Introduction to Clinical chemistry

CLINICAL CHEMISTRY
• Clinical biochemistry, chemical pathology and
clinical chemistry are synonyms
• Clinical: describes the practical observation and
treatment of a patient
• Biochemistry: is the chemistry of life. It seeks to
describe the structure, organization and functions
of living matter in molecular terms.
• Clinical chemistry: is the branch of laboratory
medicine in which biochemical methods are applied to
the study of disease.

•Clinical chemistry: the function of the clinical lab is to

perform qualitative and quantitative analysis on body
fluids such as blood, urine, and spinal fluid, as well as
feces, tissue, calculi, and other material.
• Clinical biochemistry:

• The clinical biochemistry measures change in biochemical

compounds as an indicator of health status or disease processes.

• Clinical biochemical tests comprise over one third of all hospital

laboratory investigations.

• A central function of the clinical chemistry laboratory is to

provide biochemical information for the management of patients.
 Biochemical results are useful for diagnosis and treatment
of disease.

 the tests must be performed accurately.

 validated analytical methods and good instrumentation

should be available with understanding of chemical
reactions involved in each test.

 A working knowledge of clinical chemistry and biochemistry

is essential for the technologist to effectively
communicate and interact with other health professionals
The technologist must have a comprehensive background
in the terminology and abbreviations used in clinical lab.

The technologist must have the necessary background to

understand the basis of lab tests that are used to measure
physiological parameters.

The technologist must be aware of the influence of

disease states and drug therapy on the results of lab
diagnostic tests.

This course provides the basic information in lab medicine

that is necessary for the technologist.
 CLINICAL CHEMISTRY
How biochemical tests are used

Biochemical tests are

used extensively in
medicine.
Biochemical tests are
used in diagnosis,
prognosis, monitoring
and screening.
 Use of biochemical tests
• The results of the biochemical tests are useful
to the ‎clinician in:

8
 Diagnosis is the art or act of distinguishing one disease from another.
 Medical diagnosis is based on the patient’s history combined with
the findings on examination.
 It is usually possible to make a differential diagnosis (is the term
used when making a correct decision between diseases presenting a
similar clinical picture).
 Biochemical and other investigations may then be used to distinguish
between them
 Investigations may be selected to help either confirm or disprove a
diagnosis.
 Biochemical tests are important for confirmation or rejection of clinical
diagnosis
Prognosis: a medical term indicates the doctor's prediction
of how a patient's disease will progress, and whether there
is chance of recovery, based on knowledge of the course of
the disease in other patients together with the general
health, age and sex of the patient.

Tests used primarily for diagnosis may also provide

prognostic information for example, serial measurements of
plasma creatinine concentration in progressive renal disease
are used to indicate when dialysis may be required.
Monitoring (sequential recording, keep watch over):

To do this, there should be a suitable analyte, for

instance, glucose in patients with diabetes mellitus.

To follow the course of an illness and to monitor the effects of

treatment. Examples: Glycated haemoglobin in patients with

Diabetes mellitus.

Biochemical tests may also be used to detect

complications of treatment, such as hypokalemia during
treatment of diuretics.
Screening (examine for the presence or absence of a
disease)

Biochemical tests are used to determine Subclinical

diseases: An illness that stays below the surface of clinical
detection, which has no recognizable clinical findings.

Is designed to detect individuals affected with a condition before it is

apparent clinically.

The best known example is the mass screening of all new

born babies for phenylketonuria (PKU), which is carried out in
many countries, and congenital hypothyroidism. (Analysis of
newborn blood sample for thyroid stimulating hormone (TSH)
during 1st week of life.
 Qualitative and quantitative analysis
 The clinical chemistry tests can be divided into three main category
 Core biochemistry
Core analysis: are the commonly requested tests which are of value in
many patients, carried ‎out in every biochemistry laboratory.
 Specialized tests
Not every lab is equipped to carry out all possible biochemistry
requests, may be referred to ‎larger laboratories (DNA analysis) .
 Less commonly asked tests for.
 An urgent test in The emergency lab
All clinical chemistry labs provide facilities for urgent tests.
Only a small number of test types are available from the emergency
lab.
These tests are processed rapidly.
An urgent test is designed as test on which the clinician is likely to
take immediate action. When an immediate treatment will depend on the
result.
 The clinical chemistry tests
1. Core biochemical tests
Sodium, potassium, chloride
Urea and creatinine
Calcium and phosphate
Total protein and albumin
Bilirubin and alkaline phosphatase
ALT and AST
-glutamyl transferase (GGT)
Creatinine kinase
Glucose
Amylase
Lipids
 The clinical chemistry tests

2. Specialized tests 3. Emergency tests

Hormones Urea
Specific proteins
electrolytes
Trace elements
Vitamins
Blood gases
Drugs Glucose
Lipoproteins electrophoresis Cardiac enzymes
PCR Troponins
 Tests performed away from the laboratory:
Point of care testing (POC)

• Instruments are available that can perform certain test at

different locations such as at the bedside or in a clinical care
units.
• Blood glucose (glucocheck)
• Urine analysis
• Occult blood
• Blood gases
• Electrolytes, urea, creatinine
• Cardiac markers (Troponin I and T, CK-MB)

• POC tests are always more expensive than the same tests
performed in the central laboratory.
 Tests performed away from the laboratory:
Point of care testing (POC)

• Why do we need point of care testing?

1. Tests are of urgent importance and results will affect the
immediate management of the patient such as:
• Blood gases ( Operated by respiratory therapists)
• Electrolytes
• Glucose
2. tests are so common, simple and cheap that it is more
economical to perform them at the point of care such as:
 Blood glucose
 Urine analysis
 Qualitative pregnancy test in urine. HCG (Analysis of human
chorionic gonadotropin hormone in urine)
 Tests performed away from the laboratory:
Point of care testing (POC)
•The most common is the detection of glucose conc., in a finger stab
sample in the clinic or at home by pocket-sized instruments.
•It is important for diabetic patients to monitor their blood glucose on
a regular basis.
•Advantages:
•Time ‎saving , convenience to both patient and ‎clinician.
•Provides information so that therapeutic intervention may be initiated
immediately.
•Disadvantage:
Cost: expensive ‎alternatives to the traditional methods.
The selected test or tests should be able to provide the type of
information required
Reasons for ordering lab tests:
• To make a definitive diagnosis or to confirm a clinically suspected
diagnosis.
• To rule in (or out) a differential diagnosis list.
• To screen for hidden disease.
• To determine the severity of disease (usually an acute disease).
• To determine the stage of disease (usually a chronic disease).
• To assist in determining therapy or the effect of therapy.
• To prepare the patient for a routine admission or operation.
 Steps in obtaining a laboratory test:

1.Written order is placed

2.Specimen is collected and properly labeled

3.Specimen and order are transported to the lab.

4.The specimen is accessioned in the lab.

5.The specimen is processed

6.The specimen is analyzed

7.The results are reviewed and verified by an MT

8.The results are released to the patient record.

 Specimen collection
 In order to carry out biochemical analyses. It is necessary that the
laboratory:
• be provided with both the correct specimen for the
requested test
• all information which will ensure that the right test is
carried out
• the result returned to the requesting clinician with the
minimum of delay.
 As much detail as possible should he included on the request form to
help both laboratory staff and the clinician in the interpretation of
results.
 This information can be very valuable when assessing a patient's
progress over a period
 Sample collection and processing

• Specimens used for biochemical analysis:

1. Venous blood, arterial blood, capillary blood
2. Urine
3. Stool
4. CSF
5. Amniotic fluids
6. Aspirates, Paracentesis fluid:
pleural, pericardial and ascitic fluid, joint
(synovial) fluid
7. Calculi (stones)
 Specimen collection
Collection of blood

• Blood for analysis may be obtained from veins, arteries or capillaries.

Venous blood is usually the specimen of choice.

• Skin puncture: if only a small volume of blood is required for a blood test
(e.g., a blood glucose test),

• A skin puncture may be used to obtain the sample in an infant younger

than 1 year, the lateral site surface of the foot should be used for skin
puncture.

Acceptable sites for skin puncture to collect blood from infant’s foot
 Blood Sample
Whole blood, plasma or serum can be used for testing.

Whole blood:

If whole blood is desired for testing, an anticoagulant must be added to

the specimen during the collection procedure.

Whole blood is rarely required for clinical chemistry tests; only for
blood gas, ammonia, and some trace element determinations.

Plasma

Plasma is the fluid fraction of blood. If plasma is desired for testing, an

anticoagulant must be added to the specimen during the collection
procedure.

Serum

Serum is the supernatant fluid which forms when blood clots.

Serum vs. Plasma Blood Sample
If blood is collected into a plain tube and allowed to clot after
centrifugation a serum specimen is obtained.
• Serum from coagulated blood is the specimen of choice for many assay
systems, but plasma obtained with an appropriate anticoagulant may be
an equally valid specimen.
• The use of plasma accelerates analysis in medical emergencies and when
the analyte is unstable (no time is wasted waiting for the specimen to
clot. Because serum requires a wait of 15 to 30 min for coagulation.
• The formation of fibrin clots or fragments when plasma is stored and
the subsequent risk of blockage sample probes of automated analytical
instruments is a disadvantage.
• Plasma is also not suitable for electrophoresis analysis, because the
presence of fibrinogen can confuse interpretation of electrophoresis
patterns.
Preparation of serum sample: •
Safe Re-cap Methods
Blood specimen tubes for specific biochemical tests
Serum separator tube (SST) contains a gel at the bottom to separate serum,
sodium citrate tube, the blood and anticoagulant ratio should be precisely known
Since the tube is used for coagulation study.
 Urine collection
• The type of urine to be collected is determined by the tests to be
performed.
• A clean, early-morning, fasting specimen is generally the most
concentrated specimen and thus is preferred for microscopic
examinations.
• It is satisfactory in most cases to use specimen collected with careful
attention to cleansing and to keeping the urine cool.
• Collection is preferred to be fresh, no need for preservatives. But 24
hour urine sample, must introduce a preservative.
• The most common preservatives are freeze, glacial acetic acid, nitric
acid.
• Preservatives have different roles but are usually added to reduce
bacterial action or chemical decomposition or to solublize constituents
that might otherwise precipitate out of solution.
Small aliquots of faeces are frequently analyzed to detect the presence
of “hidden” or so called occult blood, which is recognized as one of the
most effective evidences to the presence of bleeding ulcer or a
malignant disease in the GIT.

Collection of spinal fluid

Spinal fluid is normally obtained from the lumbar region. Spinal fluid is
examined when there is a question as to the presence of meningitis.

Collection of other fluids and tissues for analysis

Synovial fluid aspiration: synovial fluid is withdrawn from joints to aid

characterization of the type of arthritis and to differentiate non-
inflammatory from inflammatory fluids.
Dangerous specimens
• All specimens from patients should be considered
dangerous.
• A similar label attached to the request form !!!!.
• Hepatitis B and HIV are of most concern of the laboratory
staff.!!!!!
• All specimens should always be treated both by clinicians
and biochemistry staff as potentially hazardous.
 Sources of error in laboratory results:

• Pre-analytical error
• Analytical error
• Post analytical error
SAMPLING ERRORS

There are a number of potential errors which may contribute to the success
or failure of the laboratory to provide the correct answers to the clinician
questions.

1. pre-analytical Errors:

• Collection:

 Was the right tube used?

 Was vein puncture performed correctly?

 Was the specimen properly stored?

• Blood Sampling technique: Difficulty in obtaining a blood specimen may lead

to haemolysis with consequent release of potassium and other red cell
constituents (LDH). Results of these tests will be falsely elevated.
• Prolonged stasis during vein puncture: Plasma water diffuses
into the interstitial space and the serum or plasma sample
obtained will be concentrated. Proteins and protein-bound
components of plasma such as calcium or potassium will be falsely
elevated.

• Insufficient specimen: analysis requires certain volume of

specimen to enable the test to be carried out PT & PTT.

• Error in timing: The biggest source of error in the measurement

of any analyte in a 24-hour urine specimen is in the collection of
an accurately timed volume of urine.

• Specimens requiring special handling: should be placed

immediately on Ice: Ammonia, Acid phosphatase.
Incorrect specimen container: for each blood sample, the correct
container with the proper anticoagulant should be used.
• Samples for glucose should be collected into a special
container containing fluoride which inhibits glycolysis.
• If a sample is collected into the wrong container, it should
never be decanted into another type of tube. For example,
blood which has been exposed to EDTA (an anti-coagulant used
in sample containers  reduced calcium concentration 
approaching zero.
Inappropriate sampling site: Blood samples should not be taken
'downstream‘ from an intravenous drip. e.g Blood sample for glucose
taken from the same arm into which 5%, glucose is being infused.
Incorrect specimen storage: A blood sample stored long time before
analysis show falsely high potassium, phosphate and RBC enzymes as
lactate dehydrogenase
2. Identification:
• was the blood collected from the correct patient?
• Was the blood correctly labeled? Patient name, ID, Date,
time of collection, phlebotomist.
•Specimen identification:
• one of the commonest sources of erroneous lab results is
misidentified specimen.
•Blood bank has stricter requirements for specimen
identification.
 Biological factors affecting the
interpretation of results
• Sex of the patient.
• Age of the patient (ALK).
• Effect of diet (glucose lipids).
• Time when sample was taken (Cortisol).
• Posture of the patient (supine vs. sitting or standing),
• Effects of exercise (increase CK and decrease lipids).
• Medical history.
• Pregnancy (ALK and urea).
• Drug history (warfarin).
• Smoking ( increase ammonia)
 Biological factors affecting the interpretation
of results
Sex of the patient:
• Blood hemoglobin concentrations are lower in women;
thus, the serum bilirubin concentrations are slightly
lower.
Individual’s typical diet:
Vegetarianism: in long-term vegetarians
• The concentrations of LDL and VLDL are low.
• The total lipid and phospholipid concentrations are
reduced,
• The concentrations of cholesterol and triglyceride
may be only two-thirds of those in persons on a
mixed diet.
Age of the patient:
 In infants, bilirubin rises following birth and peaks
about the fifth to seventh day of life (the physiological
jaundice).
 The blood glucose concentration is low in newborns
because of their small glycogen reserves.
 The plasma nitrogen concentration decreases following
birth as the infant synthesis new protein, and the
concentration does not begin to rise until tissue
catabolism becomes prominent.
Time when sample was taken:
• Many constituents of body fluids exhibit cyclical variations
(Circadian variation); throughout the day: occurring in 24-
hour periods.
• These cyclical variations may be quite large  the drawing
of specimen must be strictly controlled.
• The concentration of serum of cortisol may change by 50 %
between 08:0 and 16:0.
Effects of exercise.
• The influence of exercise on the composition of
body fluids is related to the duration and intensity
of the exercise.
• The stress-response increases the blood glucose
which stimulates insulin secretion.
• Plasma pyruvate and lactate are increased with
increased metabolic activity of skeletal muscle.
Posture of the patient.

• The blood volume of an adult in an upright

position is typically less than that of an adult in
lying down position.

• total protein and albumin decreased in the supine

patient.
• Fluid reduction in plasma is associated with a
comparable increase in the plasma protein
concentration.
• The concentrations of all proteins, including
enzymes and protein hormones, and of such
compounds as drugs, calcium and billirubin,
which circulates partly bound to protein, are
also affected.
Drug history.
• Drugs may affects biochemical test results.
• It may be dependent on their side effects
and patient individual response to certain
drugs
• Effects of drugs on the composition of body
fluids are likely to be apparent when large
doses of a drug are administered. Example:
diuretic drugs often cause mild reduction of
the plasma potassium concentration;
hyponatremia may be observed.
Causes of misleading results from discrepancies in
specimen collection
Precollection
•Toilet within 30 min: water intake within 2 hours.
•Smoking
•Physical activity
•Drug or dietary supplement within 8 hours.
During Collection
•Time (Diurnal variance)
•Posture
•Hemo-concentration from prolonged tourniquet pressure
•Excessive negative pressure in syringe
•Incorrect type of tube
•Capillary versus venous blood
Handling of specimen
•Insufficient of excess anticoagulant
•Mixing of blood
•Specimen identification
•Specimen storage
•Delay in transit to laboratory
 Biochemical test results are usually compared to a
reference range considered to represent the normal
healthy state of the specific population.
Reference ranges
• Biochemical test results are usually compared to a reference range
considered to represent the normal healthy state.
• Most reference ranges are chosen randomly to include 95% of the
values found in healthy volunteers  by definition 5%, of the
population will have a result out of reference range.

• Practically, there are no

rigid limits to separate
the diseased population
from the healthy.
• The further a result is
from the limits of the
range, the more likely it is
to represent pathology.
The End