Chemical Pathology (CPY)

Useful values, formula and biochemical tests

Note: There is no need to recite all reference ranges, which could be variable across different sources. They are
provided here for your easy reference. The formulae and interpretation of dynamic tests are more important.
Maksim Chan (A&E23)

Electrolytes and acid-base balance

Plasma
Osmolarity 275-295 mOsm/L
Sodium (Na) 135-145 mmol/L
Potassium (K) 3.5-5.1 mmol/L
Chloride (Cl) 102-114 mmol/L
Calcium (Ca) – adjusted 2.1-2.55 mmol/L
Calcium (Ca) – ionized 1.13-1.32 mmol/L
Phosphate (PO4) 0.8-1.4 mmol/L
Magnesium (Mg) 0.6-1.4 mmol/L
Osmolar gap <10

Urine
Osmolarity 50-1200 mOsm/L

Arterial blood gas (mmHg to kPa: multiply 0.133)

pH 7.35-7.45
pCO2 35-45 mmHg
4.6-6.0 kPa
pO2 80-110 mmHg
10.6-14.6 kPa
HCO3 23-33 mmol/L

Calculated OsM = 2 x [Na] + [urea] + [glucose]

Osmolar gap = Measured OsM – Calculated OsM (normal: <10) à if suspect toxin
["#$%&'(]*+.+
Corrected Na = measured Na + 2.4 x +.+
à when super hypoNa and glucose is high

-[.] 1[.]
Trans-tubular K+ gradient: TTKG = -/'0 ÷ 1/'0 (<6 for mineralocorticoid deficiency)
- Only valid if UOsM > 300 and UNa > 25

[23/4]
Henderson-Hasselbach equation: 𝑝𝐻 = 6.1 + log 5.54 × 83/9

Plasma anion gap = Na + K – Cl – HCO3 (normal: 7-17 mEq/L) à if metabolic acidosis

- HAGMA (MUDPILES) vs NAGMA (e.g. RTA)

Albumin-adjusted plasma Ca = measured [Ca] + (40 – [albumin]) x 0.025 à whenever you see Ca
- Not valid when albumin < 25 or >50: order ionized Ca

Acid-base compensatory responses (mmHg to kPa: multiply 0.133) à for ALL acid-base cases
Primary condition Formula (pCO2 in mmHg) Limits of compensation
Acute respiratory acidosis HCO3 = 24 + 0.1 x (pCO2 – 40) 38 mmol/L
Chronic respiratory acidosis HCO3 = 24 + 0.4 x (pCO2 – 40) 45 mmol/L
Acute respiratory alkalosis HCO3 = 24 – 0.2 x (40 – pCO2) 18 mmol/L
Chronic respiratory alkalosis HCO3 = 24 – 0.5 x (40 – pCO2) 15 mmol/L
Metabolic acidosis pCO2 = 1.5 x [HCO3] + 8 +/- 2 15 mmHg
(Winter’s formula)
Metabolic alkalosis pCO2 = 0.7 x [HCO3] + 20 +/- 5 55 mmHg
Cardiovascular system
Lipid profile:
Triglyceride <1.7 mmol/L
Total cholesterol (TC) <5.2 mmol/L
HDL-C >1.0 mmol/L
LDL-C <2.6 or <1.8 (if CV risk factors +ve) mmol/L
Friedewald formula: LDL-C = TC – HDL-C – TG/2.2
- Not valid if TG>4.5, non-fasting or IDL disorder suspected

Familial hypercholesterolemia (AD)

Heterozygous FH LDL-C: 5-11 mmol/L 15x increase in CV risk
Homozygous FH LDL-C: 15-24 mmol/L Present in childhood, very rare

Uric acid and gout

Plasma
Uric acid <0.52 (M) mmol/L
<0.36 (F)

Differentiating over-producer and under-excreter:

- Purine-free diet for 3 days à collect 24h urine
- Over-producer if >3.6 mmol/day, under-excreter if <3.6 mmol/day

Two-way relationship between hyperuricemia and renal failure

Renal failure à Hyperuricemia Hyperuricemia à Renal failure
Pathophysiology Impaired excretion of urate Acute uric acid nephropathy
Creatinine >400 μmol/L <400 μmol/L
Urate <0.65 mmol/L >0.7 mmol/L
Urine uric acid : <0.7 >0.7
Cr ratio

Monoclonal gammopathy

Serum free light chain (FLC): kappa/lambda ratio (normal: 0.26-1.65)

Tumor markers
Tumor marker Reference range Malignant DDx Benign DDx
Alpha-fetoprotein <10 mcg/L HCC Cirrhosis / Hepatitis
(AFP) (except: pregnancy, Hepatoblastoma
infants) Non-seminomatous GCT
Carcinoembryonic <3 mcg/L (non-smoker) CRC IBD (CD/UC)
antigen (CEA) <5 mcg/L (smoker) CA lung / stomach / breast / Cirrhosis / Hepatitis /
H&N Pancreatitis
Human chorionic <1 IU/L (young F) Germ cell tumors Pregnancy
gonadotrophin <7 IU/L (old F) H. Mole / Choriocarcinoma
(hCG) <2 IU/L (M) CA gynae/breast
Prostate-specific <4 mcg/L CA prostate BPH
antigen (PSA) UTI (e.g. prostatitis)
Recent TURP / TRUS Bx
Cancer-antigen <35 kU/L CA ovary (epithelial) Menstruation
125 (CA 125) CA tube / breast / colon / … Benign ovary tumors
GI and Liver

Stool osmolar gap = 290 – 2 x (Na + K)

- <50 mOsm/kg = secretory diarrhea, >100 mOsm/kg = osmotic diarrhea

Tests for various malabsorptive disorders

Malabsorption Investigations
Carbohydrates Oral sugar tolerance test (e.g. xylose absorption test)
Hydrogen breath test: collect breath sample Q30min for 2.5h
Fat Sudan III stain
Fecal fat quantitation
Protein Total protein / Albumin
Vit B12 B12/folate, Hb, MCV, homocysteine, methylmalonic acid (MMA)
Anti-IF Ab, anti-pareital cell Ab: pernicious anemia
Schilling test:
- Part 1: Radioactive B12 PO + excess non-radioactive B12 IM
- Part 2: Radioactive B12 + IF PO + excess non-radioactive B12 IM
- Modified: repeat after antibiotics
Vit K PT / INR
Vit D Ca, PO4, PTH, ALP (bone)

Liver function tests

Total protein 66-81 g/L
Albumin 36-48 g/L
Bilirubin 5-17 μmol/L
Alanine transaminase (ALT) <58 IU/L
Aspartate transaminase (AST) 5-40 IU/L
Alkaline phosphatase (ALP) 35-100 IU/L
Gamma-glutamyl transpeptidase (GGT) <100 IU/L
Amylase 28-100 IU/L
AST/ALT > 2: suggest alcoholism
Amylase >1000: diagnostic of acute pancreatitis

Ranson’s score for acute pancreatitis

On admission (GALAW) Within 48 hours of admission (CHOBBS)
Glucose >10 mmol/L Ca < 2 mmol/L
Age >55 Hct fall >10%
LDH >350 IU/L Oxygen (PaO2 < 60 mmHg)
AST > 250 IU/L Blood urea nitrogen (BUN): increase >5 mg/dL
WBC > 16x109/L Base deficit >4 mEq/L
Sequestration of fluids >6L

-:;<( =>?#='( -:;<( 3:

Amylase clearance = 1#='>= =>?#='( ÷ 1#='>= 3: × 100%
- <1% = macroamylasemia
Renal function test

Plasma
Urea 3.0-8.0 mmol/L
Creatinine 50-120 μmol/L

Normal GFR: 120 mL/min

-×@
- Estimated by creatinine clearance: 𝐶3# = 1 (unit: mL/min)
!"
Urea : creatinine ratio
40-100:1 Normal / Post-renal AKI
>100:1 Pre-renal AKI, UGIB, catabolic state, drecreased muscle mass
<40:1 Intrinsic renal damage

Definition of acute kidney injury (AKI) by KDIGO:

- Rise in Cr > 26.5 μmol/L in 48h
- Rise in Cr > 1.5x baseline within 7 days
- Urine output <0.5mL/kg/h (oliguria) for 6h

Max urine osmolarity 1200 mmol/L à Require min UO of 1L/day to excrete obligatory solutes of 1200 mmol
- Oliguria: urine output <0.5 mL/kg/h or <400 mL/day
- Anuria: <50 mL/day

Staging of AKI:
Stage Plasma Cr increase in 1 week Urine output
1 1.5-2x baseline Oliguric for 6h
2 2-3x baseline Oliguric for 12h
3 ≥3x baseline <0.3mL/kg/h for 24h OR anuric for 12h

Criteria for differentiating pre-renal AKI from acute tubular necrosis (ATN)
Parameter Pre-renal AKI (e.g. dehydration) Acute tubular necrosis (e.g. aminoglycosides)
FENa* <1%: RAAS >2%
Urine Na (mmol/L) <20: RAAS >40
Urine osmolality (mmol/kg) >500: ADH <350
Urine:plasma urea ratio >20: ADH <10
Urine:plasma Cr ratio >40: ADH <20
-:;<( A= -:;<( 3:
*Fractional excretion of Na: 1#='>= A= ÷ 1#='>= 3: × 100%

KDIGO staging of CKD involves eGFR + albuminuria stage

(1) eGFR
KDIGO G1 G2 G3a G3b G4 G5
stage High and optimal Mild Mild-moderate Moderate-severe Severe Kidney failure
eGFR >90 60-89 45-59 30-44 15-29 <15

(2) Albuminuria stage

Normal Microalbuminuria Macroalbuminuria Nephrotic range proteinuria
KDIGO albuminuria A1 A2 A3
stage
24h Albumin <30 mg/day 30-300 mg/day >300 mg/day
urine Protein <150 mg/day Proteinuria: >150mg/day >3.5g/day
Spot Albumin : <30 mg/g 30-300 mg/g >300 mg/g >2.2 g/g
urine creatinine <3 mg/mmol 3-30 mg/mmol >30 mg/mmol >220 mg/mmol
ratio (ACR)

Renal tubular acidosis

Type 1 RTA (distal) Type 2 RTA (proximal) Type 4 RTA (aldo def.)
urine pH >5.5 <5.5 when acidotic <5.5
plasma HCO3 Very severe: <10 mmol/L Severe: 12-20 mmol/L Mild: >17 mmol/L
plasma K HypoK HypoK HyperK
Type 1 RTA (distal)
(1) Spot urine pH > 5.5 (i.e. alkaline urine in acidic pH)
(2) NH4Cl loading test – gold standard
- Urine anion gap (UAG) = UNa + UK – UCl (normal: 20-90 mmol/L) (HCO3 is not included!)
- Normal response: UAG becomes less positive and then negative (due to urine NH4 excretion)
- Type 1 RTA: UAG inappropriately positive à indicating failure of excreting NH4

Type 2 RTA (proximal)

(1) FEHCO3 > 15%
(2) Bicarbonate loading test – gold standard
- Normal: urine HCO3 unchanged because most HCO3 are absorbed
- Type 2 RTA: Urinary pH > 7.5 with FEHCO3 > 15%

Endocrine system
Serum
Thyroid axis TSH 0.27-4.20 mIU/L
fT4 12-22 pmol/L
Parathyroid axis PTH 1.0-5.5 pmol/L
Adrenal axis Renin 0.1-0.8 (erect) pmol/mL/h
0.1-0.4 (supine)
Aldosterone 10-200 (erect) pmol/L
10-150 (supine)

DM and hypoglycemia
Diabetes mellitus – ADA diagnostic criteria requires two separate measurements
- Fasting plasma glucose: ≥7.0 mmol/L
- 2-hour post OGTT plasma glucose: ≥11.1 mmol/L
- HbA1c: ≥6.5%
- Random plasma glucose: ≥11.1 mmol/L (require the presence of hyperglycemic symptoms)

Pre-diabetes:
- Impaired fasting glucose (IFG) = fasting plasma glucose 5.6-6.9
- Impaired glucose tolerance (IGT) = 2-hour post OGTT plasma glucose 7.8-11.0

Gestational diabetes: 75g OGTT performed at 24-28 weeks of gestation

Gestational diabetes (mmol/L) DM in pregnancy (i.e. same as DM) (mmol/L)
0 min 5.1-6.9 ≥7.0
60 min – only for GDM ≥10.0
120 min 8.5-11.0 ≥11.1

Hypoglycemia:
- Adult: plasma glucose ≤2.5 mmol/L
- Full-term baby: plasma glucose ≤2.0 mmol/L
- Preterm infant: plasma glucose ≤1.1 mmol/L

Serum insulin (mIU) C-peptide (μg/L)

Hypoglycemia <3 <0.6

Hypothalamus-pituitary
Triple function test: Insulin/Glucagon (GH, adrenal axes) + GnRH (gonadal axis) + TRH (thyroid axis)
Normal result
Cortisol >550 nmol/L
GH >16 mU/L
LH 5-10x baseline at 20 min
FSH 2-3x baseline at 20 min
TSH increase >2 mU/L
Cushing’s syndrome
Screening tests for Cushing’s syndrome
(1) Overnight dexamethasone suppression test (outpatient)
- Procedure: 1mg dexamethasone at 23:00, and measure cortisol at next morning 8/9am
- Cortisol ≤ 50 nM (i.e. suppressed): effectively excludes Cushing’s syndrome

(2) Low-dose dexamethasone suppression test

- Procedure: 0.5mg dexamethasone Q6h for 2 days
- Cortisol ≤ 50 nM (i.e. suppressed): effectively excludes Cushing’s syndrome

(3) 24h urine free cortisol

- Cortisol ≤ 250 nmol/24h (i.e. suppressed): effectively excludes Cushing’s syndrome

(4) Late night salivary cortisol: good for mild cases of Cushing’s syndrome

Differentiating the causes

(1) Serum ACTH
(2) High-dose dexamethasone suppression test (HDDST)
- Procedure: 2mg dexamethasone Q6h for 2 days, and measure cortisol to compare with basal value
before test
- Cortisol decreases >50%: Cushing’s disease

Adrenal insufficiency
Short Synacthen test
- Proceudre: 250mcg Synacthen IM
- Normal response: cortisol rises ≥ 200nM at 30 min to a level ≥ 550 nM

Mineralocorticoid excess
Salt loading test (used in PWH – less invasive than saline infusion test and captopril test)
- Procedure: 5 days oral NaCl à measure 24h urine aldosterone and Na
- Ensure compliance: 24h urine Na > 200 mmol
- Primary hyperaldosteronism confirmed if 24h urine aldosterone > 38nmol

Aldosterone-renin ratio (ARR): usually >1000 in primary hyperaldosteronism

Posture test in primary hyperaldosteronism (high ARR): differentiate Conn’s syndrome and BIAH
- Procedure: check renin & aldosterone at 9am (supine) and 1pm (ambulatory)
- Results: drop paradoxically in Conn’s syndrome, rise in BIAH and other cases

Reproductive hormones
B
Free androgen index (FAI) = × 100
C2DE
- ≥5: hyperandrogenemia (female)

Precocious puberty: secondary sexual characteristics <8y (female) or <9y (male)

Delayed puberty: secondary sexual characteristics >13y (female) or >14y (male)

LH/FSH ratio: >2 suggests PCOS

Lecithin-sphingomyelin ratio (L:S) < 1.5 suggests high risk of respiratory distress syndrome

Biogenic amines

24h urine catecholamines – positive results if:

- NA, A, NM, M: 2x elevation
- VMA: 3x elevation

Clonidine suppression test

- Procedure: Empty bladder and take 0.3mg clonidine PO at 2100, then collect urine 2100-0700
- Normal: urine noradrenaline <60 nmol/mmol Cr, urine adrenaline <20 nmol/mmol Cr
 - Elevated: pheochromocytoma is likely

Neuroblastoma: VMA and HVA can be used for prognosis

- VMA:HVA ratio < 1 is associated with poor prognosis

Carcinoid: at least 10x increase in urinary 5-HIAA

Miscellaneous topics

Miscellaneous fluids
Light’s criteria: Pleural fluid is exudate if any ONE of:
- Pleural fluid : Serum protein > 0.5
- Pleural fluid : Serum LDH > 0.6
- Pleural fluid LDH > 2/3 upper limit of serum LDH

Serum-ascites albumin gradient (SAAG): Transudate: >1.1 g/dL Exudate: <1.1 g/dL

Toxicology
- Therapeutic range = MTC (min. toxic conc.) – MEC (min. effective conc.)
- Therapeutic index = LC50 / EC50
Gentamicin Hartford nomogram: sampling between 6-14h
Cyclosporine C2 whole blood (not serum) – correlate best with AUC
Digoxin Ref: 0.6-1.3 nmol/L (HF) ; 1.2-2.6 nmol/L (arrhythmia)
Half-life: 40h
TDM: 6h post-dose
Lithium Ref: 0.4-1 mmol/L
TDM: 12h post-dose
Paracetamol Toxic if >150 mg/kg
Rumack-Matthew nomogram: valid starting at 4h post-dose
Salicylate Toxic if >1.8 mmol/L
Statistics
Significant change: Change in value > 2.77 x 3𝑆𝐷F9 +𝑆𝐷99
- SD1: analytical variation: repeatedly measure single specimen for 20 times
- SD2: biological variation: take samples at regular intervals

Coefficient of variation (CV) = SD / mean x 100

Disease Present Disease Absent Prevalence = (TP+FN) / all

Positive predictive value (PPV)
Test Positive True positive False positive
= TP / (TP + FP)
Negative predictive value (NPV)
Test Negative False negative True negative
= TN / (TN + FN)
Sensitivity Specificity PPV and NPV are affected by
= TP / (TP + FN) = TN / (TN + FP) prevalence L

Likelihood ratios:
'(<';G;H;G? F*'(<';G;H;G?
LR+ = F*'8(%;I;%;G? LR- =
'8(%;I;%;G?

Odds:
8:(H=#(<%( B1JKA
Pre-test odds = F*8:(H=#(<%( = BAJK1

Post-test odds = pre-test odds × likelihood ratio

Predictive values:
'(<';G;H;G? × 8:(H=#(<%(
PPV = '(<';G;H;G? × 8:(H=#(<%(J(F*'8(%;I;%;G?)×(F*8:(H=#(<%()
'8(%;I;%;G? × (F*8:(H=#(<%()
NPV = (F*'(<';G;H;G?)× 8:(H=#(<%( J '8(%;I;%;G? × (F*8:(H=#(<%()