HBC/BC 306 Clinical Biochemistry

Basic biochemistry emphasizing human metabolic pathways & their relationship to health & disease. Biochemical tests are used in the diagnosis, management, treatment and subsequent follow-up, of human disease Type of Samples
Concentration of different analytes determined in: Blood Serum or plasma Urine Cerebrospinal fluid (CSF)

Within-Individual Variation 1. Time of day- diurnal variation of: Plasma iron Adrenocorticotropic hormone (ACTH) Cortisol 2. Diet Plasma [triglyceride] Response to glucose tolerance tests Urinary calcium excretion 3. Muscular Exercise Increase plasma creatine kinase activity Increase blood [lactate] Lower blood pyruvate

4. Menstrual Cycle Plasma [iron] Plasma conc. of pituitary gonadotrophins & ovarian steroids & their metabolites Amts of hormones & their metabolites excreted in urine 5. Drugs Oestrogen-containing oral contracetives affect plasma constituents

Between-Individual Variation
1. Age Plasma [phosphate] & alkaline phosphatase activity

 Plasma & urinary conc. of gonadotrophins & sex hormones 2. Sex Plasma creatine, iron, urea conc. Plasma & urinary conc. of sex hormones 3. Race Plasma [cholesterol] & [protein] Diet???

Reference Ranges
Set of results from a particular defined population No clear-cut distinction between normal & abnormal conc. of any constituent

To interpret results, know: Reference range for healthy individuals Expected values for patients with disease Prevalence of disease in population Sensitivity of test
Ability to show +ve results in patients with particular disease (true +ve rate) The higher the sensitivity, the greater the detection rate, the lower the false ve rate Specificity of test % of ve results among people who do not have the disease The higher the specificity, the lower the false +ve rate

Use of Enzymes in Clinical Biochemistry 1. Indicators of various diseases 2. Analytical reagents 3. Therapeutic agents Release of Enzymes from Cells 1. Necrosis or severe damage to cells 2. Increased rate of cell turnover 3. Increased conc. of enzymes within cells 4. Duct obstruction Enzymes Commonly Used in Diagnosis 1. Lactate dehydrogenase (LD) 2. Creatine kinase (CK) 3. Transaminases 4. Alkaline phosphate (ALP)

Serum Markers in the Diagnosis of Tissue Damage Myocardial Infarction Myocardial infarct - lesion formed when cells of the myocardium die due to severe ischemia (territorial distribution of blood) Common cause- Artery obstruction caused by formation of thrombus (blood clot) Anti-thrombolytic therapy- protects myocardium from permanent damage by restoring blood flow Streptokinase Recombinant tissue plasminogen activator

 Measurement of circulatory proteins (enzymes & non-enzyme proteins) released from necrotic myocardial tissue are useful in diagnosis Rise rapidly to a peak between 18 & 36 hrs Return to normal dependent on life each protein in the plasma 1. Myoglobin earliest marker not cardiac specific raised by any form muscle damage

2. Total CK 3 principal CK isoenzymes Dimers BB, MB, MM Rel. early marker Not cardiac specific 3. CKMB Rel. early marker Higher cardiac specificity over total CK 4. Cardiac Troponin T Rel. early marker Cardiac specific

 But elevated in diseases of regeneration of skeletal muscle & chronic renal disease 5. Cardiac Troponin I Rel. early marker Highly cardiac specific 6. LDH Isoenzymes Late marker Not cardiac specific LD1/LD2 determination increases cardiac specificity

Acute Pancreatitis Obstruction of pancreatic duct that delivers pancreatic juice to small intestine Gall stones Alcohol abuse Inappropriate release of pancreatic enzymes & their premature activation Eg Trypsinogen is activated to trypsin - converts many other enzymes to their active forms

Lab. Diagnosis involves measurement of pancreatic digestive enzymes. 1. Serum Amylase Elevated levels sensitive diagnostic indicator Low specificity Many non-pancreatic causes of hyperamylasemia 2. Serum Lipase Higher specificity than amylase

Renal Function Tests

To identify renal dysfunction To diagnose renal disease & monitor progress To monitor response to treatment Functions of the Kidney 1. Production of urine Elimination of metabolic end products, ie urea & creatinine Elimination of foreign materials drugs Control of volume & composition of extracellular fluid - water & electrolyte balance - acid / base balance 2. Endocrine Functions

- Vitamin D - Erythropoietin - Antidiuretic hormone Biochemical Tests - Urinalysis - Measurement of glomerular filtration rate - Tubular function tests Tests rarely establish the cause BUT help in screening for damage & monitoring progression of disease Urinalysis 1.Valid sample = fresh sample 2.Appearance- Unusual colour due to blood or infection?

3.Specific gravity- sticks measure ionic species only & NOT glucose 4.pH normally acidic except after a meal 5.Glucose increased blood glucose?? 6.Proteinuria- detected using urine sticks - Raised plasma low MW proteins, Bence Jones, myoglobin? - Glomerular leak? - Decreased tubular reabsorption of protein? 7.Urine sediments- microscopic examination for cells, fat droplets? Measurement of Glomerular Filtration Rate (GFR) - GFR is essential to renal function & is a frequently performed test

- Measurement is based on concept of clearance The determination of the volume of plasma from which a substance is removed by glomerular filtration during its passage through the kidney Clearance = (U x V) / P Where U = urinary conc. of substance V = rate of urine formation in ml/min P = plasma conc. of substance Units = vol / unit time (ml/min) Eg. Creatinine Clearance (ml/min) =Urine[creatinine] x urine vol (ml) Plasma [creatinine] collection time (min) If clearance = GFR then substance - Freely filtered by glomerulus - Glomerulus is sole route of excretion, ie no tubular secretion or reabsorption - Easily measurable - Has constant plasma conc.

Tubular Function Tests Specific renal tubule disorders may affect ability to Concentrate urine Excrete appropriately acidic urine Cause impaired reabsorption of phosphate, amino acids, glucose Acute Renal Failure (ARF) Due to reduced glomerular filtration rate with resultant retention of Urea & creatinine Na & water Acid with metabolic acidosis

 Potassium with hyperkalaemia (potassium is released from cells & acidosis promotes the leakage) ARF may manifest as pre-renal, renal or postrenal Chronic Renal Failure (CRF) Progressive loss of nephrons resulting permanently impaired renal function Retention of urea, creatinine, toxins Rate of urea excretion falls & cannot balance rate of production Plasma urea rises, urea conc. in filtrate of functioning nephrons rises

 May cause osmotic diuresis in these nephrons Sodium & potassium excretion?

Liver Function Tests

Functions of the Liver 1. Carbohydrate metabolism Glycogen synthesis, storage & breakdown Gluconeogenesis 2. Lipid metabolism Synthesis of almost all lipoproteins, phospholipids, cholesterol

3. Protein Synthesis Many plasma proteins, most coagulation factors are synthesized in hepatic cells 4. Storage functions Vitamins A, D, B12 & iron 5. Excretion & Detoxification Bile pigments & cholesterol are excreted in bile Many drugs are detoxicated by the liver Ammonia derived from amino acid metabolism is converted to urea Steroid hormones are inactivated by conjugation with glucuronate & sulphate in liver & excreted in urine

6. Reticulo-endothelial function Kupffer cells lining sinusoids of liver form part of reticulo-endothelial system Bilirubin Metabolism Heme groups (from haemoglobin myoglobin, cytochromes) are freed of iron & converted to bilirubin Bilirubin is a yellow pigment that is strongly lipophilic & cytotoxic Transported to liver, bound to serum albumin At the liver, bilirubin is coupled to glucuronic acid & the conjugated bilirubin is excreted into bile

Jaundice Clinically detectable increase in plasma bilirubin levels Due to predominant rise in unconjugated bilirubin from excessive haemolysis or decreased excretion Biochemical Tests in Liver Disease Hepatocellular Damage Damage to liver cells, with or without necrosis, causes acute release of intracellular constituents into bloodstream Detected by measuring plasma enzymes, alanine & aspartate aminotransferases (transaminases)

Biliary Tract Involvement Characterized by increased production & raised plasma levels of hepatobiliary enzymes, alkaline phosphatase (ALP)& gamma- glutamyltransferase (GGT) Obstruction of biliary tract with jaundice indicates cholestasis Impaired Hepatocellular Function Affects synthesis of albumin, coagulation factors & bilirubin metabolism Hypoalbuminaemia & a prolonged prothrombin time are detectable when damage is extensive & prolonged Deficiency of Vit K may also cause prolonged prothrombin time

Disordered Metabolism Patients with severe liver disease may have: Significant decreases in plasma [urea] due to failure of liver to convert amino acids & ammonia to urea Hypoglycaemia due to impaired gluconeogenesis or glycogen breakdown Raised conc. of all plasma lipid fractions, if cholestasis is present Specific Liver Diseases Acute Hepatitis Caused by viruses or toxins

 Cell damage detectable by plasma enzyme estimations Cirrhosis During active cellular destruction, transaminase levels rise, sometimes with jaundice In alcoholic cirrhosis, GGT levels are elevated