Iligan Medical Center College

COLLEGE OF MEDICAL TECHNOLOGY

San Miguel Village, Pala-o, Iligan City
Tel No. (063) 221–4661 local 1119

PRE-DISCUSSION READING ASSIGNMENT ASSESSMENT TOPIC 2: ELECTROLYTES

I. INTRODUCTION
a. Define Electrolytes.
b. What is a cation?
c. What is an anion?
II. WATER
a. What is the average water content of the human body?
b. Explain why women has lower average water content than men.
c. Differentiate ICF from ECF.
d. Differentiate active transport and diffusion.
e. Explain how water distribution in the various body fluid compartments is controlled.
f. Osmolality
i. Define osmolality.
ii. What are the colligative properties that are the bases for measurement of
osmolality in the laboratory?
iii. Differentiate osmolality and osmolarity.
iv. List the instances wherein osmolarity measurement is inapplicable due to
inaccuracy?
v. What are the two factors controlled by the hypothalamus in response to an
increased osmolality of blood?
vi. What is the previous name of AVP?
vii. What is the natural response to the thirst sensation?
viii. What gland produces the AVP? What is the target organ of AVP? What is the
function of AVP?
g. Clinical Significance of Osmolality
i. What is the importance of osmolality in hypothalamus response?
ii. How does the regulation of osmolality affect Na + concentration in the plasma?
iii. How does regulation of blood volume affect Na + concentration?
iv. Explain the relationship between the rise and fall of osmolality and AVP
secretion controlled by hypothalamus.
v. How long is the half-life of AVP?
vi. Differentiate the importance of renal water excretion and thirst.
h. Water Load
i. Correlate polydipsia and AVP secretion.
ii. Explain why hypoosmolality and hyponatremia usually occur in patients with
impaired renal excretion of water.
i. Water Deficit
i. Correlate water deficit and AVP secretion.
ii. What is the major defense against hyperosmolality and hypernatremia?
iii. Correlate thirst sensation and advancement in age.
 Iligan Medical Center College
COLLEGE OF MEDICAL TECHNOLOGY
San Miguel Village, Pala-o, Iligan City
Tel No. (063) 221–4661 local 1119

iv. Explain the effectiveness of thirst in patients with diabetes insipidus.

j. Regulation of Blood Volume
i. What is the primary function of the RAAS?
ii. What are the functions of renin?
iii. What are the functions of angiotensin II?
iv. What is the function of aldosterone?
v. What are stretch receptors? Where are they located? What is their function?
vi. List the four other factors affecting blood volume and describe how they affect
blood volume.
vii. List the common conditions that lead to decreased urine osmolality.
viii. List the common conditions that lead to increased urine osmolality.
k. Determination of Osmolality
i. Specimen
1. What are the preferred samples for measurement of osmolality?
2. Explain why plasma is not recommended.
ii. Discussion
1. What is the basis for the methods of osmolality determination?
2. Describe the effect of an increased osmolality to the different colligative
properties that are most frequently methods of analysis.
3. List the precautions when preparing samples for osmolality
measurement.
4. Explain how osmometers are used.
5. List the importance of calculating osmolality.
6. What is an osmolal gap?
7. Indicate the two formulas that can be used for calculating osmolality.
iii. Reference range
1. Serum
2. Urine (24hrs)
3. Urine/serum ratio
4. Random urine
5. Osmolal gap
III. THE ELECTROLYTES
a. Sodium - most abundant cation in the ECF
i. What is the active transport system that is responsible for maintaining the
concentration gradient of Na+ and K+? Describe how this system works.
ii. What will happen if there is a build-up of Na + intracellularly?
iii. Regulation
1. List the three processes of primary importance in Na + regulation.
iv. Clinical Applications
1. Hyponatremia – one of the most common electrolyte disorders in
hospitalized and nonhospitalized patients.
 Iligan Medical Center College
COLLEGE OF MEDICAL TECHNOLOGY
San Miguel Village, Pala-o, Iligan City
Tel No. (063) 221–4661 local 1119

a. Specify the range of serum/plasma level of sodium indicative of

hyponatremia.
b. List the three major causes of hyponatremia and indicate their
causes.
c. Explain why K+ deficiency also causes sodium loss.
d. Explain how to use urine sodium levels to differentiate the
cause for increased sodium loss in the urine.
e. Explain why nephrotic syndrome and hepatic cirrhosis can cause
dilution of sodium.
f. Explain how to use urine sodium levels to differentiate the
cause for increased water retention.
g. Explain how SIADH can lead to hyponatremia.
h. How does pseudohyponatremia occur?
i. List the classification of hyponatremia by osmolality and
indicate their causes.
j. Explain how multiple myeloma causes hyponatremia with a
normal osmolality.
k. Explain how in vitro hemolysis can cause pseudohyponatremia
l. Explain how hyperglycemia leads to hyponatremia with a high
osmolality.
m. List the symptoms of hyponatremia between 125 and 130
mmol/L.
n. Symptoms
i. List the symptoms of hyponatremia below 125 mmol/L.
ii. List the more severe symptoms of hyponatremia.
iii. What sodium level is considered a medical emergency?
o. Treatment
i. What are the conventional treatments for
hyponatremia?
ii. What is the result of correcting severe hyponatremia
too rapidly?
iii. What is the result of correcting severe hyponatremia
too slowly?
iv. What two things are required during treatment of the
underlying cause of hyponatremia?
v. Describe the mode of action of Conivaptan.
vi. List the conditions associated with euvolemic
hypernatremia.
vii. List the conditions associated with hypervolemic
hyponatremia.
viii. Explain why Conivaptan is not an effective treatment
with hypovolemic hyponatremia.
 Iligan Medical Center College
COLLEGE OF MEDICAL TECHNOLOGY
San Miguel Village, Pala-o, Iligan City
Tel No. (063) 221–4661 local 1119

2. Hypernatremia
a. List the classification of hypernatremia related to urine
osmolality, including the causes.
b. Explain how diabetes insipidus can lead to hypernatremia.
c. List conditions that can increase the likelihood of developing
hypernatremia.
d. In what populations does hypernatremia commonly occur?
e. Chronic hypernatremia in an alert patient is indicative of what
disease?
f. Symptoms
i. List the symptoms of hypernatremia.
g. Treatment
i. Why is it important to correct hypernatremia gradually?
v. Determination of Sodium
1. Specimen
a. List the different samples acceptable for sodium measurements.
b. Indicate the suitable anticoagulants for plasma.
c. Why does hemolysis cannot affect measurement of sodium?
d. What is the effect of marked hemolysis?
e. What is the specimen of chouse for urine sodium analysis?
2. Methods
a. What is the most routinely used method? Explain its principle.
b. What is measured using the ISE?
c. What type of membrane is used in ISE measurement?
d. List the two types of ISE measurement. Describe their principles
and indicate which method is more accurate.
e. What is one source of error with ISEs, and indicate how to
address this issue.
f. Explain the principle of VITROS analyzers.
vi. Reference Ranges
1. Serum, plasma
2. Urine (24 hrs)
3. Cerebrospinal fluid
b. Potassium – major intracellular cation; 20x greater inside the cells than outside
i. List the functions of potassium.
ii. Regulation
1. Explain how aldosterone influence the excretion of potassium.
2. What is the principal determinant of urinary potassium excretion?
3. List the three factors that can influence the distribution of potassium
between cells and ECF.
4. List the different effects of exercise in potassium levels.
5. What is the effect of hyperosmolality to potassium?
 Iligan Medical Center College
COLLEGE OF MEDICAL TECHNOLOGY
San Miguel Village, Pala-o, Iligan City
Tel No. (063) 221–4661 local 1119

6. What is the effect of cellular breakdown to the potassium levels in ECF?

iii. Clinical Application
1. Hypokalemia
a. List the different causes of hypokalemia.
b. What is the most common cause of hypokalemia?
c. Explain how the following can lead to hypokalemia:
i. renal tubular acidosis
ii. Hypomagnesemia
iii. Alkalemia
iv. Insulin
v. Samples from leukemic patients can lead to
hypokalemia.
d. Symptoms
i. List the symptoms of hypokalemia.
e. Treatment
i. List the treatment for hypokalemia.
2. Hyperkalemia
a. List the causes of hyperkalemia.
b. What is the common cause of hyperkalemia?
c. Explain how the following can lead to hyperkalemia:
i. insulin deficiency
ii. Hyperglycemia
iii. Metabolic acidosis
d. List the drugs that can cause hyperkalemia.
e. Why does banked blood have increased potassium level in
plasma?
f. Explain why patients who undergo cardiac bypass may develop
mild elevation in plasma potassium during warming after
surgery.
g. Symptoms of hyperkalemia
i. List the symptoms of hyperkalemia.
ii. What symptom does not usually develop until plasma
potassium reaches 8 mmol/L?
iii. What levels of plasma potassium concentration can
alter the ECG?
iv. What can occur if plasma potassium concentration
reaches 10 mmol/L?
h. Treatment of hyperkalemia
i. List the different treatment for different cases of
hyperkalemia.
iv. Collection of Samples
 Iligan Medical Center College
COLLEGE OF MEDICAL TECHNOLOGY
San Miguel Village, Pala-o, Iligan City
Tel No. (063) 221–4661 local 1119

1. List the causes of artifactual hyperkalemia. Indicate any intervention if

mentioned.
v. Determination of Potassium
1. Samples
a. List the suitable samples.
b. Why should hemolysis be avoided?
c. What is the anticoagulant of choice for plasma samples?
d. What sample is preferrable for patients with high platelet
count?
e. What type of urine sample is preferred?
2. Methods
a. What is the method of choice?
b. What is the membrane used?
c. What is the inner electrolyte solution?
vi. Reference ranges
1. Serum
2. Plasma
3. Urine (24 hrs)
c. Chloride – major extracellular anion
i. Explain the ways chloride maintains electrical neutrality.
ii. Clinical Applications
1. List the conditions that can lead to hyperchloremia aside from the same
causes of hypernatremia.
2. List the conditions that can lead to hypochloremia aside from the same
causes of hyponatremia.
iii. Determination of Chloride
1. Specimen
a. List the appropriate samples and also indicate the anticoagulant
if applicable.
b. Why does hemolysis do not affect chloride measurement?
c. What is the effect of marked hemolysis?
2. Methods
a. List the different methodologies for chloride measurement and
indicate the most common.
b. What type of membrane is used in ISE?
c. What method uses silver ions? What is the principle of this
method?
iv. Reference range
1. Plasma, serum
2. Urine (24 h)
d. Bicarbonate – second most abundant anion in the ECF
i. What is the relationship between total CO 2 and bicarbonates?
 Iligan Medical Center College
COLLEGE OF MEDICAL TECHNOLOGY
San Miguel Village, Pala-o, Iligan City
Tel No. (063) 221–4661 local 1119

ii. What enzyme in RBCs is responsible for converting CO 2 that results to formation
of bicarbonate?
iii. Explain the process of how bicarbonate acts as a buffer.
iv. Regulation
1. What part of the excretory system reabsorbs most of bicarbonate?
2. Bicarbonates are reabsorbed in what chemical form? How does this
occur?
3. In alkalosis, what cation is carried along with the increased excretion of
bicarbonate?
4. In acidosis, what is the state of absorption of bicarbonate?
v. Clinical Applications
1. Explain why metabolic acidosis leads to decreased bicarbonate.
2. Explain why metabolic alkalosis leads to increased bicarbonate.
vi. Determination of CO2
1. Specimen
a. List the appropriate samples and indicate the anticoagulant
used if applicable.
b. What is the effect of an uncapped sample to the measurement
of bicarbonate?
2. Measurement
a. List the two methods for measurement.
vii. Reference value
1. CO2, venous
e. Magnesium – 4th most abundant cation in the body; 2nd most abundant intracellular ion
i. List the distribution of magnesium in the body
ii. In what protein do 1/3 of the magnesium present in serum is bound to?
iii. In the serum, 63% of Magnesium exist in what state?
iv. 5% of the serum magnesium is complexed with other ions such as?
v. What form of magnesium is physiologically active in the body?
vi. What are the functions of magnesium?
vii. Regulation
1. List the rich sources of Magnesium in the diet.
2. What organ controls the overall regulation of magnesium?
3. What part of the renal system is the major regulatory site of
magnesium?
4. What is the renal threshold of magnesium?
5. Describe the effect of the following to magnesium:
a. Parathyroid hormone
b. Aldosterone and thyroxine
viii. Clinical Applications
1. Hypomagnesemia
a. List the general categories and the causes of hypomagnesemia.
 Iligan Medical Center College
COLLEGE OF MEDICAL TECHNOLOGY
San Miguel Village, Pala-o, Iligan City
Tel No. (063) 221–4661 local 1119

b. Which among the categories is least likely to cause severe

deficiency?
c. Explain why the following can cause hypomagnesemia
i. hyperparathyroidism and hypercalcemia
ii. Hyperaldosteronism
iii. Diabetes
iv. Excess lactation
d. List the drugs that can increase renal loss of magnesium and
explain their mechanisms.
e. What is the effect of hypomagnesemia to pregnant women?
f. Symptoms
i. List the different categories of hypomagnesemia
symptoms.
ii. Explain why hypomagnesemia can lead to cardiac
arrhythmias.
iii. Explain why magnesium deficiency can lead to
hypocalcemia.
g. Treatment
i. What is the preferred form of treatment?
ii. How is treatment administered in severely ill patients?
2. Hypermagnesemia
a. List the categories and causes of hypermagnesemia.
b. What is the most common cause of hypermagnesemia?
c. What magnesium-containing medications can cause most
severe elevations of magnesium?
d. What patients are at greatest risk for this occurrence?
e. Explain how the following can lead to hypermagnesemia
i. Thyroxine and growth hormone
ii. Adrenal insufficiency
iii. Magnesium sulfate therapy
iv. Dehydration
v. Multiple myeloma and bone metastases
f. Symptoms
i. List the most frequent symptoms of hypermagnesemia.
ii. List the mild to moderate symptoms of
hypermagnesemia
iii. Life -threatening symptoms of hypermagnesemia
ix. Determination of Magnesium
1. Specimen
a. List the preferred specimens
b. Why should hemolysis be avoided?
 Iligan Medical Center College
COLLEGE OF MEDICAL TECHNOLOGY
San Miguel Village, Pala-o, Iligan City
Tel No. (063) 221–4661 local 1119

c. List the unacceptable anticoagulants for magnesium

measurement and indicate why they are unacceptable.
2. Methods
a. List the three most common colorimetric methods for
measuring total serum magnesium and explain each of their
principle.
b. List the limitations of serum measurement of total magnesium.
x. Reference ranges
1. Serum, colorimetric
f. Calcium
i. What are the two forms of Ca?
ii. What form is important for cardiac muscle contraction?
iii. What condition will result if there is there is decreased ionized Ca?
iv. Regulation
1. List the three hormones that regulate Calcium and explain each of their
mechanisms.
2. If there is a decreased ionized Ca, what will happen to PTH secretion?
3. If there is an increased ionized Ca, what will happen to PTH secretion?
4. On what organs do PTH exert major effects?
5. What is the major effect of PTH to bones?
6. What is the effect of bone resorption on Calcium?
7. What are the major effects of PTH to kidneys?
8. In what organ will the conversion of Vit D3 to 25-hydroxycholecalciferol
(1,25-[OH]2-D3) occur?
9. In what organ will the hydroxylation of 1,25-dihydroxycholecalciferol
occur?
10. What is the biologically active form of Vit D?
11. What is the function of the biologically active Vit D?
12. What triggers the increased concentration of Calcitonin?
13. How does Calcitonin exert its effect?
v. Distribution
1. in what body part does 99% of Calcium is found?
2. Between blood and cardiac muscles, which one has a higher
concentration of Calcium?
3. What are the distribution of Ca?
vi. Clinical Applications
1. What form of Ca is usually a more sensitive and specific marker for
Ca2disorders?
2. Hypocalcemia
a. What are the expected effects primary hypoparathyroidism?
b. What are the three ways that hypomagnesemia may cause
hypocalcemia?
 Iligan Medical Center College
COLLEGE OF MEDICAL TECHNOLOGY
San Miguel Village, Pala-o, Iligan City
Tel No. (063) 221–4661 local 1119

c. what is the effect of hypermagnesemia to Calcium?

d. Deficiency of this protein leads to hypocalcemia
e. How many mg/dL is decreased in total Ca levels for every 1g/dL
decrease in serum albumin?
f. What are the causes of hypocalcemia?
g. Why do pancreatitis lead to hypocalcemia?
h. Symptoms
i. List the symptoms of hypocalcemia
i. Treatment
i. List that treatments for hypercalcemia
3. Hypercalcemia
a. What is the main cause of hypercalcemia?
i. What population is seen most frequently with this
condition?
b. What is the second leading cause of hypercalcemia?
c. What is PTH-rp?
d. How can hyperthyroidism lead to hypercalcemia?
e. What diuretic can cause hypercalcemia?
f. Symptoms
i. List the symptoms of hypercalcemia
g. Treatment
i. List the different treatment for different cases of
hypercalcemia
vii. Determination of Calcium
1. Specimen
a. What is the preferred specimen for Ca determination?
b. EDTA is unacceptable as anticoagulant for Ca determination,
why?
c. what are the factors to consider in sample collection of Ca?
d. For analysis of Ca in urine, what should be added to acidify the
sample?
2. Methods
a. What are the two commonly used methods for total Ca
analysis?
b. in the CPC method, what is added to prevent Mg interference?
c. What is the reference method for total Ca determination?
d. What method is used in current commercial analyzers that
measure ionized calcium?
viii. Reference ranges
1. Total Calcium – serum, plasma
a. Child, <12 y
b. Adult
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COLLEGE OF MEDICAL TECHNOLOGY
San Miguel Village, Pala-o, Iligan City
Tel No. (063) 221–4661 local 1119

2. Ionized calcium – serum

a. Child
b. Adult
3. Ionized calcium – plasma
a. Adult
4. Ionized calcium – whole blood
a. Adult
5. Total calcium – urine (24 h)
g. Phosphate
i. What molecules in the body requires phosphate?
ii. What is the effect of phosphate levels in the oxygenation of tissues?
iii. Loss of regulation by this organ will have the most profound effect to phosphate
concentrations.
iv. Regulation
1. What is the effect of PTH to phosphate?
2. What is the effect of Vit D to phosphate?
3. What is the effect of GH to phosphate?
v. Distribution
1. What is the distribution of phosphate?
vi. Clinical Applications
1. Hypophosphatemia
a. List the causes of hypophosphatemia
2. Hyperphosphatemia
a. List the causes of hyperphosphatemia
b. In neonates, what make them at risk for hyperphosphatemia?
c. What conditons can lead to increased breakdown of cells,
leading to hyperphosphatemia?
d. What specific cancer is susceptible to hyperphosphatemia?
vii. Determination of inorganic phosphorus
1. Specimen
a. What specimens are acceptable for phosphate analysis?
b. What factors are to be considered in phosphate specimen
collection for analysis?
c. In urine analysis for phosphate, what is the preferred sample
collection, why?
2. Methods
a. Phosphorus determination involves the formation of what
complex?
b. How can this complex be measured?
c. If the complex is reduced, it will form molybdenum blue. In
what wavelength should this stable chromophore be read?
viii. Reference Values
 Iligan Medical Center College
COLLEGE OF MEDICAL TECHNOLOGY
San Miguel Village, Pala-o, Iligan City
Tel No. (063) 221–4661 local 1119

1. Serum
a. Neonate
b. Child ≤ 15 y
c. Adult
2. Urine (24(h)
h. Lactate
i. What physiologic condition will convert pyruvate to lactate?
ii. What is the significance of accumulation of excess lactate in the blood?
iii. Regulation
1. What is the major organ responsible for removing lactate? What
process allows for the removal of lactate?
2. What leads to rapid rise in the blood concentration of lactate?
iv. Clinical applications
1. What are the clinical applications of lactate?
2. What are the two types of lactic acidosis, and what are the associated
disorders?
v. Determination of Lactate
1. Specimen Handling
a. Why is it ideal not to apply tourniquet during blood sample
determination for lactate?
b. If tourniquet is used, what necessary precaution should be
observed?
c. What are other factors to consider during specimen collection
for lactate determination?
2. Methods
a. What is the common method used to measure lactate? What
enzyme reagents is used in this method?
b. In colorimetric method, what enzyme reagent is used?
vi. Reference ranges
1. Enzymatic, Plasma
a. Venous
b. Arterial
c. CSF
2. Colorimetric, Whole blood
a. Venous
b. Arterial
c. CSF
IV. ANION GAP
a. What is an anion gap?
b. How is anion gap calculated?
c. What are the usefulness of AG?
d. What is the equation for AG?
e. What is the reference range?
f. What are the indications of elevated AG?
 Iligan Medical Center College
COLLEGE OF MEDICAL TECHNOLOGY
San Miguel Village, Pala-o, Iligan City
Tel No. (063) 221–4661 local 1119

g. What are the indications of a low AG?

V. ELECTROLYTES AND RENAL FUNCTION

a. What is the function of glomerulus?
b. Describe what happens to the following electrolytes in the renal tubules:
i. Phosphate
ii. Calcium
iii. Magnesium
iv. Sodium
1. List the three mechanisms for sodium reabsorption in the renal tubules.
c. What is the importance of the loop of Henle in water reabsorption?
d. What is the function of the collecting ducts?