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Lecture 3 Clinical Biochemistry
Lecture 3 Clinical Biochemistry
DISEASES
Presentation by:
Dr. Petrescu Elena
Dr. Stanescu Raluca
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Functions of the liver
1. Carbohydrate metabolism
•Glycogen synthesis and breakdown
•Gluconeogenesis
•Maintenance of blood glucose level during fasting
2. Lipid metabolism
•Fatty acid and triglyceride synthesis
•Cholesterol synthesis
•Lipoprotein synthesis (VLDL, HDL)
•Ketogenesis
•Bile acid synthesis
3. Protein metabolism
•Synthesis of plasma proteins - including albumin, most coagulation factors
•Urea synthesis
• I. Hepatocellular damage
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I. Tests for hepatocytolysis
Aminotransferases
Lactate dehydrogenase
Glutamate dehydrogenease
Ornithine carbamoyl transferase
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Aminotransferases
GPT (ALT):
• Alanine + α-keto glutarate ↔ pyruvate + glutamate
• Distribution: abundant in the liver; much smaller amounts are present in the
skeletal muscle (→ relative liver specificity)
• Cellular location: cytosol
GOT (AST):
• Aspartate + α-keto glutarate ↔ oxaloacetate + glutamate
• Distribution: liver, myocardium and skeletal muscle, in similar proportions
• Cellular location: cytosol + mitochondria
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Acute hepatitis (infectious or toxic):
• GPT and GOT increase in plasma even before the onset of clinical signs
• Their elevation is 20 to 50 fold, in severe forms even 100 fold → they remain
elevated for 1-2 weeks (GPT persists longer than GOT: t1/2 is 48-60 h for GPT and
18-24 h for GOT)
• The level of aminotransferase activity correlates with the extent of liver damage
• Moderate severity → GPT increases more than GOT (only cytosolic GOT is released)
→ de Ritis ratio ↓
• Liver necrosis → GOT increases more than GPT (GOT from the mitochondrial pool
is also released) → de Ritis ratio ↑
Alcoholic hepatitis – GOT and GPT increase 5-10 fold, the de Ritis ratio > 2
(mitochondrial GOT is released due to some degree of liver cell necrosis)
Modest increase (2-5 fold) in: liver cirrhosis, liver cancer, cholestasis
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Differential diagnosis:
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II. Tests for the liver synthetic
function
Albumin
Cholinesterase
Coagulation factors
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1. Chronic liver failure
Coagulation factors
•In liver diseases - the synthesis of coagulation factors decreases
•The prothrombin time (PT) is prolonged – this is one of the earliest changes that
occur (t1/2 of prothrombin = 6 h)
•Factor VII may also be measured → it decreases in case of liver failure
•These tests are useful for the detection of a liver failure with rapid onset, but they are
also changed in chronic liver diseases
•PT may also increase due to a deficiency of vitamin K – caused by fat malabsorption
(abnormal bile production in chronic liver diseases, cholestasis)
•For differentiation – the vitamin K test: parenteral administration →
- if PT remains prolonged → liver disease
- if PT is normalized → fat malabsorption
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III. Cholestasis syndrome
Bilirubin
Alkaline phosphatase
γ-Glutamyl transferase
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Formation and excretion of bilirubin
• Bilirubin (BR) results from heme degradation in the reticuloendothelial system,
mainly in the spleen
• BR is transported to the liver bound to albumin - this form is unconjugated
(indirect) BR, which is lipophilic →
- is not filtered by the glomeruli
- can cross cell membranes, being potentially toxic
• In the liver, BR is conjugated with glucuronic acid in a reaction catalyzed by UDP-
glucuronyl transferase
• Conjugated (direct) BR is hydrophilic → can be eliminated in the urine
• Normally, conjugated BR is secreted into the biliary tree → reaches the intestine
• In the intestine, BR is deconjugated and converted to urobilinogen (UBG - colorless)
• Part of UBG is reabsorbed in the portal vein →
- undergoes enterohepatic circulation
- passes into the systemic circulation → eliminated in the urine (< 4 mg/24 h)
• The majority of UBG is converted to stercobilin (colored) → eliminated in the feces
• In blood – 80-90% is indirect BR and 10-20% is direct BR
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Types of hyperbilirubinemia
• When serum BR increases > 2.5-3 mg/dL → jaundice
Genetic syndromes
•Dubin-Johnson syndrome
•Rotor syndrome
(defect in the transfer of conjugated
BR into the biliary canaliculi)
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The investigation of jaundice
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Laboratory findings in different types of jaundice
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Alkaline phosphatase (ALP)
• Distributed in most of the tissues, but the enzyme present in plasma originates
from the liver and bone
• Its serum level increases in biliary obstruction (stimulation of enzyme synthesis in
liver cells, especially those that are adjacent to bile canaliculi)
• The increase is more marked (5-20 fold) in extrahepatic cholestasis
• Intrahepatic cholestasis leads to a 2-3 fold increase in ALP activity
• In acute hepatitis – ALP increases just slightly, because it is anchored to the liver
cell plasma membrane
Differential diagnosis – ALP also increases in diseases affecting the bone (it is
produced by the osteoblasts):
- in children - rickets
- in adults - Paget’s disease, osteogenic bone tumors
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γ-Glutamyl transferase (GGT)
• The enzyme present in plasma originates mainly from the liver (it is also
distributed in the kidney, intestine, and other tissues)
• It increases in all forms of hepatobiliary diseases → it is a sensitive test to detect
these diseases
• The most significant elevations occur in biliary obstruction (5-30, even 50 fold) –
the mechanism is similar to that involved in ALP increase (increased enzyme
synthesis due to cholestasis) – it is more specific than ALP (GGT is normal in bone
diseases)
• Just small increases in hepatocytolysis (GGT is associated with the plasma
membrane of liver cells)
Differential diagnosis:
• Significant elevations of GGT activity occur in chronic alcoholism (due to enzyme
induction by ethanol)
• It also increases in patients being on therapy with certain antiepileptic drugs
(phenytoin, phenobarbital → induction of GGT)
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BIOCHEMICAL MARKERS
IN RENAL DISEASES
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Functions of the kidney
• 1. Excretion of metabolic waste products
• 2. Homeostatic regulation of the ECF volume and composition
• 3. Control of the acid-base balance
Renal excretion:
• Glomerular filtration
• Tubular reabsorption
• Tubular secretion
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I. Tests for the glomerular function
1. Urea
• Is synthesized in the liver from ammonia, which arises from the amino group of
amino acids during protein catabolism
• It is eliminated through glomerular filtration followed by tubular reabsorption (in
the PCT - about 50% of the filtered amount)
• a. Pre-renal causes
- ↓ renal perfusion – hypovolemia/reduced blood pressure (severe dehydration,
shock), heart failure
(plasma [urea] increases relatively more than plasma [creatinine] - the reduced urine
flow causes increased passive tubular reabsorption of urea)
- ↑ urea production – high protein intake, increased protein catabolism (extreme
starvation, trauma, major surgery)
• b. Renal causes
- acute/chronic renal failure – that are associated with ↓ GFR
- limited diagnostic sensitivity:
sensitivity urea level exceeds the normal range only when the
GFR decreases by 75%
- advanced renal dysfunction => serum [urea] correlates well with the GFR
- when the GFR ↓ to 10 mL/min → the urea level ↑ 10 fold
• c. Post-renal causes
- obstruction of the urinary tract – calculi, prostate hypertrophy
- ↑ pressure in the renal tubules => ↓ filtration and ↑ reabsorption of urea
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2. Creatinine
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Increase of creatinine serum level:
• Physiological - high meat intake (→ temporary increase of [creatinine])
- vigorous physical exercise (→ transient, small increases)
- certain drugs that compete with the tubular secretion of creatinine (cephalosporins,
salicylates)
• Pathological - acute/chronic renal failure,
failure that lead to ↓ GFR
- skeletal muscle trauma
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3. Creatinine clearance
• Measures the glomerular filtration rate (GFR) – it is the plasma volume that can be
cleared of a substance in one minute
• The substance has to be filtered by the glomeruli but not reabsorbed – creatinine
is appropriate
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Diagnostic value of creatinine clearance
• It is a more sensitive test for detecting ↓ GFR compared to creatinine and urea: it
allows the detection of GFR decreases lower than by 50%
• There is an inverse hyperbolic correlation between serum creatinine and CrCl
• In chronic renal failure – CrCl allows to determine the moment when renal dialysis
is imposed
• CrCl is useful for monitoring the GFR during therapy with nephrotoxic drugs
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4. Cystatin C
• It is freely filtered by the glomerulus and then almost completely reabsorbed and
catabolized by the tubular epithelial cells (but it is not secreted)
• The blood concentration of CysC depends almost entirely on the GFR and is not
affected by diet or nutritional status, muscle mass, age or gender
• Serum concentrations of CysC offer a better estimation of the GFR compared with
creatinine or creatinine clearance
• Levels of CysC rise earlier than creatinine in acute renal failure
• Serum CysC is superior to creatinine for detecting minor GFR reduction
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II. Tests for the assessment of tubular function
• The diseases affecting the renal tubules may affect:
A - the urine concentration capacity
B - the urine acidification capacity
C - the reabsorption of amino acids and glucose
Tests:
• Urine osmolality
• Specific gravity of urine A
• Urine concentration tests (concentrating ability of the kidney)
• Urinary pH
B
• Urine acidification tests
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A. Urine osmolality and renal concentration tests
• The kidneys reabsorb HCO3– and secrete H+ in the distal portion of the nephron →
urine acidification (lower pH compared to plasma)
• Exploring the ability of urine acidification – by inducing a metabolic acidosis →
urinary pH should decrease < 5.3
• Proximal/distal tubular acidosis – loss of HCO3– or decreased capacity to secrete H+
(without a modification of the GFR)
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C. The amino acidurias
• Amino acids from plasma are filtered by the glomeruli → normally, the proximal renal
tubules reabsorb all the filtered amino acids
• Amino acids can be categorized into four groups (neutral, acidic, basic, imino acids) →
each has its own specific mechanism for transport
Causes for amino aciduria:
• Renal amino aciduria - may be due to:
- genetic defect of one of the specific transport mechanisms
- diseases of the renal tubule – affect the reabsorption of amino acids, but also of glucose
or phosphate
• Raised plasma [amino acids] (overflow amino aciduria) - the renal threshold for amino
acids is exceeded, due to overproduction/accumulation of amino acids in the body
Glycosuria
• Glucose is most commonly found in the urine in patients with diabetes mellitus,
mellitus when
the plasma [glucose] exceeds the renal threshold (180 mg/dL)
• Glycosuria in the presence of a normal plasma [glucose] - occurs in case of proximal
tubular malfunction causing a reduced renal threshold
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• Deficiency of renal 1α-hydroxylase →
synthesis of calcitriol ↓ → plasma
[calcium]
calcium ↓
• PTH ↑ - secondary hyperparathyroidism
• Plasma [phosphate]
phosphate ↑ - due to ↓ GFR
• Plasma [HCO3-] ↓ (metabolic acidosis -
due to ↓ H+ excretion)
• Anemia - due to ↓ erythropoietin
• Hyperkalemia - reduced excretion
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III. Assessment of glomerular integrity
Proteinuria
• The glomerulus filters proteins with low MW → the tubules reabsorb and catabolize
a major part of these proteins
• The urinary excretion of proteins is < 200 mg/day
• The kidney also eliminates specific proteins produced by the tubular cells: Tamm-
Horsfall protein - it represents about half of the total amount of excreted proteins
• Dipstick tests detect albumin at concentrations greater than 200 mg/L, but are less
sensitive to other proteins
1. Glomerular proteinuria
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2. Tubular proteinuria
•Tubular or interstitial damage resulting from a variety of causes, especially
pyelonephritis → the tubules fail to reabsorb proteins that have been filtered by the
normal glomeruli → elimination of α- and β-globulines with low MW (but not albumin)
•Sometimes – abnormal secretion of proteins into the urinary tract
•Usually < 1-2 g/day
3. Overflow proteinuria
•Abnormal amounts of low MW proteins (< 60 kDa) in plasma and in urine
•These proteins are normally filtered by the glomerulus, but the reabsorptive capacity
of the proximal tubule is exceeded
•E.g.: Bence-Jones protein, amylase, hemoglobin, myoglobin → diagnostic value
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Classification of proteinuria
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Nephritic and nephrotic syndrome
Nephritic syndrome:
• Proteinuria < 3.5 g/24 h
• Hematuria, RBC casts
• Arterial hypertension
• GFR ↓, plasma [urea] and [creatinine] ↑
• Inflammatory markers (C3, C4, immune complexes, IgA, CRP)
• Autoimmune markers (anti-nuclear Ab, anti-dsDNA Ab, anti-glomerular membrane Ab)
Nephrotic syndrome:
• Proteinuria > 3.5 g/24 h (of glomerular type)
• Hypoproteinemia with hypoalbuminemia → edema
• Secondary hyperlipidemia – ↑ levels of cholesterol and triglycerides
• Plasma [urea] and [creatinine], creatinine clearance – usually normal
• Impure NS – arterial hypertension, hematuria, nitrogen retention syndrome
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Bibliography
Harvey RA, Ferrier DR. Lippincott’s Illustrated Reviews –Biochemistry. 5th edition,
Lippincot Williams & Wilkins, 2011
Minodora Dobreanu Biochimie clinică. Implicații practice. Ediția a III-a, Editura
University Press, Târgu-Mureș, 2015.
Kaplan LA, Pesce AJ. Clinical chemistry; theory, analysis, correlation, 5th ed. Elsevier
Mosby, 2010
Rae P, Crane M, Pattenden R. Clinical Biochemistry – Lecture Notes, 10th ed., Wiley
Blackwell, John Wiley & Sons Ltd. 2018.
Crook MA. Clinical Biochemistry and Metabolic Medicine. 8th edition. Hodder Arnold,
Hodder & Stoughton Ltd, 2012.
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