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Unit 3

the concentrations of sodium(most abundant)


Osmolality is mainly controlled by
and other electrolytes.
Serum – 289 – 308 mOsm/kg
Serum Osmolality
Urine-24-hour osmolality 300-900 mOsm/kg
Urine-24-hour osmolality
(Up to 3 X serum level)
Urine/Serum Osmolality Ratio
Urine/Serum Osmolality Ratio – Random 1.0 – 3.0
Anti-diuretic
Hormone ADH
Acts on kidney tubules to reabsorb water
Hyponatremia Lower than normal sodium levels in the blood
(extra blood volume)osmolality of the blood is
Hypertension can occur when
increased osmolality (Na+ retension)
Increased osmolality
Excessive loss of water from the body tissues,
Dehydration
often accompanied by imbalance of sodium,
potassium, chloride, and other electrolytes
Decreased osmolality
Abnormal collection of fluid in spaces between
Edema cells, esp. just under the skin or in a given
cavity (e.g., peritoneal cavity) or organ (e.g.,
the lungs-pulmonary edema)
the conditions under which non-electrolytes In addition to proteins all other non-ionic molecules like
can contribute significantly to the serum's glucose, billirubins, medications etc, can effect osmotic
osmolality pressure when they are in abundance in a solution.
Osmotic pressure with cause water to be
increased serum osmolality drawn from the interstitial compartment into the
vascular compartment
Osmotic pressure with cause water to be
Decreased serum drawn from the vascular compartment into the
interstitial compartment
Calculated Osmolality = (2 x Na) + (BUN / 2.8) + (Glucose / 18)
Normal Gap = 0 - 20 mmol/L
the difference between the measured osmolality
Osmolal gap is
(with an osmometer), and the calculated osmolality
Osmolal gap > 20 = ketone bodies = Diabetes Mellitus
Urine osmolality – reference range 300 – 900 mOsm/Kg
Renal failure = Low osmolality
 Boiling point raises
Colligative properties of solutions as amount of
 Freezing point lowers
solute increases.
 Vapor pressure decreases
 Osmotic pressure increases
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Unit 3
The presence of a solute lowers the vapor pressure
of the solution at each temperature, making it
vapor pressure depression
necessary to heat the solution to a higher
temperature to boil the solution.
the lowering of the freezing point of a liquid by
freezing-point depression
addition of a solute.
colloid osmotic pressure osmometer For osmotic pressure of proteins
Both sides have pressure sensors
Particles are too big to get through pores

Other sugars must be converted into glucose


by the liver’s isomerase enzymes. Immediately
the fate of dietary fructose and galactose, and after a meal, non-glucose sugars may be found
explain why the only sugar found in fasting in the blood, but after an hour or so, have all
patients' blood should be glucose. been removed from the blood by the liver,
converted into glucose, and stored as
glycogen.
why patients with Hereditary Galactosemia or They lack the liver isomerase enzymes
Hereditary Fructosemia would have galactose necessary to convert fructose or galactose into
or fructose in their fasting blood and urine. glucose.
normal fasting blood glucose range 70 – 110 mg//dL
The liver and kidney are constantly
explain how this glucose level is maintained by replenishing the blood’s supply of glucose by
the hormones Insulin and Glucagon breaking down glycogen, as directed by
glucagon (pancreas) and epinephrine (adrenal)
a.Epinephrine – stimulates glycogenolysis
b. ACTH – causes an overproduction of
Cortisol
Explain why patients which produce elevated
c. Growth Hormone (GH) – stimulates
blood levels of the following hormones could
glycogenolysis and gluconeogenesis (generation
have a slightly elevated fasting blood glucose
of glucose from non-carbohydrate carbon substrates such
level.
as lactate, glycerol, and glucogenic amino acids)
a.Epinephrine b. ACTH
d.Cortisol – stimulates glycogenolysis,
c. Growth Hormone (GH) d.Cortisol
gluconeogenesis, and lipolysis.
e.Thyroid Hormone (T3 or T4)
e.Thyroid Hormone (T3 or T4) – stimulate
f. Human Placental Lactogen (HPL)
lipolysis and glycogenolysis
f.Human Placental Lactogen (HPL) - stimulates
glycogenolysis and gluconeogenesis

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Unit 3
Diabetes Mellitus resulting from lack or underproduction of insulin
has nothing to do with sugar and not serious.
Diabetes Insipidus Due to underproduction of the pituitary
hormone
majority of patients are under 20 at the onset of
disease
10% of all diabetics
Diabetes Mellitus Destruction of Beta cells (insulin producing) in
Type 1 ( IDDM) pancreas
Blood and urine glucose levels Without medical intervention, death will occur within
Blood and urine ketone levels days.
Blood pH a. Blood and urine glucose levels - panic values
Blood Insulin levels b. Blood and urine ketone levels – extremely high
c. Blood pH – very low, severe acidosis
d. Blood Insulin levels – absolute deficiency of
insulin,
majority over age 20 on onset
Diabetes Mellitus Insulin resistance and obesity-most common cause
Type 2 ( NIDDM) a. Blood and urine glucose levels – high, but not
Blood and urine glucose levels panic levels
Blood and urine ketone levels b. Blood and urine ketone levels - high, but not
Blood pH panic levels
Blood Insulin levels c. Blood pH - mild acidosis
d. Blood Insulin levels normal or elevated
OGTT The OGTT requires fasting for at least 12 hours before
Preparation the test.
Coffee, tea, gum, cigarettes, etc. interfere with results
Small amounts of water are allowed.
recommended glucose loads for: Children – 1.75 grams drink per Kg body
Children weight, up to 75 grams
Non-pregnant adults Non-pregnant adults - 75 grams
Pregnant adults Pregnant adults - 100 grams
Used to detect increased urine excretion
Several random measurements may be taken
throughout the day.
Random testing is useful because glucose
levels in healthy people do not vary widely
Random urine glucose test.
throughout the day.
Test not specific for DM
Blood glucose levels that vary widely may
Procedure – collect urine
indicate a problem.
Normal 160 – 180 md/dL
Result that indicates a problem?
Blood glucose <160, no glucose should be
found in urine.
Adv. – no preparation
measures blood glucose regardless of when
you last ate.

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Unit 3
blood test after 12 hour fast
Fasting Blood glucose Useful screening test for all carbohydrate
disorders
Diagnosis can be made (ADA/WHO)
If FBS < 126 mb/dL, a follow up test needed
1. A FBS is obtained in green heparin tube. No
smoking or eating is permitted during the test.
2. Patient must during standardized load of
OGTT
glucose within a 5 minute period. Someone
Procedure
must observer patient actually drink glucose
load. If patient vomits, discontinue test.
Urine test?
3. At exactly 30 minutes, blood and urine
specimen.
4. At one hour, another blood specimen.
• Do not administer glucose load to anyone
5. Each additional hour, blood specimens
with elevated fasting glucose level.
obtained, up to 5 hours. All blood glucose
specimens are measured as a batch.

139 and below - Normal


Result Diagnosis levels 140 to 199 - Pre-diabetes (impaired glucose
2-Hour Plasma Glucose Result (mg/dL) tolerance)
200 and above - Diabetes
conditions which an I.V. Glucose Tolerance If patient has gastric resection or any form of
Test should be used in place of the oral test. malabsorption.
blood test for glucose
2-Hour Postprandial blood glucose test.
Used for glucose intolerance, measured 2
(2HPP)
hours after a regular balanced meal.
Normal – normal blood glucose after 2 hours.
a. Hyperinsulinemia disorders - elevated levels of
insulin in the body, Typically as a result of insulin
resistance pancreas no longer has enough beta cell
capacity to keep up even with the production of
even low levels of insulin needed for basal insulin
Explain why the fasting blood glucose levels may
secretion.
be abnormally low for patients suffering:
b. Severe hepatitis – the diseased liver cannot store
Hyperinsulinemia disorders
adequate glycogen to meet the body’s needs for
Severe hepatitis
glucose reserves -
Hypothyroid disease
c. Hypothyroid disease – insufficient production of
Von Gierke's disease
thyroid hormones result in inadequate lipolysis and
Addison's disease
glycogenolysys
d. Von Gierke's disease – glycogen storage
disease, glycogen stores can be broken down, but
enzyme that cleaves off phosphate is not produced
e. Addison's disease – under production of cortisol.
lipolysis break down of stored fat to free fatty acids

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Unit 3
Used for glucose intolerance, give 2 hours after
glucose drink.
ADA recommends a FBS be included a part of
test to establish fasting baseline
If 2 hour blood glucose is >200mg/dL,
2-Hour Oral Post-challenge blood glucose
diagnostic for DM.
the rationale for, the advantages of, and the
Recommended for DM diagnosis if FBS but
procedures
<126ml/dL.
Normal – normal blood glucose after 2 hours.

- estimates the patient’s blood glucose level


over the last 4 – 6 weeks (time averaged)
glycosylation is a function of blood glucose
level and time
Glycosylated Hemoglobin test.
Normal person – 5% - 9% is glycosylated
(Glycohemaglobins)
Diabetic – 9% - 24%
Hypoglycemic - <5%
Used for monitoring diabetes therapy.
Adv. – No patient preparation or fasting
– gives time averaged estimate of blood
glucose level over previous 7 – 21 days
Serum Fructosamine test Adv. - more sensitive than GHT
Hyperglycemic – elevated fructosamine
Hypoglycemic - decreased fructosamine
to distinguish between DM type 1 and type 2
Type 1 – very low or non-detectable insulin
Insulin assay
levels
Type 2 - normal glucose tolerance
Measures how much insulin is being produced.
Adv. – 1)used to measure Type 2 DM patients
being treated with insulin injections.
Any C-Peptide in the serum represents insulin
patient is producing.
C-Peptide assay - insulin and C-Peptide are
2) tests for autoimmune antibodies against
products of the same parent protein
insulin. Test antibodies cannot bind insulin if
autoimmune antibodies are already bound to it.
3) C-Peptide has a longer biological half-life
than insulin
Sample can be collected for a longer time after
release in the body.

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Unit 3
blood urea nitrogen test reveals that your urea
nitrogen levels are higher than normal, it
probably indicates that your kidneys aren't
BUN test working properly. Or it could point to high
protein intake, inadequate fluid intake or poor
circulation.

If analytes are deficient, oslmolality will be low


If analytes are excessive, oslmolality will be high
Urine Osmolality – to evaluate? renal tubule function
Changes one 6 C sugar to another
isomerase
(glucose, mannose, galactose(milk))
Glucose 6 phosphate cannot Exit the cell membrane
Insulin
Hormone that lowers blood glucose
Makes glucose permeable to cell membranes
Glucagon, epinephrine
Cortisol, ACTH
Hormones that raises blood glucose Thyroid hormones
Growth hormone
Human placental lactogen
glycogenolysis Breaking down glycogen to glucose
Gluconeogenesis Forming glucose from non-carbohydrates
Produced by the liver by lipolysis
Acids - Change pH body fluids
Ketone bodies
Metabolic acidosis in DM
Can be used as fuel by brain and CNS
Symptoms of both Diabetes insipidus and Mellitus Thirst, dehydration,Excessive volumes of urine
Diabetes mellitus
Pheochromocytomas-(epinephrine and
norepinephrine producing tumors)
Hyperglycemic diseases Cushing’s disease
Gigantism and acromegaly
Grave’s disease and thyrotoxicosis
pregnancy
Elevated cortisol causes glycogenolysis
Cushings’ disease (tumor)
Elevates blood glucose level
conditions under which non-electrolytes can In addition to proteins all other non-ionic molecules like
contribute significantly to the serum's glucose, billirubins, medications, etc can effect osmotic
osmolality. pressure when they are in abundance in a
solution.

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Unit 3
Hepatic disease – liver can’t store enough glycogen
Myxedema – thyroid does not produce hormone
Hashimoto’s disease – autoimmune destroys thyroid
Addison’s disease – failure of adrenal to produce
Hypoglycemia diseases aldosterone and cortisol
VonGeirke’s disease – liver cannot produce G6PP and
chop off phosphate so glucose can’t leave liver cell
(Epinephrine tolerance test is diagnostic)Positive if
epinephrine does not raise blood glucose level
CNS neuropathy PNS neuropathy
Cataracts Renal hemorrhage
Complications of Blindness(degeneration) Renal failure
Diabetes Mellitus Atherosclerosis MI and strokes
Loss of feeling loss of circulation
Non-healing wounds amputations
Type 1 = No insulin or C-Peptide
Type 2 = Low to Normal insulin and C-Peptide
 Measure C-Peptide because insulin has a short half-life.
True definitive test for DM type
 C-Peptide last 4 times longer – test how much patient is
producing, does not measure added insulin.
 FBS>126 mg/dL on more than one occasion
Most severe
 All of a sudden, you cannot produce insulin
 Insulin undetectable, glucose levels extremely high
 Severe ketoacidosis
Type 1 (juvenile or IDDM) 15%  Insulin Shock - comas from hyperglycemia or severe
hypoglycemia
 Must be treated with insulin
 Caused by a virus triggering an autoimmune
response against the beta cells that produce insulin.
Most common
 Insulin produced, but is low or doesn’t work correctly
 managed by diet or oral insulin-stimulation drugs that
Type 2 (Adult onset or NIDDM) 85%
make the pancreas produce insulin
 Obesity can be sole cause.
 adipose cells enlarge, insulin receptors change position
Urine Glucose
Negative if blood glucose < 165 mg/dL
Glucose Tests  Does not rule out DM, based on renal threshold
5-hour glucose tolerance test
Gold standard - 5th hour for hypoglycemia
Fasting – no urine sugar - ½ hour – no urine sugar
5HGTT
1 hour – none to trace urine sugar
What to expect - Normal After that, back to normal

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Unit 3
Test urine and FBS before drink
***If urine has no glucose, you are safe.
If FBS>126mg/dL, don’t do test, contact Dr.
5HGTT ½ hour after glucose load – blood and urine
Take blood at 1, 2, 3, 4, 5 hour
Graph results for interpretation
For Hypoglycemia – hours 3-5 results
Fasting – above 126mg/dL or lower
5HGTT ½ hour – FBS > 170, positive urine sugar
What to expect – Diagnostic Criteria 1 hour –FBS >200, positive urine sugar
After that, FBS >200, variable urine sugar
Used when the glucose test is abnormal but
does not meet DM criteria
Impaired Glucose Tolerance (IGT)
FBS = <126 mg/dL
OGTT(2Hr) = <200 mg/dL
Used when fasting glucose is abnormally high,
but below126mb/dL. Rest of test is normal
Impaired Fasting Glucose (IFG)
FBS = Elevated, <126 mg/dl
OGTT(2Hr) = Normal Range
Get fasting specimen
If > 140 don’t give glucose load
GDM screening test
50 gms glucose, then get 1 hr. specimen
If >140, continue with confirmatory test
GDM screening test Get fasting specimen
(3HGTT) 100 gms glucose, get 1, 2, 3 hr. specimens
Fasting > 105 mg/dL
GDM screening test 1-Hr > 190 mg.dL
(3HGTT)confirmed if any 2 are exceeded 2-Hr > 165 mg.dL
3-Hr > 145 mg.dL
Global use test for both
5HGTT
Hyper and hypoglycemia
2HPP Take fasting sample
No standardization of glucose load Patient goes out for a meal
For geriatric patients Take 2 hr specimen
2HGTT Check FBS, If FBS>126mg/dL, don’t do test
Take blood at 2 hour
Accepted by ADA/WHO as cost effective If > 200 mg/dL, patient had DM
Normal 5 – 9%
Glycosylated Hemoglobin
> hyperglycemic <hypoglycemic
Any changes do not show for at least 4 weeks
Hemoglobins separated based on charge
Xylose test for malabsorption Normal – 25 grams ingested, eliminate at least 4.1 gms
Urine Xylose * Urine Volume If Urine Xylose = 128 mg/dL+ Urine Volume -= 470 mL (4.7 dL)
No malabsorption if > 4.1 gms 123mg/dL x 4.7 dL = .602 grams = abnormal
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Unit 3
Like oral 2HGTT, but lactose load
Lactose tolerance test
 blood glucose, not intolerant
Viral meningitis – normal CSF glucose and lactate
CSF glucose and lactic acid
Bacterial meningitis -  CSF glucose,  lactate levels
40 – 70 mg/dL
CSF glucose normal
Use 2/3 of plasma glucose
Patients in shock =Anaerobic glycolysis = lactic acid
CSF handling Process as STAT – glucose and lactate
Keep sample cool
Glucose is not stable for very long
Oxalate/Fl (gray)
Heparinized (least problems of anticoags)
Venous glucose handling
(green) second best
Centrifuge, ASAP, remove plasma from cells
Serum ok, but centrifuse as soon as blood clots
and remove serum from cells
clear liquid that can be separated from clotted
Serum
blood
obtained from centrifuged whole blood that has
been prevented from clotting by the addition of
plasma
anticoagulants such as citrate, oxalate, or
heparin.
Collect in Oxalate/Fl (gray) tube
Assay STAT
Lactic acid collection Fluoride is a glycolysis inhibitor
Otherwise, RBC and WBCs will catabolize
glucose anaerobically,  lactic acid.
Whole blood is ??? in glucose than serum or
10 – 12% lower
plasma
Arterial blood(or capillary) is ??? in glucose 5% higher
than normal venous
Above normal range, ??? 10 mg/dL higher
sweat glands do not reabsorb salt from sweat.
If the sweat has  NaCl and KCl, osmolarity will be 
Cystic fibrosis – sweat is saltier than normal
Sweat is assayed for osmolality, chloride, sodium,
potassium

Glucose Dehydrogenase method – one step


NADH absorbs light – unaffected by oxalate/Fl

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Unit 3
Uses high heat (stinky)
O-Toluidine method Can measure xylose and galactose
Use standards for what you are measuring
Glucose Oxidase Method

The specificity of the method for glucose. – step 1, Second step is non-specific
Interfering substances
anything that can be oxidized will cause falsely low glucose – billirubin, creatinine, uric acid, etc.

Specific for glucose all steps


Hexokinase requires Mg++ as an activator (uses NAD+ or NADH)
Anticoagulants that chellate Ca++ will chellate Mg++ - add extra Mg++
highly specific method by spectrophotometrically measuring the NADP formed from hexokinase-
catalyzed transformations of glucose
Diagnostic criteria for FBS and OGTT results - The American Diabetes Association recommends
either the fasting glucose or the OGTT to diagnose diabetes but says that testing should be done
twice, at different times, in order to confirm a diagnosis of diabetes.
FBS OGTT(2Hr)
Normal 70 – 110 mg/dL Normal range
Diabetes Mellitus (DM – Type 1) >126 mg/dl >200 mg/dL
Extreme acidosis, panic values for blood
glucose
Diabetes Mellitus (DM – Type 2) >126 mg/dl >200 mg/dL
Other Specific Types of DM 111 – 126 mg/dL Normal range
Gestational Diabetes Mellitus (GDM) >105 mg/dL >165 mg/dL
Impaired Fasting Glucose (IFG) Elevated, <126 mg/dl Normal Range
Impaired Glucose Tolerance (IGT) <126 mg/dL <200 mg/dL

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