Chapter 3: Function and

Measurement of Electrolytes
 Acknowledgements
• Addisa Ababa University
• Jimma University
• Hawassa University
• Haramaya University
• University of Gondar
• American Society for Clinical Pathology
• Center for Disease Control and
Prevention-Ethiopia
 Chapter Learning Objectives
• Upon completion of this chapter the
student should be able to:
– Describe the function of electrolytes
– Explain electrolyte and water balance,
electrolytes and acid balance in normal
conditions and conditions of imbalance.
– Explain measurement of electrolytes like
sodium, potassium, chloride, bicarbonate,
calcium, phosphorus and magnesium
 Chapter Learning Objectives
• Upon completion of this chapter the
student should be able to
• Explain serum iron and iron binding
capacity
• Describe the physiologic function,
regulation and assay of blood gases
 Outline
• Function of electrolytes
• Electrolytes and water balance
• Condition of fluid imbalance
• Conditions of electrolyte imbalance
• Electrolytes and acid-base balance
• Disturbances of acid – base balance
 Outline
• Measurement of electrolytes like sodium,
potassium, chloride, calcium,
phosphorous and magnesium, and serum
iron and iron binding capacity
• Physiological function, regulation and
assay principles of blood gases
 Learning Objectives
Upon completion of the lecture and exercise the
student will be able to:
• Define electrolytes and related terms.
• Discuss the intracellualr and extracellular
distribution of electrolytes
• Explain the typical relationship (balance) of
water and electrolytes
 Learning Objectives
• Upon completion of this lecture the student will
be able to:
• Discuss typical Na, K, Cl, CO2/HCO3 levels in
body fluids based on pathophysiological
responses.

• Describe the principle of analysis of Na, K, Cl

and total CO2 (HCO3-), in terms of electronic
components, reagents and endpoint detection.
 Learning Objectives
Upon completion of this lecture and exercise the
student will be able to:

• Describe specimen collection and handling requirements

for electrolyte analysis.

• Explain the expected reference ranges of Na, K, Cl,

CO2/HCO3 based on normal physiologic responses.

• Discuss interpretation of electrolyte results

 Outline of Electrolytes and
Lecture
• Introduction
• Source
• Clinical Significance
• Methods of Analysis
• Specimen
• Interpretation
• Quality Control
• Sources of Error
• Documentation and Reporting
• Summary
 Introduction to Electrolytes
• Definition: charged particles or ions when
in solution . Cations are positive ions.
Anions are negative ions.

• List of Major Electrolytes:

– Sodium (Na)
– Potassium (K)
– Chloride (Cl)
– Bicarbonate (HCO3-)
 The Function of Electrolytes
• Participate in:
– enzyme activation,
– coagulation and complement cascades
– contribute to plasma osmolality
– participates in cardiac rhythm
– neuromuscular excitation
– other
 Distribution of Electrolytes
• Intracellular versus Extracellular
distributions vary
– Na+, Ca++ and Cl- extracellular
– K+, Mg++ and CO3- intracellular
• Effect of hemolysis:
release of intracellular
ions
 Water and Electrolyte Balance
• Intracellular Fluid (ICF)
– More protein, K +, Mg2+, phosphates, HCO3-
• Extracellular Fluid (ECF)
– Less protein
– More Na+, Cl-
Other fluids:
• Interstitual Fluid
• Intravascular Fluid (plasma)
 Water Balance

• Total water intake = total water out-

put
• Osmotic Pressure (Na + water)
• Hormonal Influences
– Aldosterone: conserves Na and Cl
– Anti-diuretic Hormone (ADH): conserves
water
 Condition of Fluid Imbalance
• Loss of Water
– Dehydration
– Lack of ADH

• Loss of Water and Electrolytes

– GI loss
– Excessive sweating
– Burns
– Excess urine excretion
 Edema
• Fluid accumulates in tissue space
– Salt & water depletion when extreme

• Causes of Edema:
– Low plasma protein levels
– Block lymphatic vessels
– Sodium retention combined with increased
capillary blood pressure
 Electrolytes and Acid Base
Balance
Major electrolyte involved is HCO3-

Source:
(carbonic anhydrase)

• H2CO3-------------- H2O + CO2 HCO3- and

H+
• The resulting bicarbonate is reabsorbed to
help maintain acid base balance in blood
plasma.
Overview of Acid-Base Balance
• pH 7.4 is neutral
• Bicarbonate salt and carbonic acid
maintain balance
 Electrolytes and Acid Base
Balance
• Bicarbonate buffer system: most significant.
• Renal control: HCO3- and H+
• Respiratory control: H2CO3
• Normal ratio for bicarbonate ion (mmol/L):
carbonic acid = 20:1

7.40 = 6.1 + log (HCO3-/ H2CO3)

• 6.1 is the pKa and 7.40 is the normal blood pH.
 Electrolytes and Acid Base
Balance
• Additional buffering of urinary H+:
ammonium and phophate buffer systems

• Renal tubular secretion and reabsorption:

• A buffer: mixture of chemicals that are

able to resist changes in pH
 Renal Control of Electrolytes
• Renal Control of Acid Base Balance
• Distal convoluted tubules perform 2 main
functions. They are:
1) secrete H+ and NH4+
2) secrete Na+, HCO3- & H2PO4-
Disturbances of Electrolyte and
Acid Base Balance
• Metabolic Acidosis
– Indicated by decreased blood pH and
decreased bicarbonate/ total CO2
– Causes of Metabolic Acidosis are: diarrhea,
diabetic ketoacidosis and renal failure

– Compensation: Respiratory system attempts to

normal blood pH by eliminating more carbon
dioxide and decreasing blood pCO2 levels
Disturbances of Electrolyte and
Acid Base Balance
• Metabolic acidosis with increased
anion gap
- Causes: Metabolic conditions such as diabetic
ketoacidosis, renal failure or other renal
diseases, lactic acidosis.

• Metabolic acidosis with normal anion

gap is caused by diarrhea
 Renal Tubular Acidosis
• A tubular defect of acid-base and electrolyte
regulation.
• Known for an alkaline pH of the urine with acidic
blood plasma pH

• Consequence:
– depletion of potassium and bicarbonate ions

• Results in:
– Electrolyte and mineral imbalance
Disturbances of Electrolyte and
Acid Base Balance
• Metabolic Alkalosis
– Indicated by increased blood pH and increased
bicarbonate/ total CO2
– Causes of Metabolic alkalosis: excess
treatment with bicarbonate salts, prolonged
vomiting and renal causes of K depletion.

– Compensation: Respiratory system attempts to

normal blood pH by retaining carbon dioxide
and blood pCO2 levels
 Disturbance of Acid Base
Balance
• Respiratory Acidosis
– Indicated by decreased blood pH and increased
dissolved carbon dioxide/ pCO2
– Causes of respiratory acidosis are:
Respiratory illnesses that cause hypoventilation and
hypercapnia
– Emphysems
– Chronic Bronchitis
Medications that depress respiration
– Renal compensation causes increased blood
bicarbonate
 Disturbance of Acid Base
Balance
• Respiratory alkalosis
– Indicated by increased blood pH and
decreased dissolved carbon dioxide/ pCO2
– Causes: of respiratory alkalosis are:
• Hyperventilation from various reasons

• Compensation with renal control of bicarbonate

with will decrease blood bicarbonate levels to
attempt to normalize pH
 Sodium
• Major role in maintaining osmotic
pressure.
• Maintained by: kidneys

• Influence of the hormone: aldosterone

– Regulates blood pressure through Na
retention
 Clinical Significance
Hypernatremia
• Caused by renal and non-renal disorders.
• Common non-renal causes:
– Dehydration
– Burns
– Excessive Sweating
• Renal:
– Nephrogenic diabetes insipidus
• Serum osmolality & urinary sodium levels
differentiate renal loss of water versus non-
renal causes.
 Clinical Significance
Hyponatremia
Renal Causes:
• Salt losing nephritis
• Chronic renal failure can cause water overload:
• Nephrotic syndrome can cause fluid imbalances and
edema with resulting hyponatremia. Urine Na levels are
normal or decreased in hyponatremia due to edema.

Non-renal causes:
psychogenic water overload, cellular shift changes from
acidosis and edema secondary to cirrhosis or CHF
 Potassium
• Maintains cardiac rhythm and contributes
to neuromuscular conduction.
• Imbalances, hyperkalemia or hypokalemia,
will result in:
– Cardiac arrhythmia and weakness
 Clinical Significance
Hyperkalemia
• What are causes of hyperkalemia?
– Renal failure
– Diuretics
– Hypoaldosteronism: K retained and Na lost
– Hypercortisolism
– Diabetic ketoacidosis
– Hemolytic or Leukemia
 Clinical Significance
Hypokalemia
• What causes it?
– Renal tubular acidosis
– Hyperaldosteronism: K lost and Na retained
– Hypercortisolism
– Diuretics
– Vomiting or GI loss
• Note: cellular shift in insulin overdose and
alkalosis can also cause hypokalemia
 Electrolytes Methods of
Analysis
• Ion selective Electrodes: Na, K, Cl and
HCO3-
• Flame Emission Photometry: Na and K
• Colorimetry: Cl and HCO3-,
• Minor Electrolyte Methods:
– Colorimetric
– Atomic Absorption Spectroscopy
 Ion Selective Electrodes
• Only free unbound ion is measured by ion
selective electrode; significant for:
– Ca
– Mg
• Ion selective electrodes are covered by a unique
material that is more selective for one ion than
other ions.
• When the ion comes in contact with the electrode,
there is:  potential
• Lipemia interferes with indirect method
 Method of Na Analysis
Ion Selective Electrode (ISE)
• made of a lithium aluminum silicate or
other composite silicon dioxide glass
compound
• selective for Na+
– Not selective K+ or H+
 Method of K Analysis
The ISE for K typically contains a selective
membrane containing valinomycin
• binds well with K+
• does not bind well
with Na+ or H+
 Method of Na and K+ Analysis
Flame emission photometry
• Sample is mixed with internal standard.
• Solution is aspirated into a flame.
• Ions are excited with the addition of the thermal
energy and emit radiant energy.
• Photodetector detects the unique emitted
wavelengths of light specific to the Na+ and K+
• Concentration of Na+ or K+ in mmol/L is
determined.
 Specimens for Na and K
• Venous Serum
• Heparinized plasma
• Effect of Hemolysis
– No error for Na but causes false elevation of K
• Avoid lipemic sera
• Separate serum or plasma quickly from cells
• CSF for Na but not K
• Urine sample with out preservative
 Quality Control
• A normal & abnormal quality control sample
should be analyzed along with patient samples,
using Westgard or other quality control rules for
acceptance or rejection of the analytical run.
– Assayed known samples
– Commercially manufactured (Humastar)

• Validate patient results

• Detects analytical errors.
 Sources of Error for Na and K
Analysis
• Hemolysis
• Failure to quickly separate plasma/serum
from cells
• Anticoagulants other than heparin
• Prolonged use of tourniquet
• Lipemia
• Errors of analysis
– Not calibrated
Source of Error with ISE Method
for Electrolytes
• ISE system which dilutes the sample with
diluent prior to analysis with the electrode
is termed indirect.
• Interference by hyperlipidemia or
hyperproteinemia
 Interpretation of Serum Na and
K Levels
Test Unit Ref. Range

Na mmol/L 135-145

K mmol/L 3.3-4.9

Use reference ranges specific to the region or

country. Compare the patient results to the
reference ranges to determine if increase or
decrease in Na or K are observed.
 Reporting and Documentation
• To avoid post-analytic errors,
• Report the patient result with :
• right name and result
• Include reference ranges
• Timely manner

• QC and patient results should be

documented in logbook and retained in lab
Clinical Significance of Chloride
• Contributes to the acid-base balance by
the isohydric shift
• The shift is the buffering of H+ with HCO3-
and others intracellularly with movement
to extracellular fluid spaces.
• Chloride shift is:
– Movement of Cl
– Balances HCO3-
 Clinical Significance
Hyperchloremia

• Dehydration: severe diarrhea or burns

• Hyperaldosteronism: Na and Cl retention
 Clinical Significance
Hypochloremia

• Excessive urination
• Excessive sweating
• Hypoaldosteronism: Na and Cl lost, K
retained
 Method of Cl Analysis
• Ion Selective Electrode (ISE)
• made of a Cl salt compound
• selective for Cl-
– Not selective other anions
 Method of Cl Analysis
Coulometry:
• Cl- titrated with Ag+ - insoluble AgCl.
• The time of titration is proportional to Cl
activity in the sample.
• This method is commonly used for sweat
chloride analysis.
• Historical method for serum Cl analysis
 Methods for Cl Analysis

Spectrophotometric methods
Hg(SCN)2 + 2Cl-  HgCl2 +2SCN-
3SCN- + Fe3+  Fe(SCN)3
• The final chromagen is measured
photometrically at 480 nm
 Specimen for Cl Analysis
• Serum or heparinized plasma
– Mild hemolysis is accepted
• Urine
• CSF
• Sweat
 Sources of Error in Cl Analysis
Specimen errors are associated with:
• Anticoagulants other than heparin

Analysis errors:
• In ISE Br- ions may interfere in Cl- electrodes
– Protein coating on the electrode
• In spectrophotometric method, poor calibration
or in accurate instrument operation
 Quality Control
• A normal & abnormal quality control sample
should be analyzed along with patient samples,
using Westgard or other quality control rules for
acceptance or rejection of the analytical run.
– Assayed known samples
– Commercially manufactured (Humastar)

• Validate patient results

• Detects analytical errors.
 Interpretation of Cl Results
• Cl Reference Ranges:
Serum in mmol/L
adult 98-107
infant 98-113
Urine in mmol /24 hr
adult 110-250
infant 2-10
child 15-40
CSF in mmol/L
adult 118-132
infant 110-130
Sweat 5-35 mmol/L
 Reporting and Documentation
• To avoid post-analytic errors,
• Report the patient result with :
• right name and result
• Include reference ranges
• Timely manner

• QC and patient results should be

documented in logbook and retained in lab
 Discussion Point
• Why chloride levels are sometimes
analyzed in sweat?
 Bicarbonate
• CO2 + H2O-> H2CO3-> H+ + HCO3-
• tCO2 includes many components:

• Dissolved CO2 and pCO2 make up a small

% of CO2 forms

• Major metabolic component to balance pH

 Clinical Significance of
Bicarbonate Ion Levels
• Excess Blood bicarbonate
– Metabolic alkalosis
– Compensation for respiratory acidosis
• Decreased Blood bicarbonate
– Metabolic acidosis
– Compensation for respiratory alkalosis
 Electrochemical Method
Bicarbonate Analysis
• tCO2 gas electrode converts HCO3- to gas
• CO2 gas diffuses through a silicone membrane
• CO2 reacts with a bicarbonate/ carbonic acid
buffer
• Amount of H+ production is proportional to the
concentration of tCO2 in the plasma

• CO2 + H2O-> H2CO3-/ HCO3-  H +

Bicarbonate/ total CO2
Method of Bicarbonate Analysis
Photometric method:
• HCO3 + urea --(urea amidolyase) NH4+.
NH4+ + NADPH –(glutamate
dehydrogenase) NADP+ + H+
• Decrease in Abs is measured at 340 nm
 Specimens for Bicarbonate
• Serum
– Arterial
– Venous
• Heparinized whole blood
– Arterial
 Quality Control
• A normal & abnormal quality control sample
should be analyzed along with patient samples,
using Westgard or other quality control rules for
acceptance or rejection of the analytical run.
– Assayed known samples
– Commercially manufactured (Humastar)

• Validate patient results

• Detects analytical errors.
 Sources of Error for Bicarbonate
Analysis
• Specimen errors due to:
– Wrong anticoagulant
– Failing to keep the specimen stoppered
– Not fresh
– Hemolysis
• Analytic errors due to:
– Protein contamination of membrane in ISE
– Poorly calibrated analyzers
• Reporting errors due to:
– Using wrong reference ranges with type of specimen
– (whole blood versus plasma)
 Interpretation of Bicarbonate
Levels
Reference Ranges:

Specimen HCO3- Unit

Serum, Venous 22-29 mmol/L
Serum, Arterial 21-28 mmol/L
Whole blood,
Arterial 22-26 mmol/L
 Reporting and Documentation
• To avoid post-analytic errors,
• Report the patient result with :
• right name and result
• Include reference ranges
• Timely manner

• QC and patient results should be

documented in logbook and retained in lab
 Anion Gap
• Electrolytes exist in a balance to provide
electrolyte neutrality.
• Sum of anions, including chloride, bicarbonate
and ionized proteins = sums of cations, including
sodium and potassium

• The major electrolytes account for most ions

with about 15 mmol/L from unmeasured anions.
Clinical Significance Anion Gap
• In many types of metabolic acidosis, anion
gap is increased (> 20 ) due to deficit of
bicarbonate ions and presence of organic
acids, such as acetoacetic acid, lactate,
salicylate, formate or glycolate.

↑ sodium relative to ↓ bicarbonate will also

increase anion gap.
Clinical Significance Anion Gap
• Decreased anion gap may be due to:
↓ Na and or ↑ Cl and HCO3-

• A decreased anion gap may be found with:

– Rare electrolye imbalance
– More commonly, decreased anion gap is an
indication of technical problems.
 Calculation of Anion Gap
• Anion gap is a calculation of the difference
between anions and cations in blood.
• represents chemical anions other than
those used in the formulas, chloride and
bicarbonate, that might be present in
blood.
• used to estimate acid-base and electrolyte
disturbances.
 Calculation of Anion Gap
• The most commonly used formula is
• (Na + K) -(Cl +CO2) with reference range
of: 10-20 mmol/L

• The formula (Na ) -(Cl+CO2) can be used

but is generally being replaced by the
formula that includes potassium.
 Interpretation of Results
Electrolyte Analysis
• In order to classify electrolyte
abnormalities, compare results to the
reference ranges and consider critically
high or low levels.
• Critical values indicate life-threatening
situation due to the electrolyte
abnormality. They are typically
established at each institution.
 Electrolyte Analysis
• Critical Na K Cl HCO3-
Values for mmol/ mmol/ mmo/ mmol/
Electrolytes L L
L L
>160 >6.2 > 120 > 40

< 120 < 2.8 < 80 <10

 Interpretation of Serum
Electrolyte Levels
Test Unit Ref. Range

Na mmol/L 135-145

K mmol/L 3.3-4.9

Cl mmol/L 98-108

HCO3- mmol/L 22-28

Anion Gap none 10-20

 Review Questions
• What are the patient sample collection and
handling processes for electrolyte
analysis.
• What is the effect of hemolysis on Na, K,
Cl and HCO3- results?
• What are other problems to consider with
specimen collection or handling of urine or
serum electrolytes?
 Review Questions
• What are the principle of analysis by
electrochemical methods for these
electrolytes including electrode
components, reagents and how the
endpoint is detected?
– Na
–K
– Cl
– tCO2 (HCO3-)
 Review Questions
• What are other methods of analysis for
these electrolytes?
– Na
–K
– Cl
– tCO2 (HCO3-)
 Review Questions
• What are the expected electrolyte results
compared to the reference ranges for the
following conditions?
– Acute renal failure
– Primary renal tubular acidosis
– Metabolic acidosis with increased anion gap
– Metabolic acidosis with normal anion gap
– Metabolic alkalosis
 Review Questions
What are main causes of the following:
• Hyponatremia
• Hypernatremia
• Hypokalemia
• hyperkalemia
 Review Question
• What is the appropriate course of action
needed to resolve the following problems,
if they occur during electrolyte testing.
– e.g. hemolysis
– Lipemia
– Analytical interferences
– Post analytical factors
 References
• Burtis, Carl A., and Ashwood, Edward R.. Tietz:
Fundamentals of Clinical Chemistry. Philadelphia, 2001
• Arneson, W and J Brickell: Clinical Chemistry: A
Laboratory Perspective 1st ed. 2007 FA Davis