Pathophysiology 1

NATS2038

Common blood and urine

tests
Prepared by Z. Pletikosa
 Reference range
Reference range (reference interval) is the range of values that is
deemed normal for a physiologic measurement in healthy persons
Upper and lower reference limits are cut off points

Reference range is determined

statistically to include 95% of
individuals deemed healthy
Reference range is somewhat
arbitrary and should not be used as
absolute evidence of health/disease
Blood test results should be
considered in a broader clinical
context
 Full blood count – FBC (1)
 Routine automated blood test that gives:
 haemoglobin (Hb) - normal findings for men 130-180 g/L
and for women 115-165 g/L
 red blood cell count (RCC) - normal findings 4.5-6.5 x 1012/L
for men and 3.8-5.8 x 1012/L for women
 haematocrit (Hct) - portion of blood volume occupied by red
blood cells (normal for men 40-50% and for women 36-47%)
 white blood cell count (WCC) - normal values 4-10 x 109/L
 platelet count (normal values 150-400 x 109/L)
 RDW (red cell distribution width) - measure of variation in
red cell size (normal is 11-15%) - RCCs of unequal sizes is
called anisocytosis and would be associated with high RDW
Automatic FBC blood analyser

Current analysers can perform around

100 tests per hour
 Anisocytosis

Peripheral blood film (not automated): anisocytosis is usually

associated with irregularity of erythrocyte shapes (poikilocytosis)
 Full blood count (2)
 Decreased levels of Hb are found in anaemia states
 Increased Hb levels are found in haemoconcentration of
the blood such as serious dehydration or excessive
production of erythrocytes (seen in polycythaemia vera,
chronic obstructive pulmonary disease and chronic heart
failure)
 RCC is decreased in anaemia, and increased in states of
excessive erythropoiesis and serious dehydration
 Usually, the Hct parallels the RBC when the cells are of a
normal size - decreased Hct values are found in anaemia,
increased Hct is seen in excessive production of RBCs or
severe dehydration
 Full blood count (3)
• Red blood cell indices are calculated values that define
the size and haemoglobin content of the red blood cell
Normal
Test Full name Description Calculation
values
Mean average weight of 27-32 pg
MCH corpuscular haemoglobin in Hb/RBC (picogram =
haemoglobin each erythrocyte 10-12 g)
Mean average
corpuscular concentration of 300-350 g/L
MCHC Hb/Hct
haemoglobin haemoglobin in red (30-35%)
concentration blood cells
Mean 80-98 fL
average volume of
MCV corpuscular Hct/RBC (femtolitre =
one erythrocyte
volume 10-15 L)
 Full blood count (4)
 Red blood cell indices, especially MCV and MCHC, are
used in differentiating anaemias into:
• Microcytic/hypochromic anaemia (decreased MCV,
decreased MCHC) – often iron deficiency or thalassaemia
• Macrocytic/normochromic anaemia (increased MCV,
normal MCHC) – often folic acid/vitamin B12 deficiency
• Normochromic/normocytic anaemia (normal MCV,
normal MCHC); based on reticulocyte count (separate
test, can be added to FBC) this anaemia can be:
 normo-regenerative (elevated reticulocytes  increased
production of RBCs in the bone marrow) and
 hyporegenerative (low or normal reticulocyte count  no
increase in RBCs production in the bone marrow)
 Full blood count (5)
 Normocytic/normochromic anaemia types:
• Normoregenerative anaemias (appropriate reticulocyte
response – formation of new erythrocytes) – haemolytic
anaemias such as in glucose-6-phosphate dehydrogenase
(G6PD) deficiency, sickle cell disease, hereditary
spherocytosis, autoimmune haemolytic anaemia
• Hyporegenerative anaemias (inadequate reticulocyte
response) – anaemia of chronic disease (variety of
chronic inflammatory and non-inflammatory conditions),
aplastic anaemia (bone marrow suppression, often due
to unpredictable, idiosyncratic patient response to
certain drugs; in addition, many anticancer drugs
produce predictable, dose-related marrow suppression)
Full blood count (6)
 White blood cell count (WBC) (1)
• WBCs (leukocytes) are divided into
two main groups: granulocytes
(neutrophils, basophils and
eosinophils) and agranulocytes
(lymphocytes and monocytes) PMNs

• Granulocytes contain multilobed

nuclei which vary in appearance in
different cells (polymorphonuclear
leukocytes)
• Agranulocytes have nonlobular
nuclei (mononuclear leukocytes)
 Full blood count (7)
 White blood cell count (WBC) (2)
• Neutrophils and monocytes fight infections and defend
the body by a process called phagocytosis; lymphocytes
produce antibodies as a part of the immune response
• Normal values for WBC are 4-10 x 109/L
• Differential WBC (‘Diff’, typically included in FBC):
 neutrophil granulocytes 2.5-7.5 x 109/L (40-75%)
 lymphocytes 1.0-3.5 x 109/L (20-45%)
 monocytes 0.2-0.8 x 109/L (2-10%)
 eosinophil granulocytes 0.04-0.4 x 109/L (1-6%)
 basophil granulocytes 0.01-0.1 x 109/L (0-1%)
 Full blood count (8)
 White blood cell count (WBC) (3)
• Quantitative alterations of WBC are leukocytosis (the
leukocyte count is higher than normal) and leukopoenia
(the count is lower than normal)

Leukocytosis

Granulocytosis Monocytosis Lymphocytosis

Neutrophilia Eosinophilia Basophilia

 Full blood count (9)
 White blood cell count (WBC) (4)
• Neutrophilia may be due to:
 normal protective response to physiologic and pathologic
stressors: bacterial infections, strenuous exercise,
emotional changes, tissue damage (surgery, trauma,
myocardial infarction, pulmonary infarction), pregnancy,
and some drugs and toxins
 pathologic conditions such as various malignancies and
chronic inflammatory disorders (eg. rheumatoid arthritis,
systemic lupus erythematosus, ulcerative colitis,
inflammatory bowel disease)
 blood malignancies (eg. various types of leukaemia) that
increase WBC proliferation in the bone marrow
 Full blood count (10)
 White blood cell count (WBC) (5)
• Monocytosis may be observed in some chronic bacterial
infections (eg. tuberculosis, syphilis, brucellosis) and
autoimmune diseases (eg. SLE, IBD)
• Eosinophilia is usually seen in allergic disorders such as
asthma, hay fever, food allergy and drug allergic reactions
• Basophilia is a relatively uncommon phenomenon that
rarely has clinical significance, but may sometimes be
observed in allergic reactions
• Lymphocytosis can be seen in some acute viral infections
(eg. infectious mononucleosis, measles, mumps, German
measles, hepatitis), toxoplasmosis, TB; it may also be seen in
chronic lymphocytic leukaemia and lymphoma
 Full blood count (11)
 White blood cell count (WBC) (6)
• Leukopoenia is never beneficial as it increases risk of
infections; common causes:
 unwanted reaction to certain drugs (eg. neuroleptics,
antithyroid drugs, antiepileptic drugs, chloramphenicol)
 vitamin B12 and/or folic acid deficiency
 severe prolonged bacterial infections when production of
leukocytes cannot compensate for leukocyte loss
 decreased neutrophil production in the bone marrow
(exposure to radiation, cancer chemotherapy, bone
marrow infiltration by abnormal leukocytes in leukaemia)
 some viral infections due to adhesion of neutrophils to
endothelium (not a true decrease)
 Full blood count (12)
 Platelet count (1)
• Normal platelet count is 150-400 x 109/L
• Thrombocytopoenia = decrease in the number of
circulating platelets, thrombocytosis = increase in the
number of platelets
• Thrombocytopoenia increases risk for bleeding on minor
trauma or even spontaneous such as petechiae (tiny
haemorrhagic skin rash), purpura (slightly larger spots than
petechiae), ecchymoses (bruises) or bleeding from mucous
membranes (eg. nose and mouth bleeds, bleeding in the
gastrointestinal and genitourinary tract)
• Thrombocytosis generally has no consequences but, if very
marked, may predispose for thrombosis
 Full blood count (13)
 Platelet count (2)
• Thrombocytopoenia may be primary (primary idiopathic
thrombocytopoenic purpura – autoimmune disorder
children/young women in association with a viral illness or
for no apparent reason) or secondary (reaction to certain
medications, viral infections, and some autoimmune
conditions, enlarged spleen and leukaemias)
• Thrombocytosis is a normal physiologic response to
stress, bacterial infections, trauma, exercise; it may also
occur in certain chronic inflammatory disorders such as
rheumatoid arthritis, inflammatory bowel disease or
tuberculosis; very rarely it is a result of malignant
proliferative disorder of magakaryocytes
 Erythrocyte sedimentation rate
 Erythrocyte sedimentation rate (ESR) is the rate at which
erythrocytes settle out of anticoagulated blood in 1 hour
in a special vertical test tube
 This test is based on the fact that inflammatory processes
cause an alteration in blood proteins (eg. fibrinogen
increase), resulting in a faster aggregation of red cells
 Normal ESR is below 16 mm/hour
 ESR is a non-specific marker of inflammation; increased in:
• infections, especially bacterial
• cell or tissue destruction (eg. trauma, surgery, infarction etc)
• various chronic inflammatory diseases
• various tumours (not always)
ESR principle

ESR increases with

age, and is raised in
pregnancy and in
anaemia (problem
for interpretation!)
 C-reactive protein
 CRP is a protein produced in the liver in the presence of
inflammation; it is virtually absent from the blood of
healthy persons
 CRP is a more sensitive and accurate indicator of
inflammatory response than is the ESR
 Normal value is <5 mg/L; CRP is elevated in:
• bacterial and viral infections (acute)
• tissue trauma including infarction, burns and surgery
• malignancy (active, widespread)
• rheumatoid arthritis and other autoimmune conditions
 Serious liver disease decreases CRP production in
inflammation
 Iron studies (1)
 Iron studies of blood
 serum iron (normal 10-30 µmol/L)
 serum ferritin - storage form of iron (normal 15-300 µg/L)
 serum transferrin - iron binding protein (normal 1.7-3.0 g/L)
 total iron binding capacity - maximal amount of iron that
can be bound to transferrin (normal 45-80 µmol/L)
 saturation of transferrin - ratio
between serum iron and iron binding
capacity (normal 0.15-0.45 (15-45%)) TIBC
 soluble transferrin receptor (2.2-5 mg/L (mmol/L)

for men and 1.9-4.4 mg/L for women) Serum iron

(mmol/L)
 Iron studies (2)
 Iron tests are very helpful in assessment of iron deficiency
anaemia and iron overload states (haemochromatosis)
 Serum iron
• circulates in blood bound to transferrin
• decreases in iron deficiency, but also acute and chronic
inflammation, hypothyroidism
• increases in haemolytic anaemias (especially
thalassaemia), iron-overload (eg. haemochromatosis),
multiple transfusions, acute liver damage (release of iron
from liver cells)
• however considerable variation occurs within a day in
individuals, so little value on its own
 Iron studies (3)
 Transferrin/iron binding capacity
• increases in iron deficiency anaemia, but also in pregnancy
and with oral contraceptives (hormonal effect)
• decreases in hypoproteinaemia (malnutrition, chronic liver
damage, proteinuria in kidney disease), haemochromatosis,
anaemia of chronic disease, acute and chronic
inflammation
 Transferrin saturation
• increases in haemochromatosis, increased iron intake
(unnecessary iron supplements), haemolytic anaemia
• decreases in iron deficiency states, anaemia of chronic
disease, inflammation
 Iron studies (4)
 Ferritin
• increases in iron excess (haemochromatosis, iron
overadministration), acute and chronic inflammation, acute
and chronic liver disease, malignancies, megaloblastic
anaemia (B12 or folic acid deficiency), haemolytic anaemia
• decreases in iron deficiency states
 Soluble transferrin receptor (sTfR)
• increased when iron demand is increased in iron deficiency,
increased erythropoiesis (eg. haemolysis due to any cause)
• normal in the presence of inflammation and in anaemia of
chronic disease (useful in distinguishing iron deficiency
anaemia and anaemia of chronic disease)
Iron studies (5)
 Blood glucose (1)
 Normal values for fasting blood glucose are 3.0-5.5
mmol/L, and for random blood glucose are 3.3-7.7 mmol/L
 Elevated blood sugar (hyperglycaemia) occurs in:
• diabetes mellitus: > 7.0 mmol/L is diagnostic; if 5.5-7.0 mmol/L
oral glucose tolerance test with 75g of glucose is carried out,
blood glucose >11.1 mmol/L 2hr later is indicative of diabetes
(it should be below 7.7 mmol/L)
• endogenous (overproduction) or exogenous (treatment)
glucocorticoids excess (stimulate gluconeogenesis)
• acute emotional or physical stress situations (eg. myocardial
infarction, serious injury or severe infection) – sympathetic
nervous system stimulation (increased glycogenolysis)
• acute and chronic pancreatitis (-cell dysfunction/damage)
 Blood glucose (2)
 Decreased blood glucose (hypoglycaemia) occurs in:
• insulin or sulphonylurea overdose (accidental or deliberate)
• pancreatic islet cell adenoma (insulin secreting tumour)
• some extrapancreatic tumours (often certain lung carcinomas)
• Addison’s disease (adrenal insufficiency)
• alcohol abuse (impaired gluconeogenesis)
• serious liver damage (impaired gluconeogenesis)
• serious kidney damage (impaired gluconeogenesis)
• hypothyroidism
• starvation
• reactive hypoglycaemia in response to a high carbohydrate
meal (unclear cause)
 Glycosylated haemoglobin
 Glycosylated (glycated) haemoglobin (HbA1c) is formed
through non-enzymatic attachment of glucose to globin
 Its level reflects the average glucose concentration over the
life of the RBCs (previous 3 months)
 Regarded as the gold standard for assessing glycaemic
control
 Normal values: 3.5-6.0% of haemoglobin (15-42 mmol/mol)
 Higher levels of HbA1c are found in people with persistently
elevated blood glucose, as in diabetes mellitus
 In such patients this test is used to monitor treatment
effectiveness and the aim is to keep HbA1c below 7% (53
mmol/mol)
Lipoproteins

29
 Blood lipid tests (1)
 Blood lipid profile includes total cholesterol, triglycerides,
LDL (low density lipoproteins) and HDL (high density
lipoproteins)
 Cholesterol is a fat-soluble steroid alcohol only found in
animal food (including eggs and dairy)
 Elevated total cholesterol (hypercholesterolaemia) is one
of the most important risk factors for atherosclerosis
Ideal level < 4 mmol/L
Acceptable level < 5.5 mmol/L
Mild increase 5.5 – 6.5 mmol/L
Moderate increase 6.5 – 7.8 mmol/L
Severe increase > 7.8 mmol/L
 Blood lipid tests (2)
 Elevated total cholesterol can be found in:
• familial hyperlipoproteinaemia syndromes (inherited)
• liver disease, cholestasis
• nephrotic syndrome, glomerulonephritis, chronic renal failure
• hypothyroidism
• poorly controlled diabetes mellitus
• alcoholism
• diet high in cholesterol and/or saturated fats
• obesity
 HDL functions in transport of excess cholesterol from
peripheral tissues to the liver; decreased HDL levels
predispose for atherosclerosis, whereas elevated HDL levels
protect against atherosclerosis (normal 1.0-2.0 mmol/L)
 Blood lipid tests (3)
 Triglycerides (normal fasting values are < 1.7 mmol/L) in
blood are especially found in VLDL; without elevated
cholesterol elevated triglycerides are not considered to be
a major risk factor for atherosclerosis
 LDL contains most blood cholesterol; LDL is closely
associated with risk for atherosclerosis (desirable LDL is <
3.4 mmol/L, borderline high is 3.4 - 4.1 mmol/L, while
seriously high is > 4.1 mmol/L); LDL is typically calculated
(from TC, HDL and TG) rather than measured
 Certain calculated ratios are also useful in assessment of
atherosclerosis risk:
• LDL/HDL should be below 3
• total cholesterol/HDL should be below 4
 Cardiac markers (1)
 Non-traumatic cellular injury occurs in myocardial
infarction (tissue necrosis) and infections (eg. viral
myocarditis)
 During tissue injury several markers present in cells are
released into blood when cell membranes are damaged
 Cardiac markers are
• enzymes such as aspartate aminotransferase, lactate
dehydrogenase and creatine kinase
• troponins (part of contractile machinery in muscle along
with actin, myosin and tropomyosin)
• myoglobin – oxygen binding macromolecule in muscle
cells
 Cardiac markers (2)
 Aspartate aminotransferase-transaminase (AST)
• Used to be called serum glutamic oxaloacetic transaminase
(SGOT)
• Found in the heart, liver, skeletal muscle, kidney, brain,
pancreas, spleen and lungs
• AST blood levels have a rough correlation with the extent of
the infarct
• AST elevation is also common in liver cell necrosis and in
skeletal muscle necrosis (eg. injury, muscle dystrophy)
• AST is not used clinically as much as it was in the past, being
largely replaced by the more specific tests
 Cardiac markers (3)
 Lactate (lactic acid) dehydrogenase (LD or LDH)
• Widely distributed in the tissues (kidney, heart, skeletal
muscle, brain, liver, lungs)
• LDH can be measured as total enzyme or each of its 5
isoenzymes (to differentiate the source of the elevated
total LDH)
• LDH1 is  in MI (still less useful in MI diagnosis than
troponins), LDH5 is  in liver damage
• LD is also elevated in PE/pulmonary infarction, skeletal
muscle diseases (eg. muscular dystrophy) and strenuous
physical exercise, haemolytic anaemias and certain types
of cancer
 Cardiac markers (4)
 Creatine kinase (CK)
• Found primarily in the heart, skeletal muscle and brain,
and is released in tissue injury
• It is a sensitive indicator of myocardial injury;
consequently used in diagnosis of MI
• 3 main isoenzymes of CK: CK-BB (brain), CK-MM (skeletal
muscle), and CK-MB (cardiac muscle)
• Normal CK levels in blood are virtually 100% MM
isoenzyme and this fraction increases in muscle
injury/disease, including strenuous physical activity
• CK-MB isoenzyme is elevated in MI
Cardiac markers
(5)
 Troponins
• 3 types of troponin: T, I and C, found in all muscle types
• There are cardiac-specific forms of troponins T and I
termed cTnT and cTnI; in lab diagnostics these specific
forms are generally known simply as troponins
• Normally both troponin T and I are not detectable in blood
• After damage to cardiac muscle cells due to MI (or
myocarditis), troponins are released into the circulation
and can be measured in blood
• Cardiac troponins are the most sensitive and specific tests
in diagnosis of MI
 Cardiac markers (6)

 Myoglobin
• Haeme-containing, oxygen-binding protein present in the
cytoplasm of cardiac and skeletal muscle cells
• Increased levels are found in any condition causing
muscle cell damage including MI
• Myoglobin level drops to normal the following day due to
rapid excretion by the kidneys (only 153 amino acids,
small enough to be excreted in urine)
• This test is not specific for MI and needs to be done in
conjunction with other tests
Cardiac markers (7)
 Liver function tests (1)
 LFTs are several blood tests that assess the general state
of the liver and biliary system
• bilirubin
• alkaline phosphatase (ALP) enzyme
• alanine aminotransferase (ALT) and aspartate
aminotransferase (AST) enzymes
• gamma glutamyl transferase (GGT or -GT) enzyme
• serum albumin
• lactate dehydrogenase (LDH) enzyme
• prothrombin time (PT)
 Liver function tests (2)

IMPORTANT POINTS

• Only serum albumin, prothrombin time and to some

extent bilirubin actually test liver functions

• Enzymes reflect liver cell damage or cholestasis

 Stercobilinogen
Bilirubin metabolism (1) excreted in urine is
called urobilinogen

After conversion to
brown stercobilin
Bilirubin metabolism (2) Glucuronic acid

Bilirubin diglucuronide
 Liver function tests (3)
 Bilirubin (2)
•  unconjugated bilirubin: haemolysis or conjugation
defect (Gilbert’s syndrome)
•  conjugated bilirubin: intrahepatic or extrahepatic
cholestasis
• Blood tests measure only the total bilirubin and
conjugated (direct) bilirubin; unconjugated (indirect)
bilirubin is calculated as total bilirubin level minus
conjugated bilirubin level
• Elevated bilirubin (hyperbilirubinaemia), often
accompanied by jaundice, may be due to hepatic,
cholestatic or haemolytic causes
 Liver function tests (4)
 Bilirubin (3)
• Hepatocellular jaundice  injury of liver cells (viral
hepatitis, alcoholic liver disease, drug and poison toxicity);
hyperbilirubinaemia is both conjugated and unconjugated
• Cholestatic jaundice  result of obstruction of the
common bile duct by stones or tumours (often of the
pancreas); high conjugated bilirubin due to bile
regurgitation into blood
• Haemolytic jaundice  overproduction of bilirubin in
various types of haemolytic anaemias is unconjugated
 Liver function tests (5)
 Alkaline phosphatase (ALP)
• Mainly produced in liver (and excreted in bile) and bone
(from osteoblasts)
• Blood level rises as a result of biliary tract obstruction, both
extrahepatic and intrahepatic:
 acute/chronic hepatitis

 liver cirrhosis

 gallstones producing extrahepatic cholestasis

 liver tumours

 pancreatic tumour producing extrahepatic cholestasis

• Variety of bone lesions with bone destruction also elevate

ALP (eg. bone tumours, fracture, Paget’s disease)
 Liver function tests (6)
 Alanine aminotransferase-transaminase (ALT)
• Used to be called serum glutamic-pyruvic transaminase
(SGPT)
• Found mostly, although not exclusively, in the liver
• More specific to liver disease than AST but less sensitive
than AST
• ALT is  in all forms of serious liver damage, caused by
viruses, alcohol, hepatotoxic medications and toxins
• In case of hyperbilirubinaemia/jaundice, ALT can
differentiate between haemolytic/cholestatic jaundice
(normal ALT) and jaundice caused by liver disease ( ALT)
 Liver function tests (7)
 Aspartate aminotransferase (AST)
• Found in several organs, especially in heart, skeletal
muscle and liver; not specific to any tissue
• Damage to hepatocytes of any cause releases AST into
the circulation
• AST is a sensitive marker in acute hepatitis reflecting the
severity/extent of hepatocyte damage (often 10 times
normal)
• In terminal liver disease such as in advanced cirrhosis
AST and ALT are generally mild to moderately increased
as most of the tissue damage is over
 Liver function tests (8)
 Gamma glutamyl transferase (GGT, -GT)
• Found primarily in the liver and kidney, and to some
extent in heart muscle
• GGT is sensitive indicator of liver cell damage as well as
alcohol consumption (normal GGT indicates that it is
unlikely that a person has liver disease or is consuming
alcohol)
• GGT can be used to monitor the cessation or reduction of
alcohol consumption
• GGT is a sensitive marker of cholestasis; so it can show if
ALP elevations are due to cholestasis (ALP can also be
increased in certain bone diseases but GGT is not)
 Liver function tests (9)
 Serum proteins
• Serum protein levels reflect liver synthetic function
rather than cell injury
• Albumin is quantitatively the most important serum
protein synthesised entirely in the liver
• In chronic liver disease albumin concentration is often
low (hypoalbuminaemia)  reflects severity of liver
function impairment
• In acute liver disease there is little change in albumin
levels because of its fairly long half-life (2-3 weeks)
• Note that low albumin level can also develop in certain
types of kidney disease due to excessive loss in urine
Tests of haemostasis (1)

Two pathways for coagulation

 Tests of haemostasis (2)
 Prothrombin time (PT)
• This test that measures both extrinsic and common
pathways - activity of prothrombin (factor II), fibrinogen
(factor I) and factors V, VII and X (normal 11-13 sec)
• Too long PT (eg. more than 3 times normal) may lead to
bleeding tendency with spontaneous episodes of bleeding
• PT is prolonged in
 liver disease (reduced synthesis of coagulation factors)

 deficiency of vit K (used for synthesis of coagulation factors)

 anticoagulant therapy with warfarin (result is expressed as

International Normalised Ratio INR – normal 1, target 2-3)
but also heparin, direct thrombin inhibitors and factor Xa
inhibitors
 Tests of haemostasis (3)
 Prothrombin time (PT)
• CoaguChek INR monitor is a hand-held device that is used to
rapidly measure the international normalised ratio (INR)
• It is useful in patients on
anticoagulants, especially
warfarin
 Tests of haemostasis (4)
 Activated partial thromboplastin time (aPTT)
• aPTT measures both ‘intrinsic’ (contact) and common
coagulation pathways (normal 25-35 sec)
• it is prolonged in haemophilias, von Willebrand disease, in
heparin use (used for monitoring therapy), but also in other
situations that prolong PT
 Normal PT with prolonged aPTT  defect within the
intrinsic stage of the clotting cascade (factor VIII, IX, XI, or
XII)
 Normal aPTT with prolonged PT  problem in extrinsic
phase (factor VII deficiency?)
 Both PT and aPTT prolonged  deficiency of factor I, II, V
or X (common stage)
 Tests of haemostasis (5)
 Tests for platelets
• in the past bleeding time was used to assess platelet
function but it is obsolete now due to low sensitivity and
specificity, and cannot be reliably standardised
• currently platelet function is assessed through platelet
count (in FBC) and platelet function analyser (measuring
platelet aggregation)
• platelet function analyser (PFA) shows abnormal results in
thrombocytopoenia, von Willebrand disease and use of
antiplatelet medications such as aspirin and others
• additional tests exists to measure platelet aggregation
but they are difficult to do and time consuming
Kidney function tests (1)
 Urea
• Urea forms during deamination of amino acids in the liver
• The level of urea in blood is affected by dietary protein
intake, degree of protein breakdown and renal function
• Normal urea level is 3-8 mmol/L; increased urea levels
(azotaemia) occur in:
 impaired renal function (excretion problems)
 heart failure
 serious dehydration
 shock
 haemorrhage into GI tract (extra protein digestion)
 acute myocardial infarction, serious tissue trauma
 excessive protein intake
Kidney function tests (2)
 Creatinine
• This is a by-product in normal turnover/breakdown of
muscle creatine phosphate (energy rich substance)
• It is produced at a constant rate, depending on the muscle
mass and is removed from the body by the kidneys
• A disorder of kidney function reduces excretion of
creatinine, resulting in  blood levels (normal <0.12 mmol/L)
• It is also elevated in diet high in meat
• Creatinine is elevated in impaired renal function (renal
failure) that may be:
 prerenal (impaired renal blood flow, eg shock state)
 renal (kidney damage)
 postrenal (obstruction to urine flow)
 Kidney function tests (3)
 Creatinine clearance (CCr)
• Because all creatinine filtered by the kidneys is excreted
into the urine, creatinine clearance correlates well with
the glomerular filtration rate (GFR)
• It is calculated from urine creatinine level, blood
creatinine level, volume of collected urine and collection
time (typically 24 hours)
• Normal creatinine clearance is 90-120 mL/min
• Creatinine clearance test is a specific measurement of
kidney function, primarily glomerular filtration
• Decreased creatinine clearance is found in any form of
impaired kidney function (renal failure)
 Kidney function tests (4)
 Estimated glomerular filtration rate (eGFR)
• eGFR is calculated by the pathology laboratory using the
patient’s age, gender and blood creatinine level
• eGFR is accurate to approximately  30% so it is inferior to
measured creatinine clearance
• However, eGFR enables earlier detection of kidney
disease than blood creatinine alone
• Normal > 90 mL/min/1.73m2, 60 - 89 mL/min/1.73m2 -
mild reduction in GFR (still very common finding and only
likely to indicate pathological changes if blood creatinine
is high or there is other evidence of renal damage)
• A value below 60 mL/min/1.73m2 suggests some loss of
kidney function requiring additional tests
 Electrolytes importance
 Body fluids contain water and electrolytes
 Electrolytes are free ions that form after dissociation of
substances (salts, acids and bases) in solution
 Positively charged ions are called cations (eg. Na+), while
negatively charged ions are called anions (eg. Cl-)
 Intracellular fluids have higher concentration of potassium,
magnesium and phosphates, while extracellular fluids
contains more sodium, calcium, chloride and bicarbonates
 Electrolytes regulate concentration (osmolarity), state of
hydration and pH of both intracellular and extracellular
fluid, as well as membrane potentials and excitability of
nervous tissue and muscle
Electrolytes concentration units
 Electrolytes are expressed in SI units as millimoles per litre
(mmol/L); recall that mole is the amount that has a mass
in grams equal to the sum of atomic masses of all of its
atoms – eg. for sodium that is 22.99 g
 Moles of different electrolytes have different masses but
they still contain the same number of particles (6.023 x
1023 – Avogadro’s number)
 In some literature electrolyte concentration is expressed in
milliequivalents per litre (mEq/L)
 mEq/L = mmol/L X number of electrical charges (valence);
for Na+ mEq/L and mmol/L values are the same while for
Ca2+ mEq/L value is double the mmol/L value
 Milliequivalents are electrically equivalent
 Sodium (1)
 Sodium (Na+) is the major cation present in extracellular
fluid (90% of extracellular cations)
 Its primary functions in the body are to chemically
maintain osmotic pressure (osmolarity), acid-base
balance, and to generate resting membrane potentials
and actions potential needed for transmission of nerve
impulses and muscle contraction
 The body has a strong tendency to maintain total
sodium content, and only slight changes are found,
even under pathologic conditions
 Serum sodium concentration varies between 135-145
mmol/L
 Sodium (2)
 Hyponatraemia (a decreased level) usually reflects a
relative excess of body water (dilutional hyponatraemia),
rather than low total body sodium level
 Hyponatraemia is usually due to excessive water
intake/retention without or with sodium losses; this can
occur in:
• Taking sodium-free fluids with sweating, vomiting, diarrhoea
and diuresis (excessive urine production as with diuretics)
• Administration of Na+-free intravenous solutions (eg. glucose)
• Kidney disorders that impair water elimination
• Increased ADH levels and consequently increased water
reabsorption in kidneys (can occur in trauma, stress, pain)
• Psychogenic polydipsia – psychological problem characterised by
increased intake of water; there is always marked diuresis
 Sodium (3)
 Clinical manifestations of hyponatraemia are largely
due to dilution of extracellular fluid (hypo-osmolarity)
and osmotic movement of water into cells, especially
brain cells and muscle tissue
 This increase in intracellular water appears to be
responsible for: muscle cramps, weakness, fatigue,
apathy, lethargy, depression, headache, nausea,
abdominal cramps and diarrhoea
 In serious cases there is confusion, disorientation,
seizures and coma caused by brain swelling (“water
intoxication”)
 Signs and symptoms usually do not develop until
sodium level drops to 125 mmol/L
 Sodium (4)
 Hypernatraemia (an increased sodium level) is
uncommon and usually represents a deficit of water in
relation to the body’s sodium stores
 Major causes:
• dehydration and insufficient water intake (watery diarrhoea,
excessive sweating, diabetes insipidus, water unavailability)
• increased sodium reabsorption from urine as seen in primary
hyperaldosteronism (Conn’s syndrome) and to some extent
Cushing’s syndrome
 Hypernatraemia is characterised by hypertonicity
(increased osmolarity) of extracellular fluids and almost
always causes cellular dehydration (due to osmotic shift
of water from intracellular to extracellular space)
 Sodium (5)
 Clinical manifestations of hypernatraemia are largely
those of water loss and cellular dehydration:
• thirst (stimulation of osmoreceptors in the hypothalamus)
• oliguria with production of concentrated urine (due to
increased ADH production)
• dry skin/mucous membranes (intracellular dehydration)
• decreased salivation and lacrimation
• headache, agitation and restlessness, decreased reflexes,
lethargy, dizziness, confusion and even seizures and coma
(movement of water out of brain cells)
• tachycardia and weak pulse, drop in blood pressure,
weakness, dizziness (reduced blood volume)
• often decrease of body weight in line with water loss
 Potassium (1)
 Potassium is mainly an intracellular ion with only a
small, but vital, amount being present in the
extracellular fluids
 The distribution of potassium between the intracellular
and extracellular compartments regulates electrical
membrane potentials controlling the excitability of
nerve and muscle cells, as well as contractility of
skeletal, cardiac and smooth muscle
 Aldosterone hormone plays an essential role in
regulation potassium elimination by the kidney, which
occurs in exchange for sodium
 Serum potassium concentration varies between 3.5-5.3
mmol/L
 Potassium (2)
 Decreased blood potassium (hypokalaemia) occurs in
the following situations:
• Inadequate intake to compensate for obligatory urinary losses
(diet deficient in K+, often seen in elderly on plain diet)
• Excessive gastrointestinal (eg. vomiting, diarrhoea) and renal
(eg. diuretic therapy, increased mineralocorticoid level) losses
• Redistribution between the intracellular and extracellular
compartments - buffering (in alkalosis hypokalaemia is due to
exchange of extracellular K+ for intracellular H+)
• Hypokalaemia is often associated with the use of diuretics
when it is a consequence of compensatory increased sodium
reabsorption in collecting ducts in exchange for potassium,
which is due to increased sodium delivery to collecting ducts
 Potassium (3)
 Clinical manifestations of hypokalaemia are at least
partially caused by increase in resting membrane potential
(hyperpolarisation)
 Gastrointestinal manifestations such as anorexia, nausea,
constipation and abdominal distention are common
 Neuromuscular manifestations are muscle weakness,
fatigue, muscle cramps (especially during physical activity)
and tenderness, tingling sensations, lightheadedness,
confusion and depression
 Postural hypotension may develop together with
abnormalities of cardiac rhythm
 Impaired ability of kidneys to concentrate urine with
resulting polyuria also occurs
 Potassium (4)
 Increased blood potassium (hyperkalaemia) occur
when K+ shifts from cells to intracellular fluid, with
inadequate renal excretion, and excessive K+ intake as
in:
• Decreased renal function as in renal failure (the most
common cause)
• Cell damage, as in trauma, burns, surgery and cancer
chemotherapy (release of potassium into the blood)
• Redistribution between the intracellular and extracellular
compartments for H+ buffering purposes (in metabolic
acidosis such as diabetic ketoacidosis)
• Addison’s disease (shortage of aldosterone needed for
potassium elimination in urine)
• Uncontrolled diabetes (insulin normally facilitates movement
of potassium into cells)
 Potassium (5)
 Clinical manifestations of hyperkalaemia are mainly
due to decrease in resting membrane potential
(hypopolarisation), which is now closer to threshold
 This leads to increased excitability of many cells,
especially those in the muscle and heart
 Patients may complain of nausea, vomiting, diarrhoea,
abdominal cramps, tingling sensations, muscle cramps
and later weakness
 The biggest concern is the effect on the heart which
may lead to serious abnormalities of cardiac rhythm
such as extrasystoles, ventricular tachycardia and
ventricular fibrillation (cardiac arrest) depending on
level of potassium in blood (only above 6 mmol/L)
 Chloride (1)
 Chloride (Cl-), a blood electrolyte, is an anion that exists
predominantly in the extracellular spaces as a combination
in sodium chloride
• It has important role in providing electroneutrality,
particularly in relation to sodium; consequently the
movement of chloride is generally passive and follows the
active transport of sodium
• Also the concentration of chloride can inversely increase or
decrease in response to concentrations of other anions like
bicarbonate (eg. bicarbonate  chloride)
• The normal serum concentration is 96-106 mmol/L
• Alteration of sodium chloride is seldom a primary problem
 Chloride (2)
 Decreased blood chloride levels (hypochloraemia) is
usually the result of hyponatraemia, or elevated
bicarbonate concentration, as in metabolic alkalosis
 Increased blood chloride levels (hyperchloraemia)
occur when there is too much sodium (hypernatraemia)
or too little bicarbonate as in metabolic acidosis
 No specific symptoms are associated with
hypochloraemia and hyperchloraemia
 Instead it is the underlying changes in sodium or acid-
base balance that lead to clinical manifestations
(discussed separately)
 Calcium (1)
 The bulk of body calcium (98%–99%) is stored in the
skeleton and teeth, which act as huge reservoirs for
maintaining the blood levels of calcium
 About 50% of blood calcium is ionized; the rest is
protein bound
 However, only ionized calcium can be used by the body
in such vital processes as muscular contraction, cardiac
function, transmission of nerve impulses, blood clotting
and various intracellular enzyme reactions
 Calcium is inversely related to phosphate; calcium levels
fall when phosphate levels are high and vice versa
 The normal total serum calcium concentration is 2.10-
2.60 mmol/L, while ionized level is 1.16-1.30 mmol/L
 Calcium (2)
 Hypocalcaemia (decreased total serum calcium levels)
is caused by or associated with:
• Hypoparathyroidism (primary is very rare) may be due to
accidental surgical removal of parathyroid glands, irradiation
• Hyperphosphataemia caused by renal failure
• Vitamin D deficiency (insufficient intake, liver or kidney
damage and consequently impaired activation of vitamin D in
those organs)
• Malabsorption caused by caeliac disease, biliary and
pancreatic dysfunction (fatty acids combine with calcium and
are precipitated and excreted in the faeces)
• Alkalosis (more calcium ions become bound to protein)
• Acute pancreatitis (due to calcium binding to fatty acids
released from breakdown of adipose tissue in the abdomen
by released lipolytic enzymes from pancreas)
 Calcium (3)
 Clinical manifestations of hypocalcaemia are largely
due to loss of stabilizing effect on neuromuscular
excitability and decreased threshold for excitations
• This makes may cells more sensitive to stimulation
• Common complaints are numbness and tingling
sensations, skeletal muscle cramps, abdominal cramps,
hyperactive reflexes, tetany (spontaneous muscle
spasms of the muscles of the face, hands and feet)
• Cardiovascular effects are seen later: hypotension, signs
of cardiac insufficiency and certain types of cardiac
arrhythmias (especially heart block and in severe cases
ventricular fibrillation)
 Calcium (4)
 Hypercalcaemia (increased total calcium levels) is
caused by or associated with
• Hyperparathyroidism caused by parathyroid adenoma,
hyperplasia of parathyroid glands, or associated with
hypophosphataemia
• Cancers (metastatic bone cancers such as cancers of lung,
breast, thyroid, kidney, liver, pancreas, and prostate;
Hodgkin’s disease, lymphomas, leukaemia, multiple
myeloma) that cause extensive bone destruction
• Paget’s disease of bone with increased bone turnover (also
accompanied by high levels of alkaline phosphatase)
• Prolonged immobilization; bone fractures, combined with
bed rest
• Excessive intake of vitamin D and dairy products
 Calcium (5)
 Clinical manifestations of hypercalcaemia originate
mainly from changes in cellular excitability which
appears to be decreased (cellular inhibition)
 This leads to anorexia, nausea, constipation, muscle
weakness and loss of muscle tone, lethargy, confusion,
personality and behavioural changes and eventually
coma
 High calcium concentration in urine impairs the ability
of the kidneys to concentrate urine by interfering with
the action of ADH; that leads to polyuria and thirst
 Hypercalcaemia predisposes for development of urinary
stones
 Common cardiovascular manifestation is hypertension
Acid-base balance overview (1)
 An acid is a molecule that can release a hydrogen ion
(H+), and a base is a molecule that can accept or
combine with an H+ ion
 The degree to which and acid dissociates and acts as a
H+ donor determines whether it is a strong (e.g. sulfuric
acid) or weak acid (household acetic acid – vinegar or
citric acid in lemon juice)
 The same is true of a base and its ability to dissociate
and accept an H+ ion
 Most of the body’s acids and bases are weak acids and
bases; the most important are carbonic acid (H2CO3),
which is a weak acid derived from carbon dioxide, and
bicarbonate (HCO3-), which is a weak base
Acid-base balance overview (2)
 The concentration of the H+ ions in the body fluids is
low compared with other ions
 Because of this, H+ content is commonly expressed in
form of pH
 pH represents the negative logarithm of the H+
concentration in mmol/L
 For example a pH value of 7.00 means that the actual
concentration of H+ ion is 10-7 mmol/L
 pH is inversely related to the H+ concentration; a low pH
indicates a high concentration of H+ ions, and a high pH
a low concentration of H+ ions
 The lower the pH the stronger the acid; the higher the
pH the stronger the base
Acid-base balance overview (3)
 Acids are continuously generated as byproducts of
metabolic processes
 Physiologically these acids fall into two groups: the
volatile acid carbonic acid (from CO2; produced during
Krebs cycle) and other non-volatile acids such as
sulfuric, phosphoric and hydrochloric (derived largely
from metabolism of amino acids)
 The concentration of carbonic acid is determined by the
lungs and their capacity to eliminate carbon dioxide
 Non-volatile acids are not excreted by lungs; instead
they are buffered by buffer systems and then excreted
by the kidneys
Acid-base balance overview (4)
 The pH of extracellular fluid must be maintained within
a narrow range of 7.35 to 7.45 for the optimal
functioning of the body cells
 Buffers prevent rapid and drastic changes in the pH of
body fluids by converting strong acids and bases into
weak acids and bases
 Most buffer systems consist of a weak acid and the salt
of that acid which functions as a weak base
 The principal buffer systems of the body fluids are:
• Protein buffer system
• Carbonic acid-bicarbonate buffer system
• Phosphate buffer system
 Arterial blood gas analysis (1)
 Arterial blood gas analysis refers to measurement of:
• pH
• partial pressure of oxygen (PO2)
• oxygen saturation
• partial pressure of carbon dioxide (PCO2)
• concentration of HCO3
• base excess
• anion gap
 It is done to determine the respiratory status (adequacy
of oxygenation and ventilation) and the acid-base status
of the patient, especially in critically ill patients who
show signs of respiratory distress (e.g. cyanosis)
 Arterial blood gas analysis (2)
 Partial pressure of oxygen (PO2) (1)
• This test measures the pressure exerted by the amount of
O2 dissolved in the plasma
• It evaluates the ability of the lungs to oxygenate the blood
and is used to assess the effectiveness of oxygen therapy
• Partial pressure of oxygen indicates the ability of the lungs
to diffuse O2 across the alveolar membrane into the
circulating blood
• Over 98% of O2 in blood is carried by Hb, and only slightly
over 1% of O2 is dissolved in plasma
• Normal values are 80-100 mmHg for arterial blood and 30-
40 mmHg for venous blood
 Arterial blood gas analysis (3)
 Partial pressure of oxygen (PO2) (2)
• Decreased PO2 levels are associated with:
 Anaemias

 Cardiac decompensation (heart failure) with pulmonary

congestion/oedema
 Insufficient atmospheric O2 (eg. high altitude)

 Intracardiac shunts with mixing or arterial and venous

blood (eg. hole in the heart)
 Chronic obstructive pulmonary disease (COPD)

 Restrictive pulmonary disease (reduced lung compliance)

 Hypoventilation due to neuromuscular disease (e.g.

thoracic injury, myasthenia gravis, botulism, motor neuron
disease etc)
 Arterial blood gas analysis (4)
 Oxygen saturation
• This is a ratio between the actual oxygen (O2) content of
the haemoglobin (Hb) compared with the potential
maximum O2-carrying capacity of the haemoglobin
• It does not indicate real O2 content of arterial blood
• The combined measurements of O2 saturation, partial
pressure of O2, and of haemoglobin will indicate the
amount of O2 available to tissue (tissue oxygenation)
• Normal arterial blood oxygen saturation is 95% or higher,
while venous blood oxygen saturation is around 75%
• These values normally decrease with age; values are
decreased in airway/pulmonary diseases/disorders with
cyanosis, as well as intracardiac shunts with mixing or
arterial and venous blood
 Arterial blood gas analysis (5)
 Partial pressure of carbon dioxide (PCO2) (1)
• This test measures the pressure or tension exerted by
dissolved CO2 in the blood and is proportional to the
partial pressure of CO2 in the alveolar air
• CO2 is transported in the blood in three forms: physically
dissolved (7%), chemically bound to Hb (23%), converted
to bicarbonate (70%)
• Normal values PCO2 are 35-45 mmHg for arterial blood
and 41-51 mmHg for venous blood
• This test is an index of the effectiveness of alveolar
ventilation; arterial PCO2 directly reflects how well air is
exchanged with blood in the lungs
 Arterial blood gas analysis (6)
 Partial pressure of carbon dioxide (PCO2) (2)
• A rise in PCO2 (hypercapnia) is usually associated
with hypoventilation (CO2 retention):
 Obstructive lung disease (chronic bronchitis, emphysema,
serious asthma)
 Reduced function of respiratory center (e.g. head trauma,
intoxication with opioids such as morphine/heroin)
• A decrease in PCO2 (hypocapnia) is usually associated
with hyperventilation (blowing off CO2):
 Tissuehypoxia
 Nervousness, anxiety
 Pulmonary emboli
 Pain
 Arterial blood gas analysis (7)
 Concentration of HCO3- (bicarbonate)
• CO2 produced by cellular metabolism diffuses into the plasma
and combines with H2O inside red blood cells to form H2CO3
(carbonic acid)
• Carbonic acid dissociates to form H+ and HCO3-; the H+ is
buffered by haemoglobin and the bicarbonate diffuses into
the plasma, being replaced by Cl- (“chloride shift”)
• Normal bicarbonate concentration in blood is 22-32 mmol/L
• As bicarbonate is a component of the carbonic acid-
bicarbonate buffer system and as such used for buffering of
acids or formed during buffering of bases then:
 abnormally high values indicate metabolic alkalosis
 abnormally low values indicate metabolic acidosis
 Arterial blood gas analysis (8)
 Base excess/deficit
• Bases excess or deficit measures the level of all buffer
systems of the blood – haemoglobin, protein, phosphate
and bicarbonate
• It describes the amount of acid or base that must be added
to a blood sample to achieve pH of 7.4
• For practical purposes bases excess/deficit is a
measurement of bicarbonate excess/deficit
• Normal value is ±3 mmol/L
• Positive base excess value (higher than +3 mmol/L)
indicates a true base excess; seen in metabolic alkalosis
• Negative value (lower than 3 mmol/L) reflects a a true base
deficit due to nonrespiratory or metabolic disturbance
(nonvolatile acid accumulation in metabolic acidosis)
 Arterial blood gas analysis (9)
 Anion gap (1)
• Anion gap test is a measurement of the difference
between sodium (Na+) and potassium (K+) ion
concentrations (the measured cations) and the sum of
chloride (Cl-) and bicarbonate (HCO3-) concentrations
(the measured anions)
• This difference reflects the concentrations of anions that
are present in the extracellular fluid, including
phosphates, sulfates, ketone bodies, lactic acid, and
proteins
• Increased amounts of these unmeasured anions are
produced in the acidotic state; consequently pH is going
to be reduced
• Normal anion gap is 8-16 mmol/L
Arterial blood gas analysis (10)
 Anion gap (2)
• Increased anion gap is associated with an increase in
metabolic acid when there is an excessive production
of metabolic acids as in
 Alcoholic ketoacidosis
 Diabetic ketoacidosis
 Fasting and starvation
 Ketogenic (low carbohydrates) diets
 Lactic acidosis (usually due to inadequate oxygen delivery
to tissues, as in shock or cardiac arrest)
 Salicylate, ethylene glycol (antifreeze), and methanol or
propyl alcohol poisoning
 Decreased elimination of metabolic acids as in renal failure
Acid-base balance alterations (1)
Acid-base Primary Respiratory
Renal compensation
imbalance disturbance compensation
If kidneys OK, increased H+
Metabolic Decrease in Hyperventilation
excretion and increased
acidosis bicarbonate to decrease PCO2
HCO3- reabsorption
If kidneys OK, decreased H+
Metabolic Increase in Hypoventilation to
excretion and decreased
alkalosis bicarbonate increase PCO2
HCO3- reabsorption
Increased H+ excretion and
Respiratory Increase in
None increased HCO3-
acidosis PCO2
reabsorption
Decreased H+ excretion and
Respiratory Decrease in
None decreased HCO3-
alkalosis PCO2
reabsorption
Acid-base balance alterations (2)
 Acidosis and alkalosis typically involve a primary or initiating
event and a compensatory state that results from
homoeostatic mechanisms that attempt to correct or
prevent large changes in pH
 Compensatory mechanisms adjust pH toward more normal
level without correcting the underlying cause of disorder:
• The respiratory mechanisms, which compensate by increasing or
decreasing ventilation, are rapid but seldom able to return the pH
to normal because, as the pH return toward normal, the respiratory
stimulus is lost
• The kidneys compensate by eliminating acids or bases; this takes
longer to start working but renal mechanisms are more efficient
(they continue to operate until the pH has returned to a normal or
near-normal value)
Acid-base balance alterations (3)
Imbalance Findings Causes
Depression of
Respiratory acidosis, pH decreased respiratory centre (drug
acute, non- HCO3- normal overdose, head injury)
compensated PCO2 increased Respiratory disease
(airway obstruction,
asthma, emphysema,
pH low normal chronic bronchitis,
HCO3- increased (due to pneumonia, pulmonary
Respiratory acidosis, oedema)
increased renal production
chronic,
and retention of Disorders of chest wall
compensated
bicarbonate) and respiratory muscles
PCO2 increased (paralysis of respiratory
muscles, chest injuries)
Acid-base balance alterations (4)

Imbalance Findings Causes

Respiratory pH increased
Excessive ventilation
alkalosis, acute, non- HCO3- normal (anxiety and
compensated PCO2 decreased psychogenic
hyperventilation,
pH high normal hypoxia and reflex
Respiratory HCO3- decreased (due to stimulation of
alkalosis, chronic, increased kidney ventilation, high fever,
compensated elimination of bicarbonate) cerebral haemorrhage)
PCO2 decreased
Acid-base balance alterations (5)

Imbalance Findings Causes

Metabolic acidosis, pH decreased

acute, non- HCO3- decreased Acid gain (diabetic
compensated ketoacidosis, alcoholic
PCO2 normal
ketoacidosis, lactic
acidosis, renal failure)
pH low normal
Bicarbonate loss
Metabolic acidosis, HCO3- decreased
(diarrhoea, renal tubular
chronic, PCO2 decreased (due to acidosis)
compensated compensatory
hyperventilation)
Acid-base balance alterations (6)

Imbalance Findings Causes

Excessive loss of
Metabolic alkalosis, pH high hydrogen ions from
acute, non- HCO3- increased stomach by severe
compensated PCO2 normal vomiting or gastric
suctioning
pH high normal High oral intake of
bicarbonate;
Metabolic alkalosis, HCO3- increased
bicarbonate retention in
chronic, PCO2 increased (due to kidney by diuretic
compensated depressed respiration and therapy or
reduced ventilation) hyperaldosteronism
 Urine tests (1)
 Urine volume (1)
• Normal 24-hour urine output usually varies from 600-2,500
mL (average is about 1,500 mL)
• Minimum volume of about 500 mL is needed to excrete the
urinary solutes, mainly urea, uric acid, excess of sodium,
potassium and phosphate, and acids (hydrogen ions)
• Oliguria (< 500 mL/day) develops when renal blood flow
and/or glomerular filtration rate are reduced as in:
• any type of hypovolaemia (haemorrhage, serious
dehydration)
• cardiac failure, especially acute
• acute glomerulonephritis (reduced filtration)
• acute tubular necrosis (increased urine reabsorption )
 Urine tests (2)
 Urine volume (2)
• Polyuria (> 2,500 mL/day voided), an increase in urinary
output, may be caused by:
 increased intake of fluid
 treatment with diuretic drugs

 increased intake of coffee or alcohol (diuretic effect)

 acute stress and anxiety (increased BP + overactive bladder)

 diabetes mellitus (glucose loss in urine and osmotic

diuresis)
 diabetes insipidus (reduced production of ADH from the
pituitary gland - primary diabetes insipidus, or lack of
response of kidney collecting ducts to present ADH -
nephrogenic diabetes insipidus)
 Urine tests (3)
 Glucose in urine
• Positive glucose in urine (glycosuria or glucosuria) strongly
suggests diabetes mellitus (blood glucose level need to be
determined; hyperglycaemia is expected)
• Glycosuria in the absence of hyperglycaemia indicates defect in
renal reabsorption of filtered glucose (usually a mild and
benign condition inherited as autosomal recessive trait)
 Urine pH
• Normal urine pH range is 4.6–8; an average pH is about 6
• The usual diet, rich in animal protein, produces acidic urine; a
diet high vegetables produces alkaline urine
• Urine becomes increasingly acidic in states of acidosis (eg.
ketoacidosis); and alkaline in states of alkalosis in the body
• Alkaline urine may be observed in some urinary tract infections
 Urine tests (4)
 Specific gravity (SG)
• Specific gravity of urine is a ratio of density of urine to the
density of distilled water
• Specific gravity correlates roughly with osmolarity
(measurement of urine concentration)
• Normal SG is usually between 1.010 and 1.025
• High SG 1.025–1.030+ (concentrated urine) is usually seen
in reduced intake of water, DM (glycosuria) and excessive
water loss (dehydration, fever, vomiting, diarrhoea)
• Low SG 1.001–1.010 (dilute urine) may occur in increased
intake of water, diabetes insipidus and certain types of
kidney disease with reduced ability to concentrate urine
 Urine tests (5)
 Blood in urine (1)
• Blood in urine may appear as intact red cells (haematuria) or as
free haemoglobin (haemoglobinuria)
• Both red blood cells and haemoglobin are detected as
haematuria on urine testing; haematuria can be distinguished
best from haemoglobinuria by a microscopic examination of
the urine sediment from a fresh urine specimen
• Some causes of haematuria:
• urinary tract infections
• all types of glomerulonephritis
• bladder or renal cancers
• urinary calculi
• trauma; very strenuous exercise (eg. marathon running)
• overtreatment with anticoagulants (spontaneous bleeding)
 Urine tests (6)
 Blood in urine (2)
• Haemoglobinuria is usually related to conditions outside
the urinary tract and occurs when there is such extensive or
rapid destruction (haemolysis) of RBCs that cannot be
removed by body macrophages
• Some causes of haemoglobinuria:
 extensive burns and crushing injuries
 transfusion reactions with incompatible blood products
 certain poisons (poisonous mushrooms, snake venom)
 malaria
 haemolytic disorders such as sickle cell anaemia,
thalassaemia, and glucose-6-phosphate dehydrogenase
(G6PD) deficiency (the most common human enzyme
deficiency; X-linked)
 Urine tests (7)
 Ketones
• Ketones result from the metabolism of fatty acids: acetone,
β-hydroxybutyric acid and acetoacetic acid
• When carbohydrate metabolism is deficient, excessive
amounts of ketones are formed (ketosis) because fatty acids
become the predominant body fuel
• Normally there are no ketones in urine; positive ketones in
urine (ketonuria) may occur in:
 diabetes mellitus (type I)

 anorexia, starvation, fasting

 high-fat diets, low-carbohydrate diet

 increased metabolic states caused by hyperthyroidism,

fever, pregnancy
 Urine tests (8)
 Nitrites
• Produced by conversion of nitrate (derived from normal diet,
mainly vegies) by the action of various gram-negative bacteria
(normally no detectable nitrite is present)
• Presence of nitrites in urine indicates the presence of bacteria
(infection) but negative result does not negate it
• Negative results may occur when urinary tract infections are
caused by bacterial strains which do not contain reductase to
convert nitrate to nitrite (eg. staphylococci and enterococci),
when urine has not been retained in the bladder long enough
(for hours or more) for reduction of nitrate to take place, or
when dietary nitrate is absent even if bacteria that can convert
it are present in sufficient numbers
 Urine tests (9)
 Leukocytes
• Normally there are no detectable leukocytes in urine
• Usually leukocytes in the urine (pyuria) indicate a urinary
tract infection
• Urine with positive results from the dipstick test should be
examined microscopically for white blood cells and bacteria,
and urine should be cultured for bacteria
 Urine culture (1)
• Urine cultures are most commonly used to diagnose
bacterial urinary tract infection (kidneys, ureter, bladder,
and urethra)
• The combination of pyuria and significant bacteriuria
strongly suggests the presence of a urinary tract infection
 Urine tests (10)
 Urine culture (2)
• The presence of bacteria in urine is called bacteriuria; only
significant bacteriuria is consistent with urinary tract
infection
• Normal value is 104 or less in 1 mL or urine (note than voided
urine is not sterile due to contamination from the urethra)
• 104/mL bacteria or more in symptomatic patients and
105/mL in symptomatic/asymptomatic individuals is
consistent with a urinary tract infection (UTI)
• This test does not show which bacterium is actually
responsible for infection, but more than 80% of UTIs are due
to E. coli
 Urine tests (11)
• Proteins (1)
• Presence of protein in urine (proteinuria) is pathologic and
it is an important marker of kidney disease
• In a healthy renal and urinary tract system, the urine
contains no protein or only slight trace amounts of protein
• Because albumin is filtered more readily than the globulins,
it is usually very abundant in pathologic conditions;
therefore, the term albuminuria is often used synonymously
with proteinuria
• If more than a trace of protein is found in the urine on
qualitative test, a quantitative 24-hour evaluation of protein
excretion is necessary; normal amount of proteins in 24
hours is <150 mg/L
 Urine tests (12)
 Proteins (2)
• Proteinuria can result from glomerular damage or urinary
inflammatory process:
 glomerulonephritis
 nephrotic syndrome (>3 g/day)
 polycystic kidney disease
 fever, acute systemic infection
 certain leukaemias, multiple myeloma
 preeclampsia of pregnancy (complication of pregnancy)
 chronic diabetes mellitus
 chronic hypertension
 postural (orthostatic) proteinuria (seen in 3-5% of healthy
children/young adults) – cause not known
 urinary tract infection (proteins from exudate)
 Urine tests (13)
 Urine bilirubin
• Bilirubin may exist in blood in unconjugated form (bound to
albumin – most bilirubin is in this form) and conjugated
(after processing in the liver – this form is normally excreted
in bile)
• Conjugated bilirubin can pass into the urine while
unconjugated can not as it is bound to albumin in blood
• Normally no bilirubin is found in urine
• Presence of bilirubin in urine (bilirubinuria) indicates
increased level of conjugated bilirubin in blood (conjugated
hyperbilirubinaemia)
• This is seen in some forms of liver disease (hepatitis and
cirrhosis) and cholestasis (obstruction of bile flow)
 Urine tests (14)
 Urine urobilinogen (1)
• Urobilinogen is formed through action of bacterial enzymes
on bilirubin in the gut (called stercobilinogen in the gut)
• Some of the urobilinogen formed in the intestine is excreted
as part of the faeces in form of stercobilin (brown colour of
faeces)
• Another portion is absorbed into the portal bloodstream
and carried to the liver, where it re-excreted in the bile
• Traces of urobilinogen in the blood that escape removal by
the liver are carried to the kidneys and excreted in the urine
• There is normally a small amount of urobilinogen detected
in urine
 Urine tests (15)
• Urine urobilinogen (2)
• Urine urobilinogen is increased:
 in haemolytic anaemias and after a large haemorrhage into
tissues (more bilirubin produced)
 in liver disease preventing the liver from normally removing
the reabsorbed urobilinogen as in acute/chronic hepatitis,
liver cirrhosis
• Urine urobilinogen is decreased or absent when normal
amounts of bilirubin are not excreted into the intestinal
tract; this usually indicates partial or complete obstruction
of the bile ducts (cholestasis)
• Also suppression of normal gut flora may prevent the
breakdown of bilirubin to urobilinogen; therefore urine
levels will be lowered or absent
 Urine tests (16)
 Microscopic examination of urine sediment (1)
• Urine sediment can be examined under the microscope
for the presence of various cells and casts
• Casts are microscopic cylindrical structures formed in
renal tubules by coagulation of proteins, RBCs, WBCs or
epithelial cells (proteins only casts are hyaline casts)
• Red blood cells and red blood cell casts
 It is normal to find 0-3 RBCs/HPF (high-power field);
finding of higher number of RBCs is effectively
haematuria
 No RBC casts should be normally found in urine; their
presence strongly suggests glomerulonephritis
 Urine tests (16)
 Microscopic examination of urine sediment (2)
• White blood cells and white blood cell casts
 Normally it is possible to find 0-4 WBCs/HPF and no WBC
casts in urinary sediment
 More than 10 WBCs/HPF generally indicate bacterial
infection; smaller numbers are observed in
glomerulonephritis
 White cell casts occur in pyelonephritis (most common
cause), glomerulonephritis, interstitial kidney
inflammation
 Urine tests (17)
 Microscopic examination of urine sediment (3)
• Renal epithelial cells and epithelial casts
 The presence of an occasional renal epithelial cell (up to
2/HPF) is not unusual because of normal turnover of
tubular cells
 Usually no epithelial casts are seen in a low power field

 Large numbers of both are seen in various forms of

tubular damage as well as glomerulonephritis
 Urine tests (18)
 Microscopic examination of urine sediment (4)
• Hyaline casts
 Hyaline casts are formed when proteins within the
tubules precipitate and gel
 Normally none to two hyaline casts per low-power field
(LPF) are seen
 Hyaline casts indicate possible damage to the glomerular
capillary membrane, which permits leakage of proteins
through the glomerular filter system (glomerular damage
in glomerulonephritis, chronic hypertension, diabetes,
chronic heart failure etc)
 Hyaline casts can be a temporary phenomenon in fever,
strenuous exercise and emotional stress
 Tumour markers (1)
 They are proteins produced by the cancer tissue cells and
measured in blood
 They have low specificity because:
• they can be elevated in blood in non-cancerous condition
• most can be produced by more than one type of cancer
 Issues with clinical use of tumour markers:
• most cancers do not produce any marker so absence of
markers does not rule out cancer
• positive markers do not prove cancer diagnosis but aid in it
 When a diagnosis is established, marker elevation tends to
correlate with the size of cancer and extent of its spread
 Similarly markers levels drop after successful treatment
and consequently are used to monitor for recurrence
 Tumour markers (2)
underlined = main clinical use

MARKER CANCERS OTHER CONDITIONS

pregnancy, hepatitis, cirrhosis and
AFP liver, ovarian and testicular
inflammatory bowel disease
breast, lung, ovarian, cervical, GIT benign breast conditions and
CA 15-3
and pancreatic hepatitis/cirrhosis and autoimmunity
pancreatic, biliary tract, bowel
CA 19-9 pancreatitis and inflammatory bowel disease
and ovarian
endometriosis, benign ovarian disease,
ovarian, cervical, endometrial,
CA 125 pregnancy, pelvic inflammatory disease,
lung, breast, bowel and pancreatic
pancreatitis and hepatitis
hepatitis, COPD, inflammatory bowel
bowel, lung, breast, thyroid, liver,
CEA disease, pancreatitis, and in cigarette
pancreatic, cervix, and bladder
smokers
testicular, ovarian, lung, breast
hCG pregnancy
and GIT
benign prostatic hypertrophy, prostatitis and
PSA prostatic
aging