NAME GGT (Gamma glutamyltransferase )

ROLE
The purpose of this blood serum chemistry test is to provide information about hepatobiliary diseases, to assess liver function, and to detect alcohol ingestion. Another purpose is to distinguish between skeletal disease and hepatic disease when serum alkaline phosphatase is elevated. MCV = Hct/Hgb

NORMAL
Normal results in females under age 45, range from 5 to 27 U/L; in females over age 45 and in males, levels range from 6 to 37 U/L.

DIFF

A normal GGT level suggests such eleva stems from skeletal disease. Serum GGT vary with the assay method used (colori or kinetic). The sharpest increases in GG levels indicate obstructive jaundice and metastasis. Elevations may indicate any hepatic disease, acute pancreatitis, rena disease, alcohol ingestion, postoperative status, and prostatic metastasis. This te nonspecific, providing little data about t of hepatic disease. GGT is particularly se to the effects of alcohol in the liver, and may be elevated after moderate alcohol and in chronic alcoholism, even without evidence of hepatic injury.

MCV (mean corpuscular volume)

Normal values: These RBC indices are useful in the diffe MCV: 80 to 95 diagnosis of types of anemia. Anemias a femtoliter MCH: 27 classified on the basis of cell size (MCV) to 31 cell color (MCHC). MCV less than lower l picograms/cell normal: microcytic MCV within normal r MCHC: 32 to 36 normocytic MCV greater than upper limi grams/deciliter normal: macrocytic MCHC less than low of normal: hypochromic MCHC with norm range: normochromic MCHC greater tha limit of normal: hyperchromic

Anemias have been classified as follows normocytic/normochromic (NC/NC) anem acute blood loss aplastic anemia (for ex due to chloramphenicol toxicity) prosthe heart valves sepsis tumor microcytic/hypochromic anemia: iron de lead poisoning thalassemia microcytic/normochromic anemia: erythropoietin deficiency secondary to r failure macrocytic/normochromic anemi chemotherapy folate deficiency vitamin deficiency

Uric Acid

4.1 to 8.8 mg/dl

Greater-than-normal levels of uric acid (hyperuricemia) may indicate:

acidosis alcoholism diabetes mellitus renal failure

gout leukemi hypoparathyroidism nephroli polycyth lead poisoning vera toxemia of purine-r pregnancy diet

severe exercise

Lower-than-normal levels of uric acid m indicate:

Fanconi's syndrome Wilson's disease S low purine diet

Additional conditions under which the te be performed: chronic gouty arthritis inj the kidney and ureter

Cholesterol

Triglycerides

Alanine Aminotransferase (ALT, SGPT, GPT)

140 to 310 mg/dl optimal values: 140-220 mg/dl Note: mg/dl = milligrams per deciliter Normal values: 10 to 190 mg/dl Note: mg/dl = milligrams per deciliter Intracellular enzyme Normal Range: involved in amino acid Laboratory-specific and carbohydrate U/L metabolism. Present in large concentrations in liver, kidney; smaller amounts in skeletal muscle and heart. Released with tissue damage. Major component of Normal Range: 3.4plasma proteins, 4.7 g/dL influenced by nutritional state, hepatic function, renal function, various diseases.

atherosclerosis biliary cirrhosis familial hyperlipidemias high-cholesterol diet hypothyroidism myocardial infarction ne syndrome uncontrolled diabetes

cirrhosis familial hyperlipoproteinemia (r hypothyroidism low protein in diet and h carbohydrates poorly controlled diabetes nephrotic syndrome pancreatitis Increased in: Acute viral hepatitis (ALT>AST), b tract obstruction (cholangitis, choledocholithias alcoholic hepatitis and cirrhosis (AST>ALT), liv abscess, metastatic or primary liver cancer; rig failure, ischemia or hypoxia, injury to liver ("sho liver"), extensive trauma. Drugs causing choles and other hepatotoxic drugs. Additional: ALT screening of donor blood used banks to exclude non-A, non-B hepatitis.

Albumin

increased in: Dehydration, shock, hemoconcen

Decreased in: Decreased hepatic synthesis (ch liver disease, malnutrition, malabsorption, mali congenital analbuminemia [rare]). Increased lo (nephrotic syndrome, burns, trauma, hemorrha fluid replacement, fistulae, enteropathy, acute o chronic glomerulonephritis). Hemodilution (pre CHF). Drugs (eg, estrogens).

Additional: Serum albumin gives an indication severity in chronic liver disease. Useful in nutri assessment if no impairment in production or in loss.

Alkaline Phosphatase

Alkaline phosphatases Normal Range: are found in liver, bone, Method and age intestine, placenta. dependent

increased in: Obstructive hepatobiliary disease hepatotoxic drugs, bone disease (physiologic b growth, Paget's disease, osteomalacia, osteog sarcoma, bone metastases), hyperparathyroidi rickets. Benign familial hyperphosphatasemia,

pregnancy (3rd trimester), GI disease (perforat or infarct). Decreased in: Hypophosphatasia.

Additional: Normal in osteoporosis. Alkaline phosphatase isoenzyme separation by electrop or differential heat inactivation is unreliable. Us glutamyl transpeptidase (GGT), which increase hepatobiliary disease, to infer origin of increase alkaline phosphatase (ie, liver or bone).

ANA (Antinuclear Antibodies)

Heterogeneous Normal Range: < antibodies to nuclear 1:20 antigens (DNA and RNA, histone and nonhistone proteins). Antinuclear antibody is measured in patient's serum by layering serum over human epithelial cells and detecting the antibody with fluoresceinconjugated polyvalent anti-human immunoglobulin.

Elevated in: 1/3-3/4 of patients over age 65 (us low titers), systemic lupus erythematosus (98% induced lupus (100%), Sj?gren's (80%), rheum arthritis (30-50%), scleroderma (60%), mixed connective tissue disease (100%), Felty's synd mononucleosis, hepatic or biliary cirrhosis, hep leukemia, myasthenia gravis, dermatomyositis polymyositis, chronic renal failure.

Additional: A negative ANA test does not comp rule out SLE, but alternative diagnoses should considered. Pattern of staining of ANA may giv clues to diagnoses, but since the pattern also c with serum dilution, it is not routinely reported. rim (peripheral) pattern is highly specific (for SL useful as a screening test. Should be used onl there is clinical evidence of a connective tissue

ANCA (antineutrophil cytoplasmic antibodies), P-ANCA (perinuclear) C-ANCA (cytoplasmic)

Anti-Cardiolipin (Anti-Phospholipid)

Tests are on the blood serum. C-ANCA is most seen in Wegener's granulomatosus. CANCA suggests a systemic vasculitis disease, and is rarely seen in patients with lupus. P-ANCA is most seen in necrotizing, crescentic glomerulonephritis and polyarteritis nodosa. PANCA is found in some lupus patients. Anticardiolipin antibodies are a subset of a group of antibodies which react with negatively charged phospholipids. Antibodies to cardiolipin have been associated with an

Normal Range: none present

Normal Range for increased in: SLE, some connective tissue dise anti-IgG: 0 - 20 GPL and in Antiphospholipid Syndrome. Normal Range for anti-IgM: 0 - 10 MPL. Additional: Patients with acute and chronic infe (including syphilis, HIV, Lyme disease) may als increased anti-cardiolipin antibodies

incresased incidence of vascular thrombosis, thrombocytopenia and recurrent fetal loss in patients with SLE.

Anti-DNA

IgG or IgM antibodies Normal Range: < 1:10 increased in: Systemic lupus erythematosus (6 titer specificity 95%). Anti-ds-DNA antibody is not fo directed against host drug-induced lupus. double-stranded DNA.

Additional: High titers are seen only in SLE. Tit anti-ds-DNA correlate well with disease activity with occurrence of glomerulonephritis.

Antinerythrocyte antibodies (anti-RBC) also known as Coombs test

Antineurofilament antibodies

Anti-Cardiolipin (Anti-Phospholipid)

Antinerythrocyte antibodies (anti-RBC) also known as Coombs test

The direct Coombs test measures the presence of antibodies that are bound to the surface of circulating RBCs. Indirect Coombs measures *free* antiRBC antibodies. The sensitivity of this test is in question--but it remains the standard for detection of autoimmune anemia. Limited studies have been done with this test. Antibodies against neurofilaments in blood serum. 60% of diffuse NP lupus patients have shown this antibody. MPLAnticardiolipin antibodies are a subset of a group of antibodies which react with negatively charged phospholipids. Antibodies to cardiolipin have been associated with an incresased incidence of vascular thrombosis, thrombocytopenia and recurrent fetal loss in patients with SLE. The direct Coombs test measures the presence of antibodies that are bound to the surface of circulating RBCs. Indirect Coombs measures *free* antiRBC antibodies. The sensitivity of this test is

Normal Range: none present

Normal Range: non present

Normal Range for anti-IgG: 0 - 20 GPL Normal Range for anti-IgM: 0 - 10

increased in: SLE, some connective tissue dise and in Antiphospholipid Syndrome.

Additional: Patients with acute and chronic infe (including syphilis, HIV, Lyme disease) may als increased anti-cardiolipin antibodies.

Normal Range: none present

Antineurofilament antibodies

Antineuronal antibodies

Anti-ribosomal P

Anti-Ro/SS-A

in question--but it remains the standard for detection of autoimmune anemia. presentLimited studies have been done with this test. Antibodies against neurofilaments in blood serum. 60% of diffuse NP lupus patients have shown this antibody. Most specifically, this is IgG neuron-reactive antibody radioimmunoassay performed on the cerebrospinal fluid. In the general lupus population, 75% with neuro-psyciatric (NP) lupus are detected, as compared to 10% without NP lupus-*false positive*. Highest titers are found in patients with diffuse NP lupus (seizures, organic brain syndrome)--90%. 40% of focal NP are positive (stroke, cranial neuropathy, transverse myelitis). Antibodies to ribosomal P protein from blood serum. 80 - 90% positive in NP lupus that manifests with psychosis or depression. Autoantibody against acidic nuclear ribonucleoproteins that is found in patients with some connective tissue diseases, especially Sjogren's syndrome.

Normal Range: non

Normal Range: non present

Normal Range: Negative

Normal Range: Negative

Positive in: Primary Sjogren's syndrome (70%) (40%), rheumatoid arthritis (10%).

Additional: Anti-La/SS-B is another antibody ag acidic ribonucleoproteins that is less sensitive Sjogren's (50-60%) and SLE (10-15%). Patient antibodies to SS-A may have a negative ANA t

Aspartate Aminotransferase (AST, SGOT, GOT)

U/LIntracellular Normal Range: enzyme involved in Laboratory-specific amino acid and carbohydrate metabolism. Present in large concentrations in liver, skeletal muscle,

increased in: Acute viral hepatitis (ALT>AST), b tract obstruction (cholangitis, choledocholithias mononucleosis, alcoholic hepatitis and cirrhosi (AST>ALT), liver abscess, metastatic or primar cancer, myocardial infarction, myopathies, mus dystrophy, dermatomyositis, rhabdomyolysis, is injury to liver ("shock liver") or hypoxia. Hepato

brain, red cells, and heart. Released into the bloodstream when tissue is damaged.

drugs (eg, isoniazid). Additional: Test not indicated for diagnosis of myocardial infarction. Normal Range: 0.11.2 Direct (conjugated to glucuronide) bilirubin, 0.1-0.4 mg/dL (< 7 mol/L); Indirect (unconjugated) bilirubin, 0.2-0.7 mg/dL (< 12 mol/L) mg/dL

Bilirubin

Bilirubin, a product of hemoglobin metabolism, is conjugated in the liver to the mono- and diglucuronides and excreted in bile. Some conjugated bilirubin is bound to serum albumin, so-called D (delta) bilirubin. Elevated serum bilirubin occurs in liver disease, biliary obstruction, or hemolysis.

increased in: Acute or chronic hepatitis, cirrhos tract obstruction, toxic hepatitis, congenital live enzyme abnormalities (Dubin-Johnson, Rotor's Gilbert's, Crigler-Najjar syndromes), fasting, he disorders. Hepatotoxic drugs.

Additional: Assay of total bilirubin includes con (direct) and unconjugated (indirect) bilirubin plu bilirubin (conjugated bilirubin bound to albumin usually clinically unnecessary to fractionate tot bilirubin. The fractionation is unreliable by the d reaction and may underestimate unconjugated Only conjugated bilirubin appears in the urine a indicative of liver disease; hemolysis is associa increased unconjugated bilirubin. Persistence o bilirubin in serum in resolving liver disease mea total bilirubin does not effectively indicate time of resolution.

Blood Urea Nitrogen (BUN)

Urea, an end product of protein metabolism, is excreted by the kidney. BUN is directly related to protein intake and nitrogen metabolism and inversely related to the rate of excretion of urea. Urea concentration in glomerular filtrate is the same as in plasma, but its tubular reabsorption is inversely related to the rate of urine formation.

Normal Range: 8-20 mg/dL

Additional: Urease assay method commonly used. Decreased in: Hepatic failure, nephrotic syndro BUN/Cr ratio cachexia (low-protein and high-carbohydrate d (normally 12:1-20:1) decreased in acute tubular necrosis, advanced liver disease, low protein intake, following hemodialysis. BUN/Cr ratio increased in dehydration, GI bleeding, increased catabolism.

increased in: Renal failure (acute or chronic), u tract obstruction, dehydration, shock, burns, CH gastrointestinal bleeding. Drugs with renal toxic gentamicin.

Aspartate Aminotransferase (AST, SGOT, GOT)

Intracellular enzyme Normal Range: involved in amino acid Laboratory-specific and carbohydrate U/L metabolism. Present in large concentrations in liver, skeletal muscle, brain, red cells, and heart. Released into the bloodstream when tissue is damaged.

increased in: Acute viral hepatitis (ALT>AST), b tract obstruction (cholangitis, choledocholithias mononucleosis, alcoholic hepatitis and cirrhosi (AST>ALT), liver abscess, metastatic or primar cancer, myocardial infarction, myopathies, mus dystrophy, dermatomyositis, rhabdomyolysis, is injury to liver ("shock liver") or hypoxia. Hepato drugs (eg, isoniazid). Additional: Test not indicated for diagnosis of

myocardial infarction.

Bilirubin

Bilirubin, a product of hemoglobin metabolism, is conjugated in the liver to the mono- and diglucuronides and excreted in bile. Some conjugated bilirubin is bound to serum albumin, so-called D (delta) bilirubin. Elevated serum bilirubin occurs in liver disease, biliary obstruction, or hemolysis.

. Normal Range: 0.11.2 Direct (conjugated to glucuronide) bilirubin, 0.1-0.4 mg/dL (< 7 mol/L); Indirect (unconjugated) bilirubin, 0.2-0.7 mg/dL (< 12 mol/L) mg/dL

increased in: Acute or chronic hepatitis, cirrhos tract obstruction, toxic hepatitis, congenital live enzyme abnormalities (Dubin-Johnson, Rotor's Gilbert's, Crigler-Najjar syndromes), fasting, he disorders. Hepatotoxic drugs.

Additional: Assay of total bilirubin includes con (direct) and unconjugated (indirect) bilirubin plu bilirubin (conjugated bilirubin bound to albumin usually clinically unnecessary to fractionate tot bilirubin. The fractionation is unreliable by the d reaction and may underestimate unconjugated Only conjugated bilirubin appears in the urine a indicative of liver disease; hemolysis is associa increased unconjugated bilirubin. Persistence o bilirubin in serum in resolving liver disease mea total bilirubin does not effectively indicate time of resolution

Blood Urea Nitrogen (BUN)

C3

Urea, an end product of protein metabolism, is excreted by the kidney. BUN is directly related to protein intake and nitrogen metabolism and inversely related to the rate of excretion of urea. Urea concentration in glomerular filtrate is the same as in plasma, but its tubular reabsorption is inversely related to the rate of urine formation. The classic and alternative complement pathways converge at the C3 step in the complement cascade. Low levels indicate activation by one or both pathways. Most diseases with immune complexes will show decreased C3 levels. Test as usually performed is an immunoassay (by radial immunodiffusion or nephelometry).

Normal Range: 8-20 mg/dL

increased in: Renal failure (acute or chronic), u tract obstruction, dehydration, shock, burns, CH gastrointestinal bleeding. Drugs with renal toxic gentamicin.

Decreased in: Hepatic failure, nephrotic syndro cachexia (low-protein and high-carbohydrate d

Additional: Urease assay method commonly us BUN/Cr ratio (normally 12:1-20:1) decreased in tubular necrosis, advanced liver disease, low p intake, following hemodialysis. BUN/Cr ratio in in dehydration, GI bleeding, increased cataboli

Normal Range: 64166 mg/dL

increased in: Many inflammatory conditions as acute phase reactant, active phase of rheumat diseases (rheumatoid arthritis, SLE, etc), acute hepatitis, myocardial infarction, cancer, diabete pregnancy, sarcoidosis, amyloidosis, thyroiditis

Decreased by: Decreased synthesis (protein malnutrition, congenital deficiency, severe liver disease), or increased catabolism (immune com disease, membranoproliferative glomeruloneph [75%], SLE, Sjogren's, rheumatoid arthritis, disseminated intravascular coagulation, paroxy nocturnal hemoglobinuria, autoimmune hemoly anemia, gram-negative bacteremia) and increa (burns, gastroenteropathies).

Additional: Complement C3 levels may be use following the activity of immune complex disea best test to detect inherited deficiencies is CH5 Levels can confirm specific C3 defect.

C4

C4 is a component of Normal Range: 15-45 the classic complement mg/dL pathway. Depressed levels usually indicate classic pathway activation.

increased in: Various malignancies: not clinical useful.

Decreased by: Decreased synthesis, increased catabolism (SLE, rheumatoid arthritis, prolifera glomerulonephritis, hereditary angioedema), an increased loss (burns, protein-losing enteropat Congenital deficiency.

Additional: Low C4 accompanies acute attacks hereditary angioedema, and C4 is used as a fir test for the disease. C1 esterase inhibitor level indicated for the evaluation of hereditary angio unless C4 is low. Congenital C4 deficiency occ an SLE-like syndrome. Test as usually perform immunoassay and not a functional assay.

Calcium

Level of ionized Normal Range: 8.5calcium is regulated by 10.5 mg/dL parathyroid hormone and vitamin D. Serum calcium equals the sum of ionized calcium plus complexed calcium and calcium bound to proteins (mostly albumin).

increased in: Hyperparathyroidism, malignanci secreting PTH-like substances (especially squa cell carcinoma of lung, renal cell carcinoma), v excess, milk-alkali syndrome, multiple myelom Paget's disease of bone with immobilization, sarcoidosis, other granulomatous disorders, fa hypocalciuria, vitamin A intoxication, thyrotoxic Addison's disease. Drugs: antacids (some), ca salts, chronic diuretic use (eg, thiazides), lithium others.

Decreased in: Hypoparathyroidism, vitamin D deficiency, renal insufficiency, pseudohypoparathyroidism, magnesium deficie hyperphosphatemia, massive transfusion, hypoalbuminemia.

Additional: Need to know serum albumin to inte calcium level. For every decrease in albumin b mg/dL, calcium should be corrected upward by mg/dL.

CH50

The quantitative assay Normal Range: of hemolytic Laboratory-specific complement activity U/mL depends on the ability of the primary complement pathway to induce hemolysis of red cells sensitized with optimal amounts of anti-red cell antibodies. For precise

Decreased with: >50-80% deficiency of primar pathway complement components in congenita acquired deficiency.

Normal in: Deficiencies of alternative pathway, complement components.

Additional: This is a functional assay of biologic Sensitivity to decreased levels of complement components depends on exactly how the test i

Chloride

titrations of hemolytic complement, the dilution of serum that will lyse 50% of the indicator red cells is determined as the CH50. This arbitrary unit depends on the conditions of the assay and is therefore laboratory-specific. Chloride, the principal Normal Range: 98inorganic anion of 107 meq/L extracellular fluid, is important in maintaining normal acid-base balance and normal osmolality. If chloride is lost (as HCl or NH4Cl), alkalosis ensues; if chloride is ingested or retained, acidosis ensues.

performed. It is used to detect congenital and a severe deficiency disorders of the primary com pathway.

increased in: Renal failure, nephrotic syndrome tubular acidosis, dehydration, overtreatment w saline, hyperparathyroidism, diabetes insipidus metabolic acidosis from diarrhea (loss of HCO3 respiratory alkalosis, hyperadrenocorticism. Dr acetazolamide (hyperchloremic acidosis), andr hydrochlorothiazide, salicylates (intoxication).

Decreased in: Vomiting, diarrhea, gastrointesti suction, renal failure combined with salt depriv overtreatment with diuretics, chronic repiratory acidosis, diabetic ketoacidosis, excessive swea SIADH, salt-losing nephropathy, acute intermit porphyria, water intoxication, expansion of extr fluid volume, adrenal insufficiency, hyperaldost metabolic alkalosis. Drugs: aldosterone, chron laxative or bicarbonate ingestion, corticosteroid ACTH (alkalosis), diuretics.

Cholesterol

Cholesterol level is Normal Range: determined by lipid Desirable < 200 metabolism, which is in Borderline 200-239 turn influenced by High risk > 240 mg/dL heredity, diet, and liver, kidney, thyroid, and other endocrine organ functions. Total cholesterol (TC) = LDLC + HDLC + TG/5 (valid only if triglyceride [TG] < 400). Since LDL cholesterol (LDLC) is the clinically important entity, it is calculated as LDLC = TC - HDLC TG/5, and this is valid only if specimen is obtained fasting (in order to obtain relevant triglyceride and HDL levels).

increased in: Familial or polygenic hyperlipoproteinemia, familial dysbetalipoprote familial combined hyperlipidemia, hyperlipopro and hyperalphalipoproteinemia, hyperlipoprote secondary to hypothyroidism, uncontrolled diab mellitus, nephrotic syndrome, chronic hepatitis cirrhosis, obstructive jaundice, hypoproteinemi glomerulonephritis, chronic renal failure, gout, malignancy (pancreas, prostate), pregnancy, alcoholism, glycogen storage diseases types I, anorexia nervosa, GH deficiency, dietary exces Drugs: androgens, chlorpropamide, corticoster oral contraceptives, phenytoin, progestins, thia others.

Decreased in: Acute hepatitis, alcoholic cirrhos Gaucher's disease, hyperthyroidism, acute infe anemia, malnutrition, alphalipoprotein deficienc (Tangier disease), malignancy (liver), severe a illness, extensive burns, COPD, rheumatoid ar mental retardation, intestinal lymphangiectasia apolipoprotein deficiency.

Additional: It is important to treat the cause of secondary hypercholesterolemia (hypothyroidis National Cholesterol Education Program Exper

has published clinical recommendations for ch management.

Creatinine

Endogenous creatinine Normal Range: 0.6is excreted by filtration 1.2 mg/dL through the glomerulus and by tubular secretion. Clinically, creatinine clearance is an acceptable measure of glomerular filtration rate but sometimes overestimates GFR. For each 50% reduction in GFR, serum creatinine approximately doubles. White blood cell differentials are now done on automated flow cytometry instruments in order to provide reproducible data. 10,000 wbcs are classified on the basis of size and peroxidase staining as neutrophils, monocytes or eosinophils (which are all peroxidase positive) and as lymphocytes and large unstained cells (which are peroxidase negative). These large unstained cells (LUC), larger than normal lymphocytes, may be atypical lymphocytes, myeloperoxidase deficient cells or peroxidase negative blasts. Basophils are identified using two angle light scattering, based on their singular resistance to lysis. There will also be an indication of more immature neutrophils (commonly called a left shift) based on the ratio of mono/polymorphonucle ar white cells (lobularity Normal Range: 1.8-6.8 K/mL 0.9-2.9 K/mL 0.1-0.6 K/mL 0-0.4 K/mL 0-0.1 K/mL 0-0.2 K/mL

increased in: Acute or chronic renal failure; urin obstruction, nephrotoxic drugs.

Decreased in: Reduced muscle mass, possible effect.

Additional: In alkaline picrate method, substanc than Cr (eg, acetoacetate, acetone, b-hydroxyb a-ketoglutarate, pyruvate, glucose) may give fa high results. Therefore, patients with diabetic ketoacidosis may have spuriously elevated Cr. Cephalosporins may spuriously increase or de Cr measurement. Increased bilirubin may spur decrease Cr.

Differential Neutophils Lymphocytes Monocytes Eosinophils Basophils Large unstained cells

A left shift usually suggests infection (rarely leu The reproducibility of 100 cell manual different notoriously poor, because of statistical error in and observer variation, however, review of bloo smears is useful to visually identify rare abnorm blasts, nucleated rbcs, morphologic abnormalit hypersegmentation, toxic granulation, sickle ce target cells, spherocytes, basophilic stippling, a look for rouleau (stacking of red cells due to inc globulins) and clumped platelets. White blood c differential is unlikely to be abnormal with a no count or to be changed if the total wbc count is unchanged.

Increased neutrophils: suggests infection (bact early viral, rarely leukemia), acute stress, acute chronic inflammations, tumor, drugs, DKA. Decreased neutrophils: suggests aplastic anem drug-induced neutropenia (e.g., chloramphenic phenothiazine, antithyroid drugs, sulphonamide or B12 deficiency, Chediak-Higashi syndrome, malignant lymphoproliferative disease, physiolo children up to 4 years.

Increased lymphocytes: viral infection (especia infectious mononucleosis, pertussis), thyrotoxic adrenal insufficiency disease (ALL, CLL), chron infection, drug and allergic reactions, autoimmu disease. Decreased lymphocytes: immune deficiency sy Comments:

Increased monocytes: inflammation, infection, malignancy, TB, myeloproliferative disorders. Decreased monocytes: depleted in overwhelm

index).

bacterial infection.

Increased eosinophils: allergic states, drug sen reaction, skin disorders, tissue invasion by par periarteritis nodosa, hypersensitivity response malignancy (e.g. Hodgkin's disease), pulmonar infiltrative disease, disseminated eosinophilic hypersensitivity disease. Decreased eosinophils: acute and chronic inflammation, stress, drugs: steroids.

Increased basophils: hypersensitivity reactions myeloproliferative disorders (CML, polycythem myelofibrosis.

Erythrocyte Sedimentation Erythrocytes in plasma Normal Range: Male: increased in: Infections (osteomyelitis, pelvic usually settle slowly. < 10 Female: < 15 inflammatory disease [75%]), inflammatory dis Rate (Sed Rate, ESR)
However, if they aggregate for any reason (usually because of plasma proteins called acute phase reactants, eg, fibrinogen), they settle rapidly. Sedimentation of RBCs occurs because of their greater density than plasma. ESR measures the distance in mm that erythrocytes fall during 1 hour.

(temporal arteritis, polymyalgia rheumatica, rhe fever), malignant neoplasms, paraproteinemias anemia, pregnancy, chronic renal failure, GI dis (ulcerative colitis, regional ileitis).

Decreased in: Polycythemia, sickle cell anemia spherocytosis, anisocytosis, hypofibrinogenem hypogammaglobulinemia, congestive heart fail microcytosis, drugs (high dose corticosteroids) value of no diagnostic significance.

Additional: There is a good correlation between and C-reactive protein, but ESR is less expens is useful and indicated only for diagnosis and monitoring of temporal arteritis and polymyalgi rheumatica. The test is not sensitive or specific other conditions. ESR is higher in women and persons.

Gamma-Glutamyl Transpeptidase (GGT)

U/LGGT is an enzyme Normal Range: present in liver, kidney, Laboratory-specific and pancreas. It transfers C-terminal glutamic acid from a peptide to other peptides of L-amino acids. It is induced by alcohol intake and is an extremely sensitive indicator of liver disease, particularly alcoholic liver disease. Normally, the glucose . Normal Range: 60concentration in 115 mg/dL extracellular fluid is closely regulated so that a source of energy

increased in: Liver disease: acute viral or toxic hepatitis, chronic or subacute hepatitis, cirrhos tract obstruction (intrahepatic or extrahepatic), or metastatic liver neoplasm, alcoholic hepatitis mononucleosis. Drugs (by enzyme induction): phenytoin, barbiturates, alcohol.

Additional: Useful in follow up of alcoholics und treatment. Test sensitive to modest alcohol inta positive in 90% of patients with liver disease. U confirm hepatic origin of elevated serum alkalin phosphatase.

Glucose

increased in: Diabetes mellitus, Cushing's synd (10-15%), chronic pancreatitis (30%) Drugs: corticosteroids, phenytoin, estrogen, thiazides

is readily available to tissues and no glucose is excreted in the urine

Decreased in: Pancreatic islet B cell disease w increased insulin, insulinoma, adrenocortical insufficiency, hypopituitarism, diffuse liver disea malignancy (adrenocortical, stomach, fibrosarc infant of diabetic mother, enzyme deficiency di (galactosemia, etc). Drugs: insulin, ethanol, propranolol, sulfonylureas, tolbutamide, other hypoglycemic agents.

Additional: Diagnosis of diabetes mellitus is co with a fasting plasma glucose >140 mg/dL on m than one occasion. Hypoglycemia is defined as <50 mg/dL in men and <40 mg/dL in women.

Hematocrit

The hematocrit Normal Range: Male: represents the 39-49 Female: 35-45 percentage of whole Age-dependent blood volume made up by erythrocytes. Laboratory instruments calculate the Hct from the erythrocyte count and the MCV, ie, Hct = RBC x MCV.

increased in: Hemoconcentration (as in dehydr burns, vomiting), polycythemia, extreme physic exercise.

Decreased in: Anemia: macrocytic (liver diseas hypothyroidism, vitamin B12 deficiency, folate deficiency), normocytic anemia (early iron defic anemia of chronic disease, hemolytic anemia, hemorrhage) and microcytic anemia (iron defic thalassemia).

Additional: Conversion from hemoglobin to hem is roughly Hgb x3 = Hct. Hematocrit reported b laboratories is not a spun hematocrit. The spun hematocrit may be spuriously high if the centrif not calibrated, if the specimen is not spun to co volume, or if there is "trapped plasma."

Hemoglobin

Hemoglobin is the Normal Range: major protein of Male: 13.6-17.5 erythrocytes and Female: 12.0-15.5 transports oxygen from the lungs to peripheral tissues. It is measured by spectrophotometry on automated instruments after hemolysis of red cells and conversion of all hemoglobin to cyanmethemoglobin.

Hemoglobin is increased in: Hemoconcentratio dehydration, burns, vomiting), polycythemia, ex physical exercise, heavy smoking (due to pres nonfunctional carboxyhemoglobin).

Hemoglobin is decreased in: Anemia: macrocy disease, hypothyroidism, vitamin B12 deficienc deficiency), normocytic anemia (early iron defic anemia of chronic disease, hemolytic anemia, hemorrhage) and microcytic anemia (iron defic thalassemia). Additional: Hypertriglyceridemia and very high counts can cause false elevations of Hgb.

Immunoglobulins (IG)

IgG makes up about 85% of total serum immunoglobulins and predominates late in immune responses. It is the only immunoglobulin to

Normal Range: IgA: 78-367 mg/dL IgG: 583-1761 mg/dL IgM: 52-335 mg/dL

increased in: IgG: Polyclonal: Autoimmune dise (eg, SLE, RA), sarcoidosis, chronic liver diseas some parasitic diseases, chronic or recurrent infections. Monoclonal: Multiple myeloma (IgG lymphomas or other malignancies. IgM: Polyclo Isolated infections such as viral hepatitis, infec mononucleosis, early response to bacterial or p

cross the placenta. IgM antibody predominates early in immune responses. Secretory IgA plays an important role in host defense mechanisms by blocking transport of microbes across mucosal surfaces.

infection. Monoclonal: Waldenstrom's macroglobulinemia, lymphoma. IgA: Polyclona Chronic liver disease, chronic infections (espec the GI and respiratory tracts). Monoclonal: Mul myeloma (IgA).

Decreased in: IgG: Immunosuppressive therap genetic (severe combined immunodeficiency, W Aldrich syndrome, common variable immunodeficiency). IgM: Immunosuppresive th IgA: Inherited IgA deficiency (ataxia telangiecta combined immunodeficiency disorders).

Additional: IgG deficiency is associated with re and occasionally severe pyogenic infections. M common form of multiple myeloma is the IgG ty

Iron

Plasma iron Normal Range: 50concentration is 175 g/dL determined by absorption from intestine; storage in intestine, liver, spleen, bone marrow; rate of breakdown or loss of hemoglobin; rate of synthesis of new hemoglobin.

increased in: Hemochromatosis, hemosiderosi multiple transfusions, excess iron administratio hemolytic anemia, pernicious anemia, aplastic hypoplastic anemia, viral hepatitis, lead poison thalassemia. Drugs: dextran, estrogens, ethan contraceptives.

Decreased in: Iron deficiency, nephrotic syndro chronic renal failure, many infections, active hematopoiesis, remission of pernicious anemia hypothyroidism, malignancy (carcinoma), posto state, kwashiorkor, drugs.

Additional: Used in evaluation of iron deficienc TIBC and Ferritin).

Iron Binding Capacity

Iron is transported in Normal Range: 250plasma complexed to 460 g/dL the metal-binding globulin, transferrin, which is synthesized in the liver. Total iron binding capacity is calculated from transferrin levels measured immunologically. Each molecule of transferrin has two iron-binding sites, so its iron binding capacity is 1.47 mg/g. Normally, transferrin carries an amount of iron representing about 16?60% of its capacity to bind iron, ie, % saturation of iron binding capacity is 16-

increased in: Iron deficiency anemia, late pregn infancy, hepatitis. Drugs: oral contraceptives.

Decreased in: Hypoproteinemic states (eg, nep syndrome, starvation, malnutrition, cancer), ch inflammatory disorders, chronic disease, chron disease.

Additional: Increased % transferrin saturation w in iron overload (iron poisoning, hemolytic anem sideroblastic anemia, thalassemia, hemochrom pyridoxine deficiency, aplastic anemias). Decre transferrin saturation with iron: in iron deficienc (usually saturation <16%). Transferrin levels ca be used to assess nutritional status.

Lactate Dehydrogenase (LDH)

60%. LDH is an enzyme that Normal Range: catalyzes the Laboratory-specific interconversion of lactate and pyruvate in the presence of NAD/NADH. It is widely distributed in body cells and fluids and since its RBC/plasma ratio is high, it is spuriously elevated in plasma/serum following hemolysis.

increased in: Tissue necrosis, especially in acu of cardiac muscle, RBCs, kidney, skeletal mus lung, skin. Commonly elevated in various carci and in Pneumocystis carinii and B cell lymphom AIDS. Marked elevations occur in hemolytic an vitamin B12 deficiency anemia, folate deficienc anemia, polycythemia vera, acute (but not chro hepatitis, cirrhosis, obstructive jaundice, renal musculoskeletal disease, CHF. Drugs causing hepatotoxicity or hemolysis. Decreased in: Clofibrate, fluoride (low dose).

Additional: LDH is elevated after myocardial in (2-7 days), in liver congestion (eg, in CHF) and Pneumocystis carinii pneumonitis. LDH is not a liver function test and it is not specific enough f diagnosis of hemolytic or megaloblastic anemia main diagnostic use is in myocardial infarction the CKMB elevation has passed. With the avai specific LD1 measurements, the total LD level longer be useful.

Magnesium

Magnesium is primarily Normal Range: 1.8-3 an intracellular cation mg/dL (second most abundant, 60% found in bone). In extracellular fluid, it influences neuromuscular response and irritability. A magnesium deficit may exist with little or no change apparent in serum level.

increased in: Dehydration, tissue trauma, rena hypoadrenocorticism; hypothyroidism. Drugs: a (prolonged use), lithium, magnesium salts, progesterone, triamterene, vitamin D (renal fail

Decreased in: Chronic diarrhea, enteric fistula, starvation, chronic alcoholism, chronic liver dis total parenteral nutrition with inadequate replac hypoparathyroidism (especially post-parathyro surgery), high-dose vitamin D and calcium ther acute pancreatitis, delirium tremens, chronic glomerulonephritis, hyperaldosteronism, diabe ketoacidosis, SIADH, pregnancy. Drugs: albute amphotericin B, calcium salts, cisplatin, citrates transfusion), cyclosporine, diuretics, ethacrynic

Additional: Mg2+ concentration is determinated intestinal absorption, renal excretion, and exch with bone and with intracellular fluid.

Mean Corpuscular Hemoglobin (MCH)

Mean Corpuscular

MCH calculated from measured values of Hb and RBC; ie, MCH = Hb/RBC. A low MCH can mean hypochromia or microcytosis or both. A high MCH is evidence of macrocytosis. MCHC describes how fully the erythrocyte

Normal Range: 26-34 increased in: Macrocytosis. pg

Decreased in: Microcytosis (iron deficiency, thalassemia). Hypochromia (lead poisoning, sideroblastic anemia, anemia of chronic diseas

Normal Range: 31-36 increased in: Marked spherocytosis. Spuriously g/dL increased in autoagglutination, hemolysis (with

Hemoglobin Concentration volume is filled with hemoglobin and is (MCHC)

Mean Corpuscular Volume (MCV)

calculated from measurement of hemoglobin (Hb), mean corpuscular corpuscular volume (MCV) and red cell count (RBC); ie, MCHC = Hb/MCV x RBC. Average volume of the Normal Range: 80red cell is measured by 100 fL automated instrument, by electrical impedance or by light scatter.

spuriusly high Hb or low MCV or RBC), lipemia Cellular dehydration syndromes, xerocytosis.

Decreased in: Hypochromic anemia (iron defic thalassemia, lead poisoning), sideroblastic ane anemia of chronic disease. Spuriously decreas high WBC (with spuriously low Hgb or high MC RBC).

increased in: Liver disease, megaloblastic ane (folate, B12 deficiencies), reticulocytosis, newb Drugs: phenytoin. Spurious increase in autoagglutination, high WBC.

Decreased in: Iron deficiency, thalassemia; dec or normal in anemia of chronic disease.

Additional: MCV can be normal in combined iro folate deficiency. In patients with two red cell populations (macrocytic and microcytic), MCV normal.

Partial Thromboplastin Time

Patient's plasma is Normal Range: 25-35 activated to clot in vitro (range varies) Panic > by mixing it with = 60 seconds phospholipid and an activator substance. Screens the intrinsic coagulation pathway and adequacy of all coagulation factors except XIII and VII. PTT is usually abnormal if level of any factor falls below 3040% of normal.

increased in: Deficiency of any individual coag factor except XIII and VII, nonspecific inhibitors like anticoagulant), specific factor inhibitors, vo Willebrand's disease (may also be normal), he A and B, disseminated intravascular coagulatio Drugs: heparin, warfarin. Decreased in: Hypercoagulable states, DIC.

Comments: PTT is the best test to monitor ade heparin therapy. Test not always abnormal in v Willebrand's disease. Test may be normal in ch DIC. Very common cause of prolongation is sp presence of heparin in sample.

Phosphorous

The plasma Normal Range: 2.5concentration of 4.5 mg/dL inorganic phosphate is determined by parathyroid gland function, action of vitamin D, intestinal absorption, renal function, bone metabolism, and nutrition.

increased in: Renal failure, massive blood tran sarcoidosis, neoplasms, adrenal insufficiency, acromegaly, hypoparathyroidism, hypervitamin phosphate infusions or enemas, osteolytic met to bone, leukemia, milk-alkali syndrome, healin fractures, pseudohypoparathyroidism, diabetes with ketosis, malignant hyperpyrexia, cirrhosis, acidosis, respiratory acidosis. Drugs: eg, anab steroids, ergocalciferol, furosemide, hydrochlorothiazide and others.

Decreased in: Hyperparathyroidism, hypovitam (rickets, osteomalacia), malabsorption (steator malnutrition, starvation or cachexia; GH deficie chronic alcoholism, severe diarrhea, vomiting, nasogastric suction, severe hypercalcemia (an cause), acute gout, osteoblastic metatases to b

severe burns (diuretic phase), respiratory alkal hyperalimentation with inadequate phosphate r carbohydrate administration (intravenous), ren acidosis and other renal tubular defects, diabe ketoacidosis (during recovery), acid-base distu hypokalemia, pregnancy, hypothyroidism; prolo use of thiazides, glucose infusion, salicylates ( Drugs: eg, phosphate-binding antacids, anticonvulsants, estrogens, isoniazid, oral contraceptives.

Platelet Count

Platelets are released Normal Range: 150from megakaryocytes 450 X 10 3/uL in bone marrow, and they are important for adequate hemostasis. Platelet counting is done by flow cytometer based on size discrimination using either electrical impedance or electrooptical systems. Normal Range: 3.5-5.0 Potassium is meq/L predominantly an intracellular cation whose plasma level is regulated by renal excretion. Plasma concentration determines neuromuscular and muscular irritability. Elevated or depressed potassium concentrations interfere with muscle contraction. increased in: Massive hemolysis, severe tissue damage, rhabdomyolysis, acidosis, dehydration, acute or chronic renal failure, Addison's disease, renal tubular acidosis type IV (hyporeninemic hypoaldosteronism), hyperkalemic familial periodic paralysis. Drugs: potassium salts, potassiumsparing diuretics

increased in: Myeloproliferative disorders: poly vera, CML, essential thrombocythemia, myelof after bleeding, postsplenectomy, reactive thrombocytosis secondary to inflammatory dise

Decreased in: Decreased production: bone ma suppression or replacement, chemotherapeutic other drugs, eg, ethanol. Increased destruction removal: splenomegaly, DIC, platelet antibodie posttransfusion purpura, neonatal isoimmune thrombocytopenia, drugs (eg, quinidine, cephalosporins).

Potassium

(spironolactone, triamterene), nonsteroidal antiinflammatory drugs, beta-blockers, ACE inhibitors. Decreased in: Low potassium intake, prolonged vomiting or diarrhea, renal tubular acidosis (types I, II), hyperaldosteronism, Cushing's syndrome, osmotic diuresis (eg, of hyperglycemia), alkalosis, familial periodic paralysis, diuretic therapy. Additional: Spurious K+ can occur with hemolysis of sample, delayed separation of plama from erythrocytes, prolonged fist clenching during blood drawing, tourniquet placed for prolonged periods, and very high white cell or platelet counts.

Protein

The plasma protein Normal Range: 6-8 concentration is g/dL determined by the nutritional state, hepatic function, renal function, and various disease states and hydration. The plasma protein concentration determines colloidal osmotic pressure.

increased in: Polyclonal or monoclonal gammo marked dehydration. Drugs: anabolic steroids, androgens, corticosteroids, epinephrine.

Decreased in: Protein-losing gastroenteropathi acute burns, nephrotic syndrome, severe dieta protein deficiency, chronic liver disease, malab syndrome, agammaglobulinemia.

Additional: The serum total protein consists pri albumin and globulin. Hypoproteinemia usually hypoalbuminemia, since albumin is the major s protein. Globulin is calculated as total protein m albumin.

Prothrombin Time

PT screens the Normal Range: 11-15 extrinsic pathway of the seconds coagulation system. It is performed by adding calcium and tissue thromboplastin to a

increased in: Liver disease, vitamin K deficienc intravascular coagulation, circulating anticoagu massive blood volume replacement. Drugs: wa

Additional: In liver disease, the PT reflects the capacity for protein synthesis. PT responds rap

sample of citrated, platelet-poor plasma and measuring the time required for fibrin clot formation. It is most sensitive to deficiencies in the vitamin K-dependent clotting factors II, VII, and X. It is also sensitive to deficiencies of factor V. It is insensitive to fibrinogen and not affected by heparin. It is used to monitor warfarin therapy.

altered hepatic function because the serum ha factors II and VII are short (hours). Routine preoperative measurement of PT is unnecessa unless there is clinical history of a bleeding dis Efforts to standardize and report the prothromb as an INR (International Normalized Ratio) dep assigning reagents an International Sensitivity (ISI) so that INR = [PT patient/PT normal]ISI. H assignment of incorrect ISI by reagent manufa has in fact caused a greater lack of standardiza

Rheumatoid Factor

Normal Range: Heterogeneous autoantibodies usually Negative (<1:16) of the IgM class that react against the Fc region of human IgG.

Positive in: Rheumatoid arthritis (75-90%), Sjo (80-90%), scleroderma, dermatomyositis, SLE sarcoidosis, Waldenstrom's macroglobulinemia methyldopa, others. Low titer can be found in h older patients (20%). 1-4% of normals and in a of acute immune responses (eg, viral infections infectious mononucleosis, and viral hepatitis), c infections (tuberculosis, leprosy, subacute bact endocarditis) and chronic active hepatitis.

Additional: It can be useful in differentiating rhe arthritis from other chronic inflammatory arthrit However, a positive RF test is only one of seve criteria needed to make the diagnosis of rheum arthritis.

Sodium

Sodium is the Normal Range: 135predominant 145 meq/L extracellular cation. Serum sodium level is primarily determined by the volume status of the individual. Hyponatremia can be divided into hypovolemia, euvolemia, and hypervolemia categories.

increased in: Dehydration (excessive sweating vomiting or diarrhea), polyuria (diabetes mellitu diabetes insipidus), hyperaldosteronism, inade water intake (coma, hypothalamic disease). Dr steroids, licorice, oral contraceptives.

Decreased in: Congestive heart failure, cirrhos vomiting, diarrhea, excessive sweating (with replacement of water but not salt); salt-losing nephropathy, adrenal insufficiency, nephrotic syndrome, water intoxication, SIADH. Drugs: th diuretics, ACE inhibitors, chlorpropamide, carbamazepine.

Additional: Spurious hyponatremia produced b lipemia and hyperproteinemia if sodium analys involves a dilution step. Sodium falls about 1.6 for each 100 mg/dL increase in blood glucose. Hyponatremia in a normovolemic patient with u osmolality higher than plasma osmolality sugge possibility of SIADH, myxedema, hypopituitaris reset osmostat.

Uric Acid

Uric acid is an end Normal Range: Males: product of 2.4-7.4 Females 1.4nucleoprotein 5.8 mg/dL metabolism and is excreted by the kidney. An increase in serum uric acid concentration occurs with increased nucleoprotein synthesis or catabolism (blood dyscrasias, therapy of leukemia) or decreased renal excretion (eg, with use of thiazide diuretics or renal failure).

increased in: Renal failure, gout, myeloprolifera disorders (leukemia, lymphoma, myeloma, polycythemia vera), psoriasis; glycogen storag disease (type I); Lesch-Nyhan syndrome (X-lin hypoxanthine-guanine phosphoribosyltransfera deficiency); lead nephropathy. Drugs: antimeta and chemotherapeutic agents, diuretics, ethan nicotinic acid, salicylates (low dose).

Decreased in: SIADH, xanthine oxidase deficie low-purine diet. Fanconi's syndrome, neoplasti disease (various, causing increased renal excr liver disease. Drugs: salicylates (high dose), al (xanthine oxidase inhibitor).

Additional: Sex and age affect uric acid levels. incidence of hyperuricemia is greater in some r groups (eg, Filipinos) than others (Whites).

White Blood Count (WBC, Measure of the total number of leukocytes Leukocyte count)

in whole blood. Counted on automated instruments using light scattering or electrical impedance after lysis of RBCs. WBCs are distinguished from platelets by size.

Normal Range: 3.4-10 increased in: Infection, inflammation, hematolo K/L malignancy, leukemias (AML, ALL, CML, CLL), lymphoma. Drugs: corticosteroids.

Decreased in: Aplastic anemia (decreased pro B12 or folate deficiency (maturation defect), se (decreased survival). Drugs: phenothiazines, chloramphenicol, aminopyrine.

Additional: Spurious increase: with high numbe nucleated red cells.