(F3) Clinical Pathology Lecture

Dr. Ayochok :)) Feb 11-12,17-18,20 2014

1

Cases: Clinical Pathology
CASE 1
A 10 year old boy, who recently recovered from a streptococcal
infection, was taken to the doctor with symptoms including, fever, nausea,
and malaise. Physical examination reveals edema around the eyes and the
knees. Blood test reveals a decrease in serum concentration. A routine
urinalysis reveals the following results:
Chemical and physical analysis:
o Color: Yellow
o Blood: Moderate
o Clarity: hazy
o pH: 6.5
o Glucose: Negative
o Protein: 300 mg/dL (increased)
o Bilirubin: Negative
o Urobilinogen: Normal
o Ketones: Negative
o Leukocyte Esterase: Small
o Specific Gravity: 1.015
o Nitrite: Negative

Microscopic Analysis:
o 20-50 RBC/hpf
o 10-20 WBC/hpf
o 2-5 RBC casts/lpf
o 2-5 Granular casts/lpf

What is the significance of a Positive leukocyte esterase?
o A positive leukocyte esterase indicates the presence of
WBCs. These are present due to an inflammation or
infection.
o Leukocyte esterase is used to screen patients with UTI

How could there be a positive leukocyte esterase and a negative
nitrite?
a) Non Gram (-) enteric bacteria present
b) Yeast
c) Inflammation
d) A and C
e) A, B and C
o Usually if LE is positive nitritewould alsoincrease
o Yeast (Candida) and non-gram negative enteric does not have nitrate reductase

What is the significance of the presence of blood along with protein in
the urine?
o If the glomerulus was in some way damaged, its efficacy as a
filter may be compromised. As a result, RBCs, protein, and
other large particles could get into the urine.
o It gives you a clue as to where the damage is, there is a definite glomerular damage
o If your glomerulus is compromised expect proteins to leak out (+ proteinuria)

What disease are the results indicative of?
o ACUTE GLOMERULONEPHRITIS (AGN)(one sequela of strep throat).
The recent streptococcal infection is a cause of
glomerulonephritis. The physical examination of the patient
also indicates an inflammatory disease. This is further
supported by the presence of WBCs in the urine without any
bacteria. The presence of blood along with protein in the
urine suggests that the problem is occuring at the
glomerulus itself.


Correlate the formed element present with the diagnosed disease.

o Swelling of the interstitium due to edema and inflammation
obstructs capillaries and tubules. This may decrease urine flow
which may lead to the formation of casts. Since there is an
abundance of RBCs present in the tubules due to the infection in
the glomerulus, there is a possibility that these RBCs may become
trapped in the cast resulting in a RBC cellular cast.
o The longer urine stays in the kidney the higher the chance of cast formation

_____________________________________________________________________________________________________
CASE 2
A 33-year old woman complains of lower abdominal pain which
she has had for the past day. She left her job as a nurses aide (her second
day on the job) because the pain was so bad. She says the pain began after
she had fallen off a stepstool while getting a bedpan off a top shelf. No one
saw her fall, but she convinced her supervisor that she had an industrial
accident and needed medical attention because of blood in her urine. To
prove it, she brings in a urine specimen.
Physical/chemical analysis:
o Color: red
o Appearance : Clear
o Leukocyte Esterase:negative
o Nitrite: Negative
o pH: 7.0
o Protein: Negative
o Blood: Negative
o Specific Gravity: 1.015
o Ketones, Glucose, Bilirubin: Negative

Microscopic Urinalysis:
o WBC/hpf: <2/hpf
o RBC/hpf: None
o Casts: Occasional hyaline casts (normal)
o Others: few squamous epithelial cells (most commonly seen
but least significant)

How do you correlate the macroscopic and microscopic findings?
o The macroscopic appearance is red, but the test for blood is
negative and there are no RBCs microscopically. It is unlikely
to be rhabdomyolysis. This specimen could be factitious. It
would be a simple matter to have the patient produce
another sample (though she might still be carrying the same
bottle of red food coloring with her). Remember that various
drugs can also produce colored urine. Eating fresh beets can
color the urine red temporarily.

What do you thiink is happening?
o Although cae and concern should be the immediate
response of health care workers to a patient, and historical
findings should be duly noted, remember that patients may
(F3) Clinical Pathology Lecture
Dr. Ayochok :)) Feb 11-12,17-18,20 2014
2

not always be telling you everything, or telling you correctly,
particularly when compensation is being sought.

What kind of variables are pH and protein?
o These measurements represent a quantitative (measured)
variable that is discrete, with a finite number of possible
measurements in the range of 5 to 8 for pH and from 0 to
4+ for protein.
o The other form of quatitative variable is continuous with an
infinite number of possible measurements within a range, as
would be typical for a serum chemistry test such as urea
nitrogen or creatinine. Categorical variables could be
nominal or ordinal. A nominal variable is assigned (not
measured) and could be a demographic characteristic such
as sex or race. An ordinal variable is a ranking, such as mild,
moderate, or severe.

Further history:
A week later she faints on the job and is taken to the emergency
department. No external sign of trauma are noted. Laboratory studies show
negative drugs of abuse screen, normal electrolytes, but serum glucose of
only 24 mg/dL(low). The ER physician orders a plasma C-peptide, which is
low. She is given an intravenous solution containing glucose (D5050) and she
is fine within an hour.

How do you explain this episode?
o If insulin is secreted from islets of Langerhans, C-peptide is
released simultaneously. Thus, the findings suggest
exogenous insulin administration.

Further history:
A week later she comes to the emergency department
complaining of severe abdominal pain for the past 3 days. She also reports
weakness beginning in her hands and feet and moving toward her torso. On
examination she has tachycardia and hypertension. She then experiences a
tonic-clonic seizure. Laboratory studies shownegative drugs of abuse screen.
Her serum glucose is 65 mg/dL. Her urine has a reddish color, but the person
transporting the specimen to the lab noted that it glowed while passing
under an ultraviolet light. The pathologist stated that she can tie these
findings together with an in born error of metabolism, confirmed by
additional testing on the urine.

What is this patients underlying disease, and what abnormal
metabolites were present in her urine?
o Acute intermittent porphyria (AIP) is caused by
porphobilinogen-deaminase gene mutations that have an
autosomal dominant mode of inheritance. Porphyrin
precursors , porphobilinogen (PBG) and amine-levulinic acid
(ALA), accumulate and are excessively excreted in urine.
They are neurotoxins to the CNS and PNS (explains seizure
and weakness).
o Pain and other signs and symptoms are most often
mediated by neuropathy. Autonomic neuropathy can lead
to colicky abdominal pain, vomiting, and constipation.
Cardiovascular effects include hypertension and tachycardia.
Peripheral neuropathy is most often motor, leading to
weakness, often ascending from limbs. CNS problems
include psychiatric manifestations, such as depression,
seizures, and focal neurologic deficits.
o Ingestion of drugs that increase hepatic cytochrome P450
activity includesphenobarbital, sulfonamides, estrogens,
and alcohol. Decreased caloric intake with hypoglycemia
will also induce hepatic ALA synthase activity to increase
PBG and ALA. Increased excretion of porphyrin compounds
leads to dark or even reddish urine (and porphyrins
fluoresce under ultraviolet light).
_______________________________________________________________
CASE 3
A 57 year old man has a routine urinalysis as part of his companys
yearly required physical examination. He has a chronic cough (50 pack/year
smoking history). His only complaints referable to the urinary tract are some
mild dysuria and hesitancy, but he otherwise feels fine. On physical
examination there are no abnormal findings.

Physical anf chemical analysis:
o Color: amber
o Appearance: Hazy
o Leukocyte esterase: Negative
o Nitrite: Negative
o pH: 5.0
o Protein: trace
o Blood: 2+
o Specific Gravity: 1.020
o Ketones: trace
o Glucose, Bilirubin: Negative

Microscopic analysis:
o WBC/hpf: <2/hpf
o RBC/hpf: 10-30/hpf
o Casts: Occasional hyaline casts
o Others: Atypical Urothelial cells present
(urothelial- refers to transitional cells)

What do these findings suggest?
o The atypical urothelial cells suggest the possibility of a
carcinoma. The presence of the RBC's is consistent with
that.
o Might be bladder CA because patient is a smoker

What furhter studies are indicated?
o He should be referred to a urologist, who performs
cystoscopy to look at the bladder urothelium, collect urine
for cytology, and biopsy any suspicious areas. For lesions
that could be higher (ureter, renal pelvis), an IVP and CT
scan can be of use. In this case, a lesion is found in the
urinary bladder and biopsy shows urothelial carcinoma.

What social and environmental history would be important?
o Smokers have an increased risk for urothelial malignancies.
A history of exposure to beta-naphthylamine and analine
dye is also a risk. Persons with chronic
schistosomahaematobiuminfection (Egypt is one endemic
area) may develop squamous cell cancers of the bladder.
_______________________________________________________________
CASE 4
A 48-year-old man has noted increased thirst and urine output,
even getting him up at night, along with mild back pain. On physical
examination he is afebrile, but his blood pressure is 160/100 mmHg. There is
right costovertebral angle tenderness. Family history reveals that his father
died in his early 50s of kidney disease. An abdominal ultrasound
examination shows no hydronephrosis or filling defects, but both his kidneys
are markedly enlarged from numerous large cysts.

(F3) Clinical Pathology Lecture
Dr. Ayochok :)) Feb 11-12,17-18,20 2014
3

Physical/chemical analysis
o Color: Yellow
o Appearnce: Slightly Cloudy
o Leukocyte Esterase: Negative
o Nitrite: Negative
o pH: 6.5
o Protein: 1+
o Blood: 1+
o Specific Gravity: 1.010
o Ketones: Neagive
o Glucose, Bilirubin: Negative

Microscopic Analysis:
o WBC/hpf: <2/hpf
o RBC/hpf: 5-10/hpf
o Casts: none
o Others: Many oxalate crystals

What do the historical findings suggest?
o There is a possible genetic problem in the family. The most
likely diagnosis is Autosomal Dominant polycystic kidney
disease (ADPKD)/ Adult type.

What laboratory tests would be useful?
o Tests for renal function: serum creatinine and BUN,
creatinine clearance can be obtained to determine the level
of renal function that is remaining.
o Main concern is to know if the patients kidney is functioning

If you were to give the patient anti-diuretic hormone (ADH) or if he
didnt drink any water for 12 hours, and then the urinalysis was
repeated and the specific gravity was still measured at 1.010, what
would this suggest?
o The lack of change to a higher specific gravity suggests that
the kidneys have lost their concentrating ability- from renal
failure- though this is still at a stage at which some function
remains, so he has polyuria and nocturia. The fixed specific
gravity at 1.010 results from lack of tubular modification of
the glomerular ultrafiltrate of plasma. His back pain and his
CVA tenderness are likely due to rupture of a cyst or
bleeding into a cyst.
o Isosthenuric- the patient's specific gravity has the same specific gravity as the glomerulus
As the cysts would enlarge, it will have much thinner forms, making it prone to rupture.

Why do you think the kidneys are enlarged?
o ADPKD leads to massive bilateral enlargement of the kidneys
with multiple cysts. The liver may also be cystic. Affected
persons have an increased incidence of intracranial berry
aneurysms.
_______________________________________________________________
CASE 5
Two construction workers manage to dislodge a large boulder
from the path of a new water pipe installation. As the boulder begins rolling,
they suddenly become aware of a pick up truck parked below them at the
bottom of the hill. The boulder smashes through the side window and lands
on the drivers lap. The injured 44-year-old man has multiple contusions from
the blunt trauma to his thighs and lower abdomen. Radiographs reveal no
bony fractures. A paracenthesis yields no blood (no internal bleeding). That
evening in hospital, the injured mans urine output begins to drop.

Physical/chenmical analysis
o Color: yellow-brown
o Appearance: slightly Cloudy
o Leukocyte Esterase: Negative
o Nitrite: Negative
o pH: 7.0
o Protein: trace
o Blood: 3+
o Specific Gravity: 1.010
o Ketones: Negative
o Glucose, Bilirubin: Negative

Microscopic anlaysis:
o WBC/hpf: <2/hpf
o RBC/hpf: 0-1/hpf
o Casts: Occasional hyaline, granular casts
o Other: Squamous andrenal tubular epithelial cells.

How do you explain the macroscopic findings in view of the
microscopic findings in view of the microscopic findings? How does
the history fit with this?
o The urine is brownish and the test for blood is markedly
positive, but there are no RBCs visualized. Perhaps this is
hemoglobinuria or myoglobinuria (the dipstick test for
blood is even more sensitive for myoglobin). The history
suggests a crush injury to soft tissue, including muscle (lower
abdomen and thigh).

What other studies would be of help?
o Laboratory test for serum and urine myoglobin are available
(confirm myoglobinuria). More likely, the patient had serum
chemistries ordered on admission, one of which should have
been creatine kinase (CK) in view of the history (should be
increased).

Explain the appearance of the casts and epithelial cells.
o The damage to the kidney from the excessive myoglobin
excretion leads to acute tubular necrosis.

What are some other causes for this condition?
o Muscle ischemia from lying in one position for a long time
(comatose patient or alcoholic found down),
hyperthermia, cocaine or phencyclidine intoxication.
o May also be due to strenuous exercise
_______________________________________________________________
CASE 6
A 22-year-oldAfrican-American woman is admitted to hospital
because of swelling, of the legs and a weight gain of 4kg (10lbs) over the
past week. She has felt extremely tired for the past month. On physical
examination she is afebrile. Her blood pressure is 145/95 mmHg. A chest
radiograph shows marked pleural effusions.
Physical/ chemical analysis:
o Color: yellow
o Appearance: Cloudy
o Leukocyte esterase: negative
o Nitrite: Negative
o pH: 6.0
o Protein: 3+
o Blood: 2+
o Specific gravity: 1.020
(F3) Clinical Pathology Lecture
Dr. Ayochok :)) Feb 11-12,17-18,20 2014
4

o Ketones: Negative
o Glucose, Bilirubin: Negative

Microscopic analysis:
o WBC/hpf: <5/hpf
o RBC/hpf: 5-10/hpf
o Casts: Many hyaline, WBC, RBC, granular casts
o Other: Mucus, Renal tubular cells

What is suggested by these findings?
o The presence of RBCs, WBCs, and numerous casts suggests
nephritis. The presence of so many elements suggests
severe renal disease from glomerulonephritis.

What are possible underlying disease processes?
o Systemic Lupus Erythematosus should be high on the list.
Other diseases such as membranoproliferatve
glomerulonephritis can give a similar picture.

Serologies:
o Her ANA and anti-dsDNA serologies are positive. Her serum
C4 and C1qcomplement components are decreased. Renal
biopsy can be considered to determine the extent of renal
disease for therapy.
_______________________________________________________________
CASE 7
A 45-year-old man comes to his physician after spending a second
sleepless night with excruciating lower abdominal pain. The pain seemed to
come in waves and was unrelieved by aspirin, tylenol, a six-pack of beer, or
lying or standing in any position. He has not experienced any similar pain
before. When asked to rate the pain on a scale of 0 (no pain at all) to 10
(worst pain ever) he replies, 11. On physical examination there are no
abnormal findings.

His serum creatinine is 1mg/dL, urea nitrogen 12mg/dL, calcium
9mg/dL(high), phosphorus 3 mg/dL (low), and uric acid 5mg/dL. He is
instructed to strain urine over the next 24 hours and collect it into a
container. The urine sample collected has a volume of 1440 mL, with
creatinine of 1440 mg. There are 140 mg of protein. There are 800 mg of
calcium (high). His urine osmolality is 300 mOsm/mLand his plasma
osmolality is 300 mOsm/mL. His serum cystatin C is 1mg/L (one way of
determining GFR).

Physical/chemical analysis:
o Color: Dark Yellow
o Appearance: Cloudy
o Leukocyte Esterase: Negative
o Nitrite: Negative
o pH: 6.0
o Protein: Negative
o Blood: 3+
o Specific gravity: 1.015
o Ketones: Negative
o Glucose, Bilirubin: Neagative

Microscopic analysis:
o WBC/hpf: 2-5/hpf
o RBC/hpf: >100/hpf
o Casts: None
o Other: occasional squamous epithelial cells

There is cloudiness with microscopic hematuria
o Hematuria can be due to numerous causes: inflammation,
trauma, glomerulonephritis, calculi, instrumentation,
neoplasms, etc.

What diagnosis do you suspect?
o The severe pain suggests a renal calculus.

What other studies could be done?
o Radiographic studies. A plain film will demonstrate about
80% of stones (those with calcium). An IVP may show a
filling defect. The urine could be strained to catch a passed
stone so that it could be sent for analysis. Uric acid stones
suggest gout, magnesium, ammonium phosphate stones
suggest urinary tract infection

What is his creatinine clearance, free water clearance, and
calcium/creatinine ratio?
o His creatinine clearance is 100 mL/min, which is normal.
Cr Cl = (urine Cr x urine volume) / (serum Cr x 1440 min)
Cr Cl = (100 mg/dL x 1440 mL) / (1 mg/dL x 1440 min)
Cr Cl = (100/1) mL/min = 100 mL/min
o Another estimate of glomerular filtration rate (GFR) in
ml/min is 100/ serum cystatin C, yielding the same value:
100 ml/min
o Free water clearance is 0
o His calcium/creatinine ratio (normal 20-240 mg/g) is 555.
o Urine Ca/Cr 800 mg/1.44g = 555 mg/g

o Normally, if the serum (plasma) osmolality increases (as with
dehydration), the free water clearance decreases, the ADH
increases, and the urine flow decreases. Drinking a lot of
water ill diminish serum osmolality, increasing free water
clearance through a decrease in ADH with increase in urine
flow. If his urine osmolality is high (>300 mosm/mL) then
excretion of a solute pulling the water with it is likely, such
as glucosuria or hypercalciuria. His high excretion of calcium
with normal serum calcium is consistent with idiopathic
hypercalciuria with calcium-containing urinary calculi.
_______________________________________________________________
CASE 8
A 5 year old boy usually drove his mother crazy by running around
the house all day long, but he has been lethargic for the past 2 weeks. On
physical examination he is afebrile, but there is puffiness around his eyes.
Physical/chemical analysis:
o Color: Yellow
o Appearance:Hazy
o Leukocyte Esterase: Negative
o Nitrite: Negative
o pH: 6.0
o Protein: 4+
o Blood: Negative
o Specific gravity: 1.020
o Ketones: Negative
o Glucose, Bilirubin: Negative

Microscopic analysis:
o WBC/hpf: 1-2/hpf
o RBC/hpf: None
(F3) Clinical Pathology Lecture
Dr. Ayochok :)) Feb 11-12,17-18,20 2014
5

o Casts: None
o Other: occasional oval fat bodies
What key abnormal finding is present? Just what does the dipstick
measure here, and what other test could be done on the urine?
o The protein is markedly positive. The dipstick protein test
uses bromphenol blue, which is more sensitive to albumin
than to globulin. Thus, a semiquantitativesulfosalicylic acid
test, which precipitates all proteins, would be helpful if one
suspected globulins (such as Bence-Jones protein with
myeloma) were present. The presence of proteins other
than albumin would make this a 'non-selective' proteinuria
less likely to be minimal change disease.

What is suggested by the childs physical findings?
o The loosest skin in a child is periorbital, so this is the first
place that edema is often noticed.

What other laboratory test(s) would be helpful?
o A 24 hour urine proteintest would help establish a diagnosis
of nephrotic syndrome. One could get a serum creatinine to
establish that the child's "renal function" is normal. In
reality, obtaining a reliable 24 hour urine sample on a child is
difficult, and depends in large measure on how compulsive
his mother is. Since the amount of creatinine excreted in the
urine is relatively constant for body size ,one could do a
protein/creatinine ratio on what sample was obtained, and a
ratio of 0 to 0.2 is likely to be normal, 0.2 to 2.0 is pathologic
proteinuria, and >2 is nephrotic.
o Hypoalbuminemia (serum albumin) below 2.5 g/dL is often
present with childhood nephrotic syndrome. Hyperlipidemia
with increased serum cholesterol may be present. This lipid
can be taken up into renal tubular cells, which slough and
degenerate to form the oval fat bodies seen microscopically.
o Of course, a blood pressure measurement is part of the
physical examination and an elevated blood pressure would
cast some doubt on presumed diagnosis of nephrotic
syndrome from minimal change disease in a child, as would
an increasing blood urea nitrogen or creatinine, and would
suggest a more serious renal disease.
o Nephrotic syndrome is always secondary to something

What is the diagnosis?
o Nephrotic syndrome. The most likely etiology in this setting
is minimal change disease leading to nephrotic syndrome.
o Minimal change disease- one of the spectrums of disease that would lead to a
nephritic or nephrotic syndrome. It is diagnosed through biopsy of the kidney and
counting the number of glomeruli affected as well as inspecting each glomerulus
to determine the percentage of damage to that particular glomerulus.
_______________________________________________________________

CASE 9

A 23 year old woman has noted an increase in her appetite and
thirst over the past six months, although she has lost 2 kg (5 pounds)/ she
also has had considerable frequency of urine output, without associated
dysuria. On physical examination her vital signs included T: 37 C; PR: 77/min;
RR: 26/min; and BP 120/70 mmHg. A midstream clean catch urine sample is
obtained.

Physical/chemical analysis:
o Color: Yellow
o Appearance: Clear
o Leukocyte Esterase: Negative
o Nitrite: Negative
o pH: 5.5
o Protein: Negative
o Blood: Negative
o Specific gravity: 1.025
o Ketones: 4+
o Glucose: 4+
o Bilirubin: Negative

Microscopic analysis:
o WBC/hpf: None
o RBC/hpf: 1-2/hpf
o Casts: None
o Other: None

What disease is suggested by these findings?
o Diabetes mellitus, Type 1

Will all sugars be detected by the reagent test strip for glucose? Why?
o Only glucose will be detected, because the reagent strip
uses glucose oxidase. Other sugars must be detected by a
test for reducing substances (Benedicts copper reduction
method) which will pick up such sugars as fructose. Sucrose
will NOT be present unless you are a member of the plant
kingdom. Deliberately putting table sugar, which is sucrose,
into urine to make it appear as diabetic urine will NOT work
because it will not be detected by the dipstick.

What is the significance of the positive test for ketones? What would
you suspect if the ketones were positive and everything else was
normal?
o The ketones suggest that insulin is lacking and that in the
diabetic catabolic state adipose tissue is being metabolized
with utilization of fatty acids to produce ketone bodies,
typical of type 1 diabetes mellitus. In the absence of
glucosuria, ketone bodies suggest starvation.

What other test would be helpful?
o Serum glucose. Persons with diabetes mellitus do not use
urine dipsticks to monitor their urine, but use fingerstick
measurements of blood glucose obtained with a portable
meter, and they become very adept at getting accurate
results. Measuring haemoglobin A1C would give an
indication of glucose control over a longer time frame.













(F3) Clinical Pathology Lecture
Dr. Ayochok :)) Feb 11-12,17-18,20 2014
6

I. Renal Function Test Categories:
I. Tests predominantly of glomerular function.
- Clearance test
II. Tests reflecting glomerular damage, tubular damage, or both
- BUN
- creatinine
III. Tests of predominantly tubular function(absorption test and secretion test)
- Specific gravity
- Osmolality
- PSP excretion
- Free water clearance test
_______________________________________________________________
I. Tests predominantly of glomerular function

CLEARANCE TESTS:

- Measures the rate at which the kidneys are able to remove
(clear) a filterable substance from the blood
- Estimate of mild to moderate diffuse glomerular damage (AGN)
- UV/P
U: urine conc. of substance cleared (mg/dL)
V: Urine flow rate (mL/min)
P: Plasma/serum conc. of substance being cleared
(mg/dL)

Features of a good Clearance test (CT):
o Substance neither reabsorbed or secreted by the kidney
o Consistency of its plasma level
o Substance availability in the body
-it is better to use endogenous substances
o Stability of the substance in urine during a 24-hour
collection period/ timed urine specimen
o Availability of the test

A. UREA CT
o Earliest
o Product of Protein Metabolism
o 40% reabsorbed back
o Via passive back diffusion
o Values parallel true GFR at 60%
o Dependent on Urine flow
o <2mL/min: inaccurate values
o Concentration affected by:
diet
diurnal change

B. INULIN CT
o NOT routinely used
o Polymer of fructose
o Stable(consistent in plasma): NOT reabsorbed nor secreted by the
tubules
o Healthy adults:
MEN: 127 mL/min/1.73 m
2

WOMEN: 118 mL/min/1.73 m
2

o Exogenous procedure
o IV infusion, timed urine collection
o Availability, cost

C. RADIONUCLEOTIDE CT
o NO need for urine collection (convenient)
o NOT as accurate as those with urine collection
o Measured plasma disappearance of radioactive material
o I-iothalamate
o Tc-DTPA (diethylenetriaminepenta-acetic acid)
o Allows visualization of filtration
o Exogenous, expensive

D. B2 MACROGLOBULIN CT
o More sensitive and specific than CCT
o Endogenous CT
o Dissociates from human leukocyte Ags at a constant rate
o Rapidly removed from plasma by glomerular filtration
o NOT reliable for patients with immunologic problems,
malignancies(Crea clearance result is expected to be
abnormal).

E. CREATININE CT
o Routinely used
o Endogenous, inexpensive
o Relatively constant level in blood
More constant production rate than urea
o Excretion: by GF (70-80%) and tubular secretion
o Secretion increases as blood levels rise(high serumcrea=high
secretion)
Chromogens in plasma false increase
Disintegration of creatinine by
bacteria if kept at room temperature
-long standing urine would cause proliferation of
bacteria
false decrease

Heavy meat diet false increase
o Not reliable in muscle wasting disorders(affected by muscle mass)
o Incomplete urine collection

Reference value: 90-120 mL/min
Men: 107-139 mL/min
Women: 87-107mL/min
o C=UV/P
U:urine creatinine in mg/dL
V: urine volume in mL/min(if per 24 hours- 1440mins)
P: Plasma creatinine in mg/dL

FORMULAS TO ESTIMATE CCT AS ESTIMATE OF GFR:
1. Cockroft and Gault formula (mL/min)

(140-age) x (IBW)/(72 x SCr), x 0.85 if female

- IBW=50kg+2.3Kg for each inch over 5 ft (males)
- IBW=45.5Kg+2.3Kg for each inch over 5 ft (females)

o Decreases variability of serum creatinine estimates of GFR
due to difference in creatinine production
Differences in muscle mass based on sex and age
o Use in adults

Drawback:
o Does not consider differences in creatinine production due
to variation in muscle mass due to disease
Overestimation of GFR: obese, debilitated
o Does not consider variations due to extrarenal elimination
and tubular secretion.

2. MDRD formula (mL/min/1.73m
3
)
o 6 variables:
Age
Race
Sex
BUN
Serum creatinine
Albumin

GFR=170x Cr
-0.999
x age
-0.176
x (0.762 if female)x(1.180 if black)x BUN
-0.170
x alb
0.318


o Simplified formula: 4 variables
Creatinine
Age
Race
Sex

GFR=186.3xCr
-1.164
x age
-0.203
x1.212 (for black) x 0.742 (for women)
-Does not include body weight


(F3) Clinical Pathology Lecture
Dr. Ayochok :)) Feb 11-12,17-18,20 2014
7

3. Creatinine clearance in Children:
a. Schwartz formula:
o GFR=0.55xheight (cm)/SCr (mg/dL)
o GFR=43xheight (cm)/SCr (umol/L)
b. Modified Counahan Barrett formula
o GFR=40xheight (cm)/SCr (umol/L)

DETERMINE EXTENT OF NEPHRON DAMAGE IN A KNOWN CASE OF RENAL
DISEASE (CCT)
Mild: 60-80% of NV
Moderate: 40-60% of NV
Sever: 20-40% of NV
In AGN:
- Follow clinical course and monitor effectiveness of treatment
- Determine feasibility of administering medications
- Measurement of overall renal function impairment.
______________________________________________________________
II. Tests reflecting glomerular damage, tubular damage, or both

BLOOD UREA NITROGEN
- Main waste product of nitrogen-containing chemicals
- Serum, urine
- Produced in liver (ammonia, amino acid)
- Excreted by the kidney
- Elevation: Azotemia
o High BUN + severe renal damage (s/s) = UREMIA (clinical
azotemia)
- Not specific for intrinsic kidney disease
- Decreased: severe liver disease; late pregnancy
- Widely used as measure of renal dysfunction

Limitations in its use to measure GFR:
1. Conc. in serum depends on renal function and rate of urea
production: depends on CHON intake
2. Freely filtered by glomerulus, but reabsorbed in PCT and inner
medullary collecting ducts (CD).
Amount reabsorbed in PCT: depends on status of
effective vascular volume
Amount reabsorbed in inner medullary CD: depends
on urine flow rate.
For GFR it is better to use CCT than BUN alone; remember that not all
elevations of BUN are reflective of a renal disease
When will you suspect a renal disease? If the creatinine is high, with high
BUN

DISEASES:
A. PRERENALAZOTEMIA:
- Anything that causes decrease blood flow or perfusion to kidneys/
factors that would overwhelm the kidneys
- Traumatic shock (head injuries; postsurgical hypotension)
- Hemorrhagic shock (varices, ulcer, postpartum hemorrhage)
- Severe dehydration or electrolyte loss (vomiting, diarrhea, DKA,
Addisons dse)
- Acute cardiac decomposition
- Infections, toxemia
- Excess intake of protein, extensive protein breakdown.

Etiology of prerenalazotemia:
1. Decreased blood volume/blood flow
Blood volume deficit, heart failure to pump enough
blood, toxic effects on blood vessels
Structural renal damage not necessary
2. Increased CHON intake or endogenous CHON catabolism
High: CHON tube feedings, GIT hemorrhage, low
calorie diet, adrenocortical steroid therapy.

B. RENAL AZOTEMIA
- Intrinsic damage to the kidneys
a. Chronic diffuse bilateral kidney disease (Chronic GN, bilateral
chronic Pyelonephritis)
b. ATN (Acute tubularnecrosis)
Due to hypotension/shock
Rhabdomyolysis
transfusion reactions
Precipitation of uric acid/sulfa crystals in tubules
c. Severe Acute glomerular damage (AGN)

C. POSTRENALAZOTEMIA
- Ureteral /Urethral obstruction
Strictures
stones, pelvic
tumors
- Obstructing tumors of UB; congenital defects in UB or Urethra
- Prostatic Obstruction
Tumor
BPH

CREATININE
- Muscle metabolism
- Standard clearance test
- Synthesized from creatine and creatinePO4 via non-enzymatic
dehydration process.
- Rate of production dependent on body muscle mass
- Increase after meals; diurnal variation (lowest at 7am, peak at
7pm)true value of Creatinine: test should be done in am
- Significant increase: suggest chronicity of renal damage (but must be
interpreted in conjunction with an elevated BUN value)
- In a renal patient: BUN increases earlier than creatinine
- Increase: some significance with BUN, but rises later
- BUN/crea ratio: 10:1(20:1)

Most widely used marker of GFR: (CT >BUN)
1. Endogenous substance of fairly constant rate of
production(amount in plasma is stable)
2. Not bound to plasma CHONs, thereby freely filtered by
glomerulus
-approximate GFR: 80%; BUN GFR: 60%
3. Not reabsorbed by renal tubules; only a small amount is secreted
by tubules.

DRAWBACKS OF CREATININE AS A MEASURE OF GFR:
- Substantial individual variation, depending mainly on muscle
mass.
o Severe muscle wasting: creatinine decreased to 25%
of value predicted from body weight
- Also derived from dietary meat
- Assayed MC by alkaline picrate method
o Endogenous and exogenous chromogens: interfere
with results(false elevation)
o Ketones, glucose, fructose, CHON, urea, ascorbic
acid(false elevation)
- Partial tubular secretion blocked by certain drugs: (false elevation)
Cimetidine
Pyrimethamine
Trimethoprim
Salicylate

TUBULAR REABSORPTION TEST:
- 1
ST
FUNCTION affected by renal disease
- LAST function to be lost
- Important in differentiating prerenalazotemia from renal failure
o When will the test be abnormal? Prerenal or renal failure?
o If pt is in shock vs blood transfusion reaction- the latter would have an abnormal result
___________________________________________________________________________________
III. Tests of predominantly tubular function

CONCENTRATION TESTS:
- Determine the ability of the tubules to reabsorb essential salts
and water filtered by the glomerulus

URINE SPECIFIC GRAVITY:
- determines the concentrating ability of tubules
After GF: 1.010
After TR: higher, more concentrated
-Initial filtrate SG 1.010 (iso) after tubular reabsorption the Sp Gravity of filtrate should
increase due to reabsorption
-NV: 1.015-1.025
(F3) Clinical Pathology Lecture
Dr. Ayochok :)) Feb 11-12,17-18,20 2014
8

a) Fishberg concentration test:
- Sp. Gravity after 24-hr H2O deprivation
-N: expect it to increase
b) Mosenthal concentration test:
- Compares volume and specific gravity of day and night
urine samples
-urine sample taken at night should have a higher SG
-Higher volume -during the day
- Normally: sp. Gravity of 1.025 after water deprivation of
16 hours.

FREE WATER CLEARANCE TEST:
- Assesses reabsorption of fluid and electrolytes with formation of
free water
- Measures osmolar clearance
Amount of water to be cleared each minute to
produce urine with same osmolarity as plasma
- Determines ability of tubules to respond to state of hydration
-2: dehydration
0: no renal concentration/ dilution


Free water clearance:
Clearance (osm)=U(osm) x V/P(osm)
Subtract Clearance (osm) from urine volume [V-Cosm]
- Reference range: -20 to -100
- ATN/CRF (Acute tubular necrosis or chronic renal failure):
near 0 or (+)
- Needs accurately timed urine collection
- Interference by diuretics
Loop diuretics: block reabsorption of NaCl: urine
isotonic with little free water or negative free
water
Mask a sick kidney? Will it worsen a truly normal kidney?

SPECIFIC GRAVITY
- Simple, readily available
- NV: 1.025 (1.015 to 1.035)
- Does not measure dissolved substances
- Early chronic diffused bilateral kidney disease
- Monitor course of illness
useful in pts with known renal disease

- Monitor electrolyte and fluid therapy
To be accurate: deprive patient of H2O (16-17 hours)
10 gm CHON: rise in sp g by 0.003
1% glucose: rise in spg by 0.004
Contrast media for IVP: increase sp g
Urine at ref temp (2-8^c): decrease in sp g

Isosthenuric (1.010)
urine has the same specific gravity as initial filtrate

- Occurs in advance of final renal decompensation

Fixation of sp g:
- Manifested by nocturia
frequent urination during the night

- Reversal or decrease in day/ night urine excretion ratio to 1:1
(N 3:1 or 4:1)
Other causes to be considered:
- Diabetes insipidus
- Diuretic phase of ATN
- Hyperthyroidism
- Severe salt restricted diets
- Sickle cell anemia
OSMOLALITY
- Best quantitative measurement of renal concentratingability
- Urea, Na, Cl
Plasma Osmolality = 2 x [ Na + K ] + Urea
24 hr.Urine Osmolality: Osmol excreted/day
V (liters)
- Osmometers:
based on freezing point

- NV: 800-1300 m0sm/L (after 14 hr period of dehydration);
275-300 m0sm/L (serum);
24 hour: 500-800 m0sm/kg water;
Random: 50- 1400 m0sm/Kg water
- Normal urine: serum osm; 1:1 to 3:1

Uses of osmolality
- Initial evaluation of renal concentrating ability
- Monitor course of renal disease
- Monitor fluid and electrolyte therapy
- Secretion and renal response to ADH:
Failure to respond: renal defect
Response: production defectpositive response:defect in higher center
Hyperosmolality
- Excessive water loss
- Inadequate water replacement


Hypoosmolality
- Increased water intake with or without an increased solute load
- Plasma osmolality:
Osmolality (calc)= 2 x Na + glucose + urea
**if all measurement in mmol/L (SI)

Osmolality (calc)= 2 x Na + glucose/18 + urea/2.8
**if measurements are in mg/dL(MC used for conventional units)
Given:
- Plasma Na= 123 mEq/L
- Glucose = 98 mg/dL
- Urea= 22 mg/dL
- Compute for plasma osmolality

Answer: 259.301 mosm/Kg
(Below reference range: 275-300 m0sm/L)

-Effective osmolality:refers to overall effect of sodiumto ECF tonicity, which is primarily
influenced by sodium

EO (calc)= 2 x Na + glucose
**if all measurements in mmol/L (SI)

Osmolality (calc)= 2 x Na + glucose /18
**if measurements are in mg/dL
<275: hyponatremia
true hypo vs artifactualhyponatremia

Given:
- Plasma Na= 123 mEq/L
- Glucose= 98 mg/dL
- Urea= 22 mg/dL
Osmolality= 2(123) + (98/18)
Answer: Osmolality= 251.44

TUBULAR SECRETION TESTS:
Important: use a substance completely removed from the blood
(plasma) by peritubular capillaries (located in the cortex of the kidneys- similar to vasa
recta in medulla of kidney)
- Measures blood flow (q) through the nephron
- Abnormal result
Impaired tubular secretory activity
Decreased renal blood flow (q)
P-AMINOHIPPURIC TEST
- Non-toxic, high MW substance,
exogenous substance

- Does not bind strongly to plasma proteins
- Permits complete removal
- NV: 600-700 mL/min
Average renal q: 1200 mL/min

TITRATABLE ACIDITY AND URINARY AMMONIA
- Measure PCT (H+ secretion) and DCT (NH4+) functions
- NV: 70 mEq/day
Alkaline tides: after rising, postprandial (2pm.
8pm)
Lowest pH: night time
- Significance:
RTA/ renatubular acidosis: inability to produce
an acid urine in the presence of metabolic
acidosis


(F3) Clinical Pathology Lecture
Dr. Ayochok :)) Feb 11-12,17-18,20 2014
9

Patient:
o Primed with an acid load (oral NH4+Cl)
o Fresh urine collected (2hr intervals)
o [NH4+]= total acidity titratable acidity
Titratable acidity: [H+]
______________________________________________________________

II. Water Balance:
- Body has an influence on the Extracellular fluid
Which Part of the body has an influence in ECF and tonicity?
1. Thirst center
2. ADH effect on collecting tubules
3. RAA system

2 Disorders regarding water content:
1. Dehydration - decreased amount
o Causes:
Diarrhea
Vomiting
Fever
Diuretic use if not monitored could lead
to DHN
Excessive sweating/ profuse sweating
2. Overhydration - excessive

2 Renal function test: BUN and creatinine
Not all elevation would indicate a renal disease
BUN = creatinine: parallel elevation may be indicative of a
kidney disease
BUN > creatinine : Lab abnormality could lead you to
investigate dehydration

How would you diagnose DHN?
It is a clinical diagnosis NEVER a laboratory diagnosis

Urine: serum osmolality ratio is usually more than 1 (n 1:1, 3:1)
Addison's disease:
Problem: Dehydration
Volume overload:
- There is an increased in total body tonicity specifically sodium
Seen in the ff conditions:
o SIADH
o CHF
o Nephrotic Conn's disease
o syndrome ( + edema)
o Cirrhosis
- Elevated aldosterone or ADH and elevation of total body water
o SIADH
o Pleural effusion
o Ascites

Diagnosis of volume overload: clinical diagnosis ;))
_______________________________________________________________

III. Electrolytes
ECF and ICF
ECF:
o Sodium - major cation
o Chloride - major anion
o bicarbonate
ICF:
o potassium- major cation
*Express electrolytes: either in mmol/ L or mEq/L
_______________________________________________________________
EXTRACELLULAR FLUID
Sodium
- Principal osmotic particle outside the cell
- Major ECF cation
- In the Kidney- it is reabsorbed up to 70%
- Reference range: 135-145 mmol/L

Abnormalities:
A.HYPONATREMIA
1. Sodium loss with water excess:
Sodium (solute) and water (solvent)
Serum Osmolality: decreased
2 Subdivisions:
a) Renal:
Adrenal insufficiency
Ketonuria with accompanying hyponatremia
Urinary sodium: Below 20 mmol/L
b) Extrarenal:
Vomiting/ diarrhea
Peritonitis- third space loses
Burns
Urinary sodium: less than 10 mmol/L
**Measure urinary sodium to differentiate renal form extrarenal

Symptoms of hyponatremia:
o Ex. History of prolonged diuretic use: patient would
present with:
Musculoskeletal: muscle cramps, weakness
and fatigue, slow to movement and thinking
Neurologic: Changes in behavior, change in
mentation, may not be oriented/
disoriented
Rate of decrease: Gradual or sudden fall of
sodium is said to be directly proportional to
the severity of symptoms
Ex:
Over days and weeks- gradual
increase in Fatigue, muscle cramps,
lassitude etc.
With in Hours- severe
disorientation, confusion,
convulsions and coma

2. Hyponatremia with excessive total body water
Example:
Nephrotic syndrome
Cirrhosis
CHF
renal failure (both acute and chronic)
o Actual body sodium is increased
o Hyponatremia- because there is greater excess fluid
(water is even greater)
o Urinary sodium
Low: less than 10 mmol/ L except for renal
failure, which may be above 20 mmOl/L

3. Hyponatremia with euvolemia
o Euvolemia: No visible increase in ECF volume
Ex:Inhyponatremia with glucocorticoid
deficiency
Free water excretion tends to be
inhibited
No apparent increase in ECF volume
o Endocrine disorder:
Hypothyroidism - High level ADH secretion;
inability to dilute urine maximally
SIADH
Continuously secreting ADH despite
a decrease plasma osmolality (more
of a condition rather than a disease)
usually accompanying a disease
(F3) Clinical Pathology Lecture
Dr. Ayochok :)) Feb 11-12,17-18,20 2014
10

Pt in extreme pain may have SIADH?
Yes. Such as in Appendicitis or
emotional stress
Delt as a Paraneoplastic
Metabolic CNS disorder Such as
after trauma to head if with seizure
disorder
Brain abscess
COPD
Decreased plasma osmolality - more
of a condition
4. Artifactualhyponatremia
Cause:
Hyperglycemia-there is an increase serum osmolality that
causes a shift of whatever is in ICF to ECF
Relative decrease in serum sodium
Each 100mg increase in blood glucose would cause a 1.6
mmol decrease in serum sodium
Other causes:
o High / increase protein
o Lipemic blood or increased CHON: sodium
concentration will be restricted to water space (Or
where water is available) which is proportionately
decreased by lipid or protein volume
Serum sodium is low
Plasma volume is low
o Displaced or occupied by fat and protein that is why
there is low serum sodium
o We have to be careful because we may treat it as a
true hyponatremia

Treatment: treat underlying cause, if caused by
hyperglycemia, treat the increased sugar, because the
sodium is normal

Psuedohyponatremia
o Serum osmolality: normal

True sodium value for specimen that is lipemic
Ask pt to fast then come back For re-extraction
If Lipemic again -> Centrifuge the specimen

Among the four categories, which will present with a decreased
anion gap secondary to decrease in unmeasured anion?
- Hyponatremia with increased ECF volume
- Mechanism of low anion gap :Kidneyalso excretes unmeasured
anions

High serum sodium/ hypernatremia
Causes:
Excessive loss of water relative to sodium
Really increased amount of body sodium
Hypotonic fluid loss:
Etiology
o Renal
o Extrarenal

Hypotonic fluid loss renal etiology:
Osmotic diuresis - urine osmolality could be low or normal
Urine sodium is above 20 mmoL/L

Extra renal etiology:
Diarrhea
Profuse sweating
Febrile child
Urine osmolality: increased
Urine sodium: Less than 10 mmol/L


B.HYPERNATREMIA

1. Hypernatremia due to water loss ONLY
a. Renal
DI (nephrogenic and Central)
o Central- above the kidney
o Nephrogenic- in the kidney (Insensitive to ADH)
** medulla- responds to ADH
Drugs
o Lithium
Urine osmolality is either normal or low
b. Extrarenal
Urine osmolality- increased
Ex:
Cushings- too much aldosteronism leading
to elevation of sodium that is reabsorbed
Excessive sodium intake- such as sodium
bicarbonate
urinary osmolality is normal or increased
_______________________________________________________________
INTRACELLULAR FLUID
Potassium
- Major intracellular cation
- Total body potassium: 2% extracellular
- Reference range: 3.8-5-5 mmol/L
- Average diet - consume 50-150 mmol of K/ day
Majority Excreted: 90% via kidneys
- Daily urinary excretion:25-125 mmol of K

Abnormalities
A. HYPOKALEMIA
2 forms:
1. Hypokalemia with normal body potassium
- Hypokalemia is secondary to the shift of potassium
from ICF to ECF
Example:
Seen in(Unmonitored) insulin therapy
Periodic paralysis (this is also true for hyperkalemia)
Hypokalemia with periods of
hyperkalemia(intermittent attack "waxing and
waning")
Familial disease: AD pattern
Clinically how will you distinguish
hypokalemia or hyperkalemia?
No difference in clinical
manifestation
Measure serum potassium

2. Hypokalemia with low body potassium
GIT losses: Vomiting and diarrhea
Renal loss of potassium: Diuretics(*except k sparing diuretics)
Metabolic disorders:
RTA (Renal Tubularacidosis)
Metabolic acidosis
Mineralocorticoid excess
** For both type Urinary potassium is above 20 mmol/ L
**Exception: if the loss of potassium is gradual and the etiology is
extrarenal the urinary potassium is below 20 mmol/L

B. HYPERKALEMIA
o Due to shifts or increase in body potassium
o Mineralocorticoid deficiency
o Acute and Chronic Renal failure
o Shifting from ICF to ECF:
Rhabdomyolysis
hemolysis




(F3) Clinical Pathology Lecture
Dr. Ayochok :)) Feb 11-12,17-18,20 2014
11

1. Artifactual hyperkalemia
Reasons:
a) High platelet count
- The k present in platelet is also released
b) Prolonged tourniquet application during venipuncture
-Maximum of 2 minutes
- beyond: leakage due to venular injury causing false
elevation
c) making a fist during venipuncture tomake the vein prominent
d) Hemolyzed specimen
- 105 mmol/L k in RBC
e) Contaminate sample with potassium EDTA
Avoided by: Using plain or yellow top
Vacutainer technique:
-This avoided by rearranging the order of draw, K
specimen first before CBC
_______________________________________________________________

Chloride
- Major extracellular fluid anion
- Referencerange: 98-106 mmol/L
- With normal daily urinary output 110-250mmol/L

Disorders:
A. HYPOCHLORIDEMIA
- Diarrhea and vomiting
- Mineralocorticoid excess
- Chronic salt losing renal disease with hyponatremia
- Hypochloridemia with high serum bicarbonate
- Common in metabolic alkalosis or decompensated
form of renal acidosis due to Intracellular shift of
bicarbonate with increased renal excretion

B. HYPERCHLORIDEMIA
- Mineralocorticoid deficiency
- hyperparathyroidism: indirect effect of PTH to Cl,
influencing the reabsorption of bicarbonate: decreasingPCT
reabsorption of bicarbonate secondarily augment the Cl
reabsorption
- Metabolic acidosis from bicarbonate loss: diarrhea, renal
tubularacidosis
- Ammonium chloride administration
- Exocrine glandular disorder: cystic fibrosis
- Measure chloride in sweat: NV:5-45 mmol/L
Children with CF: above 60 mmol/L
Adults with CF: above 70 mmol/ L
*How do we measure this? We induce sweating by :
iontophoresis
Administer Pilocarpine ID
Ensure Quality control: check chloride and sodium in sweat
*How will you know that the test is right?
- The diff between the sodium and cl should be10
mmol/L of each other, if it exceeds REPEAT test

Bicarbonate (HCO3-)
- Second most important anion
- Dissociation of carbonic acid (H2C03)
- Anion that is freely filtered by the glomerulus
- 85% reabsorbed by proximal tubules
- 15% reabsorbed by distal tubules
- Measured as total C02
- Range of bicarbonate:
Venous-23-30mmol/L
Arterial: 19-25mmol/L
- Excess and deficiency are more appreciated in ascitic disorder
_______________________________________________________________
Anion gap
- Gap: diff between anion and cation
Routine calculation
Cation: na and k
Anion: cl and bicarbonate
Formula:
sodium - (chloride + HCO3)= anion gap

Normal: less than 17 mmol/L
Consider unmeasured:
Unmeasured Cation: calcium and mg:7 mmol/l
Unmeasured Anions: phosphate, sulfate, chon, anions of organic
acids:24 mmol/L

Abnormalities:
HIGH ANION GAP
Value: more than 17 mmol/L
Example:
- DKA
- Starvation
- Too much dieting
- Shock secondary to lactic acidosis
*Anything that would increase the amount of unmeasured anion will lead to an elevation of
anion gap
- Uremia: retention of phosphate and sulfate
- Dehydration: increased plasma protein

LOW ANION GAP
Value: less than 10 mmol/L
Disorders:
A. Decreased unmeasured cations:
1. Multiple myeloma
2. Hypermagnesemia
- Increased unmeasured cation: Mg and Calcium
3. Polyclonalgammopathy- cause a decreased in anion gap
-The gammaglobulins will have a net positive charge at
physiologic PH thus decreasing anion gap
- Proteins are negatively charged therefore an increase
protein would yield a high anion gap BUT this is an
exception
B. Decreased unmeasured anions:
Value: less than 10 mmol/L
1. Hypoalbuminemia
- low amount of albumin in the body leading to decrease in anion
gap
______________________________________________________________

Calcium
More on extracellular 10^4:1
Measure: ECFCalcium
Reference range: 2.25- 2.5 mmol/L
4.5-5 mEq/L
*For K, Na and Cl: mmol/L = mEq/L

Calcium in ECF
1. Bound calcium- bound to albumin or globulin: 45% of ECF
2. Ionized or free calcium- 50%,- physiologically active form
3. Complexed form- either with phosphate or citrate: 5%

Body: 98% in skeleton
Remaining ca is 50:50 ;ECF: tissue

PTH on calcium
Stimulation: Low calcium
Vitamin D on calcium
Absorption- Increase blood calcium
Calcitonin
Decrease serum calcium
Inhibitosteoclastic activity

Conditions associated with excess PTH secretion:
Hyperparathyroidism:
- High calcium
- MC common: Parathyroid Adenoma
Other test:
PTH measurement: high
Serum phosphorus: low
Phosphate excreted: increased
(F3) Clinical Pathology Lecture
Dr. Ayochok :)) Feb 11-12,17-18,20 2014
12


Malignancy associated hypercalcemia
2 types:
1. Local osteolytichypercalcemia
- due to CA with bone metastasis
- leukemia (primary hematologic malignancy)
- Multiple myeloma

2. Humoralhypercalcemia of malignancy
- tumor producing a PTH related protein that is causing the
hypercalcemia
- Can also influence thereby promoting bone resorption
- Usually a solid tumor such as sarcoma
- No bone metastasis
______________________________________________________________
Magnesium
- Mainly in ICF
- ICF: ECF; 10:1
- 4th most abundant cation
- 50% in bone and 50% tissue
- Less than 1% in blood
- Reference range: 0.7-1.1 mEq/L; 1.3-2.1 mmol/L
- Function:
1. Activates enzymes ex. phosphatase, hexokinase,
carboxylase
2. Preservation of macromolecular structure for
DNA, RNA, and ribosomes
Disorder:
A. HYPOMAGNESIMIA:
Symptoms similar to hypocalcemia and hypokalemia
- Weakness
- Seizure
- Agitation
- Arrhythmia
B. HYPERMAGNESIMIA
Less clinically significant compared to hypomagnesimia
Symptoms:
- Flaccid paralysis
- hypotension
















































(F3) Clinical Pathology Lecture
Dr. Ayochok :)) Feb 11-12,17-18,20 2014
13

Acid Base Balance:
Arterial blood gases (ABG)
Parameters:
1. Blood pH- is the concentration of H ions in the blood
NV: 7.35-7.45 Blood pH

Less than 6.8 or more than 7.8 not compatible with life
Buffers in the body regulate Blood pH by:
a.
Binding to H ions without causing marked changes in pH:
these buffers are weak acids with its conjugate base
containing solution or other weaker acids
o Buffers: descending order base on buffering capacity
Bicarbonate/ carbonic acid buffer
Hemoglobin
Plasma proteins
Erythrocytes
Plasma Phosphate
o Henderson hasselbach equation:

o Bicarbonate:
Formation of HCO3 from the kidneys by:
a. Hydrogen phosphate to dihydrogen
phosphate release bicarbonate
b. Ammonia formation via amino acid
deamination
c. Resident bicarb inside tubular cells
o Carbonic acid:
Formed in the lungs:
Carbonic acid Is converted to
water and CO2
In interpreting ABG check ratio of bicarbonate and carbonic
acid:

Bicarbonate/ Carbonic
acid
b/a Ratio pH
Increase bicarbonate Increase Increase/alkalosis
Increase carbonic acid decrease Decrease/Acidosis

Normal Bicarbonate to carbonic acid ratio: 20:1

_______________________________________________________________

Lab determination of pH and CO2

1.
Carbon dioxide combining power
Specimen: Venous blood drawn aerobically
serum equilibrated to normal alveolar levels of 40
mmHg
Blow air into the specimen via a
tube arrangement
Adjusts amount of dissolved C02
to normal amount found in
arterial blood
HCO3 converted to CO2 by acid hydrolysis in a vacuum:
released gas measured
Released CO2: dissolved CO2+ specimen +
converted HCO3
HCO3 alone: subtract know amount of
dissolved CO2 and H2CO3 in normal blood;
combining power
2.
CO2 content:
From heparinized arterial or venous blood drawn
anaerobically
Vacuum tube, quickly capped
syringe
Blood centrifuged, plasma removed
Plasma analyzed for CO2
Method: convert HCO3 and
H2CO3 to gas form
Measures sum of HCO3 + H2CO3 + dissolved CO2
Result: more accurate than that obtained from
CO2 combining power
3. Serum HCO3
o Venous blood drawn aerobically
o Assayed for HCO3 without equilibrium
o Less accurate than CO2 combining power
o Serum frequently exposed to air for
longer periods
o Underfilling of tubes: decreased HCO3
values
4. Partial P of CO2 (PCO2)
- In mmHg or Torr
- Proportional to amount of dissolved CO2
- Proportional to the denominator of Henderson-
hasselbach equation
o Denominator: represents dissolved CO2
- Whole blood collected anaerobically
- Direct measurement via PCO2 electrode
o HCO3 calculated (from the HH equation)
o PCO2: used with pH to differentiate acid
base disorders
- Measured together with pH
5. pH measurment
- Before: difference in electric charge between 2
electrodes placed in solution (plasma, WB)
- Now: direct- reading pH electrode
- Room temperature:
o Plasma PH decrease at a rate of 0.015 pH
unit every 30 minutes
o Refrigerate immediately: viable up to 4
hours

pH determination:
CO2 combining power (HCO3) 24 meq/L (20-28)
CO2 content 25 meq/L (22-28)
PCO2 40 mmHg (35-45)
PO2 80-100 mmHg

_______________________________________________________________
pH Disturbacnces
I. Metabolic pH disturbances:
Metabolic Acidosis
Acid gaining
Base losing
Renal Type
Metabolic Alkalosis
II. Respiratory pH disturbances:
Respiratory Acidosis
_______________________________________________________________
Metabolic pH disturbances

Metabolic Acidosis:
1. Acid gaining
- Lactic acidosis
- Diabetic ketoacidosis
- Severe starvation
- Severe dehydration
- Iatrogenic: thru administration of ammonium chloride
- Aspirin toxicity (late phase)
o Bicarbonate: decreased
o pH: decreased
o Carbon dioxide: decrease
(F3) Clinical Pathology Lecture
Dr. Ayochok :)) Feb 11-12,17-18,20 2014
14

Rule: if the primary disorder is metabolic
compensation is respiratory
2. Base losing
- Severe diarrhea
- No bicarbonate
- Serum bicarbonate: decrease
- Ratio: decrease
o pH: decrease
o Carbon dioxide: decrease
3. Renal acidosis
- Both acute and chronic type
- Retaining hydrogen ions in bloodstream
- ratio: decreases
o CO2: decreases

Metabolic alkalosis:
1. Alkali administration:
o Sodium bicarbonate administration
o numerator: increases
o pH: increase
o carbon dioxide: increases
2. Acid losing:
o Retching or vomitng
o HH: increased
o pH: increased
o CO2: increased
3. Hypokalemic type
o Diuretic use
o HH: Numerator: increased
o pH: increased
o Compensatory CO2: increased
_______________________________________________________________
Respiratory pH disturbances
Respiratory acidosis
- Retention of carbon dioxide: emphysema, CHF, encephalitis
- Basic problem: excess of denominator (carbonic acid excess)
- HH equation: decrease in pH
o Carbon dioxide: increased or normal

Respiratory alkalosis
- Early phase of aspirin toxicity
- MC: Hyperventilation
- Carbonic acid: decreased
- pH: Increased
- Decreased CO2 in blood
_______________________________________________________________
Compensation:
Parameter: Degree of PCO2 change
1. Uncompensated
o Metabolic: pH abnormal; PCO2 normal
o Respiratory: pH, PCO2 abnormal or outside their
reference ranges (severe)
2. Partially compensated:
o M and R: pH, PCO2: outside reference range
3. Compensated:
o M and R: PCO2 out of range; pH within range
_______________________________________________________________
Interpret ABG:

I. 1. Look at PH:
2. Check PCO2:
-if pH and PCO2: same direction = primary metabolic disorder
-if pH is high and PCO2 is low = primary respiratory disorder

II. 1. Look at PCO2:
-if decreased =either respiratory alkalosis or metabolic acidosis
-if increased = respiratory acidosis or metabolic alkalosis
2. Look at pH:
LOW PCO2
a.Respiratory Alkalosis:
Uncompensated and partially compensated:pH =high
Compensated: pH=normal or above 7.4

b.Metabolic Acidosis:
Partially compensated: pH=low
Compensated: pH= normal or below 7.4

HIGH pCO2
a. Respiratory Acidosis:
Uncompensated and partially compensated: pH= low
Compensated: pH= normal or below 7.4

b. Metabolic alkalosis
Uncompensated or partially compensated: pH= high
Compensated: pH= normal or above 7.4
_______________________________________________________________

Case1

A 44 year old moderately dehydrated man was admitted with a
two day history of acute severe diarrhea. Electrolyte results: Na
+
: 134, K
+
:2.9
(low), Cl
-
108, HCO3
-
:16, BUN: 31, Cr: 1.5.

ABG:
pH: 7.31
HCO
3
: 16
pCO2: 33 mmHg (RR: 35-45)
pO2 : 93 mmHg
Interpretation: (Primary)Metabolic Acidosis

Calculate the anion gap:
sodium - (chloride + HCO3)= anion gap
134 - (108 + 16) = 10
Answer: 10 (normal)

Based on the clinical scenario, likely acid base diorders in this patient are:
o Normal anion gap acidosis from diarrhea or,
o Elevated anion gap acidosis secondary to lactic acidosis as a result
of hypovolemia and poor perfusion

Look at the pH:
- The pH is low, (less than 7.35) therefore by definition,
patient is acidemic.

Look at the PCO2, HCO3:
- PCO2 and HCO3 are abnormal in the same direction, therefore
less likely a mixed acid base diorder. Need to distinguish the initial change
from the compensatory response. A low PCO2 represents alkalosis and is not
consistent with the pH. A low HCO3 represents acidosis and is consistent
with the pH, therefore it must be the initial change. The low PCO2 must be
the compensatory response. Since the primary change involves HCO3, this is
a metabolic process, i.e. Metabolic Acidosis.

Is compensation adequate?
- Since the actual PCO2 falls within the estimated range, we can
deduce that the compensation is adequate and there is no separate
respiratory disorder present.

Assessment: Normal anion gap metabolic acidosis with adequate
compensation most likely secondary to severe diarrhea
_______________________________________________________________












(F3) Clinical Pathology Lecture
Dr. Ayochok :)) Feb 11-12,17-18,20 2014
15

Case 2

A 22 year old female with type 1 Diabetes Mellitus, presents to
the emergency department with one day history of nausea, vomiting,
polyuria, polydipsia and vague abdominal pain. PE noted for deep sighing
breathing, orthostatic hypotension, and dry mucous membranes.

Laboratory:
- Sodium: 132
- Potassium: 6.0
- Cl: 93
- HCO3: 11
- Glucose: 720 mg/dL
- BUN: 38
- Crea: 2.6
- UA: pH- 5.0, sg- 1.010, ketones- negative, glucose-+
- plasma ketones: trace
- ABG: pH- 7.27, HCO3- 10, PCO2-23

What is the acid base disorder?
Based on the clinical scenario, likely acid base disorders in this patient are:
a) Elevated anion gap acidosis secondary to DKA; or
b) Elevated anion gap acidosis secondary to lactic acidosis in the
setting of vomiting and polyuria which may lead to hypovolemia;
or
c) Metabolic alkalosis in the setting of vomiting

Look at the pH:
The pH is low, (less than 7.35)therefore by definition, patient is
acidemic

Look at the PCO2, HCO3:
PCO2 and HCO3- are abnormal in the same direction, therefore
less likely a mixed acid base disorder but not yet ruled out. (it is a pure
metabolic disorder.)

Again, need to distinguish the initial change from the
compensatory response. A low HCO3- represents acidosis and is consistent
with the pH, therefore it must be the initial change. To maintain the
PCO2/HCO3, the PCO2 is reduced in response (compensatory).
The low PCO2 must be the compensatory response. Since the primary
change involves HCO3, this is a metabolic process. Ex metabolic acidosis

Calculate the anion gap:
The anion gap is Na- (Cl + HCO3)= 132- (93 +11)= 28
Since gap is greater than 17, it is therefore abnormal.

Is compensation adequate?
Since the actual PCO2 falls within the estimated range we can
deduce that the compensation is adequate and there is no separate
respiratory disorder present.

Assessment: compensated elevated anion gap metabolic acidosis most likely
secondary to DKA, note the absence of ketones in the urine. This is
sometimes seen in early DKA due to the predominance of beta-
hydroxybutyrate. The dipstick test for ketones detect acetoacetate but not
beta-hydroxybutyrate
_______________________________________________________________














Case 3

A previously wel 55 year old woman is admitted with a complaint
of severe vomiting for 5 days. PE reveals postural hypotension, tachycardia
and diminished skin turgor. The laboratory finding include the ff:
Electrolytes: Na-140; K- 3.4; Cl-77; HCO3-9; Crea-2.1;
ABG: pH-7.23, PCO2- 22 mmHg

What is the acid base disorder?
Based on the clinical scenario, the likely acid base disorders in this patient
are:
Elevated anion gap acidosis secondary to lactic acidosis in the
setting of severe persistent vomiting which may lead to
hypovolemia and/or
Metabolic alkalosis in the setting of persistent vomiting

Look at the pH:
The pH is low (less than 7.35) therefore by definition patient is
acidemic

Look at the PCO2, HCO3.
PCO2 and HCO3 are abnormal in the same direction, therefore
less likely a mixed acid base disorder but not yet ruled out.

Again, need to distinguish the initial change from the
compensatory response. A low HCO3 represents acidosis and is consistent
with the pH, therefore it must be the initial change. The low PCO2 must be
the compensatory response. Since the primary change involve HCO3, this a
metabolic process, i.e. metabolic acidosis.

Calculate the anion gap:
sodium - (chloride + HCO3)= anion gap
140- (77+9) = 54

Since the actual PCO2 falls within the estimated range, we can deduce that
the compensation is adequate and there is no separate respiratory disorder
present.

Since anion gap is elevated, calculate the delta ratio to rule out concurrent
metabolic alkalosis:

DELTA RATIO:
Measured anion gap normal anion gap
Normal HCO3 Measured HCO3

=AG-12/ 24-HCO3
=54-12/24-9
= 2.8

Delta ratio interpretations:
<0.4 hyperchloremic normal anion gap acidosis
<1 High AG and Normal AG acidosis
1-2 pure anion gap acidosis, lactic acidosis (Average: 1.6), DKA (Closer to
1 due to urine ketones
>2 High AG acidosis and concurrent metabolic alkalosis or pre-existing
compensated respiratory acidosis.

Since the delta ratio is greater than 2, we can deduce that there is a
concurrent metabolic alkalosis. This is likely due to vomiting.

Another possibility is a pre-existent high HCO3 level due to compensated
respiratory acidosis. But we have no reason to suspect respiratory acidosis
base on history.

Assessment: mixed elevated AG metabolic acidosis and metabolic alkalosis
likely due to lactic acidosis and vomiting.