Electrolytes and Inorganic ions
of the filtered sodium is passively
Electrolytes = Inorganic subs that dissociates into ions: cation
anion
- They are charged
- It has different specialties
Anion Gap
 Used for Electrolyte profile
 Makes use of 4 major electrolytes
- Sodium
- Potassium
- Chloride
- Bicarbonate
 Formula: [Na+] – [Cl- + HCO3]
 Normal Value = 10-17mmol/L
 Quality control purposes: low normal, normal, high for
electrolytes result
 Cation = + ion
 Anion = - ion
 Electrical Neutrality = Electrolytes exists in the body
with a 0 net charge.
- In the body, electrical neutrality must be
maintained
 Sum of cation = sum of anion
- difference arise due to the presence of other
electrolytes
 We only use them for prob id esstimate =
 Increase in anion gap was observed in:
- Uremia
- DM complication
- Ketoacidosis
- Dehydration
 Decrease in anion gap was observed in:
- Monoclonal and Polyclonal Gammopathies
- Lithium toxicity
- Hypermagnesemia
Functions:
 Maintain fluid balance (Mainly Na)
 Acid base balance (Mainly HCO3)
 Production of action potential (Mainly K)
 It can act as a cofactor for different enzyme systems
(Mg = most widely used activator)
 Maintenance of electrical neutrality
Sodium (Na; Natrium)
 Maintains the fluid balance in the body.
 It is the most abundant extracellular cation in the
body.
- Monovalent cation
- 1:12 intracellular:extracellular ratio
 It controls osmosis of the water between different fluid
compartments.
 Principal osmotic particle:
- It is osmoticaly active which draws water (so as
Cl) that creates osmotic pressure in the plasma.
- Almost half of the osmolality of the plasma water
attributes to sodium.
 ~280-290 mOsmol/kg
- Osmolality must be balanced to maintain blood
volume and blood pressure
 Regulation:
- ADH (vasopressin) - secreted from the posterior
pituitary gland. It promotes water absorption.
 It affects sodium balance if imbalance.
- Aldosterone – secreted by adrenal cortex. It
promotes sodium reabsorption.
 Increases sodium
 Proximal Convoluted Tubules = Where 70%
reabsorbed
- Atrial natriuretic peptide:
 CHF marker
 Produced by the heart when it works too
much.
 Natriuresis = sodium excretion in the urine
(water follows) that causes the blood volume
to decrease that in turn alleviates its work
load
 RAAS – Renin is produced in low BP (low
salt concentration). In turn i will promote
sodium reabsorption at Distal Convoluted
Tubules
 Related Imbalances:
- Hypernatremia
- Hyponatremia
- (plasma water has an effect in sodium levels in
the blood;
 Hyponatremia
- Overhydration = water retention.
- It is due to excessive loss
- Dietary is not a quite significant cause
- Addison’s disease
 Adrenal gland problem
 Primary Hypoadrenalism
o Low Aldosterone production that causes
decreased sodium conservation
- It can be a result of diarrhea
- Pseudohyponatremia
 Artefactual
 High glucose, lipids and protein levels
(especially from DM patients, MM patients
and dyslipidemia)
- Electrolyte Exclusion Effect = Principles followed
by the electrolytes in the blood especially when it
comes to their measurement
 Electrolytes are only measured in the water
phase of the plasma (93-95% of water),
because electrolytes are only found in water
phase.
 All electrolytes measurements are in low
concentration due to the total volume of the
specimen.
- Sodium is the most affected in imbalance
 Hypernatremia:
- Dehydration
- High sodium levels
- Insulin therapy
- Cushing syndrome and DM insipidus
 Its hallmark is high sodium
 Excessive aldosterone production
 Reference value: 135-150
 Analytical techniques:
- Use serum as a specimen = no additives that
might interfere with the reaction performed
 11-30 min to clot
- Heparinized plasma is the second preferred
specimen
 Specimen processing is faster
 You will not wait for clotting.
 Sodium Heparin must not be used in Sodium
measurement.
- Ion Selective Electrode
  Potentiometry = method of choice. It
measures electrode that binds to the
electrolyte.
o Glass electrode must be used in sodium
- 2 types of ISE (2 modes of operation).
 Direct
o No specimen dilution
o The risk of pseudohyponatremia will not
be a problem
o Most oftenly used
 Indirect
o Specimen dilution.
o Electrolyte exclusion effect
o More prone in pseudohyponatremia.
o Hemolysis specimen = Most common
cause of pseudohyponatremia
 Ruptured RBC can lead to
electrolytes increase.
 False decrease in sodium
and chloride, due to
dilution.
- Flame photometry for sodium measurement;
 Obsolete
 Performs dilution
 Sodium = yellow flame
- Spectrophotometric and Colorimetric Method
 Uses Bradbury method (Yellow end color)
 Adopted in:
o Albanese Lein - Zinc urinylacetate
o Maruna Trinder - Mg uranylacetate
- Enzymatic Sodium Method
 Uses beta-galactosimase
 Sodium act as an activator
- Atomic absorption
 Gold standard
 Reference method
 Reference Values:
- Serum= 135 - 150 mmol/L
- CSF= 136 - 150 mmol/L
- Urine= 40 - 220 mmol/day (24-hr urine)
- Conversion of mmol/L to mEQ/L is based on the
number of valence.
Potassium (K; Kalium)
 Potassium balance.
 Generation of action potential.
 Involved in muscle contraction and nerve impulse
transmission
 Most important in normal cardiac function
- Too much or little can make the heart stop
beating
- If not that extreme, only the muscles will be
affected.
 Most abundant intracellular cation
- 23:1 intracellular:extracellular ratio
 Low levels in blood serum.
 Levels are controlled by aldosterone in an opposite
manner
- Potassium excretion = decreases potassium in
the body
 Hypokalemia
- Due to potassium shift from extracellular
compartment to intracellular compartment as
seen in alkalosis
 Potassium replaces hydrogen as it goes out
of the cell to compensate alkalosis
o Electrical neutrality = Hydrogen needs
replacement to balance the charges
o Acidosis = Potassium is pushed out of
the cell and hydrogen comes in which
causes high potassium levels
- As seen in Insulin therapy where potassium
comes along as the glucose comes in.
- Potassium loss
- Associated with GI and Renal due to massive
excretion
 Diuretic = potassium decrease
o Potassium sparring diuretic which
prevents potassium loss
 Remedy: Eat foods rich in Potassium
 Hyperkalemia
- high potassium
- Opposite reasons
- Acidosis
- Cell damage
- Renal failure
- Mineralocorticoid deficiency
 Deficiency in Aldosterone which promotes
potassium excretion
o If the aldosterone levels are high the
potassium level decreases
o If deficient the potassium level increases
- Pseudohyperkalemia
 Artefactual
 False hyperkalemia
o Potassium is collection sensitive
o Most significantly affected in hemolysed
samples
 RBC contains ~105 mmol/L of
Potassium against in serum that
contains only 3.85 - 5.5 mmol/L
o Excessive tourniquet time
o Excessive clenching of fist
o Delayed separation and refrigeration
can result to pseudohyperkalemia due
to cellular activity
o The same is true if the specimen is high
platelet count
 When the blood clots the platelets
will rapture and potassium will be
release.
 Remedy: use plasma
 Serum potassium is a little
higher due to clotting process
than plasma potassium val has
a diff.
 Barter syndrome
- Low sodium
- Low potassium
 Analytical technique:
- Potassium Ion Selective Electrode
 Uses liquid membrane electrode with
valinomycin incorporated as a potassium
binder.
 Valinomycin is part of the electrode that
serves as potassium binder
- Flame photometry
 Potassium = Violet flame
- Spectrophotometric technique
 Lockhead and Purcell
o Old method
o Blue violet to violet
 - Turbidimetric
 Hillman and Beyer
o Uses sodium tetraphenylboron which
produces turbidity
- Atom Absorption Spectroscopy
 Gold standard
 Reference Value:
- Serum = 3.8-5.5 mmo/L
- Urine = 25-125 mmol/day
Chloride
 Counter-ion of sodium
- Regulates osmotic pressure and water balance
together with sodium.
 Has a role in acid-base balance
- Chloride shift
 Bicarbonate acts as its reciprocal ion.
 Serves as its “Kapalitan” to preserve
electrical neutrality
 Bicarbonate is an important base if it needs
to cross the membranes and go other
places, the chloride take its place.
 Reciprocal in relationship
 Most abundant extracellular anion
 Hyperchloridemia
- Metabolic alkalosis
- Respiratory acidosis
 Hypochloridemia
- Metabolic acidosis
- Respiratory alkalosis
 Analytical techniques:
- Ionic Selective Electrode
 Uses Silver chloride
- Colorimetric method
 Schales and Schales
o Uses mercurimetric titration
 Mercury has high affinity for
chloride. Chloride and Mercury will
react to produce HgCl, titrated with
diphenylcarabazome to a blue end
point
- Skeggs modification
 Uses mercuric thiocyanate
o Mercuric thiocyanate will react with
chloride to produce HgCl.
o Then thiocyante ions are liberated (this
is we are up to),
o Ferric iron is reacted to thiocyante to
produce a red or reddish brown complex
of ferric thiocyanate:
- Colometric ampherometric
 Gold standard
 Cotlove chlorinometer
o Electrochemical technique like ISE
o An electrode is used that will produce
silver ions then it will react with the
chloride in the specimen producing
silver chloride precipitate (basis).
o The instrument will correlate the timed
elapse from the start to the end of the
silver chloride production
 Correlated in chloride
concentration.
- Sweat chloride determination
 Special area in chloride testing
 Specifically designed to detect Cystic
Fibrosis
o Mucoviscidosis
 The patient has viscous secretions
to the point that the internal organs
are affected (e.g pancreas, lungs).
o Sodium is also elevated
o Elevation of chloride = 60mmol/L or
higher sweat chloride in CF.
 How to collect the sweat?
o Use Pilocarpine Iontophoresis
 Devised by Gibson Coolie
 Uses pilocarpine nitrate to induce
sweating (so does increase
salivation but this is not we are up
to), then collected in goose pad
then pathlab chlorinometer.
 Reference Values:
- Serum = 98-106 mmol/L
- Urine = 110-250 mmol/day
- Sweat = 5-45mmol/L (Higher than 60 implies
Cystic Fibrosis)
Calcium
 5th most abundant mineral element in the body
 Lower than potassium
 98% is found in the bones in the form of
hydroxylapatite crystals
 2% is left for the other parts of the body
 Ca is also a clotting factor
 For muscle contraction
 Regulated by PTH produced by the parathyroid
hormone
- PTH can cause blood calcium levels elevation by
a process called bone resorption
 1% of bone calcium is exchangeable in the
plasma then calcium will go to the plasma
which causes calcium elevation
- PTH promoting calcium absorption in the kidneys
- Promotes vitamin D synthesis
- Elevates calcium due to intestinal absorption of
calcium and phosphorous:
 Acetone, came from thyroid gland, has an
opposite effect which decreases blood
calcium.
 It has different forms in the blood
- Not exclusively ions compared to others.
 Some fractions cannot be measured by ISE due to its
many forms:
- 10% anion bound (not a subject to ISE)
- 50% - free or ionized form (active form)
- 40% - protein bound (bound to albumin)
- Ionization of calcium is pH dependent
 Increase in pH
o Decrease ionized fraction
 Decrease in pH
o Increase in ionized fraction
Ionization and pH has an Inversely
proportional relationship
 Analytical techniques:
- 2 Types of Calcium testing:
 Ion Selective Electrode
o Ionized fraction measurement
 Specimen consideration:
 Closed system – don’t open
the tube unless for testing. It
will be at risk for aerosol
contamination, hence a false
results will be generated.
 For ionized calcium, if the
tube was left open, the pH
 will increase due to
liberation of CO2. Magnesium
 Atomic absorption  2nd most abundant intracellular cation
o Total calcium methodology  4th most abundant cation in the body
- Colorimetric method for total calcium  Forms in the Blood: Free or Ionized (2/3) and Protein
 Clark and Collip Bound (1/3) with Albumin.
o Calcium is treated with ammonium  Acts as an activator
oxalate then calcium oxalate is  Analytical Method:
precipitated this then converts calcium - Atomic absorption spectroscopy
oxalate to oxalic acid. After which we  Reference method
titrate with potassium permanganate - Flame photometry
(purple end color; but its endpoint is  Magnesium = blue flame
colorless (colorless manganese)) - Colorimetric and Spectrophotometric method
- EDTA titration  Titan yellow
 Bachra,Dawer & Sobel o A yellow dye that becomes red in the
 Use of indicator called Calcin red (pinkish), presence of magnesium.
then place a drop in the solution with o Not that sensitive
calcium, afterso it will form a yellowish green  Calmalite green formazan with methylene
fluorescence. Apply EDTA. blue (dye binding)
It will compete with calcin red via chelation  Cynidil blue (dye binding is the most
so that calcin red will be degraded. After common in Mg and Ca)
degradation it will form salmon pink end
color Bicarbonate
- Spectrophotometry  Acid base balance maintenance, act as an important
 Dye binding base
 O-cresolpthalein complex method  2nd most abundant in extracellular anion
o It turns into a violet solution
 Could be a part in Blood Gas analysis (collected in
o Has an additional reagent, 8-
arterial blood)
Hydroxyguinoline to prevent magnesium
- Venous blood has a higher bicarbonate levels
interference.
than arterial
 Because calcium and
 Because bicarbonate originates in carbon
magnesium interfere with each
dioxide which is a waste product of cellular
other’s’ reaction.
metabolism.
- Atomic absorption
 Acidifying the specimen
 Has AAS but it has phosphate.
- All the bicarbonate will be converted into gaseous
o This is the reason why we add
Carbon dioxide which then measured using
lanthanum chloride which prevents
pCO2 Electrode
phosphorous to interact with calcium
producing Calcium phosphate  Anion that measures partial pressure of CO2
- If alkalinized = enzymatic
Phosphorous  Coupled enzyme assay
o Uses 2 enzymes:
 It has inverse relationship with Calcium in the body
 phospoinolpyruvate carboxylase
 Influenced by PTH, Calcitonin and Vitamin D
 mallate dehydrogenase as copling
 For structural support enzyme
 Energy generation and storage
 Majority of which is found in the bone in the form of
hydroxyapatite crystals around 85%;
 Widely distributed
 Analytical Techniques:
- Colorimetric
 Fiske and Subarrow Method
o Inorganic P (PI) is reacted with
ammonium molybdate which produces
phosphomolybdic/date acid (colorless)
read in 340nm. It could be continued to
a visible method, just add reducing
agents:
 Ascorbic acid
 Stannous chloride
 P-aminonapthtolsulfonic acid
And it will turn to a colored end product
called phospomolybdenum blue – blue
and red at 600nm wavelength