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DAY 4: LIVER FUNCTION and ENZYMOLOGY

Questions Notes
Liver Function

1. Which of the following may be used to evaluate the synthetic function of the liver?
1. Total protein
2. Prothrombin time
3. Albumin
4. Gamma globulins Functions of the Liver:
1. Synthetic function
a. 1 and 3 ✓ Total protein
b. 2 and 4 ✓ Prothrombin time
c. 1, 2, and 3 ✓ Albumin
d. 1, 2, 3, and 4 ✓ Globulins (except gamma globulins)
2. Conjugation function
3. Detoxification function
✓ Drug metabolism
✓ Conjugation of bilirubin
2. Which of the following are related to the detoxification function of the liver?
✓ Formation of urea
a. Drug metabolism
4. Secretory and Excretory function
b. Conjugation of bilirubin
✓ Elevated levels of plasma conjugated bilirubin are caused by hepatic
c. Formation of urea
function defects, specifically secretory/excretory function
d. All of these
5. Storage function
3. Elevated levels of plasma conjugated bilirubin may be caused by an impairment of
which hepatic function?
a. Synthesis
b. Storage
c. Conjugation
d. Secretory/excretory

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Liver functions can be tested by:

✓ ALT
4. Which of the following enzymes would not be useful to quantify in the assessment ✓ ALP
of liver function? ✓ GGT
a. ALT ✓ Cholinesterase
b. ALP
c. GGT  CK (primarily from skeletal muscles and cardiac muscles)
d. CK
Hepatocellular markers ALT, AST,
Hepatobiliary markers ALP, GGT

5. What is the immediate precursor of bilirubin formation?

Y and Z proteins Intracellular transport of unconjugated bilirubin (B1) to the
a. Protoporphyrin
Ligandin smooth ER (site of conjugation)
b. Biliverdin
ABCC2 proteins Facilitate the secretion of conjugated bilirubin (B2) to the
c. Urobilinogen
bile canaliculi
d. Bilirubin monoglucuronide
Albumin Transports the bilirubin to the liver

Biliverdin
✓ Bilirubin precursor
6. Bilirubin is transported in the portal system, bound mainly to .
a. Y and Z proteins Uridyldiphosphoglucuronyl transferase (UDPGT)
b. Ligandin ✓ Also known as glucuronyl transferase
c. ABCC2 protein ✓ Esterifies bilirubin
d. Albumin
Urobilinogen
✓ Taken up by the portal system again
⎯ Reabsorbed by the liver
⎯ Re-excreted to form urobilin (brown color of the stool)
✓ While urobilinogen is being recirculated, a small amount may escape to the
7. What enzyme is responsible for the esterification of bilirubin? urine (explains why there is <1 EU or <1mg/dL of urobilinogen in the urine).
a. Uridyldiphosphoglucuronyl transferase ✓ A product of bilirubin catabolism reabsorbed from the intestine through the
b. Heme oxygenase portal system
c. Biliverdin reductase
d. Gamma glutamyl transferase Urobilin
✓ Breakdown product of bilirubin metabolism produced in the colon from the
oxidation of urobilinogen by microorganisms

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Urine Bilirubin Urine Urobilinogen

Pre-hepatic – 3
Hepatic (B1 and B2) –/+ 2
8. In viral hepatitis, the increase in urine urobilinogen levels can be caused by Post-hepatic 3 – (normal)
a. Failure of the enterohepatic circulation
b. Secondary renal insufficiency Viral hepatitis
c. Extrahepatic reduction of bilirubin ✓ Hepatocellular jaundice)
d. All of these ✓ Increased urine urobilinogen due to failure of the enterohepatic circulation

*Failure of hepatic uptake of recirculated urobilinogen will lead to increased urine

urobilinogen.

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9. The following describe delta bilirubin except

Delta bilirubin
a. Contributes to direct bilirubin value
✓ Contributes to direct bilirubin value
b. Reacts directly with diazotized sulfanilic acid
✓ Reacts directly with diazotized sulfanilic acid
c. B2 covalently bound to albumin
✓ B2 covalently bound to albumin
d. Associated with pre-hepatic jaundice

B1 B2
Origin Pre-hepatic Post-hepatic
10. Which of the following is NOT true about conjugated bilirubin? Structure Unconjugated Conjugated
a. Assayed in the presence of accelerator Solubility Insoluble Soluble
b. Excreted in urine Polarity Non-polar Polar
c. Elevated in obstructive jaundice Rxn with diazo reagent Indirect Direct
d. Water-soluble Appearance in urine No Yes (except delta bilirubin)
CNS Affinity Yes No
*B1 can cross the BBB and can lead to kernicterus if left untreated.
Bilirubin
11. What term refers to the yellow discoloration of the skin and sclera resulting from
severe hyperbilirubinemia? ✓ Conversion factor = 17.1
a. Kernicterus Jaundice
b. Icterus ✓ Yellow discoloration of the skin and sclera
c. Cholestasis ✓ Severe hyperbilirubinemia (>3 mg/dL)
d. Jaundice
Kernicterus Icterus
12. The clinical manifestation of jaundice develops when total bilirubin levels exceed
✓ Brain damage ✓ Yellow color of serum
a. 1.2 mg/dL
✓ Panic value = >15 mg/Dl
b. 17.0 µmol/L Cholestasis
c. 3.0 mg/dL Pre-hepatic Jaundice ✓ Decrease in bile flow
d. 20.5 µmol/L ✓ Increased B1
✓ Excessive destruction of RBCs Hepatic Combined Hyperbilirubinemia
✓ Hemolytic jaundice ✓ Increased B1 and B2
13. Which of the following types of jaundice is attributed to excessive destruction of
the red cells? Hepatic Jaundice
a. Hepatocellular ✓ Increased B1 and B2
b. Pre-hepatic ✓ Hepatocyte injury caused by alcohol, viruses, and parasites
c. Post-hepatic ✓ Impaired cellular uptake
d. Physiologic ✓ Defective conjugation
✓ Abnormal secretion of bilirubin by the liver cells

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Post-hepatic Jaundice
✓ Increased B2
✓ Failure of bile to flow to the intestine
✓ Impaired bilirubin excretion

Obstructive Jaundice
✓ Intra-hepatic cholestasis
⎯ Markedly elevated ALP and GGT
⎯ Slight elevations in ALT, LD, and total bilirubin
✓ Extra-hepatic cholestasis

↑ B1
Physiologic jaundice of the newborn
14. Which of the following is a characteristic of hemolytic jaundice? Erythroblastosis fetalis
a. B1 level greater than normal Gilbert’s syndrome
b. B2 level greater than normal Crigler-Najjar syndrome
c. Both B1 and B2 are greater than normal Hemolytic anemia
d. Both B1 and B2 are normal Hepatocellular disease
Lucey Driscoll syndrome
G6PD deficiency
↑ B2
Rotor’s syndrome
Dubin-Johnson syndrome
Pancreatic (head) cancer
Alcoholic and Viral hepatitis
Biliary atresia
Cholelithiasis (Gall stones)
Biliary obstruction (Gall stones)

15. Which of the following is the cause of physiologic jaundice of the newborn?
Physiologic jaundice of the newborn
a. ABO incompatibility
✓ Caused by transient deficiency in bilirubin conjugation
b. Failure of bilirubin secretion
⎯ Transient because it only persists for a short period of time
c. Deficiency in bilirubin conjugation
✓ Can lead to kernicterus and death of the newborn
d. Stricture of the common bile duct

16. Which of the following syndromes are characterized by unconjugated

hyperbilirubinemia? ↑ B1 ↑ B2
1. Rotor Physiologic jaundice of the newborn Rotor’s syndrome
2. Crigler-Najjar Erythroblastosis fetalis Dubin-Johnson syndrome
3. Dubin-Johnson Gilbert’s syndrome Pancreatic (head) cancer
4. Gilbert Crigler-Najjar syndrome Alcoholic and Viral hepatitis
Hemolytic anemia Biliary atresia
a. 1 and 3 Hepatocellular disease Cholelithiasis (Gall stones)
b. 2 and 4 Lucey Driscoll syndrome Biliary obstruction (Gall stones)
c. 1, 2, and 3 G6PD deficiency
d. 1, 2, 3, and 4

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17. Which of the following hereditary diseases of bilirubin metabolism is considered

the most serious and life threatening?
a. Dubin-Johnson Crigler-Najjar syndrome
b. Gilbert ✓ Serious and life-threatening disease because levels exceed kernicterus
c. Rotor
d. Crigler-Najjar Dubin-Johnson syndrome
✓ Caused by failure of bilirubin secretion
18. Which of the following disorders is characterized by an inability to transport
✓ Dark-stained granules in the liver biopsy
bilirubin from the sinusoidal membrane into the hepatocyte?
✓ ↑ B2 =↑ Urine bilirubin
a. Gilbert syndrome
b. Carcinoma of the bile duct
Rotor syndrome
c. Dubin-Johnson syndrome
✓ Cytosolic inclusion bodies in biopsy
d. Crigler-Najjar syndrome

19. Which of the following does NOT characterize Dubin-Johnson syndrome? Gilbert syndrome
a. Failure of bilirubin secretion ✓ Transport defect and mild USPGT deficiency
b. Dark-stained granules in liver biopsy ✓ Inability to transport bilirubin from sinusoidal membrane into the hepatocyte
c. Cytosolic inclusion bodies
d. Elevated urine bilirubin

↑ B1 ↑ B2
Physiologic jaundice of the newborn Rotor’s syndrome
20. In which of the following disease states is conjugated bilirubin a major serum
Erythroblastosis fetalis Dubin-Johnson syndrome
component?
Gilbert’s syndrome Pancreatic (head) cancer
a. Cholelithiasis
Crigler-Najjar syndrome Alcoholic and Viral hepatitis
b. Hemolysis
Hemolytic anemia Biliary atresia
c. Neonatal jaundice
Hepatocellular disease Cholelithiasis (Gall stones)
d. Erythroblastosis fetalis
Lucey Driscoll syndrome Biliary obstruction (Gall stones)
G6PD deficiency

21. Which of the following is not consistent with biliary obstruction?

a. Increased ALP and GGT
Biliary Obstruction has normal TP, albumin, ALT, and AST with increased ALP,
b. Normal TP and albumin
GGT, and urine bilirubin.
c. Negative urine bilirubin
d. Normal ALT and AST

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In the small intestine, urobilinogen is formed through the enzymatic reduction

process of anaerobic bacteria on bilirubin.
22. What reduction product of bilirubin catabolism is reabsorbed from the intestine
through the portal system? The fate of urobilinogen is such that some of the urobilinogen will be excreted
a. Urobilinogen unchanged in the stool, a portion will be oxidized to urobilin for excretion in the
b. Biliverdin stool, and up to 20% will be absorbed from the intestine into the portal
c. Urobilin circulation.
d. Bilirubin glucuronide
This circulating urobilinogen is almost completely picked up by the liver, with only
a small amount excreted in the urine.

23. What breakdown product of bilirubin metabolism is produced in the colon from
the oxidation of urobilinogen by microorganisms?
a. Stercobilinogen In the colon, a portion of the urobilinogen is oxidized by microorganisms to
b. Porphobilinogen urobilin, which is excreted in the feces as an orange-brown pigment.
c. Urobilin
d. Uroporphyrin
24. Which statement below regarding serum bilirubin determination is true?
a. Total bilirubin is a more sensitive marker of hepatobiliary disease than the
direct level. Direct bilirubin cannot be hydrolyzed back to indirect bilirubin as the only path is
b. Total bilirubin level often exceeds 50 µmol/L in hemolytic anemia. unconjugated bilirubin to conjugated bilirubin.
c. Direct bilirubin level is elevated in most necrotic and cholestatic diseases.
d. Some direct bilirubin may be hydrolyzed back to indirect bilirubin.
25. In bilirubin determination, the purpose of adding concentrated caffeine solution or
methanol is to:
a. Allow indirect bilirubin to react with the reagent
b. Dissolve conjugated bilirubin Accelerators or Solubilizers
c. Precipitate proteins ✓ Used to allow unconjugated bilirubin to react with the diazo reagent
d. Prevent any change in pH
26. What is the accelerator used in Jendrassik-Grof method? Caffeine sodium benzoate (Jendrassik-Groff)
a. Methanol 50% methanol (Evelyn Malloy)
b. Caffeine
c. Sodium acetate
d. Alkaline tartrate buffer

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27. What is the SI unit for bilirubin?

a. mg/dL
mg/dL for Conventional
b. mEq/L
µmol/L for SI
c. µmol/L
d. mmol/L
28. If the total bilirubin is 3.1 mg/dL and the conjugated bilirubin is 2 mg/dL, the Unconjugated bilirubin + Conjugated bilirubin = Total bilirubin
unconjugated bilirubin concentration is: (0.2-0.8) (0-0.2) (0.2-1.0)
a. 8.5 µmol/L
b. 1.1 mg/dL Total bilirubin – Conjugated bilirubin = Unconjugated bilirubin
c. 2.2 mg/dL 3.1 mg/dL – 2 mg/dL = Unconjugated bilirubin
d. 31.1 µmol/L 3.1 mg/dL – 2 mg/dL = 1.1 mg/dL

Enzymes

29. The majority of clinically important enzymes perform their catalytic functions
primarily in the
a. Plasma
b. CSF
c. Interstitial fluid
d. Intracellular environment

Causes of Increased Serum Enzyme Levels

30. What does an increase in the serum enzyme levels usually indicate?
Impaired removal of enzyme from plasma
a. Decreased enzyme catabolism
Tissue necrosis and degradation
b. Accelerated enzyme production
Increased permeability of cell membrane
c. Tissue damage and necrosis
d. Increased glomerular filtration rate
Decrease in enzyme activity as reaction takes place.
31. Enzymes are primarily classified based on:
a. Nature of product formed
b. Type of reaction catalyzed EC Class Function Examples
c. Substrate requirements 1 Oxidoreductases Catalyze the removal or addition CO, LDH, MDH,
d. Coenzyme requirements of electrons (redox reaction) ICD, G6PD
2 Transferases Catalyze the transfer of a CK, PK, AST, ALT,
32. What is the enzyme classification of LDH and G-6-PD?
chemical group other than OCT, GGT
a. Oxidoreductases
hydrogen from one substrate to
b. Transferases
another
c. Hydrolases
Transfer of functional groups
d. Lyases

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3 Hydrolases Catalyze hydrolysis or splitting of Esterases:

a bond by the addition of water ACP, ALP, CHS, LPS
(hydrolytic reactions)
Peptidases:
Trypsin, Pepsin,
LAP

33. Which of the following is NOT a transferase? Glycosidase:

a. GGT Galactosidase,
b. ALT AMS
c. PK
d. 5’NT Cholinesterase,
Chymotrypsin,
Elastase-1,
5-Nucleotidase

4 Lyases Catalyze removal of groups from Glutamate

substrates without hydrolysis decarboxylase,
The product contains double pyruvate
bonds. decarboxylase,
tryptophan
decarboxylase,
aldolase
5 Isomerase Catalyze the intramolecular Glucose
34. The following are hydrolases EXCEPT: arrangement of the substrate phosphate
a. Trypsin compound. Catalyze the isomerase, ribose
b. Lyase interconversion of isomers. phosphate
c. Acid phosphatase isomerase
d. Cholinesterase 6 Ligases Catalyze the joining of two Synthase
substrate molecules, coupled with
breaking of the pyrophosphate
bond in ATP or similar compound.

*GGT is a type of transpeptidase.

35. When [S] = Km, the velocity of the enzyme-catalyzed reaction is expressed as:
a. 2Vmax Michaelis-Menten Formula
b. Vmax V = Vmax [S]/Km + [S]
c. Vmax/2 Km = [S] at 1/2 Vmax or Vmax/2
d. 1/Vmax

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Lineweaver-Burk Plot
36. The y-intercept in the Lineweaver-Burk plot is:
1/v = Km/Vmax x 1/[S] +1/Vmax
a. 1/Vmax
b. Km/Vmax
✓ Double reciprocal plot of Michaelis-Menten equation.
c. -1/Km
✓ Y-intercept = 1/Vmax
d. 1/[S]
✓ X-intercept = -1/Km
37. Which of the following represents an enzyme’s catalytic mechanism?
a. E + S → ES → E + P
b. E + P → EP → E + S
c. E + S + P → ESP
d. ESP → E + S + P
38. Which of the following is true about an enzyme-catalyzed reaction under first-
1st order (Reaction rate is directly proportional to substrate concentration)
order kinetics?
[E] > [S] — the more the substrate is added, the faster the reaction
a. [S] > [E]
b. [E] > [S]
Zero order (Reaction rate depends only on enzyme concentration)
c. [S] = [E]
[S] > [E]
d. [S] > [P]
Fixed-time/Endpoint
39. Which of the following methods involves multiple measurements of absorbance
✓ Addition of weak acid to stop the reaction at designated time before enzyme
change as a function of time?
activity is measured.
a. Fixed-time
b. Endpoint
Kinetic
c. Kinetic
✓ Measurement of absorbance change at specific time intervals or continuous
d. None of these
monitoring.
40. In the laboratory, enzyme activity may be measured by determining all of the
Enzymes are primarily classified according to their type of reaction catalyzed and
following EXCEPT:
measured according to:
a. Amount of product liberated
✓ Amount of product liberated
b. Degree of NADH consumption
✓ Degree of NADH consumption
c. Change in substrate concentration
✓ Change in substrate concentration
d. Decrease in enzyme concentration as a function of time
41. Which of the following represents the amount of enzyme that catalyzes the
reaction of 1 µmol of substrate per minute? International Unit (IU) Katal Unit (K/U)
a. IU ✓ 1 µmol/min ✓ 1 mol/sec
b. mU ✓ 1 micromole of substrate per min ✓ 1 molecule of substrate per second
c. Katal
d. µkatal

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42. Convert 18 U/L to µkat/L.

U/L to µkat/L = 0.0167
a. 0.03
U/L to nkat/L = 16.7
b. 0.3
c. 3.0
18 U/L x 0.0167 = 0.3 µkat/L
d. 300
43. Most enzyme-catalyzed reactions occur in the pH range of:
7-8 pH is where most enzyme catalyzation reaction happens.
a. 4-5
b. 5-6
ACP at 4.5 pH (acidification)
c. 7-8
ALP at 9-10 pH
d. 9-10
44. For each 10 °C increase in temperature, the rate of the reaction:
a. Decreases by half
b. Increases by 10%
c. Increases 10x
d. Increases 2x
45. Use of higher temperature in an enzyme assay generally improves:
a. Accuracy Use of higher temperature in an enzyme assay generally improves sensitivity
b. Precision (because of the doubling to catalysis) while isoenzyme assays are performed to
c. Sensitivity improve specificity.
d. Specificity
46. The denaturation point for most clinically important enzymes is at:
a. 40–60°C
Denaturation point is 40-50°C
b. 25–35°C
Inactivation is 60-65°C.
c. 100°C
d. 37°C
47. Nonprotein entities that must bind to particular enzymes before a reaction occurs Cofactors are nonprotein entities that bind to particular enzymes before a
are called: reaction.
a. Prosthetic groups
b. Apoenzymes Coenzymes are organic compounds that serve as second substrates.
c. Cofactors ✓ ↑ coenzyme concentration = ↑ velocity of an enzymatic reaction
d. Inhibitors ✓ NAD(P) and NAD(P)H

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48. Which of the following may serve as second substrates for enzymatic reactions?
a. Activators Activators are inorganic ions that alter the spatial configuration of the enzyme for
b. Apoenzymes proper substrate binding.
c. Coenzymes ✓ K+, Zn2+, Cl-, Mg2+, Ca2+, and Mn2+.
d. Inhibitors ✓ Phosphate is not an activator.
✓ ALP needs activators like magnesium and zinc.
49. The protein portion of an enzyme with a prosthetic group is called the: ✓ PK, CK, and Kinases need magnesium.
a. Apoenzyme ✓ AMS need chloride and calcium (needed in amylase catalyzed reaction).
b. Coenzyme
c. Holoenzyme Apoenzyme (protein portion of an enzyme) + Prosthetic group = Holoenzyme
d. Proenzyme

50. Samples from patients with vitamin B6 deficiency may have decreased levels of:
NAD(P)/NADP(H) are coenzymes required by oxidoreductases while Vitamin B6 or
a. CK
pyridoxal phosphate is the coenzyme required by aminotransferases (AST and ALT).
b. SGOT
c. LD
Vitamin B6 deficiency has decreased levels of SGOT (AST) and SGPT (ALT).
d. amylase

51. Inorganic cofactors include the following EXCEPT: Mg++ Zn++

a. Ca2+
Fe++/Fe+++ Cu+/Cu++
b. Mn2+ Inorganic factors
Ca++ Co++
c. Zn2+
d. PO42- Mn++

52. Which of the following types of inhibitors binds to allosteric sites causing a change
in the enzyme’s conformation?
a. Competitive
b. Non-competitive
c. Uncompetitive
d. None of these

53. Competitive inhibition may be reversed by:

Competitive inhibition may be reversed by increasing the substrate concentration
a. Increasing the substrate concentration
or through dilution of sample.
b. Increasing the sample volume
c. Decreasing the reagent concentration
Non-competitive inhibition reaction cannot be reversed.
d. Performing a kinetic assay

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54. Increasing the substrate concentration will increase inhibition.

a. Competitive
b. Non-competitive
c. Uncompetitive
d. End product

Macroenzymes/Macroforms are enzymes bound to high molecular weight

55. Enzymes with macroforms include the following EXCEPT: substances which would be immunoglobulin of non-immunoglobulin.
a. Amylase ✓ Has 2 types:
b. CK 1. Type 1 — bound to immunoglobulin.
c. GGT 2. Type2 — bound to non- immunoglobulins.
d. G6PD ✓ Enzymes with macroenzymes include ACP, ALP, AST, ALT, LDH, and LPS.
✓ G6PD has no macroforms.

Enzyme markers
✓ AST (normalizes within 4-5 days)
56. Which cardiac enzyme produces the longest plasma elevation following myocardial
✓ CK-MB (highest elevation and most useful marker; normalizes within 2-3 days)
infarction?
✓ LD (longest sustained duration of elevation; normalizes within 10 days)
a. AST
✓ Total CK (non-specific as the large part of this would be CK-MM)
b. CK-MB
c. LD
Non-enzyme markers
d. Total CK
✓ Myoglobin (negative predictor of MI)
✓ Troponin (standard marker for MI)

57. Which of the following is the most abundant CK isoenzyme found in striated CK isoforms
muscle and normal serum? ✓ CK1 (CK-BB)
a. CK1 ⎯ bound to immunoglobulin,
b. CK2 ⎯ fastest and most anodal
c. CK3 ⎯ most labile among the three
d. Macro-CK ✓ CK2 (CK-MB) — <6%
✓ Macro CK
58. Which is the most labile CK isoenzyme? ✓ CK3 (CK-MM)
a. CK-BB ⎯ 94-100% of serum total CK
b. CK-MB ⎯ least anodal, slowest and near origin
c. CK-MM ⎯ most abundant isoenzyme in striated muscle and normal in serum
d. CK-Mi ✓ Mi — mitochondrial CK that migrates to the cathode

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Pronounced CK elevations (>5x ULN)

59. The following are characterized by pronounced CK elevation EXCEPT:
✓ Duchenne’s muscular dystrophy — produces the highest serum CK elevations
a. Duchenne’s muscular dystrophy
✓ Polymyositis/Dermatomyositis
b. Polymyositis
✓ Myocardial infarction
c. Myocardial infarction
d. Pulmonary infarction
 Mild to moderate CK elevation (2-4x ULN) for pulmonary infarction.

60. A slow cathodic peak and an intermediate peak in CK isoenzyme fractionation are
consistent with
a. Muscular dystrophy
CK-MM
b. Viral hepatitis
c. Brain tumor
d. Myocardial infarction

61. Which of the following statements concerning creatine kinase is false?

Creatine Kinase
a. Rises within 4-6 hours after AMI
✓ Increases within 4-6 hours, peaks at 12-24 hours; normalizes within 2-3 days
b. Catalyzes the phosphorylation of creatine by ATP
✓ Catalyzes the phosphorylation of creatine by ATP
c. Requires Zn2+ for optimal activity
✓ Found mainly in muscle, brain tissues, skeletal and cardiac muscles
d. Found mainly in muscle and brain tissues

CREATINE KINASE
62. In the reverse CK method, which enzymes are used in the coupling reactions?
Methods Coupling Enzymes
a. Hexokinase, G-6-PD
Tanzer-Gilvarg/Forward PK & LD
b. PK, LD
(Decrease in absorbance at 340 nm)
c. Hexokinase, LD
Oliver-Rosalki/Reverse Hexokinase & G-6-PD
d. PK, G-6-PD
(Increase in absorbance at 340 nm)
63. Which enzyme is least useful in differentiating necrotic from obstructive jaundice? ✓ GGT
markers for obstructive jaundice
a. GGT ✓ 5’Nucleotidase
b. LD ✓ ALT is very specific marker for hepatocellular damage of necrotic liver disease.
c. 5’ Nucleotidase
d. ALT  LD is the least useful even though it is produced in the liver; it is non-specific.

64. Which of the following is a common cause of falsely elevated LD1 level? LD1 is abundant in RBCs, heart muscles, and kidneys (renal cortex). Therefore, it
a. Liver disease is falsely elevated in sample hemolysis.
b. Drug toxicity
c. Use of EDTA blood Hemolysis causes false increased results in AST, ACP, CK, LD, and ALP.
d. Sample hemolysis For lipase, it causes false decrease results.

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In normal serum, LD2>LD1345.

65. What is the most abundant LD isoenzyme in normal serum?
a. LD1 Flipped pattern = LD1>LD2345:
b. LD2 ✓ MI
c. LD3 ✓ Hemolytic anemia
d. LD4 ✓ Renal Infarction
✓ Intramedullary destruction of RBCs (pernicious and megaloblastic anemia)

LD isoenzyme % of Total LD
LD1 17-27%
LD2 27-37%
LD3 18-25%
LD4 3-8%
66. Which is the most cold-labile LD isoenzyme? LD5 0-5%
a. LD2
b. LD3 The most cold-labile LD isoenzyme is LD5.
c. LD4
d. LD5 LD6
✓ Alcohol dehydrogenase isoenzyme
✓ 6th band in the electrophoresis
✓ Elevated in drug hepatoxicity and obstructive jaundice
✓ Metabolic conversion of methanol and ethylene glycol to toxic compounds
✓ Present in patients with arteriosclerotic failure
✓ This isoenzyme is atherosclerotic
Wacker/Forward LD
67. Which of the following is measured to assess LD activity using the Wacker method? ✓ Lactate + NAD —LD→ Pyruvate + NADH
a. Color intensity produced by pyruvate ✓ Increase in absorbance of NADH at 340 nm
b. Color intensity produced by NADH
c. Increase in absorbance of NADH at 340 nm Wrobleuski-Ladue/Reverse
d. Decrease in absorbance of NAD at 340 nm ✓ Pyruvate + NADH —LD→ Lactate + NAD
✓ Decrease in absorbance of NAD at 340 nm
68. Which of the following is NOT associated with pronounced AST elevation?
a. Acute hepatocellular disorders
Hepatocellular markers ALT, AST
b. Circulatory collapse
Hepatobiliary markers ALP, GGT
c. Myocardial infarction
d. Biliary obstruction

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Isoforms
✓ CK
✓ ALP (increased serum ALP = pregnant women and growing children)
69. Which of the following enzymes does not have isoforms? ✓ Amylase
a. CK ✓ AST
b. ALT ⎯ Cytoplasmic
c. ALP ⎯ Mitochondrial.
d. Amylase ▪ Increased in alcoholic liver disease
▪ DeRitis ratio of >3 (AST/ALT ratio)
▪ It has a long half-life
▪ Not easily removed from the body
70. In the Reitman-Frankel method, the quantitation of enzyme activity is based on the
a. Reaction of 2,4-DNPH with an amine Reitman-Frankel method is used for AST and ALT.
b. Increase in absorbance of NADH at 340 nm The quantitation of enzyme activity is based on the reaction of 2,4-DNPH with a
c. Reaction of 2,4-DNPH with a ketoacid ketoacid.
d. Decrease in absorbance of NAD at 340 nm
71. The coupling enzymes in the Karmen method for transaminases are classified
under which class?
a. Hydrolases
MDH and LDH
b. Lyases
c. Oxidoreductases
d. Transferases
AST Karmen Method
72. Malate dehydrogenase is added to the AST assay to catalyze the conversion of ✓ Aspartate + α-ketoglutarate —AST→ Oxaloacetate + Glutamate
a. α-ketoglutarate to aspartate ✓ Oxaloacetate + NADH —MDH→ Malate + NAD
b. α-ketoglutarate to malate
c. Aspartate to oxaloacetate ALT Karmen Method
d. Oxaloacetate to malate ✓ Alanine + α-ketoglutarate —ALT→ Pyruvate + Glutamate
✓ Pyruvate + NADH —LDH→ Lactate + NAD
73. Marked increase in aminotransferases and slight increase in ALP and GGT are most
consistent with:
a. Acute hepatitis
Aminotransferases = AST, ALT
b. Alcoholic liver disease
c. Biliary obstruction
d. Hepatic tumor

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74. Based on the following serum test results, what is the most likely diagnosis? ALP-
markedly elevated, ALT-slightly elevated, LD-slightly elevated, GGT-markedly If ALP is elevated, it could either be because of problems with liver and bone.
elevated, total bilirubin-slightly elevated It can be specified through testing with GGT.
a. Alcoholic cirrhosis
b. Bone disease ↑ ALP and ↑ GGT — Liver
c. Viral hepatitis ↑ ALP and Normal GGT — Bone
d. Intrahepatic cholestasis

75. Which of the following is a true statement concerning serum enzymes?

a. Hemolysis is of no significance for an accurate assay of most serum enzymes.
b. Serum AST but not serum LD, is usually elevated in acute myocardial infarction.
Hemolysis and diet/fat molecules are sources of analytical errors; elevated serum ALP.
c. Increased serum ALP may be found in pregnant women and growing children.
d. Aspartate transaminase was formerly known as glutamate pyruvate
transaminase

76. Given the following results, what is the most likely diagnosis? ALP-markedly
increased, GGT-normal
a. Biliary obstruction ↑ ALP and ↑ GGT — Liver
b. Cirrhosis ↑ ALP and Normal GGT — Bone
c. Hepatitis
d. Osteitis deformans

77. Which of the following enzyme assays is subject to end product inhibition by
ALP assays are prone to end product inhibition which is why it needs a reagent to
inorganic phosphorus?
block this from happening.
a. Forward LD
b. Reverse CK
The reagent buffer is the AMP buffer or the 2-amino-2-methyl-1-propanol and this
c. GGT
prevents inorganic phosphorus inhibition on ALP.
d. ALP
78. Isoenzyme assays are performed to improve:
a. Accuracy
b. Precision
c. Sensitivity
d. Specificity

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ALP Isoenzymes:
79. When ALP isoenzymes are electrophoresed, the order from cathode to anode is: From most anodal to least anodal
a. Intestinal, bone, placental, liver 1. Liver
b. Liver, bone, placental, intestinal 2. Bone
c. Placental, intestinal, liver, bone 3. Placental
d. Intestinal, placental, bone, liver 4. Intestinal

80. Which of the following isoenzymes of ALP will retain its activity after heating at Heat Stability in decreasing order
65°C for 10 min? 1. Placental
a. Pancreatic 2. Intestinal
b. Liver 3. Liver
c. Bone 4. Bone — most heat labile
d. Regan * Heat stability test is performed at 56°C for 10-15 mins.

81. Which ALP isoenzyme is most likely present if less than 20% activity remains after Regan ALP
heating serum to 56°C for 10 minutes? ✓ Lung, breast, ovarian, and gynecological cancers
a. Liver ✓ bone ALP co-migrator
b. Bone ✓ most heat stable ALP (65°C for 10 minutes)
c. Intestinal ✓ inhibited by phenylalanine reagent
d. Placental
Nagao ALP
✓ Adenocarcinoma of the pancreas and bile duct, pleural cancer
82. The intestinal and placental isoenzymes of ALP are both strongly inhibited by ✓ variant of Regan
a. L-leucine ✓ inhibited by L-leucine and phenylalanine
b. Phenylalanine ✓ 56°C for 10-15 minutes
c. Urea
d. Levamisole Phenylalanine inhibits placental and intestinal ALP.
3M Urea inhibits bone ALP.
Levamisole inhibits liver and bone ALP.
83. Individuals who have B or O blood group and are secretors are more likely to have
which ALP fraction?
a. Liver B or O blood types have increased intestinal ALP.
b. Bone After consumption of fatty meals also cause increased intestinal ALP.
c. Intestinal
d. Placental

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84. The Kasahara ALP isoform is associated with tumors involving the:
a. Lungs and pancreas
b. Breast and ovaries
c. Pleural surfaces
d. Liver and GI tract
Bowers-McComb assay
85. What is the substrate used in the Bowers-McComb assay?
✓ Reference method for ALP
a. α-naphthylphosphate
✓ Reagent is PNPP
b. β-glycerophosphate
✓ Principle is spectrophotometric
c. phenylphosphate
d. p-nitrophenylphosphate
Bowers and McComb (Szasz modification) — IFCC recommended method
86. Which of the following enzyme assays requires freezing or acidification of the
specimen in case of delay in the analysis?
a. LD
b. ACP
c. amylase
d. GGT
87. Thymolphthalein monophosphate is most specific for which isoform of ACP?
a. Erythrocyte
b. Prostatic
c. Platelet
d. Bone
88. Compared to ACP, PSA is:
1. Tissue-specific
2. Cancer-sensitive
3. Cancer-specific
PSA is tissue-specific and cancer-sensitive.
a. 1 and 2
b. 2 and 3
c. 1 and 3
d. 1, 2, and 3
89. Which of the following enzymes is normally present in urine?
a. Amylase
b. CK Amylase is normally present in the urine (1-15 IU/hr).
c. AST
d. Lipase

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90. Which of the following sets of results would be consistent with macroamylasemia?
a. Normal serum AMS, ↑ urine AMS
b. ↑ serum AMS, normal urine AMS
c. ↑ serum AMS, ↑ urine AMS
d. Normal serum AMS, normal urine AMS

91. Which amylase assay method measures the disappearance of the starch substrate? Saccharogenic
a. Saccharogenic ✓ Reference method for monitoring ↑ reducing agents or reducing sugars
b. Chromogenic ✓ Measures the product formed
c. Amyloclastic
d. Coupled-enzymatic Chromogenic
✓ Measuring the ↑ in color intensity of the soluble dye substrate complex
*They start in complex bound to each other dye substrate. But as the amylase acts
on the substrate, the dye becomes soluble and the dye is released producing
colors. The increase in color is measured spectrophotometrically.
92. The saccharogenic method for amylase determinations measures the amount of:
a. Substrate consumed
Amyloclastic
b. Iodine present
✓ Amylase assay method
c. Starch present
✓ Measures the disappearance of the starch substrate
d. Product formed
*Decreased in color in starch iodine-complex. As long as the starch remains intact,
it will be bound to iodine producing dark blue or black color. As the starch is
hydrolyzed, there will be a proportional disappearance in color intensity.
93. Compared to AMS, LPS has:
1. Greater specificity
2. Longer half-life
Lipase
3. More sustained elevation
✓ Greater specificity
✓ Longer half-life
a. 1 and 2
✓ More sustained elevation
b. 2 and 3
c. 1 and 3
d. 1, 2, and 3
94. Which of the following enzymes will be falsely low on a hemolyzed specimen? Lipase
a. CK ✓ Falsely low on a hemolyzed specimen
b. ALP ✓ Involves monitoring the decrease in turbidity or light scatter as the substrate
c. lipase is hydrolyzed
d. ALT

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95. Which of the following enzyme assays involves monitoring the decrease in turbidity
or light scatter as the substrate is hydrolyzed?
a. Lipase
b. Amylase
c. GGT
d. 5’NT
96. If a peroxidase-coupled reaction is used in the Cherry-Crandall assay, which Cherry-Crandall assay
reaction product is actually estimated? ✓ Similar to Triglyceride assay
a. NADH ✓ TG + H2O —LPS→ Glycerol + 3FAs
b. Fatty acids
c. Glycerol Glycerol is estimated while the 3FAs is titrated.
d. Triolein Triglyceride reagent include triolein and olive oil.
97. Which of the following enzymes will be falsely elevated following intake of
antiepileptic drugs? GGT is falsely elevated following intake of:
a. Amylase ✓ Anti-epileptic drugs
b. GGT ✓ Anticoagulant drugs (Warfarin therapy) microsomal induction of GGT
c. ALP ✓ Alcohol
d. LD
98. What is the required specimen for G-6-PD assay?
a. Heparinized plasma
G-6-PD assay = confirm G6PD deficiency = EDTA whole blood
b. Serum
= screen (newborns) = capillary blood spots from heel stick
c. 24-hour urine
d. EDTA whole blood
99. Which of the following statements is not associated with pseudocholinesterase? Pseudocholinesterase
a. Inhibited by organic insecticides ✓ Inhibited by organic insecticides
b. Erythrocytes are the primary tissue source ✓ Liver is the primary tissue source
c. Levels are normally high in serum ✓ Levels are normally high in serum
d. Acts on the substrate propionylthiocholine ✓ Acts on the substrate propionylthiocholine

100. The best confirmatory tests for skeletal muscle disease would be:
a. CK and GLDH
Both are abundant in the skeletal muscles.
b. GGT and ALP
*CK-MM (94-100%)
c. Aldolase and CK
d. LD and MDH

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