Clinical chemistry

An introduction to clinical chemistry and key terminologies

Dr. Naureen Shehzadi

Punjab University College of Pharmacy, University of the Punjab, LHR

What is clinical chemistry?

Definition

Clinical chemistry is a sub-discipline of laboratory medicine that is concerned with the

qualitative and quantitative procedures designed to identify, quantify or characterize the
biologically important chemical substances in the bodily fluids.

Synonyms

 Clinical biochemistry
 Medical biochemistry
 Chemical pathology

How chemistry helps in clinical situations?

ALL DISEASES HAVE BIOCHEMICAL BASIS

Life on earth depends upon biochemical reactions and their cessation results in death.

Health may be defined as “the harmonious functioning of thousands of biochemical reactions

and processes that occur in normal cells and that operate to maintain homeostasis (constancy) of
the internal environment”.
Any disturbance in the harmonious functioning of biochemical reactions and processes that occur
in normal cells to maintain homeostasis of the internal environment results in a “disease”.

A disease can be defined as “a disorder of structure or function in a human, animal, or plant,

especially the one that produces specific symptoms or affects a specific location and is not
simply a direct result of physical injury”.

Biochemical causes of a disease

The biochemical cause of a disease may be perturbations of the structures and amounts of
biomolecules or biochemical reactions and processes.

1. Structure of biomolecules

Certain diseases arise due to alterations in the structure of biomolecules.

Example:

Sickle cell anemia

Glutamate (hydrophilic amino acid) in the β-chain of hemoglobin is replaced with valine
(hydrophobic amino acid) due genetic defect (point mutations in β-globin gene). This
abnormality in the structure exposes a sticky patch on the surface of the molecule in hypoxic
conditions that interacts with hydrophobic pocket of another hemoglobin molecule. The deoxy
hemoglobin molecules aggregate and polymerize resulting in an insoluble and rigid fiber that
extends throughout the length of the RBC. The distort RBCs hence acquire a sickle shape. The
deformed cells are unable to pass through microvessels and capillaries and exacerbate the disease
symptoms.
 2. Amounts of biomolecules

Certain diseases arise due to abnormal amounts (increased or decreased) of different

biomolecules.

Example:

Hyperglycemia

Due to increased blood glucose

Hyperuricemia

Due to increased uric acid in blood

Hyperlipidemia

Due to increased triglycerides, cholesterol and abnormal lipoproteins in blood

3. Biochemical reactions

Oxidative stress

Mitochondrial dysfunction (leading to excessive oxidative phosphorylation) and increased lipid

peroxidation results in reactive oxygen species and free radicals which damage the biomolecules
such as nucleic acid, proteins and lipid layers. Initially, the body’s defense mechanisms try to
compensate the damage, however, an imbalance between the oxidative specie and antioxidants in
the body results in oxidative stress.

Ketoacidosis

Increased production of ketone bodies (acetone, acetoacetic acid and β-hydroxy butyric acid) due
to prolonged starvation, ketogenic diet, and uncontrolled diabetes decreases alkaline reserves of
the body leading to ketoacidosis.
Summary

Course of a disease

Biochemistry is altered

Emergence of clinical situation

Lab tests advised

Identification of biomolecules altered as a course of a disease

Confirmation of the root cause of a disease

Decision on treatment strategy

Follow up treatment upon re-tests

Impact of clinical chemistry services in healthcare: A case scenario

A 54-year old female presents to the emergency department, Itefaq Hospital, LHR with fever and
chills. She had a history of multiple urinary tract infections, diabetes mellitus, type 2 with
diabetic nephropathy and chronic kidney disease. Upon physical exam, right flank tenderness is
also observed.

Important aspects of the case

 Fevers and chills

 History of multiple urinary tract infections
 Type 2 diabetes
 Diabetic nephropathy and chronic kidney disease
 Right flank tenderness

Clinical tests

 Urinalysis
 Serum creatinine
How will clinical chemistry help?

Confirm clinical diagnosis through urinalysis

 Raised leukocyte esterase indicates the presence of WBCs in the urine and hence urinary
tract infection
 Ketones and glucose indicate of diabetes
 Protein in urine indicate kidney damage

Guide appropriate dosing of antibiotics

Dose adjustment for reduced glomerular filtration rate on serum creatinine

Journey from clinical question to the biochemical answer

Request form Collection of

Clinical Transit to
with clinical biological
question laboratory
data specimen

Reception and
Collation Quality control Analysis labeling of
specimen

Interpretation of Reporting the Biochemical

the results results answer
Terminologies

Analyte

Chemical constituent of interest in an analytical procedure is called an analyte.

Common analyte/s in clinical chemistry laboratory

Analytes

Small Large
Ions, salts
organic macromolecu
and minerals
molecules les

1- Ions, salts and minerals

 Potassium
 Sodium
 Calcium
 Chloride
 Magnesium
 Phosphorous
 Iron
 Carbon dioxide
 Bicarbonates
 Heavy metals (lead, arsenic, chromium, nickel, mercury etc.)
2- Small organic molecules

Metabolites Therapeutic drugs Drugs of abuse

Glucose Vancomycin Alcohol
Cholesterol Theophylline Cocaine
Urea Digoxin Barbiturates
Lactic acid Phenytoin Amphetamines
Bilirubin Valproic acid Opiates
Creatinine Salicylates Cannabinoids
Triglycerides Acetaminophen
Cystatin C

3- Large macromolecules

Proteins Enzymes Biomarkers

Transport proteins Lipase Hemoglobin A1C
1. Albumin Amylase
2. Hemoglobin Alanine aminotransferase
3. Heptoglobin Aspartate
4. Lipoproteins (high-density, aminotransferase
low-density, very low Alkaline phosphatase
density and intermediate Lactate dehydrogenase
density lipoproteins) Creatinine kinase
5. Transferrin
Storage proteins
Ferritin
Specific proteins
1. Immunoglobulins
(IgA, IgG, IgM)
2. Complement proteins
(C3 and C4)
3. C-reactive proteins
 Biological fluids

A biological fluid refers to the representative part of a body fluid to be investigated in the
laboratory.

Biological fluids typically used in clinical chemistry tests

Blood

Urine

Cerebrospinal fluid

Amniotic fluid

Bio-fluids Saliva

Synovial fluid

Pleural fluid

Pericardial fluid

Peritoneal fluid

1- Blood

Blood – drawn from a vein into the evacuated tubes (Phlebotomy) – is the most common
biological fluid for clinical laboratory testing.

It is collected in screw-capped glass containers (vacutainers) with or without anti-coagulants.

Components of blood

Ions

Fluid Plasma or serum Molecules

Components of
Red blood cells Clotting proteins
blood
Cells White blood cells

Platelets

Plasma = blood – blood cells

Serum = plasma – clotting proteins

Preparation of blood for testing

Most clinical chemistry analytes are found in the fluid compartment of blood. Hence, the
collected samples require separation of the fluid from blood cells before determination of
analytes.

Separation of plasma from blood

Separation of serum from blood

 2- Urine

Urine is a liquid by-product of metabolism in humans.

It is collected in screw-capped plastic containers with or without preservatives. The containers

having preservatives are chosen to carry the urine sample when it cannot be tested immediately
upon collection. The preservatives reduce bacterial metabolism and prevent decomposition of an
analyte.

Most commonly used urine preservatives include;

 Potassium phosphate
 Benzoic acid
 Sodium bicarbonate
 Acetic acid
 Hydrochloric acid
 Boric acid

Urine sampling

Types of urine How it is used

sample
First morning Provides a concentrated sample of urine that contains the overnight
sample accumulation of metabolites.
Useful for detection of proteins or unusual analyte(s).
Random Convenient sample that can be collected at any time.
Most often used for routine screening tests.
Timed Typically 2 to 6 hours of urine output to give a representative sample;
duration of collection depends on the analyte(s).
24-h Used for metabolites whose excretion rates may vary with time of day
and full 24-hour collection is needed to be representative.
3- Amniotic fluid

The amniotic fluid is the liquid contained by the amniotic sac. It nourishes and protects the fetus.
The chemical tests on amniotic fluid determine fetal health and maturity.

During pregnancy, amniotic fluid may be useful for determining;

 Bilirubin which indicates hemolytic disease in newborn

 Phosphatidyl glycerol which indicates fetal lung maturity
 Creatinine which indicates fetal age
 Alpha fetal proteins which indicate neural tube defects

4- Peritoneal fluid

Peritoneal fluid is a liquid which lubricates the surface of tissue that lines the abdominal wall and
pelvic cavity, and covers most of the organs in the abdomen.

The peritoneal fluid is tested to help diagnose the cause of;

 Peritonitis, an inflammation of the membrane lining the abdomen

 Peritoneal fluid accumulation (ascites)

5- Pericardial fluid

The pericardium – a sac containing the heart and the roots of the great vessels – consists of two
layers, an outer fibrous layer and the inner serous layer. Pericardial fluid is the fluid secreted by
the serous layer into the pericardial cavity.
Pericardial fluid analysis is used to;

 Diagnose the cause of inflammation of the pericardium (pericarditis)

 Fluid accumulation around the heart (pericardial effusion)

6- Pleural fluid

Pleural fluid is a lubricant liquid in the pleural space; space between the two-layer membrane
that covers the lungs and lines the chest cavity.

It is tested to determine;

 Cause of inflammation of the lungs

 Pleural effusion
The peritoneal, pericardial and pleural fluid are used to assess the origin of fluid i.e. whether it
has leaked from blood vessels because of pressure differences (transudate, which is relatively
low in protein) or because of inflammation or injury (exudate, which is relatively high in
protein).

7- Cerebrospinal fluid

Cerebrospinal fluid is a clear, colorless body fluid found in the brain and spinal cord.

The changes in the glucose and protein content of the fluid indicate infections, tumors or trauma.

8- Synovial fluid

Synovial fluid is a viscous fluid in joint cavities.

Abnormal protein, glucose, uric acid lactate dehydrogenase and rheumatoid factor indicate
inflammatory or infectious diseases in the joint.
9- Saliva

Saliva is a thick and colorless fluid produced by salivary glands. It is 98% water, but contains
many important substances such as electrolytes, mucus, antibacterial compounds and various
enzymes.

Saliva testing is used for measuring hormones like cortisol, estrogen and testosterone, and low
molecular weight substances such as alcohol and drugs of abuse.

Profiles/panels

A combination of chemical tests, ordered as a group and performed on the same biological
sample is called a panel or profile.

Profile or panels are advised when an individual test is not sufficient to assess a medical
condition.

Common laboratory profiles/panels

1- Lipid profile
2- Liver profile (LFT)
3- Kidney profile (RFT)
4- Metabolic profile
5- Electrolyte profile

Example
 Interpretation of results of a lab report

The results of a lab test are expressed in numbers with units which reflect the amount of analyte
in a given volume of fluid. These results are interpreted by comparison to a reference interval (a
range that has been documented to reflect the results expected for healthy people).

Example

Analyte Reference range Interpretation

Fasting glucose < 100 mg/dL Non-diabetic
100-125 mg/dL Pre-diabetic
≥ 126 mg/dL Diabetic
Cholesterol < 200 mg/dL Desirable
200-239 mg/dL Moderate risk of cardiac complications
≥ 240 mg/dL High risk of cardiac complications