CLINICAL CHEMISTRY Topics:

Medical Technology Assessment Program Endocrinology

Toxicology

Acid-Base Balance
Yerenze Gregory W. Flores, MD
Saint Louis University
School of Nursing, Allied Health, and Biological Sciences
Department of Medical Laboratory Science
Blood Gases

Endocrinology Anterior Pituitary Gland

Pituitary Gland v Anterior pituitary gland
ü Master gland
Thyroid Gland ü It has 6 major hormones:
o (1) prolactin (PRL), (2) growth hormone
(GH), (3) adrenocorticotropic hormone
Parathyroid Gland (ACTH), (4) luteinizing hormone (LH), (5)
follicle-stimulating hormone (FSH), and (6)
thyroid- stimulating hormone (TSH)
Adrenal Gland

Anterior Pituitary Gland Anterior Pituitary Gland

v Anterior pituitary gland
ü Each of these pituitary hormones
elicits specific trophic responses in
peripheral target tissues including the
adrenal, thyroid, and gonads, as well as
tissues involved in metabolism
v Anterior pituitary gland
ü Elicited hormonal products of
peripheral glands, in turn, exert
feedback control at the level of the
hypothalamus and pituitary to
modulate pituitary function
Anterior Pituitary Gland
v Anterior pituitary gland
ü Disorders can increase or decrease the
level of hormones
ü Diagnoses are often elusive. this
emphasizes the importance of
recognizing subtle clinical
manifestations and performing the
correct laboratory diagnostic tests.
1. Growth Hormone
v GH secretion is pulsatile, with
highest peak levels occurring at
night, generally correlating with
sleep onset.
1. Growth Hormone
v The most abundant anterior
pituitary gland hormone
ü GH-secreting somatotrope cells
constitute up to 50% of the total
anterior pituitary cell population.
1. Growth Hormone
v Decline in hormone:
ü Age (middle age vs pubertal levels)
ü Obesity, Hyperglycemia
v Increase in hormone:
ü Deep sleep
ü Exercise
ü Trauma, Malnutrition, Sever fasting
ü Sepsis
ü Women (estrogen replacement)
1. Growth Hormone
v Note:
ü Using standard assays, random GH
measurements are undetectable in 50% of
daytime samples obtained from healthy
subjects and are also undetectable (<1 μg/L)
in most obese and elderly subjects.
ü Thus, single random GH measurements do
not distinguish patients with adult GH
deficiency from those with GH levels in the
normal range.
1. Growth Hormone 1. Growth Hormone
v Note: v Tests:
ü Using ultrasensitive GH assays with a 1. Insulin tolerance test
sensitivity of 0.002 μg/L, a glucose load 2. GHRH test
suppresses GH to <0.7 μg/L in women and to
<0.07 μg/L in men.
3. L-arginine test
ü GH is stimulated by oral ghrelin receptor 4. L-dopa test
agonists, intravenous l-arginine, dopamine,
and apomorphine (a dopamine receptor
agonist), as well as by α-adrenergic
pathways.

1. Growth Hormone 2. ACTH

v Disease association: v ACTH-secreting corticotrope cells
ü Increase GH → Gigantism/Acromegally constitute 20% of the pituitary cell
o Tests: population.
1. Increase serum IGF-1
2. Failure to suppress serum GH
following oral glucose tolerance
test
3. Pituitary mass seen on brain MRI.

2. ACTH
v ACTH secretion is pulsatile and
exhibits a characteristic circadian
rhythm, peaking at about 6:00 a.m.
and reaching a nadir about
midnight.
v Adrenal glucocorticoid secretion,
which is driven by ACTH, follows a
parallel diurnal pattern.
2. ACTH
v ACTH secretion is pulsatile and
exhibits a characteristic circadian
rhythm, peaking at about 6:00 a.m.
and reaching a nadir about
midnight.
v Adrenal glucocorticoid secretion,
which is driven by ACTH, follows a
parallel diurnal pattern.
2. ACTH 2. ACTH
v Hormone increase: v Tests:
ü Acute inflammation 1. CRH test
ü Sepsis 2. Metyrapone test
o Acute inflammatory or septic insults
activate the HPA axis through the
integrated actions of proinflammatory
cytokines, bacterial toxins, and neural
signals.

3. TSH
v TSH-secreting thyrotrope cells
constitute 5% of the anterior
pituitary cell population.
v TSH shares a common α subunit
with LH and FSH but contains a
specific TSH β subunit.

3. TSH
v TSH secretion is stimulated by TRH,
whereas thyroid hormones,
dopamine, somatostatin, and
glucocorticoids suppress TSH by
overriding TRH induction.
3. TSH
v Thyrotrope cell proliferation and
TSH secretion are both induced
when negative feedback inhibition
by thyroid hormones is removed.
ü Thus, thyroid damage (including surgical
thyroidectomy), radiation-induced
hypothyroidism, chronic thyroiditis, and
prolonged goitrogen exposure are
associated with increased TSH levels.
3. TSH
v Tests:
1. Basal thyroid tests
2. TRH test
4. LH, FSH
v GnRH is secreted in discrete pulses
every 60‒120 min, and the pulses in turn
elicit LH and FSH pulses
v The pulsatile mode of GnRH input is
essential to its action; pulses prime
gonadotrope responsiveness, whereas
continuous GnRH exposure induces
desensitization.
3. TSH
v Single determinations of TSH
suffice to precisely assess its
circulating levels.
ü low amplitude of the pulses and the
relatively long half-life of TSH.
4. LH, FSH
v Gonadotrope cells constitute 10% of
anterior pituitary cells and produce two
gonadotropin hormones̶LH and FSH.
v Like TSH and human chorionic
gonadotropin, LH and FSH are
glycoprotein hormones that comprise α
and β subunits. The α subunit is
common to these glycoprotein hormones
4. LH, FSH
v Estrogens act at both the hypothalamus
and the pituitary to modulate
gonadotropin secretion.
v Chronic estrogen exposure is inhibitory,
whereas rising estrogen levels, as occur
during the preovulatory surge, exert
positive feedback to increase
gonadotropin pulse frequency and
amplitude.
LH, FSH
v Tests:
1. LH, FSH, Testosterone, Estrogen
2. GnRH test
Prolactin
v Normal adult serum PRL levels are about 10‒
25 μg/L in women and 10‒20 μg/L in men.
v PRL secretion is pulsatile, with the highest
secretory peaks occurring during non‒rapid
eye movement (non-REM) sleep.
v Peak serum PRL levels (up to 30 μg/L) occur
between 4:00 and 6:00 a.m. The circulating
half-life of PRL is 50 min.
Posterior Pituitary Gland
v The neurohypophysis, or posterior
pituitary, is composed of large neuronal
axons that originate in cell bodies in the
supraoptic and paraventricular nuclei of
the hypothalamus.
v Hormones:
1. Vasopressin (Supraoptic nucleus)
2. Oxytocin (Paraventricular nucleus)
Prolactin
v PRL acts to induce and maintain lactation
and to suppress both reproductive
function and sexual drive. These
functions are geared toward ensuring
that maternal lactation is sustained and
not interrupted by pregnancy.
Prolactin
v Tests:
ü Serum Prolactin
Posterior Pituitary Gland
v The neurohypophysis, or posterior
pituitary, is composed of large neuronal
axons that originate in cell bodies in the
supraoptic and paraventricular nuclei of
the hypothalamus.
v Hormones:
1. Vasopressin (Supraoptic nucleus)
2. Oxytocin (Paraventricular nucleus)
1. Vasopressin
v The most important, if not the only,
physiologic action of AVP is to reduce
water excretion by promoting
concentration of urine.
v This antidiuretic effect is achieved
primarily by increasing the hydroosmotic
permeability of principal cells that line
the distal tubule and medullary collecting
ducts of the kidney
1. Vasopressin
v In the absence of AVP, these cells are
impermeable to water and reabsorb
little, if any, of the relatively large
volume of dilute filtrate that enters from
the proximal nephron.

1. Vasopressin
v Disease association:
ü Deficiency in ADH → Diabetes Insipidus
o Diabetes insipidus (DI) is a syndrome
characterized by the excretion of
abnormally large volumes of dilute urine.
The 24-h urine volume exceeds 40 mL/ kg
body weight, and the 24-h urine
osmolarity is <280 mosm/L.

1. Vasopressin
v Tests:
1. 24-hour urine osmolarity
2. Basal plasma arginine vasopressin test
1. Vasopressin
v Disease association:
ü Increase in ADH → SIAD
o Characterized by excessive free water
retention, euvolemic hyponatremia with
continued urinary Na+ excretion, urine
osmolality > serum osmolality.
2. Oxytocin
v Act mainly on mammary ducts to
facilitate milk letdown during nursing.
v It also may help initiate or facilitate labor
by stimulating contraction of uterine
smooth muscle.
Thyroid Gland
v Hormones:
1. T3
2. T4
ü Acting through thyroid hormone receptors
(TR) α and β, these hormones play a critical
role in cell differentiation and organogenesis
during development and help maintain
thermogenic and metabolic homeostasis in
the adult.
1. T4
v Forms about 90% (bound to
thyroglobulin) of the total thyroid
hormone secretions
v 99 % of the circulating T4 are bound to
carrier proteins.
v 75% to thyroxine-binding globulin (TBG)
v 15% to thyroxine-binding pre-albumin
v 9% to albumin
1. T4
v T4 acts for longer periods than T3
v T4 has more affinity and strongly binds
with plasma proteins so that it is
released slowly
Conversion of T4 to T3
2. T3
v About 99.5% is bound to TBG, and about
0.5 % is free
v Potency of T3 is four times more than
that of T4
v Has less affinity for plasma proteins and
combines loosely with them so that it is
released quickly
Conversion of T4 to T3
v T4 may be thought of as a precursor for
the more potent T3.
v T4 is converted to T3 by the deiodinase
enzymes
1. Type I deiodinase: Low affinity for T4
2. Type II deiodinase: High affinity for T4
3. Type III deiodinase: Inactivates T3 and
T4
2. T3
v Only 9% to 10% of the total secretion
v More active form than T4
v 80% comes from the extrathyroidal
deiodination (removal of one iodine in the
liver and kidneys) of T4
Disease association
Thyroid function tests
Thyroid function tests
v Other tests:
1. Measurement of TPO antibodies or
TRAb in the diagnosis of Grave s
disease

Grave s Disease
v Triad:
1. Dermopathy
2. Ophthalmopathy
3. Thyrotoxicosis

Grave s Disease Grave s Disease

v The hyperthyroidism of Graves disease
is caused by thyroid-stimulating
immunoglobulins (TSIs)
v Such antibodies can be detected by
bioassays or by using the more widely
available immunoassays (TSH receptor
antibody [TRAb])
v Other thyroid autoimmune responses,
similar to those in autoimmune
hypothyroidism, occur concurrently in
patients with Graves disease. In
particular, thyroid peroxidase (TPO) and
thyroglobulin (Tg) antibodies occur in up
to 80% of cases.
Hashimoto s Thyroiditis
v Autoimmune hypothyroidism
v Most common cause of hypothyroidism in
iodine- sufficient regions.
v Laboratory:
ü Once clinical or subclinical hypothyroidism is
confirmed, the etiology is usually easily
established by demonstrating the presence
of TPO and Tg antibodies, which are present
in >95% of patients with autoimmune
hypothyroidism.
Parathyroid Gland
Adrenal Gland
v The adrenal cortex produces three classes of
corticosteroid hormones: glucocorticoids (e.g.,
cortisol), mineralocorticoids (e.g., aldosterone),
and adrenal androgen precursors (e.g.,
dehydroepiandrosterone [DHEA])
v Disorders of the adrenal cortex are
characterized by deficiency or excess of one or
several of the three major corticosteroid
classes
Parathyroid Gland
v Hormone: Parathyroid Hormone
v Action: Calcium and Phosphate
Metabolism
ü Kidney: Inc. Ca reabs (DT), dec. phosphate
reabs (PCT), Inc. activation of Vit. D
ü Bone: Inc. Ca and Phosphate resorption
ü Net effect: Inc. serum Calcium, Dec. serum
Phosphate
Adrenal Gland
v The adrenal cortex produces three classes of
corticosteroid hormones: glucocorticoids (e.g.,
cortisol), mineralocorticoids (e.g., aldosterone),
and adrenal androgen precursors (e.g.,
dehydroepiandrosterone [DHEA])
v Disorders of the adrenal cortex are
characterized by deficiency or excess of one or
several of the three major corticosteroid
classes
Adrenal Gland
v Diagnostic tests assessing the HPA axis make
use of the fact that it is regulated by negative
feedback.
v Glucocorticoid excess is diagnosed by
employing a dexamethasone suppression test.
Adrenal Gland
v Dexamethasone, a potent synthetic
glucocorticoid, suppresses CRH/ACTH by
binding hypothalamic-pituitary glucocorticoid
receptors (GRs) and, therefore, results in
downregulation of endogenous cortisol
synthesis.

Adrenal Gland Adrenal Gland

v Disease association: Cushing s v Disease association: Cushing s
syndrome syndrome
ü Inc. cortisol due to a variety of causes: ü Presentation:
o Exogenous glucocorticoids
o Primary adrenal adenoma, hyperplasia, or
carcinoma
o ACTH-secreting pituitary adenoma
(Cushing disease); paraneoplastic ACTH
secretion (eg, small cell lung cancer,
bronchial carcinoids)

Adrenal Gland
v Diagnostics:
ü Inc. free cortisol on 24-hr urinalysis,
ü Inc. late night salivary cortisol
ü Suppression with overnight low-dose
dexamethasone test
Toxicology Toxicology
Basic concepts v Toxicology is the study of toxic
drugs or poisons.
Laboratory tests v A toxicant (poison) is any substance
that, when taken in sufficient
Drugs quantity, causes sickness or death.

Toxicology Therapeutic drug monitoring

v Toxicity is a relative term used to vMost
v often performed
Performed by patient
to determine atomic
compare one substance with absorption
compliancespectrophotometry.
to the drug-taking regimen,
another; a toxic substance is one to monitor drug interactions, and to
with a toxicity defined as monitor drugs that are used for a
extremely or super toxic. preventive effect.

Therapeutic drug monitoring Therapeutic drug monitoring

vMost
v often
Changes inperformed by atomic in the
drug concentrations 1.Most
v often performed by atomic
Liberation
absorption spectrophotometry.
body are related to the course of the absorption spectrophotometry.
ü Release of the ingredients
pharmacologic effects: ü Drug passes into solution
1. Liberation
2. Absorption
3. Distribution
4. Bioavailability
5. Metabolism
6. Elimination
Therapeutic drug monitoring
2.Most
v often performed by atomic
Absorption
vabsorption spectrophotometry.
Drug is taken up by the blood circulation
v First-pass elimination or metabolism
ü Intestinal mucosa → Veins of the
intestine → Portal vein → Hepatic
circulation
Therapeutic drug monitoring
4.Most
v often performed by atomic
Bioavailability
vabsorption
The amount spectrophotometry.
of drug that is absorbed into
the system and is available for
distribution
Therapeutic drug monitoring
6.Most
v often performed by atomic
Elimination
vabsorption
process of spectrophotometry.
excretion of the drug from
the body. Drugs are typically excreted in
the urine but also can be eliminated in the
feces, sweat, expired air, and saliva.
Therapeutic drug monitoring
3.Most
v often performed by atomic
Distribution
vabsorption spectrophotometry.
Drug molecule leave the blood stream
and enter the extravascular space, or
they can migrate into various tissues.
v Occurs between a period of 30 minutes
and 2 hours.
Therapeutic drug monitoring
5.Most
v often performed by atomic
Metabolism
vabsorption spectrophotometry.
Transformation of the parent drug
molecule to its metabolites.
v Metabolites are usually water soluble and
can be easily excreted.
v Most of the metabolism occurs in the
liver, where enzymes catalyze oxidation,
reduction, or hydrolysis of the drug.
Therapeutic drug monitoring
vMost
v TDM often performed
measures by atomic
drug concentration
absorption spectrophotometry.
during therapy with pharmaceutical
agents.
v A steady-state drug level (complete with
peaks and troughs) exists for each drug.
Therapeutic drug monitoring Therapeutic drug monitoring
vMost
v Whenoften performed
a single dose of by atomic
a drug is vMost
v often performed
For single-dose by atomicthe rate
administration,
absorption spectrophotometry.
administered orally, the blood level absorption spectrophotometry.
of decline in concentration is ex- pressed
changes markedly over time and, at some in terms of half-life, which is the time
time, the concentration in the plasma required for the concentration of the
reaches its peak (highest point) and then drug to decrease by 50% (Figure 1‒6).
declines. The half-life is different for each drug.
v Immediately before the next dose of
medication, a trough level occurs.

Therapeutic drug monitoring Specimen consideration

vMost
v oftenstate
At steady performed
levels, by
theatomic
rate of v Most often performed by atomic
absorption spectrophotometry.
administration of the drug is equal to the absorption spectrophotometry.
rates of metabolism and excretion,
allowing the drug level to remain
constant.

Specimen consideration Specimen consideration

v Most often performed by atomic v Most often performed by atomic
absorption spectrophotometry. absorption spectrophotometry.
Toxicology
v Screening VS Confirmatory
Screening
v Neutral and basic drugs as well as
drug metabolites are best detected
in urine, whereas acidic drugs are
best found in detectable
concentrations in blood and serum.
v Following a positive drug screen,
confirmatory methods must be used
to quantitatively analyze drug levels
in a patient.
Screening
v Methods:
1. Handheld immunoassay
2. Gas-liquid chromatography
Screening
v The drug screen rapidly identifies a
drug or drugs present in the blood,
urine, or gastric contents of a
patient suffering from toxicity
Screening
v Neutral and basic drugs as well as
drug metabolites are best detected
in urine, whereas acidic drugs are
best found in detectable
concentrations in blood and serum.
v Following a positive drug screen,
confirmatory methods must be used
to quantitatively analyze drug levels
in a patient.
1. Handheld immunoassay
v The most common type of drug screen.
They detect a wide variety of drugs but
cannot separate closely related
compounds. Blood and urine can both be
analyzed with this method.
2. Gas-liquid chromatography Confirmatory tests
v allows for greater sensitivity in the v Methods:
identification of drugs. It can be used as 1. Gas chromatography/mass
a confirmatory technique for drugs spectrometry
detected by drug screen. 2. Immunoassay technique
3. Ethanol
4. Heavy metal testing

1. GC/MS 2. Immunoassays
v a sensitive technique used to confirm v use antibodies to detect drugs. These
drugs detected by screening techniques. methods are usually automated and in
v Typically, urine samples are initially the form of enzyme immunoassays.
analyzed by gas chromatography to
determine the presence of compounds,
then reanalyzed by mass spectrometry to
examine fragments of these compounds
for relative abundance in the sample.

3. Ethanol testing Toxicology

v Typically performed using gas v Categories of Toxicants
chromatography. However, an enzyme 1. Analgesics
assay using alcohol dehydrogenase and 2. Barbiturates
measuring the increase in NADH 3. Narcotics
formation following the reaction is widely 4. Pesticides
used and can be automated. 5. Carbon monoxide
6. Metal poisoning
7. Substance of abuse
Toxicology
v Therapeutic drugs
1. Cardioactive drugs
2. Antiarrhythmic drugs
3. Anticonvulsants
4. Bronchodilators
5. Psychotropic/antipsychotic drugs
6. Antineoplastic drugs

Acid Base Acid-Base Disorders

Acid Base Disorders

Acid-Base Disorders Blood gases

3 STEPS IN ABG INTERPRETATION Laboratory tests
1. Identify if it is ACIDOSIS or ALKALOSIS

2. Identify if it is RESPIRATORY or
METABOLIC

3. Identify if it is COMPENSATED or
UNCOMPENSATED
Specimen collection Laboratory testing
v Specimen collection: Arterial blood v FACTORS AFFECTING ABG
v Anticoagulant: 0.05mL heparin/mL of ü Temperature
blood ü Elevated plasma protein
v Common errors in specimen collection concentrations
and handling: ü Bacterial contamination
ü Form and concentration of heparin ü Improper transport
ü Speed of syringe filling
ü Maintenance of anaerobiosis
ü Collection device
ü Transport

Laboratory testing Laboratory testing

1. Gasometric (Van Slyke or Natelson)
v Reagents:
ü Mercury: provides vacuum
ü Lactic acid: releases carbon dioxide
ü Caprylic alcohol: prevents foaming
ü Sodium hydroxide absorbs carbon
dioxide

Laboratory testing
2. Electrodes
v pH: glass electrode connected to a
reference electrode (calomel electrode
and mercury-mercuric chloride Thank you!
electrode)
v pCO2: Severinghaus electrode
v pO2: Clark electrode