Interpretation of Laboratory

Results
Buma, DC
Pharmacy Department
Muhimbili National Hospital
 Objectives
• Recognize normal ranges for common laboratory
values in adults.
• Identify common causes for abnormal laboratory
values.
• List circumstances that may produce false-
negative or false-positive laboratory results.
• Interpret the clinical significance of abnormal
laboratory values.
• Utilize clinical laboratory data to monitor various
disease states.

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 Always Remember
• Normal values may vary from laboratory to
laboratory
• Normal values may also vary depending on
the patient’s age, sex, weight, height, and
other factors.
• Laboratory error is a fairly uncommon
occurrence; however, it can happen.

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 Causes of lab error
• Technical error
• Improper calculation
• Inadequate specimen
• Incorrect sample timing
• Improper sample preservation
• Food substances affecting specimen
• Medication interference with laboratory tests.

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 Action on Lab results error
• If laboratory error is suspected, the test
should be repeated.
• Remember: always treat the patient, not the
laboratory value

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 Complete Blood Count (CBC)

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 CBC
• Common laboratory test that provides values for:
– hemoglobin (Hb)
– hematocrit (Hct)
– white blood cells (WBCs)
– red blood cells (RBCs)
– red cell indices
• mean corpuscular volume (MCV)
• mean corpuscular hemoglobin(MCH)
• mean corpuscular hemoglobin concentration (MCHC)
– platelet count
– WBC differential

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 Haemoglobin
Normal Range
Male 14-18 g/dL Female 12-16 g/dL

Description
• Oxygen-carrying compound found in the RBCs
• An indicator of the oxygen-carrying capacity of
the blood
• Adaptation to high altitudes, extreme exercise,
and pulmonary conditions may cause variations

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 Clinical Significance of Haemoglobin
Increased Hemoglobin
• Polycythemia vera
• Chronic obstructive lung disease
• Chronic smokers
• Regular vigorous exercise
• live at high altitudes.
Decreased Hemoglobin
• Anemia of all types (iron deficiency)
• Blood loss
• Hemolysis
• Pregnancy
• Fluid replacement
• Increased fluid intake

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 Hematocrit
Normal Range
Male 39%-50% Female 33%-45%

Description
• The hematocrit (Hct) describes the volume of
blood that is occupied by RBCs
• It is expressed as a percentage of total blood
volume
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 Clinical Significance of Hematocrit
Increased Hematocrit
• Similar to increases in Hb, Dehydration, Shock

Decreased Hematocrit
• All types of anemias, blood loss, hemolysis,
pregnancy
• Cirrhosis
• Hyperthyroidism
• leukemia
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 Erythrocyte Count (RBC)
Normal Range
• Male 4.2-5.9 × 106 cells/mm3 Female 3.5-5.5 × 106
cells/mm3
Description
• Produced in the bone marrow.
• Released into the systemic circulation and serve to
transport oxygen from the lungs to the body tissues
• life span of approximately 120 days
• RBCs are cleared by the reticuloendothelial system.

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 Clinical Significance of RBC
Increased RBCs (erythrocytosis)
• Polycythemia vera
• high altitudes
• strenuous exercise

Decreased RBCs
• Various types of anemias
• lymphomas
• Leukemia
• After puberty, females have lower RBCs due to
menstrual bleeding
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 Mean Corpuscular Volume (MCV)
Normal Range
76-100 fL
Description
• The MCV provides an estimate of the average
volume of the erythrocyte
– Macrocytic
– Microcytic
– Normocytic

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 Clinical Significance of MCV
Increased MCV
• Folate and vitamin B12 deficiencies,
• Alcoholism
• chronic liver disease
• Hypothyroidism
• Anorexia
• Medications
– valproic acid, zidovudine, stavudine, and antimetabolites
Decreased MCV
• iron deficiency anemia
• hemolytic anemia,
• lead poisoning
• thalassemia

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Mean Corpuscular Hemoglobin (MCH)
• Normal Range
26-34 pg/cell

Description
• The MCH indicates the average weight of
hemoglobin in the RBC Cells
– Hypochromic
– Hyperchromic
– Normochromic

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 Clinical Significance of MCH
Increased MCH
• folate or vitamin B12 deficiency
• hyperlipidemia
• false elevated because of specimen turbidity
Decreased MCH
• iron deficiency anemia

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 Mean Corpuscular Hemoglobin
Concentration (MCHC)
Normal Range
32-37 g/dL

Description
• MCHC is a measure of average hemoglobin
concentration in the RBC

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 Clinical Significance of MCHC
Increased MCHC
• hereditary spherocytosis
Decreased MCHC
• iron deficiency anemia
• hemolytic anemia
• Leadpoisoning
• thalassemia

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 Reticulocytes
• Normal Range
• 0.1%-2.5% RBC
• Description
• Reticulocytes are immature RBCs formed in the
bone marrow.
• An increase in reticulocytes usually indicates an
increase in RBC production, but may also be
indicative of a decrease in the circulating number
of mature erythrocytes

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 Clinical Significance of Reticulocytes
Increased Reticulocytes reticulocytosis
• Hemolytic anemia
• Hemorrhage
• sickle cell disease
• indicative of response to treatment of anemias secondary to iron,
vitamin B12 or folate deficiency
Decreased Reticulocytes
• infection causes
• alcoholism
• renal disease (from decreased erythropoietin)
• Toxins
• untreated iron deficiency anemia
• drug-induced bone marrow suppression

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 Leukocyte Count (WBC)
• Normal Range
3.2-11.3 × 10^9 cells/L

• Description
• The WBC count represents the total number of WBCs in a
given volume of blood.
• Mature white blood cells exist in many forms
– Neutrophils
– Lymphocytes
– monocytes
– Eosinophils
– Basophils

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 Clinical significance of WBC
Increased WBCs ( leukocytosis)
• infection
• Leukemia
• Trauma
• thyroid storm
• corticosteroid use.
• Emotion
• Stress
• seizures

Decreased WBCs (leukopenia)

• viral infection
• aplastic anemia
• bone marrow depression caused by the use of chemotherapy or anticonvulsants.

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 Neutrophils
Normal Range
Segs 36%-73%
Bands 3%-5%
Description
• common type of WBCs.
• fight bacterial and fungal infections by phagocytosis
• involved in the pathogenesis of some inflammatory
disorders (rheumatoid arthritis and inflammatory bowel
disease)
• Bands are immature neutrophils
• An increase in bands, often referred to as a “left shift,” may
occur during infection or leukemia

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Clinical Significance of Neutrophils
Increased Neutrophils (neutrophilia)
• Infection
• metabolic disorders(eg, diabetic ketoacidosis),
• Uremia
• Response to stress
• emotional disturbances
• Burns
• acute inflammation
• medications such as corticosteroids

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Clinical Significance of Neutrophils
• Decreased Neutrophils (neutropenia)
• Viral infections (eg, mononucleosis, hepatitis)
• Septicemia
• overwhelming infection
• use of chemotherapy agents

• Absolute neutrophil count (ANC)

– is the total number of circulating segs and bands
ANC = WBC × [(% segs + % bands)/100]
• The risk of infection increases dramatically as the ANC decreases
• An ANC < 500/mm3 is associated with a substantial risk of
infection

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 Lymphocytes
Normal Range
20%-40%
Description
• Lymphocytes are the second most common type of circulating WBCs.
• They are important in the immune response to foreign antigens.

Clinical Significance
• Increased Lymphocytes (lymphocytosis)
• hepatitis, mononucleosis, chickenpox, herpes simplex, herpes zoster and other
viral infections
• Some bacterial infections (eg, syphilis, brucellosis)
• Leukemia
• multiple myeloma
A decreased lymphocyte (lymphopenia)
• may result from acute infections, burns, trauma, lupus, HIV, and lymphoma.

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 Monocytes
• Normal Range
2% and 8%.
• Description
• Monocytes are synthesized in the bone marrow,
released into the circulation, and subsequently
migrate into lymph nodes, spleen, liver, lung, and
bone marrow
• In these tissues, monocytes mature into
macrophages and serve as scavengers for foreign
substances.

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 Clinical Significance of Monocytes
Increased Monocytes (monocytosis)
• recovery phase of some infections,
• subacute bacterial endocarditis (SBE)
• tuberculosis (TB)
• Syphilis
• Malaria
• Leukemia
• lymphoma
Decreased Monocytes (monocytopenia)
• Monocytopenia is usually not associated with a specific
disease, but may be seen with use of bone marrow
• suppressive agents or severe stress.
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 Eosinophils
• Normal Range
0% and 4%.
Description
• phagocytic white blood cells that assist in the killing of
bacteria and yeast.
• They reside predominantly in the intestinal mucosa
and lungs.
• They are also involved in allergic reactions and in the
immune response to parasites.
• Eosinophil count must be taken at the same time daily
due to diurnal variation.

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 Clinical Significance of Eosinophils
Increased Eosinophils (eosinophilia)
• allergic disorders
• allergic drug reactions
• collagen vascular disease
• parasitic infections,
• immunodeficiency disorders
• some malignancies.
Decreased Eosinophils
• A decreased eosinophil (eosinopenia)
• It is commonly attributed to an increase in adrenal
steroid production.
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 Basophils
• Normal Range
less than 1%.
Description
• Basophils are phagocytic white blood cells present in
small numbers in the circulating blood. They contain
heparin, histamine, and leukotrienes and are probably
associated with hypersensitivity reactions.
Clinical Significance
• Increased basophils (basophilia) may be seen in
hypersensitivity reactions to food or medications,
certain leukemias, and polycythemia vera.

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 Platelets
• Normal Range
SI 150-450 × 10^9/L
Description
• Platelets are a critical element in blood clot
formation. The risk of bleeding is low unless
platelets fall below 20,000 to 50,000/μL.

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 Clinical significance of Platelets…
Increased Platelets((thrombocytosis)
• infection,
• Malignancies
• Splenectomy
• chronic inflammatory disorders (eg, rheumatoid
arthritis)
• polycythemia vera
• Hemorrhage
• iron deficiency anemia
• Myeloid metaplasia.
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 Clinical significance of Platelets…
Decreased Platelets (thrombocytopenia)
• Autoimmune disorders such as idiopathic
thrombocytopenic purpura (ITP)
• aplastic anemia
• Radiation
• Chemotherapy
• space-occupying lesion in the bone marrow
• bacterial or viral infections
• use of heparin or valproic acid.
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ELECTROLYTES AND BLOOD CHEMISTRY

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• Electrolytes and blood chemistries are usually the
first set of laboratory tests
• ordered upon initial patient presentation.
• Depending on the institution, these tests may be
ordered using different acronyms.
– A basic metabolic panel (BMP)includes sodium,
potassium, chloride, carbon dioxide (CO2), glucose,
blood urea nitrogen (BUN), and creatinine.
– An abbreviated method for reporting the BMP is: A
comprehensive metabolic panel (CMP) includes
albumin, alkaline phosphatase, alanine
aminotransferase (ALT), aspartate aminotransferase
(AST), total bilirubin, and calcium, in addition to the
components of the BMP.
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 Sodium
Normal Range
SI 135-147 mmol/L
Description
• the most prevalent cation in the extracellular
fluid.
• important in regulating serum osmolality, fluid
balance, and acid-base balance.
• assists in maintaining the electric potential
necessary
• for transmission of nerve impulses.

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 Clinical Significance of Sodium
Increased Sodium (hypernatremia)
• increased sodium intake
• increased fluid loss
Thirst is the primary mechanism to prevent
hypernatremia
• Fluid loss from gastroenteritis, diabetes insipidus,
Cushing disease, hyperaldosteronism, and
administration of hypertonic saline solution are
causes of hypernatremia

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 Clinical Significance of Sodium…
• Decreased Sodium (hyponatremia)
• decrease in total body sodium
• excess accumulation of body water (dilutional
hyponatremia).
• Common causes of dilutional hyponatremia
– CHF, cirrhosis, severe burns, chronic renal failure, and nephrotic
syndrome.Sodium depletion
• cystic fibrosis, mineralocorticoid deficiency, or fluid
replacement with solutions that do not contain sodium.
• Cancer
• use of medications (chlorpropamide, thiazide diuretics, and
carbamazepine)

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 Potassium
Normal Range
SI 3.5-5.2 mmol/L
Description
• main intracellular cation
• Serum concentrations of potassium are not always an
accurate indicator of potassium levels because potassium is
an intracellular ion.
• Potassium plays a key role in many bodily functions:
– regulation of nerve excitability, acid-base balance, and muscle
function.
• Cardiac function and neuromuscular function can be
significantly affected by either an increase or decrease in
potassium levels.
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 Clinical Significance of Potassium
Increased Potassium (hyperkalemia)
• metabolic or respiratory acidosis
• renal failure
• Addison disease
• Dehydration
• massive cell damage from burns, injuries, and surgery.
• Medications such as angiotensin enzyme converting
(ACE) inhibitors, angiotensin receptor blockers (ARBs),
potassium supplements, potassium-sparing diuretics,
and oral contraceptives containing drospirenone

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 Clinical Significance of Potassium…
• It is important to remember that a high
potassium value may be reported if the
specimen was hemolyzed when the laboratory
test was performed.

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 Clinical Significance of Potassium…
Decreased Potassium (hypokalemia)
• severe diarrhea and/or vomiting
• respiratory alkalosis
• Hyperaldosteronism
• Cushing disease
• alcoholism,
• use of amphotericin B or thiazide, loop, or
osmotic diuretics.

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 Clinical Significance of Potassium…
• If a patient is hypokalemic and potassium
supplements have not helped to correct the
low potassium, check to see if the magnesium
is also low.
• Decreased potassium is difficult to correct
while magnesium remains low

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 Calcium
Normal Range
SI 2.1-2.7 mmol/L
Description
• The majority of calcium (Ca2+) in the body (98%-99%) is found in the
skeletal bones and teeth
• The remainder is found in the blood, muscle, and other tissues.
• In addition to playing a role in bone mineralization, calcium is important in
cardiac and skeletal muscle contraction, blood coagulation, enzyme
activity, glandular activity, and transmission of nerve impulses.
• In the blood, approximately half of the calcium is in the ionized “free”
state, and the other half is bound to proteins or complexed with anions.
• Calcium levels are regulated by a complex system that involves the
skeleton, kidneys, intestines, parathyroid hormone, vitamin D, and serum
phosphate

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 Clinical Significance of Calcium
Increased Calcium (hypercalcemia)
• Malignancies
• primary hyperparathyroidism
• Paget disease,
• Sarcoidosis
• vitamin D intoxication
• milk-alkali syndrome
• Addison disease
• use of thiazide diuretics and lithium.

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 Clinical Significance of Calcium…
Decreased Calcium (hypocalcemia)
• Hypoparathyroidism
• Vitamin D deficiency
• Hyperphosphatemia
• acute pancreatitis
• Alkalosis
• alcoholism
• renal disease
• use of loop diuretics
(Pseudohypocalcemia)

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 Chloride
Normal Range
SI 95-106 mmol/L

Description
• Chloride is the principal extracellular anion.
• Chloride primarily serves a passive role in the
maintenance of fluid balance and acid-base
balance.
• Serum chloride values are useful in identifying
fluid or acid-base balance disorders.

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 Clinical Significance of Chloride
Increased Chloride (hyperchloremia)
• metabolic acidosis
• Respiratory alkalosis
• Dehydration
• Diabetes insipidus
• Eclampsia
• Renal disorders

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 Clinical Significance of Chloride…
Decreased Chloride (hypochloremia)
• prolonged vomiting
• gastric suctioning
• metabolic alkalosis
• CHF
• SIADH
• Addison disease
• use of acid suppressants (H2 blockers and proton
pump inhibitors )
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 Carbon Dioxide Content
Normal Range
SI 22-30 mmol/L
Description
• The majority of CO2 in the plasma is present as bicarbonate ions,
and a small percentage is dissolved CO2. The CO2 content is the
sum of both bicarbonate ions and dissolved CO2.
• CO2 and bicarbonate are extremely important in regulating
physiologic pH.
• It is important not to confuse the terms CO2 content and CO2 gas
(ie, pCO2).
• CO2 content is composed mostly of bicarbonate (HCO3−) and is a
base.
• CO2 content is regulated by the kidneys.
• CO2 gas is acidic and is regulated by the lungs

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 Clinical Significance CO2 Content
Increased CO2 Content (metabolic alkalosis)
• Diuretic therapy
• Primary aldosteronism
• Bartter syndrome.

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 Bartter Syndrome
• Mutations of genes
encoding proteins that
transport ions across renal
cells in the thick ascending
limb of Nephron
• Characterized by:
– Hypokalemia
– Alkalosis
– Normal to low BP
• RX
– Na, K supplement
– Spironolactone
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Clinical Significance CO2 Content…
Decreased CO2 Content (metabolic acidosis)
• Diabetic ketoacidosis
• Methanol or salicylate toxicity
• Lactic acidosis
• Renal failure

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 Anion Gap
• Normal Range
SI 3-11 mmol/L
• Description
• The anion gap is calculated using the following formula:
Anion gap = [Na+ − (Cl− + HCO3−)]
• Reflective of unmeasured acids.
• An increase in anion gap suggests an increase in the number of negatively
charged weak acids in the plasma.
• Anion gap is useful in evaluating causes of metabolic acidosis.

Clinical Significance
• Increase in Anion gap
• Conditions (renal failure, lactic acidosis, ketoacidosis)
• Toxicity (salicylate, methanol, or ethylene glycol toxicity).

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 Glucose
Normal Range
Fasting 70-110 mg/dL SI 3.9-6.1 mmol/L
Description
• Energy source for most cellular functions.
• Blood glucose regulation is achieved through a
complex set of mechanisms that involves
insulin, glucagon, cortisol, epinephrine, and
other hormones.
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 Clinical Significance of Glucose
Increased Glucose (hyperglycemia)
• diabetes mellitus
– A fasting blood glucose greater than 126 mg/dL on two
occasions or a random blood glucose greater than 200
mg/dL (along with symptoms of diabetes) on two
occasions is consistent with a diagnosis of diabetes
mellitus.
– Impaired fasting glucose (IFG) if blood glucose levels are
100 to 125 mg/dL when fasting.
– Impaired glucose tolerance (IGT) when a random glucose
level greater than or equal to 140 mg/dL but less than 200
mg/dL
– Both IFG and IGT are suggestive of prediabetes

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 Clinical Significance of Glucose…
Decreased Blood Glucose (hypoglycemia)
• Missing a meal
• Oral hypoglycemic agents
• insulin overdose
• Addison disease.

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 Clinical Significance of Glucose…
• Cushing disease
• Sepsis
• Pancreatitis
• shock
• Trauma
• myocardial infarction
• use of corticosteroids or niacin.

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 Inorganic Phosphorus
Normal Range
SI 0.8-1.6 mmol/L
Description
• Phosphate (PO4) is an intracellular anion involved in
several critical physiologic functions.
• Phosphate is necessary for formation of the cellular
energy source adenosine triphosphate (ATP) and the
synthesis of phospholipids.
• Phosphate also plays a role in protein, fat, and
carbohydrate metabolism, as well as acid-base balance.

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Clinical Significance of Inorganic phosphate

Increased Phosphate (hyperphosphatemia)

• Renal dysfunction,
• Increased vitamin D intake
• Increased phosphate intake
• Hypoparathyroidism
• Bone malignancy
• use of laxatives

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Clinical Significance of Inorganic phosphate…

Decreased Phosphate (hypophosphatemia)

• Overuse of aluminum- and calcium-containing
antacids (these bind phosphorus in the GIT)
• Alcoholism
• Malnutrition
• Hyperparathyroidism
• Respiratory alkalosis

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 Magnesium
Normal Range
SI 0.75-1.2 mmol/L
• Description
• Magnesium (Mg2+) is a necessary cofactor in
physiologic functions utilizing ATP.
• It is also vital in protein and nucleic acid
synthesis, carbohydrate metabolism, and
contraction of muscle tissue.
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Clinical Significance of Magnesium
Increased Magnesium (hypermagnesemia)
• Addison disease
• Administration of Mg supplements or Mg
containing antacids or laxatives to patients
with renal dysfunction

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 Clinical Significance of Magnesium…
Decreased Magnesium(hypomagnesemia)
• Diarrhea
• renal wasting
• Vomiting
• Malabsorption
• Alcoholism
• hyperaldosteronism
• Chronic pancreatitis
• Diabetes mellitus
• Hypercalcemia
• Use of loop diuretics, amphotericin B or cisplatin

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 Uric Acid
Normal Range
Male 3.4-8.5 mg/dL
Females 2.3-6.6 mg/dL

Description
• Uric acid is the main metabolic end product of
the purine bases of DNA

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 Clinical Significance of Uric Acid
• Increased Uric Acid (hyperuricemia)
• Excessive production of purines or inability of the
kidney to excrete urate
• Renal dysfunction
• Metabolic acidosis
• Tumor lysis syndrome
• purine-rich diet
• use of furosemide, thiazide diuretics, and niacin
Hyperuricemia may be associated with the development
of gouty arthritis, nephrolithiasis and gouty tophi

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 Clinical Significance of Uric Acid …
Decreased Uric Acid
• Decreased uric acid levels (hypouricemia) are
usually of little clinical significance but may
occur with a low-protein diet, deficiency of
xanthine oxidase, or use of allopurinol,
probenecid, high doses of aspirin or vitamin C.

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 Total Serum Protein
Normal Range
6.0-8.5 g/dL
Description
• The total serum protein is the sum of albumin,
globulins, and other circulating proteins in the
serum.
• Albumin and globulins are indicators of
nutritional status
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Clinical Significance of Total Serum Protein
Increased Protein (hyperproteinemia)
• May be associated with collagen vascular diseases (lupus,
rheumatoid arthritis, scleroderma)
• Sarcoidosis
• Multiple myeloma
• Dehydration

Decreased Protein (hypoproteinemia)

• may result from a decreased ability to synthesize protein
(liver disease) or an increased protein wasting as seen in
renal disease, nephrotic syndrome and third-degree
burns.2

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 Blood Urea Nitrogen
Normal Range
SI 2.1-7.1 mmol/L
Description
• Urea nitrogen is an end product of protein
catabolism
• It is produced in the liver, transported in the
blood, and cleared by the kidneys.
• BUN concentration serves as a marker of renal
function

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 Clinical Significance of BUN
Increased BUN (azotemia)
• may be associated with acute or chronic renal failure
• CHF
• Gastrointestinal bleeding (gut flora metabolizes blood to ammonia
and urea nitrogen)
• high-protein diet
• Shock
• Dehydration
• Antianabolic
• nephrotoxic medications
• Decreased BUN
Decreased BUN is seen in liver failure because of inability of the liver to
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synthesize urea, and in disease states such as SIADH and acromegaly
 Creatinine
Normal Range
0.6-1.3 mg/dL SI 50-115 μmol/L
Description
• Muscle creatine and phosphocreatine break down to form
creatinine
• Creatinine is released into the blood and excreted by
glomerular filtration in the kidneys.As long as muscle mass
remains fairly constant, creatinine formation remains
constant
• An increase in serum creatinine in the face of unchanged
creatinine formation suggests a diminished ability of the
kidneys to filter creatinine. Thus, serum creatinine is used
as a tool to identify patients with renal dysfunction.

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 Clinical Significance of Creatinine
Increased Creatinine
• Renal dysfunction
• Dehydration
• Urinary tract obstruction
• Vigorous exercise
• Hyperthyroidism myasthenia gravis
• increased meat intake
• use of nephrotoxic drugs such as cisplatin and
amphotericin B
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Clinical Significance of Creatinine…
Decreased Creatinine
• Serum creatinine may be reduced in patients with
cachexia, inactive elderly or comatose patients,
and spinal cord injury patients
BUN/Creatinine Ratio
• Calculating the BUN/creatinine ratio may suggest
an etiology for renal dysfunction.
– A BUN/creatinine ratio greater than 20 suggests a
prerenal cause such as GI bleeding
– A BUN/creatinine ratio between 10 and 20 indicates
intrinsic renal disease

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 Creatinine Clearance
• This calculation provides an estimate of the glomerular
filtration rate (GFR) and is a better indication of renal
function than using serum creatinine alone.
• In addition to assessing kidney function in patients with
renal failure, the creatinine clearance (CrCl) can be used to
monitor patients on nephrotoxic medications and to assess
need for renal dosing adjustments.
The CrCl using the Cockroft and Gault formula is calculated as
follows:

CrCl (mL/min) = *(140 − age) × wt in kg]/(SCr × 72)

The equation must be multiplied by 0.85 if the patient is
female

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 Urinalysis
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 URINALYSIS
Description
• Urinalysis is a useful laboratory test that enables the
clinician to identify patients with renal disorders, as well as
some nonrenal disorders.
• Components of the UA
– gross appearance
– pH
– specific gravity (SG)
– Protein
– Glucose
– Ketones
– Blood
– Bilirubin
– leukocyte esterase
– nitrites
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 Appearance
• On visual examination, the normal urine color
should range from clear to dark
• yellow.
• Some cloudiness is normal and may be caused
by phosphates or urate.
• The presence of WBCs, RBCs, or bacteria may
cause abnormal urine cloudiness.

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 Color
Abnormal urine colors include the following:
• Red-orange
– Presence of myoglobin (from muscle breakdown from seizures,
cocaine, or injuries)
– Hemoglobin
– medications (rifampin, phenazopyridine, phenolphthalein,
phenothiazines)
– Foods beets, carrots, blackberries)
• Blue-green
– amitriptyline or methylene blue, or pseudomonal infection
• Brown-black
– Presence of myoglobin or porphyrins from porphyria or sickle
cell crisis, phenol poisoning, or rhubarb ingestion

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 Specific Gravity
Normal Range
1.005 to 1.025.
Description
• Specific gravity is an indication of the ability of
the kidney to concentrate urine
• Unusually low specific gravity would suggest
that the kidneys are not able to concentrate
urine appropriately
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 Clinical Significance of Specific Gravity
Low Specific Gravity (hyposthenuria)
• chronic renal failure
• diabetes insipidus
High Specific Gravity (hypersthenuria)
• Dehydration
• excretion of radiologic contrast media
• congestive heart failure (CHF
• Toxemia of pregnancy
• syndrome of inappropriate antidiuretic hormone (SIADH)
• Increased excretion of glucose or protein greater than 2
g/day may also increase urine specific gravity

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 pH
Normal Range
4.5 to 8
Description
• Normal urine specimens are acidic. The average pH
value is approximately 6
Clinical Significance
• Alkaline urine may be found in certain urinary tract
infections (UTIs caused by urea-splitting organisms
Proteus, Pseudomonas)
• renal tubular acidosis
• Use of acetazolamide or thiazide diuretics
• Acidic urine may be caused by metabolic acidosis,
pyrexia, or diabetic ketosis.
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 Protein
Normal Range
0 (< 30 mg/dL) to 1 + (30-100 mg/dL).
Description
• Trace protein in the urine is a common clinical finding and
often has no clinical significance
Clinical Significance
• Repeated positive tests or proteinuria of greater than 150
mg/dL may be a marker of renal disease.
• Causes of protein in the urine include diabetic
nephropathy, interstitial nephritis, hypertension, fever,
exercise, pyelonephritis, multiple myeloma, lupus, and
severe CHF

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 Glucose and Ketones
Normal Range
• Both glucose and ketones should be negative.
Description
• Glucose begins to spill into urine (glucosuria)
when serum blood glucose is greater than
180.

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 Clinical Significance of Glucose and Ketones

• Glucose in the urine suggests diabetes mellitus or, in a

known diabetic, suggests the need for improved
glucose control.
• Cushing disease
• pancreatitis
• Use of thiazide diuretics steroids, or oral
contraceptives.
• Excess amounts of ketones form when carbohydrate
metabolism is altered
• Diabetic ketoacidosis (DKA), starvation, high-
protein/low-carbohydrate diets and alcoholism may
produce ketones in the urine
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 Blood
Normal Range
• The normal value should be negative to trace.
Description
• Blood in the urine (hematuria) may indicate urinary tract damage
Clinical Significance
• Common causes of hematuria are infection, nephrolithiasis,
malignancies, and benign prostatic hypertrophy (BPH)
• False-positive results for blood in the urine may occur when
povidone iodine is used as a cleansing agent before urine specimen
collection.
• False-negative results may occur in patients taking high doses of
vitamin C or ascorbic acid.

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 Bilirubin
Normal Range
• The normal value should be from zero to trace.
Description
• Bilirubin in the urine usually produces a dark yellow or brown color
• It appears in the urine before other signs of liver dysfunction
appear.
Clinical Significance
• Bilirubin in the urine may be associated with liver disease (eg,
hepatitis), septicemia, or obstructive biliary tract disease
• Phenazopyridine or phenothiazines may cause a false-positive
result for bilirubin in the urine.

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 Leukocyte Esterase
Normal Range
• The normal value should be from zero to trace.
Description
• Positive leukocyte esterase provides an indication
of WBCs in the urine.
Clinical Significance
• Leukocyte esterase in the urine is associated with
infections and/or inflammation of the urinary
tract

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 Nitrites
Normal Value
• The normal value is negative.
Description
• Gram-negative bacteria are capable of converting
dietary nitrates into nitrites
Clinical Significance
• Presence of nitrites in the urine suggests
colonization or infection with gram negative
organisms

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 CARDIAC TESTS

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 Creatine Kinase
Normal Range (vary with the assay used)
Total CK
Male 38-200 IU/L
Female 26-150 IU/L
CK-MB
Less than 12 IU/L or less than 4% of total CK.

Description
• Creatine kinase is an enzyme that is found primarily in skeletal
and cardiac muscle and in smaller fractions in the brain
• CK levels may be fractionated into isoenzymes to distinguish CK
from muscle (CK-MM), brain (CK-BB), and cardiac tissue (CK-MB).
CK-MB is an important marker in the diagnosis of acute
myocardial infarction (AMI)
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 Clinical Significance of CK-MB
• The CK-MB levels begin to rise 4 to 8 hours after
onset of AMI
• The concentration usually peaks between 12 and
24 hours, and levels return to normal 2 to 3 days
after AMI.
• Serial CK-MB tests are useful in the diagnosis of
AMI.
• An elevated CK-MB level or a CK-MB fraction
greater than 4% to 5% of total CK is suggestive of
AMI
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 Clinical Significance of CK-MB…
An elevation of total CK
• Trauma
• Surgery
• Shock
• Seizures
• Muscular dystrophy
• Cerebrovascular accident
• Polymyositis
• Dermatomyositis
• Chronic alcoholism
• Reye syndrome
• malignant hyperthermia
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 Troponin
Normal Range
Troponin I (cTnI) < 1.5 ng/mL (varies with
assay)
Troponin T (cTnT) < 0.2 ng/mL
Description
• Troponin I and T are sensitive markers of cardiac
injury.
• Troponin I is found solely in the cardiac muscle,
and Troponin T is found in both cardiac and
skeletal muscle.

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 Clinical Significance of Troponin
• Troponin levels begin to rise within 4 hours of
onset of chest pain.
• Levels should be drawn on admission and within
8 to 12 hours thereafter.
• Patients with elevated troponin levels are
considered at high risk for a significant cardiac
event.
• Approximately 30% of patients with no elevation
in CK-MB may demonstrate elevated troponin
and thus be diagnosed with a non-Q-wave
myocardial infarction.
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 LIPOPROTEIN PANEL (LPP)
Total Serum Cholesterol
Blood Levels
Desirable level < 200 mg/dL SI < 5.17 mmol/L
Borderline high 200-239 mg/dL SI 5.17-6.19 mmol/L
High cholesterol ≥ 240 mg/dL SI > 6.20 mmol/L
Description
• Cholesterol is an important component of cell membranes and is
necessary for the synthesis of many hormones and bile acids
• Elevated total serum cholesterol is well known to be associated
with an increased risk of developing coronary heart disease (CHD)
• Total serum cholesterol is a useful screening test to determine CHD
risk
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 Clinical Significance of LPP
• Adults over 20 years of age should have a baseline fasting
lipoprotein profile and testing should be repeated at least every 5
years thereafter.
• Cholesterol levels should be performed after the patient has fasted
for at least 9 to 12 hours.

Increased Serum Cholesterol (hypercholesterolemia)

• the need for diet or drug therapy should be based on the individual
components of the lipid profile(LDL, HDL, and triglycerides [TG])
and the number of CHD risk factors.
• Some causes of hypercholesterolemia include obesity, familial
hypercholesterolemia, and cholestasis.
Decreased Serum Cholesterol
• Decreased cholesterol levels may be seen in malabsorption,
malnutrition, hyperthyroidism, chronic anemia, or severe liver
disease.
• However, low total serum cholesterol
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usually indicates good health.99
 Low-Density Lipoproteins
Desired Range
• No CHD and < 2 CHD risk factors
– < 160 mg/dL (4.13 mmol/L)
• No CHD and ≥ 2 CHD risk factors
– < 130 mg/dL (3.36 mmol/L)
• With CHD or diabetes
– < 100 mg/dL (2.58 mmol/L)

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 Low-Density Lipoproteins…
Description
• Low-density lipoprotein (LDL) is a major
cholesterol transport protein which comprises
60% to 70% of total serum cholesterol. LDL is
considered the “bad” cholesterol, and has
been linked to atherosclerosis

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 Low-Density Lipoproteins…
• When the triglycerides are less than 400
mg/dL, LDL may be calculated using
Friedewald formula

LDL = total cholesterol − HDL − (TG/5)

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 High-Density Lipoproteins
• Blood Levels
Low < 40 mg/dL SI < 1.03 mmol/L
High ≥ 60 mg/dL SI > 1.55 mmol/L
Description
• High-density lipoproteins (HDL) are responsible
for transport of 20% to 30% of serum cholesterol.
• HDL removes excess cholesterol from peripheral
tissues to the liver. It is considered the “good”
cholesterol, and elevated HDL levels are
associated with a decreased risk for CHD

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 Clinical Significance of HDL
• Decreased HDL may be associated with cigarette
smoking, poorly controlled diabetes mellitus, lack
of exercise, familial hypertriglyceridemia, and use
of anabolic/androgenic steroids or β-blockers.
• It is estimated that CHD risk increases by 2% to
3% with each 1 mg/dl
• decrease in HDL Elevated HDL may be seen with
moderate alcohol intake or in patients taking
estrogen, oral contraceptives, or nicotinic acid
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 Triglycerides
• Blood Levels
Normal range < 150 mg/dL SI < 1.7 mmol/L
Borderline high 150-199 mg/dL SI 1.7-2.26 mmol/L
High 200-499 mg/dL SI 2.26-5.64 mmol/L
Very high ≥ 500 mg/dL SI > 5.64 mmol/L

Description
• Triglycerides are the main storage form of fatty acids,
and they account for greater than 90% of dietary fat
intake

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 Clinical Significance of Triglycerides
• Triglycerides may be significantly elevated in the nonfasting state and
should be measured after a fast of at least 12 to 14 hours.

hypertriglyceridemia
• nonfasting sample, poorly controlled diabetes mellitus, pancreatitis,
nephrotic syndrome, chronic renal failure, alcoholism, gout, and use of
oral contraceptives or intravenous lipid infusion.
• Most patients with elevated triglycerides may also have some of the
other characteristics of the metabolic syndrome such as abdominal
obesity, insulin resistance, hypertension, or low HDL.
• Decreased triglycerides may be associated with malnutrition or brain
infarction

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