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INTRODUCTION TO CLINICAL CHEMISTRY • Clinical chemistry is an applied core MT subject.

The major aim of the course is to relate chemical changes that occur in the body to the health status of the individual. The course includes lectures, tutorials and practical classes to cover various topics that are important to the clinical practice and reflect the body chemical status. • Clinical chemistry covers the scientific, pathophysiological, chemical and biochemical nature of the analyte, and analytical aspects. o Analytical aspects include; specimen requirements, methods of determination, precautions, normal values and patient correlations. In addition, quality control aspects that requires awareness of the sources of errors and how to prevent them are covered. • Because the results obtained in clinical chemistry are quantitative, the student is also required to know how to recognize, interpret and convert units as well as other essential lab mathematics including reagent preparations which necessitates knowledge and practice of concentrations, dilutions, specific gravity, water of hydration…etc. • The human body is made up of various organs and tissues which are made from a number of biochemical compounds such as proteins, carbohydrates, lipids, nucleic acids, minerals, electrolytes, enzymes, hormones, growth factors and trace elements. All the functions of the body involve chemical interactions. • Blood represents the major transport system of chemicals to and from all the body tissues. It is therefore provide valuable information about most of the body chemicals. Other body fluids such as urine, cerebrospinal fluid (CSF) also contain many types of chemicals which are mainly specific to that type of fluid. In all of the body fluids, there is a normal range for the chemicals that it contains. For example; Analyte Glucose Protein Albumin Na Urea Creatinine K Cholesterol Triglycerides • Blood 4.1-5.9 mmol/L 65-83 g/L 40-50 g/L 135-145 mmol/L 2.1-7.1 mmol/L 62-115 µ mol/L 3.5-4.5 mmol/L Sex & age variation Sex & age variation All the chemical substances that can be measured (analyzed) they are called

"analyte" • Under the various circumstances that the body goes through, it tries to keep the levels of all the chemicals within a specified range.

LH. lipoproteins and phospholipids • Increase in TG and cholesterol indicate serious condition that may affect the heart and blood circulation as the excess fat will deposit on arteries resulting in blockage of the blood supply to some sections of the heart (heart attack). • Some analytes show variations with sex. triglycerides(TG). For example.5 is underweight BMI 18. a person who just ate a meal high in fat will have falsely increased triglycerides. FSH. Diet and medications can affect the results of many analytes. On the other hand. if the protein value for a patient was = 55 g/L then the condition is known as hypoproteinemia.5-25 is normal BMI 25-30 is overweight BMI > 30 is obese Increase in TG is dangerous to women especially above 30 Increase in LDL-Cholesterol is dangerous to men and post- .  For example. many body functions affect many analytes and any disturbance to their function will affect those analytes. This is called interference. o Many analytes such as cholesterol and triglycerides are higher in males than females o Testosterone is present in much higher concentrations in males than females o Estrogen. age and status of the person. o Simple methods are also possible to determine whether a person is normal or fat. for example. o It is therefore important to obtain carefully controlled sample.      Body mass index (BMI) = weight (kg)/[height (m)]2 BMI <18. o In addition to single analytes. if the protein value was = 95 g/L then the condition is known as hyperproteinemia. a person who ate a lot of sweets he will have a falsely elevated glucose. for example fasting blood sample. where the patient is asked to stop eating and drinking for a period 10-14 hours before the collection of blood. lipids include cholesterol.• If the values fall below the lower end of the range or increase above the upper limit then the results are considered abnormal and take the prefix (hypo OR hyper). o menopause women o years of age. progesterone are mainly female hormones o ALP is age dependent with high levels in children and old people o Not all abnormal results always indicate disease.

treatment and management of the patient. o Other aspects of clinical chemistry involves endocrinology. pH. Cushings Disease. Types of results obtained in the clinical laboratories. hazy. Increase in blood urea and creatinine indicates abnormal renal function.8 is normal. cloudy. 1/16. o For example in jaundice. glucose = 4. storage and detoxification. acidosis & alkalosis. amounts of TG  abnormal  abnormal  synthesis. total protein.. GGT. bilirubin. TNC Titre. 1/32…….5 g/dL Semi-quantitative (subjective) Score. > 1 is The liver performs many metabolic functions such as • When there is a liver dysfunction a number of analytes are affected and measurement of these analytes represent LIVER FUNCTION TEST(LFT) o LFT include measurement of albumin. ++++ . AST. 11-20 Descriptive. 1/4. 1/8. turbid . RNA& DNA.5 mmol/L protein = 78 g/L Hb= 13. Hypo & hyperthyroidism. ++ . electrolytes. clear. trace elements. 6-10. + . thyroid function. blood gasses. tumor markers. o It also deals with diseases especially those that affect chemical balance and metabolism such as diabetes mellitus. > 0. 1/2. Enzymology. o  o     Quantitative (objective) (numerical value + units) e. 0-5.g. The function of the clinical chemistry laboratory • To carry out tests and investigations on patients specimens upon the doctors request and produce meaningful and timely results which help in the diagnosis of disease. porphyrins and other functions. ALT.8 is For men W/H ratio of upto 1 is normal. -ve. bilirubin will be high o In liver biliary obstruction ALP. Also waist/hip ratio (W/H ratio) indicate the excess For women W/H ratio of <0. nucleic acid. vitamins. ALP. Addison's Disease. inborn errors of metabolism.1/256 Range. +++ . GGT and bilirubin will be high o The kidneys perform removal of watersoluble waste products especially urea and creatinine. minerals.

filled by doctor or nurse and includes the following information. -patient's name -hospital No. nurses. conventional. weakly +ve The majority of results obtained in clinical o Meaningful results: Reliable results which are Expressed in Acceptable (correct) units Reliable results Accurate : close to the real “true” value Precise : similar results if repeated on same specimen Acceptable (correct) units (quantitative: SI. -medications -diet -physical condition -smoking -any other relevant information that may be useful for the lab • patient instruction. patient.o  o chemistry are QUANTITATIVE Qualitative (objective) Abscent. Pre analytical stage – Outside the control of the lab – Clear and accurate instructions must be given to personnel – Involves: doctors. -Consultant's Name -Date & time of collection -Information about the patient regarding. urine. messenger (porter) – Includes: • request for investigation by the doctor after examination of the patient. qualitative and semi-quantitative) – – – • Timely results: Available to the doctor when needed routine urgent (LIFE SAVING INVESTIGATIONS) Components (Stages) of QA Program – Pre analytical (~ 68-86% sources of errors) – Analytical (~ 40 % sources of errors) – Post analytical (~ 20 % sources of errors) • To obtain meaningful and timely results ALL components of the QA Program MUST observe and adhere to the specific instructions set by the lab regarding all the aspects included in the specific component. present. -ve. • request form. or Medical Record No. File No. stool …etc. +ve. the patient must receive clear and accurate instructions regarding the following.) – Fasting or random sample: • -clinical fasting (10-14 hours) • Patient usually fasts from the last evening meal (~ 7 pm) until the specimen is collected in the next morning between 7 & 8 am • Fasting sample used for diagnostic and confirmatory tests • . -age (DOB) -sex -date of request -specimen type -tests required -possible diagnosis (or query) -unit/ ward -Doctor's Name -Doctor's signature -Doctor's Bleep or phone No.. – importance of the test & how it will help in the diagnosis and treatment of his illness – Type of specimen to be collected (blood. phlebotomist.

• the patient must be properly identified as the person who is mentioned on the request form • the patient must be relaxed before. sleeping habit other life-style and method of transportation • Random specimen (on spot sample): taken just before analysis. • almost all types of medications affect laboratory results • the type of medication chronically used by the patient must be written on the request form • if the type of medication used by the patient affects the required tests. night and day related) this includes hormone releasing factors (released fro the hypothalamus) & ACTH • some analytes follow a diurnal rhythm (24 hours exactly) e. is mainly used for screening tests – Dietary restrictions. physical activities. serum and plasma are the most common types of specimen received in clin chem. the patient must have enough sleeping hours before collection of the specimen • some analytes follow a circadian rhythm (~24 hours. • Strenuous exercises may affect the results of some tests • Walking under hot or cold climate to the hospital may also affect some results • The patient must be clearly informed if his physical activities affect the result and if he needs to refrain from such activities one or more days before collection of the specimen.• It provides information about the body status for the last 24hours • Fasting sample also means that the patient observes other restrictions regarding diet. cortisol highest level at 7:30 am & lowest level at 7:30 pm . then the patient may be asked to stop taking the medicine for upto 24hrs until the specimen is collected – Physical activities restrictions.g. smoking. during and after the collection • stress on the patient can lead to increase levels of adrenalin which will result in hyperventilation and increased rate of blood flow in the body which may affect many tests • appropriate patient posture must be observed during collection (sitting.specimen collection & handling for every test there is a specific type of specimen for every test there are specific conditions for collection & handling of specimen specimen is any part of the patient which is collected for specific investigation Whole blood. some types of diet may affect the analysis and results. • carrots may affect the colour of urine and colourimetric procedures. Lab Also urine & CSF are commonly received in clin chem serum is the ideal specimen for clinical chemistry analysis (plain tube) (red top tube) . • bananas and mango may elevate the level of K in blood • high intake of salt will increase the levels of Na & Cl – Use of medications. For example. or recumbent) .patient preparation. medications. – Life style • All types of Smoking interfere non-specifically with many test results • The patient must be told to refrain from smoking for at least 24hours before collection of specimen • sleeping habit. • lipids intake must be controlled for lipid profile analysis.

o It inhibits glycolysis by inhibiting glycolysis enzymes o It must always be collected as the last tube. - . – The quality of the result is dependent on the quality of the specimen. contamination and minimize the affects of slight hemolysis specimens for pH & blood gasses must be transported in syringes immersed in normal ice immediately to the lab and analyzed within 1hour. Mg & many enzymes NaF/Koxalate (Grey Top tube) is used for glucose analysis only.Li heparin is the preferred anticoagulant because. so there are no interferences on analysis EDTA. specimen for bilirubin must be transported in fully covered tube to prevent exposure to light which will oxidize bilirubin and decrease the result avoid exposure of specimen to direct sunlight or high temperature samples should be placed in a double pocket (side-pocket) transparent plastic bag which has keeps the specimen separate from the request form storage plasma must be separated immediately after receiving the sample serum must be separated immediately after clot formation (10-15 minutes after collection) for routine analysis for most tests samples can be analyzed within 2hours after collection at room temperature refrigerate the sample (4-8 oC) if analysis is delayed (upto 8 hours) normal freezers (-18 to -22 oC) for upto 3months deep freezers (~-70 oC) for months and years liquid nitrogen (-140 oC) for months and years NEVER FREEZE WHOLE BLOOD -- severe hemolysis Never repeat freezing and thawing of the sample. If some of the analysis are done on separate days. then the sample is divided into several aliquots (number of tests +1). o NaF is a non-competitive enzyme inhibitor o The tourniquet must not be applied for more than one minute for most tests o The specimen in the tube must be gently mixed by inversion 6-7 times to ensure good mixing of anticoagulant with the blood o Never shake the tube or mix vigorously as this may cause hemolysis o Avoid hemolysis of the sample (K & Mg increased. Li exist in insignificant concentrations in the body & heparin is the physiological anticoagulant in the body. transportation. Then one aliquot is used once on the particular day for the required tests. Aliquots are frozen. This will denature most proteins and polypeptide hormones and also affect some analytes. most colourimetric procedures are affected) o Avoid collection from an intravenous line site (dilution of all analytes and exaggerated increase in the infused analytes concentration) transportation blood samples must be transported within 45 minutes of collection for routine tests urgent samples must be sent immediately to the lab (within 10 minutes of collection) turn around time for urgent samples is 20 minutes (collection. analysis and return of results) other specimens must be delivered to the lab as soon as collection is completed specimens must be transported in an upright position to prevent spillage. Citrate & Oxalate should not be used as they lower the concentrations of Ca.

routine & urgent requests) • Filing -Queries and complaints SOURCES OF ERRORS IN CLINCAL CHEMISTRY ANALYSIS TYPES OF ERRORS: TWO TYPES: 1) QUALITATIVE (UNMEASURABLE) o The severity of the error is proportional to the severity of the outcome. lab consultant. contradictions. clerk. secretary.Fire Radiation – General -Safety equipments -Waste disposal – Rules and regulations – ALWAYS PRACTICE SAFETY – NEVER EXPOSE YOURSELF OR OTHERS TO HAZARDS Personnel • • Post analytical stage – Mostly controlled by the lab. Multi Rule. machine printout. technologist. manual writing. animal sera…. CuSum. wrong order. o Upto 5% are considered as human errors o Four types exist: a)-Administrative & managerial ERRORS: errors concerning the following. . clerks. wrong decision.) – Systems for quantitative results (Levy-Jennings Chart. porter. secretary. instructions. – Involves: technologists. storage • Equipments and instruments: • Procedure of analysis • QC system – Heart of the QA program – No QC No results – Checks for errors – QC materials (human. aliquoting. doctor – includes • Results acquisition • Use of QC for results validation • Results reporting (result form. water & kits Safety – Physical -Chemical -Health . separation. Delta Check) – Systems for qualitative results – System for semi-quantitative results – Automated or manual QC – Recording of QC and actions taken • • Chemicals. organizations. nurse. appointments. locations. supervisor. lab supervisor. Replicate Analysis. administration – Policy & Procedure Manuals – Includes: • Specimen reception and booking • Centrifugation. lab director.• Analytical stage – Within the control of the lab – Involves technicians. lab manager. engineers. lab director. lab aids.

standards 4. improper writing of numbers. file No. 1.96 SD (2SD) • Values ± 2SD . no communication rules present.. experience 2-Systematic error (SE) o should not occur in the procedure o it has magnitude o it has direction o it shifts the mean o affects accuracy Two types: aConstant SE (CSE) The size of the error is the same regardless of the causative factor. smoking. tests requested. temperature. diet.± 3SD indicate the presence of RE • Values ≥ ± 3SD indicate the presence of large RE & considered as outliers (result rejected) • cv gives an estimate about the precision & RE o smaller cv small RE & high precision o bigger cv big RE & low precision sources: Normal: vibration. activites) 2-permenant damage (lamp. language problems. air current.Random error (RE) • Occurs by chance • In every procedure • Fluctuates about the mean • It shifts the SD • Affects the precision • No magnitude • No direction • Value= ±1. 2) QUANTATIVE (MEASURABLE) (ANALYTICAL) -Analytical: relates to errors in the analysis. specimen type. late filing. tubes. doctor's name. unit or ward. wrong filing. pipetting. typing errors. lack of experience b)-Clerical/ Secretarial ERRORS:. doctor's bleep.inadequate skill 6. ictraemia. untidy writing. c)-Typographical ERRORS:. humidity 5. humidity. photocopying. lack of knowledge. errors in assignment.B.) 3. air current. lack of communication. lost results.lack of experience . mis-communication. date of request.errors concerning the following. electronic circuit …. lipaemia) Exogenous (wrong anticoagulant. temperature. mis-placing of forms or specimens. skill. improper placement of decimal point d)-Communication ERRORS:. unclear writing. patient name.extreme variations in vibration. patient sex. contacting the wrong person.misplacement..errors concerning the following. medications.O. mis-matching of request form and specimen. Due to: 1-interference: Endogenous (haemolysis.errors concerning the following. date & time of collection. patient age or D. electrode. mis-spelling.expired reagents. phoning of results.

then the machine must measure it as 7.g the minimum volume that can be measured manually and automatically by many measuring devices is in µ L quantities. Mg <0.35 mmol/L  Values lower than the minimum detectable level are reported as : Less than the detectable limit ( e. • Reporting of results depend on.345 mL or 150.5 mmol/L (one decimal place) Ca = 2. i. For example if the level of weight is in g quantities. to three decimal places or to the nearest mg) then the device used must fulfill this requirement .5 g. 15. equipments and analytes there are limits which determine the acceptable levels of accuracy and precision • The acceptable precision for all analytes. The actual result is then obtained by multiplying by the dilution factor (df). deteriorating reagents. diaphragam. then we must write to three decimal places e. lamps.3757. So when writing a volume of solution in mL. the measuring device level of accuracy has to be one decimal place more than the clinically acceptable number of decimal places.g.g 12. o Clinical relevance of the values : glucose = 6. Due to. electrodes. equipments and instruments is a cv upto 5% EXCEPT for enzymes and polypepetide hormones where the acceptable cv is upto 10% • The acceptable accuracy for all analytes.54 mmol/L (two decimal places) pH = 7.b.35 mmol/L) o Maximum (upper) detectable limit: For values higher than the upper detectable limit.250 mL o the required level of measurement will also determine the level of accuracy. equipments and instruments is upto 2% deviation from the "true" or "expected" value. weights or lengths depend on.Proportional SE (PSE) The size of the error depends on the size of the causative factor.385) o Reporting of volumes. the sample should be diluted until the result fall within the detectable range of the analyte which is usually a straight line (on a plain graph paper) when the reaction obeys Beer's Law.g. For example the pH measuring machine must be able to measure pH upto 3 decimal places so that the pH can be accurately reported in 2 decimal places. instrument. components Limits of Precision & Accuracy • For every procedure. Generally.38.45 (two decimal places) o Minimum detectable limits of the analyte e. Mg = 0.380 (7.g.e if the true pH of the patient is 7. a) the minimum amount that can be accurately measured b) the required level of measurement c) the stated level of accuracy  e. then we write the weight to one decimal place (1/10g). o sometimes a specific limit of accuracy is stated in such measurements (e. o Limit of accuracy of the measuring device. transformers.