide diuretics
Ø Prolonged immobilization
Ø Paget's disease
 Phosphate
Ø Major intracellur anion; Found everywhere in living cells, participating in many of the
most important biochemical processes
Ø Structure: Bone, Cell membrane, Nucleic acids
Ø Reservoir of biochemical energy: ATP, creatine phosphate, phosphoenolpyruvate
Ø Oxygen Deliveryy: 2,3-biphosphoglycerate (2,3-BPG); Blood buffer
Ø Coenzymes are esters of phosphoric or pyrophosphoric acid
DISTRIBUTION
Ø 80% is in the bones and teeth; 20% in sof tissues, <1% in blood/ECF (12 mg/dL)
Ø a. Organic phosphate: confined within cells
Ø b. Inorganic phosphate: 3-4 mg/dL of blood
 Phosphate
REGULATION
Intestinal Bone Kidney Overall Effect
Absorption Resorption Reabsorption to Blood Levels
PTH
Vit. D3
Calcitonin
GH
SPECIMEN CONSIDERATIONS
Ø Non-hemolyzed serum/Plasma (lithium heparin) Urine: 24-hour collection
Ø Circadian rhythm: highest in the morning, lowest in the evening
LABORATORY METHODS
Ø a. Colorimetric: Fiske-Subbarow
Ø Uses TCA to precipitate serum proteins; followed by reaction that results to the formation of
ammonium phosphomolybdate complex which may be measured by:
Ø UV absoorption (340 nm)
Ø reduction (using ascorbic acid/pictrol/elon/semidine/stannous chloride) to molybdenum blue read at
600-700nm
Ø b. Enzymatic: involves 3 enzymes
Ø c. AAS
REFERENCE RANGES *Conversion Factor: 0.323
Ø Neonate: 1.45–2.91 mmol/L (4.5–9.0 mg/dL)
Ø </=15 years: 1.07–1.74 mmol/L (3.3–5.4 mg/dL)
Ø Adult: 0.78–1.42 mmol/L (2.4–4.4 mg/dL)
Ø Urine (24-h): 13–42 mmol/day (0.4–1.3 g/day)
 Phosphate
CAUSES OF HYPOPHOSPHATEMIA
Ø *1-5% of hospitalized patients
Ø *20-40% in patients with the ff disorders: diabetic ketoacidosis, chronic
obstructive pulmonary disease (COPD), asthma, malignancy, longterm treatment
with total parenteral nutrition (TPN), inflammatory bowel disease, anorexia
nervosa, and alcoholism.
Ø 60% to 80% in ICU patients with sepsis
Ø Increased Renal Excretion: Hyperparathyroidism, Fanconi syndrome
Ø Decreased Intestinal Absorption: Vitamin D deficiency (including rickets and
osteomalacia), use of antacids (those containing Mg(OH)2 or Al(OH)2
 Phosphate
CAUSES OF HYPERPHOSPHATEMIA
Ø Acute/chronic renal failure, Chronic glomerulonephritis, Uremia
Ø Increased intake of phosphate/Increased release of cellular phosphate
Ø Increased cellular breakdown: severe infections, intensive exercise, neoplastic
disorders, intravascular hemolysis
Ø Lymphoblastic leukemia
Ø Infants: immature PTH and Vitamin D metabolism
Ø Hypoparathyroidism, pseudohypoparathyroidism
Ø Excess Vitamin D
Ø Excess GH (Acromegaly)
 Electrolytes and Renal Function
The kidney is central to the regulation and conservation of electrolytes in the body.
The following is a summary of electrolyte excretion and conservation in a healthy
individual:
Ø Glomerulus: This portion of the nephron acts as a filter, retaining large proteins
and protein-bound constituents while most other plasma constituents pass into
the filtrate. The concentrations in the filtered plasma should be approximately
equal to ECF without protein.
Ø Renal tubules:
Ø a. Phosphate reabsorption is inhibited by PTH and increased by 1,25-
dihydroxycholecalciferol. Excretion of PO4 is stimulated by calcitonin.
Ø b. Ca2 is reabsorbed under the influence of PTH and 1,25-dihydroxycholecalciferol.
Calcitonin stimulates excretion of Ca2 .
Ø c. Mg2 reabsorption occurs largely in the thick ascending limb of Henle’s loop
Electrolytes and Renal Function
Ø d. Sodium reabsorption can occur through three mechanisms:
Ø Approximately 70% of the Na in the filtrate is reabsorbed in the proximal tubules by iso-osmotic
reabsorption. It is limited, however, by the availability of Cl to maintain electrical neutrality.
Ø Na is reabsorbed in exchange for H. This reaction is linked with HCO3 and depends on carbonic
anhydrase.
Ø Stimulated by aldosterone, Na is reabsorbed in exchange for K in the distal tubules. (H competes
with K for this exchange.)
Ø e. Cl is reabsorbed, in part, by passive transport in the proximal tubule along the
concentration gradient created by Na.
Ø f. Kis reabsorbed by two mechanisms:
Ø Active reabsorption in the proximal tubule almost completely conserves K.
Ø Exchange with Na is stimulated by aldosterone. H competes with K for this exchange.
Ø g. Bicarbonate is recovered from the glomerular filtrate and converted to CO2 when H
is excreted inthe urine.
 Electrolytes and Renal Function
Ø Henle’s loop: With normal AVP function, it creates an osmotic gradient that
enables water reabsorption to be increased or decreased in response to body
fluid changes in osmolality.
Ø Collecting ducts: Also under AVP influence, this is where final adjustment of water
excretion is made.
TRACE ELEMENTS
 Trace Elements
SPECIMEN CONSIDERATIONS
1. Whole blood, plasma (Heparinized) and serum
2. 24-hour urine: Polyethylene bottles with glacial acetic acid as preservative
3. Pre-analytical factors: age, sex, ethnic origin, time of day, food intake, medication,
tobacco usage

METHODOLOGY
1. Spectrophotometry
2. Atomic Absorption Spectrophotometry
3. Inductive Coupled Plasma-Optical Emission Spectrometry
4. Inductive Couple Plasma-Mass Spectrometry
 Iron
Ø Dietary Requirements: 8mg/L; Higher in menstruating women, children (~18 mg/L)
Ø Distribution: majority in hemoglobin; myoglobin; storage form-ferritin and
hemosiderin (BM, liver and spleen); transport: transferrin
Ø Absorption, Transport and Excretion:
Ø Only 10% of dietary iron is absorbed by the intestines
Ø Intestinal mucosal cells: Ferrous --> bound to apoferritin --> oxidized by ceruloplasmin -->
Ferric bound to ferritin --> Absorbed in the blood by apotransferrin --> Apotransferrin
becomes transferrin after binding two ferric ions
Ø Decrease in iron levels = inhibition of apoferritin formation = formation of transferrin
receptor
Ø Small amount excreted daily (urine/feces); 20-40 mg iron lost ever menstrual cycle
Ø Functions:
Ø Oxygen binding/delivery (ferrous form in hemoglobin)
Ø Myoglobin facilitate oxygen diffusion in tissues
Ø Enzyme constituent/cofactor (peroxidase, catalase, thyroperoxidase)
 Iron
Ø Iron deficiency anemia (15% of population)
Ø High Risk: Women (Pregnant, Reproductive age), children and adolescents
Ø Causes: Increased blood loss, decreased intake, decreased release from ferritin
Ø CBC results: Decreased RBC count, MCV and MCHC
Ø Hemochromatosis: collective term for iron overload disorders (excess absorption)
Ø Hemosiderosis: increased serum iron/TIBC/Transferrin; no tissue damage
Ø Hereditary hemochromatosis: Tissue accumulation; affects liver function; hyperpigmentation
of the skin
Ø Laboratory Methods for Iron Status
Ø CBC: Packed cell volume, Hemoglobin, RBC count and RBC Indexes
Ø Serum iron/Total iron content; Reference ranges (Serum iron): 3-5mg/L
Ø Total iron binding-capacity
Ø Percent Saturation = Total iron / TIBC x 100
Ø Transferrin (nephelometry) and Ferritin (Immunochemical: IRMA, ELISA)
 Zinc
Ø Second most abundant trace elment in the body (next to iron)
Ø Distribution: 60% in muscle, 30% in bones, the rest are in the liver, prostate, semen
Ø Absorption, Transport and Excretion:
Ø Increased absorption: Intake of calcium; presence of amino acids, animal proteins, and/or
unsaturated fatty acids in a meal
Ø Decreased absorption: intake of iron and high amounts of copper; Empty stomach; Age
Ø Absorbed in jejunum; ~65% transported by albumin, ~35% by A2-macroglobulin
Ø Functions:
Ø a.Most common metal cofactor for enzyme activity (>300 enzymes) *DNA/RNA polymerase
Ø b.Protein, glucose (affects insulin functions) and cholesterol metabolism
Ø c.Growth and wound healing (affects GH)
Ø d.Others: connective tissue integrity; reproductive functions; immune system
 Zinc
Ø Zinc deficiency: (has many various symptoms)
Ø Common in patients who have: DM, alcoholism, liver and kidney disease
Ø May cause teratogenic effects, fetal dysmaturity, neural tube defects and spina bifida if
deficiency occurs during pregnancy
Ø Acrodermatitis enteropathica = rare autosomal recessive disease
Ø impaired intestinal absorption and trans port of Zn
Ø Zinc excess: rarely occur as zinc is relatively non-toxic
Ø Inhalation of zinc oxide fumes = metal fume fever
Ø Excess in diet = copper depletion
Ø Respiratory manifestations, fever, leg and chest pain, vomiting
 Zinc
Ø Specimen Requirements
Ø Serum value is 10% higher than plasma (preferred)
Ø Diurnal variation: highest in the morning; decreased after meals, in the presence of
infections/inflammation, steroid administration, pregnancy, and hypoalbuminemia
Ø Laboratory Methods
Ø a.Atomic absorption spectroscopy = most reliable
Ø b.Spectrophotometry
Ø c.Emission spectroscopy
Ø d.Evaluation of zinc-containing enzymes may also be useful (ALP, carbonic anhydrase)
Ø Reference Ranges: 70-120 um/dL or 11-18 umol/L
 Copper
Ø Third most abundant trace elment in the body
Ø Distribution: Present in all living cells
Ø Absorption, Transport and Excretion:
Ø Decreased absorption: intake high amounts of iron and zinc
Ø Increased intake = decreased iron (IDA) and zinc absorption
Ø Copper-containing proteins: Transport proteins (Ceruloplasmin [60-95% ], albumin,
trancuprein), Metallothionein, Clotting Factor V
Ø *Henry's: Copper in ceruloplasmin is not exchangeable; thus, it is not its transport protein

Ø Functions:
Ø Component of enzymes involved in oxidation-reduction reactions (Ceruloplasmin,
Cytochrome C oxidase, Superoxide dismutases *w/ Zn, dopamine-B-hydroxylase,
tyrosinase)
 Copper
 Disorders
Ø Copper deficiency = uncommon
Ø Occur more in pindividuals with malnutrition and malababsorption
Ø May also be caused by increased zinc intake
Ø Neutropenia (early manifestation); IDA may be present when ceruloplasmin is low
Ø Severe deficiency = neurologic symptoms, decreased pigment
Ø Arrhytmia, hyperlipidemia and aneurisms leads to coronary heart disease
Ø Menke’s syndrome = X-linked recessive defect in copper transport leading to deficiency
Ø normal RBC copper, low serum/liver copper
Ø Manifestations: Metal retardation, failure to thrive, low enzyme activities, kinky/twisted/sheep wool
hair, connective tissue abnormalities
Ø Copper toxicity
Ø not reported from food intake
Ø Occurs mostly due to accidental ingestion of copper solutionn, IUD use, exposure to fungicides,
industrial exposure, excess supplements/contaminated water
Ø Causes nausea, vomiting, diarrhea, abdominal cramps, liver injury (more common in infants)
 Copper
Ø Disorders:
Ø Wilson’s disease (hepatolenticular degeneration)
Ø Copper transport from intestine to liver is normal but cannot be transported out of the liver, causing
copper accumulation in liver, brain, kidneys, cornea
Ø Manifestations: Low serum copper, high urine copper, Kayser-Fleischer rings (copper in cornea)
Ø Treatment: Zinc (*molybdenum) administration; Chelation therapy: Dimer-caprol, Penicillamine,
Ø Specimen Considerations
Ø Serum/plasma
Ø Diurnal variation: highest in the morning; increased in inflammation and pregnancy; steroid
hormones causes levels to decrease
Ø Reference Ranges (Serum): 750-1500ug/L
Ø Laboratory Methods
Ø a.Atomic Absorption Spectroscopy – widely used for direct copper measurement
Ø b.Ceruloplasmin – index of good copper status (indirect assessment)
Ø c. RBC superoxide dismutases (indirect assessment)
 Cobalt
Ø Distribution: Muscle, liver, fat
Ø Functions: Constituent of Vitamin B12, which is involved in folate metabolism and
erythropoiesis (DNA metabolism)
Ø Disorders:
Ø Cobalt deficiency = megaloblastic anemia, anorexia, stunted growth
Ø Cobalt toxicity = GI dysfunction, cardiomyopathy, hypothyroidism
Ø Specimen Requirements: serum, plasma, urine
Ø Laboratory Methods: Atomic Absorption Spectroscopy
Ø Reference ranges (Serum): 0.11-0.45 ug/L
 Chromium
Ø Glucose Tolerance Factor: biologically active form of chromium in brewer’s yeast
Ø Functions: Activator of insulin (glucose metabolism)
Ø Chromodulin = bind to chromium to enhance insulin receptor response
Ø Disorders:
Ø Deficiency (Prone to individuals with IV fluids, diabetes or malnutrition): Glucose intolerance,
Weight loss, Glycosuria, Hypercholesterolemia, Neurological symptoms, cardiovascular
problems, Impaired fertility (decreased sperm count in males)
Ø Toxicity: Transient renal defects (Low dose exposure); Skin disorders (e.g. dermatitis
[allergic and others], ulcers); Respiratory tract irritation; Liver, and immune system problems
Ø Specimen Requirements: Serum, plasma, whole blood, urine
Ø Laboratory Methods: Flameless atomic absorption
 Fluoride
Ø Most widely used of the pharmacologically beneficial trace element
Ø Functions: Integrity of the bones and the teeth *Closely associated to Vit D3
Ø Disorders:
Ø Toxicity: Mottled enamel, calcifications in the soft tissues, severe bone abnormalities
Ø Specimen Requirements: Serum, plasma, urine
Ø Laboratory Methods: Ion-selective electrodes
 Manganese
Ø 80% constituting ferromanganese
Ø Non-essential/non-specific: can be replaced by magnesium, iron, copper
Ø Transported in plasma by albumin, A2-macroglobulin and transferrin
Ø Functions: Activator of several enzymes like SODs (prevents oxygen toxicity),
pyruvate carboxylase (hepatic synthesis of glucose) and glycosyltransferase (bone
and skin integrity, wound healing)
Ø Disorders:
Ø Deficiency: Manganese is non-specific and can be substituted by Mg/Fe/Cu; thus,
minimizing effects of its deficiency
Ø Toxicity: High oral doses are not toxic; inhalation causes toxicity which may cause multiple
signs and symptoms
Ø Most involves hepatic and neurologic symptoms
Ø In chronic forms, may resemble Parkinson’s disease
Ø Locura manganica (manganese madness) = described in Chilean miners after aerosol intoxication
Ø A
 Manganese
Ø Specimen Requirements
Ø WB, RBC or lymphocyte concentration may be more reliable than serum/plasma in
assessing the tissue stores of manganese
Ø Urine manganese may be used in conjunction with serum manganese to evaluate the
possibility of toxicity or deficiency
Ø Laboratory Methods: Most practical is flameless atomic absorption with selective
chelation and extraction
 Molybdenum
Ø Absorbed at a high rate and may inhibit copper and iron absorption
Ø Functions
Ø Nucleic Acid catabolism/uric acid production
Ø hpoxanthine--xanthine oxidase--> uric acid
Ø molydopterin = cofactor of xanthine oxidase
Ø Treatment for Wilson’s diseases
Ø Disorders:
Ø Deficiency = Mental disturbances, Keratin formation defect, thyroid problems, hypouricemia
Ø Toxicity = Anemia, thyroid problems, hyperuricemia
Ø Specimen Requirements
Ø Serum/plasma/whole blood too low to detect deficiency; urine is more responsive to
increases or decreases of intake, especially urate or sulfite measurement in urine
 Selenium
Ø Functions:
Ø Enzyme constituent (glutathione peroxidase, iodothyronine deiodinase)
Ø Considered to have close association with Vitamin E and its functions (anti-oxidant;
protection from free radicals)
Ø Thyroid hormone metabolism
Ø Specimen Requirements: serum, plasma, whole blood, RBC
Ø Laboratory Methods: Atomic absorption spectroscopy
VITAMINS
 Introduction
SOLUBILITY
Ø 1.Fat-soluble vitamins include A, D, E, and K.
Ø 2.Water-soluble vitamins include C, ascorbic acid; B1, thiamin; B2, riboflavin; B6,
pyridoxine; B12, cobalamin; niacin, nicotinic acid; pantothenic acid; biotin; folate,
folic acid
METABOLISM
Ø 1.Fat-soluble vitamins stored in liver or adipose tissue; may accumulate to toxic
levels
Ø 2.Water-soluble vitamins easily excreted in urine; generally do not accumulate to
toxic levels
 Functions
Ø 1.Vitamin A: Vision in dim light (most clearly defined), cellular differentiation, growth,
reproduction, immunity
Ø 2.Vitamin D: Proper skeleton formation and mineral homeostasis (Promotes
absorption of calcium and phosphorus); Pro-apoptopic effect
Ø 3.Vitamin E: Antioxidant, scavenge free radicals; RBC integrity; Cellular respiration
(esp. In muscles) strengthen cell membranes; augment drug metabolism, heme
biosynthesis, and neuromuscular function
Ø 4.Vitamin K: Formation of coagulation proteins (serves as cofactor)
Ø 5.Vitamin C: Coenzyme in oxidation-reduction reactions; hydroxylation of collagen
Ø 6.Vitamin B1: Coenzyme in decarboxylation reactions in carbohydrate pathways
and branched-chain amino acid metabolism
Ø 7.Vitamin B2: Component of coenzymes (flavin mononucleotide and flavin adenine
dinucleotide) which catalyzes various oxidation-reduction reactions
 Functions
Ø 8.Vitamin B6: Coenzymes in intermediary reactions; amino acid, phospholipid and
glycogen metabolism
Ø 9.Vitamin B12: Hematopoiesis-DNA synthesis; fatty acid metabolism
Ø 10.Vitamin B3: component of coenzymes (NAD and NADP)associated for oxidation-
reduction reactions necessary for various metabolic processes including tissue
respiration, and lipid, fatty acid and glucose metabolism
Ø 11.Vitamin B5: Incorporated in coenzyme A
Ø 12.Vitamin B7: Cofactor in carboxylation reactions in glucose; lipid and fatty acid
synthesis
Ø 13.Vitamin B9: Hematopoiesis-DNA synthesis; Amino acid synthesis
 Clinical Significance - Deficiency
Ø 1.Vitamin A (Retinal, Retinol, Retinoic acid) deficiency: Drying, degeneration, and
increased risk of infection in conjunctiva, cornea, skin, and mucous membranes;
night blindness (Nyctalopia), xeropthalmia; Growth retardation; Abnormal taste
response; Reproductive disorders, vulnerability to infection
Ø 2.Vitamin D (Cholecalciferol) deficiency: Rickets, osteomalacia, osteoporosis,
hypocalcemia, tetany
Ø 3.Vitamin E (A-Tocopherol) deficiency: Hemolytic disease of premature neonates;
RBC fragility; Ataxia; Spinocerebellar degeneration
Ø 4.Vitamin K deficiency: Easy bruising to massive bruising; Hemorrhage, Post-
traumatic bleeding
Ø 5.Vitamin C (Ascorbic acid) deficiency: Acute: Vague aches and pains; Chronic:
Scurvy, necrosis of gums, emotional disturbances
 Clinical Significance - Deficiency
Ø 6.Vitamin B1 (Thiamine) deficiency: Infants: Dyspnea, Cyanosis, Diarrhea and
Vomiting Adults: Beriberi, Wernicke-Korsakoff syndrome
Ø 7.Vitamin B2 (Riboflavin) deficiency: Cheilosis, angular stomatitis, glossitis,
seborrheic dermatitis, ocular disturbances/photophobia, neurologic changes
Ø 8.Vitamin B6 (Pyridoxine,Pyridoxal, Pyridoxamine) deficiency: Infants: Irritability,
seizures, anemia, vomiting, weakness Adults: Eczema, seborrheic dermatitis,
cheilosis, glossitis, angular stomatitis, mental depression, anemia
Ø 9.Vitamin B12 (Cobalamin) deficiency: Hematologic effects, including macrocytic
anemia, and neurologic effects, including peripheral nerve degeneration
Ø 10.Vitamin B3 (Niacin-nicotinic acid, nicotinamide) deficiency: Pellagra: dementia,
dermatitis, diarrhea
Ø 11.Vitamin B5 (Pantothenic acid) deficiency: Metabolism affected; causes nausea,
vomiting, muscular weakness, malaise; (Henry’s: no syndrome recognized)
 Clinical Significance - Deficiency
Ø 12.Vitamin B7 (Biotin) deficiency: Cutaneous, ophthalmic, and neurologic symptoms
*Rare: commonly due to to lack of biotin in total parenteral nutrition
Ø 13.Vitamin B9 (Folate,Folic acid) deficiency: Megaloblastic anemia, anorexia,
glossitis, nausea hepatosplenomegaly, hyperpigmentation of skin, neural tube
defects
 Clinical Significance - Toxicity
Ø 1.Vitamin A: Acute: Can cause drowsiness, headache, vomiting, stupor, skin peeling,
and papilledema Chronic: Teratogenic, osteoporosis, hepatotoxicity. Carotenoids in
excess, distinct orange-yellow skin color
Ø 2.Vitamin D: Hypercalcemia and hypercalciuria; Bone demineralization, constipation,
muscle weakness, renal calculi
Ø 3.Vitamin E: Mild GI distress, nausea, coagulopathies in patients receiving
anticonvulsants (Bishop: do not produce toxic effects)
Ø 4.Vitamin K: Excess amounts of vitamin K may decrease clotting time (Bishop: not
commonly seen in adults; hyperbilirubinemia in infants)
Ø 5.Vitamin C: Chronic megadoses of 10–150 times the RDA (1–15 g), cramps,
diarrhea, nausea, kidney stones. With megadoses, body accelerates drug
metabolism (interfering with its action); May interfere with Vitamin B12 metabolism;
Can produce scurvy if megadoses abruptly stop
 Clinical Significance - Toxicity
Ø 6.Vitamin B1: Only when given parenterally. Headache, muscle weakness, cardiac
arrhythmia, convulsions
Ø 7.Vitamin B2: Toxicity to riboflavin has not been reported. Absorption limited
normally
Ø 8.Vitamin B6: Long-term megadose supplementation causes ataxia and sensory
neuropathy.
Ø 9.Vitamin B12: No appreciable toxicity
Ø 10.Vitamin B3: Excess pre-formed niacin and nicotinic acid cause vascular dilation,
“flushing”; hepatotoxic (Lipid-lowering therapies)
Ø 11.Vitamin B5: Very high doses: Diarrhea
Ø 12.Vitamin B7: No known toxicity
Ø 13.Vitamin B9: No adverse effects at high oral doses
 Laboratory Methods
Ø HPLC, Fluorometric assays, liquid chromatography-tandem mass spectrometry,
spectrophotometry, electrochemical assays
Ø Competitive protein-binding assays, immunoassays, enzyme activation tests, RIA
Ø Microbiological assays, bioassays