CLINICAL CHEMISTRY

Presented by:
Haya Mansour
SLLE Exam
2022
 • Sample collection.
• Carbohydrates.
• Acid-base balance.
Outline • Electrolytes.
• Proteins.
• Enzymes.
• Lipids and lipoproteins.
• Endocrinology.
• Tumor markers.
• Chemistry questions for SLLE Exam.
Sample collection
Types of tubes used in chemistry lab:
1- Plan tube or red tube:
- Serum “without anticoagulant”.
- Used for most chemistry tests.
2- Heparin tube “lithium heparin”
- Plasma “with anticoagulant”.
- Used for chemistry test.
3- Sodium fluoride tube:
- Used for measurement blood glucose. “glycolysis inhibitor”
4- EDTA tube:
- Whole blood.
- Used for HbA1C measurement.

Factors that affect test results:

• Exercise: creatine kinase (CK)
• Exposure light: False decreased bilirubin.
• Prolonged Tourniquet “called hemoconcentration”: falsely elevated results for
glucose, potassium, and protein-based analytes such as cholesterol.
• Hemolysis sample:
- INCREASED: ALT, AST, LDH, CK, Lipase, Mg, Creatinine, Potassium, Phosphate,
Urea, protein, Iron, Ammonia.
- DECREASED: Bilirubin, Insulin, Albumin.

Should be collected Ammonia and lactic acid into EDTA or heparin tubes, Ammonia concentrations increase rapidly in blood after
separated immediately and the plasma kept on ice until analysis. venepuncture so samples must be immediately placed on ice
after labelling and sent to the laboratory within 20 minutes of
venepuncture. Inform the laboratory before the sample is taken
so that analysis can be performed without delay.
CARBOHYDRATES
Introduction
• Carbohydrates are distributed widely in the body, and have:
- Metabolic functions - Glucose (the principal form and the major fuel for cellular metabolism)
- Structural functions: - the precursor of other sugars, such as ribose which is found in: nucleic acids,
and of the carbohydrate moieties of glycoproteins.

Three main classes of carbohydrates:

• Monosaccharides:
- Glucose.
- Fructose.
- galactose.
Regulation of carbohydrate metabolism:
• Disaccharides
- Two monosaccharides linked by a glycosidic bond:
• Insulin is the key hormone of carbohydrate metabolism,
▪ Maltose (glucose and glucose)
it also influences the metabolism of fat and proteins. It
▪ Lactose (glucose and galactose),
lowers blood glucose by increasing glucose transport in
▪ Sucrose (glucose and fructose).
muscle and adipose tissue and stimulates the synthesis of
glycogen, fat, and protein.
• Polysaccharides
- Starch and glycogen.

Carbohydrate metabolism terminology:

• Glycolysis: Process that converts glucose to pyruvate for energy purposes

• Gluconeogenesis: Formation of glucose from non-carbohydrate sources (amino acids, lactate
glycerol [lipids])
• Glycogenolysis: Breakdown of glycogen to form glucose.
• Glycogenesis: Conversion of glucose to glycogen for storage purposes.

 Glucose is the only source of energy for brain.

 Glucose is the only carbohydrate to be directly used for energy or stored as glycogen.
Glycolysis has two major function:
1- Generate energy in the form ATP.
2- Generate pyruvate for final oxidation in the mitochondria, along with NADH.

 Glycolysis consist of 10 reactions that take place in the cytosol and are catalyzed by
different enzymes.

Measurement:
• Three enzymatic methods are available:
- Hexokinase, glucose oxidase and glucose dehydrogenase.

Specimen Considerations:
• Glucose may be analyzed on a variety of samples including:
- Serum.
- Plasma (5% lower than serum).
- Whole blood (~15% lower than plasma).
- Urine: looking for glucose and ketones

Hemoglobin A1c
• Hemoglobin A is composed of three forms, Hb A I a, Hb A I b, and Hb A I c, which
are referred to as glycated or glycosylated hemoglobin.
• Glycated hemoglobin is formed by attachment of glucose to hemoglobin A.
• Is used as a measure of long-term gly-cemic control (2- to 3-month period).
• Used to diagnose and monitor treatment of diabetes.
• Sample: whole blood “EDTA”.
Diabetes mellitus
• Is a disorder in which the body does not produce enough or respond normally to insulin,
causing blood sugar (glucose) levels to be abnormally high.

• Types of diabetes mellitus:

1- Type I Diabetes:
- Pancreas’s failure to produce enough insulin” Insulin - dependent diabetes mellitus“.
- The cause is unknown.
- Most cases present before 30 years of age.
2- Type 2 Diabetes:
- Insulin resistance, a condition in which cells fail to respond to insulin properly.
3- Gestational Diabetes Mellitus:
- Occurs in pregnant women without a previous history of diabetes.
4- Diabetes Associated with Other Disorders (Secondary Diabetes):
- Chronic pancreatitis.
- Endocrinopathies (endocrine disorders) which result in: increased secretion of counter-
regulatory hormones can induce insulin resistance.

Types of glucose test in the laboratory :

1- Random blood sugar.
2- Fasting blood sugar.
3- Glucose Tolerance.

Increase plasma glucose level: diabetes mellitus, hypoadrenalism and Cushing's

syndrome.
Decrees plasma glucose level: hypoadrenalism, anti-diabetic treatment and hyper-insulinism.
Lactic acid
• Final product of glucose metabolism is pyruvate.
• Is a substance made by muscle tissue and by red blood cells, which carry
oxygen from your lungs to other parts of your body.

Acidosis:
Is usually associated with renal failure.
ACID-BASE
The pH of plasma is a function of two independent variables: the (PC02),
which is regulated by the lungs or (respiratory mechanism), and the
concentration of bicarbonate (HC03), which is regulated by the kidneys
(renal mechanism).
Normal values:
• PH = 7.35 – 7.45 PCO2 = 35 – 45 mmhg HCO3 = 22 – 28 meq/L.

• Sample: Blood – used heparin anticoagulant.

- Should be avoided Air bubbles during collection sample.
- Should be kept in ice for glycolysis prevention.

Interpretation of ABG results:

Respiratory acidosis is characterized as?

A. Low PH+ High PCO2 + Normal HCO3.

B. High PH+ Low PCO2 + Normal HCO3.
C. Low PH+ Normal PCO2+ low HCO3.
D. High PH+ Normal PCO2+ High HCO3.

A. Low PH+ High PCO2 + Normal HCO3.

ELECTROLYTES
• Are Charged particles “iron” that are dissolved in body fluids:

Electrolytes “dissolved iron”:

 Major positive Ions “Cations” :
- Sodium “Na+”.
- Potassium “K+”.
- Calcium “Ca +”.
- Magnesium ‘Mg”.
 Major negative Ions “Anions’:
- Chloride “Cl-”.
- Bicarbonate ‘HCO3-”
- Phosphate.
- Sulfate “SO”.

Major cations

Extracellular: Intracellular:
Sodium “Na+”. Potassium “K+”
• Sodium (Na+):
- Major cation of extracellular fluid. - 85% is reabsorbed in the kidney tubules.
- Largest constituent of plasma osmolality.
- Hypernatremia (High Na):
a Cushing’s syndrome.
b- Dehydration.
c- Hyperaldosteronism.
d- diabetes insipidus.
- Hyponatremia (Low Na):
a- Diabetes acidosis
b- Diarrhea
c- Addison’s disease

• Potassium (K+):
- Major cation of intracellular fluid.
- 23 times higher in cells than plasma.
 Specimen collection and handling:
- Separate serum from cell quickly to present K+ from shifting to serum.
- False increase in K+ (psuedohyperkalemia) seen in hemolysis, prolonged tourniquet.
- Hypokalemia (Low K+):
A - insulin injection.
B - Alkalosis.
C - Diarrhea and vomiting.
D - Hyperaldosteronism.
E - Cushing’s disease.
- Hyperkalemia (High K+):
A- Diabetes acidosis.
B- Intravascular hemolysis.
C- Adisson’s disease.
Chloride (Cl-)
- Major inion of intracellular fluid.
- Maintains hydration, osmotic pressure and normal anion-cation balance.
- Cl generally follows Na+ so high and low in same condition.
- Hypochloremia (Low Cl-):
a- Diabetese acidosis.
b- Chronic Pyelonephritis.
c- Aldosterone Deficiency.
- Hyperchloremia (High Cl-):
- Prolonged diarrhea.
- Renal tubular acidosis.
- Adrenocortical hyperfunction.

Calcium (Ca+):
• Three forms present in plasma: 45% ionized calcium (biologically active form),
• 45% protein bound, and 10% complexed with anions.
• Controlled by action of PTH and vitamin D on bone and kidney and intestines.
• Has widespread functions, including formation of bone, coagulation, neurologic and
neuromuscular function, and nonspecific binding.
• Hypercalcemia:
- primary hyperparathyroidism.
- other endocrine disorders such as hypothyroidism.
- Acute adrenal insufficiency.
- Malignancy involving bone,.
- Renal failure.
• Hypocalcemia:
- Hypoparathyroidism.
- Hypoalbuminemia
- Chronic renal failure, magnesium deficiency, and vitamin D deficiency.
Phosphorus (PO4):
• Functions in energy metabolism, nucleic acid metabolism, bone formation, cell
signaling, and acid-base homeostasis.

Regulators of Calcium and Phosphorus:

1- Vitamin D: Exist in 2 forms (D2 –dietary form) and (D3-

photosynthesized in skin due to sun exposure).
• 1,25 hydroxyl vitamin D causes high blood calcium and phosphorus
by increasing intestinal absorption and kidney reabsorption.

2- Parathyroid Hormone (PTH): Synthesized by parathyroid gland and

stimulated by low Ca, and suppressed by high calcium.
• Causes high Ca.
3- Procalcitonin: .
• Normally made in thyroid and converted to calcitonin which causes
low blood Ca.
Iron
• Over 65% of total body iron is in hemoglobin – O2 transport. - Transported by
Transferrin, haptoglobin. - Stored as ferritin and hemosiderin.

Methods to Measure Iron:

• Serum Iron: “Colorimetric”: is the technique normally used to determine the
concentration of analyte through comparing the color changes of the solution.
• TIBC (Total Iron Binding Capacity).
• Transferrin: Direct method if immunochemical assay (Nephelometer).
• Ferritin.
• Decreased serum iron:
- Iron-deficiency anemia.
- Malnutrition.
- Blood loss, and chronic infection.
• Increased serum iron:
- Iron overdose.
- sideroblastic anemia.
- viral hepatitis, and hemochromatosis.

Osmolality
• is a measure of solute concentration of a solution; a measure dependent on the
number (not size and charge) of particles in solution.
PROTEINS.
• Proteins are essential compounds comprising 50-70% of the cell’s dry
weight.
• They are present in all of the body cells, fluids, secretions and excretions.
• Made up of many different amino acids linked together.
• Made up of thousands of different proteins, each with a specific
function. They make up the structural components of our cells and
tissues as well as many enzymes, hormones and the active proteins
secreted from immune cells.

Classifications of proteins:
1- Simple proteins:
• Contain only polypeptide chain and yield amino acid upon hydrolysis.
• These may be Globular e.g. albumin or Fibrous in shape e.g. collagen
and keratin.

2- Conjugated proteins:
• These are composed of globular proteins plus a non-protein moiety that
could be a lipid, a carbohydrate, porphyrins, or a metal.

Methods of analyzing total serum / plasma proteins:

• Blood sample collection criteria:
- Fresh serum or plasma is the preferred sample for total protein determination.
- If analysis is delayed then freeze sample immediately until the day of assay.
• Should be Avoid: Proteins are also measured in
- Hemolysis of blood sample. Spinal fluid by using a turbidimetric procedure.
- Prolonged tourniquet.
- Vigorous shaking of the samples allows denaturing of proteins.
Electrophoresis: Serum protein electrophoresis:

• A separation technique.
• Simple, rapid and highly sensitive.
• Used in clinical laboratories to separate charged molecules from each other in
presence of electric field.
Agarose gel electrophoresis
depends upon consistent current
 Proteins in body fluids: serum, urine, CSF flow for a specific time period, this
 Proteins in erythrocytes: HB. allows proteins to migrate towards
 Nucleic acids: DNA, RNA. anode.

• Principle:
• Migration of charged particle of any size in liquid medium “agarose gel or cellulose
acetate” under the influence of electric field.
• Depending on kind of charge the molecule carry, they move towards either to
“cathode” or to “Anode”.
• Negatively charged particles migrate toward the positive electrode (anode), and
positively charged particles migrate toward the negative electrode (cathode).
Stained protein gel shows
• Medium is put in contact with the buffer (stain used are: ponceau S, amido black),
various fractions. The main
while ethidium bromide used for DNA.
fractions being albumin,
alpha 1, alpha 2, beta and
gamma.
 Protein types % in blood g/l in blood

Total - 60-84

1- Albumin 60 35-55

2- Globulins – alpha 1 4 23-35

3- - alpha 2 8
4- - beta 10
5- - gamma 18
 Abnormal electrophoretic patterns

1- Multiple myeloma 2- Hypogammaglobulinemia 3- Hepatic cirrhosis 4- Nephrotic syndrome

“Monoclonal gammopathy”. “primary genetic immune “polyclonal gammopathy”
system defects or secondary
effects such as medication,
blood cancer, or poor
Decrees of Albumen nutrition” Increase of gamma and beta Increase of a2 macroglobulin
Increase of gamma Decrease of albumin and beta lipoprotein.
Decrease of albumin

Decrees of gamma
 Abnormal electrophoretic patterns

5- Acute inflammatory 6- Chronic inflammatory

response response

Increase of a1, a2 and

Increase of a1 & a2 gamma
Decrease or normal of Decrease or normal of
albumin albumin
Albumin
• Highest concentration in serum (~60%).
• Electrophoresis pattern is significant, as albumin is the major component
of the total protein.
• Is a protein made by your liver.

• Function:
- Contributes in maintaining colloidal osmotic pressure of the
intravascular fluid.
- Binds and transports generally insoluble substances in the blood e.g.
bilirubin, salicylic acid, fatty acids, cortisol and other drugs.
- Binds and transports some metals such as Calcium and Magnesium.
- Carries various substances throughout your body, including hormones,
vitamins, and enzymes.
- Low albumin levels can indicate a problem with your liver or kidneys.
 OTHER PROTEINS OF IMPORTANCE

Myoglobin
• Myoglobin is the primary oxygen-carrying protein found in striated skeletal and cardiac muscles.
• When striated muscle is damaged, myoglobin is released, elevating the blood levels.
• In an acute myocardial infarction (AMI), this increase is seen within 2-3 hours of onset and reaches peak
concentration in 8-12 hours.
• For the diagnosis of AMI, serum myoglobin should be measured serially. If a repeated myoglobin level
doubles within 1-2 hours after the initial value, it is highly diagnostic of an AMI.

Troponin
• is a complex of three regulatory proteins (cTnC, cTnT and cTnI).
• It is found in the heart and not normally found in the blood.
• When heart muscle becomes damaged, troponin sent into blood stream, as heart damage increases, greater
amounts of troponin are released in the blood.

Is used as an AMI indicator(specific).

• Troponin T and Troponin I have a very high specificity for cardiac injury.
• They are released early (2-4 hr) with peak at (10-24 hr) and can persist for up to 7 days.
• Their testing is primarily used as a tool to diagnose myocardial infarction (MI). - Elevated levels suggest MI or
other form of cardiac damage.

Acute myocardial infarction:

Troponin > CK-MB > LDH > Myoglobin>AST.
 Nonprotein Nitrogen

• All non NPN (Urea, Creatinine, uric acid and ammonia) are high in plasma in renal 3- Uric Acid:
impairment; referred to as azotemia. • End product of purine metabolism.
• Best laboratory evaluation when renal impairment is suspected is globular filtration • The levels of uric acid in the blood increases:
rate (GFR). - Too much production of uric acid.
• Creatinine clearance evaluate GFR (More sensitive than BUN or creatinine). - The body is unable to get rid of excess uric acid.
• Increased uric acid: in gout, renal failure and chemotherapy
• eGFR (estimated glomerular filtration rate). treatment.
• more sensitive than creatinine clearance and use measured serum creatinine and the • Decreased uric acid: kidney disease or liver disease
patient demographic info (gender, age, race).
• 24 hrs. urine not needed.
3- Ammonia:
• Derived from action of bacteria content of colon.
1- Creatinine • Metabolized by liver normally.
• The kidneys are working on filtration of creatinine out of the blood. • Liver convert ammonia to urea for excretion.
• Creatinine exits your body as a waste product in urine. • Produced from deamination of amino aside and transported
• The methods most frequently used to measure creatinine are based on the Jaffe via blood to the liver in form of alanine and glutamine.
reaction, in this reaction, creatinine reacts with picric acid in alkaline solution to • Elevation in plasma ammonia toxic to CNS.
form a red-orange chromogen. • Hyperammonemia: seen in advanced liver disease.
• Increased serum creatinine: Renal disease and renal failure. • False high results due to failure to place specimen on ice or
incompletely filling the tube.
Creatinine + alkaline picrate → red-orange complex.

2- Urea:
• Urea is water soluble compound that could be excreted in urine by Kidneys.
• Urea is the end-product of amino acid metabolism found in proteins.
• Increased urea: Renal failure, glomerular nephritis, urinary tract obstruction.
• Decreased urea: Severe liver disease, vomiting, diarrhea, malnutrition.
LIVER
• The liver is the largest internal organ in the human body.
• The liver is the only organ involved in bilirubin metabolism, because
bilirubin is formed from the breakdown of old RBCs.

• Functional unit of the liver is the lobule and lobules contain two cell
types:
 Hepatocytes:
- Responsible for metabolic function of the liver.
 Kupffer cells:
- Are phagocytic macrophages capable of ingesting bacteria and other
foreign material.

• Functions of the Liver:

 Synthetic:
- Proteins Albumen 70%.
- Coagulation: fibrinogen, prothrombin, factor V, VII, IX, X, XI, XII.
- Transport proteins: such as iron need tansfeerin.
- Immun proteins: commplement system.
 Protection and clearance: killing bacteria, medication metabolism.
 Nutriens: glucogenis “glycogen”, libids metabolism “LDL, HDL”.

Normal Hepatic Function: Conjugation and Detoxification.

Bilirubin:

• Is a yellowish pigment that is made

during the normal breakdown of red
blood cells.
• Bilirubin forms a complex with albumin
for transport to the liver. In this form,
bilirubin is unconjugated and not water
soluble and is eventually excreted out
of the body.
• Higher than normal levels of bilirubin
may indicate different types of liver or
bile duct problems.
• Formation of Bilirubin diglucuronide
(conjugated bilirubin) by the addition
of two molecules of glucuronic acid.
This conjugation process is catalyzed by
bilirubin (UDP) glucuronyltransferase.
Bilirubin Metabolism

1 – Creation of Bilirubin:
• Reticuloendothelial cells are macrophages which are responsible for the maintenance of the blood,
through the destruction of old or abnormal cells. They take up red blood cells and metabolise the
hemoglobin present into its individual components; hem and globin. Globin is further broken down
into amino acids which are subsequently recycled.
• Meanwhile, hem is broken down into iron and biliverdin, a process which is catalyzed by hem
oxygenase. The iron gets recycled, while biliverdin is reduced to create unconjugated bilirubin.

2 – Bilirubin Conjugation:
• In the bloodstream, unconjugated bilirubin binds to albumin to facilitate its transport to the liver. Once
in the liver, glucuronic acid is added to unconjugated bilirubin by the enzyme glucuronyl transferase.
• This forms conjugated bilirubin, which is soluble. This allows conjugated bilirubin to be excreted into
the duodenum in bile.

3 – Bilirubin Excretion:
• Once in the colon, colonic bacteria deconjugate bilirubin and convert it into urobilinogen.
• Around 80% of this urobilinogen is further oxidised by intestinal bacteria and converted
to stercobilin and then excreted through faeces. It is stercobilin which gives faeces their colour.
• Around 20% of the urobilinogen is reabsorbed into the bloodstream as part of the enterohepatic
circulation. It is carried to the liver where some is recycled for bile production, while a small percentage
reaches the kidneys. Here, it is oxidised further into urobilin and then excreted into the urine.
Bilirubin causes of Jaundice:

• Is a yellow pigment which causes discoloration

of the skin and when serum levels of Bilirubin exceed 35-40 µmol/L.

• Concentrations may increase for three reasons:

- Prehepatic jaundice /hemolytic jaundice : “occurs prior to the liver” the production
rate of bilirubin is increased, exceeding the excretory capacity of the liver.
- Hepatic jaundice: “located within the liver” conjugating and excretory functions are
reduced.
- Post hepatic jaundice / obstructive jaundice: “located after the conjugation of bilirubin
in the liver” Biliary obstruction interferes with the flow of bile and thus bilirubin
excretion.

Prehepatic jaundice /hemolytic jaundice Hepatic jaundice Post hepatic jaundice / obstructive jaundice

• Caused by increased destruction of • Congenital disorders lead to: • occurs when the liver cells malfunction and
erythrocytes such as in case of hemolytic • defective uptake, reduced conjugation or cannot take up, conjugate, or secrete bilirubin
anemia, and the liver’s can not ability to impaired excretion of bilirubin. “Obstruction of biliary drainage”
conjugate bilirubin. • Generalized hepatocellular dysfunction may
• This causes an unconjugated occur in hepatitis and hepatic cirrhosis.
hyperbilirubinaemia “indirect bilirubin” this is • Drugs may cause hepatocellular damage.
not excreted by the kidney.
Specimen Collection and Storage:
• A fasting serum specimen that is neither hemolyzed no lipemic in nature is preferred.
• Prior to testing, serum should be stored in the dark and measured as soon as possible
(within 2-3 h) after collection.
• Serum may be stored in the dark in a refrigerator for up to 1 week and freezer for 3
months without any change in the bilirubin concentration.

• Increase Direct bilirubin in serum:

- Acute hepatitis.
- Biliary obstructive jaundice.
- Dubin syndrome.

Increase indirect bilirubin in serum:

- Gilbert`s Syndrome
- Crigler N. syndrome.
- Hemolytic anemia.
- Neonatal jaundice.
- acute hepatitis.
- biliary obstructive jaundice
Summary in liver function tests in the differential diagnosis
of jaundice
ENZYMES
• Enzymes are protein that catalyze chemical reactions in the biological
system, without being consumed or changed in composition as the other
substances in the reaction which converted to products.
• They have the physical and chemical characteristics of proteins and they
are found in small amounts in all body tissue.

Major Enzymes of Diagnostic Interest

1- Alkaline Phosphatase:
• Is found in liver, bone, intestine, placenta and kidney.
• The main sources of serum enzyme are the hepatobiliary and osteoblasts
• Pathologically increases in serum alkaline phosphatase occur mainly in
hepatobiliary disease “liver disease” and bone disease.
• In obstructive disease the ALP levels are increased more significantly than ALT
and AST.

2- Aspartate Aminotransferase “AST”:

• is found in heart, liver, skeletal muscle and kidney being rich sources.
• Smaller amounts are found in erythrocytes and slight increases can occur in
hemolysis.
• The major diagnostic applications are in the investigation of myocardial
infarction, liver disease and muscle disease.

3- Alanine aminotransferase “ALT”:

• The largest amounts occur in liver and Smaller amounts occur in the heart and
ALT usually remains normal following myocardial infarction.
• Is more specific for liver disease than AST.

4- Gamma-glutamyl transferase “GGT”:

• Is found in kidney, liver and pancreas.
• Major diagnostic of GGT measurements in the investigation of hepatobiliary
disease.
5- Amylase:
• Is produced by the pancreas and salivary glands.
• Only common enzyme normally excreted in urine.
• Increased levels of amylase: Acute pancreatitis.

6- Lipase:
• Found in pancreas.
• Lipase along with amylase is utilized in the diagnosis of pancreatitis.
• Lipase is more sensitive and specific than amylase as a marker of Acute pancreatitis.
• Lipase increased in pancreatitis and usually remains elevated for a longer period of
time compared to amylase.

Amylase & Lipase are affected by meals.

7- Creatine Kinase “CK”:

• The richest source in skeletal muscle, cardiac muscle and brain.
• CK isoenzyme:
- CK1= CK-BB (Brain, colon, prostate, uterus).
- CK2= CK-MB (Cardiac muscle).
- CK3= CK-MM (Skeletal muscle and Cardiac muscle).

- CKMB is used in the diagnosis of acute myocardial infarction “AMI” (CK-MB >6% of
total CK is diagnostic for AMI).
- Additionally, CK-MB has a typical rise and fall pattern after an AMI that is used in
conjunction with troponin levels to diagnose AMI.
8- Lactate Dehydrogenate “LD”:
• Found in most tissue in: Liver, heart, skeletal muscle, kidney and
erythrocytes.
• Increased in cardiac disorders (acute myocardial infarction), hepatic
diseases, skeletal muscle diseases and hemolytic disorders.

• Tissue Specificities of the LD Isoenzymes:

1- Predominant isoenzymes in myocardium and erythrocytes:
- LD-1
- LD-2
2- Predominant isoenzymes in lungs and spleen
• - LD-3
• - LD-4
3- Predominant isoenzymes in liver and skeletal muscle
• - LD-5
LIPIDS AND LIPOPROTEINS.
Lipids

• Organic compounds that consist of Carbon, Hydrogen and to a lesser

amount, Oxygen.
• Large molecular mass.
• Hydrophobic in nature (don’t like mixing in water).
• In humans lipids include: Cholesterol, Triglycerides and Phospholipids.

1- Cholesterol:
• Cholesterol is a major component of cellular membrane.
• Synthesis of cholesterol:
- By all cells except erythrocytes.
- Major sites of synthesis are the liver and mucosa of small intestine.
- Low-density lipoprotein (LDL) is the primary carrier of cholesterol.
- Increase hypercholesterolaemia: defects of lipid metabolism, Diabetes
mellitus 2, Hypothyroidism, Nephritic syndrome, Pregnancy.
- Decrees hypocholesterolemia: Malnutrition, Hyperthyroidism,
Macroglobulinemia (Waldenstrom disease), Polycythaemia Vera.

Specimen requirements:
• Fasting (minimum 12 hours) serum is required.
• Avoid lipemia and hemolysis.
• Avoid prolonged tourniquet application (increase in cholesterol 2-5%
per two minute application)
2- Triglycerides (TG):
• Is stored in adipose tissue.
• The small intestine synthesizes TG from digested exogenous TG (monoglycerides + diglycerides).
• The liver and the adipose tissues synthesize endogenous TG from glycerol + plasma FFa
• Chylomicrons are the major transporters of exogenous TG.
• VLDL “very-low-density lipoprotein” is the major transporter of endogenous TG.
• Increase TG: Pancreatitis, Chronic liver disease, Chronic renal disease and Pregnancy.

Lipoproteins:
• Proteins that transport Lipids.
• Large molecules of spherical micellular structure.
• Lipid transporting vehicle in blood.
• Made up of protein (apoprotein), phospholipid, TG, Cholesterol & Cholesterol ester.

Chylomicron: (largest; lowest in density due to high lipid/protein ratio; highest in triglycerides as % of weight).
formed in the intestines and transport triglycerides.
VLDL: (very low density lipoprotein: 2nd highest in triglycerides as % of weight), carries endogenous triglycerides
synthesized in the liver.
IDL: (intermediate density lipoprotein) “bad cholesterol”: result of VLDL breakdown taken to the liver then
transformed to LDL.
LDL: (low density lipoprotein): highest in cholesterol esters as % of weight), major cholesterol carrier and transports a
large amount of endogenous cholesterol and LDL more induct diagnosis for Atherosclerosis.
HDL: (high density lipoprotein) "good cholesterol”: highest in density due to high protein/lipid ratio), is synthesize
in the intestine and liver cells.
ENDOCRINOLOGY
 Endocrine system

Hormones:
• Are chemical compounds that are synthesized by endocrine glands and secreted directly into
the blood, which carries them to organs and tissues of the body “target site” to exert their.

Types of hormones according to effect sit:

1. Endocrine action: the hormone is distributed in blood and binds to distant target cells. Such
as ( insulin, cortisol and thyroxine ).
2. Paracrine action: the hormone acts locally by diffusing from its source to target cells in the
neighborhood. Such as ( neurohormones ).
3. Autocrine action: the hormone acts on the same cell that produced it. Such as ( Growth
factors ).

Hypothalamus
• is a part of the brain that has a vital role in controlling many bodily functions
including the release of hormones from the pituitary gland.
• is located on the undersurface of the brain.

Two sets of nerve cells in the hypothalamus that produce hormones:

1- Posterior lobe of the pituitary gland:
- Anti-diuretic hormone: causes water reabsorption at the kidneys.
- Oxytocin: stimulates contraction of the uterus in childbirth and is important in
breastfeeding.
2- Anterior lobe of the pituitary gland “produces stimulating and inhibiting hormones”:
gonads, thyroid gland and adrenal cortex, as well as the production of growth hormone,
and prolactin.
 Pituitary gland

• Called 'master gland' because it controls the activity of most other hormone-secreting • Luteinising hormone (LH) and follicle stimulating
glands. hormone (FSH):
• The pituitary gland controls metabolism, growth, sexual maturation, reproduction, - Known as gonadotrophins.
blood pressure and many other vital physical functions and processes. - They act on the ovaries or testes to stimulate sex hormone
• Produces prolactin: acts on the breasts to induce milk production. production, and egg and sperm maturity.
• Secretes hormones: that act on the adrenal glands, thyroid gland, ovaries and testes.
• Prolactin (PRL):
Adrenal Glands: - Which stimulates milk production.
- Cortisol: stimulates glycogenolysis, lipolysis, and gluconeogenesis.
- Aldosterone: controls the retention of Na + , Cl-, and H20, the • Thyroid stimulating hormone (TSH):
excretion of K+ and H+ and, therefore, the amount of fluid in the body. - Which stimulates the thyroid gland to secrete thyroid
hormones.
- Epinephrine (Adrenaline) and Norepinephrine (Noradrenaline):
Two hormones are produced by the hypothalamus and then
• Adrenocorticotropic hormone ( ACTH ): stored in the posterior pituitary gland before
- which stimulates the adrenal glands to secrete steroid hormones, principally cortisol. being secreted into the bloodstream. These are:
- High ACTH and cortisol called (Cushing syndrome).
1- Anti-diuretic hormone (ADH): (also called Vasopressin)
• Growth hormone (GH): - which controls water balance and blood Pressure.
- Which regulates growth, metabolism and body composition.
2- Oxytocin:
- Which stimulates uterine contractions during labour and
milk secretion during breastfeeding.
 Thyroid gland

• The thyroid gland is part of the endocrine system and produces thyroid hormones:
Thyroxine(T4) and triiodothyronine(T3), which are important for metabolic health.
• The hypothalamus releases its own hormone thyrotropin-releasing hormone (TRH).
TRH in turn stimulates the release of TSH in the pituitary, which then signals to the
thyroid gland.
• This whole network is also referred to as the hypothalamic pituitary-thyroid axis
(HPT) and it adapts to metabolic changes and your body’s needs.
• Thyroid hormones circulate in blood bound to thyroxine-binding globulin (TBG).
• There are other hormone-producing cells within the thyroid gland called C-cells.
These cells produce Calcitonin. Calcitonin plays a role in regulating calcium and
phosphate levels in the blood

Thyroid function test:

• Primary hyperthyroidism:
- High T3/T4: due to excessive production.
- Low TSH: due to negative feedback on the pituitary/hypothalamus.
- Causes: Graves’ disease (75% of all cases).
• Secondary hyperthyroidism:
1- TSH production is increased.
2- The excess TSH causes overstimulation of the thyroid gland, resulting in high levels of
T3 and T4 production.
3. Normally a raised T3 and T4 level would cause negative feedback, decreasing TSH
production, in this instance, the TSH production is not responsive to any negative
feedback, resulting in continued excess production.
- High T3/T4: due to excessive production.
- High TSH: due to excess production.
- Causes: TSH-secreting tumor and Chorionic-gonadotropin secreting tumors (hCG secreting).
• Primary hypothyroidism:
1. Less T4 and T3 are produced due to the thyroid’s reduced capacity to produce hormone or
respond to TSH therefore, cause primary hypothyroidism.
2. is the most common cause of hypothyroidism, accounting for 99% of all cases.
3. As a result, there is reduced negative feedback on the pituitary and hypothalamus.
4. The reduction in negative feedback results in increased production of TSH.
5. The end result is low T4 and T3 and a high TSH.
- High TSH: due to the absence of negative feedback.
- low T4: due to the thyroid’s inability to produce enough T4.
- Causes:
1- Autoimmune thyroiditis “Hashimoto disease” (50%).
2- Iodine deficiency or excess, Thyroidectomy.
3- Therapy with radioactive iodine – a treatment for hyperthyroidism.
4- External radiotherapy.
5- Thyroid agenesis or dysgenesis. Calcitonin:
• Hormone that is produced in humans by C-cells
• Secondary hypothyroidism: of the thyroid gland.
1. Reduction in the hormones that stimulate the thyroid to produce thyroxine. • Regulate levels of calcium and phosphate in the
2. Decreased production of TRH and TSH, causing secondary hypothyroidism. blood.
3. Rare cause of hypothyroidism, accounting for 1% of all cases.
- Low T4 and T3: due to the absence of any positive feedback from TSH. Calcitonin reduces calcium levels in the blood by two
- Normal/low TSH: due to a lack of production. main mechanisms:
- Causes: 1. It inhibits the activity of osteoclasts (the cells
- Pituitary causes: responsible for breaking down bone).
• Pituitary adenoma: the most common cause. 2. It can also decrease the resorption of calcium in
• Pituitary surgery or radiotherapy which damages the pituitary tissue. the kidneys, leading to lower blood calcium levels.
- Hypothalamic causes:
- • Hypothalamic tumour.
- • Surgery or radiotherapy which damages the hypothalamic tissue.
 Thyroid Test Results Chart
Type of Thyroid TSH T3 T4
Primary hypothyroidism increased low low
Secondary hypothyroidism low low low
Primary hyperthyroidism Normal or low increased increased
Secondary hyperthyroidism increased increased increased
 Parathyroid gland

• The parathyroid glands produce a hormone called parathyroid hormone ( PTH).

• Important in tightly controlling calcium levels in the bloodstream.
• The main target organs where parathyroid hormone exerts its effects are the bones and the
kidneys and intestine.
• low calcium: parathyroid hormone is released by the parathyroid glands into the blood and
causes the:
1. Bones – parathyroid hormone stimulates the release of calcium from large calcium stores in
the bones into the bloodstream. This increases bone destruction and decreases the formation
of new bone.
2. Kidneys – parathyroid hormone reduces loss of calcium in urine. Parathyroid hormone also
stimulates the production of active vitamin D in the kidneys.
3. Intestine – parathyroid hormone indirectly increases calcium absorption from food in the
intestine, via its effects on vitamin D metabolism.

• Parathyroid hormone ( PTH):

1. Hyperparathyroidism: 2. Hypoparathyroidism:
- Increase release of parathyroid hormone due to high level of calcium in the bloodstream. - Is a rare condition.
- The most common cause of primary hyperparathyroidism is benign growth or nodule - Causes: Damage to parathyroid glands during
(adenoma). neck surgery, autoimmune attack or by
- Hypercalcemia: calcium levels in the bloodstream are raised above normal levels radiation.
- Hypercalciuria: calcium levels in urine are increased
- Kidney stones: occur in about 15–20% patients with primary hyperparathyroidism.
- osteoporosis: parathyroid hormone increases calcium release from bones and increased
- risk of bone fractures.
 Pancreas

• It makes hormones that control blood glucose levels.

1- Insulin:
- Is released by the 'beta cells’, lower glucose levels in the bloodstream and
promote the storage of glucose in fat, muscle, liver and other body tissues.
- Hyperinsulinemia: “insulin resistance”, insulinomas (insulin-producing
tumors of the, which result in hypoglycemia.
- Hypoinsulinemia: low level of insulin or ineffective insulin, which results in
diabetes mellitus.

2- Glucagon:
- Is released by the 'Alpha cells’ , opposite effect to insulin, by helping
release energy into the bloodstream from where it is stored, thus raising
blood sugar levels.
- Stimulates the conversion of stored glycogen (stored in the liver) to
glucose, which can be released into the bloodstream, this process is called
glycogenolysis.
- High level Glucagon “Hyperglucagonemia”: associated with glucagon-secreting tumors
of the pancreas(sugar appear in urine)

3- Somatostatin: it is playing a part in regulating and fine-tuning the insulin

and glucagon-producing cells.
 Adrenal glands

• Composed of two distinct parts:

- Adrenal cortex and adrenal medulla.

• Adrenal cortex produces three hormones:

1. Mineralocorticoids: the most important is aldosterone.
- Aldosterone:
- Helps to maintain the body’s salt and water levels, regulates blood pressure. Without
aldosterone, the kidney loses excessive amounts of salt (sodium) and water, leading to
severe dehydration and low blood pressure.
- balances the levels of sodium Na + and potassium K+.
- Hyperaldosteronism: high blood pressure.

2. Glucocorticoids: cortisol.
- Cortisol: helps to regulate body metabolism. Cortisol stimulates glucose production
helping the body to free up the necessary ingredients from storage (fat and muscle) to
make glucose. “stimulates glycogenolysis, lipolysis, and gluconeogenesis.”
- Disorders: Cushing's syndrome and Addison's disease.

3. Adrenal androgens:
- Male sex hormones: dehydroepiandrosterone (DHEA) and testosterone.

Adrenocorticotropic hormone (ACTH) primarily affects release of glucocorticoids

“cortisol” and adrenal androgens by the adrenal gland, also stimulates aldosterone
release.
• Adrenal medulla produces hormone:
- Catecholamines: include adrenaline, noradrenaline and small amounts of dopamine,
hormones are responsible for all the physiological characteristics of the stress
response.

• The ovaries is secreted hormones of oestrogen and progesterone.

• Growth hormone (GH):
- secretion is stimulated by growth hormone-releasing hormone (GHRH)
and is inhibited by somatostatin.
TUMOR MARKERS.
 GOOD LUCK
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