ELECTROLYTES

 These are ions capable of carrying an electric charge – cations or anions

 Fluid always contains equal numbers of cations and anions – this balance of
charges is referred to as electroneutrality.
 Dissociation of solutes into charged particles (ions) depends on the chemical
composition of the compound and on the concentration of other charged particles
in the medium.

Distribution:
 40-75 % is the average water content of the human body (advanced age and
obesity – decreased values.
 Extracellular fluid (ECF) – is one third of the total body water (16 liters).
 Intracellular fluid (ICF) – is two thirds of total body water (24 liters).
 60% of the body’s water is inside cells, and the rest is in the bloodstream or
tissue fluids.
 About 30 liters of fluid passes from the blood to the tissue spaces daily.
 Normal plasma – 93% water + 7% solutes (glucose, lipids, proteins, NPN, amino
acids, and ions).
 Water content of plasma is 12% higher than that of whole blood.
 Retention of 3 liters of fluid in the tissues will result to edema.
 Deficiency of vasopressin caused 10-20 liters of water excreted daily.
 Sweat contains about 50 mmol/L of sodium and 5 mmol/L of potassium.
 Salt content of the body is the main determinant of the extracellular volume.

Functions of Electrolytes:
1. For volume and osmotic regulation.
2. For myocardial rhythm and contractility.
3. Important cofactors in enzyme activation.
4. For the regulation of adenosine triphosphatase (ATPase) ion pumps.
5. For neuromuscular excitability.
6. For the production and use of ATP from glucose.
7. Maintenance of acid-base balance.
8. Replication of DNA and the translation of mRNA.

I. SODIUM
 Also known as “Natrium”
 The major extracellular cation, hence the major contributor of osmolality (ECF
is 1/3 of the total body water).
 The principal osmotic particle outside the cell.
 For every 100mg/dl increase in blood glucose, serum sodium decreases by
1.6 mmol/L – glucose is osmotically active and induces flow of water from the
cells to the ECF, diluting its electrolytes.
 The plasma sodium concentration depends greatly on the intake and
excretion of water.
 Reference values: 135-145 mmol/L
 CSF sodium: 136-150mmol/L

Hormones Affecting Sodium Levels:

1. Aldosterone
 It promotes absorption of sodium in the distal tubule.
 It promotes sodium retention and potassium excretion.
2. Atrial Natriuretic Factor (ANF)
 It is an endogenous antihypertensive agent secreted from the cardiac
atria.
 It blocks aldosterone and renin secretion, and inhibits the action of
angiotensin II and vasopressin.
 It causes natriuresis.

Hypernatremia:
1. Excess water loss
a. Diabetes insipidus
b. Renal tubular disorder
c. Prolonged diarrhea
d. Profuse sweating
e. Severe burns
f. Vomiting
g. Fever
h. hyperventilation
2. Decreased water intake
3. Increased intake or retention
a. Hyperaldosteronism (Conn’s disease)
b. Sodium bicarbonate infusion
c. Increased oral IV intake of NaCl
d. Ingestion of sea water

Hyponatremia:
1. Increased sodium loss
-Diuretic use
-Saline infusion
2. Increased water retention
a. Renal failure
b. Nephrotic syndrome
c. Aldosterone deficiency
d. Cancer
e. Syndrome of Inappropriate ADH Secretion (SIADH)
f. Hepatic cirrhosis
g. Primary polydipsia
h. CNS abnormalities
i. Myxedema
 Methods:
1. Emission Flame Photometry
2. Ion Selective Electrode (Glass aluminum silicate) – most commonly used
method
3. Atomic Absorption Spectrophotometry
4. Colorimetry (Albanese Lein)

II. POTASSIUM
 Is otherwise known as “Kalium”
 Is the major intracellular cation – only 2% of the body’s total potassium circulates
in plasma.
 The concentration in RBC is 105 mmol/L (23x its concentration in plasma).
 It is filtered at the glomeruli and is mostly (70-80%) reabsorbed by active and
passive mechanisms in the proximal tubule.
 In the ascending limb of Henle’s loop, K
 The single most important analyte in terms of an abnormality being immediately
life threatening.

Functions: neuromuscular excitability, heart contraction, ICF volume and hydrogen

ion concentration.
Reference values: 3.5-5.2 mmol/L
Threshold critical values: 6.5 mmol/L (hyperkalemia)
II.5 mmol/L (hypokalemia)

Specimen Considerations:
a. Hemolysis of 0.5% RBC can increase levels by 0.5 mmol/L (30% increase
in gross hemolysis).
b. Plasma levels are lower (1.1-0.7 mmol/L) compare to serum levels because
of the released of platelets into serum on clot formation.
c. Muscular activity like exercise and prolonged standing – 10-20% increase
- 0.3-1.2 mmol/L = mild to moderate exercise
- 2-3 mmol/L = vigorous exercise; fist clenching
d. Prolonged contact of serum and red cell.
e. Prolonged application of tourniquet.
Hyperkalemia:
1. Decreased renal excretion
 Acute or chronic renal failure
 Severe dehydration
 Addison’s disease
2. Extracellular shift
 Acidosis
 Muscle/cellular injury
 Chemotherapy
 Digitalis intoxication
3. Increased intake – oral or IV infusion
4. Use of immunosuppressive drugs
- tacrolimus and cyclosporine

Hypokalemia:
1. Gastrointestinal loss
a. Gastric suction
b. Intestinal tumor and malabsorption
c. Cancer and radio therapy
d. Vomiting and diarrhea
2. Renal loss
a. Diuretics use (thiazides)
b. Hyperaldosteronism
c. Cushing syndrome
d. Leukemia
e. Bartter’s syndrome
f. Gitelman’s syndrome
g. Liddle’s syndrome
h. Malignant hypertension
3. Intracellular shift – alkalosis and insulin overdose

Methods:
 Heparinized plasma is preferred over serum due to potassium released during
blood clotting.
 Platelets contain K+ that is released into serum on clot formation.

1. Emission Flame Photometry

2. Ion Selective Electrode (Valinomycin gel)
3. Atomic Absorption Spectrophotometry
4. Colorimetry (Lockhead and Purcell)

III. CHLORIDE
 It is the major extracellular anion – chief counter ion of sodium in ECF.
 It promotes maintenance of water balance and osmotic pressure in
conjunction with sodium.
 It is the only anion to serve as an enzyme activator.
 It is excreted in the urine and sweat.
 Disorders of chloride are the same as sodium since they are both
extracellular. Cations.
 Functions: maintains osmolality, blood volume and electric neutrality
 Reference values: 98-107 mmol/L

Specimen Considerations:
1. Marked hemolysis may cause decreased levels of chloride due to dilutional
effect.
 2. Slightly lower values are observed in post prandial specimen.
3. Low serum values are observed in conditions with high HCO3 levels.

Methods:
 Interferences: bromide, cyanide and cysteine (chemical test and
coulometry)
 Methods for chloride also measure bromide.
1. Mercurimetric Titration (Schales and Schales)
Diphenylcarbazone = indicator
HgCl2 (blue violet) = end product
2. Spectrophotometric Methods
a. Mercuric Thiocyanate (Whitehorn Titration Method) = reddish
complex
b. Ferric Perchlorate = colored complex
3. Coulometric Amperometric Titration – Cotlove Chloridometer
4. Ion Selective Electrode – using ion exchange membrane (tri-n-
octylpropylammonium chloride decanol); most commonly used method).

Hyperchloremia Hypochloremia
1. Renal tubular acidosis 1. Prolonged vomiting
2. Diabetes insipidus 2. Aldosterone deficiency
3. Salicylate intoxication 3. Metabolic alkalosis
4. Primary hyperparathyroidism 4. Salt-losing nephritis
5. Metabolic acidosis
6. Prolonged diarrhea

IV. CALCIUM
 It is present almost exclusively in the plasma; fifth most common
element.
 It is involved in blood coagulation, enzyme activity, excitability of
skeletal and cardiac muscle, and maintenance of blood pressure.
 It is maximally absorbed in the duodenum.
 The absorption is favored at an acidic pH.
 99% is part of bones and 1% is in the blood and ECF.
 Reference values: 8.6 – 10 mg//dL (adult) / 8.8 – 10.8 mg/dL (child) –
total calcium
4.6– 5.3 mg/dL (adult) / 4.8 – 5.5 mg/dL (child) –
ionized calcium
Three Forms of Calcium:
1. Ionized (active) Calcium – 50%
2. Protein-bound Calcium – 40%
3. Complexed with anions – 10%
 Ionized calcium is a sensitive and specific market for calcium
disorders.
  For every 1g/dL serum albumin decrease, there is 0.8 mg/dL decrease
in total Ca+2 – hypocalcemia can be a consequence of reduced plasma
albumin.

Factors Affecting Serum Calcium Levels:

1. 1.25 Dihydroxylcholecalciferol [1,25 – (OH)2-D3]
 increases intestinal absorption of calcium
 increases reabsorption in the kidneys.
 increases mobilization of calcium from bones.
2. Parathyroid Hormone (PTH)
 conserves calcium by increasing reabsorption in the kidneys.
 increases the level by mobilizing bone calcium.
 it activates the process of bone resorption.
 it suppresses urinary loss of calcium.
 it stimulates the conversion of inactive vitamin D to active vitamin D3 in the
kidneys.
3. Calcitonin
 a thyroid hormone, secreted by the parafollicular C cells of the thyroid
gland.
 it inhibits PTH and vitamin D3 – hypocalcemic hormone.
 it inhibits bone resorption.
 it promotes urinary excretion of calcium.

Practical Considerations:
1. Serum is the specimen of choice for analysis.
2. A decrease in plasma protein concentration will result in decrease total calcium.
3. Avoid prolonged contact of serum with cell clot – decreased Ca+2 (ionized Ca+2 –
pH dependent).
4. Recumbent posture – decreased Ca+
5. Venous occlusion – increased Ca+ (acidosis)
6. Urinary excretion is the major net loss of calcium.

Methods:
1. Precipitation and Redox Titration
a. Clark Collip Precipitation – end product: Oxalic acid (purple color)
b. Ferro Ham Chloranilic Acid Precipitation – end product: Chloranilic acid
(purple color)
2. Ortho-Cresolpthalein Complexone Dyes (Colorimetric Method)
Dye: Arzeno III
Mg+ inhibitor: 8-hydrozyquinoline (chelator)
3. EDTA Titration Method (Bachra, Dawer and Sobel)
4. Ion Selective Electrode (Liquid-membrane)
5. Atomic Absorption Spectrophotometry – reference method
6. Emission Flame Photometry
Hypercalcemia Hypocalcemia
1. Primary hyperparathyroidism – main cause 1. Alkalosis
2. Cancer (Lung & Mammary) 2. Vitamin D deficiency
3. Acidosis 3. Primary hypoparathyroidism
4. Increased vitamin D 4. Acute pancreatitis
5. Multiple myeloma 5. Hypomagnesemia
6. Sarcoidosis 6. Malabsorption Syndrome
7. Hyperthyroidism 7. Renal tubular failure
8. Milk-alkali syndrome

Causes of Hypercalcemia: CHIMPS (cancer, Hyperthyroidism, Iatrogenic causes,

Multiple myeloma, Hyperparathyroidism, and Sarcoidosis)
Causes of Hypocalcemia: CHARD (Calcitonin, Hypoparathyroidism, Alkalosis, Renal
failure, vitamin D deficit)

V. INORGANIC PHOSPHORUS
 It is omnipresent in its distribution; 85% in the bones and 15% in the ECF in
the form of inorganic phosphate.
 It is inversely related to calcium
 Maximally absorbed in the jejunum.
 Phosphate is essential for the insulin-mediated entry of glucose into cells by a
process involving phosphorylation of the glucose and the co-entry of K+.
 Most phosphate in serum is in inorganic form.
 Reference values: 2.7 – 4.5 mg/dL (adult) / 4.5 – 5.5 mg/dL (child)

Inorganic phosphorus exists as:

a. Organic phosphate – principal anion within cells
b. Inorganic phosphate – part of the blood buffer

Forms:
1. Free – 55%
2. Complexed with ions – 35%
3. Protein-bound – 10%

Factors Affecting Phosphate Concentration:

1. PTH – decreases phosphate by renal excretion
2. Calcitonin – inhibits bone resorption
3. Growth hormone – increases phosphate renal reabsorption

Practical Considerations:
1. Fasting is required – a high CHO diet can result to decrease levels.
2. Separate the serum from the red cells immediately after clotting is completed.
Methods:
 Phosphorus is measured in terms of PO4 – only inorganic phosphate is
measured in clinical laboratory.
  Laboratory results cannot be expressed in mEq/L because different PO4
groups normally present at physiologic pH have different valences.
 Blood collection is affected by circadian rhythm – high levels in late
morning and low levels in the evening.
 Fasting serum phosphate is controlled by the parathyroid gland.

Fiske Subbarow Method (Ammonium molybdate method)

 Is the most commonly used method to measure serum inorganic
phosphate
 Most common reducing agent – Pictol (Amino Naphthol Sulfonic Acid)
 Other reducing agents:
a. Elon (methyl amino phenol), ascorbic acid
b. Senidine (N-phenyl-p-phenylene diamine hydrochloride)
 End product: ammonium-molybdate complex (unstable)
 The unreduced complex at 340nm is the most accurate measurement of
inorganic phosphorus in serum.
 The pH must be maintained in the acid range because higher range
(alkaline) can result in reduction of the complex.
 The reduced form of the end product yields a blue color and determined
between 600nm to 700nm.

Hyperphosphatemia Hypophosphatemia
1. Hypoparathyroidsim 1. Alcohol abuse – most common cause
2. Renal failure (tubular failure) 2. Primary hyperparathyroidism
3. Lymphoblastic leukemia 3. Avitaminosis D
4. Hypervitaminosis D 4. Myxedema

VI. MAGNESIUM
 Is an intracellular cation second in abundance to potassium.
 Is the fourth most abundant cation in the body; an enzyme activator.
 Majority is stored in the bones; an enzyme activator.
 It is present 53% in bone; 46% in muscles and soft tissues; 1% in serum
and RBC.
 It is a vasodilator and cause decrease uterine hyperactivity in eclampsic
states and increase uterine blood flow.
 Life threatening symptoms occur if the serum level reach 5 mmol/L.
 Magnesium loss leads to decreased intracellular K+ levels.
 Functions: important in maintaining the structures of DNA, RNA and
ribosomes; synthesis of CHO, CHONS and lipids; neuromuscular
transmission; cofactor; regulates movement of potassium across
myocardium.
 Reference values: 1.2 – 2.1 mEq/L
 Forms:
1. Free Mg+2 (Ionized form – 55 (physiologically active)
2. Protein-bound Mg+2 – 30%
3. Complexed w/ ions - 15%

Factors Affecting Magnesium Level in Blood:

1. Parathyroid Hormone
 Increases renal reabsorption of magnesium.
 Increases intestinal absorption of magnesium.
2. Aldosterone and Thyroxine
 Increase renal excretion of magnesium.

Hypermagnesemia Hypomagnesemia
1. Diabetic coma 1. Acute renal failure
2. Addison’s disease 2. Malnutrition
3. Chronic renal failure 3. Malabsorption syndrome (sprue)
4. Increased intake of antacids, 4. Chronic alcoholism
enemas and cathartics 5. Severe diarrhea

Methods:
1. Colorimetric Methods
a. Calmagite Method = (+) reddish-violet complex
b. Formazen Dye Method = (+) colored complex
c. Magnesium Thymol Blue Method = (+) colored complex
2. Atomic Absorption Spectrophotometry
3. Dye-Lake Method – Titan Yellow Dye (Clayton Yellow or Thiazole Yellow)

VII. BICARBONATE
 Is the second most abundant anion in the ECF.
 It accounts for 90% of the total CO2 at physiologic pH.
 It is composed of undissociated Na CO3, carbonate and carbamate.
 It diffuses out of the cell in exchange for chloride to maintain ionic
charge neutrality within the cell (chloride shift) – the buffering capacity
of blood is maintained by a reversible exchange process between
bicarbonate and chloride.
 It buffers excess hydrogen ion by combining with acid.
 Function: major component of the buffering system in the blood.
 Specimen: blood anaerobically collected
 Methods: Ion selective electrode (using the pCO2 electrode) and
Enzymatic (phosphoenolpyruvate carboxylase and dehydrogenase)
 Reference values: 21-28 mEq/L (venous blood – plasma or serum)
Other Significant Information:
1. Anion Gap (AG)
 Is the difference between the unmeasured cations (sodium and
potassium) and unmeasured anions (chloride and bicarbonate).
 It is used to monitor recovery from diabetic ketoacidosis.
 It is a form of quality control for the analyzer used to measure these
electrolytes.
 It is used to monitor recovery from diabetic ketoacidosis.
 Abnormal anion gaps in serum from healthy person indicates an
instrument problem.

Formulas: AG = Na+ - (Cl- + HCO-3) RV = 7-16 mmol/L

AG = (Na+ + K+) – (Cl- + HCO-3) RV = 10-20 mmol/L
Increased: uremia/renal failure (phosphate and sulfate retention);
Ketoacidosis (starvation or diabetes); poisoning by
methanol, ethanol ethylene glycol or salicylate; lactic
acidosis; hypernatremia and instrument error.
Decreased: hypoalbuminemia (decreased unmeasured anions);
hypercalcemia (elevated unmeasured cations);
hyperlipidemia; elevated myeloma proteins.

2. Cystic Fibrosis (Mucoviscidosis)

 An inherited disorder of the exocrine glands, causing those glands to
produce abnormally thick secretions of mucus, elevation of sweat
electrolytes, increased organic and enzymatic constituents of saliva,
and overactivity of the automatic nervous system.
 Signs: chronic cough, frequent foul-smelling stool and persistent URT
infection
 Affected organs and glands: pancreas, respiratory system and sweat
glands
 Test requirements: 48 hours of age (newborn); without rashes, cuts or
skin inflammation
 Sweat Inducer: Pilocarpine
 Diagnostic test: Sweat Test ( sodium and chloride) – Coulometric
Principle
 Reference Method: Gibson and Cookie Pilocarpine Iontophoresis
- > 50 mg sweat (sample) collected within 30 minutes
- (+) Result: > 65 mmol/L of sweat electrolytes (N.V. = 5-40
mmol/L)
3. Iron
 A common metallic element important for the synthesis of hemoglobin.
 A prooxidant, contributing to lipid peroxidation, atherosclerosis, DNA
damage and carcinogenesis
  Of the total 3-5 mg of iron in the body, 2 – 2.5 is in hemoglobin; 130mg
is in myoglobin; 8 mg is in tissue; 3-5 mg is in plasma (albumin and
free hemoglobin).
 Serum ferritin must be depleted first, before iron level declines – a low
serum ferritin level is diagnostic of iron deficiency.
 Reference values: 50-160 ug/dL – male
45-150 ug/dL – female
 Increased: iron poisoning (overdose), hemochromatosis, viral hepatitis,
noniron deficiency anemias (thalassemia, aplastic, megaloblastic,
sideroblastic, hemolytic and pernicious anemias)
 Decreased: iron deficiency anemia (IDA), malnutrition, malignancy,
chronic infection, nephrotic syndrome.

Methods for testing:

1. Colorimetry (HCL and ferrozine – (+) blue color)
2. Anodic Stripping Voltammetry
 The first step in the quantitation of serum iron is separation from
transferrin by acidification.
 Serum iron levels are falsely elevated by hemolysis and affected
by diurnal variation.
 Diurnal variation means highest concentration in the morning
and lowest at night.

Terminologies:
1. Total Iron Binding Capacity (TIBC)
 It refers to the amount of iron that could be bound by saturating
transferrin and other minor-iron binding proteins present in the serum
or plasma sample.
 Is a direct measure of the total number of functional ferrous ion-binding
sites in transferrin.
 Excess iron is then removed by adding magnesium carbonate to
measure the bound iron.
 IDA has high TIBC; non-iron deficiency (non-IDA) anemias have low
TIBC.
 Reference values: 245 – 425 ug/dL (adult male and female)
10 – 250 ug/dL (>40 years old)
100 – 200 ug/dL (newborn and child)
 Formula: TIBC = UIBC + Serum Iron
TIBC (ug/dL) = serum transferrin (mg/dL) x 1.25 21
 Increased: IDA, hepatitis, iron-supplemented pregnancy
 Decreased: non-IDA and nephrosis

2. Unsaturated Iron Binding Capacity (UIBC)

 A measure of the reserve iron binding capacity of transferrin.
 Formula: TIBC – Serum Iron
3. Percent Saturation
 It is also known as the transferrin saturation; an index of iron storage.
 It is the ratio of serum iron to TIBC.
 Increased: iron overdose, hemochromatosis, sideroblastic anemia
 Decreased: IDA (lowest % saturation), malignancy, chronic infection,
anemia of chronic disease.
 Reference values: 20-50%
% Saturation = Total iron (ug/dL) X 100
TIBC (ug/dL)
4. Serum transferrin
 Transferrin is the principal iron transport protein.
 Formula: TIBC (ug/dL) x 0.70 = mg/dL