METHODS IN PATHOLOGY AND LABORATORY VALUES OF CLINICAL SIGNIFICANCE

PATHOPHYSIOLOGY ASSIGNMENT

Topic: Methods in Pathology and Laboratory Values of

Clinical Significance

Submitted by, Rinju Alias Roll no:22 Pharm D II nd year

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METHODS IN PATHOLOGY AND LABORATORY VALUES OF CLINICAL SIGNIFICANCE

Interpretation of Lab Test Profiles

The various multiparameter blood chemistry and hematology profiles offered by most labs represent an economical way by which a large amount of information concerning a patient's physiologic status can be made available to the physician. The purpose of this monograph is to serve as a reference for the interpretation of abnormalities of each of the parameters. Reference ranges ("normal ranges") Because reference ranges (except for some lipid studies) are typically defined as the range of values of the median 95% of the healthy population, it is unlikely that a given specimen, even from a healthy patient, will show "normal" values for all the tests in a lengthy profile. Therefore, caution should be exercised to prevent overreaction to miscellaneous, mild abnormalities without clinical correlate.

The Analytes
Sodium Increase in serum sodium is seen in conditions with water loss in excess of salt loss, as in profuse sweating, severe diarrhea or vomiting, polyuria (as in diabetes mellitus or insipidus), hypergluco- or mineralocorticoidism, and inadequate water intake. Drugs causing elevated sodium include steroids with mineralocorticoid activity, carbenoxolone, diazoxide, guanethidine, licorice, methyldopa, oxyphenbutazone, sodium bicarbonate, methoxyflurane, and reserpine. Decrease in sodium is seen in states characterized by intake of free water or hypotonic solutions, as may occur in fluid replacement following sweating, diarrhea, vomiting, and diuretic abuse. Dilutional hyponatremia may occur in cardiac failure, liver failure, nephrotic syndrome, malnutrition, and SIADH. There are many other causes of hyponatremia, mostly related to corticosteroid metabolic defects or renal tubular abnormalities. Drugs other than diuretics may cause hyponatremia, including ammonium chloride, chlorpropamide, heparin, aminoglutethimide, vasopressin, cyclophosphamide, and vincristine. Potassium Increase in serum potassium is seen in states characterized by excess destruction of cells, with redistribution of K+ from the intra- to the extracellular compartment, as in massive hemolysis, crush injuries, hyperkinetic activity, and malignant hyperpyrexia. Decreased renal K+ excretion is seen in acute renal failure, some cases of chronic renal failure, Addison's disease, and other sodium-depleted states. Hyperkalemia due to pure excess of K+ intake is usually iatrogenic.

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Drugs causing hyperkalemia include amiloride, aminocaproic acid, antineoplastic agents, epinephrine, heparin, histamine, indomethacin, isoniazid, lithium, mannitol, methicillin, potassium salts of penicillin, phenformin, propranolol, salt substitutes, spironolactone, succinylcholine, tetracycline, triamterene, and tromethamine. Spurious hyperkalemia can be seen when a patient exercises his/her arm with the tourniquet in place prior to venipuncture. Hemolysis and marked thrombocytosis may cause false elevations of serum K+ as well. Failure to promptly separate serum from cells in a clot tube is a notorious source of falsely elevated potassium. Decrease in serum potassium is seen usually in states characterized by excess K+ loss, such as in vomiting, diarrhea, villous adenoma of the colorectum, certain renal tubular defects, hypercorticoidism, etc. Redistribution hypokalemia is seen in glucose/insulin therapy, alkalosis (where serum K+ is lost into cells and into urine), and familial periodic paralysis. Drugs causing hypokalemia include amphotericin, carbenicillin, carbenoxolone, corticosteroids, diuretics, licorice, salicylates, and ticarcillin. Chloride Increase in serum chloride is seen in dehydration, renal tubular acidosis, acute renal failure, diabetes insipidus, prolonged diarrhea, salicylate toxicity, respiratory alkalosis, hypothalamic lesions, and adrenocortical hyperfunction. Drugs causing increased chloride include acetazolamide, androgens, corticosteroids, cholestyramine, diazoxide, estrogens, guanethidine, methyldopa, oxyphenbutazone, phenylbutazone, thiazides, and triamterene. Bromides in serum will not be distinguished from chloride in routine testing, so intoxication may show spuriously increased chloride [see also "Anion gap," below]. Decrease in serum chloride is seen in excessive sweating, prolonged vomiting, saltlosing nephropathy, adrenocortical defficiency, various acid base disturbances, conditions characterized by expansion of extracellular fluid volume, acute intermittent porphyria, SIADH, etc. Drugs causing decreased chloride include bicarbonate, carbenoxolone, corticosteroids, diuretics, laxatives, and theophylline. CO2 content Increase in serum CO2 content for the most part reflects increase in serum bicarbonate (HCO3-) concentration rather than dissolved CO2 gas, or PCO 2 (which accounts for only a small fraction of the total). Increased serum bicarbonate is seen in compensated respiratory acidosis and in metabolic alkalosis. Diuretics (thiazides, ethacrynic acid, furosemide, mercurials), corticosteroids (in long term use), and laxatives (when abused) may cause increased bicarbonate. Decrease in blood CO2 is seen in metabolic acidosis and compensated respiratory alkalosis. Substances causing metabolic acidosis include ammonium chloride, acetazolamide, ethylene glycol, methanol, paraldehyde, and phenformin. Salicylate poisoning is characterized by early respiratory alkalosis followed by metabolic acidosis with attendant decreased bicarbonate.

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Critical studies on bicarbonate are best done on anaerobically collected heparinized whole blood (as for blood gas determination) because of interaction of blood and atmosphere in routinely collected serum specimens. Routine electrolyte panels are usually not collected in this manner. The tests "total CO2" and "CO2 content" measure essentially the same thing. The "PCO 2" component of blood gas analysis is a test of the ventilatory component of pulmonary function only. Anion gap Increased serum anion gap reflects the presence of unmeasured anions, as in uremia (phosphate, sulfate), diabetic ketoacidosis (acetoacetate, beta-hydroxybutyrate), shock, exercise-induced physiologic anaerobic glycolysis, fructose and phenformin administration (lactate), and poisoning by methanol (formate), ethylene glycol (oxalate), paraldehyde, and salicylates. Therapy with diuretics, penicillin, and carbenicillin may also elevate the anion gap. Decreased serum anion gap is seen in dilutional states and hyperviscosity syndromes associated with paraproteinemias. Because bromide is not distinguished from chloride in some methodologies, bromide intoxication may appear to produce a decreased anion gap. Glucose Hyperglycemia can be diagnosed only in relation to time elapsed after meals and after ruling out spurious influences (especially drugs, including caffeine, corticosteroids, estrogens, indomethacin, oral contraceptives, lithium, phenytoin, furosemide, thiazides, thyroxine, and many more). Previously, the diagnosis of diabetes mellitus was made by demonstrating a fasting blood glucose >140 mg/dL (7.8mmol/L) and/or 2-hour postprandial glucose >200 mg/dL (11.1 mmol/L) on more than one occasion. In 1997, the American Diabetes Association revised these diagnostic criteria. The new criteria are as follows:
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Symptoms of diabetes plus a casual plasma glucose of 200 mg/dL [11.1 mmol/L] or greater. OR

Fasting plasma glucose of 126 mg/dL [7.0 mmol/L] or greater. OR

Plasma glucose of 200 mg/dL [11.1 mmol/L] or greater at 2 hours following a 75gram glucose load.

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At least one of the above criteria must be met on more than one occasion, and the third method (2-hour plasma glucose after oral glucose challenge) is not recommended for routine clinical use. The criteria apply to any age group. This means that the classic oral glucose tolerance test is now obsolete, since it is not necessary for the diagnosis of either diabetes mellitus or reactive hypoglycemia. Diagnosis of gestational diabetes mellitus (GDM) is slightly different. The screening test, performed between 24 and 28 weeks of gestation, is done by measuring plasma glucose 1 hour after a 50-gram oral glucose challenge. If the plasma glucose is 140 mg/dL or greater, then the diagnostic test is performed. This consists of measuring plasma glucose after a 100-gram oral challenge. The diagnostic criteria are given in the table below. Time Fasting 1 hour 2 hours 3 hours Glucose (mg/dL) 105 190 165 145 Glucose (mmol/L) 5.8 10.5 9.2 8.0

In adults, hypoglycemia can be observed in certain neoplasms (islet cell tumor, adrenal and gastric carcinoma, fibrosarcoma, hepatoma), severe liver disease, poisonings (arsenic, CCl4, chloroform, cinchophen, phosphorous, alcohol, salicylates, phenformin, and antihistamines), adrenocortical insufficiency, hypothroidism, and functional disorders (postgastrectomy, gastroenterostomy, autonomic nervous system disorders). Failure to promptly separate serum from cells in a blood collection tube causes falsely depressed glucose levels. If delay in transporting a blood glucose to the lab is anticipated, the specimen should be collected in a fluoride-containing tube (gray-top in the US, yellow in the UK). In the past, the 5-hour oral glucose tolerance test was used to diagnose reactive (postprandial) hypoglycemia, but this has fallen out of favor. Currently, the diagnosis is made by demonstrating a low plasma glucose (<50 mg/dL[2.8 mmol/L]) during a symptomatic episode. Urea nitrogen (BUN) Serum urea nitrogen (BUN) is increased in acute and chronic intrinsic renal disease, in states characterized by decreased effective circulating blood volume with decreased renal perfusion, in postrenal obstruction of urine flow, and in high protein intake states.

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Decreased serum urea nitrogen (BUN) is seen in high carbohydrate/low protein diets, states characterized by increased anabolic demand (late pregnancy, infancy, acromegaly), malabsorption states, and severe liver damage. In Europe, the test is called simply "urea." Creatinine Increase in serum creatinine is seen any renal functional impairment. Because of its insensitivity in detecting early renal failure, the creatinine clearance is significantly reduced before any rise in serum creatinine occurs. The renal impairment may be due to intrinsic renal lesions, decreased perfusion of the kidney, or obstruction of the lower urinary tract. Deranged metabolic processes may cause increases in serum creatinine, as in acromegaly and hyperthyroidism, but dietary protein intake does not influence the serum level (as opposed to the situation with BUN). Some substances interfere with the colorimetric system used to measure creatinine, including acetoacetate, ascorbic acid, levodopa, methyldopa, glucose and fructose. Decrease in serum creatinine is seen in pregnancy and in conditions characterized by muscle wasting. BUN:creatinine ratio BUN:creatinine ratio is usually >20:1 in prerenal and postrenal azotemia, and <12:1 in acute tubular necrosis. Other intrinsic renal disease characteristically produces a ratio between these values. The BUN:creatinine ratio is not widely reported in the UK. Uric acid Increase in serum uric acid is seen idiopathically and in renal failure, disseminated neoplasms, toxemia of pregnancy, psoriasis, liver disease, sarcoidosis, ethanol consumption, etc. Many drugs elevate uric acid, including most diuretics, catecholamines, ethambutol, pyrazinamide, salicylates, and large doses of nicotinic acid. Decreased serum uric acid level may not be of clinical significance. It has been reported in Wilson's disease, Fanconi's syndrome, xanthinuria, and (paradoxically) in some neoplasms, including Hodgkin's disease, myeloma, and bronchogenic carcinoma. Inorganic phosphorus Hyperphosphatemia may occur in myeloma, Paget's disease of bone, osseous metastases, Addison's disease, leukemia, sarcoidosis, milk-alkali syndrome, vitamin D excess, healing fractures, renal failure, hypoparathyroidism, diabetic ketoacidosis, acromegaly, and malignant hyperpyrexia. Drugs causing serum phosphorous elevation

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include androgens, furosemide, growth hormone, hydrochlorthiazide, oral contraceptives, parathormone, and phosphates. Hypophosphatemia can be seen in a variety of biochemical derangements, incl. acute alcohol intoxication, sepsis, hypokalemia, malabsorption syndromes, hyperinsulinism, hyperparathyroidism, and as result of drugs, e.g., acetazolamide, aluminum-containing antacids, anesthetic agents, anticonvulsants, and estrogens (incl. oral contraceptives). Citrates, mannitol, oxalate, tartrate, and phenothiazines may produce spuriously low phosphorus by interference with the assay. Calcium Hypercalcemia is seen in malignant neoplasms (with or without bone involvement), primary and tertiary hyperparathyroidism, sarcoidosis, vitamin D intoxication, milk-alkali syndrome, Paget's disease of bone (with immobilization), thyrotoxicosis, acromegaly, and diuretic phase of renal acute tubular necrosis. For a given total calcium level, acidosis increases the physiologically active ionized form of calcium. Prolonged tourniquet pressure during venipuncture may spuriously increase total calcium. Drugs producing hypercalcemia include alkaline antacids, DES, diuretics (chronic administration), estrogens (incl. oral contraceptives), and progesterone. Hypocalcemia must be interpreted in relation to serum albumin concentration (Some laboratories report a "corrected calcium" or "adjusted calcium" which relate the calcium assay to a normal albumin. The normal albumin, and hence the calculation, varies from laboratory to laboratory). True decrease in the physiologically active ionized form of Ca++ occurs in many situations, including hypoparathyroidism, vitamin D deficiency, chronic renal failure, magnesium deficiency, prolonged anticonvulsant therapy, acute pancreatitis, massive transfusion, alcoholism, etc. Drugs producing hypocalcemia include most diuretics, estrogens, fluorides, glucose, insulin, excessive laxatives, magnesium salts, methicillin, and phosphates. Iron Serum iron may be increased in hemolytic, megaloblastic, and aplastic anemias, and in hemochromatosis, acute leukemia, lead poisoning, pyridoxine deficiency, thalassemia, excessive iron therapy, and after repeated transfusions. Drugs causing increased serum iron include chloramphenicol, cisplatin, estrogens (including oral contraceptives), ethanol, iron dextran, and methotrexate. Iron can be decreased in iron-deficiency anemia, acute and chronic infections, carcinoma, nephrotic syndrome, hypothyroidism, in protein- calorie malnutrition, and after surgery.

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Alkaline phosphatase (ALP) Increased serum alkaline phosphatase is seen in states of increased osteoblastic activity (hyperparathyroidism, osteomalacia, primary and metastatic neoplasms), hepatobiliary diseases characterized by some degree of intra- or extrahepatic cholestasis, and in sepsis, chronic inflammatory bowel disease, and thyrotoxicosis. Isoenzyme determination may help determine the organ/tissue responsible for an alkaline phosphatase elevation. Decreased serum alkaline phosphatase may not be clinically significant. However, decreased serum levels have been observed in hypothyroidism, scurvy, kwashiokor, achrondroplastic dwarfism, deposition of radioactive materials in bone, and in the rare genetic condition hypophosphatasia. There are probably more variations in the way in which alkaline phosphatase is assayed than any other enzyme. Therefore, the reporting units vary from place to place. The reference range for the assaying laboratory must be carefully studied when interpreting any individual result. Lactate dehydrogenase (LD or "LDH") Increase of LD activity in serum may occur in any injury that causes loss of cell cytoplasm. More specific information can be obtained by LD isoenzyme studies. Also, elevation of serum LD is observed due to in vivo effects of anesthetic agents, clofibrate, dicumarol, ethanol, fluorides, imipramine, methotrexate, mithramycin, narcotic analgesics, nitrofurantoin, propoxyphene, quinidine, and sulfonamides. Decrease of serum LD is probably not clinically significant. There are two main analytical methods for measuring LD: pyruvate->lactate and lactate>pyruvate. Assay conditions (particularly temperature) vary among labs. The reference range for the assaying laboratory must be carefully studied when interpreting any individual result. Many European labs assay alpha-hydroxybutyrate dehydrogenase (HBD or HBDH), which roughly equates to LD isoenzymes 1 and 2 (the fractions found in heart, red blood cells, and kidney). ALT (SGPT) Increase of serum alanine aminotransferase (ALT, formerly called "SGPT") is seen in any condition involving necrosis of hepatocytes, myocardial cells, erythrocytes, or skeletal muscle cells. [See "Bilirubin, total," below]

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AST (SGOT) Increase of aspartate aminotransferase (AST, formerly called "SGOT") is seen in any condition involving necrosis of hepatocytes, myocardial cells, or skeletal muscle cells. [See "Bilirubin, total," below] Decreased serum AST is of no known clinical significance. GGTP (GAMMA-GT) Gamma-glutamyltransferase is markedly increased in lesions which cause intrahepatic or extrahepatic obstruction of bile ducts, including parenchymatous liver diseases with a major cholestatic component (e.g., cholestatic hepatitis). Lesser elevations of gamma-GT are seen in other liver diseases, and in infectious mononucleosis, hyperthyroidism, myotonic dystrophy, and after renal allograft. Drugs causing hepatocellular damage and cholestasis may also cause gamma-GT elevation (see under "Total bilirubin," below). Gamma-GT is a very sensitive test for liver damage, and unexpected, unexplained mild elevations are common. Alcohol consumption is a common culprit. Decreased gamma-GT is not clinically significant. Bilirubin Serum total bilirubin is increased in hepatocellular damage (infectious hepatitis, alcoholic and other toxic hepatopathy, neoplasms), intra- and extrahepatic biliary tract obstruction, intravascular and extravascular hemolysis, physiologic neonatal jaundice, Crigler-Najjar syndrome, Gilbert's disease, Dubin-Johnson syndrome, and fructose intolerance. Disproportionate elevation of direct (conjugated) bilirubin is seen in cholestasis and late in the course of chronic liver disease. Indirect (unconjugated) bilirubin tends to predominate in hemolysis and Gilbert's disease. Decreased serum total bilirubin is probably not of clinical significance but has been observed in iron deficiency anemia. Total protein Increase in serum total protein reflects increases in albumin, globulin, or both. Generally significantly increased total protein is seen in volume contraction, venous stasis, or in hypergammaglobulinemia. Decrease in serum total protein reflects decreases in albumin, globulin or both [see "Albumin" and "Globulin, A/G ratio," below].

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Albumin Increased absolute serum albumin content is not seen as a natural condition. Relative increase may occur in hemoconcentration. Absolute increase may occur artificially by infusion of hyperoncotic albumin suspensions. Decreased serum albumin is seen in states of decreased synthesis (malnutrition, malabsorption, liver disease, and other chronic diseases), increased loss (nephrotic syndrome, many GI conditions, thermal burns, etc.), and increased catabolism (thyrotoxicosis, cancer chemotherapy, Cushing's disease, familial hypoproteinemia). Globulin, A/G ratio Globulin is increased disproportionately to albumin (decreasing the albumin/globulin ratio) in states characterized by chronic inflammation and in B-lymphocyte neoplasms, like myeloma and Waldenstrm's macroglobulinemia. More relevant information concerning increased globulin may be obtained by serum protein electrophoresis. Decreased globulin may be seen in congenital or acquired hypogammaglobulinemic states. Serum and urine protein electrophoresis may help to better define the clinical problem. T3 uptake This test measures the amount of thyroxine-binding globulin (TBG) in the patient's serum. When TBG is increased, T3 uptake is decreased, and vice versa. T3 Uptake does not measure the level of T3 or T4 in serum. Increased T3 uptake (decreased TBG) in euthyroid patients is seen in chronic liver disease, protein-losing states, and with use of the following drugs: androgens, barbiturates, bishydroxycourmarin, chlorpropamide, corticosteroids, danazol, dthyroxine, penicillin, phenylbutazone, valproic acid, and androgens. It is also seen in hyperthyroidism. Decreased T3 uptake (increased TBG) may occur due to the effects of exogenous estrogens (including oral contraceptives), pregnancy, acute hepatitis, and in geneticallydetermined elevations of TBG. Drugs producing increased TBG include clofibrate, lithium, methimazole, phenothiazines, and propylthiouracil. Decreased T3 uptake may occur in hypothyroidism. Thyroxine (T4) This is a measurement of the total thyroxine in the serum, including both the physiologically active (free) form, and the inactive form bound to thyroxine-binding globulin (TBG). It is increased in hyperthyroidism and in euthyroid states characterized by increased TBG (See "T3 uptake," above, and "FTI," below). Occasionally,

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hyperthyroidism will not be manifested by elevation of T4 (free or total), but only by elevation of T3 (triiodothyronine). Therefore, if thyrotoxicosis is clinically suspect, and T4 and FTI are normal, the test "T3-RIA" is recommended (this is not the same test as "T3 uptake," which has nothing to do with the amount of T3 in the patient's serum). T4 is decreased in hypothyroidism and in euthyroid states characterized by decreased TBG. A separate test for "T4" is available, but it is not usually necessary for the diagnosis of functional thyroid disorders. FTI (T7) This is a convenient parameter with mathematically accounts for the reciprocal effects of T4 and T3 uptake to give a single figure which correlates with free T4. Therefore, increased FTI is seen in hyperthyroidism, and decreased FTI is seen in hypothyroidism. Early cases of hyperthyroidism may be expressed only by decreased thyroid stimulation hormone (TSH) with normal FTI. Early cases of hypothyroidism may be expressed only by increased TSH with normal FTI. Currently, the method of choice for screening for both hyper- and hypothyroidism is serum TSH only. Modern methodologies ("ultrasensitive TSH") allow accurate determination of the very low concentrations of TSH at the phyisological cutoff between the normal and hyperthyroid states. ASSESSMENT OF ATHEROSCLEROSIS RISK: Triglycerides, Cholesterol, HDLCholesterol, LDL-Cholesterol, Chol/HDL ratio All of these studies find greatest utility in assessing the risk of atherosclerosis in the patient. Increased risks based on lipid studies are independent of other risk factors, such as cigarette smoking. Total cholesterol has been found to correlate with total and cardiovascular mortality in the 30-50 year age group. Cardiovascular mortality increases 9% for each 10 mg/dL increase in total cholesterol over the baseline value of 180 mg/dL. Approximately 80% of the adult male population has values greater than this, so the use of the median 95% of the population to establish a normal range (as is traditional in lab medicine in general) has no utility for this test. Excess mortality has been shown not to correlate with cholesterol levels in the >50 years age group, probably because of the depressive effects on cholesterol levels expressed by various chronic diseases to which older individuals are prone. HDL-cholesterol is "good" cholesterol, in that risk of cardiovascular disease decreases with increase of HDL. An HDL-cholesterol level of <35 mg/dL is considered a coronary heart disease risk factor independent of the level of total cholesterol. One way to assess risk is to use the total cholesterol/HDL-cholesterol ratio, with lower values indicating lower risk. Triglyceride level is risk factor independent of the cholesterol levels. Triglycerides are important as risk factors only if they are not part of the chylomicron fraction. To make this determination in a hypertriglyceridemic patient, it is necessary to either perform lipoprotein electrophoresis or visually examine an overnight- refrigerated serum sample for the

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presence of a chylomicron layer. The use of lipoprotein electrophoresis for routine assessment of atherosclerosis risk is probably overkill in terms of expense to the patient. LDL-cholesterol (the amount of cholesterol associated with low-density, or beta, lipoprotein) is not an independently measured parameter but is mathematically derived from the parameters detailed above. Some risk- reduction programs use LDL-cholesterol as the primary target parameter for monitoring the success of the program. The "desirable" level for LDL-cholesterol is less than 100 mg/dL. Triglycerides Markedly increased triglycerides (>500 mg/dL) usually indicate a nonfasting patient (i.e., one having consumed any calories within 12-14 hour period prior to specimen collection). If patient is fasting, hypertriglyceridemia is seen in hyperlipoproteinemia types I, IIb, III, IV, and V. Exact classification theoretically requires lipoprotein electrophoresis, but this is not usually necessary to assess a patient's risk to atherosclerosis [See "Assessment of Atherosclerosis Risk," above]. Cholestyramine, corticosteroids, estrogens, ethanol, miconazole (intravenous), oral contraceptives, spironolactone, stress, and high carbohydrate intake are known to increase triglycerides. Decreased serum triglycerides are seen in abetalipoproteinemia, chronic obstructive pulmonary disease, hyperthyroidism, malnutrition, and malabsorption states. RBC (Red Blood Cell) count The RBC count is most useful as raw data for calculation of the erythrocyte indices MCV and MCH [see below]. Decreased RBC is usually seen in anemia of any cause with the possible exception of thalassemia minor, where a mild or borderline anemia is seen with a high or borderline-high RBC. Increased RBC is seen in erythrocytotic states, whether absolute (polycythemia vera, erythrocytosis of chronic hypoxia) or relative (dehydration, stress polycthemia), and in thalassemia minor [see "Hemoglobin," below, for discussion of anemias and erythrocytoses]. HEMOGLOBIN, HEMATOCRIT, MCV (mean corpuscular volume), MCH (mean corpuscular hemoglobin), MCHC (mean corpuscular hemoglobin concentration) Strictly speaking, anemia is defined as a decrease in total body red cell mass. For practical purposes, however, anemia is typically defined as hemoglobin <12.0 g/dL and direct determination of total body RBC mass is almost never used to establish this diagnosis. Anemias are then classed by MCV and MCHC (MCH is usually not helpful) into one of the following categories:
y

Microcytic/hypochromic anemia (decreased MCV, decreased MCHC) o Iron deficiency (common) o Thalassemia (common, except in people of Germanic, Slavonic, Baltic, Native American, Han Chinese, Japanese descent) o Anemia of chronic disease (uncommonly microcytic)

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Sideroblastic anemia (uncommon; acquired forms more often macrocytic) Lead poisoning (uncommon) Hemoglobin E trait or disease (common in Thai, Khmer, Burmese,Malay, Vietnamese, and Bengali groups) Macrocytic/normochromic anemia (increased MCV, normal MCHC) o Folate deficiency (common) o B12 deficiency (common) o Myelodysplastic syndromes (not uncommon, especially in older individuals) o Hypothyroidism (rare) Normochromic/normocytic anemia (normal MCV, normal MCHC) The first step in laboratory workup of this broad class of anemias is a reticulocyte count. Elevated reticulocytes implies a normo-regenerative anemia, while a low or "normal" count implies a hyporegenerative anemia: o Normoregenerative normocytic anemias (appropriate reticulocyte response)  Immunohemolytic anemia  Glucose-6-phosphate dehydrogenase (G6PD) deficiency (common)  Hemoglobin S or C  Hereditary spherocytosis  Microangiopathic hemolytic anemia  Paroxysmal hemoglobinuria o Hyporegenerative normocytic anemias (inadequate reticulocyte response)  Anemia of chronic disease  Anemia of chronic renal failure  Aplastic anemia
o o o

POLYCYTHEMIA Polycythemia is defined as an increase in total body erythrocyte mass. As opposed to the situation with anemias, the physician may directly measure rbc mass using radiolabeling by 51Cr, so as to differentiate polycythemia (absolute erythrocytosis, as seen in polycythemia vera, chronic hypoxia, smoker's polycythemia, ectopic erythropoietin production, methemoglobinemia, and high O2 affinity hemoglobins) from relative erythrocytosis (as seen in stress polycythemia and dehydration). Further details of the work-up of polycythemias are beyond the scope of this monograph. RDW (Red cell Distribution Width) The red cell distribution width is a numerical expression which correlates with the degree of anisocytosis (variation in volume of the population of red cells). Some investigators feel that it is useful in differentiating thalassemia from iron deficiency anemia, but its use in this regard is far from universal acceptance. The RDW may also be useful in monitoring the results of hematinic therapy for iron-deficiency or megaloblastic anemias. As the patient's new, normally-sized cells are produced, the RDW initially increases, but then decreases as the normal cell population gains the majority.

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Platelet count
Thrombocytosis is seen in many inflammatory disorders and myeloproliferative states, as well as in acute or chronic blood loss, hemolytic anemias, carcinomatosis, status post-splenectomy, post- exercise, etc.

Thrombocytopenia is divided pathophysiologically into production defects and consumption defects based on examination of the bone marrow aspirate or biopsy for the presence of megakaryocytes. Production defects are seen in Wiskott-Aldritch syndrome, May-Hegglin anomaly, Bernard-Soulier syndrome, Chediak-Higashi anomaly, Fanconi's syndrome, aplastic anemia (see list of drugs, above), marrow replacement, megaloblastic and severe iron deficiency anemias, uremia, etc. Consumption defects are seen in autoimmune thrombocytopenias (including ITP and systemic lupus), DIC, TTP, congenital hemangiomas, hypersplenism, following massive hemorrhage, and in many severe infections. WBC (White Blood Cell) count The WBC is really a nonparameter, since it simply represents the sum of the counts of granulocytes, lymphocytes, and monocytes per unit volume of whole blood. Automated counters do not distinguish bands from segs; however, it has been shown that if all other hematologic parameters are within normal limits, such a distinction is rarely important. Also, even in the best hands, trying to reliably distinguish bands from segs under the microscope is fraught with reproducibility problems. Discussion concerning a patient's band count probably carries no more scientific weight than a medieval theological argument. Granulocytes Granulocytes include neutrophils (bands and segs), eosinophils, and basophils. In evaluating numerical aberrations of these cells (and of any other leukocytes), one should first determine the absolute count by multiplying the per cent value by the total WBC count. For instance, 2% basophils in a WBC of 6,000/L gives 120 basophils, which is normal. However, 2% basophils in a WBC of 75,000/L gives 1500 basophils/L, which is grossly abnormal and establishes the diagnosis of chronic myelogenous leukemia over that of leukemoid reaction with fairly good accuracy. Neutrophils Neutrophilia is seen in any acute insult to the body, whether infectious or not. Marked neutrophilia (>25,000/L) brings up the problem of hematologic malignancy (leukemia, myelofibrosis) versus reactive leukocytosis, including "leukemoid reactions." Laboratory work-up of this problem may include expert review of the peripheral smear, leukocyte alkaline phosphatase, and cytogenetic analysis of peripheral blood or marrow granulocytes. Without cytogenetic analysis, bone marrrow aspiration and biopsy is of

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limited value and will not by itself establish the diagnosis of chronic myelocytic leukemia versus leukemoid reaction. Smokers tend to have higher granulocyte counts than nonsmokers. The usual increment in total wbc count is 1000/L for each pack per day smoked. Repeated excess of "bands" in a differential count of a healthy patient should alert the physician to the possibility of Pelger-Hut anomaly, the diagnosis of which can be established by expert review of the peripheral smear. The manual band count is so poorly reproducible among observers that it is widely considered a worthless test. A more reproducible hematologic criterion for acute phase reaction is the presence in the smear of any younger forms of the neutrophilic line (metamyelocyte or younger). Neutropenia may be paradoxically seen in certain infections, including typhoid fever, brucellosis, viral illnesses, rickettsioses, and malaria. Other causes include aplastic anemia (see list of drugs above), aleukemic acute leukemias, thyroid disorders, hypopitituitarism, cirrhosis, and Chediak-Higashi syndrome. Eosinophils Eosinophilia is seen in allergic disorders and invasive parasitoses. Other causes include pemphigus, dermatitis herpetiformis, scarlet fever, acute rheumatic fever, various myeloproliferative neoplasms, irradiation, polyarteritis nodosa, rheumatoid arthritis, sarcoidosis, smoking, tuberculosis, coccidioidomycosis, idiopathicallly as an inherited trait, and in the resolution phase of many acute infections. Eosinopenia is seen in the early phase of acute insults, such as shock, major pyogenic infections, trauma, surgery, etc. Drugs producing eosinopenia include corticosteroids, epinephrine, methysergide, niacin, niacinamide, and procainamide. Basophils Basophilia, if absolute (see above) and of marked degree is a great clue to the presence of myeloproliferative disease as opposed to leukemoid reaction. Other causes of basophilia include allergic reactions, chickenpox, ulcerative colitis, myxedema, chronic hemolytic anemias, Hodgkin's disease, and status post-splenectomy. Estrogens, antithyroid drugs, and desipramine may also increase basophils. Basopenia is not generally a clinical problem. Lymphocytes Lymphocytosis is seen in infectious mononucleosis, viral hepatitis, cytomegalovirus infection, other viral infections, pertussis, toxoplasmosis, brucellosis, TB, syphilis, lymphocytic leukemias, and lead, carbon disulfide, tetrachloroethane, and arsenical poisonings. A mature lymphocyte count >7,000/L is an individual over 50 years of age

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is highly suggestive of chronic lymphocytic leukemia (CLL). Drugs increasing the lymphocyte count include aminosalicyclic acid, griseofulvin, haloperidol, levodopa, niacinamide, phenytoin, and mephenytoin. Lymphopenia is characteristic of AIDS. It is also seen in acute infections, Hodgkin's disease, systemic lupus, renal failure, carcinomatosis, and with administration of corticosteroids, lithium, mechlorethamine, methysergide, niacin, and ionizing irradiation. Of all hematopoietic cells lymphocytes are the most sensitive to whole-body irradiation, and their count is the first to fall in radiation sickness. Monocytes Monocytosis is seen in the recovery phase of many acute infections. It is also seen in diseases characterized by chronic granulomatous inflammation (TB, syphilis, brucellosis, Crohn's disease, and sarcoidosis), ulcerative colitis, systemic lupus, rheumatoid arthritis, polyarteritis nodosa, and many hematologic neoplasms. Poisoning by carbon disulfide, phosphorus, and tetrachloroethane, as well as administration of griseofulvin, haloperidol, and methsuximide, may cause monocytosis. Monocytopenia is generally not a clinical problem.

Laboratory Values

Albumin Alkaline phosphatase (Adults: 25-60) Adults > 61 yo: Ammonia Bilirubin, direct Bilirubin, total

3.2 - 5 g/dl 33 - 131 IU/L 51 - 153 IU/L 20 - 70 mcg/dl 0 - 0.3 mg/dl 0.1 - 1.2 mg/dl

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Blood Gases Arterial pH pCO2 pO2 HCO3 O2 Sat % BUN 7.35 - 7.45 35 - 45 70 - 100 19 - 25 90 - 95 7 - 20 mg/dl Complete blood count (CBC) Adults Male Hemoglobin (g/dl) Hematocrit (%) RBC's ( x 106 /ml) RDW (RBC distribution width) MCV MCH MCHC % Platelet count 13.5 - 16.5 41 - 50 4.5 - 5.5 < 14.5 80 - 100 26 - 34 31 - 37 100,000 to 450,000 Female 12.0 - 15.0 36 - 44 4.0 - 4.9 Venous 7.32 - 7.42 38 - 52 28 - 48 19 - 25 40 - 70

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Creatinine kinase (CK) isoenzymes CK-BB CK-MB (cardiac) CK-MM Creatine phosphokinase (CPK) Creatinine (mg/dl) Electrolytes Calcium Calcium, ionized Chloride Magnesium Phosphate Potassium Sodium 8.8 - 10.3 mg/dL 2.24 - 2.46 meq/L 95 - 107 mEq/L 1.6 - 2.4 mEq/L 2.5 - 4.5 mg/dL 3.5 - 5.2 mEq/L 135 - 147 mEq/L 0% 0 - 3.9% 96 - 100% 8 - 150 IU/L 0.5 - 1.4

Ferritin (ng/ml) Folate (ng/dl) Glucose, fasting (mg/dl)

13 - 300 3.6 - 20 60 - 110

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Glucose (2 hours postprandial) (mg/dl) Hemoglobin A1c Iron (mcg/dl) Lactic acid (meq/L) LDH (lactic dehydrogenase) Lipoproteins and triglycerides Cholesterol, total HDL cholesterol LDL cholesterol Triglycerides

Up to 140 6-8 65 - 150 0.7 - 2.1 56 - 194 IU/L

< 200 mg/dl 30 - 70 mg/dl 65 - 180 mg/dl 45 - 155 mg/dl (< 160)

Osmolality SGOT (AST) SGPT (ALT) Thyroid Function tests Free T3 Serum T3 Free T4

289 - 308 mOsm/kg < 35 IU/L (20-48) <35 IU/L

2.3-4.2 pg/ml 70-200 ng/dl 0.5-2.1 ng/dl

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Serum T4 TSH Total iron binding capacity (TIBC) Transferrin Uric acid (male) (female) WBC + differential WBC (cells/ml) Segmented neutrophils Band forms Basophils Eosinophils lymphocytes Monocytes

4.0-12.0 mcg/dl 0.25-4.30 microunits/ml 250 - 420 mcg/dl > 200 mg/dl 2.0 - 8.0 mg/dl 2.0 - 7.5 mg/dl

4,500 - 10,000 54 - 62% 3 - 5% (above 8% indicates left shift) 0 - 1 (0 - 0.75%) 0 - 3 (1 - 3%) 24 - 44 (25 - 33%) 3 - 6 (3 - 7%)

LIVER FUNCTION TESTS Liver function tests (LFTs or LFs), are groups of clinical biochemistry laboratory blood assays designed to give information about the state of a patient's liver.[1] The parameters measured include PT/INR, aPTT, albumin, billirubin(direct and indirect) and others. (According to some, liver transaminases(AST/ALT (SGOT/SGPT)) are NOT liver function tests but are biomarkers of liver injury in a patient with some degree of intact liver function.[citation needed] Other sources include transaminases.) Most liver diseases cause only mild symptoms initially, but it is vital that

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these diseases be detected early. Hepatic (liver) involvement in some diseases can be of crucial importance. This testing is performed by a medical technologist on a patient's serum or plasma sample obtained by phlebotomy. Some tests are associated with functionality (e.g., albumin); some with cellular integrity (e.g., transaminase) and some with conditions linked to the biliary tract (gamma-glutamyl transferase and alkaline phosphatase). Several biochemical tests are useful in the evaluation and management of patients with hepatic dysfunction. These tests can be used to (1) detect the presence of liver disease, (2) distinguish among different types of liver disorders, (3) gauge the extent of known liver damage, and (4) follow the response to treatment. Some or all of these measurements are also carried out (usually about twice a year for routine cases) on those individuals taking certain medications- anticonvulsants are a notable example- in order to ensure that the medications are not damaging the person's liver.

Standard liver panel This section is missing citations or needs footnotes. Please help add inline citations to guard against copyright violations and factual inaccuracies. (November 2008) Albumin (Alb) Albumin is a protein made specifically by the liver, and can be measured cheaply and easily. It is the main constituent of total protein; the remaining fraction is called globulin (including the immunoglobulins). Albumin levels are decreased in chronic liver disease, such as cirrhosis. It is also decreased in nephrotic syndrome, where it is lost through the urine. Poor nutrition or states of impaired protein catabolism, such as in Mntrier's disease, may also lead to hypoalbuminaemia. The half-life of albumin is approximately 20 days. Albumin is not considered to be an especially useful marker of liver synthetic function; coagulation factors (see below) are much more sensitive Alanine transaminase (ALT) Alanine transaminase (ALT), also called Serum Glutamic Pyruvate Transaminase (SGPT) or Alanine aminotransferase (ALAT) is an enzyme present in hepatocytes (liver cells). When a cell is damaged, it leaks this enzyme into the blood, where it is measured. ALT rises dramatically in acute liver damage, such as viral hepatitis or paracetamol (acetaminophen) overdose. Elevations are often measured in multiples of the upper limit of normal (ULN). Aspartate transaminase (AST) Aspartate transaminase (AST) also called Serum Glutamic Oxaloacetic Transaminase (SGOT) or aspartate aminotransferase (ASAT) is similar to ALT in that it is another enzyme associated with liver parenchymal cells. It is raised in acute liver damage, but is also present in red blood cells, and cardiac and skeletal muscle and is therefore not specific to the liver. The ratio of AST to

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ALT is sometimes useful in differentiating between causes of liver damage. Elevated AST levels are not specific for liver damage, and AST has also been used as a cardiac marker. Alkaline phosphatase (ALP) Alkaline phosphatase (ALP) is an enzyme in the cells lining the biliary ducts of the liver. ALP levels in plasma will rise with large bile duct obstruction, intrahepatic cholestasis or infiltrative diseases of the liver. ALP is also present in bone and placental tissue, so it is higher in growing children (as their bones are being remodelled) and elderly patients with Paget's disease. Total bilirubin (TBIL) Bilirubin is a breakdown product of haem (a part of haemoglobin in red blood cells). The liver is responsible for clearing the blood of bilirubin. It does this by the following mechanism: Bilirubin is taken up into hepatocytes, conjugated (modified to make it water-soluble), and secreted into the bile, which is excreted into the intestine. Increased total bilirubin causes jaundice, and can signal a number of problems:
y y

1. Prehepatic: Increased bilirubin production. This can be due to a number of causes, including hemolytic anemias and internal hemorrhage. 2. Hepatic: Problems with the liver, which are reflected as deficiencies in bilirubin metabolism (e.g., reduced hepatocyte uptake, impaired conjugation of bilirubin, and reduced hepatocyte secretion of bilirubin). Some examples would be cirrhosis and viral hepatitis. 3. Posthepatic: Obstruction of the bile ducts, reflected as deficiencies in bilirubin excretion. (Obstruction can be located either within the liver or in the bile duct).

Direct bilirubin (Conjugated Bilirubin) The diagnosis is narrowed down further by looking at the levels of direct bilirubin.
y

If direct (i.e. conjugated) bilirubin is normal, then the problem is an excess of unconjugated bilirubin, and the location of the problem is upstream of bilirubin excretion. Hemolysis, viral hepatitis, or cirrhosis can be suspected. If direct bilirubin is elevated, then the liver is conjugating bilirubin normally, but is not able to excrete it. Bile duct obstruction by gallstones or cancer should be suspected.

Gamma glutamyl transpeptidase (GGT) Although reasonably specific to the liver and a more sensitive marker for cholestatic damage than ALP, Gamma glutamyl transpeptidase (GGT) may be elevated with even minor, sub-clinical levels of liver dysfunction. It can also be helpful in identifying the cause of an isolated elevation in ALP. (GGT is raised in chronic alcohol toxicity).

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5' Nucleotidase (5'NTD) 5' Nucleotidase is another test specific for cholestasis or damage to the intra or extrahepatic biliary system, and in some laboratories, is used as a substitute for GGT for ascertaining whether an elevated ALP is of biliary or extra-biliary origin. Coagulation test (e.g., INR) The liver is responsible for the production of coagulation factors. The international normalized ratio (INR) measures the speed of a particular pathway of coagulation, comparing it to normal. Increased levels of INR means that it is taking longer than usual for blood to clot. The INR will be increased only if the liver is so damaged that synthesis of vitamin K-dependent coagulation factors has been impaired; it is not a sensitive measure of liver function. It is very important to normalize the INR before operating on people with liver problems (usually by transfusion with blood plasma containing the deficient factors) as they could bleed excessively. Serum glucose (BG, Glu) The liver's ability to produce glucose (gluconeogenesis) is usually the last function to be lost in the setting of fulminant liver failure. Lactate dehydrogenase (LDH) Lactate dehydrogenase is an enzyme found in many body tissues, including the liver. Elevated levels of LDH may indicate liver damage. RENAL FUNCTION TESTS Renal function, in nephrology, is an indication of the state of the kidney and its role in renal physiology. Glomerular filtration rate (GFR) describes the flow rate of filtered fluid through the kidney. Creatinine clearance rate (CCr or CrCl) is the volume of blood plasma that is cleared of creatinine per unit time and is a useful measure for approximating the GFR. Creatinine clearance exceeds GFR due to creatinine secretion, which can be blocked by cimetidine. In alternative fashion, overestimation by older serum creatinine methods resulted in an underestimation of creatinine clearance, which provided a less biased estimate of GFR. Both GFR and CCr may be accurately calculated by comparative measurements of substances in the blood and urine, or estimated by formulas using just a blood test result (eGFR and eCCr). The results of these tests are important in assessing the excretory function of the kidneys. For example, grading of chronic renal insufficiency and dosage of drugs that are excreted primarily via urine are based on GFR (or creatinine clearance).

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It is commonly believed to be the amount of liquid filtered out of the blood that gets processed by the kidneys. In physiological terms, these quantities (volumetric blood flow and mass removal) are related only loosely.

Indirect markers Most doctors use the plasma concentrations of the waste substances of creatinine and urea (U), as well as electrolytes (E), to determine renal function. These measures are adequate to determine whether a patient is suffering from kidney disease. However, blood urea nitrogen (BUN) and creatinine will not be raised above the normal range until 60% of total kidney function is lost. Hence, the more accurate Glomerular filtration rate or its approximation of the creatinine clearance is measured whenever renal disease is suspected or careful dosing of nephrotoxic drugs is required. Another prognostic marker for kidney disease is an elevated level of protein in the urine. The most sensitive marker of proteinuria is elevated urine albumin. Persistence presence of more than 30 mg albumin per gram creatinine in the urine is diagnostic of chronic kidney disease (Microalbuminuria is a level of 30299 mg/g; a concentration of albumin in the urine that is not detected by usual urine dipstick methods). Glomerular filtration rate Glomerular filtration rate (GFR) is the volume of fluid filtered from the renal (kidney) glomerular capillaries into the Bowman's capsule per unit time. Central to the physiologic maintenance of GFR is the differential basal tone of the afferent and efferent arterioles (see diagram). Glomerular filtration rate (GFR) can be calculated by measuring any chemical that has a steady level in the blood, and is freely filtered but neither reabsorbed nor secreted by the kidneys. The rate therefore measured is the quantity of the substance in the urine that originated from a calculable volume of blood. Relating this principle to the below equation - for the substance used, the product of urine concentration and urine flow equals the mass of substance excreted during the time that urine has been collected. This mass equals the mass filtered at the glomerulus as nothing is added or removed in the nephron. Dividing this mass by the plasma concentration gives the volume of plasma which the mass must have originally come from, and thus the volume of plasma fluid that has entered the bowman's capsule within the aforementioned period of time. The GFR is typically recorded in units of volume per time, e.g., milliliters per minute ml/min. Compare to filtration fraction.

There are several different techniques used to calculate or estimate the glomerular filtration rate (GFR or eGFR).

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Measurement using inulin The GFR can be determined by injecting inulin into the plasma. Since inulin is neither reabsorbed nor secreted by the kidney after glomerular filtration, its rate of excretion is directly proportional to the rate of filtration of water and solutes across the glomerular filter. Compared to the MDRD formula, the inulin clearance slightly overestimates the glomerular function. In early stage renal disease, the inulin clearance may remain normal due to hyperfiltration in the remaining nephrons. Incomplete urine collection is an important source of error in inulin clearance measurement. Pressure Definition More precisely, GFR is the fluid flow rate between the glomerular capillaries and the Bowman's capsule:

[4][

Where:

y y y y y y

is the GFR. Kf is called the filtration constant and is defined as the product of the hydraulic conductivity and the surface area of the glomerular capillaries. PG is the hydrostatic pressure within the glomerular capillaries. PB is the hydrostatic pressure within the Bowman's capsule. G is the colloid osmotic pressure within the glomerular capillaries. and B is the colloid osmotic pressure within the Bowman's capsule.

Kf Because this constant is a measurement of hydraulic conductivity multiplied by the capillary surface area, it is almost impossible to measure physically. However, it can be determined experimentally. Methods of determining the GFR are listed in the above and below sections and it is clear from our equation that Kf can be found by dividing the experimental GFR by the net filtration pressure:

PG The hydrostatic pressure within the glomerular capillaries is determined by the pressure difference between the fluid entering immediately from the afferent arteriole and leaving through the efferent arteriole. The pressure difference is approximated by the product of the

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total resistance of the respective arteriole and the flux of blood through it:

Where:
y y y y y y

Pa is the afferent arteriole pressure. Pe is the efferent arteriole pressure. Ra is the afferent arteriole resistance. Re is the efferent arteriole resistance. Qa is the afferent arteriole flux. And, Qe is the efferent arteriole flux.

PB The pressure in the Bowman's capsule and proximal tubule can be determined by the difference between the pressure in the Bowman's capsule and the descending tubule:

Where:
y y
G

Pd is the pressure in the descending tubule. And, Rd is the resistance of the descending tubule.

Blood plasma has a good many proteins in it and they exert an inward directed force called the colloid osmotic pressure on the water in hypotonic solutions across a membrane, i.e., in the Bowman's capsule. Because plasma proteins are virtually incapable of escaping the glomerular capillaries, this oncotic pressure is defined, simply, by the ideal gas law: G = RTc Where:
y y y

R is the universal gas constant T is the temperature. And, c is concentration in mol/L of plasma proteins (remember the solutes can freely diffuse through the glomerular capsule).
B

This value is almost always taken to be equal to zero because, in a healthy nephron, there should be no proteins in the Bowman's Capsule. Creatinine-based approximations of GFR

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In clinical practice, however, creatinine clearance or estimates of creatinine clearance based on the serum creatinine level are used to measure GFR. Creatinine is produced naturally by the body (creatinine is a break-down product of creatine phosphate, which is found in muscle). It is freely filtered by the glomerulus, but also actively secreted by the peritubular capillaries in very small amounts such that creatinine clearance overestimates actual GFR by 10-20%. This margin of error is acceptable, considering the ease with which creatinine clearance is measured. Unlike precise GFR measurements involving constant infusions of inulin, creatinine is already at a steady-state concentration in the blood, and so measuring creatinine clearance is much less cumbersome. However, creatinine estimates of GFR have their limitations. All of the estimating equations depend on a prediction of the 24-hour creatinine excretion rate, which is a function of muscle mass. One of the equations, the Cockcroft and Gault equation (see below) does not correct for race, and it is known that African Americans, for example, both men and women, have a higher amount of muscle mass than Caucasians; hence, African Americans will have a higher serum creatinine level at any level of creatinine clearance. A common mistake made when just looking at serum creatinine is the failure to account for muscle mass. Hence, an older woman with a serum creatinine of 1.4 may actually have a moderately severe degree of renal insufficiency, whereas a young muscular male, in particular if African American, can have a normal level of renal function at this serum creatinine level. Creatinine-based equations should be used with caution in cachectic patients and patients with cirrhosis. They often have very low muscle mass and a much lower creatinine excretion rate than predicted by the equations below, such that a cirrhotic patient with a serum creatinine of 0.9 may have a moderately severe degree of renal insufficiency. Creatinine Clearance CCr One method of determining GFR from creatinine is to collect urine (usually for 24-hours) to determine the amount of creatinine that was removed from the blood over a given time interval. If one removes, say, 1440 mg in 24 hours, this is equivalent to removing 1 mg/min. If the blood concentration is 0.01 mg/mL (1 mg/dL), then one can say that 100 mL/min of blood is being "cleared" of creatinine, since, to get 1 mg of creatinine, 100 mL of blood containing 0.01 mg/mL would need to have been cleared. Creatinine clearance (CCr) is calculated from the creatinine concentration in the collected urine sample (UCr), urine flow rate (V), and the plasma concentration (PCr). Since the product of urine concentration and urine flow rate yields creatinine excretion rate, which is the rate of removal from the blood, creatinine clearance is calculated as removal rate per min (UCrV) divided by the plasma creatinine concentration. This is commonly represented mathematically as

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The common procedure involves undertaking a 24-hour urine collection, from empty-bladder one morning to the contents of the bladder the following morning, with a comparative blood test then taken. The urinary flow rate is still calculated per minute, hence:

To allow comparison of results between people of different sizes, the CCr is often corrected for the body surface area (BSA) and expressed compared to the average sized man as mL/min/1.73 m2. While most adults have a BSA that approaches 1.7 (1.6-1.9), extremely obese or slim patients should have their CCr corrected for their actual BSA.

. BSA can be calculated on the basis of weight and height. The creatinine clearance is not widely done any more, due to the difficulty in assuring a complete urine collection. When doing such a determination, to assess the adequacy of a complete collection, one always calculates the amount of creatinine excreted over a 24-hour period. This amount varies with muscle mass, and is higher in young people vs. old, in blacks vs. whites, and in men vs. women. An unexpectedly low or high 24-hour creatinine excretion rate voids the test. Nevertheless, in cases where estimates of creatinine clearance from serum creatinine are unreliable, creatinine clearance remains a useful test. These cases include "estimation of GFR in individuals with variation in dietary intake (vegetarian diet, creatine supplements) or muscle mass (amputation, malnutrition, muscle wasting), since these factors are not specifically taken into account in prediction equations." Estimated values A number of formulae have been devised to estimate GFR or Ccr values on the basis of serum creatinine levels. Estimated creatinine clearance rate (eCCr) using Cockcroft-Gault formula A commonly used surrogate marker for estimate of creatinine clearance is the CockcroftGault formula, which in turn estimates GFR in mL/min: It is named after the scientists who first published the formula, and it employs serum creatinine measurements and a patient's weight to predict the creatinine clearance. The formula, as originally published, is:

This formula expects weight to be measured in kilograms and creatinine to be measured in mg/dL, as is standard in the USA. The resulting value is multiplied by a constant of

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0.85 if the patient is female. This formula is useful because the calculations are simple and can often be performed without the aid of a calculator. When serum creatinine is measured in mol/L:

Where Constant is 1.23 for men and 1.04 for women. One interesting feature of the Cockcroft and Gault equation is that it shows how dependent the estimation of CCr is based on age. The age term is (140 - age). This means that a 20-year-old person (140-20 = 120) will have twice the creatinine clearance as an 80-year-old (140-80 = 60) for the same level of serum creatinine (120 is twice as great as 60). The C-G equation also shows that a woman will have a 15% lower creatinine clearance than a man at the same level of serum creatinine. Estimated GFR (eGFR) using Modification of Diet in Renal Disease (MDRD) formula The most recently advocated formula for calculating the GFR is the one that was developed by the Modification of Diet in Renal Disease Study Group. Most laboratories in Australia, and The United Kingdom now calculate and report the MDRD estimated GFR along with creatinine measurements and this forms the basis of Chronic kidney disease#Staging. The adoption of the automatic reporting of MDRD-eGFR has been widely criticised. The most commonly used formula is the "4-variable MDRD," which estimates GFR using four variables: serum creatinine, age, race, and gender The original MDRD used six variables with the additional variables being the blood urea nitrogen and albumin levels. The equations have been validated in patients with chronic kidney disease; however both versions underestimate the GFR in healthy patients with GFRs over 60 mL/min. The equations have not been validated in acute renal failure. Estimated GFR (eGFR) using the CKD-EPI formula The CKD-EPI (Chronic Kidney Disease Epidemiology Collaboration) formula was published in May 2009. It was developed in an effort to create a formula more accurate than the MDRD formula, especially when actual GFR is greater than 60 mL/min per 1.73 m2. Researchers pooled data from multiple studies to develop and validate this new equation. They used 10 studies that included 8254 participants, randomly using 2/3 of the data sets for development and the other 1/3 for internal validation. Sixteen additional studies, which included 3896 participants, were used for external validation. The CKD-EPI equation performed better than the MDRD (Modification of Diet in Renal Disease Study) equation, especially at higher GFR, with less bias and greater accuracy. When looking at NHANES (National Health and Nutrition Examination Survey) data, the median estimated GFR

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was 94.5 mL/min per 1.73 m2 vs. 85.0 mL/min per 1.73 m2, and the prevalence of chronic kidney disease was 11.5% versus 13.1%. The formula CKD-EPI may provide improved cardiovascular risk prediction over the MDRD Study formula in a middle-age population. Estimated GFR (eGFR) using the Mayo Quadratic formula Another estimation tool to calculate GFR is the Mayo Quadratic formula. This formula was developed by Rule et al. in an attempt to better estimate GFR in patients with preserved kidney function. It is well recognized that the MDRD formula tends to underestimate GFR in patients with preserved kidney function. Estimated GFR for children using Schwartz formula In children, the Schwartz formula is used. This employs the serum creatinine (mg/dL), the child's height(cm) and a constant to estimate the glomerular filtration rate:

Where k is a constant that depends on muscle mass, which itself varies with a child's age: In first year of life, for pre-term babies K=0.33 and for full-term infants K=0.45 For infants and children of age 1 to 12 years, K=0.55. The method of selection of the K-constant value has been questioned as being dependent upon the gold-standard of renal function used (i.e., creatinine clearance, inulin clearance, etc.) and also may be dependent upon the urinary flow rate at the time of measurement. In 2009, the formula was updated to use standardized serum creatinine (recommend k=0.413) and additional formulas that allow improved precision were derived if serum cystatin measured in addition to serum creatinine. Importance of calibration of the serum creatinine level and the IDMS standardization effort One problem with any creatinine-based equation for GFR is that the methods used to assay creatinine in the blood differ widely in their susceptibility to non-specific chromogens, which cause the creatinine value to be overestimated. In particular, the MDRD equation was derived using serum creatinine measurements that had this problem. The NKDEP program in the United States has attempted to solve this problem by trying to get all laboratories to calibrate their measures of creatinine to a "gold standard", which in this case is isotope dilution mass spectroscopy (IDMS). At the present time in late 2009 not all labs in the U.S. have changed over to the new system. There are two forms of the MDRD equation that are available, depending on whether or not creatinine was measured by an IDMS-calibrated assay. The CKD-EPI equation is designed to be used with IDMS-calibrated serum creatinine values only.

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Cystatin C Problems with creatinine (varying muscle mass, recent meat ingestion, etc.) have led to evaluation of alternative agents for estimation of GFR. One of these is cystatin C, a ubiquitous protein secreted by most cells in the body (it is an inhibitor of cysteine protease). Cystatin C is freely filtered at the glomerulus. After filtration, Cystatin C is reabsorbed and catabolized by the tubular epithelial cells, with only small amounts excreted in the urine. Cystatin C levels are therefore measured not in the urine, but in the bloodstream. Equations have been developed linking estimated GFR to serum cystatin C levels. Most recently, some proposed equations have combined creatinine and cystatin. Normal ranges The normal range of GFR, adjusted for body surface area, is similar in men and women, and is in the range of 100-130 ml/min/1.73m2. In children, GFR measured by inulin clearance remains close to about 110 ml/min/1.73m2 down to about 2 years of age in both sexes, and then it progressively decreases. After age 40, GFR decreases progressively with age, by about 0.4 - 1.2 mL/min per year. Chronic kidney disease stages Main article: Chronic kidney disease Risk factors for kidney disease include diabetes, high blood pressure, family history, older age, ethnic group and smoking. For most patients, a GFR over 60 mL/min/1.73m2 is adequate. But significant decline of the GFR from a previous test result can be an early indicator of kidney disease requiring medical intervention. The sooner kidney dysfunction is diagnosed and treated the greater odds of preserving remaining nephrons, and preventing the need for dialysis. The severity of chronic kidney disease (CKD) is described by six stages; the most severe three are defined by the MDRD-eGFR value, and first three also depend on whether there is other evidence of kidney disease (e.g., proteinuria): 0) Normal kidney function GFR above 90mL/min/1.73m2 and no proteinuria 1) CKD1 GFR above 90mL/min/1.73m2 with evidence of kidney damage 2) CKD2 (Mild) GFR of 60 to 89 mL/min/1.73m2 with evidence of kidney damage 3) CKD3 (Moderate) GFR of 30 to 59 mL/min/1.73m2 4) CKD4 (Severe) GFR of 15 to 29 mL/min/1.73m2 5) CKD5 Kidney failure - GFR less than 15 mL/min/1.73m2 Some people add CKD5D for those stage 5 patients requiring dialysis; many patients in CKD5 are not yet on dialysis. Note: others add a "T" to patients who have had a transplant regardless of stage.

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Not all clinicians agree with the above classificaiton, suggesting that it may overlabel patients with mildly reduced kidney function, especially the elderly, as having a disease.[28][29] A conference was held in 2009 regarding these controversies by Kidney Disease: Improving Global Outcomes (KDIGO) on CKD: Definition, Classification and Prognosis, gathering data on CKD prognosis to refine the definition and staging of CKD.[30]

PULMONARY FUNCTION TESTS Pulmonary function tests are confusing to many patients. But, as those with heart disease are usually aware of their blood pressure and cholesterol levels, the importance of knowing your numbers as they apply to pulmonary function tests (PFTs) and COPD is commonly overlooked. The National Lung Health Education Program is currently on a mission to encourage patients to be aware of their pulmonary function test results by focusing on their mantra "test your lungs; know your numbers." Their mission also includes increasing the percentage of doctors who use spirometry in general practice, as it is currently reported that only 30% are doing so at this time. Knowing your numbers is just another way for you to be your own patient advocate when it comes to your health. It also gives you a method of comparison to determine how well you are responding to treatment and if your disease is progressing. Purpose of Pulmonary Function Tests In the diagnosis of COPD, pulmonary function tests are performed to assess lung function and determine the degree of damage to the lungs. Along with patient history, lung imaging studies and open lung biopsy, PFTs have become important for doctors in the evaluation of respiratory health. Pulmonary function tests can be used for a number of reasons:
y y y y

Screening for the existence of lung diseases Determining the patient's condition prior to surgery to assess the risk of respiratory complications after surgery. Evaluating the ability for a patient to be weaned from a ventilator Assessing the progression of lung disease and the effectiveness of treatment

Three types of pulmonary function tests are used in the diagnosis of COPD - spirometry testing, diffusion studies and body plethysmography.

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Spirometry Testing The most common of all pulmonary function tests is the spirometry test. It is performed with a hand-held device called a spirometer and can easily be used by patients with the assistance of an experienced technician. It is normally the clinician's first choice when attempting to diagnose a respiratory problem. A convenient, noninvasive procedure, spirometry can be performed in the privacy of your doctor's office or any inpatient or outpatient facility. Spirometry requires the patient, after all air has been expelled, to inhale deeply. This maneuver is then followed by a rapid exhalation so that all the air is exhausted from the lungs. Results of spirometry tests vary, but are based on predicted values of a standardized, healthy population. COPD causes the air in the lungs to be exhaled at a slower rate and in a smaller amount compared to a normal, healthy person. The amount of air in the lungs will not be readily exhaled due to either a physical obstruction (such as with mucus production) or airway narrowing caused by chronic inflammation. Common Terminology of Spirometry Tests Critical in Diagnosing COPD
y y y y

y y y

VC-Vital Capacity - The amount of air that can be forcibly exhaled from your lungs after a full inhalation. FVC-Forced Vital Capacity - The amount of air which can be forcibly exhaled from the lungs after taking the deepest breath possible. FEV1-Forced Expiratory Volume in One Second - The amount of air which can be forcibly exhaled from the lungs in the first second of a forced exhalation. FEV1/FVC-FEV1-Percent (FEV1%) - The ratio of FEV1 to FVC and tells the clinician what percentage of the total amount of air is exhaled from the lungs during the first second of forced exhalation. PEFR Peak Expiratory Flow Rate- Measures if treatment is effective in improving airway diseases such as COPD. FEF-Forced Expiratory Flow - A measure of how much air can be exhaled from the lungs. It is an indicator of large airway obstruction. MVV-Maximal Voluntary Ventilation - A value determined by having the patient inhale and exhale as rapidly and fully as possible in 12 seconds. The results reflect the status of the muscles used for breathing, how stiff the lungs are and if there is any resistance in the airways when breathing. This test tells surgeons how strong a patient's lungs are prior to surgery. If patients demonstrate poor performance on this test, it suggests to the doctor that respiratory complications may occur after surgery.

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What Do the Numbers Mean? Doctors also use spirometry testing to evaluate the severity of COPD. Your test results will be compared with tables of normal values that use variables such as age, gender, body size and race as a method of standardization. With spirometry, test results will usually be measured twice, both before and after you are given a bronchodilator. If there is an improvement in two of three measurements, this means you will respond well to treatment. Although there are a number of systems to choose from, the following is the method recommended by the Global Initiative for Obstructive Lung Disease (GOLD): GOLD Spirometric Criteria for COPD Severity GOLD Spirometric Criteria for COPD Severity I. Mild COPD * FEV1/FVC < 0.7 * FEV1 >/= 80% predicted II. Moderate * FEV1/FVC < 0.7 COPD * 50% </= FEV1 < 80% predicted III. Severe COPD * FEV1/FVC < 0.7 * 30% </= FEV1 < 50% predicted IV. Very * FEV1/FVC < 0.7 Severe COPD * FEV1 < 30% predicted or FEV1 < 50% predicted with chronic respiratory failure At this stage, the patient is probably unaware that lung function is starting to decline

Symptoms during this stage progress, with shortness of breath developing upon exertion.

Shortness of breath becomes worse at this stage and COPD exacerbations are common.

Quality of life at this stage is gravely impaired. COPD exacerbations can be life threatening.

Along with spirometry testing, two other pulmonary function tests are important in the diagnosis of airway disease.

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Diffusion Studies - This PFT tells you how well the oxygen that you breath moves into your bloodstream. Body Plethysmography - A test which determines how much air is present in your lungs when you take a deep breath and how much air is left in your lungs after you exhale as much as you can.

REFERENCE: 1.Ed Uthman[internet]; Texas,August 1994;update[December2009];Laboratory values,available from:www.web2.airmail.net.com. 2. Guardian Lifecare Private Limited[internet];India,August2005;update[August 2009];Kidney Function Tests,available from:www.myhealthguardian.com. 3. American Lung Association of Michigan[internet];America,February 2000;update[March 2011];Pulmonary Function Test,available from: www.getasthmahelp.org. 4.The British Liver Trust[internet];U.K,April 2007;update[July 2011];Liver Function Test,available from: www.britishlivertrust.org.

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