CCHM 31 | CLINICAL CHEMISTRY 1 (LEC) WEEK 7-11

Carol Jane P. Lorenzo || 3rd Year

Transcribed by: Cordial, Ellen Marie C.

• Laboratory results submitted to the wrong physician

who did not request for the lab test
OUTLINE:
1. QUALITY MANAGEMENT
QUALITY CONTROL
A.
B. • Analytical phase
C. • It is a system of ensuring accuracy and precision in the
2. QUALITY CONTROL laboratory by including quality control reagents in every
3. CARBOHYDRATES series of measurements
4. CLINICAL CONDITIONS OF CARBOHYDRATE • It is a process of ensuring that analytical results are correct
METABOLISM by testing known samples that resemble patient samples.
5. LIPIDS
• Concerned with the analytic phase of QA
• Process or system for monitoring the quality of laboratory
testing
• Routinely collect and analyze data from every test run or
QUALITY MANAGEMENT
procedure
QUALITY MANAGEMENT • Allows for immediate corrective reaction
• A management philosophy and approach that focuses on
processes and their improvement as the means to satisfy
customer needs and requirements. QC vs.QA
• As defined by CLSI and ISO, it is coordinated activities to Quality Control Quality Assurance
direct and control an organization with regard to quality. • The aim of quality • Concerned with much
control is to simply more: that the right test
THREE PHASES OF CLINICAL CHEMISTRY TESTING ensure that the results is carried out on the
PROCESS generated by test are right specimen, and that
Process = Quality assurance correct/ensures validity the right result and right
of test methos interpretation is
PRE-ANALYTICAL PHASE
• Corrective tool delivered to the right
Before analyzing/testing • Product-oriented person at that time
• Individual medtech • Managing tool –
PRE-ANALYTICAL PHASE ERRORS responsibility manages the three
• Incorrect identification phases
• Mislabeled specimen • Process-oriented
• Incorrect order of draw • Everyone’s
• Incorrect anticoagulant-to-blood ratio (short draw) responsibility
• Improper mixing of blood and anticoagulant
• Improper patient separation • Interpretation and
• Improper specimen collection delivered – Post-
• Incorrect used of tubes for blood collection Analytical phase
• Incorrect specimen preservation
• Mishandled specimen (transport and storage) TWO MAJOR TYPES OF QUALITY CONTROL
• Incorrectly interpreted/ordered laboratory test 1. Internal QC (Intra-Laboratory QC)
• Incomplete centrifugation • Primarily monitors the day-to-day performance of
• Incorrect data log in laboratory tests namely precision.
• Daily monitoring of quality control sera
Note: 32-75% problem • Immediate decisions to accept or reject patient results
• Detects both random and systematic error
ANALYTICAL PHASE -within laboratory
Testing procedures
2. External QC (Inter-Laboratory)
ANALYTICAL PHASE ERRORS • Monitors primarily the accuracy of laboratory test of the
• Incorrect sample and reagent volume different laboratories be it free standing or hospital-based
• Incorrect incubation of solution clinical laboratories. – Important in maintaining long term
• Equipment instrument malfunction accuracy of the analytical method.
• Improper calibration of equipment/calibration error • Comparing of performance to other laboratories (peer to
peer comparisons)
Incubator – used to prevent contaminants of the solution • The main objective of EQC is not to bring about day-to-day
consistency but to establish inter-laboratory comparability.
POST-ANALYTICAL PHASE
Release of results -Involvement of other laboratories

POST-ANALYTICAL PHASE ERRORS A TYPICAL EXTERNAL QC SCHEME

• Unavailable or delayed laboratory results • Participants receive unknown samples
• Wrong transcription of the patient’s data and o These are analyzed by the personnel in the lab
laboratory results o The results are returned to scheme organizer -
• Long turnaround time NRL
• Incomplete laboratory results o They statistically analyzed to generate a
• Missing laboratory results comparative report
o Report is sent back to the participant
2 CCHM 321 LEC | LESSON TITLE

EXTERNAL QC (INTER-LABORATORY QC) IN THE QUALITY CONTROL MATERIALS

PHILIPPINES
• This is embodied under DOH AO no. 86 series of 2009
which is about the implementation of external quality
assessment program as regulatory requirement for the
licensing of clinical laboratories
• Mandatory participation in the National External Quality
Assessment Scheme (NEQAS) conducted by the BFHS
of the National Reference Laboratories (NRL’s)
NATIONAL REFERENCE LABORATORIES (NRLs)
Under DOH Department Order No. 393-E s. 2000
• Research Institute for Tropical Membrane – National
Reference Laboratory for Dengue, Influenza, Tuberculosis
and other Mycobacteria, Malaria, and other parasites.
Bacterial enteric diseases. Measles and other viral
exanthems, Mycology, Enteroviruses, Antimicrobial
resistance and Emerging Diseases; NRL for confirmatory
testing of blood units
• San Lazaro Hospital (STD-AIDS Cooperative Central -
Laboratory /SACCL) – National Reference Laboratory for
HIV/AIDS, Hepatitis, Syphilis and other Sexually
Transmitted Infections (STIs)
• East Avenue Medical Center – National Reference
Laboratory for Environmental and Occupational Health;
Toxicology and Micronutrient Assay
• National Kidney and Transplant Institute – National
Reference Laboratory for Hematology including
Immunohematology, Immunopathology and Anatomic
Pathology
• Lung Center of the Philippines – National Reference
Laboratory for anatomic pathology and biochemistry
Standard Solution
Control Solution
Blank Solution
Parameters/Implications of Quality Control
1. Sensitivity –The ability of an analytical method to measure
smallest concentration of the analyte of interest
(SCREENING TEST)
2. Specificity – The ability of an analytical method to
measure only the analyte of interest (CONFIRMATORY
TEST)
3. Diagnostic sensitivity – The ability of an analytical
method to detect the proportion of individuals with the
disease. It also indicates the ability of the test to generate
true-positive and few false-negative results. (POSITIVITY)
4. Diagnostic specificity – The ability of an analytical
method to detect the proportion of individuals without the
disease. It also indicates the ability of the test to generate
true-negatives and few false-positives. (NEGATIVITY)
5. Accuracy – The nearness or closeness of the assayed
value to the true or target value.
6. Precision/Reproducibility – The ability of an analytical
method to give repeated results on the same that agreed to
one another
7. Practicality – The degree by which a method is easily
repeated
8. Reliability – The ability to maintain accuracy and precision
over an extended period of time during which equipment,
reagents and personnel may change

Additional NRL and additional designations amending

DOH Department order Np. 393-E s. 2000
• Lung Center of the Philippines – NRL in Anatomic
Pathology for Pulmonary Diseases
• Philippine Heart Center – NRL in Anatomic Pathology for
Cardiac Diseases
• National Kidney and Transplant Institute – NRL in
Anatomic Pathology for Renal diseases and other
unassigned Organ System Diseases, and Automated
method for Urinalysis.

REFERENCE MATERIALS
Standard = Colorless
• A substance that has an exact known value, and that,
when accurately weighed or measured, can produce a
solution of an exact concentration
• Also called “reference materials”
• Used to calibrate new instruments, recalibrate instruments
after repair, at manufacturer’s recommended intervals
• Used to check for the accuracy of the test

Control = Yellow
• A “Patient-Like” sample that is composed of one or many
constituents.
• It is a solution that contains the same constituents as those
being analyzed in the patient sample
• Controls are used to monitor the precision of the testing
system.
-Resemblance the patient’s sample
QUALITY ASSURANCE CONTROL
OBJECTIVES OF QUALITY CONTROL
• To check the stability of the machine.
• To check the quality of reagents
• To check technical (operator) errors.
BENEFITS OF OBTAINED FROM A QUALITY CONTROL
PROGRAM
• Provision of continuous record of reliability of laboratory
results
• Permits valid judgments on the accuracy of results by
monitoring precision and permitting comparisons assay
values on known control sera with stated values.
• Gives early warning of trends and shifts in control results
so that remedial actions may be taken before serious loss
of precision.
• Monitors the performance and stability of equipment used
on the assay.
3 CCHM 321 LEC | LESSON TITLE

3. CLERICAL ERROR – Problems with handwritten

labels and request form
• Problem of a medical technologist

Note: Online computer input is the most error-free means of

STATISTICAL TOOL OF QUALITY ASSURANCE AND requesting laboratory tests
QUALITY CONTROL
1. ARITHMETIC VALUE
2. STANDARD DEVIATION (SD) QUALITY CONTROL CHARTS (HISTOGRAMS)
3. COEFFICIENT OF VARIATION (CV)
4. VARIANCE (V) SHEWHART-LEVEY JENNINGS CHART
• Most commonly used chart for QC recording
STATISTICAL TERMINOLOGIES • Also referred as DOT chart
• Inferential Statistics – Used to compare the means or • Graphic representation of the acceptable limits of
standard deviations of two groups of data variation in the result of an analytical method
• F-Test – Is used to determine whether there is a
statistically significant difference between the standard
deviation of two group data
• T-Test – Is used to determine whether there is a
statistically significant difference between the means of
two group data
• Median – is the value of the observation that divides the
observations into two groups. It is the midpoint of a
distribution.
• Mode – The most frequent observation
• Range – The difference between the highest and the
lowest score in a data.

ARITHMETIC VALUE OR MEAN OR AVERAGE

𝚺𝐱 𝑆𝑢𝑚 𝑜𝑓 𝑡ℎ𝑒 𝑛𝑢𝑚𝑏𝑒𝑟𝑠
Formula: x̅ = mean =
𝑛 𝑠𝑖𝑧𝑒 𝑜𝑓 𝑡ℎ𝑒 𝑠𝑎𝑚𝑝𝑙𝑒

STANDARD DEVIATION ERRORS THAT CAN BE OBSERVED ON LJ CHART

Formula: A. Trend – formed by control values that either increase
or decrease for six consecutive days

COEFFICIENT OF VARIATION (CV)

𝑆𝐷
Formula: 𝐶𝑉 = 𝑋 100
𝑀

VARIANCE (V)
Formula: 𝑉 = (𝑆𝐷)2

VARIATIONS
Variations are errors encountered in the collection, preparation,
and measurement of samples including transcription and
release of laboratory results.
B. Shift – formed by control values that distribute
TYPES OF ERROR themselves on one side or either side of the mean for
six consecutive days
1. RANDOM ERROR – Present in all measurements and
it is due to chance.
• Problem of a medical technologist
• Mislabeling
• Improper Pipetting
• Improper mixing of sample and reagent
• Voltage/Temperature Fluctuations
• Dirty optics
2. SYSTEMATIC ERROR – Problem in the machines
• Hard to correct
• Calibration problems
• Deterioration of reagents and control materials
• Improperly made standard solutions
• Contaminated solutions
• Unstable and inadequate reagent blanks
• Leaky ion selective electrode
• Failing instrumentation
• Poorly written procedures
4 CCHM 321 LEC | LESSON TITLE

C. Outliers – these are control values that are far from

the main set of values
GAUSSIAN CURVE
• It will group any series of measurement in the same
sample in a cluster around the mean in a bell-shaped
curve
• Also known as bell-shaped curve
• It occurs when the data can be accurately described
by the SD and the mean.
• The total area under the curve is 1.0-100%
QUALITY CONTROL
Benefits of obtained from a Quality Control Program
• Provision of a continuous record of reliability of
laboratory results
• Permits valid judgments on the accuracy of results by
monitoring precision and permitting comparisons
assay values on known control sera with stated
values.
• Gives early warning of trends and shifts in control
results so that remedial actions may be taken before
serious loss of precision.
• Monitors the performance and stability of equipment
used ion the assay.

INTERPRETATION OF RESULTS
In control
Out of control

WESTGARD CONTROL RULES

This uses the term “control rule” to indicate if the analytical
process is out of control.

• 13s
• Criteria for violation:

CUMULATIVE SUM GRAPH

• It calculates the difference between QC results and
the target means
• Plotted with the accumulated differences from the
mean of individual values with the middle value being
zero.
• Also referred as CUSUM

• 12s
• Acceptable

YOUDEN PLOT
• It displays the results of the analysis by plotting the
mean values for one specimen on the x and y-axis.
• A 2-mean chart drawn at right angles to one another
with one set of values on one axis and another set of
values on the other axis.
• Uses cartesian plain
• Also referred as TWIN PLOT
5 CCHM 321 LEC | LESSON TITLE

• 22s

• 41s

• 10 s
6 CCHM 321 LEC | LESSON TITLE
CARBOHYDRATES
They are the major food source and energy supply of the body
and are stored primarily as liver and muscle glycogen. Disease
states involving carbohydrates are split into groups—
hyperglycemia and hypoglycemia. Early detection of diabetes
mellitus is the aim of the American Diabetes Association (ADA)
guidelines established in 1997. Acute and chronic
complications may be avoided with proper diagnosis,
monitoring, and treatment. The laboratory plays an important
role through periodic measurements of glycosylated
hemoglobin and microalbumin.
• Carbohydrates are compounds containing C, H, and O.
The general formula for carbohydrate is Cx(H2O)y. All
carbohydrates contain C=O and =OH functional groups.
The classification of carbohydrates is based on four different
properties:
(1) the size of the base carbon chain,
(2) the location of the CO function group,
(3) the number of sugar units, and
(4) the stereochemistry of the compound.
CLASSIFICATION OF CARBOHYDRATES
• Carbohydrates can be grouped into generic classifications
based on the number of carbons in the molecule. For
example, trioses contain three carbons, tetroses contain
four, pentoses contain five, and hexoses contain six. In
actual practice, the smallest carbohydrate is
glyceraldehyde, a three-carbon compound.
• Carbohydrates are hydrates of aldehyde or ketone
derivatives based on the location of the CO functional
group. The two forms of carbohydrates are aldose and
ketose.
• The aldose form has a terminal carbonyl group (O=CH)
called an aldehyde group, whereas the ketose form has a
carbonyl group (O=C) in the middle linked to two other
carbon atoms (called a ketone group).
STEREOISOMERS
The central carbons of a carbohydrate are asymmetric
(chiral)—four different groups are attached to the carbon atoms.
This allows for various spatial arrangements around each
asymmetric carbon (also called stereogenic centers) forming
molecules called stereoisomers. Stereoisomers have the same
order and types of bonds but different spatial arrangements and
different properties. For each asymmetric carbon, there are 2n
possible isomers; therefore, there are 21, or two, forms of
glyceraldehyde. Because an aldohexose contains four
asymmetric carbons, there are 24, or 16, possible isomers.
MONOSACCHARIDES, DISACCHARIDES, AND
POLYSACCHARIDES
Another classification of carbohydrates is based on number of
sugar units in the chain: monosaccharides, disaccharides,
oligosaccharides, and polysaccharides.
1. Monosaccharides – are simple sugars that cannot be
hydrolyzed to a simpler form. These sugars can contain
three, four, five, and six or more carbon atoms (known as
trioses, tetroses, pentoses, and hexoses, respectively).
The most common include glucose, fructose, and
galactose.
2. Disaccharides – are formed when two monosaccharide
units are joined by a glycosidic linkage. On hydrolysis,
disaccharides will be split into two monosaccharides by
disaccharide enzymes (e.g., lactase) located on the
microvilli of the intestine. These monosaccharides are then
actively absorbed. The most common disaccharides are
maltose (comprising 2--D-glucose molecules in a 1→ 4
linkage), lactose, and sucrose.
3. Oligosaccharides – are the chaining of 2 to 10 sugar
units, whereas polysaccharides are formed by the linkage
of many monosaccharide units. On hydrolysis,
polysaccharides will yield more than 10
monosaccharides. Amylase hydrolyzes starch to
disaccharides in the duodenum. The most common
polysaccharides are starch (glucose molecules) and
glycogen.
CHEMICAL PROPERTIES OF CARBOHYDRATES
• Some carbohydrates are reducing substances; these
carbohydrates can reduce other compounds. To be a
reducing substance, the carbohydrate must contain a
ketone or an aldehyde group. This property was used in
many laboratory methods in the past in the determination
of carbohydrates.
• All monosaccharides and many disaccharides are reducing
agents. This is because a free aldehyde or ketone (the
open-chain form) can be oxidized under the proper
conditions.
• As disaccharide remains a reducing agent when the
hemiacetal or ketal hydroxyl group is not linked to another
molecule. Both maltose and lactose are reducing agents,
whereas sucrose is not.
FATE OF GLUCOSE
Glucose is the only carbohydrate to be directly used for energy
or stored as glycogen. Galactose and fructose must be
converted to glucose before they can be used. After glucose
enters the cell, it is quickly shunted into one of three possible
metabolic pathways, depending on the availability of substrates
or the nutritional status of the cell. The ultimate goal of the cell
is to convert glucose to carbon dioxide and water.
The first step for all three pathways requires glucose to be
converted to glucose-6-phosphate using the high energy
molecule, ATP. This reaction is catalyzed by the enzyme
hexokinase. Glucose-6-phosphate can enter the Embden-
Myerhof pathway or the hexose monophosphate pathway or
can be converted to glycogen. The first two pathways are
important for the generation of energy from glucose; the
conversion to glycogen pathway is important for the storage of
glucose.
PATHWAYS IN GLUCOSE METABOLISM
Glycolysis- Metabolism of glucose molecule to pyruvate or
lactate for production of energy
Gluconeogenesis- Formation of glucose-6-phosphate from
noncarbohydrate sources
Glycogenolysis- Breakdown of glycogen to glucose for use as
energy
Glycogenesis- Conversion of glucose to glycogen for storage
Lipogenesis- Conversion of carbohydrates to fatty acids
Lipolysis- Decomposition of fat
REGULATION OF CARBOHYDRATE METABOLISM
Control of blood glucose is under two major hormones: insulin
and glucagon, both produced by the pancreas. Their actions
oppose each other. Other hormones and neuroendocrine
substances also exert some control over blood glucose
concentrations, permitting the body to respond to increased
demands for glucose or to survive prolonged fasts. It also
permits the conservation of energy as lipids when excess
substrates are ingested.
A. Insulin
• The primary hormone responsible for the entry of glucose
into the cell. It is synthesized by the cells of islets of
Langerhans in the pancreas. When these cells detect an
increase in body glucose, they release insulin. The release
of insulin causes an increased movement of glucose into
the cells and increased glucose metabolism.
• Insulin is normally released when glucose levels are high
and is not released when glucose levels are decreased. It
decreases plasma glucose levels by increasing the
7 CCHM 321 LEC | LESSON TITLE

transport entry of glucose in muscle and adipose tissue by 6. Non- beta cell tumors
way of nonspecific receptors. It also regulates glucose by 7. Hypoglycemia of infancy and childhood
increasing glycogenesis, lipogenesis, and glycolysis and 8. Alimentary (reactive) hypoglycemia
inhibiting glycogenolysis. Insulin is the only hormone that 9. Idiopathic (functional) postprandial hypoglycemia
decreases glucose levels and can be referred to as a
hypoglycemic agent. HYPERGLYCEMIA
It is an increase in blood glucose concentration.
B. Glucagon It is toxic to beta cell function and impairs insulin
The primary hormone responsible for increasing glucose levels. secretion.
It is synthesized by the cells of islets of Langerhans in the FBS: 126 mg/dL or more
pancreas and released during stress and fasting states. When
these cells detect a decrease in body glucose, they release It is an increase in plasma glucose levels.
glucagon. Glucagon acts by increasing plasma glucose levels In healthy patients, during a hyperglycemia state, insulin is
by glycogenolysis in the liver and an increase in secreted by the cells of the
gluconeogenesis. It can be referred to as a hyperglycemic pancreatic islets of Langerhans. Insulin enhances membrane
agent. permeability to cells in the
liver, muscle, and adipose tissue. It also alters the glucose
metabolic pathways.
CLINICAL CONDITIONS OF CARBOHYDRATE Hyperglycemia, or increased plasma glucose levels, is caused
METABOLISM by an imbalance of hormones.
Causes: Stress, severe infection, dehydration, pregnancy,
HYPOGLYCEMIA pancreatectomy,
• It involves decreased glucose levels and can have many hemochromatosis, insulin deficiency or abnormal insulin
causes. receptor.
65-70mg/dL - glucagon and other glycemic hormones are FBS: 126 mg/dL or more
released into the circulation Random plasma glucose: 200 mg/dL or more ( 11.1 mmol/L),
60mg/dL or less - strongly suggest Hypoglycemia with symptoms of diabetes

• It involves decreased plasma glucose levels and can have

many causes—some are transient and relatively
insignificant, but others can be life-threatening.
• The plasma glucose concentration at which glucagon and
other glycemic factors are released is between 65 and 70
mg/dL (3.6–3.9 mmol/L);
• At about 50 to 55 mg/dL (2.8–3.0 mmol/L), observable
symptoms of hypoglycemia appear. The warning signs and
symptoms of hypoglycemia are all related to the central
nervous system.
• The release of epinephrine into the systemic circulation
and of norepinephrine at nerve endings of specific neurons
act in unison with glucagon to increase plasma glucose.
Glucagon is released from the islet cells of the pancreas
and inhibits insulin. Epinephrine is released from the
adrenal gland and increases glucose metabolism and
inhibits insulin.
• In addition, cortisol and growth hormone are released
and increase glucose metabolism.
• A diagnosis should not be made unless the patient meets
the criteria of WHIPPLE'S Triad:
1. Low blood glucose concentration
2. Typical Symptoms
LABORATORY FINDINGS
3. Symptoms alleviated by glucose administration
1. Increase glucose in plasma and urine
• Symptoms of hypoglycemia are increased tremors,
2. Increase urine specific gravity
palpitations, anxiety, diaphoresis (neurogenic symptoms),
3. Ketones in serum and urine (Type 1 DM patients)
hunger, sweating, nausea and vomiting, dizziness,
nervousness and shaking, blurring of speech and sight, 4. Decrease blood and urine pH (acidosis)
5. Electrolyte Imbalance (Decrease Sodium and Bicarbonate,
and mental confusion (neuroglycopenic symptoms).
increase Potassium)
Laboratory findings include decreased plasma glucose
levels during hypoglycemic episodes and extremely
elevated insulin levels in patients with pancreatic-cell • 180 mg/dL- glucose will excrete in the urine
tumors (insulinoma). • 300-500mg/dL - (period of plateau)
• Diagnostic Test: 5-hour glucose tolerance test
(hypoglycemic "dip" often is not seen until after 3 hours) DIABETES MELLITUS
• 50 mg/dL or less (2.8 mmol/L) in infants is considered • It is actually a group of metabolic diseases characterized
ABNORMAL and requires diagnostic assessment. by hyperglycemia resulting from defects in insulin
secretion, insulin action, or both. In 1979, the National
CAUSES AND CLASSIFICATION OF HYPOGLYCEMIA Diabetes Data Group developed a classification and
diagnosis scheme for diabetes mellitus.
1. Drug Administration
• This scheme included dividing diabetes into two broad
2. Critical Illnesses
categories: type 1, insulin-dependent diabetes mellitus
3. Hormonal Deficiency
(IDDM); and type 2, non–insulin-dependent
4. Endogenous Hyperinsulinism
diabetes mellitus (NIDDM).
5. Autoimmune Hypoglycemia
8 CCHM 321 LEC | LESSON TITLE
• The ADA/World Health Organization (WHO) guidelines
recommend the following
categories of diabetes:
■ Type 1 diabetes
■ Type 2 diabetes
■ Other specific types of diabetes
■ Gestational diabetes mellitus (GDM)
TYPE 1 DIABETES MELLITUS
• Type 1 diabetes is characterized by inappropriate
hyperglycemia primarily a result of pancreatic islet-cell
destruction and a tendency to ketoacidosis
• Type 1 diabetes mellitus is a result of cellular-mediated
autoimmune destruction of the cells of the pancreas,
causing an absolute deficiency of insulin secretion.
• Upper limit of 110 mg/dL on the fasting plasma glucose is
designated as the upper limit of normal blood glucose.
• Type 1 constitutes only 10% to 20% of all cases of
diabetes and commonly occurs in childhood and
adolescence. This disease is usually initiated by an
environmental factor or infection (usually a virus) in
individuals with a genetic predisposition and causes the
immune destruction of the cells of the pancreas and,
therefore, a decreased production of insulin.
• Characteristics of type 1 diabetes include abrupt onset,
insulin dependence, and ketosis tendency.
• Signs and symptoms include polydipsia (excessive thirst),
polyphagia (increased food intake),
• polyuria (excessive urine production), rapid weight loss,
hyperventilation, mental confusion, and possible loss of
consciousness (due to increased glucose to the brain).
• Complications include microvascular problems such as
nephropathy, neuropathy, and retinopathy.
• Increased heart disease is also found in patients with
diabetes.
Idiopathic type 1 Diabetes
• Idiopathic type 1 diabetes is a form of type 1 diabetes that
has no
known etiology, is strongly inherited, and does not have -cell
autoimmunity. Individuals with this form of diabetes have
episodic
requirements for insulin replacement.
• not associated with autoantibodies but for which insulin
treatment is required for survival, although an absolute
requirement for insulin replacement therapy and
ketoacidosis may be episodic.
TYPE 2 DIABETES MELLITUS
• Type 2 diabetes mellitus is characterized by hyperglycemia
as a result of an individual’s resistance to insulin with an
insulin secretory defect. This resistance results in a
relative, not an absolute, insulin deficiency.
• Type 2 constitutes the majority of diabetes cases. Most
patients in this type are obese or have an increased
percentage of body fat distribution in the abdominal region.
• This type of diabetes often goes undiagnosed for many
years and is associated with a strong genetic
predisposition, with patients at increased risk with an
increase in age, obesity, and lack of physical exercise.
• Characteristics usually include the adult onset of the
disease and milder symptoms than in type 1, with
ketoacidosis seldom occurring. However, these patients
are more likely to go into a hyperosmolar coma and are at
an increased risk of developing macrovascular and
microvascular complications
• It has been described as a geneticist's nightmare.
• not related to autoimmune disease
• Risk factors: Obesity, family history, advanced age,
hypertension, lack of exercise, GDM, impaired glucose
metabolism
• It is recommended that adults ages 45 and older be
screened for diabetes every 3 years, but screening should
be performed earlier and more frequent if the individual is
at high risk.
COMPARISON BETWEEN TYPE 1 DM AND TYPE 2 DM
PATHOPHYSIOLOGY OF DIABETES MELLITUS
• In both type 1 and type 2 diabetes, the individual will be
• Glucosuria can also occur after the renal tubular
transporter system for glucose becomes saturated. This
happens when the glucose concentration of plasma
exceeds roughly180 mg/dL in an individual with normal
renal function and urine output.
• As hepatic glucose overproduction continues, the plasma
glucose concentration reaches a plateau around 300 to
500 mg/dL (17–28 mmol/L). Provided renal output is
maintained, glucose excretion will match the
overproduction, causing the plateau Pathophysiology of
Diabetes Mellitus hyperglycemic, which can be severe.
GESTATIONAL DIABETES MELLITUS
• GDM is “any degree of glucose intolerance with onset or
first recognition during pregnancy.”
• Causes of GDM include metabolic and hormonal changes.
Patients with GDM frequently return to normal postpartum.
However, this disease is associated with increased
perinatal complications and an increased risk for the
development of diabetes in later years.
• Infants born to mothers with diabetes are at increased risk
for respiratory distress syndrome, hypocalcemia, and
hyperbilirubinemia. Fetal insulin secretion is stimulated in
the neonate of a mother with diabetes. However, when the
infant is born and the umbilical cord is severed, the infant’s
9 CCHM 321 LEC | LESSON TITLE
oversupply of glucose is abruptly terminated, causing
severe hypoglycemia.
• Diagnostic Criteria:
FBS: 92 mg/dL or more
1-hour GCT: 180 mg/dL or more
2-hours OGTT: 153 mg/dL or more
OTHER SPECIFIC TYPES OF DIABETES
Other specific types of diabetes are associated with certain
conditions
(secondary), including genetic defects of - cell function or
insulin action, pancreatic disease, diseases of endocrine origin,
drug- or chemical induced insulin receptor abnormalities, and
certain genetic
syndromes. The characteristics and prognosis of this form of
diabetes
depend on the primary disorder. Maturity-onset diabetes of
youth (MODY) is a rare form of diabetes that is inherited in an
autosomal dominant fashion.
GLUCOSE METHODOLOGIES
• Venous Plasma Glucose- standard specimen
• FBS level in whole blood is 15% lower than in serum or
plasma
• Venous blood glucose is 7 mg/dL lower than capillary
blood
• CSF glucose should be approximately 60% of the plasma
concentrations
• Peritoneal fluid glucose is the same as plasma glucose
• Lower plasma glucose levels are seen in infants than in
adults
• Plasma glucose increase with age
SPECIMEN HANDLING
• At room temperature (20-25'C), glycolysis decreases
glucose by 7mg/dL/hour in normal uncentrifuged
coagulated blood.
• At refrigerated temperature (4'C), glucose is metabolized at
the rate of about 2 mg/dL/hour.\
• Samples for Glucose Measurement: RBS, FBS, 2-hour
PPBS, GTT, Glycosylated Hemoglobin (HBA1c),
Fructosamine
SAMPLES FOR GLUCOSE MEASUREMENT
1. RBS - requested during insulin shock and hyperglycemic
ketonic coma
2. FBS - measure overall glucose homeostatis
3. 2-hour PPBS - measure how well the body metabolizes
glucose over a period of time
4. GTT - a multiple blood sugar test; measure how well the
body metabolizes glucose
• Oral Glucose Tolerance Test (Janney-Isaacson, Exton
Rose)
• Intravenous Glucose Tolerance Test
5. Glycosylated Hemoglobin (HBA1C) - reliable method in the
monitoring of long-term glucose control. It should be performed
every 3-6 months.
Specimen: EDTA whole blood
Methods: Electrophoresis, Immunoassay, HPLC, Affinity
Chromatography
6. Fructosamine - also known as glycosylated albumin/ plasma
protein
ke
toamine. This if for short term glucose control (3-6 weeks). May
be useful for monitoring diabetic individuals with chronic
hemolytic
anemias and hemoglobin variants (Hb S and Hb C) Methods:
Affinity Chromatography, HPLC and Photometry.
CHEMICAL METHODS
OXIDATION REACTION METHOD
• Alkaline Copper Reduction Method – the principle is the
reduction of cupric ions to
cuprous ions forming cuprous oxide in a hot alkaline solution by
glucose
1. Folin Wu Method
2. Nelson Somogyi Method
3. Neocuprine Method
4. Benedict's Method (Modification of Folin Wu)
• Alkaline Ferric Reduction Method - reduction of a yellow
ferricyanide to a colorless ferrocyanide by glucose (inverse
colorimetry)
1. Hagedorn Jensen
2. Condensation Method - Dubowski Method
ENZYMATIC METHODS
INBORN ERRORS OF CARBOHYDRATES METABOLISM
1. Galactosemia - a cause of failure to thrive syndrome in
infants, is a congenital deficiency of one of three enzymes
involved in galactose metabolism, resulting in increased
levels of galactose in plasma. The most common enzyme
deficiency is galactose-1-phosphate uridyl transferase
2. Essential Fructosuria - fructokinase deficiency; the
presence of Fructose in urine
3. Hereditary Fructose Intolerance- Defect of fructose-1,6-
biphosphate aldolase B activity in the liver, kidney, and
intestine. Clinical features include irritability, lethargy,
seizures, and hepatomegaly
4. Fructose-1,6-biphosphate Deficiency - Defect of
fructose-1,6-biphosphate results in the failure of hepatic
glucose generation by gluconeogenic precursors such as
lactate and glycerol. Clinical features include
Hypoglycemia, lactic acidosis, convulsions and coma
5. Glycogen Storage Disease (GSD) - inherited deficiencies
of enzymes that control the synthesis of glycogen 1
10 CCHM 321 LEC | LESSON TITLE
GLYCOGEN STORAGE DISEASE
• Glycogen storage diseases are the result of the deficiency
of a specific enzyme that causes an alternation of glycogen
metabolism. The most common congenital form of
glycogen storage disease is glucose-6-phosphatase
deficiency type 1, which is also called von Gierke
disease, an autosomal recessive disease. This disease is
characterized by severe hypoglycemia that coincides with
metabolic acidosis, ketonemia, and elevated lactate and
alanine
• Other enzyme defects or deficiencies that cause
hypoglycemia include glycogen synthase, fructose-1,6-
bisphosphatase, phosphoenolpyruvate carboxykinase, and
pyruvate carboxylase. Glycogen debrancher enzyme
deficiency does not cause hypoglycemia but does cause
hepatomegaly
LIPIDS AND LIPOPROTEINS
Lipids, commonly referred to as fats, have a dual role. First,
because they are composed of mostly carbon-hydrogen (C-H)
bonds, they are a rich source of energy and an efficient way for
the body to store excess calories. Because of their unique
physical properties, lipids are also an integral part of cell
membranes and, therefore, also play an important structural
role in cells.
The lipids transported by lipoproteins, namely triglycerides,
phospholipids, cholesterol, and cholesteryl esters, are also the
principal lipids found in cells.
A lipoprotein is a biochemical assembly whose primary
function is to transport hydrophobic lipid (also known as fat)
molecules in water, as in blood plasma or other extracellular
fluids.
LIPIDS
Fatty acids
The building blocks of the fat in our bodies and in the food we
eat. During digestion, the body breaks down fats into fatty
acids, which can then be absorbed into the blood. Fatty acid
molecules are usually joined together in groups of three,
forming a molecule called a triglyceride.
Triglycerides
As can be inferred from the name, triglycerides contain three
fatty acid molecules attached to one molecule of glycerol by
ester bonds. Most triglycerides from plant sources, such as
corn, sunflower seeds, and safflower seeds, are rich in
polyunsaturated fatty acids and are oils, whereas triglycerides
from animal sources contain mostly saturated fatty acids and
are usually solid at room temperature.
1. Transfat
2. Monosaturated
3. Saturated
Phospholipids
are similar in structure to triglycerides except that they only
have two esterified fatty acids. Because phospholipids contain
both hydrophobic fatty acid C-H chains and a hydrophilic head
group, they are by definition amphipathic lipid molecules and,
as such, are found on the surface of lipid layers. The polar
hydrophilic head group faces outward toward the aqueous
environment, whereas the fatty acid chains face inward away
from the water in a perpendicular orientation with respect to the
lipid surface.
• Most abundant lipids
• originates from the liver and intestine (in the lungs, it is
produced by type II pneumocytes in the form of lamellar
bodies.
• allows effective gas exchange, and prevents alveolar
collapse during expiration.
• participates in cellular metabolism and blood coagulation.
• also important substrates in for a number of lipoprotein
metabolizing enzymes
FORMS OF PHOSPHOLIPID
1. Lecithin
2. Sphingomyelin
3. Cephalin
*Deficiency can lead to Neonatal Respiratory Distress
Syndrome (RDS)1. 2. 3.
CHOLESTEROL
an unsaturated steroid alcohol containing four rings (A, B, C,
and D), and it has a single C-H side chain tail similar to a fatty
acid in its physical properties. The only hydrophilic part of
cholesterol is the hydroxyl group in the A-ring. Cholesterol is,
therefore, also an amphipathic lipid and is found on the surface
of lipid layers along with phospholipids.
11 CCHM 321 LEC | LESSON TITLE

3. High-Density Lipoprotein (HDL)

• does not serve as a source of fuel • Smallest, most dense
• its transport and excretion is promoted by estrogen • Pre-beta lipoprotein, “Good cholesterol”
• precursor of five major classes of steroids: progestins, 4. Low-Density Lipoprotein (LDL)
glucocorticoids, mineral corticoids, androgens and • “Bad Cholesterol”
estrogens • Primary marker for CHD
• important constituent in the assembly of cell • Beta lipoprotein
membranes and bile acids
• evaluates the risk of atherosclerosis, myocardial and MINOR LIPOPROTEINS
coronary arterial occlusions 1. Intermediate Density Lipoprotein (IDL)
• used as thyroid, liver and renal function tests; and for • APO: C, E, B100
DM studies • Contains equal amounts of cholesterol, TAG,
• diagnosis and management of lipoprotein disorders Phospholipids
• monitor effectiveness of lifestyle changes and stress
management 2. Lipoprotein (a)/ Lp(a)
• LDL-like
FORMS OF CHOLESTEROL • “Sinking” lipoprotein
1. Cholesterol Ester
2. Free Cholesterol ABNORMAL LIPOPROTEINS1
1. Lipoprotein X (Lpx)
Cyclopentanoperhydrophenanthrene – biochemical structure
• Found in patient with obstructive jaundice and LCAT
of cholesterol
deficiency
• Indicator of cholestasis
LIPIDS AND LIPOPROTEIN TRANSPORT AND 2. Beta-VLDL (Floating B Lipoprotein)
METABOLISM • Dysbetalipoproteinemia
• Type III Hyperlipoproteinemia
• The dietary or exogenous pathway of lipid transport
involves absorption of triglycerides (TAG) and cholesterol SPECIMEN CONSIDERATIONS
(Ch) through the intestine, with formation and release of PATIENT PREPARATION
chylomicrons (CM) into the lymph and into the blood by
way of the thoracic duct. 1. Fasting - When TAG and LDL are being measured, fasting
becomes a requirement
• The CMs released TAG to adipose tissues as they
2. Diet - LDL and HDL concentrations temporarily decline
circulate.
after eating
• The lipoprotein lipase (LPL) liberated fatty acids (FA) from
3. Posture - current guidelines recommend that patients be
TAG, thereby reducing size of CM to become remnants
seated for 5 mins before sampling to prevent
which is in turn taken up by the liver.
hemoconcentration
• The free FA liberated from TAG is taken up by muscle and
adipose tissue.
• In the endogenous pathway, production of TAG from FA by
the liver take place, with synthesis of VLDL particles
containing apo B100 and apo E.
• These VLDL particles are then converted by LPL to IDL
than can either be removed by the liver through Apo E or
be converted to LDL.
• The Ch-rich LDL particles can be taken up by the liver or
into other tissues for steroid synthesis or part of cell
membranes.

Enzymes for Transport and Metabolism

1. Lipoprotein Lipase (LPL)
2. Hepatic Lipase
3. Lecithin Cholesterol Acyl Transferase (LCAT)
4. Endothelial Lipase
5. ATP-binding cassette protein A1 (ABCA1)

LIPOPROTEINS
• large molecular complexes of lipids with specialized
proteins known as apolipoproteins
• transport TAG and cholesterol to sites of energy storage
and utilization
• Cholesterol and TAG travel in plasma not as free-floating
molecules, but as part of water-soluble complexes called
lipoproteins.

MAJOR LIPOPROTEINS
1. Chylomicron (CM)
• Largest, least dense
• Highest amount of fat, (+) creamy layer
• APO: A1, A2, C, B48
2. Very Low-Density Lipoprotein (VLDL)
• Pre-beta lipoprotein, (+) turbid
• APO: C, E, B100