ELECTROLYTES

MS. MARTINA DEANNE C. MENDOZA, RMT

INTRODUCTION

• Electrolytes are ions (minerals) capable of carrying an electric

charge.
o Classified as: cations (positive charge) or anions (negative
charge)
o The major cations in the sodium: sodium, potassium,
calcium, and magnesium
o The major anions in the body are chloride, bicarbonate,
phosphate, sulfate, organic acids, and protein.
• Fluid always contains equal numbers of cations and anions, and
this balance of charges is referred to as electroneutrality.
INTRODUCTION
• It is an essential component in numerous processes including:

Function Electrolytes
Volume and osmotic regulation Na, K, Cl
Myocardial rhythm and contractility K, Mg, Ca
Important cofactors in enzyme activation Cl, Mg, Ca, Zn
Regulation of adenosine triphosphatase
Mg
(ATPase) ion pumps
Neuromuscular excitability K, Ca, Mg
Maintenance of acid-base balance HCO3, K, Cl, PO4
Replication of DNA and the translation of
Mg
mRNA
Blood coagulation Ca, Mg
Production and use of ATP from glucose Mg, PO4
WATER DISTRIBUTION
• Average water content of the human body varies from 40% to 75% of total body weight.
• Water is the solvent for all processes in the human body as it is responsible for
transporting nutrients to cell, determining cell volume by its transport in and out
of cells, removal of wastes product by way of urine, and acting as the body’s
coolant by way of sweating.
o Intracellular fluid (ICF) – fluid inside the cells; accounts for about two-thirds of
total body water
o Extracellular fluid (ECF) – accounts for one-third of total body water
▪ Subdivided into:
• Intravascular fluid – IVF, plasma
• Interstitial fluid – surrounds the cells in the tissue
• Transcellular fluid – CSF
WATER DISTRIBUTION

• Normal plasma is about 93% water, with the remaining volume

occupied by lipids and proteins.
• The water content of plasma is 12% higher than that of whole
blood.
• Deficiency in arginine vasopressin (retains water) causes 10 to 20
liters of water excreted daily.
• Sweat contains about 50 mmol/L of sodium and 5 mmol/L of
potassium.
• Salt content of the body is the main determinant of the
extracellular volume.
MAINTAIN ELECTRONEUTRALITY
• Active transport – a mechanism that requires energy to move ions
across cellular membranes.
• Diffusion – the passive movement of ions (no energy consumed)
across a membrane and depends on both size and charge of the ion
being transported and on the nature of the membrane through which it
is passing.
OSMOLALITY

• Colligative properties refer to the properties of a solution that

are influenced by the number of molecules in solution, but not
their individual composition.
• Four types of colligative properties:
▪ Boiling point
▪ Freezing point
▪ Osmotic pressure
▪ Vapor pressure
OSMOLALITY
• Osmolality is a physical property of a solution that is based on the concentration of
solutes per kilogram of solvent.
• It is regulated by the hypothalamus through the sensation of thirst and the signaling
to secrete antidiuretic hormone (ADH).
• When the osmolality of the blood is increased, two processes occur:
• Regulation of Plasma Osmolality
o Sensation of thirst
▪ Prevents dehydration (consuming water will decrease the osmolality)
o Arginine vasopressin hormone (AVP; formerly known as antidiuretic
hormone)
▪ Secreted by the posterior pituitary gland.
▪ Acts on the collecting ducts of kidneys to increase water reabsorption.
▪ Control water excess
OSMOLALITY

• Osmometry – method used to measure all particles (molecules

and ions) in solution; measure of osmolality
• Two formulas used to calculate estimated osmolality:

𝑮𝒍𝒖𝒄𝒐𝒔𝒆 𝑩𝑼𝑵
𝟐 𝑵𝒂 + + = 𝒎𝑶𝒔𝒎/𝒌𝒈
𝟐𝟎 𝟑

𝑮𝒍𝒖𝒄𝒐𝒔𝒆 𝑩𝑼𝑵
𝟏. 𝟖𝟔 𝑵𝒂 + + + 𝟗 = 𝒎𝑶𝒔𝒎/𝒌𝒈
𝟏𝟖 𝟐. 𝟖
OSMOLALITY

• In healthy individuals, the calculated osmolality equals the

measured osmolality.
• The osmolal gap represents the difference between the
measured and calculated osmolality.
• The osmolal gap should be < 15.
• An osmolal gap can exist for a variety of reasons:
▪ Excess production of beta-hydroxybutyrate.
▪ Ingestion of toxins such as ethylene glycol.
▪ Ingestion of an excessive amount of alcohol.
OSMOLALITY

• Measuring Osmolality
o Measuring serum and urine osmolality is useful in assessing
electrolyte disorders and acid-base status.
o Major molecules measured by serum osmolality include
sodium, chloride, glucose, and urea.
oFreezing point depression osmometry: Particles in solution
cause the freezing point of pure water to be decreased, with the
decrease in temperature being directly proportional to the total
number of particles present.
OSMOLALITY

• Measuring Osmolality
oVapor pressure depression osmometry: Water evaporation
is decreased when solute is present in water, which is indicated
by an inverse relationship between the osmolality of the
solution (amount of particles present) and the vapor pressure.
OSMOLALITY
• Polydipsia – increased thirst; caused by excess intake of water.
o Lowers plasma osmolality = both AVP and thirst are suppressed
o In the absence of AVP, water is not reabsorbed, causing a large volume of
dilute urine to be excreted; as much as 3 to 20 L of water daily.
o Hypoosmolality and hyponatremia usually occur only in patients with
impaired renal excretion of water.
• Dehydration = increased plasma osmolality = AVP secretion and thirst are
activated
o Diabetes insipidus – a disease of water and salt imbalance; deficiency of
AVP, causing increased urinary excretion, which may or may not interfere
with Na+ concentration.
OSMOLALITY
• Regulation of Blood Volume
o Regulation of both Na+ and water is interrelated in controlling blood
volume.
o Renin-Angiotensin-Aldosterone System (RAAS) – responds primarily
to a decreased blood volume.
1. Renin is secreted in response to decreased renal blood flow (decreased blood
volume or blood pressure).
2. Renin converts the hormone angiotensinogen to angiotensin I, which then
becomes angiotensin II.
3. Angiotensin II causes both vasoconstriction, which quickly increases blood
pressure, and secretion of aldosterone (increases reabsorption of Na+).
OSMOLALITY

• DECREASED BLOOD VOLUME/BLOOD PRESSURE

resulting to decrease renal blood flow stimulates the RENIN-
ANGIOTENSIN ALDOSTERONE SYSTEM (RAAS).
• Resulting to:
o Vasoconstriction = ↑ blood pressure
o Secretion of aldosterone = ↑ blood volume
o Secretion of ADH/arginine vasopressin = ↑ sodium
OSMOLALITY

Reference Ranges for Osmolality

Serum 275 – 295 mOsm/kg
Urine (24 h) 300 – 900 mOsm/kg
1.0 – 3.0
Urine/serum ratio

Random urine 50 – 1,200 mOsm/kg

Osmolal gap 5 – 10 mOsm/kg
OSMOLALITY

NORMAL TO MODERATELY
MARKEDLY
SLIGHT ELEVATED (UP HYPOOSMOLALITY
ELEVATED (> 10)
ELEVATION TO 10)
Dehydration ACIDOSIS: POISONING: Hyponatremia
Hypernatremia Ketoacidosis Ethanol Hypoalbuminemia
Azotemia Renal acidosis Ethylene glycol
Diabetes Lactic acidosis Methanol
insipidus
ELECTROLYTES | SODIUM
• It is also known as “natrium”.
• It is the major extracellular cation, hence the major contributor of
osmolality.
• It is the principal osmotic particle outside the cell.
• Its plasma concentration depends greatly on the intake and excretion of
water.
• Its level in blood is an important determinant of several biological
pathways in the nervous system.
ELECTROLYTES | SODIUM
• Extracellular volume depends primarily on plasma Na+, which is closely
regulated by AVP (water retention) and aldosterone (sodium retention).
• All confirmed serum sodium abnormalities must be monitored together with
urine sodium and osmolality including urinalysis.
• 60% to 75% of filtered sodium is reabsorbed in proximal tubule.
• Blood volume is regulated by changes in sodium balance.

Reference Ranges for Sodium

Serum, plasma 135 – 145 mmol/L
120 – 240 mmol/d, varies
Urine (24 h) with diet
Cerebrospinal fluid 136 – 150 mmol/L
ELECTROLYTES | SODIUM

• Hormones Affecting Plasma Sodium Levels

▪ Aldosterone
▪ Synthesized in the adrenal cortex.
▪ Enhances absorption of sodium in the distal tube.
▪ Promotes sodium retention and potassium excretion.
▪ Induces sodium retention in the renal tubules, thereby
promoting conservation of water.
ELECTROLYTES | SODIUM

• Hormones Affecting Plasma Sodium Levels

▪ Atrial Natriuretic Factor
▪ An endogenous anti-hypertensive agent secreted from the
cardiac atria.
▪ Blocks aldosterone and renin secretion and inhibits the
action of angiotensin II and vasopressin.
▪ Causes natriuresis (increased renal sodium excretion).
ELECTROLYTES | SODIUM
• Hormones Affecting Plasma Sodium Levels
▪ Urodilantin
▪ Produced in the renal tubules.
▪ Belongs to the group of natriuretic peptides.
▪ Promotes natriuresis.

▪ Angiotensin II and Catecholamines

▪ Influences the renal tubular reabsorption of sodium.
▪ Catecholamines also affect the renal blood flow.
ELECTROLYTES | SODIUM
• Hypernatremia
▪ It is characterized by increased plasma sodium >145 mmol/L.
▪ It is caused by loss of water, gain of sodium, or both.
▪ It usually does not occur unless thirst mechanism is impaired.
▪ Perspiration and breathing would result in one liter water loss/day in
adults.
▪ A water deficit of 1% - 2% leads to a severe thirst.
▪ Thirst is the major defense against hyperosmolality and
hypernatremia.
ELECTROLYTES | SODIUM
• Clinical Correlations
▪ Hyponatremia is usually associated with hypovolemia (low blood
volume).
▪ Urine osmolality is essential to evaluate the causes of
hypernatremia.
▪ Renal loss of water: Normal or decreased urine osmolality
▪ Extra renal water loss: Increased urine osmolality
Serious case of hypernatremia ≥ 160 mmol/L
Serum Na+ indicative of moderate 150 – 160 mmol/L
deficit of water
Serum Na+ indicative of severe > 165 mmol/L
deficit of water
ELECTROLYTES | SODIUM
• Hyponatremia
▪ It is the most common electrolyte disorder encountered in clinical
practice.
▪ It is defined as having plasma sodium < 135 mmol/L.
▪ Clinical concern arises when the serum sodium is < 130 mmol/L.
▪ Serum sodium level < 125 mmol/L may result in severe
neuropsychiatric symptoms.
ELECTROLYTES | SODIUM
• Hyponatremia
▪ Decreased osmolality is the most common cause of hyponatremia
either due to sodium loss or water retention.
▪ By examining the urinary sodium, potassium, and osmolarity, the
causes of hyponatremia and hypernatremia can be readily
determined.
▪ Urine Na+ may help differentiate renal failure (≥ 20 mmol/day) from
hepatic cirrhosis, congestive heart failure, and nephrotic syndrome
(<20 mmol/day).
ELECTROLYTES | SODIUM
• Clinical Correlations
▪ If renal failure occurs, the kidneys ultimately fail to concentrate the
urine, resulting in hyponatremia.
▪ In nephrotic syndrome and hepatic cirrhosis, plasma proteins and
colloid pressure are low, causing edema – low plasma volume causes
arginine vasopressin secretion resulting to fluid retention and Na+
dilution.
▪ If urine sodium is > 20 mmol/day, there is ongoing renal loss of
sodium and water; but if < 20 mmol/day it may be due to prolonged
vomiting and diarrhea.
ELECTROLYTES | SODIUM
• Clinical Correlations
▪ Potassium deficiency also cause loss of sodium because of the
inverse relationship of the two ions in the renal tubules. When serum
potassium levels are low, the tubules will conserve potassium and
excrete sodium in exchange for the loss of the monovalent cation.
▪ Dilutional hyponatremia may be observed in hypothyroidism and
Addison disease (hypoadrenalism).
▪ High urinary loss of sodium may also be seen in aldosterone
deficiency.
ELECTROLYTES | SODIUM
• Effect of Hyperglycemia to Plasma Sodium
▪ For every 100 mg/dL increase in blood glucose, serum sodium
decreases by 1.6 mmol/L.
▪ Accumulation of glucose or mannitol in the ECF is a common cause
of hyponatremia because glucose is osmotically active and induces
diffusion of water from the cells to the ECF, thus diluting its
electrolytes.
▪ In diabetes mellitus, sodium loss occurs with ketonuria.
ELECTROLYTES | SODIUM
• Syndrome of Inappropriate ADH Secretion (SIADH)
▪ It is characterized by continuous secretion of ADH in the absence of
stimulus.
▪ It is described as having euvolemic hypoosmolar hyponatremia
associated with hyperosmolar urine.
ELECTROLYTES | SODIUM
• Pseudohyponatremia
▪ It is the reduction of serum sodium concentration caused by a
systemic error in measurement.
▪ The most common cause is in vitro hemolysis.
▪ Marked hemolysis may cause decreased of sodium levels due to
dilutional effect.
▪ Artifactual hyponatremia is also associated with hyperlipidemia or
hypoproteinemia.
ELECTROLYTES | SODIUM
• Methods
▪ Sample: serum or lithium heparin
▪ Avoid hemolyzed and milky serum or plasma.
1. Emission Flame Photometry – YELLOW
2. Ion-Selective Electrode – routine method
▪ It uses a semipermeable membrane to develop an electrical potential produced by having different ion
concentrations on either side of the membrane.
▪ Direct method: an undiluted sample interacts with the ISE membrane; used in blood gas analyzers.
▪ Indirect method: a diluted sample is used for measurement; used in most automated chemistry
analyzers.
▪ ISE Membrane: Glass aluminum silicate
3. Colorimetry: Albanese-Lein
▪ Reagent: Sodium uranyl zinc acetate
▪ End color: Yellow
 HYPONATREMIA

INCREASED SODIUM INCREASED WATER

WATER IMBALANCE
LOSS RETENTION
Hypoadrenalism Renal failure Excess water intake
(Addison’s disease) Nephrotic syndrome SIADH
+
K deficiency Hepatic cirrhosis Pseudohyponatremia
Diuretics use Congestive heart
Ketonuria failure
Salt-losing nephropathy
Prolonged vomiting or
diarrhea
Severe burns
 HYPERNATREMIA

EXCESS WATER DECREASED WATER INCREASED INTAKE OR

LOSS INTAKE RETENTION
Diabetes insipidus Older persons Hyperaldosteronism
Renal tubular Infants Sodium bicarbonate
disorder Mental impairment excess
Prolonged diarrhea Dialysis fluid excess
Profuse sweating Severe dehydration
Severe burns Cushing’s syndrome
ELECTROLYTES | POTASSIUM
• It is otherwise known as “kalium”.
• It is the major intracellular cation, and only 2% of the body’s total
potassium circulates in the plasma.
• It is the single most important analyte in terms of an abnormality being
immediately life threatening.
• Its concentration in the red blood cells is 105 mmol/L or 23x its
concentration the plasma.
• In the ascending limb of Henle’s loop, it is reabsorbed together with Na+
and Cl- by the sodium potassium chloride co-transporter.
ELECTROLYTES | POTASSIUM
• It is filtered at the glomeruli and is mostly (70 – 80%) reabsorbed by
active and passive mechanisms in the proximal tubule.
• It is involved in cardiac contraction, neuromuscular excitability,
ICF volume regulation, and hydrogen ion concentration – K+ has a
major effect on the contraction of skeletal muscle and cardiac muscles.
• Its plasma concentration is greatly influenced by the kidney and
aldosterone.
• Important in the regulation of K+: tubular reabsorption and secretion
• Principal determinant of urinary K+: distal nephron
ELECTROLYTES | POTASSIUM
• ACIDOSIS = HYPERKALEMIA
• ALKALOSIS = HYPOKALEMIA

Reference Ranges for Potassium

Serum, plasma 3.5 – 5.1 mmol/L

Urine (24 h) 33 – 86 mmol/d

ELECTROLYTES | POTASSIUM
• Hormones Affecting Plasma Potassium Levels
▪ Aldosterone
▪ Regulates urinary loss of potassium in the cortical
collecting duct.
▪ Epinephrine
▪ Provides a channel for the cellular entry of potassium.
▪ Insulin
▪ Promotes the entry of potassium into skeletal muscles and
hepatic through the action of the sodium-potassium
ATPase.
ELECTROLYTES | POTASSIUM
• Hyperkalemia
▪ It is almost always due to impaired renal excretion.
▪ Major mechanism of diminished renal potassium excretion: reduced
aldosterone or aldosterone responsiveness, renal failure, and
reduced distal delivery of sodium.
▪ Elevations in serum K+ can directly stimulate the adrenal cortex to
release aldosterone.
▪ Hyperkalemia inhibits NaCl reabsorption in the distal convoluted
tubule, whereas angiotensin II stimulates it.
ELECTROLYTES | POTASSIUM
• Pseudohyperkalemia
▪ Causes: sample hemolysis, thrombocytosis, prolonged
torniquet application, fist clenching, blood stored in ice, IV
fluid, and high blast count in acute or accelerated phase
leukemias.
▪ Thrombocytosis and severe leukocytosis cause potassium release
from the platelets and white blood cells during clotting.
▪ Patients with high blast counts in leukemias-cells can lyse and
release potassium during normal phlebotomy.
ELECTROLYTES | POTASSIUM
• Hypokalemia
▪ Plasma K+ levels of 3.0 – 3.4 mmol/L is mild hypokalemia.
▪ Critical hypokalemic symptom: < 3 mmol/L (arrythmia, may cause
sudden death)
▪ Hypomagnesemia leads to hypokalemia by promoting urinary loss of
potassium.
ELECTROLYTES | POTASSIUM
• Pseudohypokalemia
▪ Leukocytosis can cause falsely decreased potassium levels –
because K+ is taken up by WBC if sample is left at room
temperature.
ELECTROLYTES | POTASSIUM
• Differential Diagnosis
▪ First step in the differential diagnosis of hyperkalemia: To rule out
pseudohyperkalemia
▪ Once pseudohyperkalemia is ruled out, the next step is to differentiate
among the three major causes of hyperkalemia: increased K+ intake, shift
of K+ from the cell, and impaired renal excretion.
▪ First step to differential diagnosis of chronic hyperkalemia of renal causes:
measure plasma renin activity, plasma aldosterone, and urinary excretion of
Na+ and K+
▪ First step in the differential diagnosis of hypokalemia: measure urinary
excretion of K+
ELECTROLYTES | POTASSIUM
• Methods
• Heparinized plasma is preferred over serum due to potassium released during
clotting.
• Avoid hemolyzed sample.
• Diet rich in fats may lead to elevated serum potassium.
• Muscular activity such as exercise and prolonged standing increase potassium
level by 10 – 20%
▪ Mild to moderate exercise: ↑ 0.3 – 1.2 mmol/L
▪ Vigorous exercise and fust clenching: ↑ 2 – 3 mmol/L
1. Flame Emission Photometry = VIOLET/PURPLE/LILAC
2. Ion-Selective Electrode – current method of choice
▪ ISE Membrane: Valinomycin Gel
3. Colorimetry: Lockhead and Purcell
 HYPOKALEMIA

GASTROINTESTINAL CELLULAR
RENAL LOSS HYDRATION
LOSS SHIFT
Vomiting Diuretics Alkalosis Decreased
Diarrhea Nephritis Insulin overdose intake
Gastric suction Renal tubular
Intestinal tumor acidosis
Malabsorption Hyperaldosteronism
Cancer therapy Cushing’s syndrome
Large doses of Hypomagnesemia
laxatives Acute leukemia
 HYPERKALEMIA

DECREASED CELLULAR INCREASED

ARTIFACTUAL
RENAL EXCRETION SHIFT INTAKE

Acute or chronic Acidosis Oral or Sample hemolysis

renal failure Muscle/cellular intravenous Thrombocytosis
Hypoaldosteronism injury potassium Prolonged
Addison’s disease Chemotherapy replacement tourniquet use
Diuretics Leukemia therapy or excessive fist
Hemolysis clenching
ELECTROLYTES | CHLORIDE
• It is the major extracellular anion.
• It is the chief counter ion of sodium.
• It promotes maintenance of water balance and osmotic pressure in
conjunction with sodium, an enzyme activator, and maintains electroneutrality.
• It is the only anion to serve as an enzyme activator.
• It is excreted in the urine and sweat.
• Its concentration is influenced by aldosterone.

Reference Ranges for Chloride

Serum, plasma 98 – 107 mmol/L

110 – 250 mmol/d, varies
Urine (24 h)
with diet
ELECTROLYTES | CHLORIDE
• CSF Chloride
▪ It is a significant test in the diagnosis of meningitis.
▪ Cryptococcal meningitis: CSF chloride < 121.7 mmol/L, serum
chloride > 101.45
▪ Ratio of CSF chloride: Serum chloride > 1.200
▪ Reference range: 110 – 125 mEq/L
ELECTROLYTES | CHLORIDE
• Specimen Considerations
1. Marked hemolysis may cause decreased levels of chloride due to
dilutional effect.
2. Slightly lower values are observed in post-prandial specimen.
3. Low serum values are expected in conditions with high HCO3- levels.
ELECTROLYTES | CHLORIDE
• Methods
1. Mercurimetric Titration (Chales and Schales)
▪ Reagent: Mercuric nitrate
▪ Indicator: Diphenylcarbazone
▪ End color: blue violet (mercuric chloride)
2. Spectrophotometric Assay
▪ Mercuric Thiocyanate (Whitehorn Titration Method) = (+) reddish
complex end product
▪ Ferric Perchlorate = (+) colored complex end product
ELECTROLYTES | CHLORIDE
• Methods
1. Coulometric Amperometric Titration (Cotlove Chloridometer)
▪ It measures the total chloride concentration in the sample.
▪ With this method, the passage of a constant direct current between silver
electrodes produces silver ions.
▪ The free silver ions react with the chloride forming silver chloride.
2. Ion-Selective Electrode
▪ It is the most commonly used method.
▪ ISE Membrane: Tri-n-octylpropylammonium chloride decanol
▪ Interferences: bromide, bicarbonate, iodide, and high serum protein
3. Ion Chromatography/Inductively Coupled Plasma Mass Spectrometry –
reference method
▪ IFCC-recommended reference method: Colorimetric titration with amperometric
end-point
 HYPERCHOLEREMIA HYPOCHOLEREMIA
1. Renal tubular acidosis 1. Prolonged vomiting
2. Diabetes insipidus 2. Aldosterone deficiency
3. Salicylate intoxication 3. Metabolic alkalosis
4. Primary hyperparathyroidism 4. Salt-losing nephritis
5. Metabolic acidosis
6. Prolonged diarrhea
ELECTROLYTES | CALCIUM
• Most abundant cation in the body.
• 99% of calcium is part of bones and 1% is mostly in the blood and other
ECF.
• Bone contains 1kg of calcium and serves as a repository for calcium,
phosphate, and magnesium.
• It is involved in blood coagulation, enzyme activity, excitability of
skeletal and cardiac muscle, and maintenance of blood pressure.
ELECTROLYTES | CALCIUM
• Important activator to the coagulation system.
• It is maximally absorbed in the duodenum and absorption is favored at
an acidic pH.
• Decreased ionized calcium concentrations in blood can cause
neuromuscular irritability, which may become clinically apparent as
tetany/citrate toxicity.
• Primary hypokalemia (low PTH) is due to parathyroid gland disease,
and secondary hypocalcemia (high PTH) is due to renal failure.
Reference Ranges for Calcium

Total Calcium – Serum, Plasma

Adult: 8.5 – 10.5 mg/dL (2.24 – 2.53 mmol/L)
Child, <3 y: 9.0 – 10.1 mg/dL (2.13 – 2.63 mmol/L)
Ionized Calcium - Serum
Adult: 4.6 – 5.3 mg/dL (1.15 – 1.33 mmol/L)
Child: 4.8 – 5.5 mg/dL (1.20 – 1.38 mmol/L)
Ionized Calcium – Whole blood
Adult: 4.6 – 5.1 mg/dL (1.15 – 1.27 mmol/L)
ELECTROLYTES | CALCIUM
• Forms of Calcium
1. Ionized (active) Calcium – 50%
2. Protein-bound Calcium – 40%
3. Complexed with Anions – 10%

▪ Ionized calcium is a sensitive and specific marker for calcium disorders.

▪ For every 1 g/dL serum albumin decrease, there is 0.8 mg/dL decrease in total
calcium and hypocalcemia can be a consequence or reduced plasma albumin.
ELECTROLYTES | CALCIUM

• Hormones Affecting Plasma Calcium Levels

▪ Vitamin D3/Calcitrol/1-25 Dihydroxycholecalciferol
▪ Increases intestinal absorption of calcium.
▪ Increases reabsorption in the kidneys.
▪ Increases mobilization of calcium from bones.
ELECTROLYTES | CALCIUM
• Hormones Affecting Plasma Calcium Levels
▪ Parathyroid Hormone (PTH) - INCREASE
▪ Conserves calcium by increasing calcium reabsorption in
the kidneys.
▪ Increases the level by mobilizing bone calcium.
▪ Activates the process of bone resorption (activates
osteoclasts)
▪ Suppresses urinary loss of calcium.
▪ Stimulates the conversion of inactivate vitamin D to active
vitamin D3 in the kidneys.
ELECTROLYTES | CALCIUM
• Hormones Affecting Plasma Calcium Levels
▪ Calcitonin - DECREASE
▪ Secreted by the parafollicular C cells of the thyroid gland
(thyroid hormone).
▪ Hypocalcemic hormone.
▪ Inhibits PTH and vitamin D3.
▪ Inhibits bone resorption.
▪ Promotes urinary excretion of calcium.
ELECTROLYTES | CALCIUM

• Practical Considerations INCREASED DECREASE

TOTAL CALCIUM TOTAL CALCIUM
▪ A decrease in plasma
Elevated serum Prolonged contact of
protein concentration will
albumin: serum with cell clot
result in decrease total Dehydration Recumbent posture
calcium. Hemoconcentration
▪ Decreased pH of the Prolonged tourniquet
reagent (acidification) application
results in liberation of Venous occlusion
calcium from albumin.
▪ Urinary excretion is the
major net loss of calcium.
ELECTROLYTES | CALCIUM
• Sample Preparation
• Best sample for total calcium: Serum (heparinized plasma,
alternate sample)
• Best sample for ionized calcium: heparinized plasma (serum,
alternate sample)
• Heparin preparation: Dry heparin (sodium/lithium heparin and
calcium titrated heparin)
ELECTROLYTES | CALCIUM
• Sample Preparation

• Preferred anticoagulant: Calcium titrated heparin

• Sample collection and transport: Anaerobically, transported on ice
• If there is delay in the analysis, store at 4°C to prevent glycolysis and loss
of CO2.
• Interference with colorimetry: Hemolysis, icterus, lipemia, and
paraproteins
• Total calcium measurement includes the free calcium and protein-bound
calcium levels.
ELECTROLYTES | CALCIUM
• Hypocalcemia
▪ A decrease or defect PTH will result a decrease in calcium levels.
▪ Vitamin D deficiency and malabsorption can cause decreased absorption, which
leads to increased PTH production or secondary hyperparathyroidism and
hypocalcemia.
▪ Pseudohypoparathyroidism is a rare hereditary disorder where PTH response is
decreased.
▪ Hypomagnesemia may cause hypocalcemia caused by three mechanisms:
a. It inhibits the glandular secretion of PTH across the parathyroid gland membrane.
b. It impairs PTH action at its receptor site on bone.
c. It causes vitamin D resistance.
ELECTROLYTES | CALCIUM
• Hypocalcemia
▪ Hypermagnesemia may also inhibit PTH release and target tissue
response, potentially leading to hypocalcemia and hypercalciuria.
▪ Symptoms of Primary Hypocalcemia:
a. Neuromuscular irritability – tetany and muscle cramps
b.Cardiac irregularities – arrythmia or heart block
▪ CHARD: Calcitonin, Hypoparathyroidism, Alkalosis, Renal failure,
and vitamin D deficit
ELECTROLYTES | CALCIUM
• Hypercalcemia
▪ Primary hyperparathyroidism (excess secretion of PTH) is the main
cause of hypercalcemia.
▪ The second leading cause of hypercalcemia is associated with various
types of malignancy, with hypercalcemia sometimes being the sole
biochemical marker for disease.
▪ Symptoms of Hypercalcemia:
a. Neurologic symptoms – weakness, coma
b. GI symptoms – peptic ulcer disease, anorexia, nephrolithiasis, digitalis
toxicity
▪ CHIMPS: Cancer, Hyperparathyroidism, Iatrogenic causes, Multiple
myeloma, Hyperparathyroidism, and Sarcoidosis
ELECTROLYTES | CALCIUM
• Ionized Calcium
▪ In hypercalcemia, both total calcium and ionized calcium are
elevated.
▪ It is frequently elevated in asymptomatic hyperparathyroidism.
▪ It is decreased in secondary hyperparathyroidism.
▪ Rate of fall in ionized calcium initiates tetany.

• Effect of pH Imbalance to Calcium

▪ Acidosis promotes leaching of calcium from bones, promoting
hypercalcemia; while alkalosis promotes deposition of calcium in
bones.
ELECTROLYTES | CALCIUM
• Methods
❑Precipitation and Redox Titration (for Total Calcium)
1. Clark-Collip Precipitation
▪ End-product: Oxalic acid (purple color)
2. Ferro-Ham Chloranilic Acid Precipitation
▪ End-product: Chloranilic acid (purple color)
ELECTROLYTES | CALCIUM
• Methods
❑Colorimetric Methods (for Total Calcium)
a. Ortho-Cresolpthalein Complexone (OCC) Dye
▪ Requires acidification of the sample to release the calcium from its carrier
protein and increase the affinity of calcium ions to the reagent.
▪ It has an additional step in which the reaction solution is treated with the
compound 8-hydroxyquinolone at an alkaline pH.
▪ Acidic reagent: HCl
▪ Major interference: Magnesium (it inhibits measurement of serum total
calcium)
▪ End color reaction: RED/PURPLE in alkaline solution
▪ OCC reagent is a chelating agent similar with arzenaso dye.
▪ The pH of the solution should be alkaline to prevent the binding of
magnesium with calcium.
ELECTROLYTES | CALCIUM
• Methods
❑Colorimetric Methods (for Total Calcium)
a. Arzenazo III Dye
▪ It has a high affinity for calcium ions.
▪ This dye inhibits magnesium in the reaction.
▪ Requires an acidic solution to measure calcium.
▪ Buffer: Imidazole (pH 6.0)
▪ Major interference: Citrate and hemolyzed samples
▪ End color reaction: VIOLET COLORED COMPLEX
ELECTROLYTES | CALCIUM
• Methods
❑EDTA Titration Method
❑Ion-Selective Electrode (Liquid-membrane)
▪ Free calcium can be measured directly without acid treatment
step.
▪ It can measure ionized calcium directly without any pre-treatment
since it is not bound to albumin.
❑Atomic Absorption Spectrophotometry (AAS) – reference method
❑Emission Flame Photometry = BRICK RED
 HYPERCALCEMIA HYPOCALCEMIA
Primary hyperparathyroidism Primary hypoparathyroidism
Cancer (Lung and Mammary) Chronic renal failure
Acidosis Alkalosis
Increased vitamin D Vitamin D deficiency
Multiple myeloma Acute pancreatitis
Sarcoidosis DiGeorge syndrome
Hyperparathyroidism Severe hypomagnesemia
Milk-alkali syndrome (MAS) Malabsorption syndrome
Fluoride poisoning

• Milk-alkali syndrome in its classic form described in the 1930s follows the oral
administration of very high (>20 g) amount of calcium and large amounts of milk
to control gastric acid levels in patients with peptic ulcer disease.
ELECTROLYTES | INORGANIC PHOSPHOROUS

• Predominant intracellular anion

• It is omnipresent in its distribution; 80% in the bones, almost 20% in soft
tissues, with less than 1% in plasma.
• Its concentration is inversely related to calcium.
• It is maximally absorbed in the jejunum.
• It is essential in cardiac and neuromuscular excitability, ion transport,
and cellular oxygenation.
ELECTROLYTES | INORGANIC PHOSPHOROUS

• It is an important constituent of ATP, nucleic acids (DNA and RNA),

enzyme cofactors (NADPH), and lipids (phospholipids) – these are the
functions of the organic phosphate.
• Phosphorous exists as organic phosphate (principal anion within cells)
and inorganic phosphorous (part of the blood buffer system)
• Affected by circadian rhythm – high levels in late morning and low
levels in the evening
• Hyperphosphatemia, hypocalcemia, elevated BUN, and
creatinine = strongly suggest RENAL TUBULAR FAILURE
Reference Ranges for Inorganic Phosphorous
Serum
Neonate 4.5 – 9.0 mg/dL (1.45 – 2.91 mmol/L)
Child ≤ 15 y 4.0 – 7.0 mg/dL (1.29 – 2.26 mmol/L)
Adult 2.5 – 4.5 mg/dL (0.81 – 1.45 mmol/L)
Urine (24 h) 0.4 – 1.3 g/d (13 – 42 mmol/d)

• Forms of Phosphorous
1. Free or unbound – 55%
2. Complexed with ions – 35%
3. Protein-bound – 10%
ELECTROLYTES | INORGANIC PHOSPHOROUS

• Hormones Affecting Plasma Inorganic Phosphate Levels

▪ PTH – DECREASES phosphate by renal excretion
▪ Calcitonin – inhibits bone resorption (DECREASE)
▪ Growth hormone – INCREASES phosphate by renal
reabsorption
▪ Vitamin D3 – INCREASE
ELECTROLYTES | INORGANIC PHOSPHOROUS

• Methods
▪ Sample: Fasting is required – high CHO diet can result in decreased
levels.
▪ Separate the serum from the red cells immediately after clotting is
completed.
▪ Only the inorganic phosphate is routinely measured in serum.
▪ Phosphorous is complexed with sodium, calcium, and magnesium.
▪ Physical activity may cause false increase in phosphorous.
▪ Interference: Hemolysis (falsely increased)
ELECTROLYTES | INORGANIC PHOSPHOROUS

• Fiske-Subbarow Method (Phosphomolybdate Method)

▪ It is the most commonly used method to measure serum inorganic
phosphate.
▪ Most common reducing agent: Pictol (Amino Naphthol Sulfonic Acid)
▪ Other reducing agents: Ascorbic acid, elon (methyl amino phenol), and
sanidine
▪ End product: Ammonium-molybdate complex
▪ The unreduced complex at 340 nm is the most accurate measurement of
inorganic phosphorous in serum.
▪ The reduced form of the end product yields a BLUE color and is
determined between 600 nm to 700 nm.
ELECTROLYTES | INORGANIC PHOSPHOROUS

• Notes to Remember
▪ Increased serum PO4 causes serum calcium to diminish.
▪ Alcohol abuse is the most common cause of hypophosphatemia.
▪ Pseudohypoparathyroidism is one of the causes of hypercalcemia.
HYPERPHOSPHATEMIA HYPOPHOSPHATEMIA
1. Hypoparathyroidism 1. Primary
2. Renal failure hyperparathyroidism
3. Lymphoblastic leukemia 2. Alcohol abuse
4. Hypervitaminosis D 3. Myxedema
5. Cytolysis 4. Avitaminosis D
5. Diabetic coma
6. Renal tubular defects
7. Diuretics
ELECTROLYTES | MAGNESIUM
• It is an intracellular cation second in abundance to potassium.
• 4th most abundant cation in the body.
• It is stored in the bones and muscles: 53% in bones; 46% in muscles and
soft tissues; 1% in plasma and RBCs.
• It is vital in neuromuscular excitability or transmission of nerve
impulses and regulates the movement of potassium across myocardium.
ELECTROLYTES | MAGNESIUM
• It is an enzyme activator and important in maintaining the structures of
nucleic acids and ribosomes, as well as the synthesis of organic
compounds (carbohydrates, proteins, and lipids).
• It is a vasodilator and causes decrease in uterine hyperactivity and
increase uterine blood flow.
• It is a cofactor for Taq DNA polymerase (most common enzyme used
for PCR amplification).
• Magnesium loss leads to decreased intracellular potassium levels.
ELECTROLYTES | MAGNESIUM
• CSF Magnesium: 2.0 to 2.7 mg/dL
• Conversion Factor for CSF Magnesium: 0.5000 (mg/dL to mmol/L)

Reference Range for Magnesium

Serum, colorimetric: 0.66 – 1.07 mmol/L (1.7 – 2.4 mg/dL)
Ionized Magnesium: 0.44 – 0.60 mmol/L
Symptoms of Hypomagnesemia: ≤ 0.5 mmol/L
Symptoms of > 1.5 mmol/L (1.5 – 2.5 mmol/L)
Hypermagnesemia:
Life threatening symptoms: 5 mmol/L
ELECTROLYTES | MAGNESIUM
• Forms of Magnesium
1. Free/Ionized (active) form – 61%
2. Protein-bound – 34%
3. Complexed with other ions – 5%
• Hormones Affecting Plasma Magnesium Levels
1. Parathyroid hormone
2. Aldosterone and Thyroxine
 HYPERMAGNESEMIA

DECREASED MISCELLANEOUS
INCREASED INTAKE
EXCRETION CAUSES
Acute or chronic Antacids Dehydration
failure Enemas Bone carcinoma
Hypothyroidism Cathartics Bone metastases
Hypoaldosteronism Therapeutic –
Hypopituitarism (↓ eclampsia, cardiac
growth hormone) arrythmia
 HYPOMAGNESEMIA

INCREASED DECREASED MISCELLANEOUS

REDUCED INTAKE
EXCRETION ABSORPTION CAUSES
Tubular disorder Poor diet/starvation Malabsorption Excess lactation
Glomerulonephritis Prolonged syndrome Pregnancy
Pyelonephritis magnesium Pancreatitis
Hyperparathyroidism deficient IV Vomiting
Hyperaldosteronism therapy Diarrhea
Hyperthyroidism Chronic alcoholism Laxative abuse
Hypercalcemia
Diabetic ketoacidosis
Diuretics
Antibiotics
ELECTROLYTES | MAGNESIUM
• Methods

1. Colorimetric Methods
a. Calmagite – most commonly used method/(+) reddish-violet complex in
alkaline pH at 530 nm
b. Formazan Dye – (+) colored complex
c. Methylthymol Blue – (+) colored complex
2. Dye-Lake Method –Titan Yellow Dye (Clayton Yellow or Thiazole Yellow)
3. Atomic Absorption Spectrophotometry – reference method
4. Ion-Selective Electrode (natural ionophores) – measures free magnesium
▪ ISE Membrane: Neutral carrier polymer
5. Flame Emission Photometry – BLUE/WHITE
ELECTROLYTES | BICARBONATE
• Major component of the buffering system in the blood.
• It is the second most abundant anion in the ECF.
• It accounts for 90% of the total CO2 at physiologic pH.
• It is composed of undissociated sodium bicarbonate, carbonate,
carbamate.
• It buffers excess hydrogen ion by combining with acid.
• Alkalosis: Increase urinary loss of HCO3- and Na+ (correct blood pH)
ELECTROLYTES | BICARBONATE
pH imbalance
• It diffuses out of the cell in exchange for chloride to maintain ionic
charge neutrality within the cell.
• The buffering capacity of blood is maintained by a reversible exchange
process between bicarbonate and chloride.

Reference Ranges for Bicarbonate

Serum, plasma 21 – 28 mEq/L

ELECTROLYTES | BICARBONATE
• Methods
▪ Sample: Blood, anaerobically collected
▪ Sample Precaution: if the sample (serum or heparinized plasma) is
left uncapped before analysis, levels decrease by 6 mmol/L/hour.

1. Ion-Selective Electrode (using the pCO2 electrode)

2. Enzymatic (Phosphoenolpyruvate carboxylase and dehydrogenase using
alkaline reagent)
OTHER SIGNIFICANT INFORMATION
• Iron
▪ It is a common metallic element important in the synthesis of hemoglobin.
▪ It is stored as ferritin and hemosiderin, primarily in the spleen, bone
marrow, and liver.
▪ Of the total 3 g to 5 g of iron in the body, 2 g to 2.5 g is in hemoglobin; 130 mg
is in myoglobin; 8 mg is in tissue; and 3 g to 5 mg is in plasma (albumin and
free hemoglobin).
▪ It is a pro-oxidant, contributing to lipid peroxidation, atherosclerosis, DNA
damage, and carcinogenesis.
▪ Serum ferritin must be depleted first, before iron level declines.
▪ Low serum ferritin level is diagnostic of iron deficiency.
Reference Ranges for Iron
Male 50 – 160 µg/dL
Female 45 – 150 µg/dL

INCREASED DECREASED
1. Iron poisoning (overdose) 1. Iron deficiency anemia (IDA)
2. Hemochromatosis 2. Malnutrition
3. Viral hepatitis 3. Malignancy
4. Non-iron deficiency anemia 4. Chronic infection
(Thalassemia, aplastic, 5. Nephrotic syndrome
megaloblastic, sideroblastic,
hemolytic, and pernicious anemia)
TERMINOLOGIES
• Total Iron-Binding Capacity (TIBC)
▪ It refers to the amount of iron that could be bound by saturating transferrin and
other minor iron-binding proteins present in the serum or plasma sample.
▪ It is a direct measure of the total number of functional ferrous iron-binding sites in
transferrin.
▪ All TIBC method require addition of excess iron to saturate transferrin.
▪ Excess iron is then removed by adding magnesium carbonate to measure the
bound iron.
▪ Formula:
TIBC = UIBC + Serum Iron
TIBC (ug/dL) = Serum transferrin (mg/dL) x 1.2521
 Reference Range
Newborn and child: 100 – 200 µg/dL
Adult Male and 245 – 425 µg/dL
Female:
> 40 years old: 10 – 250 µg/dL

NORMAL or LOW
INCREASED DECREASED
TIBC
1. IDA 1. Non-IDA 1. Anemia of chronic
2. Hepatitis 2. Nephrosis infection
3. Iron-supplemented
pregnancy
TERMINOLOGIES
• Unsaturated Iron-Binding Capacity (UIBC)
▪ It is a measure of the reserve iron-binding capacity or transferrin.
▪ It can be measured spectrophotometrically or through indirect
method (calculation).
▪ Formula: TIBC – Serum Iron
TERMINOLOGIES
• Percent Saturation
▪ It is also known as the transferrin saturation; an index of iron storage.
▪ It is the ration of serum iron to TIBC (Normal ratio: 1:3)
▪ In IDA, it is significantly reduced to values of around 1:5 or lower.
𝐓𝐨𝐭𝐚𝐥 𝒊𝒓𝒐𝒏
▪ Formula: 𝐓𝐈𝐁𝐂 × 𝟏𝟎𝟎
▪ Reference range: 20 – 50%

INCREASED DECREASED
1. Iron overdose 1. Iron deficiency anemia
2. Hemochromatosis (IDA)
3. Sideroblastic anemia 2. Malignancy
3. Chronic infection
4. Anemia of chronic disease
TERMINOLOGIES
• Serum Transferrin
▪ Transferrin is the principal iron transport protein.
▪ Formula (mg/dL): TIBC (µg/dL) x 0.70
OTHER SIGNIFICANT INFORMATION
• Ferritin
▪ It is a protein that functions as a storage form of iron in the body.
▪ It is one of the inflammatory markers or acute phase reactants that is
increased in tissue injury or necrosis.
▪ It is included in the biomarkers for COVID-19 due to its reaction to
cytokine storm.
OTHER SIGNIFICANT INFORMATION
• Anion Gap (AG)

▪ It is the difference between the unmeasured cations (sodium and

potassium) and unmeasured anions (chloride and bicarbonate).
▪ It is a form of quality control for the analyzer used to measure
electrolytes.
▪ It is used to monitor recovery from diabetic ketoacidosis.
OTHER SIGNIFICANT INFORMATION
• Anion Gap (AG)

▪ The total concentration of unmeasured anions is about 23 mmol/L, and the

total concentration of unmeasured cations is about 11 mmol/L
▪ An elevated anion gap signifies the presence of metabolic acidosis.
▪ Abnormal anion gaps in sera from healthy person indicate an instrument
problem.
▪ Formula:
AG = Na – (Cl + HCO3)
AG = (Na + K) – (Cl + HCO3)
 INCREASED AG DECREASED AG
Uremia/renal failure Hypoalbuminemia (decreased
Ketoacidosis unmeasured anions)
Chemical poisoning (methanol, Hypercalcemia (elevated
ethanol, ethylene glycol or unmeasured cations)
salicylate) Hyperlipidemia
Lactic acidosis Elevated myeloma proteins
Hypernatremia
OTHER SIGNIFICANT INFORMATION
• Cystic Fibrosis
▪ It is usually recognized in infancy ore early childhood.
▪ It is an inherited disorder of the exocrine glands, causing these glands to
produce abnormally thick secretions of mucus, elevation of sweat
electrolytes, increased organic and enzymatic constituent of saliva, and
overactivity of the autonomic nervous system.
▪ Increase in sweat electrolytes is due to defective gene and protein known
as the cystic fibrosis transmembranous conductance regulator, located on
chromosome 7.
▪ Signs: chronic cough, frequent foul-smelling stool, and persistent URT
infection
OTHER SIGNIFICANT INFORMATION
• Cystic Fibrosis
▪ Affected organs and glands: Pancreas, respiratory system, and sweat
glands
▪ Test requirement: without rashes, cuts or skin inflammation; for neonates,
at least 48-hour old
▪ Sweat Inducer: Pilocarpine (sweat is collected using filter paper)
▪ Diagnostic test: Sweat Test-Coulometry (↑ sodium and chloride)
▪ Reference method: Gibson and Cooke Pilocarpine Iontophoresis
▪ Reference range: 5 – 40 mmol/L
▪ 50 mg of sweat sample collected within 30 minutes.
▪ (+) result cystic fibrosis = > 65 mmol/L if sweat electrolytes