NOTES IN CLINICAL CHEMISRY 2: MT4B / 3RD YR / 2ND SEMESTER / MIDTERM /

Osmolal gap indirectly indicates the presence of osmotically

ELECTROLYTES active substances other than sodium, urea, or glucose.
Ions capable of carrying an electric charge. Classified as anions
or cations based on the charge they carry. REFERENCE RANGES FOR OSMOLALITY

Anions- have negative charge and move toward the anode Serum - 275-295 mOsm/kg
Cations- have positive charge and migrate in the direction of Urine (24 hr) - 300-900 mOsm/kg
the cathode. Urine/serum ratio - 11.0-3.0
Random urine - 50-1200 mOsm/kg
Page |
ELECTROLYTES AND FUNCTIONS Osmolal gap - 5-10 mOsm/kg 1

1. Sodium, Chloride & Potassium - for regulation SODIUM (NA+)

2. Potassium, Magnessium & Calcium - myocardial rhythm and
contractility Most abundant cation in the ECF, representing 90% of all
3. Magnessium, Calcium & Zinc - cofactors in enzyme extracellular cations. Cone in the ECF is much larger than inside
activation the cells because a small amount of Na+ can diffuse through the
4. Magnesium - regulation of ATPase ion pumps cell membrane.
5. Potassium, Calcium, Magnesium - neuromuscular excitability
6. Magnesium, Phosphate - production and use of ATP from Na+, K+ ATPase ion pump Moves three Na+ ions out of the cell in
glucose exchange for two K + ions moving into the cell as ATP is
7. Bicarbonate, Potassium, Chloride - acid-base balance converted to ADP.
8. Calcium, Magnesium - blood coagulation
HYPONATREMIA
• Serum/plasma level less than 135 mmol/1
WATER • Levels below 130 mmol/1 are clinically significant
• Average water content of the human body varies from 40% • Caused by increased Na+ loss, increased water retention, or
to 75% of total body weight, with values declining with age, water imbalance
especially with obesity. • When rbc lyse, Na+, K+, and water are released. Na+
• Solvent for all processes in the body. concentration is lower in rbc, resulting in a false decrease.
• Transports nutrient to cell, remove waste products by way of • Hyponatremia with a high osmolality is associated with
urine, and body's coolant by way of sweating. hyperglycemia. This solute causes a shift of water from the
cells to the blood, resulting in a dilution of Na+.
ECF - EXTRACELLULAR FLUID
Symptoms of hyponatremia:
accounts for one third of total body water and can be • More severe neuropsychiatric symptoms are seen below 125
subdivided into the intravascular extracellular fluid(plasma) and mmol/1, including nausea, vomiting, muscular weakness,
the interstitial cell fluid headache, lethargy and ataxia.
• Severe symptoms include seizures, coma, and respiratory
ICF- INTRACELLULAR FLUID depression
fluid inside the cells and accounts for about two thirds of total
body weight. Treatment of hyponatremia:
• Hypertonic saline and other pharmacological agents that
Active transport- a mechanism that requires energy to move ions may take several days to reach the desired effect and may
across cellular membranes. have delerious side effects.
Diffusion - passive movement of ions across a membrane. • Correcting severe hyponatremia too rapidly can cause
Osmolality - a physical property of a solution that is based on the cerebral myelinolysis and too slowly can cause cerebral
concentration of solutes in plasma it is important because it is the edema.
parameter to which the hypothalamus responds. • Contivaptan is the drug of choice

Means of controlling osmolality: Thirst, secretion of A VP HYPERNATREMIA

FOUR FACTORS AFFECT BLOOD VOLUME Results from excess loss of water relative to Na+ loss, decreased
water intake, or increased Na+ intake or retention.
1. Atrial natriuretic peptide (ANP) - released from the
myocardial atria in response to volume expansion, promotes Symptoms of Hypernatremia:
sodium excretion in the kidney. Altered mental status, lethargy, irritability, restlessness, seizures,
2. Volume receptors independent of osmolality stimulate the muscle twitching, hyperreflexes, fever, nausea, vomiting, difficult
release of AVP respiration, and increased thirst.
3. GFR- increases with volume expansion and decreases with
volume depletion. Determination of sodium:
4. All other things equal, an increased plasma sodium will • Serum, urine and plasma
increase urinary sodium excretion and vice versa. • Lithium heparin, ammonium heparin, lithium oxalate
• Hemolysis doesn't interfere, but marked hemolysis will
Osmolality may be measured in serum or urine. Plasma use is not decrease as a result of dilutional effect.
recommended because osmolality active substances may be
introduced into the specimen from the anticoagulant.

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 NOTES IN CLINICAL CHEMISRY 2: MT4B / 3RD YR / 2ND SEMESTER / MIDTERM /

Methods:
• FES, AAS Symptoms:
• ISE Muscle weakness, tingling, numbness, or mental confusion by
o method of choice. altering neuromuscular conduction.
o Uses a semipermeable membrane to develop a
potential produced by having different ion Treatment of hyperkalemia:
concentrations on either side of the membrane. • Ca++ may be given to reduce threshold potential of
• Direct ISE- provides an undiluted sample to interact with the myocardial cells, it. will provide immediate but short-lived Page |
ISE membrane. More accurate. protection to the myocardium. 2
• Indirect ISE - diluted sample is used for measurement • Substances that acutely shift K + back into cells, such as
sodium bicarbonate, glucose, or insulin may be
Source of error with ISE: administered.
o is protein buildup on the membrane through
continuous use. Collection of samples
o Causes poor selectivity. • Plasma, urine, and serum is used.
• Serum is preferred, because, the coagulation process
releases K + from platelets. Heparin is the anticoagulant of
POTASSIUM (K +)
choice.
• Major intracellular cation in the body. • Do not prolong the application of tourniquet
• Functions include: • Closing and opening of fist during extraction will increase K+
o regulation of neuromuscular excitability • Storing blood on ice promotes the release of K + from cells,
o contraction of the heart, ICF volume, and H+ whole blood samples should be stored at R.T. and analyzed
cone. promptly or centrifuged to remove cells.
• Kidneys are important in the regulation of K+ balance, distal • Do not use hemolyzed sample, it will falsely elevate K+
nephron is the principal determinant of urinary K+ excretion, • Significantly elevated pit ct. may result in the release of K+
the excess is excreted in the urine but may accumulate to during clotting from rupture of these cells, causing a spurious
toxic levels if renal failure occurs. hyperkalemia, in this case, plasma is preferred.
• Both alkalemia and insulin increase cellular uptake of K +.
Methods of measurement:
3 factors that influence the distribution of K+ between cells and • ISE
ECF: o method of choice
• K + loss frequently occurs whenever the Na+. K+ -ATPase o valinomycin membrane is used to selectively bind K +,
pump is inhibited by conditions. causing an impedance change that can be
• Insulin promotes acute entry of K + into skeletal muscle and correlated to K + cone. KCl is the inner electrolyte
liver by increasing Na+, K + -ATPase activity solution.
• Catecholamines, such as epinephrine, promote cellular
entry of K+, whereas propanolol (B-blocker) impairs cellular Chloride (Cl-)
entry of K +
• Major extracellular anion
Exercise • Involved in maintaining osmolality, blood volume, and
• K + is released from cells during exercise, which may electric neutrality.
increase plasma K + by 0.3-1.2 mmol/1. These changes are • Excess is excreted in the urine and sweat.
usually reversed after several minutes of rest.
• Forearm exercise during venipuncture can cause 2 ways Cl- maintains its electrical neutrality:
erroneously high plasma K + cone. • Na+ is reabsorbed along with Cl- in the proximal tubules, Cl-
acts as the rate-limiting component, in that Na+
HYPOKALEMIA reabsorption is limited by the amount of Cl- available
• Electroneutrality is maintained by Cl- through the Cl- shift.
Symptoms of hypokalemia:
• Muscle weakness or paralysis, which can interfere with CHLORIDE SHIFT
breathing.
• In this process, carbon dioxide (CO2) generated by cellular
Treatment: metabolism within the tissue diffuses out into both the
• Oral KCl replacement of K + over several days, IV plasma and the red cell
replacement; food such as dried fruits, nuts, bran cereals, • In the red cell, CO2 forms carbonic acid (H2CO3), which
bananas and orange juice. splits into H+ and HCO3- (bicarbonate)
• Deoxyhemoglobin buffers H+ whereas the HCO3- diffuses
into the plasma and Cl- diffuses into the red cell to maintain
HYPERKALEMIA
the electric balance of the cell.
• Often have an underlying disorder, ·such as renal
insufficiency, diabetes mellitus, or metabolic acidosis, that HYPERCHLOREMIA
contributes to hyperkalemia. • Will occur if there is excess loss ofHCO3 as a result of GI
• Most common cause in hospitalized patients is due to loses, RTA or metabolic acidosis.
therapeutic K + administration.
• Hypothermia causes movement of K + into cells.

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 NOTES IN CLINICAL CHEMISRY 2: MT4B / 3RD YR / 2ND SEMESTER / MIDTERM /

HYPOCHLOREMIA
Magnesium (Mg++)
• Excessive loss of Cl-from prolonged vomiting, diabetic
ketoacidosis, aldosterone deficiency, or salt-losing renal • Fourth most abundant cation and second most abundant
diseases such as pyelonephritis. intracellular ion.
• High serum HCO3- such as compensated respiratory • 53% found in bone, 46% in muscle and other organs and soft
acidosis or metabolic alkalosis. tissues, less than 1 % in serum and RBC.
• In the serum, one third bound to protein, primarily albumin,
Determination of Cl- of the remaining two thirds, 61% exists in the free or ionized
state and about 5% is complexed with other ions. Page |
• Serum or plasma with lithium heparin.
• Hemolysis does not cause a significant change in serum or • Like calcium, it is the free ion that is physiologically active in 3
plasma values as a result of decreased levels of intracellular the body.
Cl- • Rich sources in the diet includes raw nuts, dry cereal, "hard"
• 24-hour urine collection drinking water, vegetables, meat, fish and fruit
• Sweat collection
Regulation:
Methods for CI- determination • Overall regulation of body Mg++ is controlled largely by the
• ISE- ion-exchange membrane is used kidney, which can reabsorb Mg++ in overload states.
• Amperometric-coulometric titration- uses coulometric- • PTH increases the renal reabsorption of Mg++ and enhances
generation of silver ions (Ag+), which combine with Cl- to the absorption of Mg++ in the intestine.
quantitate the Cl- concentration
• Mercurimetric titration HYPOMAGNESEMIA
• Colorimetry • Frequently observed in hospitalized individuals in intensive
care units or those receiving diuretic therapy or digitalis
therapy.
Bicarbonate
• Mg++ decrease during starvation chronic alcoholism, or
• Second most abundant anion in the ECF. Mg++ deficient IV therapy
• Total CO2 comprises the bicarbonate ion (HCO3-), carbonic • Pseudohypomagnesemia may also be the result of
acid (H2CO3), and dissolved CO2, with HCO3- accounting hyperaldosteronism caused by increased water
for more than 90% of the total CO2 reabsorption.
• The major component of the buffering system in the blood. • In persons with diabetes, excess urinary loss of Mg++ is
• Diffuses out of the cell in exchange for Cl- to maintain ionic associated with glycosuria.
charge neutrality within the cell (chloride shift)
Symptoms of hypomagnesemia:
REGULATION OF BICARBONATE • Cardiovascular, neuromuscular, psychiatric, and metabolic
abnormalities.
• In the kidneys, 85% is reabsorbed by the proximal tubules, • Weakness to tremors, tetany, paralysis or coma
with 15 being reabsorped by the distal tubules.
• Almost all excess HCO3- flows into the urine. Treatment:
• In alkalosis, with a relative increase in HCO3- compared to Oral intake using magnesium lactate, magnesium oxide, or
CO2, the kidneys increase excretion of HCO3- into the urine, magnesium chloride or an antacid that contains M++
carrying along a cation· such as Na+. This loss ofHCO3- from
the body helps correct Ph.
HYPERMAGNESEMIA
Clinical application • Involves cardiovascular dermatologic, GI, neurologic,
• Decreased HCO3- may occur from metabolic acidosis as neuromuscular, metabolic, and hemostatic abnormalities,
HCO3- combines with H+ to produce CO2, which is exhaled hypotension, bradycardia; skin flushing~ increased skin
by the lungs. temperature, nausea, vomiting and lethargy
• Typical response to metabolic acidosis is compensated by • Life threatening symptoms: ECG changes, heart block,
hyperventilation, which lowers pCO2. asystole, sedation, coma, respiratory depression or arrest,
• Elevated total CO2 cone occur in metabolic alkalosis as paralysis
HCO3- is retained, often with increased pCO2 as a result of • May inhibit PTH release and target tissue response. This may
compensation by hypoventilation. lead to hypocalcemia and hypercalciuria
• Typical causes of metabolic alkalosis include severe
vomiting, hypokalemia, and excessive alkali intake. Treatment:
Discontinue the source of Mg++
Determination of carbon dioxide Mg++ determination:
• Serum or lithium heparin plasma Non-hemolyzed serum or lithium heparin plasma. 24-hour urine
• Anaerobic collection for the highest accuracy or sample
sample is capped until the serum or plasma is COLORIMETRIC METHODS:
separated and the sample is analyzed immediately. • Calmagite- Mg++ binds with calmagite to form a reddish-
• If left uncapped, CO2 escapes, will decrease by 6 violet complex that may be read at 532 nm.
mmol/1 per hour • Formazen dye- Mg++ binds with the dye to form a colored
• Two methods for ISE and an enzymatic method. complex that may be read at 660 nm.
• Methylthymol blue- Mg++ binds with the chromogen to form
a colored complex.
• AAS- reference method for Mg++
Reference range: 0.63-1.0 mmol/L (l.26 - 2.10 mEq/L)

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 NOTES IN CLINICAL CHEMISRY 2: MT4B / 3RD YR / 2ND SEMESTER / MIDTERM /

Calcium HYPOCALCEMIA
• Sepsis, thermal burns, renal failure, or cardiopulmonary
• 3 hormones, PTH, Vitamin D, and calcitonin regulate insufficiency.
serum Ca++ Symptoms: neuromuscular irritability (parasethesia, muscle
cramps, tetany and seizures) and cardiac irregularities (arrhytmia
• PTH secretion in blood is stimulated by a decrease or heart block)
in ionized Ca++, conversely PTH secretion is stopped Treatment: Oral or parenteral Ca++ therapy
by an increase in ionized Ca++ Page |
HYPERCALCEMIA
• 45% circulates as free calcium (ionized Ca++) 40% 4
• Primary hyperparathyroidism (common in older women) or
bound to protein, mostly albumin, and 15% is excess secretion of PIB Various types of malignancy Thiazide
bound to anions, such as HCO3-, citrate, Po4- and diuretics increase Ca++ reabsorption
Symptoms: Mild drowsiness, weakness, depression, lethargy, and
lactate. coma. GI symptoms: constipation, nausea, vomiting, anorexia,
peptic ulcer disease, nephrolithiasis and nephrocalcinosis,
3 major effects of PTH exert in kidney and bone symptoms of digitalis toxicity
• Bone- activates a process known as bone resorption, in Treatment: Salt and water intake encourages increase Ca++
which activated osteoclasts break down bone and excretion and avoid dehydration. Thiazide diuretics should be
subsequently release Ca++ into the ECF. discontinued.
• Kidneys- PTH conserves Ca++ by increasing tubular Biosphanates the main drug used to lower Ca++
reabsorption of Ca++ ions. PTH also stimulates renal
production of active Vitamin D Determination of Ca++
• Vitamin D3 is then converted in the liver to 2- • Serum or lithium heparin plasma collected without venous
hydroxycholecalciferol (25-OH-D3), still an inactive form of stasis, collected anaerobically.
vitamin D. In the kidney, 25-OH-D3 is specifically • Process in less than 30 minutes and at room tempearture.
hydroxylated to form 1,25 dihydroxycholecalciferol (1,25-[ Na+, lithium heparin partially binds to Ca++ which lowers
oh]2-D3), the biologically active form ionized Ca++
• Timed urine collection
• Vitamin D3- a cholecalciferol, obtained from the diet or
exposure of skin to sunlight Methods for Ca++ determination
• l,25-[OH]2-D3- 1,25 dihydroxycholecalciferol- active form of • OCPC/ CPC -ortho-cresolphthalein complexone- uses 8-
Vitamin D that increases Ca++ absorption in the intestine hydroxyquinoline to prevent Mg++ interference
and enhances the effect of PTH on bone resorption. • Arsenazo- arsenazo III dye reacts with Ca++ to form a
• Calcitonin- from the medullary cells of the thyroid gland, complex. Ca++ is released from its protein carrier and
secreted when the concentration of Ca++ in blood complexes by acidification of the sample
increases. Inhibits the actions of both PTH and vitamin D • ISE- reference method
therefore lowering the calcium
Phosphate
HYPOCALCEMIA • It participates in many of the most important biochemical
• Primary hypoparathyroidism, lack of vit D, hypoalbuminemia processes.
(each 1g/dl decrease in serum albumin, there is 0.2 mmol/L • Phosphate deficiency can lead to ATP depletion.
(0.8 mg/dl) • In blood may be absorbed in the intestine from dietary
• acute pancreatitis: decrease in total Ca++ levels sources, released from cells into blood, and lost from bone.
• Vitamin D acts to increase phosphate in the blood,
Hypomagnesemia in three ways: phosphate absorption in the intestine and phosphate
• Inhibits the glandular secretion of PTH across the parathyroid reabsorption in the kidney.
gland membrane • The predominant intracellular anion.
• Impairs PTH action at its receptor site on bone • About 80% of the total body pool of phosphate is contained
• Causes vit D resistance in bone, 20% in soft tissues, and less than 1 % is active in the
serum/plasma.
PSEUDOHYPOPARATHYROIDISM
HYPOPHOSPHATEMIA
• Rare hereditary disorder in which PTH target tissue response
is decreased. • Diabetic ketoacidosis, chronic obstructive pulmonary
• Calcium is lost in urine or remains in the bone storage pool. disease (COPD), asthma, malignancy, long-term treatment
• Clinical features: short stature, obesity, shortened with total parenteral nutrition (TPN) inflammatory bowel
metacarpals and metatarsals and abnormal calcification disease, anorexia nervosa and alcoholism
HYPERPHOSPHATEMIA
During surgery and intensive care:
Controlling Ca++ cone may be critical in open heart surgery • Greater risk is those with acute or chronic renal failure.
when the heart is restarted and during liver transplantation • Neonates are susceptible caused by increased intake, such
because large volumes of citrated blood are given. as from cow's milk or laxatives.
NEONATALMONITORING: Determination:
Blood ionized Ca++ in neonates are high at birth and then • Serum or lithium heparin is acceptable
rapidly decline by 10%-20% after 1-3 days. After about a week, • Highest in morning and lowest in evening.
ionized Ca++ cone in the neonate stabilize at levels slightly • Urine 24-hour sample
higher than in adults.

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 NOTES IN CLINICAL CHEMISRY 2: MT4B / 3RD YR / 2ND SEMESTER / MIDTERM /

Lactate
• By-product of an emergency mechanism that produces a
small amount of ATP when oxygen delivery is severely
diminished.
• Liver is the major organ for removing lactate by converting
lactate back to glucose by gluconeogenesis
• Useful for metabolic monitoring in critically ill patients, for
indicating the severity of the illness, for determining patient Page |
prognosis. 5
Two types of lactate acidosis:
• Type A- associated with hypoxic conditions, such as shock,
MI, severe congestive heart failure, pulmonary edema, or
severe blood loss.
• Type-B is metabolic origin, DM, severe infection, leukemia,
liver or renal disease and toxins.

• Tourniquet should not be used to avoid venous stasis.

Heparinized blood may be used, and placed in ice, and
process blood immediately.
• Measurement has been hindered because methods were
slow and laborious.
• Replaced methods to measure oxygenation were
indwelling catheters, pulse oximeters, base- excess
determinations, and oxygen consumption (VO2)

Anion gap

• Difference between unmeasured anions and unmeasured

cations.
• It is created by the concentration difference between
commonly measured cations (Na+ + K+) and commonly
measured anions (Cl+HCO3)

ELEVATED ANION GAP- Caused by uremia/renal failure, which

leads to PO4 and SO4 retention; ketoacidosis, in cases of
starvation or diabetes, methanol, ethanol, ethylene glycol
poisoning, or salicylate; lactic acidosis; hypernatremia and
instrument error

LOW ANION GAP- Rare but may be seen in hypoalbuminemia or

severe hypercalcemia

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