Basic Clinical Chemistry PDF

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Introduction II. SPECIALIZED TESTS
Recommended Preparation
A. Hormones and the Endocrine
Glossary
System
B. Immunoglobulins and Immunity
I. GENERAL CLINICAL CHEMISTRY TESTS
C. Toxicology
A. Electrolytes D. Special Chemistry
B. Chemistry Profile E. Coagulation
C. Enzymes Summary
Summary Review Questions (II)
Review Questions (I)
Integrative Summary
References
Self-assessment Post-test
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INTRODUCTION
Introduction
linical Chemistry is a fundamental science that seeks to understand the relationship
C of biochemical tests and their results. Results are then correlated to disease
processes to assist with the diagnosis of disease and to select treatment options.
Clinical Chemistry involves testing of many different types of samples. Testing may be
performed using serum, plasma, urine, spinal fluid, and/or any other body fluid, as
manufacturer states.
Recommended Preparation
This module is not intended to be inclusive but presents just a representative selection of
clinical chemistry tests.
We have not quoted reference ranges because their values can vary. You should deter-
mine the reference range for each assay you run in the laboratory. If you are sending
tests to a reference laboratory, they will furnish you with their reference ranges.
Basic Clinical Chemistry 94922-101 November 2001 page 2 of 69

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RECOMMENDED PREPARATION
When you see these symbols be aware of specimen handling.
Keep stoppered. Short samples can affect results.
Hemolysis can affect results.

Protect from light.
Lipemia can affect results.

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GLOSSARY
Glossary
Acidosis: state of decrease of alkali and an accumulation of acid metabolites in blood
or body fluids.
Addison’s disease: chronic adrenocortical insufficiency.
Adipose [AD ih pohs]: of or relating to fat in blood or body fluids.
Alkalosis: state of excess of base or loss of acid in blood or body

fluids.
Amino acid: organic acid used to form proteins.
Analyte: substance that is being measured, eg, glucose, sodium.
Antibody: protein formed as the result of antigenic stimulation.
Antigen: foreign substance that results in antibody production.
Body fluid: fluid in body cavities or spaces, eg, pleural, abdominal, pericardial.
Catalyst: substance that accelerates a chemical reaction.

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GLOSSARY
Cation [KAT igh ahn]: ion carrying a positive charge.
Colostrum [kah LOS trum]: first milk secreted at the termination of pregnancy.
Complement: group of serum proteins that produce inflammatory effects and lysis of
cells when activated.
Cryoglobulinemia [KRIGH oh glahb yoo lin EE mee uh]: presence of cryoglobulin,

an abnormal plasma protein, in the blood plasma.
Cushing’s syndrome: adrenal hyperplasia caused by an adenoma of the pituitary gland.
Disseminated intravascular coagulation (DIC): hemorrhagic syndrome following

uncontrolled activation of clotting and fibrinolytic enzymes throughout the small
blood vessels.
Dubin-Johnson syndrome: inherited defect in hepatic excretory function, character-

ized by abnormally high levels of conjugated bilirubin.
Enzyme: protein in the body that acts as a catalyst.
Excretion: process by which undigested food and waste products are separated from
the blood and cast out.

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GLOSSARY
Extracellular: outside the cell.
Exudate [EKS yoo dayt]: fluid which has leaked out of a tissue or capillary, usually in
response to inflammation or injury.
Gaucher’s disease: lysosomal storage disease resulting from a genetic deficiency, most
commonly seen in infants.
Hemoglobin: protein of red blood cells that transports oxygen from the lungs to
tissues.
Hemolysis [hee MAH luh sis]: rupture of red blood cells and release of hemoglobin
into plasma or serum.
Hemostasis: state of balance in the body, between blood clotting and clot lysis.
Hodgkin’s disease: malignant neoplasia of the lymphoid cells, of uncertain origin.
Homeostasis: state of balance in the body.
Immunoassay [IM yoo noh uh say]: assay which relies on an antigen-antibody

reaction.
Neonatal: referring to the period immediately following birth.

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GLOSSARY
Nephrotic [nef RAH tik]: relating to diseases of renal tubules.
Osmotic pressure: force that moves water or another solvent across a membrane sepa-
rating a solution. Usually, the movement is from the lower to the higher concentra-
tion.
Paget’s disease: skeletal disease, frequently familial, leads to softening of bones.
Plaque: lipid deposits in arteries.
Plasma: the clear, yellow fluid obtained when blood is drawn into a tube containing
anticoagulant (usually a purple, green, or light blue tube) and is centrifuged.
Polymyositis [PAH lee migh oh SIGH tis]: inflammation of a number of voluntary

muscles.
Renal: relating to the kidney.
Reye’s syndrome: a rare, acute, and often fatal encephalopathy of childhood marked
by acute brain swelling; most often occurs as a consequence of influenza and URT
infections.
Serum: liquid portion of plasma that remains after clot is removed.

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GLOSSARY
Thrombosis: formation of a clot.
Titer: the amount of a known or unknown analyte determined by volumetric means.
Waldenstrom’s macroglobulinemia: hyperglobulinemia with peak in γ or β2 globulins,

frequently exhibits mucosal bleeding.

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GENERAL CHEMISTRY TESTS
I. GENERAL CHEMISTRY TESTS

he Clinical Chemistry laboratory measures chemical changes in the body for diag-
T nosis, therapy, and prognosis of disease. Primarily, testing is performed using
serum, plasma, and urine to determine the chemical components.
Objectives
These objectives will help you to focus on the expected learning outcomes. After
reviewing the following material, you should be able to:
1. Differentiate the tests used to diagnose a disease from those used to evaluate a
disease process.
2. Describe the use for certain chemical tests.
3. Describe some possible causes for error in testing.
4. Identify some panels used in diagnosing a disease process.

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Key Concepts
1. Many tests are not specific for a certain disease process.
2. Many times a panel of tests is used in diagnosing a disease process.
3. Some tests are very specific for a disease and can be used for diagnosis.
4. Maintaining a sample in a proper manner can eliminate result errors.
5. Because hemolysis will affect many laboratory results, it is essential to notify the
physician that hemolysis is present.
Double click on the

triangle to see glossary A. Electrolytes
term definition.
The term electrolytes in the medical usage is applied to
sodium, potassium, chloride, and carbon dioxide.
Electrolytes help regulate water balance and acid-base Body
water Electrolytes
balance in the body. These analytes are primarily used
to measure kidney function.

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CO2 is a byproduct of food. 1. Carbon Dioxide (CO2 / Bicarbonate). Fats, proteins, and carbohydrates are broken
down in the body to create energy, and the carbon atoms are converted to carbon
CO2 is eliminated by the dioxide. During the process of respiration, the lungs rapidly eliminate carbon dioxide.
lungs and the kidneys.
The kidneys can also eliminate excess carbon dioxide through the urine.
Samples for carbon dioxide should be maintained in a stoppered tube until

analyzed as the analyte will evaporate and give falsely decreased values.
Metabolic alkalosis ↑ CO2 An increased carbon dioxide level is found in metabolic alkalosis, compensated respira-
levels.
tory acidosis, and frequently in alkalosis when there is a large deficiency of potassium.
Metabolic acidosis ↓ CO2 Decreased carbon dioxide levels are found in metabolic acidosis and compensated respi-
levels.
ratory alkalosis.
Cl– is the #1 extracellular 2. Chloride (Cl–). Chloride is the element that has the highest extracellular concen-
element.
tration in the serum. Chloride plays an important role in maintaining electrolyte
balance, hydration, and osmotic pressure. It is ingested through a normal diet,
absorbed in the intestine, and removed from the body by excretion in urine and sweat.
Excessive amounts of chloride can be lost during periods of intense perspiration.

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↑ Cl– is found with ↑ Na+. Normally elevations of chloride will be accompanied by elevations of sodium.
Dehydration ↑ Cl– levels.
Increased chloride level is found in dehydration, certain types of renal tubular acidosis,
and hyperventilation. Decreased levels are found in uncontrolled diabetes,
vomiting, metabolic acidosis, and Addison’s disease.
K+ is the #1 element in 3. Potassium (K+). Potassium is the element that has the highest
cells.
concentration within cells. It is ingested through a normal diet and
The kidneys excrete K+. absorbed through the intestines. The kidney excretes excess
potassium through urine. Elevated levels of potassium may cause
serious problems with muscle irritability. Potassium also plays an
important role in nerve conduction.
Potassium samples should not have hemolysis, which can give falsely elevated
results. Increased levels are found in shock, circulatory failure, and in both meta-
Vomiting and diarrhea ↓ K+ bolic and renal tubular acidosis. Decreased levels can be caused by vomiting,
levels.
diarrhea, diuretics, and some carcinomas.

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Na+ is the #1 cation in the 4. Sodium (Na+). Sodium is the most abundant cation and the chief base (alkali) of
blood.
the blood. Through excretion and reabsorption in the kidneys, the body attempts to keep
sodium levels constant, so values do not vary much. Sodium helps to maintain osmotic
↑ Na+ is accompanied by pressure, acid-base balance, and nerve impulses. Remember that, normally, chloride
↑ Cl–.
rises and falls with sodium.
Dehydration ↑ Na+ levels. Increased levels are found in severe dehydration, Cushing’s syndrome, comatose dia-
betics, and diabetes insipidus. Decreased levels are found following a large loss of gas-
Diarrhea ↓ Na+ levels. trointestinal secretions, such as from diarrhea, intestinal fistulas, or severe
gastrointestinal disturbances. Additional causes include renal disease and Addison’s
disease.
B. Chemistry Profile
Chemistry profiles are a group of tests, which when used together give the physician
results that can aid in diagnosing or following treatment of a disease process.

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Proteins can be antibodies, 1. Proteins. Proteins are present in all body fluids. Their
clotting factors, or Where do you find
enzymes.
concentration is normally high only in blood, serum, plasma,
high levels
lymph fluid, and some exudates. There is a small amount of
of proteins?
protein in spinal fluid and a trace of protein in urine.
Proteins have many purposes. They function as antibodies, form part of the endocrine
system, and provide a complex blood-clotting system. Additionally, they are carriers for
other compounds, provide tissue nutrients, and function as enzymes. To determine
disease processes it is more important to compare levels for each fraction of the proteins
to normal values.
Table 1 on pages 15 and 16 summarizes the different protein fractions and the effects
when levels are abnormal.
Serological tests measure Other tests measure analytes which are proteins in structure but which are not consid-
the body’s response to ered part of the protein panel. Rather, they are used to monitor the body’s response to
disease.
certain disease states and are usually performed in the serology laboratory. Table 2 on
page 17 shows some serological tests for proteins.

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TABLE 1 Proteins Increased Decreased

Proteins: total protein Total Protein Dehydration; monoclonal disease; some chronic Inadvertent overhydration,
and fractions are impor- polyclonal diseases, eg, liver cirrhosis, sar- protein loss through the
tant in many disease coidosis, systemic lupus erythematosus (LE), kidneys, severe burns, star-
states. and chronic infections vation, and severe nonviral
liver cell damage
(continued)
Albumin* Rare and temporary, in acute dehydration or Same conditions as total
shock protein
Prealbumin Hodgkin’s disease Inflammation, malignant liver

disease
Microalbumin Indicates an increased risk of diabetic neuro- Not significant

pathy, end-stage renal disease, and proliferative
retinopathy in the diabetic patient
α1 Infections and inflammations Acute hepatitis
α2 Rheumatoid arthritis, LE, and myocardial Acute hepatocellular disease

infarction (MI)
β Hyperlipemias Not significant
γ Viral hepatitis, sarcoidosis, rheumatoid arthritis, Terminal stages of Hodgkin’s

chronic infections, and some leukemias disease and in congenital
conditions
*If your albumin assay uses bromcresol purple (BCP) as an indicator, you cannot use controls that contain
animal albumin. If your assay uses bromcresol green (BCG) it will bind with animal albumin.

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TABLE 1 (CONT’D) Proteins Increased Decreased

Proteins: total protein C3 and C4 Acute phase reactions such as C3 and C4—LE, subacute
and fractions are impor- Complement proteins that surgery, MI, infections, and bacterial endocarditis, and
tant in many disease function with antigen- tumors gram-positive bacteremia
states. antibody complexes to C3—rheumatoid vasculitis,
destroy viruses, bacteria, streptococcal glomeru-
and host cells lonephritis, and gram-
negative bacteremic shock
Haptoglobin Acute phase reactions Chronic intravascular

Transports free hemo- hemolysis
globin from destroyed
red cells

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TABLE 2 Proteins Increased Decreased

Serological protein C-reactive protein-CRP Rheumatic fever, rheumatoid arthri- Not significant
assays: important in Nonspecific method for evaluat- tis, LE, MI, malignancy, bacterial
inflammatory processes. ing the severity and progress of and viral infections
inflammatory diseases. Detected
18–24 hrs after onset of tissue
damage
Anti-streptolysin O (ASLO/ ASO) A two-dilution-step rise in titer is a Not significant after it

Serological test used to detect a good indication of infection returns to normal
recent streptococcal infection
Rheumatoid factor Rheumatoid arthritis, LE, endo- Not significant

carditis, tuberculosis, syphilis,
cancer, viral infections, diseases
affecting the liver, lung, and/or
kidney

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Ca+ is vital to blood 2. Calcium (Ca+). Calcium, a mineral present in the body that is a vital
clotting.
component in the skeleton, bones, and teeth, is involved in the coagulation
process.
Ca+ and P deposits are Calcium and phosphorus have a reciprocal relationship. When calcium levels
linked.
are decreased, the phosphorus levels are increased; when calcium levels are
increased, the phosphorus levels are decreased.
Ca+↓ → P↑
Ca+↑ → P↓
Increased calcium levels are found in hyperparathyroidism, some malignancies, multiple

↓ Ca+ levels are accompa- myeloma, and Paget’s disease. Decreased values are found in hypoparathyroidism,
nied by ↓ vitamin D levels.
pseudohypoparathyroidism, vitamin D deficiency, chronic renal disease, and acute pan-
creatitis.
3. Bilirubin (Conjugated and Total). Bilirubin, a breakdown product of hemoglobin

in the red blood cells, is a by-product of hemolysis and is removed by the liver.
Conjugated bilirubin circulates freely in the blood until it reaches the liver where it is
excreted into the bile.

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Handle bilirubin samples Samples to be analyzed for bilirubin must be handled carefully
carefully.
in the preanalytical stage. They should be protected from light
and heat and, for best results, stored in the dark at low tempera-
tures. Lipemia and hemolysis should also be avoided.
Total bilirubin checks liver Total bilirubin checks for impairment of the excretory function of the liver and for
function.
excessive hemolysis of red cells. Conjugated bilirubin checks only for the impairment
of the excretory function of the liver, such as blockage.
Hepatitis and cirrhosis ↑ Increased values for total bilirubin are found in viral hepatitis, cirrhosis, and infectious
bilirubin levels.
mononucleosis. Increased values for conjugated bilirubin are found in cancer of the
head of the pancreas, choledocholithiasis, and Dubin-Johnson syndrome. Decreased
value for any bilirubin is of no clinical significance.

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CSF bathes brain and 4. Cerebrospinal Fluid

spinal cord.
Protein. Cerebrospinal fluid
How do you
(CSF) is a clear, colorless liquid obtain CSF?
found in the brain and the spinal
cord. Fluid is obtained by per-
CSF
forming a spinal tap.
Do not test bloody CSF. Spinal Test results for CSF protein are not valid if the
cord sample is bloody. Increased values for CSF protein
Vertebral are found in meningitis, neuro-syphilis, some cases
bone
of encephalitis, and frequently after cerebral hemor-
rhage. Decreased values for CSF protein are of no
clinical significance.
Red blood cells may use up 5. Cerebrospinal Fluid Glucose. Bloody samples for CSF glucose may give falsely
CSF glucose.
decreased values because the red blood cells may use the glucose before analysis.
Increased values for CSF glucose are of no clinical significance. Decreased values for
CSF glucose may indicate bacterial meningitis.

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6. Cholesterol. Cholesterol is a complex alcohol that is con-

verted by the adrenals and the gonads into steroid hormones.
Elevated serum cholesterol has been implicated as one of the risk
factors in coronary artery disease.
Nephrotic syndrome Increased values for cholesterol also suggest hypothyroidism,

↑ cholesterol levels.
uncontrolled diabetes mellitus, and nephrotic syndrome.
Decreased values for cholesterol are found in hyperthy-
roidism, hepatocellular disease, anemias, starvation, and
certain genetic defects.
7. Creatinine. Creatinine is a waste product formed in muscle tissue after energy pro-
duction and is excreted in the urine.
Blood urea nitrogen (BUN), usually correlates with creatinine.
BUN↑ → Creatinine↑
BUN↓ → Creatinine↓

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Vomiting and diarrhea Increased values for creatinine are found in congestive heart failure, shock, vomiting,
↑ creatinine levels.
diarrhea, diabetes insipidus, uncontrolled diabetes mellitus, and excessive use of
diuretics. Decreased values for creatinine are of no clinical significance. [Fischbach,
1980]
8. Fructosamine. Fructosamine is the generic name for the

Fructosamine levels check plasma protein ketoamines. It is used to determine whether What other test might
diabetes control. be ordered with
a patient’s diabetes is in control. This test will probably be
used along with glycosylated hemoglobin to monitor glucose fructosamine?
levels over a long period of time.
Increased values for fructosamine would indicate that the diabetic patient has had a wide
fluctuation of glucose levels (poor diabetic control). [Sacks, 1994]
9. Glucose. Glucose testing is the screening procedure

What two hormones used to detect disorders of metabolism. Two hormones
regulate glucose? directly regulate glucose—glucagon and insulin.

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Diabetes ↑ glucose levels. Increased values for glucose are found in diabetes mellitus, Cushing’s disease, acute
stress, hyperthyroidism, pancreatitis, chronic liver disease, and brain trauma. Decreased
Insulin overdose ↓ glucose values are found in insulin overdose, Addison’s disease, bacterial sepsis, hepatic
levels.
necrosis, hypothyroidism, and glycogen storage disease.
Glycosylated hemoglobin 10. Glycosylated Hemoglobin. Glycosylated or glycated hemoglobin measures the
is a less sensitive glucose
measure.
average plasma glucose concentrations over the preceding 4 to 8 weeks. Values are not
as subject to day-to-day fluctuations as plasma glucose levels are.
FIGURE 1 High
Glycosylated hemoglobin:
used to check control of Normal
diabetes.
Glucose
Low Glycosylated Hgb
0 1 2 3 4
Weeks
Increased values for glycosylated hemoglobin indicate that the glucose values for the
last 4 to 8 weeks have varied widely (poor control). Decreased values are of no clinical
significance.

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HDL and LDL transport 11. High-density Lipoprotein Cholesterol. High-density

cholesterol.
lipoprotein (HDL) removes cholesterol from tissues and What is one difference
carries it to the liver for disposal. Low-density lipoproteins between HDL and
(LDL) move cholesterol to the peripheral tissues. When this LDL?
process is halted, plaque begins to form and clog arteries.
APO is a part of Apolipoproteins (APO) are proteins that are part of the structure of the lipoproteins. It
lipoproteins.
is possible to directly measure the APO of HDL and LDL by using a test called an
ELISA (enzyme-linked immunoassay) to measure the APO A-1 and APO B proteins.
[Stein, 1994]
Hypertriglycemia ↓ HDL Increased values for high-density lipoprotein are found in nephrotic patients, and
levels.
patients on a high carbohydrate diet. Decreased values are found in hypertriglyceri-
demic patients.
12. Homocystine. Homocystinuria, homocystine in the urine, is generally recognized

in late childhood because of physical abnormalities with or without retardation.
Homocystine is an amino acid which is not used to build proteins but rather is impor-
tant in metabolic pathways.

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↑ homocystine is a genetic Increased values for homocystine are found in patients who have a defective enzyme.
defect.
This problem causes blood clots and defects in connective tissue—collagen. Decreased
values for homocystine are not clinically significant.
13. Iron (Fe+)/TIBC/UIBC/Transferrin. Iron is an

essential component of heme proteins that function in What are the ways the
oxygen transport. Most of the body’s iron is contained in body loses Fe+?
Fe+ is recycled in the body. hemoglobin. Iron stores are recycled in the body.
UIBC is the serum unsaturated iron binding capacity—the

What is the difference
reserve iron binding capacity of serum transferrin.
between TIBC and
Normally, only about one third of the iron binding sites of
UIBC?
transferrin are occupied by iron.
Bone marrow
makes Hgb
Transferrin regulates Fe+ Transferrin is a protein that regulates iron absorption and
stores. transport in the body. The quantity of transferrin is
Plasma RBCs
measured by the amount of iron with which it can transferrin
bind, referred to as the total iron binding capacity
Blood Bleeding and
(TIBC). Table 3 on the next page catalogs the main Iron stores other excretion
and food
tests which monitor iron stores in the body. RBC
destruction
[Fairbanks, 1994]
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TABLE 3 Test Increased Decreased

Iron and iron stores: Iron Hemolytic anemia, pernicious anemia, Dietary deficiency, acute blood loss,
important in assessing lead poisoning, acute hepatic cell neoplasia, and rheumatoid arthritis
anemias. necrosis
TIBC Late pregnancy, iron deficiency anemia, Infection, neoplasia, uremia, nephrosis
after acute hemorrhage or destruction
of liver cells
Transferrin Hemolytic anemia, acute hepatitis, and Iron deficiency anemia, late pregnancy,
pernicious anemia infection, neoplasia, and after acute
hemorrhage
Mg+ is the #4 intracellular 14. Magnesium (Mg+). Magnesium is the fourth most abundant cation in the body. It
cation.
is most prevalent in the cells, second only to potassium. Absorbed in the upper intes-
tines, it is needed for blood clotting. Along with sodium, potassium, and calcium it reg-
ulates neuromuscular irritability. Decreases in calcium sometimes lead to decreases in
magnesium; decreased potassium also accompanies decreased magnesium.
↓Ca+ → ↓Mg+ ↓K+ → ↓Mg+

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Chronic renal disease ↑ Increased values for magnesium are found in chronic renal disease, severe dehydration,
Mg+ levels.
and adrenal insufficiency. Decreased values are found in malabsorption, prolonged
diarrhea, acute pancreatitis, acute alcoholism, and with the use of some diuretics.
Neonatal bilirubin is 15. Neonatal Bilirubin. Neonatal bilirubin refers to the unconjugated or indirect
unconjugated bilirubin.
bilirubin. Under normal conditions this bilirubin is bound to albumin and causes no
Increased neonatal biliru- problem. However, if the unconjugated bilirubin levels exceed the binding capacity, the
bin can cause CNS
bilirubin can pass into the infant’s central nervous system and cause mental retardation,
problems.
hearing deficits, or cerebral palsy. Figure 2 on the next page illustrates unbound biliru-
bin crossing the blood-brain barrier.
Samples for bilirubin determination must be protected from light until

analysis.

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FIGURE 2 Blood-brain
barrier
Bilirubin: unconjugated
can present problems in
neonates.
A-B
Bilirubin
bound to Brain tissue
albumin
Neonatal
B
problems
Unbound
bilirubin
Ca+ and P deposits are 16. Phosphorus. Most phosphorus is found in the body in the bone matrix.
linked.
Phosphorus is excreted in the urine. Levels of calcium and phosphorus are
closely linked because they are both deposited in the bone together.
Remember:
↑Ca+ → ↓P
↓Ca+ → ↑P

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↑ vitamin D accompanies Increased values for phosphorus are found in advanced renal insufficiency, pseudohy-
↑ P.
poparathyroidism, hypervitaminosis D, and with patients who have hypersecretion of
growth hormone. Decreased values are found in hyperparathyroidism, rickets, steator-
rhea, and in some renal diseases.
Triglycerides are fatty acids. 17. Triglycerides. Most of the fatty acids in the body are components of triglycerides
and stored in the adipose tissue as fat. Cells must also contain glucose for triglyceride
formation. A 10–14-hour fasting specimen is required when testing for triglycerides.
[Tietz, 1994]
Acute alcoholism Increased values for triglycerides are found in hypothy-

↑ triglyceride levels.
roidism, nephrotic syndrome, acute alcoholism, obstructive
What is the typical
liver disease, acute pancreatitis, uncontrolled diabetes, and
appearance of serum
glycogen storage disease. When triglycerides are high, the high in triglycerides?
serum or plasma is usually turbid or milky, called lipemia.
Decreased values are found in abetalipoproteinemia.
18. Uric Acid. Uric acid, the result of the breakdown or destruction of cells, circulates
in plasma and is excreted by the kidney. This test is used to diagnose or follow the
treatment of gout. It can also be used to evaluate renal failure and leukemia.

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Renal disease and leukemia Increased values for uric acid are found in gout, renal disease, leukemia, polycythemia,
↑ uric acid levels.
toxemia, and resolving pneumonia. Decreased values are found in patients on certain
medications including steroids, aspirin, allopurinol (a gout medicine), and penicillamine.
Values can also be decreased when renal tubular absorption is defective.
19. Urinary Protein. Urinary protein is usually tested to What is the typical
evaluate some renal diseases. Most often a urine sample is sample for urinary
tested using a sample that has been collected for 24 hours. protein?
Nephrotic syndrome ↑ Increased values for urinary protein are found in nephrotic syndrome
urinary protein levels.
and in other diseases that produce renal lesions. The amount
excreted depends on the stage and the severity of the disease.
Decreased values are of no clinical significance. [Fischbach,
1980]

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C. Enzymes
Enzymes are metabolic Metabolic reactions in the body are regulated by biological catalysts called enzymes.
catalysts.
Enzymes are present in all body cells, and each has a specific purpose. Table 4 on the
next page summarizes the most clinically important enzymes.
High levels of acid 1. Acid Phosphatase (ACP). Acid phosphatase is an enzyme that is distributed in the
phosphatase are found in
the prostate gland.
bone, liver, spleen, kidney, red blood cells, and platelets. The largest pool of acid phos-
phatase is found in the prostate gland. The main function of this test is to diagnose and
monitor treatment of prostate cancer.
Prostate cancer ↑ acid Increased values for acid phosphatase are found in metastatic carcinoma of the prostate,
phosphatase levels.
Gaucher’s disease, and in some bone diseases. Decreased values are of no clinical
significance.

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TABLE 4 Enzyme Major Source Application

Enzymes: these sub- Acid phosphatase Prostate Prostate cancer
stances are important
indicators of many Alkaline phosphatase Bone Bone diseases
disease states. Intestine Liver diseases
Liver
Amylase Salivary gland Pancreatic disorder
Pancreas
Creatine kinase Bone Muscle damage
Heart Brain damage (rarely)
Brain Myocardial infarction
Aspartate amino-transferase Heart Liver disease
Bone Muscle damage
Liver
Alanine aminotransferase Liver Liver disease
Bone
Heart
Gamma-glutamyl-transferase Kidney Liver disorders
Pancreas
Liver
Lactate dehydrogenase Liver Heart disease
Heart Hemolysis
Bone Myocardial infarction
RBCs
Lipase Pancreas Pancreatic disorder

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Alkaline phosphatase is 2. Alkaline Phosphatase (ALP). Alkaline phosphatase is widely distrib-

found in bone and liver.
uted in the body and is present in high concentrations in bone, intestinal
mucosa, and renal tubule cells. Lower concentrations appear in the liver,
leukocytes, and placenta.
Liver disease ↑ alkaline Increased values for alkaline phosphatase are found in all bone disorders,
phosphatase levels.
liver disease, and during the third trimester of pregnancy. Decreased values
are found in hypophosphatasemia, hypothyroidism, pernicious anemia, and in
dwarfs.
Amylase digests starches. 3. Amylase. Amylase is an enzyme that is secreted by the Where is amylase
salivary and pancreatic glands. It is important for the diges- produced?
tion of starches and is rapidly cleared by the kidneys.
Pancreatitis ↑ amylase Increased values for amylase are found in acute pancreatitis, obstruction of the pancre-
levels.
atic ducts, and (mildly) in obstruction of the parotid gland. Decreased values are found
in acute or chronic hepatocellular damage. This is not a sensitive liver function test.

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Creatine kinase is found in 4. Total Creatine Kinase (CK). Creatine kinase is present
muscle and brain.
in high concentration in skeletal muscle, cardiac muscle,
What are some
thyroid, prostate, and brain tissue.
differences between
Increased values for creatine kinase are found when skeletal CK and CK-MB?
muscle, myocardium, and (rarely) brain tissue have been
damaged. Decreased values are of no clinical significance.
Myocardial infarction ↑ 5. Creatine Kinase-MB (CK Isoenzyme). Creatine kinase-

creatine kinase-MB, . . .
Which enzyme is MB usually can be found in patients’ samples about 4–6 hours
increased in CO after the onset of chest pain in acute
poisoning? myocardial infarction. It is important
to note that some disease processes
can also give positive creatine kinase-MB results but these
. . . it returns to normal in levels will stay constant. With a myocardial infarction the
24–48 hours.
creatine kinase-MB levels will typically return to normal
within 24 to 48 hours. Figure 3 on the next page shows the
different timelines of some enzymes important in monitoring
heart disease.

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FIGURE 3 6
Serum enzyme levels: Serum

5
monitors of heart disease. enzyme
activity x
normal 4
upper
limit 3
1 2 3 4 5 6 7 8 9 10
Time after onset of chest pain (days)
Creatine kinase-MB Creatine kinase—total

Aspartate transaminase LDH—total
Severe angina ↑ CK-MB Increased values for creatine kinase-MB can be found in acute myocardial infarction,
levels.
severe angina, pericarditis, carbon monoxide poisoning, muscular dystrophy,
polymyositis, malignancy, and open-heart surgery. Decreased values have no clinical
significance.

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6. Aspartate Aminotransferase (AST). Aspartate aminotransferase is present in

Liver disease ↑ AST levels. heart, skeletal muscle, and liver in equal amounts. Measurement of AST is valuable in
the diagnosis of liver disease. However, it is present in tissues other than liver and can
be elevated due to other disease processes.
Myocardial infarction ↑ AST and ALT usually rise and fall together when the patient has hepatic cell damage.
AST levels.
Increased values for AST are found in myocardial infarction, liver disorders, trauma or
diseases affecting skeletal muscle, after renal infarction, and in various hemolytic condi-
tions. Decreased values are not clinically significant.
↑AST ↑ALT ↓AST↓ALT
ALT is more specific for 7. Alanine Aminotransferase (ALT). The highest ALT levels are found in liver
liver disease than AST.
tissue and the primary use of this test is to diagnosis liver disease. ALT is more
specific for liver malfunction than AST. Hemolysis will affect test results.
Increased values for ALT are found in acute hepatitis, alcoholic hepatitis, cirrhosis,
Reye’s syndrome, hepatomas, and cholestatic disease. Decreased values are of no

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8. Gamma-glutamyltransferase (GGT). Gamma-

glutamyltransferase is present in the kidney, pancreas,
Liver disease and alco- liver, and prostate. It is a sensitive indicator of liver
holism ↑ GGT levels.
disease, is very helpful in diagnosing hepatobiliary
obstruction, and is elevated in all forms of liver disease
and alcoholism.
Increased values for GGT are found in hepatocellular liver disease and obstructive liver
disease. Decreased values are of no clinical significance.
9. Lactate Dehydrogenase (LDH/ LD-1). Lactate dehydrogenase is distributed

in the liver, cardiac muscle, kidney, skeletal muscle, erythro-
Myocardial infarction cytes, and other tissues. This test is used primarily to
↑ LDH levels.
diagnose myocardial infarction because the elevation lasts
LDH stays elevated longer for about 7 to 10 days. Hemolysis will affect test results by
than CK-MB.
falsely increasing levels. Freezing may falsely decrease values.
Increased values for LDH are found in myocardial infarction, liver

disease, muscle trauma, renal infarct, hemolytic diseases, and per-
nicious anemia. Decreased values are not clinically significant.

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10. Lipase. Lipase is primarily produced in the pancreas.

Rapidly elevated in acute pancreatitis, it remains elevated In pancreatitis, which
longer than amylase. is elevated longer,
lipase or amylase?
Pancreatitis ↑ lipase levels. Increased values for lipase are found in acute pancreatitis;
decreased values are of no clinical significance.
11. Pseudocholinesterase. Pseudocholinesterase is an

Which enzyme reacts enzyme that reacts with succinylcholine, a short-acting
with a common muscle muscle relaxant that is used when patients are going to
relaxant? surgery. Some people have a genetic deficiency of the
enzyme pseudocholinesterase and, when injected with the
succinylcholine, may have an extended reaction to the drug. The succinylcholine
usually only reacts for about 2 minutes.
BUN is a protein 12. Urea (Blood Urea Nitrogen) (BUN). Blood urea nitrogen is
byproduct.
the end product of protein breakdown. BUN levels are influenced
by factors not connected with renal function or urine excretion.
Creatinine is a better indicator of kidney function even though
BUN and creatinine usually rise and fall together.

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High protein diets ↑ BUN ↑BUN ↑Creatinine ↓BUN ↓Creatinine

levels.
Increased values for BUN are found in high protein diets, administration of cortisol-like
steroids, and stressful situations. Decreased values for BUN are found in late preg-
nancy, starvation, and in patients whose diet is grossly deficient in proteins. [Fischbach,
1980]
Summary
Chemistry testing is a vital part of laboratory testing and is an aid to physicians diagnos-
ing and treating patients. It is important to understand the use of each of the tests and
the proper testing procedures for each.
Electrolytes help the physician monitor the patient’s acid-base and fluid balance.
Chemistry profiles are a panel of tests which are usually accompanied by other special-
ized tests to monitor or aid in diagnosing a patient. Enzymes tests monitor patients’
reactions to a disease process.

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Review Questions (I)

1. The test used primarily to diagnose prostate cancer is
_________________________.
a. acid phosphatase
b. alanine aminotransferase
c. alkaline phosphatase
d. aspartate aminotransferase
2. When chloride is elevated, what else is usually elevated?
a. calcium
b. CO2
c. potassium
d. sodium
3. Which is the best method to monitor diabetic glucose control over a 6-week
period?
a. glucose
b. glycosylated hemoglobin
c. haptoglobin
d. phosphorus

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4. The test primarily performed to evaluate the patient for gout is

_____________.
a. iron
b. magnesium
c. sodium
d. uric acid
5. Which test requires that the sample be kept in a sealed tube because of a problem
with evaporation?
a. carbon dioxide
Click on this link to go
b. chloride
to the Answers page.
When you are finished,
c. sodium
click the BACK button d. potassium
to return to the
Review Questions. Check Your Responses

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SPECIALIZED TESTS
II. SPECIALIZED TESTS

pecialized testing is used to evaluate a specific organ system. Some of the systems
S that are addressed in this section are thyroid function, immunity, coagulation, and
drug testing. Drug testing includes therapeutic drugs and those that are abused.
Objectives
These objectives will help you focus on the expected learning outcomes. After review-
ing the following material, you should be able to:
1. Describe some testing used to evaluate coagulation.
2. Differentiate between drugs of abuse and therapeutic drugs.
3. Describe the tests used to evaluate thyroid function.
4. Define how to test for immunity.

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SPECIALIZED TESTS
Key Concepts
1. Evaluating a patient’s ability to form a clot involves many different tests. Each
test usually has a specific purpose.
2. Testing a patient for a therapeutic level of a medication is very important to treat-

ment. Treatment may vary when a diagnosis of drugs of abuse is made.
3. To keep the body in a balanced state, thyroid function tests are performed.
Results are used to determine treatment.
4. The body defends itself against foreign proteins by producing immunoglobulins.

Evaluation of immunoglobulins can assist with treatment options.
A. Hormones and the Endocrine System

The endocrine system consists of ductless glands that
produce chemical regulators called hormones. Hormones
Why are the thyroid
regulate metabolism, preserve homeostasis, control the rates hormones so
of growth and development, and influence behavior. Some important?
of the most important hormones are those produced in the
thyroid glands, because they regulate the body’s metabolism.

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SPECIALIZED TESTS
1. Thyroxine (T4). Thyroxine is the principal hormone secreted by the thyroid gland.
T4 and T3 are linked. Used along with other thyroid tests to determine thyroid disease, it is an indicator of the
thyroid secretory rate. Many times thyroxine and triiodothyronine (T3) rise and fall
together.
2. Triiodothyronine (T-uptake). T-uptake

is a test that estimates unoccupied binding
↑ T-uptake indicates a sites on serum proteins for T3. Increased
hyperthyroid state.
T-uptake may be the first indication of
hyperthyroidism and in some rare cases may
be the only indication.
FT4 corrects T-uptake. 3. Free Thyroxine Hormone Index (FT4).

FT4 values are used to eliminate problems that
can alter the results of the T-uptake. Some medications
directly affect the results of T-uptake and this calculation can
eliminate some of the confusion.

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SPECIALIZED TESTS
Increased values for the FT4 are found in hyperthyroidism, decreased values in
hypothyroidism.
Calculation is as follows: Total T4 x T-uptake = FT4

100
The pituitary gland 4. Thyroid-stimulating Hormone (TSH). Thyroid-stimulating hormone, used to

produces TSH.
diagnose hypothyroidism, is produced in the pituitary gland.
Increased values of TSH are found in hypothyroidism, decreased values in hyperthy-

roidism. Some hyperthyroid patients have undetectable TSH levels. Figure 4 on the
next page shows an algorithm that can be used to interpret thyroid tests. [Marshall,
1988]

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SPECIALIZED TESTS
FIGURE 4 Measure T4 or FT4

Thyroid test algorithm:
use when checking
for suspected Normal Low normal Low
hypothyroidism. euthyroid
Measure TSH
Normal Borderline Raised

euthyroid incipient or primary
compensated hypothyroidism
hypothyroidism
Reassess after
3–6 months if
treatment not
indicated clinically

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SPECIALIZED TESTS
B. Immunoglobulins and Immunity

Infection ↑ immuno- Immunoglobulins are circulating antibodies essential for defense against foreign proteins
globulin levels.
of any sort. Increased levels of immunoglobulins are found in chronic infection. In
some conditions known as monoclonal diseases, only one of the immunoglobulins may
Multiple myeloma is a increase. Monoclonal diseases include multiple myeloma, Waldenstrom’s
monoclonal disease.
macroglobulinemia, cryoglobulinemia, and some cases of lymphomatous diseases.
1. Immunoglobulin A (IgA). The IgA class of immunoglobulins protects mucous

IgA is found in milk and membrane surfaces from bacterial or viral attack. IgA is in various fluids like
other secretions.
colostrum, milk, saliva, tears, and sweat. About 10% to 15% of the circulating
immunoglobulins are IgA.
IgG is the predominant 2. Immunoglobulin G (IgG). IgGs make up about 75% to

immunoglobulin.
80% of the total immunoglobulins. Production of IgGs is
stimulated by an invasion of bacteria or viruses. The IgGs What stimulates
attach to the pathogen and serve as places for other cells to IgG response?
attach and destroy the foreign body. IgG immunoglobulins
also cross the placenta and give passive immunity to a fetus.

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SPECIALIZED TESTS
IgM is the largest 3. Immunoglobulin M (IgM). The largest immunoglobulins in size, IgMs are the first
immunoglobulin and the
first to form.
of the immunoglobulins to be formed. They make up about 5% to 10% of the
immunoglobulins and work to eliminate foreign bodies by activating complement.
Figure 5 shows the difference in the time of response of IgM and IgG following an
infection. [Fischbach, 1980]
FIGURE 5
Level of antibody
Immunoglobulin IgG
response: IgM rises more
quickly than the other
IgM
immunoglobulins, but
IgG rises higher.
Time of 3 6 9
exposure Time (weeks)

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SPECIALIZED TESTS
C. Toxicology
Therapeutic drug monitor- The main goal of today’s clinical laboratory is to monitor therapeutic drugs. Physicians
ing is an important lab
function.
monitor medication levels in the patient and determine if the level of drug present is
meeting the patient’s needs. Therapeutic Drug Monitoring (TDM) also helps the physi-
cian control medications and avoid overmedication and its resulting problems. Table 5
summarizes the most common drugs that are routinely monitored.
TABLE 5 Common Name Drug Name Condition Treated

TDMs: some of these Acetaminophen Tylenol® Pain and fever
drugs can be toxic and Digoxin Lanoxin ®
Heart failure
even lethal.
Lithium — Manic-depressive disorders
Phenytoin Dilantin ®
Ventricular arrhythmias
Seizures
Phenobarbital Luminal® Sedation
Epilepsy
Theophylline (aminophylline) — Acute and chronic bronchial
asthma
Tobramycin Tobrex® External ocular infections
Gentamicin Garamycin ®
Serious infections
Carbamazepine Tegretol ®
Seizures
Valproic acid Depakene , Depakote
® ®
Seizures

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SPECIALIZED TESTS
Drugs of abuse have very Some drugs are not routinely prescribed for therapeutic purposes but are considered
limited or no therapeutic
value.
drugs of abuse. Some of the most common drugs of abuse are listed in Table 6 on the
following page.
A number of other substances are monitored in the toxicology laboratory, eg, ethanol
and salicylate.
TABLE 6 Common Name Common Brands/Names Uses of Drug

Drugs of abuse: instances Amphetamines Dexedrine , Ritalin , Nodoz
® ® ®
Central nervous system stimu-
of abuse can be lants (“uppers”)
important in legal Barbiturates Pentobarbital, Talbutal, Barbital, Sedatives and hypnotics
considerations. Triclofos
Benzodiazepines Xanax®, Tranxene®, Vistaril®, Antianxiety agents
Valium®
Cannabinoids — Hallucinogens
(eg, marijuana)
Cocaine — Stimulants
Methadone — Analgesic—severe pain
narcotic abstinence
Opiates Percocet®, Fiorinal®, Tylox®, Analgesic—moderate to severe
heroin pain
PCP phencyclidine, “Angel Dust” Hallucinogen

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SPECIALIZED TESTS
Ethanol or alcohol levels 1. Ethanol. Serum is the sample of choice. This test is most often used to determine
can be important legally.
if the patient is impaired according to legal limits set in each state. Physicians will also
use this information to determine treatment. To collect a sample for ethanol requires
that the arm be cleaned with some commercial cleaning solution. Never use alcohol as
the sample could become contaminated.
Normal patients with no alcohol consumption will have results of 0–10 mg/dL. Levels
of >400 mg/dL may be lethal. Increased levels of ethanol are found in patients who
have consumed alcohol.
Aspirin or salicylates can 2. Salicylate. The most common salicylate is aspirin; sali-
be abused. Patients with what
cylates are found in many over-the-counter medications.
disease take high levels
Aspirin is used to reduce fever, pain, and inflammation. No of aspirin?
salicylates should appear in the serum of people who are not
taking the drug.
Increased levels of salicylates are found in patients who are taking this medication for
therapy in certain disease processes like rheumatoid arthritis, or in cases of overdose.

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SPECIALIZED TESTS
D. Special Chemistry
Some tests do not fit easily into a category but provide valuable pieces of the diagnostic
puzzle. Only two are mentioned here.
1. Ammonia. Ammonia is one of the end products of protein metabolism.

Ammonia levels monitor Measurement of ammonia levels is used to evaluate metabolism and to follow severe
liver function.
liver disease. Ammonia levels help to evaluate a patient’s response to treatment.
Ammonia should be collected in a heparin tube and placed on ice immediately.

Specimens should be analyzed as quickly as possible. If rapid analysis is a
problem, the sample should be centrifuged, separated, and frozen. Probing for a
vein, use of a heparin lock, drawing blood into a syringe and transferring it to a
tube containing anti-coagulant, or only filling the evacuated
tube partially are all causes of an increased ammonia level. What are some pre-
Smoking by the patient or the phlebotomist is a source of analytical concerns
ammonia contamination. The patient should not smoke with ammonia levels?
after midnight.

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SPECIALIZED TESTS
Cirrhosis ↑ ammonia levels. Increased levels for ammonia are found in liver disease,
cirrhosis, severe hepatitis, severe heart failure, acute
bronchitis, and pericarditis. Decreased levels are of no
Lactic acid comes from 2. Lactic Acid. Lactic acid is found in muscle tissue and is released into the circula-
muscles.
tion when there is muscle tissue damage.
Increased levels of lactic acid are found in cases of shock, muscle fatigue, diabetic
ketoacidosis, and tissue hypoxia. Decreased levels are of no clinical significance.
[Fischbach, 1980]
E. Coagulation
Handle specimens for Coagulation testing consists of a group of tests that check the body’s
coagulation testing with
clotting mechanisms for disorders and for response to disease and injury.
extreme care.
The most important single factor that can affect all coagulation tests is the
sample collection and storage. It is very important to process samples
according to the requirements stated for the tests. Tests for coagulation cannot be run on
hemolyzed samples or on samples that are short sampled. Coagulation testing requires

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SPECIALIZED TESTS
that the sample have the correct amount of blood to diluent ratio. If this ratio is not
correct the test will be invalid. The incorrect ratio will cause the patient results to be
falsely increased.
ATIII tests for coagulation 1. Antithrombin III (ATIII). The test for antithrombin III
problems. What test is frequently
is used with tests for heparin to detect coagulation problems.
ATIII is used most often to evaluate patients with recurrent ordered with ATIII?
venous or arterial thromboses and to detect hereditary and
acquired problems with ATIII.
DIC ↑ ATIII levels. Decreased ATIII levels are found in disseminated intravascular coagulation (DIC),
liver disease, extensive thromboses, protein wasting nephropathies or enteropathies, and
use of heparin.
Increased levels of ATIII are not a concern.
Low or no fibrinogen can 2. Fibrinogen. The determination of fibrinogen is used to detect bleeding problems.
cause bleeding problems.
Fibrinogen is the precursor of the clot-forming protein, fibrin. Problems with low fib-
rinogen levels can be either inherited or acquired.

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SPECIALIZED TESTS
DIC ↓ fibrinogen levels. Increased levels of fibrinogen are found in inflammatory and
What conditions can
neoplastic conditions, heart disease, and thromboses.
cause abnormally
increased or decreased Decreased levels of fibrinogen are found in DIC, liver
fibrinogen? disease, massive bleeding, and in states where fibrinogen is
present but does not function properly.
FDP tests for fibrinolysis. 3. Fibrin/Fibrinogen Degradation Products (FDP). The

test for fibrin/fibrinogen degradation products is used to
determine the level of degradated circulating fibrinogen or What can cause a false
fibrin. False positives can occur if the fibrinogen has not positive FDP test?
been totally converted to fibrin or if there is a high titer of
rheumatoid factor in the serum.
DIC ↑ FDP levels. Fibrinogen Fibrin Increased levels of FDP are found in DIC, primary fibri-
nolytic syndromes, and severe liver disease. They can also
Fibrinogen/fibrin be elevated by lytic therapy, acute thromboembolic episodes,
degradation products injury, and surgery. Decreased levels of FDP are not of
concern. [Macik, 1994]

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SPECIALIZED TESTS
Summary
Specialized testing usually targets a specific system, and the test results are required to
define the specific problem. Test results from the thyroid series identify treatment
required. Thyroid hormones regulate metabolism, growth, and development.
When a physician is concerned about a patient’s immunological status, tests identify and
quantify immunoglobulins. Immunoglobulins help the body fight against any foreign
protein.
Monitoring of medications used to treat disease is vital to treatment. Drug levels help to
establish whether a medication is working at a maximum level or whether excess levels
may be contributing to symptoms. Also, they can monitor for drugs of abuse to deter-
mine if there is an induced problem.
Tests used to evaluate problems of a patient’s coagulation system are necessary for
treatment after surgery or illness. Hemostasis must be maintained to prevent either
thrombosis or bleeding.

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SPECIALIZED TESTS
Review Questions (II)

1. The principal hormone secreted by the thyroid is ___________.
a. FT4
b. T3-uptake
c. thyroxine
d. TSH
2. The immunoglobulin which makes up about 80% of the total immunoglobulins is

_________.
a. IgA
b. IgD
c. IgG
d. IgM
3. Which of the following drugs is used to treat seizures?
a. acetaminophen
b. gentamicin
c. tobramycin
d. valproic acid
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SPECIALIZED TESTS
4. A drug used to treat anxiety that has a high potential for abuse is
_______________.
a. barbiturate
b. benzodiazepine
c. cannabinoid
d. cocaine
5. What is a common form of salicylate?
a. aspirin
b. digoxin
c. lithium
d. Tylenol®
6. What test is used to evaluate a patient who is in DIC?
a. ethanol
Click on this link to go b. FDP
to the Answers page.
c. lactic acid
When you are finished,
click the BACK button d. TSH
to return to the
Review Questions. Check Your Responses

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INTEGRATIVE SUMMARY
Integrative Summary
linical Chemistry is a health science that uses test results to help make a diagnosis.
C Certain disease processes are expected to give certain results, but because the
human body does not always perform as expected, Clinical Chemistry is not always a
definite science. This module is a guide to use with the majority of the population.
Electrolytes are used to assess the acid-base balance in the body. Many disease
processes can make this balance shift. Surgery, trauma, and acute illness may also affect
electrolyte results.
Chemistry profiles are a group of tests used together to determine a possible disease
process and select treatment options.
Monitoring of therapeutic drug levels assists in maintaining a balance in medication and

ensures that medication works to the maximum capability. Monitoring patients for
drugs of abuse enables the provider to determine proper treatment regimens for disease
processes. Many drugs of abuse can cause patients to have symptoms that a provider
cannot treat until the drug is no longer in the system.

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INTEGRATIVE SUMMARY
Specialized testing usually is directed towards a specific diagnosis. Frequently, these

tests are used to confirm a diagnosis or to determine treatment.
Coagulation testing is used to monitor patients who are suspected of having either a
thrombotic or a bleeding disorder. Both states could cause very serious problems and
should be monitored, evaluated, and treated.

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REFERENCES
References
Fairbanks VF, Klee GG. Biochemical Aspects of Hematology. In: Burtis CA,
Ashwood ER, eds. Tietz Textbook of Clinical Chemistry. 2nd edition.
Philadelphia, PA: WB Saunders; 1994:1974–2072.
Fischbach FT. A Manual of Laboratory Diagnostic Tests. Philadelphia, PA: J.B.

Lippincott; 1980:75–667.
Kaplan A, Szabo LL, Opheim KE. Clinical Chemistry: Interpretation and Techniques.
Philadelphia, PA: Lea & Febiger; 1988:91–366.
Kaplan L, Pesce A. Clinical Chemistry: Theory, Analysis, and Correlation. St. Louis,
MO: CV Mosby; 1989:635–636, 959.
Macik BG, Berkowitz SD, Ortel TL, et. al. Duke University Medical Center Clinical
Coagulation Manual. Durham, NC: Duke University; 1994:14–17.
Marshall WJ. Illustrated Textbook of Clinical Chemistry. Philadelphia, PA: JB

Lippincott; 1988:139–154, 219–231.
Potter D. Nurses Reference Library, Drugs. Springhouse: Springhouse, PA;

1984:74–1072.

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REFERENCES
Sacks DB. Carbohydrates. In: Burtis CA, Ashwood ER, eds. Tietz Textbook of
Clinical Chemistry. 2nd edition. Philadelphia, PA: WB Saunders;
1994:928–1001.
Silverman LM, Christenson RH. Amino acids and proteins. In: Burtis CA, Ashwood
ER, eds. Tietz Textbook of Clinical Chemistry. 2nd edition. Philadelphia, PA:
WB Saunders; 1994:688–691.
Stein EA, Myers GL. Lipids, Lipoproteins, and Apolipoproteins. In: Burtis CA,
Ashwood ER, eds. Tietz Textbook of Clinical Chemistry. 2nd edition.
Philadelphia, PA: WB Saunders; 1994:1002–1093.

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SELF-ASSESSMENT POST-TEST
Self-assessment Post-test
For further review, click 1. The clear, yellow fluid obtained when blood is drawn into a tube containing anti-
on the arrow icon to coagulant is called ________________.
link to relevant material.
Use the BACK button to
a. plasma
return to the test.
b. serum
c. spinal fluid
d. urine
2. Part of the electrolyte panel is a test for _____________.
a. calcium
b. glucose
c. lipase
d. sodium
3. Proteins are present in all body fluids.
a. true
b. false

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4. Decreased α1 protein levels are found in _________________.
a. acute hepatitis
b. rheumatoid arthritis
c. severe burns
d. syphilis
5. What protein transports free hemoglobin from destroyed red cells?
a. α2
b. haptoglobin
c. rheumatoid factor
d. total protein
6. A waste product produced in muscle after energy production and excreted into
the urine is ____________.
a. cholesterol
b. creatinine
c. fructosamine
d. homocystine

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7. Diabetes is monitored by testing for __________.
a. calcium
b. glucose
c. iron
d. magnesium
8. What is the element essential in oxygen transport?
a. BUN
b. cholesterol
c. creatinine
d. iron
9. The fourth most abundant cation in the body is __________.
a. calcium
b. magnesium
c. potassium
d. sodium

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10. Which enzyme has its largest pool in the prostate gland?
a. acid phosphatase
b. alanine aminotransferase
c. amylase
d. aspartate aminotransferase
11. Decreased values for AST indicate myocardial infarction.
a. true
b. false
12. Highest values for _______________ are found in the liver.
a. ALT
b. amylase
c. creatine kinase-MB
d. lipase

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13. The enzyme used to detect acute pancreatitis is ________________.
a. blood urea nitrogen.

b. creatine kinase.
c. creatine kinase-MB.
d. lipase.
14. Which enzyme used for surgery reacts with a muscle relaxant?
a. gamma-glutamyltransferase
b. LDH
c. lipase
d. pseudocholinesterase
15. The hormone which is an indicator of the thyroid secretory rate is ___________.
a. FT4
b. thyroxine
c. TSH
d. T-uptake

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16. What immunoglobulin comprises about 15% of the circulating immuno-

globulins?
a. IgA
b. IgD
c. IgG
d. IgM
17. Which drug is used to treat manic-depressive disorders?
a. digoxin
b. lithium
c. phenytoin
d. theophylline
18. What is the common name for the drug Tegretol®?
a. carbamazepine.
b. luminal.
c. PCP.
d. tobrex.

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19. Which drug is classified as a hallucinogen?
a. benzodiazepine
b. cannabinoid
c. carbamazepine
d. valproic acid
20. Which coagulation factor is the precursor of the clot-forming protein fibrin?
a. ATIII
b. FDP
c. fibrinogen
d. FTA
To close the course,

click on the "X" in the
upper right corner of
the window.

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BASIC CLINICAL
CHEMISTRY
Abbott Laboratories
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REVISION STATUS
Revision History Pages Revised and Added
94922-101 11/01 Electronic version
TYLENOL and TYLOX are registered trademarks of Johnson & Johnson

LANOXIN is a registered trademark of Glaxo Wellcome Inc.
DILANTIN is a registered trademark of Warner-Lampbert Company
LUMINAL is a registered trademark of Abbott Laboratories
TOBREX is a registered trademark of ALCON Laboratories, Inc.
GARAMYCIN is a registered trademark of Schering-Plough Products, Inc.
TEGRETOL and RITALIN are registered trademarks of Ciba-Geigy Corporation
DEPAKENE, DEPAKOTE, and TRANZENE are registered trademarks of Sanofi
DEXEDRINE is a registered trademark of Smithkline Beecham
NODOZ is a registered trademark of Bristol-Myers Squibb Company
XANAX is a registered trademark of Pharmacia & Upjohn Company
VISTARIL is a registered trademark of Pfizer, Inc.
VALIUM is a registered trademark of Roche Products Inc.
PERCOCET is a registered trademark of Chase Manhattan Bank, as collateral agent
FIORINAL is a registered trademark of Sandoz Pharmaceutical Corporation
Abbott Laboratories, 1921 Hurd Drive, Irving, TX 75038.
This guide was developed and produced by the Customer Support Center and
CCN Learning Services in Irving, TX.
Copyright ©2001 Abbott Laboratories
Basic Clinical Chemistry 94922-101 November 2001

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ANSWERS TO REVIEW QUESTIONS
Answers to Review Questions

Click the BACK button I. 1. a
to return to the
2. d
Review Questions.
3. b
4. d
5. a
II. 1. c
2. c
3. d
4. b
5. a
6. b
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Basic Clinical Chemistry 94922-101 November 2001 page 2 of 69

When you see these symbols be aware of specimen handling.

Keep stoppered. Short samples can affect results.

Hemolysis can affect results.

Lipemia can affect results.

Basic Clinical Chemistry 94922-101 November 2001 page 3 of 69

Addison’s disease: chronic adrenocortical insufficiency.

Adipose [AD ih pohs]: of or relating to fat in blood or body fluids.

Alkalosis: state of excess of base or loss of acid in blood or body

Amino acid: organic acid used to form proteins.

Analyte: substance that is being measured, eg, glucose, sodium.

Antibody: protein formed as the result of antigenic stimulation.

Antigen: foreign substance that results in antibody production.

Catalyst: substance that accelerates a chemical reaction.

Cation [KAT igh ahn]: ion carrying a positive charge.

Cryoglobulinemia [KRIGH oh glahb yoo lin EE mee uh]: presence of cryoglobulin,

Cushing’s syndrome: adrenal hyperplasia caused by an adenoma of the pituitary gland.

Disseminated intravascular coagulation (DIC): hemorrhagic syndrome following

Dubin-Johnson syndrome: inherited defect in hepatic excretory function, character-

Enzyme: protein in the body that acts as a catalyst.

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Extracellular: outside the cell.

Hodgkin’s disease: malignant neoplasia of the lymphoid cells, of uncertain origin.

Homeostasis: state of balance in the body.

Immunoassay [IM yoo noh uh say]: assay which relies on an antigen-antibody

Neonatal: referring to the period immediately following birth.

Nephrotic [nef RAH tik]: relating to diseases of renal tubules.

Paget’s disease: skeletal disease, frequently familial, leads to softening of bones.

Plaque: lipid deposits in arteries.

Polymyositis [PAH lee migh oh SIGH tis]: inflammation of a number of voluntary

Renal: relating to the kidney.

Serum: liquid portion of plasma that remains after clot is removed.

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Thrombosis: formation of a clot.

Titer: the amount of a known or unknown analyte determined by volumetric means.

Waldenstrom’s macroglobulinemia: hyperglobulinemia with peak in γ or β2 globulins,

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I. GENERAL CHEMISTRY TESTS

2. Describe the use for certain chemical tests.

3. Describe some possible causes for error in testing.

4. Identify some panels used in diagnosing a disease process.

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2. Many times a panel of tests is used in diagnosing a disease process.

4. Maintaining a sample in a proper manner can eliminate result errors.

Double click on the

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Samples for carbon dioxide should be maintained in a stoppered tube until

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TABLE 1 Proteins Increased Decreased

Prealbumin Hodgkin’s disease Inflammation, malignant liver

Microalbumin Indicates an increased risk of diabetic neuro- Not significant

α1 Infections and inflammations Acute hepatitis

α2 Rheumatoid arthritis, LE, and myocardial Acute hepatocellular disease

β Hyperlipemias Not significant

γ Viral hepatitis, sarcoidosis, rheumatoid arthritis, Terminal stages of Hodgkin’s

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TABLE 1 (CONT’D) Proteins Increased Decreased

Haptoglobin Acute phase reactions Chronic intravascular