Chapter 1: Water & Electrolyte Metabolism

Water distribution in body compartments

 Divided into 2 compartments:

(i) Intracellular fluid (ICF)
(ii) Extracellular fluid (ECF)
- Can be further divided into interstitial fluid between cells and plasma found in circulatory system
 ECF and ICF compartments is separated by semi-permeable cell membrane which the water can
pass.
 Solutes only pass through if there is specific mechanism (e.g.: calcium)

Figure 1. Water tank model of body fluid compartments

Figure 2. Water volume depletion

- Dehydration: Loss of fluid in ICF and ECF due to increased urinary losses
Figure 3.Water volume expansion

- Overhydration: Increased fluid in ICF and ECF due to increase intake

Body Fluid Compartments and Distribution of Electrolytes

 Sodium (Na+): Principle extra-cellular cation

 Potassium (K+): Principle intracellular cation
 Inside cells, main anions are protein and phosphate

Osmolality

 Major electrolytes: Na+, K+, Ca2+, Mg2+, Cl-, HCOO3-, HPO43- and SO42-
 Number of dissolved particles in body water is measured by osmolality
 Dissolved particles exert osmotic pressure across semi-permeable cell membrane, causes
water to flow into compartments with high conc. of dissolved solutes relative to other
compartments (movement from low solute conc. to high solute conc.)
  E.g.:
- If cell is placed in a solution with high concentration of solutes (hypertonic solution), water will
move out of the cell, causing it to shrink or undergo plasmolysis.
- If cell is placed in a solution with lower concentration of solute (hypotonic solution), water will
move into cell, causing it to swell or undergo cytolysis.
- In isotonic solution, both sides of the membrane have equal concentration, there is no net
movement of water.
 Role of semi-permeable membranes is to move water freely.
 Osmotic pressure must always be the same on both sides of cell membrane (Osmolality of
ECF and ICF are normally the same, which is to prevent osmotic imbalances that could affect
cell shape and function)
 This is achieved by movement of water across the semi-permeable membrane to keep the
osmolality the same, even if this water movement causes the cells to shrink or expand in
volume.
 Osmolality expressed as mmol solute per kilogram of solvent (usually water)
 Plasma/serum osmolality can be measured directly by using osmometer.
 Osmolarity is the number of osmoles of solute per litre of solution
 Calculation of osmolarity, if the concentration of major solutes is known:
- Calculated osmolarity= 2 (Na+) + 2 (K+) + Glucose + Urea (mmol/L)
- Calculated osmolarity= 2 (Na+) + Glucose + Urea (mmol/L)

Osmolality of Regulation

 Antidiuretic hormone (ADH)/ Arginine vasopressin (AVP): control water excretion.

 AVP causes water retention by the kidneys
 Specialised cell (osmoreceptor cells) in hypothalamus sense differences between osmolality
of ICF and ECF. A rising of osmolality promotes AVP secretion while a declining switches it off.
Thus, by regulating water excretion or retention, AVP maintains normal electrolyte
concentrations within the body.
 Water intake is regulated by thirst. Thirst trigger by receptors in hypothalamus that detected
the increased plasma osmolality or decreased body fluid volume.
 Water excretion by the kidneys is regulated primarily by ADH, which released by the
posterior pituitary and results in increased water reabsorption in the distal nephron.
 ADH release is stimulated by:
- Increased plasma osmolality
- Decreased blood volume
- Decreased blood pressure
- Stress
Specialized cells in hypothalamus called osmoreceptor cells sense differences in osmolality
between ICF and ECF. These cells, located in supraoptic and paraventricular nuclei of the
hypothalamus, monitor blood osmolality. When there’s an increase in blood osmolality, indicating
dehydration or increased salt levels, osmoreceptor cells activate and regulate the release of ADH.
ADH acts on kidney, promoting water reabsorption and reducing the production of dilute urine,
ultimately helping to restore osmotic balance in the body.
Sodium

 75% of Na is exchangeable and is in ECF, the concentration is around 140mmol/L. (remaining 25%
of sodium is found in bone and other structure that not as readily exchangeable)
 Regulation of Na is done through kidneys.
 If Na concentration increases, water need to be consumed to maintain osmolality by diluting the
Na. This in turn increases fluid volume and blood pressure.
 Urinary Na output is regulated by 2 hormones:
(i) Atrial natriuretic peptide (ANP)
(ii) Aldosterone

Atrial Natriuretic Peptide (ANP)

 A polypeptide predominantly secreted by cardiocytes of the right atrium of the heart.

 It increases Na excretion.
 Regulation of ECF volume and Na balance

Aldosterone

 Decreases Na excretion by increasing Na reabsorption at renal tubules

 Major stimulus to aldosterone secretion is volume of ECF. (Specialized cells in juxtaglomerular
complex of nephron sense decrease in BP and secrete renin)

Renin-angiotensin system (RAS)/ Renin-angiotensin-aldosterone system (RAAS)

 A hormone system that regulates BP and water balance.

 When blood volume is low, juxtaglomerular cells in the kidneys secrete renin directly into
circulation.
 Plasma renin converts angiotensinogen released by the liver to angiotensin I.
 Angiotensin I is converted to Angiotensin II by enzyme Angiotensin converting enzyme (ACE)
found in the lungs.
 Angiotensin II is a potent vaso-active peptide, causing blood vessels to constrict. This results in
increased in BP.
 Angiotensin II also stimulates the secretion of hormone aldosterone from adrenal cortex.
 Aldosterone causes the tubules of the kidneys to increase the reabsorption of sodium and water
into blood.
 This increases the volume of fluid in the body, which also increase blood pressure.
The process begins with release of renin, an enzyme from specialized cells called juxtaglomerular
cells located in kidneys. Renin is released in response to low BP, low blood volume, or low sodium
levels.

Renin acts on angiotensinogen, converting it into angiotensin I. Angiotensin I is relatively inactive.

However, it is converted into active form, angiotensin II, by the angiotensin-converting enzyme
(ACE), mainly in the lungs.

Angiotensin II has several physiological effects such as it causes vasoconstriction of blood vessels,
leading to an increase in BP. It stimulates the release of aldosterone from adrenal glands and ADH
from hypothalamus, and it promotes thirst, encouraging water intake.

Aldosterone acts on the kidneys, promoting the reabsorption of sodium and water and the
excretion of potassium. This helps increase blood volume and BP.

ADH promotes water reabsorption in the kidneys, further contributing to an increase in blood
volume.

As BP and volume increase, the release of renin decreases, providing a negative feedback loop
that helps regulate the system.

Loss of Fluids

Sign and Symptoms of:

(i) ICF loss: cellular dysfunction, notably evident as lethargy, confusion, coma
(ii) ECF loss: circulatory collapse, renal shutdown and shock

Electrolytes replacement

 Na+ is present in highest conc. and makes the largest contribution to total plasma osmolality.
 K+ conc. is low in ECF but compared to ICF even minor are very important.
 Common scenarios when electrolytes replacement is require:
- Dehydration
- Exercise and sweating
- Medical conditions
- Malnutrition or imbalanced diet
Sodium Metabolism- Hyponatraemia
 Definition: Serum sodium concentration below reference interval of 135-145mmol/L
 Caused by:

- Loss of sodium ions

- Retention of water

Development of Hyponatraemia- Loss of sodium

 Na+ is the main extracellular cation which function in maintaining of blood volume and BP by
osmotically regulating passive movement of water.
 When there is a decrease in sodium (Na+) levels, water is also lost, leading to the appearance of
typical signs linked to the depletion of the extracellular fluid (ECF) compartment. (The loss of
water from ECF results in decrease ECF volume, contributes to signs and symptoms such as low
BP, increased heart rate and dizziness. The movement of water into cells affects the ICF volume
leading to cellular swelling.)

Sodium Loss

 Na+ depletion is very rare.

 Occurs when pathological Na+ loss either from GIT or in urine.
(i) GIT losses sodium:
- Commonly due to vomiting and diarrhoea
- Patients with fistulae due to bowel disease
(ii) Sodium loss from urine:
- Due to mineralocorticoid deficiency (esp. aldosterone: control sodium reabsorption)
- Drugs that antagonise aldosterone (e.g.: spironolactone)
Development of Hyponatraemia- Water retention

 Occurs more frequently than Na+ loss

 Frequency is higher in females, elderly, and patients who are hospitalized
 Retention of water dilutes constituents of the extracellular space including Na+ causing
hyponatraemia

Water Retention

 Usually results from impaired water excretion

 Most cases of hyponatraemia due to water retention have SIAD (syndrome of inappropriate anti-
diuresis)
 SIAD results of inappropriate secretion of AVP/ADH
 It encounters condition such as infection, malignancy, heart diseases, trauma including surgery.
(E.g.: infection, especially of the lungs pneumonia or the CNS, can trigger SIADH)
 AVP:

- In healthy state, AVP conc. fluctuates between 0-5pmol/L, due to changes in osmolality. (When
blood becomes more concentrated, AVP released to promote water retention and concentration
of urine)

- In SIAD, huge increase occurs because of non-osmotic stimuli, up to 500pmol/L.

 Powerful non-osmotic stimuli include:

(i) Hypovolaemia and/or hypotension
- Low blood volume or low BP can stimulate the release of ADH to conserve water and increase
blood volume
(ii) Nausea and vomiting
- The gastrointestinal symptoms, esp. if severe, can trigger the release of ADH as part of body’s
response to potential hydration
(iii) Hypoglycaemia
- Low blood sugar level can stimulate AH release. This is a protective mechanism to prevent
further water loss in urine when glucose is low.
(iv) Pain
Pseudohyponatremia

 A phenomenon that occurs when measured sodium concentration in the blood appears low, but
the actual concentration of sodium in plasma is normal.
 This phenomenon is typically related to changes in water content of blood sample rather than
actual imbalance of sodium.
 Hyponatraemia is sometimes reported with patients with severe hyperproteinaemia or
hyperlipidaemia.
 The increased amounts of protein or lipoprotein occupy more of plasma volume than usual and
the water less. (When blood sample contains high levels of lipids and proteins, the water
component of the blood is reduced in proportion.)
 Na+ and other electrolytes are distributed in water phase only; these patients have normal Na+
in their plasma water.
 However, many analytical instruments measure the sodium concentration in the total plasma
volume. It takes no account of water fraction that occupies less of the total plasma than usual.
 An artefactually low sodium result may be thus obtained in such circumstances.

 Blood or plasma contains two phase:

(i) An aqueous phase containing practically all the ions
(ii) A lipid/ protein phase which contains virtually none.
 Modern ISE instruments:
- Direct ISE can make measurements directly on whole blood or plasma without preliminary
dilution
- The measurements are of the concentration of the ion in the plasma water
- Even if there are abnormal amounts of lipid or/and protein present in some patients, a direct
ISE instruments will still measure the correct concentration of ion in the plasma water phase.
 Any method involves dilution before measurement will measure the mean concentration of ion
in the plasma water phase and the lipid/protein phase (e.g.: mean concentration per total
sample volume)
 Thus, indirect electrolytes might be expected to be some 5% lower than direct ISE results.
 It has been agreed that all direct ISE instruments will produce results equivalent to those
obtained by dilution methods on normal plasma. This means that reference ranges for the two
methods will be similar.

 Pseudohyponatremia should be suspected if there is discrepancy between the degree of

apparent hyponatraemia and the symptoms might expect in due to actual low sodium.
 The serum osmolality is unaffected by any changes in the fraction of the total plasma volume
occupied by the proteins and lipids since they are not dissolved in water fraction and therefore
do not make any contribution to osmolality.
 A normal serum osmolality in patient with severe hyponatraemia is thus strongly suggestive of
pseudohyponatraemia.
Sodium Metabolism: Hypernatremia

 Increase of serum sodium concentration above the reference interval of 135-145mmol/L

 Occurs due to:
(i) Water loss
(ii) Sodium gain

Water Loss

 Pure water loss arises from:

- Decreased intake
- Excessive loss
 Severe hypernatremia due to poor intake often seen in elderly patients (e.g.: unconscious patient
after a stroke, which fails to match the ongoing insensible water is the cause of hypernatremia)
 Less common cause: Failure of AVP (ADH) secretion or acting resulting in water loss (diabetes
insipidus)
 Diabetes insipidus (DI)
- Central DI is due to failure of AVP secretion
- Nephrogenic if renal tubules do not respond to AVP.
 Water and sodium loss can result in hypernatremia if water loss exceeds sodium loss as in:
- Excessive sweating or diarrhoea, esp. in children

Sodium Gain

 Due to sodium gain much less common than water loss

 Occurs when:
(i) Na bicarbonate given to correct acidosis
(ii) Near drowning on sea where there is ingestion of salt-water
(iii) Infants if given high sodium feeds
 Pathological:
- Conn’s syndrome: Excessive secretion of aldosterone resulting in sodium retention by renal
tubules. Na+ serum rarely >150mmol/L.

Clinical Features

Mild hypernatremia

 Associated with decreased, normal or expanded ECF volume

 Mild hypernatremia (Na+ less than 150mmol/L)
- If patient has obvious features of dehydration it is likely that ECF is reduced
- Due to loss of both water and Na+
More severe hypernatremia

 Na+ 150-170mmol/L
 Pure water loss likely if clinical signs of dehydration are mild in relation to severity of the
hypernatremia. This is because pure water is loss is distributed evenly throughout all body
compartments (ECF and ICF); the Na+ is unchanged

Gross hypernatremia

 Na+ more than 180mmol/L

 Suspect salt poisoning if there is little or no evidence of dehydration
 Salt gain may be present with clinical evidence of overload such as raised jugular venous
pressure or pulmonary oedema.
Chapter 2: Acid Base Balance and Blood Gases

Production of Hydrogen Ions

 Almost 150 moles of H+ are produced daily.

 Most are produced from intermediary metabolism which produces energy from ingested and
stored carbohydrates, proteins and lipids.
 Excess hydrogen ions come from:
(i) Carbon dioxide (volatile acid)
- Although large amounts (15-20moles) are produced every day as carbonic acid, with the
potential to disturb acid-base balance, it is readily excreted by the lungs.
(ii) Non-volatile acid
- Sulphuric, phosphoric, lactic (100mmol/day)

pH and Hydrogen Ion Concentration

 pH is a measure of the H+ concentration in the body

 pH is the negative logarithm of H+
 As H+ rises, pH falls
 A low pH indicates that the blood is more acid than normal
 A high pH indicates that the blood is less acid than normal

Acids and Bases

 An acid is any molecule that able to donate a H+ ion (The donation of H+ ions to the solution
increases the concentration of hydrogen ions in the solution)
 A base is any molecule able to accept an H+ (The acceptance of H+ ions by a base lead to a
decrease in the concentration of free H+ ions in the solution. As H+ conc. decrease, the pH
solution increase, more alkaline)
 The products formed by acceptance of a H+ is dependent upon the nature of the base.
 If the base is an acid anion (bicarbonate), an dissociated acid (carbonic acid) will produced.
Normal pH

 Normal pH maintain between 7.35-7.45

 Body function such as heart contraction and nerve conduction are adversely affected by H+
outside this range.
(i) Heart contraction: Cardiac muscle function is sensitive to changes in pH. Deviations from
the normal pH range can affect the contractility of the heart muscles.
(ii) Nerve conduction: Nerve conduction is influenced by pH levels. Extreme pH values can
interfere with proper transmission of nerve impulses.
 pH values of <7.00 or >7.8 usually incompatible with life.
 Three primary systems exist to maintain and restore pH within the range compatible with life:
(i) Extracellular buffer (immediate)
(ii) The lungs
(iii) The kidneys (Storing pH around 24hrs to 48hrs)

Buffer Systems

 Buffer acts like sponge which mops up excess [H+] ions but they do not remove ions.
 A buffer solution of the salt (bicarbonate) of a weak acid (carbonic acid) is able to combine with
hydrogen ions.
 The weak acid mentioned is carbonic acid (H2CO3), and its salt is bicarbonate (HCO3-).
 The bicarbonate ion (HCO3-) has the ability to combine with hydrogen ions (H+) in a
reversible reaction. HCO3−+H+⇌H2CO3
 When excess hydrogen ions (acid) are added to the solution, the bicarbonate ions can
combine with them, neutralizing the excess acidity.
 If there’s a shortage of hydrogen ions (base), the bicarbonate ions can release hydrogen ions
to neutralize the excess alkalinity.
 Buffering is only a short term solution until the body actually excretes excess hydrogen ions via
the lungs or via the kidneys.

Body Buffer Systems

 Four buffer systems exist in ECF:

(i) Bicarbonate (most important)
(ii) Proteins
(iii) Haemoglobin
(iv) Phosphate
Bicarbonate Buffer System

Henderson-Hasselbalch Equation

 The bicarbonate buffer system is present in the plasma and in the RBCs, and is the first line
defence against changes in [H+].
 The relationship between [H+], carbonic acid and its dissociation to CO2 can described by the
Henderson-Hasselbalch equation.
 The equation states that pH equals to the sum of pK plus the logarithm of the ratio of
bicarbonate to carbonic acid.
 The normal ratio of bicarbonate to carbonic acid is 20:1

Carbon dioxide reacts with water to form carbonic acid. Carbonic acid dissociates into
bicarbonates ions and protons. Bicarbonate ions acts as buffer, readily accepting protons to
neutralize excess acidity or donating protons to counteract alkalinity.
Respiratory Buffer System

 Bicarbonate buffer system: After combining with a hydrogen ion to form carbonic acid, this can
then dissociate to carbon dioxide and water.
 The carbon dioxide can then excreted via the lungs which ensures that the system does not reach
equilibrium and can continue to buffer more hydrogen ions.
 By removing CO2, the equilibrium in the bicarbonate buffer system is shifted to the left
(dissociation of carbonic acid), favouring the production of more bicarbonate ions. This
prevents the system from reaching a state of equilibrium and allows it to continue buffering
additional hydrogen ions.
 The ongoing removal of CO2 ensures that the bicarbonate buffer system remains dynamic
and can continue its role in buffering, maintaining the pH.
 The lungs therefore represent the next line of defence against changes in [H+] after plasma
buffers can respond in minutes by increasing or decreasing ventilation.
 When all the bicarbonate is used up, the system has no more buffering capacity.
 This lead to a loss of buffering capacity, making the solution more vulnerable to rapid shifts in
acidity or alkalinity. The depletion of bicarbonate can result in disruptions in acid-base balance,
potentially causing acidosis or alkalosis.
Renal Buffer System

 Renal Buffer System can respond within hours to days to an acid-base balance.
 Any hydrogen ion which is derived from non-volatile acids and buffered must eventually be
excreted from the body by the kidneys.
 Secretion of hydrogen ion into urine allows the bicarbonate to recovered by the kidney.
 Regeneration of bicarbonate also takes place in the kidney.
 Hydrogen ion excreted in the tubular fluid is buffered by phosphate and ammonia ions in
order to prevent the urine becoming too acid.
Reference Ranges (Arterial)

Reference Ranges (Venous)

pH (7.32-7.38) α¿ ¿
(pH is proportional to the ratio of bicarbonate and pCO2)

Acidosis and Alkalosis

 Acidosis contain two types:

(i) Metabolic
(ii) Respiratory
 Alkalosis contain two types:
(i) Metabolic
(ii) Respiratory

 Metabolic- involving HCO3

 Respiratory- involving CO2
 Metabolic Respiratory
Acidosis HCO3 (Decreased) CO2 (Increased)
Alkalosis HCO3 (Increased) CO2 (Decreased)

Acid Base Disorders

Simple acid-base imbalance: An acid-base disorder where there is only one primary lesion.
Four types:
1. Simple metabolic acidosis
2. Simple metabolic alkalosis
3. Simple respiratory acidosis
4. Simple respiratory alkalosis

 Acidaemia: A low blood pH (pH <7.35)

 Alkalaemia: A high blood pH (pH >7.45)
 Acidosis: Any process tending to acidify body fluids (increased production of [H+])
 Alkalosis: Any process tending to alkalinise body fluids (decreased production of [H+])

Evaluation of Acid-Base Disorders

1. Clinical assessment
2. Laboratory Test

Simple Evaluation Approach

1. Evaluate the pH:
- Acidaemia, alkalaemia, normal
2. Evaluate the pCO2:
- Respiratory acidosis or alkalosis
3. Evaluate the HCO3-:
- Metabolic acidosis or alkalosis
4. Combine the information from (1), (2), (3) to arrive at a provisional diagnosis
Chapter 3: Calcium and Phosphate metabolism

 Principle minerals: Calcium, Phosphate, Magnesium, Sodium, Potassium, and Sulphur

 Calcium and phosphorus individually have their own functions
 Calcium + Phosphorous together are required for formation of hydroxyapatite and
physical strength of skeleton tissue

Distribution

Calcium: Phosphate:
Skeleton- 99% Skeleton-90%
Muscle- 0.3% Intracellular-5%
Other tissues-0.7% Extracellular- Less than 0.03%

Serum (plasma) calcium- Types:

1. Free/ionized calcium (50%)
2. Complexed calcium (10%): tightly bound to anions, bicarbonate, lactate, phosphate,
citrate
3. Plasma protein-bound calcium (40%): 80% associated with albumin and globulin

Calcium Phosphate Ratio

 Calcium: Phosphate ratio (2:1)

 Ratio is always constant
 Normal total calcium: 9-10.5 mg/dL (2.20-2.58mmol/L)
 Normal ionized calcium: 4.55-5.6g/dL (1.16-1.32mmol/L)

Serum Phosphate Levels

 Children: 4-7 mg/dL (1.26-2.26mmol/L)

 Adults: 3-4.5mg.dL (0.87-1.45mmol/L)

Dietary Sources:

Calcium: Phosphates:
- Milk and Milk products - Same as calcium
- Egg - Present in high amount in cereals and
- Fish pulses
- Vegetables
- Fruits (oranges)
- Nut
Function of Calcium
 Muscle contraction
 Formation of bone and teeth
 Nerve transmission
 Preservation of cell membrane integrity and permeability
 Resting membrane potential of the cells
 Release of certain hormones
 Major structural elements in the vertebrate skeleton (bones and teeth) in the form of
calcium phosphate (Ca10(PO4)6(OH)2) known as hydroxyapatite
 Maintenance of cell structure
 Membrane rigidity, permeability and viscosity are partly dependent on local calcium
concentrations.

Functions of Phosphate

 Formation of bones
 Important component of teeth
 Important constituent of cells
 Forms energy rich bonds in ATP
 Forms co-enzymes
 Regulates blood and urinary pH
 Forms organic molecules like DNA and RNA

Absorption of Calcium

 Taken through dietary sources such as calcium phosphate, carbonate, tartrate and
oxalate.
 Absorbed from GIT into blood and distributed to various parts of the body
 Two mechanism of calcium absorption by gut mucosa:
(i) Simple Diffusion
(ii) Active transport process (involves energy and calcium pump)
 While passing through kidney, large quantity of calcium is filtered in glomerulus.
 From the filtrate, 98-99% of calcium is reabsorbed in renal tubules into blood and only
small quantity is excreted through urine.
 In the bone, calcium may deposited or resorbed depending on the level of calcium in
plasma.

Factors controlling absorption:

1. Those acting on mucosal cells
2. Those affecting the availability of calcium and phosphates in the gut

Factors acting on mucosal cells

 Vitamin D
 Pregnancy and growth
 PTH

Vitamin-D

 Calcitriol (1,25-DHCC) is the biologically active form of Vit-D

 Function: Regulates plasma levels of Ca and P
 Calcitriol acts on 3 different levels: Intestine, kidney, bones

Action on Intestines

 Calcitriol increase intestinal absorption of Ca and P.

 In the intestinal cells, calcitriol binds with a cytosolic receptor to form a calcitriol-
receptor complex
 This complex then approaches the nucleus and interacts with a specific DNA leading to
synthesis of specific Ca binding protein. This protein increases the Ca uptake by intestine

Action on bone
In osteoblasts of bone, calcitriol stimulates Ca uptake for deposition as CaPO4.

Calcitriol facilitates the absorption of calcium and phosphate from the intestine, ensuring
a sufficient supply of these minerals for bone mineralization. Moreover, it stimulates the
activity of osteoclasts, cells responsible for breaking down bone tissue and releasing
calcium and phosphate into the bloodstream. Simultaneously, calcitriol inhibits the
secretion of PTH, a regulator of bone resorption. By suppressing PTH, calcitriol helps
prevent excessive bone breakdown. Additionally, calcitriol promotes the function of
osteoblast, cells involved in building new bone tissue. This dual in regulating both bone
resorption and formation contributes to maintenance of optimal bone mineral density.

Action on kidney
It is involved in minimizing the excretion of Ca and P through kidney by decreasing their
excretion and enhancing reabsorption.
Pregnancy and growth
Pregnancy
 During later stage of pregnancy, greater amount of calcium absorption is seen
 50% of this calcium is used for development of foetal skeleton and the rest is stored in
bones to act as a reserve for lactation
 This is due to increased level of placental lactogen and oestrogen which stimulates
increased hydroxylation of Vit-D.

Growth

 There is increased level of growth hormone. GH acts by increasing calcium absorption

Parathyroid Hormone (PTH)

 One of the main hormones controlling Ca absorption

 Mainly acts by controlling the formation of 1,25-DHCC (active form of Vit-D) which
responsible for increased Ca absorption

Hormonal Control of Calcium & Phosphate metabolism

 Three hormones regulate calcium and phosphate metabolism

(i) Vitamin D
(ii) PTH
(iii) Calcitonin

Vitamin D
(i) Cholecalciferol/ D3
(ii) Ergocalciferol/ D2
 Called as hormone because it produced in the skin when exposed to sunlight
 Vit-D has very little intrinsic biological activity
 Vit-D itself is not an active substance, it must be first converted through a series of
reaction in the liver and kidneys to final active produce 1,25-DHCC (Calcitriol)
Daily requirement

 Adult: 2.5mg
 Lactating mother, pregnancy, adolescents, infants: 5mg

Dietary Sources

 Cod liver oil

 Fish-salmon
 Egg, liver

Actions of Vitamin D

 Increase plasma level of calcium

 Increase intestinal Ca and P absorption
 Increase renal reabsorption of calcium and phosphate

Parathyroid Hormone (PTH)

 Secreted by parathyroid gland

 Glands are four in number
 Present posterior to thyroid gland
 Histologically contain two types of cells:
(i) Chief cells (Forming PTH)
(ii) Oxyphilic cells (Replaces the chief cells stores hormone)
 Single chain polypeptide
 Molecular weight 9000
 Consist of 84 a.a
 Plasma conc.: 10-50ug/mL
 Measured by immunoassay

Actions of PTH

 Function: Increase plasma Ca level within critical range 9-11 mg

 Parathormone:
- Inhibits renal phosphate reabsorption in proximal tubule, so increases phosphate
excretion
- Increases renal Calcium reabsorption in distal tubule, which increases the serum calcium

Net effect of PTH:

(i) Increased serum calcium
(ii) Decrease serum phosphate

Stimulation of PTH secretion

(i) The release of PTH is triggered when conc. of calcium in plasma is low
(ii) Maximum secretion occurs when plasma level falls below 7mg/dL
(iii) When plasma calcium level increases to 11mg/dL there is decreased secretion of PTH

Calcitonin (Thyrocalcitonin)

 Minor regulator of Ca and P phosphate metabolism

 Secreted by parafollicular cells or C-cells of thyroid gland
 Single chain polypeptide
 Molecular weight 3400
 Plasma conc.: 10-20ug/ml

Action of Calcitonin

 Net effect of calcitonin Decrease Serum Ca

 Target site
- Bone (osteoclast): decreased ability of osteoclast to resorb(breakdown) bone
 Osteoclast cells
- Loss their ruffled borders
- Undergo cytoskeletal rearrangement
- Decreased mobility
- Detach from bone

Excretion of Calcium and Phosphorous

Calcium excretion

 Calcium is excreted through urine, bile and digestive secretions.

 Renal threshold for serum ca is 10mg/dL
 70-90% of calcium elimination from the body is excreted in the feces.

Phosphorous excretion

 Excreted through urine.

 Almost 2/3rd of total phosphorous that excreted is found in urine as phosphate of various
cations.
 Found in faeces is the non-absorbed form of phosphorus

Clinical Importance
(i) Hypercalcaemia
 Elevated serum calcium level: 12-15mg/dl (2.1mmol/L-2.7mmol/L)
  Conditions leading to hypercalcaemia:
(a) Hyperthyroidism (influence bone resorption, altering calcium and vit-D metabolism)
(b) Acute osteoporosis
(c) Thyrotoxicosis
(d) Vit-D intoxication

Signs:
- Diminished reflexes
- Short QT interval on ECG

Symptoms:
- Polyuria
- Dehydration
- Confusion
- Depression
- Fatigue
- Nausea/ vomiting
- Anorexia
- Abdominal pain and renal calculi

(ii) Hypocalcaemia
 Decreased level of calcium in blood (<4mg/dL)
 Conditions leading to hypoglycaemia:
- Insufficient dietary calcium
- Hypoparathyroidism
- Insufficient vit-D
- Increased in calcitonin levels

Symptoms:
- Irritability
- Muscle cramps
- Depression
- Bronchospasm and seizures
Vitamin D deficiency
(i) Rickets
 Occurs in children between 6 months to 2 years of age
 Affects long bones
 Lack of calcium causes failure of mineralization resulting into formation cartilaginous
form of bone
 Most critical area that gets affected: Central endochondral ossification at epiphyseal
plates

(ii) Osteomalacia
 Softening of bones caused by not having enough vit-D or by problems with
metabolism of this vitamin.
 These softer bones have a normal amount of collagen that gives the bone its
structure, but they are lacking in calcium.
 Occurs in adults
 Flat bones affected
 Softening and distortion of skeleton bone

Symptoms:


Fractures of brittle bones occur even after minor accident

Pain due to fractures of vertebrae which may radiate round the trunk, to the buttocks
or down the legs
 Oral manifestation include alveolar bone loss resulting in ill-fitting dentures and
periodontitis.
 Alveolar bone loss: The part of jawbone that surrounds and supports the teeth. Loss
of this bone can have significant consequences for dental health
 Ill-fitting dentures: Dentures are artificial teeth that replace natural teeth. Alveolar
bone loss can result in changes to the jaw structure, making dentures fir poorly and
uncomfortably.
 Periodontitis: Severe form of gum disease, involve inflammation and infection of
structure supporting teeth, including alveolar bone.

Prevention:

 Physical activity
 Androgen and Oestrogen
 Increased calcium intake and strontium and sodium fluoride ingestion
Hyperparathyroidism
(i) Primary hyperparathyroidism
 A primary abnormality of the parathyroid glands causes inappropriate, excess
PTH secretion
 Caused mainly by an adenoma of parathyroid

(ii) Secondary hyperparathyroidism

 High levels of PTH occur as a compensation rather than as a primary
abnormality of parathyroid glands
 It can caused by vitamin D deficiency or chronic renal disease

Primary hyperparathyroidism is usually caused by benign tumour on one of

parathyroid glands, it may also due to hyperplasia of multiple parathyroid glands.
Overactive parathyroid gland releases excessive amounts of PTH. Elevated PTH leads
to increased calcium release from bones, increased calcium absorption in the
intestines, and reduced calcium excretion by the kidneys. Resulting in elevated blood
calcium levels (hypercalcemia).

Secondary hyperparathyroidism is a response to condition that result in low calcium

levels in the blood, often due to chronic kidney disease (CKD) or vitamin D deficiency.
It is a compensatory mechanism where the parathyroid glands become overactive to
maintain normal blood calcium levels. The increased secretion of PTH aims to
enhance calcium absorption from the intestines and release calcium from bones.
Hypoparathyroidism

 Decrease level of PTH

 Due to:
- Surgical removal of parathyroid gland
- Congenital absence of gland
- Atrophy of the gland
 Diagnosis
- Decrease plasma calcium and increase plasma phosphate level

Hyperphosphatemia

 Increased intake Diet containing Vit-D

 Increased release of P from cells (DM, Acidaemia, Starvation)
 Increased release of P from bone (Malignancy, Renal failure, increased PTH)
 Decreased excretion (Renal failure, Hyperparathyroidism, increased growth hormone)

Effects of Hyperphosphatemia

 Phosphate trapping
 Respiratory insufficiency
 Erythrocyte dysfunction
 Nerve Dysfunction
 Leukocyte Dysfunction
 Metabolic acidosis

Treatment

 Treat underlying cause

 In patients with hypoparathyroidism, calcium and vitamin D supplementation are
generally prescribed to correct hypocalcaemia.
 In hyperphosphatemia due to chemotherapy, for leukaemia or lymphoma, vigorous
saline diuresis will lead to increased phosphaturia. Alternatively, the administration of
acetazolamide, 500mg every six hours will enhance renal phosphate excretion through
urinary alkalinization and natriuresis.
Hypophosphatemia

 Decreased intake (Starvation, malabsorption, vomiting)

 Increased cell uptake (high dietary carbohydrate, liver disease)
 Increased excretion (diuretics, hypomagnesaemia, increased PTH)

Treatment

 Treat the underlying cause

 2-3 grams of elemental phosphorus daily, two to four divided doses orally

Hypophosphatasia

 Basic disorder is a deficiency of the enzyme alkaline phosphatase in serum or tissues and
excretion of phosphoethanolamine in the urine.
 Clinical features:
- Infantile: severe rickets, hypercalcemia, bone abnormalities and failure to thrive
- Childhood: Premature exfoliation of deciduous teeth, increased infection, growth
retardation, rachitic like deformities, pulmonary, GIT, and renal abnormalities
 Oral manifestation:
- Loosening and premature loss of deciduous teeth, chiefly the incisors.

Tutorial Questions:
Strategy of investigation of hypercalcemia and hypocalcaemia?
Investigation of hypercalcemia
The reference interval of calcium ion is 2.1 to 2.7mmol/L. From total calcium test, it is
supposed to be hypercalcemia as the serum calcium ion concentration shows above
2.7mmol/L. Hypercalcemia is mainly caused by the abnormal PTH level. If PTH level is higher
than normal range, it is related to the clinical conditions like primary hyperthyroidism with
low phosphate and high calcium levels and familial hypocalciuric hypercalcemia shown as
decreased urinary calcium levels. Also, insufficient PTH level can be compensated by
excessive production of other hormones. PTH2-peptide is the principal cause of
hypercalcemia malignancy. The granulomatous disease like sarcoidosis might be induced
since the calcitriol concentration increased. Vitamin D intoxication generally results from
elevated calcifediol synthesis. There are other possible causes of leading to hypercalcemia
with PTH and vitamin D level is normal.
Chapter 4: Endocrinology
Hormone: Any substance in an organism that carries a “signal” to generate some sort of
alteration at the cellular level.
(i) Endocrine hormones:
- Act on cells distant from the site of their release
- Examples: Insulin, glucagon, epinephrine, steroid hormones
- Endocrine signals: Directed at distant cells through intermediacy of bloodstream

(ii) Paracrine hormones:

- Act only on cells close to the cell that released them
- Examples: Polypeptide growth factor: interleukin-1 prostaglandins
- Paracrine signals: Directed at nearby cells

(iii) Autocrine
- Act on the same cell that release them
- Examples: Interleukin-2 (Stimulates T cell proliferation)
- Autocrine signals: Directed at the cell that produced them

Hormonal Cascade System

The cascade of hormonal signals starts with an external or internal environment signal. The
single stimulus generates a series of hormones in progressively large amounts and with
increasing stabilities. The ultimate hormone affects most of the cells in the body.
Classification of Hormones:
(i) Polypeptide
- Example: Insulin, GH, LH, Glucagon, hCG, FSH and ACTH

(ii) Steroid
- Example: Aldosterone, Testosterone, Cortisol and oestrogen

(iii) Amino Acid Derivatives

- Example: Norepinephrine, Epinephrine, Thyroid hormone

(iv) Eicosanoid (FA Derivatives)

- Example: Prostaglandins, Leukotrines, Tromboxanes

Polypeptide Hormones:

 Hydrophilic (Water-soluble)
 Do not penetrate plasma membranes, so it must bind to receptors in plasma membranes
of target cell.
 The extracellular signal of a hormone get transmitted into the cell by generating second
messenger (e.g.: cAMP)
 Second messenger carry information from first messenger hormone into the cell.
 The second messenger are often produced using common proteins associated with
plasma membrane called G-proteins.

G-protein mediated signal transduction (cAMP as a second messenger)

 G-protein are coupled to receptors in the plasma membrane of the cell.

 G-protein coupled receptors can mediate the responses to signals (such as hormones
and neurotransmitters)
 G-protein is responsible for relaying the hormonal information to downstream signalling
pathways within the cell.
 G-proteins have 3 subunits, an alpha subunit, beta subunit and gamma subunit.
 When g-protein is in an inactive state, the alpha subunit has a bound GDP.
 The binding of hormone to G-protein coupled receptors initiate a conformational change
in the G-protein. This stimulate the alpha subunit of G-protein to exchange its bound
GDP for a GTP. (GDP  GTP)
 With this GTP bound, the G-protein in an active state.
 The activated G-protein dissociate into alpha subunit and a beta-gamma complex.
 The actual target of the activated subunit depends on the G-protein that is activated. In
this pathway cAMP serves as a second messenger. The G-protein in this case is
stimulatory protein called GS.
 The activated alpha subunit of GS binds to enzyme Adenylyl cyclase.
 Adenylyl cyclase converts ATP into cAMP.
 cAMP serve directly as a signalling molecule, or it can indirectly through activation of
proteins within the cell.
 E.g.: 4 cAMP molecules can bind to the regulatory subunits of protein kinase A (PKA).
This allows the catalytic subunits of PKA to dissociate, and PKA can then phosphorylate
intracellular targets. (cAMP binds with pKA and activates it. 4 cAMP will binds to
regulatory subunit and release catalytic subunit which able to phosphorylate proteins to
produce a cellular effect)
G-proteins play a crucial role in cellular signalling, particularly through G-protein
coupled receptors (GPCRs) located in the plasma membrane. These receptors
respond to various signals, such as hormones and neurotransmitters. Comprising
three subunits—alpha, beta, and gamma—G-proteins relay hormonal information
to downstream signaling pathways within the cell. In an inactive state, the alpha
subunit of the G-protein is bound to GDP. However, when a hormone binds to the
GPCR, it induces a conformational change, prompting the alpha subunit to
exchange GDP for GTP, rendering the G-protein active.

Once activated, the G-protein dissociates into an alpha subunit and a beta-
gamma complex. The specific target of the activated subunit depends on the type
of G-protein involved. In the case of the stimulatory G-protein, GS, the alpha
subunit activates the enzyme Adenylyl cyclase. This enzyme, in turn, converts ATP
into cAMP, a crucial second messenger.

cAMP can act directly as a signaling molecule or indirectly by activating proteins

within the cell. For instance, when four cAMP molecules bind to the regulatory
subunits of protein kinase A (PKA), it enables the catalytic subunits of PKA to
dissociate. This activated PKA can then phosphorylate intracellular targets,
initiating a cascade of events that mediate the cellular response to the initial
hormonal signal
Glucagon action in the liver cell

 Hormone glucagon travel through the blood stream to liver and bind to G-protein
coupled receptor (GPCR). This initiates an increase in cAMP, which leads to generation of
pKA resulting increase the glucose level by two ways:
(1) Blocking glycogen synthesis
(2) Accelerate glycogen degradation

Blocking glycogen synthesis

When the body requires an increase in blood glucose levels, hormones like epinephrine and
glucagon are released. These hormones activate a signalling pathway that involves the
production of cAMP, which then activates pKA. pKA plays a central role in cellular responses
and phosphorylates glycogen synthase kinase (GSK). When GSK is activated, phosphorylates
and inhibits glycogen synthase, causing it to transition from an active ‘a’ form to an inactive
‘b’ form. In this inhibited state, glycogen synthase is less effective in catalysing the addition
of glucose units to glycogen chains, thereby blocking the synthesis of glycogen.
Accelerate glycogen degradation

When the body requires an increase in blood glucose levels, hormones like epinephrine and
glucagon are released. These hormones activates a signalling cascade that involves the
conversion of ATP to cAMP, leading to activation of pKA. pKA in turns activates
phosphorylase kinase.

The activated phosphorylase kinase plays a crucial role in glycogen degradation. It

phosphorylates and activates glycogen phosphorylase b, converting it into its active form,
glycogen phosphorylase a. This active form is essential for breaking down glycogen into
glucose units.

 For proper cell function, the cell must be able to stop the G-protein signalling pathway
after it has accomplished its task.
 To terminate the signal, cAMP is broken down using enzyme cAMP phosphodiesterase.
 The catalytic subunits of pKA then re-associate with regulatory subunits.
 To inactivate G-protein, alpha subunit is hydrolyze its bound GTP back into GDP using
GTPase activity.
 Alpha units then re-associate with beta-gamma complex, and the G-protein is once again
back to inactive state.
 Finally, the cell is ready to be stimulated by another hormone.
Ca++, IP3 and DAG as second messenger

 Utilizes intracellular calcium as a second messenger.

 The hormone release from the blood circulation into interstitial fluid.
 Hormone then binds to a GPCR in plasma membrane of target cell.
 The G-protein in this signalling pathway called GQ.
 The alpha subunit of the G-protein exchanges its bound GDP for GTP, and activated
alpha subunit dissociates from the rest of G-protein.
 Alpha subunits activates phospholipase ‘C’ (PLC).
 PLC act on the molecule Phosphatidylinositol4,5-biphosphate (PIP2).
 PLC cleaves PIP2 into two molecules:
(1) Inositol 1,4,5 triphosphate (IP3)
(2) Diacylglycerol (DAG)
 IP3 is a small, water soluble molecule that is released into cytosol, and travels to
endoplasmic reticulum. The endoplasmic reticulum stores a large amount of calcium in
the lumen.
 IP3 binds to ligand-gated calcium release channel in the membrane of the endoplasmic
reticulum, and calcium flows into the cytosol.
 At the same time that IP3 is initiating calcium release, DAG is migrating through plasma
membrane to activate protein kinase C.
 The calcium released from the endoplasmic reticulum by IP3 assists in full activation of
PKC.
 This intracellular Ca++ acts as a second messenger in two ways:
(1) It binds to an effector molecule, such as an enzyme (e.g.: proteinkinase)
(2) It binds to an intermediary cytosolic calcium binding protein (e.g.: CALMODULIN)
 Ca++ bind to calmodulin will activate protein kinase this results stimulating a variety of
cellular process. (E.g.: Smooth muscle contraction, stimulating mitosis and growth)
 Once activated, PKC phosphorylates a number of intracellular targets, this transmitting
the initial message of the hormone binding to the hormone receptor.
How the IP3 calcium signalling pathway switched off

 To terminate this signal, calcium is re-sequestered in the endoplasmic reticulum and PIP2
is formed.
 The alpha subunit of the G-protein hydrolysis its bound GTP into GDP, and the G-protein
reassociate.
 This restores the resting state of the cell so that another hormone can initiate cellular
effects.

Mode of action for steroid hormones

 Steroid hormones binds to specific intracellular protein receptors.

Steroid hormones exert their physiological effects through a multi-step process that involves
intricate interactions with target cells. Initially synthesized and released by endocrine glands,
such as the adrenal glands and gonads, these lipid-soluble hormones navigate through the
bloodstream, often bound to carrier proteins. Upon reaching target cells, steroid hormones
diffuse through cell membranes and bind to specific intracellular receptors located in the
cytoplasm or nucleus. This binding triggers a conformational change in the receptor, forming
a hormone-receptor complex. In some instances, this complex translocate into the cell
nucleus. Once in the nucleus, it will binds to specific DNA sequences known as hormone
response elements (HREs), initiating or enhancing the transcription of specific genes. This
transcriptional activation leads to the synthesis of messenger RNA, which upon existing the
nucleus, directs the synthesis of proteins or enzymes in the cytoplasm. The newly
synthesized proteins then mediate the physiological response associated with the steroid
hormone, contributing to the regulation of diverse processes such as metabolism,
development and immune responses.

Types of Endocrine control

1. Negative feedback:
 Occurs when the rate of process decreases as the concentration of the product
increases.

Neurons in the hypothalamus secrete thyroid releasing hormone (TRH), which stimulates
anterior pituitary to secrete thyroid-stimulating hormone (TSH). TSH binds to receptors on
epithelial cells in the thyroid gland, stimulating synthesis and secretion of thyroid hormones,
which affect probably all cells in the body. When blood concentration of thyroid hormones
increases above a certain threshold, TRH-secreting neurons in the hypothalamus are
inhibited and stop secreting TRH.
Positive feedback control:

 Occurs when the rate of a process increases as the concentration of the product
increases.

Secretion of breast milk

The stimulation of a baby sucking its mother’s breast leads to secretion of oxytocin into the mother’s
blood, which leads to milk being available to the baby via the breast. The mother’s production and
release of oxytocin ceases when the baby stops feeding.

The positive feedback mechanism involved in the secretion of breast milk is a vital process ensuring
the effective initiation and sustenance of lactation. Initiated by the suckling stimulus of an infant,
nerve signals are transmitted from the nipple to the hypothalamus in the brain. In response, the
hypothalamus signals the posterior pituitary gland to release oxytocin, a key hormone in milk
ejection. Oxytocin in turn acts on the smooth muscles surrounding the milk-producing glands (aveoli)
and ducts within the breast. The action induces the milk ejection reflex, leading to contraction of
muscles and the release of stored milk into the ducts. The process is characterized by positive
feedback, whereby the continued suckling of the infant perpetuates the releases of oxytocin. This
self-reinforcing loop ensure that the more the baby suckles, the more milk is ejected, facilitating
ongoing nutritional supply required for the infant’s well-being.
Chapter 12

Vitamin A function:

i. Normal synthesis of mucopolysaccharides and growth of epithelial tissue for growth and
development
ii. Maintenance of immune system
iii. Needed by the retina of the eye in form of retinal, which combines with protein opsin to
form rhodopsin

Vitamin A:

- B-carotene: Antioxidant agents

- Retinol/Retinoic acid: Acting like “Steroid hormone”. Protein synthesis in regulation of growth,
transferrin and cell differentiation and maintenance of epithelium tissue
- Retinyl phosphate: Glycoprotein synthesis & mucopolysaccharides
- Retinol,retinal: Normal reproduction
- 11-cis-retinal: Visual cycle: rhodopsin- visual pigment of rod cells

Vitamin A Deficiency:

Mild Deficiency:

1. Night blindness: Night blindness, or nyctalopia, is one of the early symptoms of

vitamin A deficiency. It is characterized by difficulty seeing in low-light conditions or
in the dark. This occurs because vitamin A is essential for the production of
rhodopsin, a pigment in the retina that is necessary for vision in low-light
environments

2. Anaemia: Vitamin A deficiency can contribute to anemia by impairing the

mobilization of iron stored in the liver. Iron is necessary for the production of
hemoglobin, the protein in red blood cells that carries oxygen. Vitamin A deficiency
can lead to a lack of transferrin, a protein that transports iron in the bloodstream,
resulting in reduced iron availability for haemoglobin synthesis.

3. Follicular hyperkeratosis: Follicular hyperkeratosis refers to the thickening of the skin

around hair follicles, resulting in rough and dry skin with raised bumps. This condition
is a common manifestation of vitamin A deficiency and occurs due to the impairment
of normal skin cell turnover and keratinization processes

4. Growth retardation: Vitamin A deficiency can impair growth and development in

children. It may lead to loss of appetite, partly due to the keratinization of taste buds,
which can affect the sense of taste and reduce food intake. Additionally, vitamin A
deficiency can retard bone development, leading to growth retardation and stunted
growth in children.
Severe Vitamin A Deficiency:

1. Xerophthalmia: Caused by a severe vitamin A deficiency is described by pathologic dryness of

the conjunctive and cornea. The conjunctiva becomes dry, thick and wrinkled. If untreated, it
can lead to corneal ulceration and ultimately to blindness as a result of corneal damage.

2. Follicular hyperkeratosis: It’s a skin condition characterized by excessive development of

keratin in hair follicles, resulting in rough, cone shaped, elevated papules. The openings are
often closed with a white plug of encrusted sebum

Vitamin E (α,β,γ,δ-tocopherol)

Source: Plants oils, animal fat

Function:

1. Very strong natural antioxidant

- Vit E is a strong reducing agent and can protect PUFA at cell membrane from oxidative break
down β free radicals. Vit. E accumulates in lipoprotein, cell membrane and fat, thus protecting
cells from free radicals.
2. Therapeutic Drug
- Prevents infarcts occurs in heart muscle which can reduce risk of heart diseases
3. Plays a role in neurological functions.

Deficiency:

1. Erythrocyte haemolysis: Common in pre-developed babies

2. Neurological problems in older children and adult (disrupt the myelin making)

Excessive Intake

1. Possesses very low toxicity

2. No visible toxic effect has been observed in dosage not exceeding 3,200mg/day

Vitamin K

1. Phylloquinone (Vit K1): In plants (green vegetables)

2. Menaquinone (Vit K2): Synthesized by intestinal bacteria

Functions:

1. Regulate bone metabolism

2. Required for conversion of several clotting factors & prothrombin precursors to the active
state
 3. Function as cofactor with glutamyl carboxylase (microsome) to convert glutamyl residues to
γ-carboxyglutamic acid residues on prothrombin (precursor protein)

Deficiency:

1. Hypoprothrombinaemia
- Less Vit.K synthesizing microorganisms in the intestine
- Patients on long-term antibiotic therapy or moderate malnutrition

2. Newborn infants

Water-soluble vitamins

 Readily excreted
 Often are coenzymes in the pathways for energy generation
 Dietary sources: milk, meat, egg and seed products

Energy-releasing water-soluble vitamins

1. Thiamine (B1)
2. Riboflavin (B2)
3. Niacin (B3)
4. Biotin (B7)
5. Pantothenic acid (B5)

Thiamine (B1)

Active form: Thiamine pyrophosphate (TPP)

Source: Cereal grains, meat, egg

Function:

1. Energy metabolism
- Coenzyme for oxidative decarboxylase reactions (e.g. Pyruvate DH, α-ketoglutarate DH)
2. Other metabolism
- Trans-ketolase in pentose phosphate pathways

Deficiency:

Mild Deficiency: Loss of appetite, nausea, mental depression, peripheral neuropathy, irritability,
fatigue
Moderately severe deficiency:

1. Wernicke-Korsakoff Syndrome
- Mental confusion, ataxia, ophthalmoplegia (loss of eye coordination) selective neuronal damage
and severe memory loss
- Commonly seen in chronic alcoholics

Severe deficiency: Beriberi

- A neurological and cardiovascular disease

- Three major forms of Beriberi:
(i) Dry beriberi: muscular atrophy & weakness
(ii) Wet beriberi: associated with mental confusion, muscular atrophy, oedema, tachycardia
and congestive heart failure
(iii) Infantile beriberi: Occurs in infants breast-fed by thiamine deficient mothers

Riboflavin (B2)

- Central component of cofactors FAD and FMN

- Sources: Milk, cheese, leafy vegetables, yeast
- Functions:
(i) Oxidation-reduction reaction, energy production & cellular respiration
(ii) FAD act as coenzyme for several reactions
(iii) Oxidation of pyruvate, alpha-ketoglutarate requires FAD
(iv) FAD require to convert retinol to retinoic acid

Deficiency

- Angular cheilitis
- Stomatitis
- Glossitis

Niacin (B3)

- Active form: NAD and NADP

- Functions:
(i) Oxidation-reduction reactions
(ii) Hyperlipidaemia treatment Niacin inhibits lipolysis in adipose tissues
(iii) NAD is require for catabolism of fat, carbohydrate, protein, alcohol, cell signalling and
DNA repair
(iv) NADP mostly in anabolism reaction such as Fatty acid and cholesterol synthesis
Deficiency:

Moderate deficiency

- Weakness, skin problems, glossitis, pellagra

Pellagra

- Caused by niacin deficiency

- Symptoms: Diarrhoea, dermatitis, dementia, lesion on the lower neck, hyper pigmentation,
thickening of skin, inflammation of the mouth and tongue
- Death occurs if treatment is not carried out

Pantothenic Acid (A5)

Function:

(i) Used to synthesize CoA to transport carbon atom within the cell
(ii) CoA important for biosynthesize of fatty acids and cholesterol

Sources: Meat, whole grains, vegetable (broccoli)

Deficiency symptoms:

- Similar to other Vit. B deficiency

- Impiared energy production due to low CoA levels
- Symptoms: Irritability and fatigue
Lesch-Nyhan syndrome (Juvenile gout)

Biochemical deficiency: Lesch-Nyhan syndrome is caused by deficiency of enzyme hypoxanthine-

guanine phosphoribosyl transferase (HPRT). HPRT deficiency is due to mutation occur in HPRT gene.
This enzyme deficiency leads to build-up of uric acid in all body fluids.

Symptoms: Severe intellectual disability, self-injurious behaviours such as biting their lips and fingers,
involuntary movements such ass spasticity and dystonia, and the presence of uric acid crystals in
urine leading to gout-like symptoms.

Diagnosis: Based on clinical presentation and confirmed by genetic testing to identify mutations in
the HPRT1 gene.

Phenylketonuria (PKU)

Biochemical Deficiency: Mutation in the gene for hepatic enzyme phenylalanine hydroxylase (PAH),
rendering it non-functional, which responsible for converting the amino acid phenylalanine into
tyrosine. When PAH activity is reduced, phenylalanine accumulates and is converted into
phenylpyruvate.

Symptoms: Without treatment, individuals with PKU may develop intellectual disability, seizures,
behavioural problems, and a musty odour due to accumulation of phenylalanine and its breakdown
products in the body.

Diagnosis: Screening of PKU can be performed by using Guthrie test, immunoassays using
fluorometric or photometric detection, or amino acid measurement using mass spectrometry.
Confirmatory diagnosis involves measuring phenylalanine levels in blood plasma and genetic testing
to identify mutations in the PAH gene.

Medium Chain Acyl-CoA Dehydrogenase (MCAD) deficiency:

Biochemical Deficiency: MCAD deficiency is caused by a deficiency of the enzyme medium-chain

acyl-CoA dehydrogenase, which involved in breakdown of fatty acids for energy production.

Symptoms: Drowsiness, lack of energy and diarrhoea, and also lead to risk of complications such as
seizures, breathing difficulties and even coma and sudden death.

Diagnosis: Based on clinical presentation, biochemical testing such as measurement of acylcarnitine

levels in blood, and confirmatory genetic testing to identify mutations in the ACADM gene.

Explain the screening for phenylketonuria using Guthrie Test.

The Guthrie test is a semiquantitative assay designed to detect elevated blood levels of the amino
acid Phe, using the ability of phenylalanine to facilitate bacterial growth in a culture medium with an
inhibitor. A drop of blood is usually obtained by prickling the heel of a newborn infant on the 6 th or 7th
day of life. The blood is collected on a piece of filter paper and sent to a central laboratory. A small
disk of filter paper is punched out and placed on an agar plate containing Bacillus subtilis and B-
2thienylalanine. Each gel holds 60-80 disks. The agar gel is able to support bacterial growth but B-2-
thienylalanine inhibits bacterial growth. However, in the presence of extra phenylalanine leached
from the impregnated filter paper disk, the inhibition is overcome and the bacteria grow. Within a
day, the bacteriala growth surrounding the paper disk is visible to the eye. The amount of growth,
measured a the diameter of the colony, is roughly proportional to the amount of phenylalanine in
the serum. The result is read by comparing the diameter of each sample disk’s colony with standard
phenylalanine content included on each large plate.