Review in Clinical Chemistry

 Lipid Profile (Cholesterol, Triglyceride, HDL,

LDL, VLDL)
PRINCIPLES OF MEASUREMENT
Fluids Typically Used for Clinical Chemistry Tests
Photometry – relies on measurement of light by a  Blood (Whole Blood in HBA1c, serum or plasma)
photodetector
 Urine
 CSF
Turbidimetry and Nephelometry – based on formation
 Amniotic Fluid
of insoluble particles that interfere with the passage of
 Saliva
lght through the solution
 Synovial Fluid
Example: HDL measurement – we make insoluble
solution first. More turbid=high concentration  Pleural Fluid
 Pericardial Fluid
Fluorescence – certain kinds of chemical structures are  Peritoneal Fluid
able to absorb light of one wavelength and emit light of
another wavelength ANALYTES

Potentiometry – based on measurement of an electrical GLUCOSE

potential between two electrodes. One of the electrodes  The standard clinical specimen in venous
is affected by contact with ions in solution. plasma glucose
Example: electrolytes using Ion Selective Electrode  Fasting glucose in Whole Blood is 15% lower
than in serum or plasma
End-Point Reactions – suitable for chemical reactions  A major source of energy for many tissues –
that are completed in a relatively short time and are regulated by hormones, such as insulin, cortisol
“stoichiometric”, meaning that they produce one product and glucagon
of molecule of complex for each molecule of analyte. Why measured? – to test for diabetes; in critical care
Example: Glucose, Uric Acid, Cholesterol setting to test metabolic state

Rate Reactions (Kinetic) – if the analyte is an enzyme, Increased – Diabetes, Cushing’s disease, stress
a molecule which can catalyze the conversion of Decreased – insulin excess, starvation, adrenal
unlimited numbers of reagent molecules to product, the insufficiency
amount of product at the endpoint would not reflect the
amount of enzyme Reference Value: FPG 70-99 mg/dL
100-125 (impaired plasma glucose)
ROUTINE LABORATORY TESTING >126 (diabetes mellitus)
Conversion Factor: 0.0555 (mg/dL to mmol/L)
Panel of Tests
- When an individual test alone is not sufficient to HBA1c GLYCATED HEMOGLOBIN
assess a medical condition, a combination of  Largest subfraction of normal hemoglobin A in
several tests may be used both diabetic and non-diabetic individuals
- The pattern of results from the combination of  Hb molecule with a glucose molecule covalently
tests may provide better insight into the status of bound
the patient than any single test result. Why measured? – a reliable method in the monitoring of
Example: FBS and OGTT (patient drinks 75g glucose long-term glucose control. Gives a good estimate of
load for 5 – 10 minutes) in diagnosing DM glucose control over a 3-month period

TYPICAL PANELS OF TEST Reference Value: <5.7%

5.7-6.4% (prediabetic)
 Electrolyte Panel (Na, K, Cl, PCO2, HCO3, > 6.5% (DM)
anion gap)
 Hepatic Panel (Liver Profile) – Bilirubin test TOTAL PROTEIN (serum/plasma)
 Comprehensive Metabolic Profile  Measures the amount of proteins, primarily
 Basic Metabolic Panel (Na, K, Cl, CO2, Glucose, albumin and globulins, found in serum or plasma
Creatinine, BUN)  Maintains circulatory system oncotic pressure
Why measured? – it is a screening test to see if protein
levels are at expected value Reference Value: 8-23 mg/dL
Conversion factor: 0.357
Increased – dehydration, infections, some cancers like Urea to BUN: Urea/2.14
myelomas and lymphomas
Decreased – protein loss (from kidney or GI tract), liver CREATININE
disease, malnutrition  A waste product from the muscle breakdown of
a compound called creatine, which is excreted
Reference Value: 6.4-5.3 g/dL into urine by kidneys
Conversion factor: 10 (g/dL to g/L)  Produced by three amino acids such as
METHIONINE, ARGININE, LYSINE
ALBUMIN  A measure of completeness of 24-hour urine
 Protein present in highest concentration in collection
plasma (1/2 the plasma protein mass)  Used to evaluate the fetal kidney maturity
 Major protein in blood made in the liver, it binds Why measured? – to evaluate kidney function and
and transports many substances monitor therapy for kidney disease; creatinine may be
 Sensitive and highly prognostic marker in cases measured I blood, urine or both to evaluate kidney
of cystic fibrosis function
Why measured? – albumin level is a general indicator of
health and nutritional status Increased – kidney dysfunction (drug toxicity, poorly
controlled diabetes, inadequate blood flow – shock or
Increased – dehydration, infection, malignancy congestive heart failure)
Decreased – starvation, burns, kidney disease, liver Decreased – decreased muscle mass, advanced and
disease severe liver disease

Reference Value: 3.5-5.0 g/dL Reference Value: Male 0.9-1.3 mg/dL

Conversion factor: 10 (g/dL to g/L) Female 0.6-1.1 mg/dL
Conversion Factor: 88.4 (mg/dL to mmol/L)
GLOBULINS
 Group of proteins consists of a1, a2, beta, and Elevated plasma creatinine concentration is associated
gamma fractions with abnormal renal function, especially as it relates to
Why measured? – calculated as total protein minus glomerular function
albumin, globulins are the other major protein fractions
CREATININE CLEARANCE
Increased – infections, multiple myeloma  Provides an estimate of an amount of plasma
Decreased – leukemias, immunosuppression that must flowed through the kidney
glomeruli/minute. Major limitation: accurate urine
Reference Value: 2.3-3.5 g/dL collection
Conversion Factor: 10 (g/dL to g/L)  Clearance (ml/min) = UV(ml/minute)/P x 1.73/A
Reference Value: Male = 85 – 125 ml/min
UREA NITROGEN (BUN) Female = 75 – 112 ml/min
 Waste product from protein breakdown formed Conversion Factor: 0.0167 (mL/min to mL/s)
by the liver and excreted by the kidney
 It is the major end product of protein and amino URIC ACID
acid catabolism – 45% of the total NPN  A waste product from breakdown of purines
 The concentration of urea is expressed only the (DNA components) that is excreted by the
the nitrogen content of urea kidneys; too much uric acid can lead to deposits
 To obtain the concentration of urea from BUN: or urate crystals in joints (gout) or in kidneys
2.14 (f) x BUN = urea (mg%) (stones)
Why measured? – often ordered with creatinine to  Freely filtered, partially reabsorbed and secreted
evaluate kidney function; also used to monitor dialysis in the renal tubules
patients  About 1 gram of uric acid is excreted normally
Why measured? – to evaluate joint inflammation that
Increased – kidney dysfunction, stress, high protein diets may be due to gout; often ordered to monitor uric acid
Decreased – low protein diets, liver disease
production in patients undergoing chemotherapy or stored fat and the predominant form of glyceryl
radiation treatments ester found in plasma
 The breakdown of triglycerides are facilitated by
Increased – gout, kidney disease, leukemia lipoprotein lipase, epinephrine, and cortisol
Decreased – Fanconi’s syndrome, Wilson’s disease,  People with low calorie intake have relatively low
Hodgkin’s disease triglyceride levels
Why measured? – part of the cardiovascular risk profile.
Reference Value: Male 3.5 – 7.2 mg/dL; Female 2.6 – It evaluates suspected atherosclerosis and measured
6/0 mg/dL the body’s ability to metabolize fat
Conversion Factor: 0.0595
Increased – hypothyroidism, alcoholism, liver disease,
AMMONIA uncontrolled diabetes
 A waste product of amino acid breakdown Decreased – malabsorption syndrome, hyperthyroidism,
converted to urea by the liver; increased malnutrition, brain infarction
ammonia levels an cause mental and neurologic
changes in the brain Reference Value: <150 mg/dL (normal)
Why measured? – to evaluate disorientation, confusion 150-199 (borderline high)
and coma in adults; to evaluate irritability, lethargy and 200 – 499 (high triglycerides)
seizures in newborns >500 (very high triglycerides)
Conversion Factor: 0.0113
Increased – severe liver disease, cirrhosis, severe
hepatitis, Reye’s syndrome, inherited genetic HIGH DENSITY LIPOPROTEIN/ALPHA LPP
deficiencies  HDL removes excess cholesterol rom tissue for
disposal; elevated HDL has been found to
Reference Value – 40 – 80 µg/dL protect against coronary artery disease
Conversion Factor: 0.587  Transports excess cholesterol from the tissues
and return it to the liver (reverse cholesterol
CHOLESTEROL transport)
 Found on the surface of lipid layers; synthesized Why measure? Part of the cardiovascular risk profile
in the liver
 Its transport and excretion is promoted by Increased – estrogen therapy, alcohol consumption
estrogen Decreased – smoking
 Precursors of five major classes of steroids:
progestins, glucocorticoids, mineralocorticoids, Reference Value: Male >37 mg/dL
androgens and estrogens Female >40 mg/dL
 Cholesterol ester (70%) and Free Cholesterol Conversion Factor: 0.0260
(30%)
Why measured? – high cholesterol has been implicated LOW DENSITY LIPOPROTEIN/BETA LPP
as a risj factor for coronary artery disease. Evaluates the  Carries cholesterol from the liver to peripheral
risk for atherosclerosis, myocardial and coronary arterial tissue; contributes to formation of plaques that
occlusions clog arteries and lead to coronary heart disease
 Synthesized in the liver; major end product from
Increased – Hypothyroidism, uncontrolled diabetes, the catabolism of VLDL
kidney disease  Most atherogenic LPP; target of therapy
Decreased – Liver diseases, starvation, anemia Why measured? – part of the cardiovascular risk profile

Reference Value: <200 mg/dL (desirable) Increased – high saturated fat diets, inherited disorders
200-239 (borderline high) of cholesterol metabolism
>240 (high cholesterol) Decreased – high fiber intake, drug treatment
Conversion Factor: 0.0260
Reference Value: <100 mg/dL
TRIGLYCERIDES (fasting required – 10 - 14hrs) Conversion Factor: 0.0260
 Chemical form of fatty acids for transport and
storage in adipose tissue – constitutes 95% of
VERY LOW DENSITY LIPOPROTEIN/PRE-BETA LPP Why measured? – calculated as Total Bilirubin – Direct
 Triglyceride-rich lipoprotein that is secreted by Bilirubin; it reflects the difference between the total and
the liver and is the precursor to LDL direct forms
 Transports endogenous triglycerides from the
liver to muscle, fat depots, and peripheral Increased – Hereditary conditions like Gilbert’s disease
tissues (bilirubin transport deficit; impaired cellular uptake of
 Prolonged consumption of high fat diets – bilirubin; elevated B1) and Crigler-Najjar syndrome (type
elevated triglycerides in the VLDL particles 1 – deficiency of enzyme glucoroneotransferase, total
Why measured? – part of the cardiovascular risk profile absence of B2 production; type 2 – partial deficiency of
the enzyme)
Increased – high saturated fat diets, inherited disorders
of cholesterol metabolism  Van den Berg reaction is diazotization of bilirubin
Decreased – high fiber intake, drug treatment to produce azobilirubin
Reference Value:
Reference Value:<30 mg/dL(same conversion factor w/  Total Bilirubin = 0.2 – 1.0 mg/dL
LPPs)  Conjugated Biliruin = 0.0 – 0.2 mg/dL
Formula for LDL and VLDL  Unconjugated Bilirubin = 0.2 – 0.8 mg/dL
LDL = Total cholesterol – HDL – VLDL Conversion Factor: 17.1 (mg/dL to µmol/L)

Friedewald Method AUTOMATION

 VLDL (mmol/L) = plasma TAG/2.175  Increase the number of tests to be performed in
 VLDL (mg/dL) = Plasma TAG/5.0 a given period
 Minimizes variation of result from one
De Long Method: laboratorian to another
 VLDL (mmol/L) = Plasma TAG/2.825  Eliminated the potential error in manual analyses
 VLDL (mg/dL) = Plasma TAG/6.5 such as pipetting, calculation and transcription of
results
TOTAL BILIRUBIN o Continuous Flow Analyzer
 This breakdown product of hemoglobin is o Centrifugal Analyzer
excreted by the liver into the bile – it circulated in o Discrete Analyzer
blood in two forms referred to as conjugated and
unconjugated, reflecting whether the carboxyl Definition of terms:
groups are free (unconjugated) or esterified  Batch Testing – all samples are loaded at the
(conjugated) same time, and a single test is conducted on
Why measured? – to assess liver function each sample
 Parallel Testing – more than one test is
Increased – Hepatitis, cirrhosis, hemolytic diseases and analyzed concurrently on a given clinical
obstruction of biliary or hepatic ducts specimen
 Random access testing – any test can be
DIRECT BILIRUBIN (CONJUGATED BILIRUBIN) performed on any sample, in any sequence
 Water-soluble, made in the liver and excreted in  Sequential testing – multiple test analyzed one
the blood, it reacts directly with diazo dye, so it is after another on a given specimen
called direct reacting  Open reagent system – other than
Why measured? – to test the liver’s ability to conjugate manufacturer’s reagent
bilirubin and excrete it  Closed reagent system – only the
manufacturer’s reagent
Increased – Obstruction of biliary of hepatic ducts, and in  Pneumatic tube delivery system – point-to-
hereditary conditions like Dubin-Johnson syndrome point delivery of specimens
(bilirubin excretion deficit)
CONTINUOUS FLOW ANALYZER
INDIRECT BILIRUBIN (UNCONJUGATED BILIRUBIN)  Liquids are pumped through a system of
 Fat-soluble and the product of hemoglobin continuous tubing
breakdown; it reacts with diazo dyes only in the  Sample flow through a common reaction vessel
presence of activators so it is called indirect or pathway
reacting
  Disadvantage: all tests are performed in parallel and assay processing, giving you accurate,
efficient result reporting
CENTRIFUGAL FORCE ANALYZER  Method: Colorimetric/Rate, Potentiometric (direct
 It uses force generated by centrifugation to ISEs), Immuno-rate, Turbidimetric, Enhanced
transfer specimen and reagents Chemiluminiscence
 Liquids are placed in separate cuvettes for  Sample Types: Serum, Plasma, Whole Blood,
measurement at the perimeter of a spinning Urine, CSF, Amniotic Fluid
rotor (1000 rom)  Sample Volume: 2 – 80 uL (per assay)
 Major advantage: Batch analysis (discrete-batch  Dead Volume: minimum of 35 uL
type system)

DISCRETE ANALYZER
 Most popular and versatile analyzer – measures
only the tests requested on a sample
 Requires 2-6 uL of the sample (minimum
volume)
 Major Advantage: Random access capability –
allows STAT samples to be easily tested

ABBOTT DIAGNOSTICS ARCHITECT c4000

 Demonstrates high-quality testing results and
rapid STAT turnaround time. The ARCHITECT
c4000 enhances laboratory productivity and
provides users high confidence in clinical results.
 Offers a maximum throughput of up to 800 tests
per hour. Featuring a load-up capacity of 100
samples with 35 priority positions, the
ARCHITECT c4000 allows for up to 90
refrigerated reagent positions on board, plus
Integrated Chip Technology (Na+, K+ and Cl-).
 Wet chemistry analyzer
 Methods: Photometric, Potentiometric,
Turbidemetric
 Sample Types: Serum, Plasma, Whole Blood,
Urine, CSF
 Sample Cup: 50 uL (dead volume)
 Sample Volume: 1.5 – 35 u: (average of 6 uL)

VITROS 5600 INTEGRATED SYSTEM (dry chemistry

analyzer)
 VITROS Microslide – design filters out protein
and lipids when appropriate, minimizing sample
interferences
 VITROS Microtip – eliminated carry-over and
contamination risk of water-based systems
 VITROS Microwell – delivers precise results,
with fewer unnecessary dilutions, repeats and
redraws
 VITROS Microsensor – detects endogenous
interferences without the need for extra sample
or reagent – and with no effect on turnaround
time
 VITROS Intellicheck – monitors, verifies, and
documents diagnostic checks throughout sample
 ANALYTE REFERENCE RANGE UNIT CONVERSION FACTOR
70 – 99 (normal)
GLUCOSE 100 – 125 (prediabetic) mg/dL 0.0555 (to mmol/L)
>126 (DM)
<5.7 (normal)
HBA1c 5.7 – 6.4 (prediabetic) % N/A
>6.5 (DM)
TOTAL PROTEIN 6.4 – 8.3 g/dL 10 (to g/L)

ALBUMIN 3.5 – 5.0 g/dL 10 (to g/L)

GLOBULIN 2.3 – 3.5 g/dL 10 (to g/L)

BUN to Urea (mg%) = BUN x 2.14
UREA NITROGEN (BUN) 8 - 23 mg/dL UREA to BUN = Urea/2.14
BUN CU to SI unit = 0.357
Male: 0.9 – 1.3
CREATININE mg/dL 88.4
Female: 0.6 – 1.1
Male: 85 – 125
CREATININE CLEARANCE mL/min 0.0167 (to mL/s)
Female: 75 - 112
Male: 3.5 – 7.2
URIC ACID mg/dL 0.0595
Female: 2.6 – 6.0
AMMONIA 40 – 80 µg/dL 0.587
<200 (desirable)
CHOLESTEROL 200 – 239 (borderline high) mg/dL 0.0260
>240 (high cholesterol)
<150 (normal)
150 – 199 (borderline high)
TRIGLYCERIDES mg/dL 0.0113
200 – 499 (high TG)
>500 (very high TG)
Male: >37
HDL mg/dL 0.0260
Female: >40
LDL <100 mg/dL 0.0260

VLDL <30 mg/dL 0.0260

TOTAL BILIRUBIN 0.2 – 1.0 mg/dL 17.1
CONJUGATED (DIRECT) BILIRUBIN 0.0 – 0.2 mg/dL 17.1
UNCONJUGATED (INDIRECT) BILIRUBIN 0.2 – 0.8 mg/dL 17.1