MTAP - SEMR421

PROF. LARA MELISA OLGUERA, RMT, DTA, pHIV, MSMT (c)

SEPTEMBER 10, 2022
TOPIC: ENZYMES
--Enzymes catalyze many specific physiologic reactions. These reactions
are facilitated by the enzyme structure and several other factors.
--As a protein, each enzyme contains a specific amino acid sequence
(primary structure), with the resultant polypeptide chains twisting
(secondary structure), which then folds (tertiary structure) and results in
structural cavities.
--If an enzyme contains more than one polypeptide unit, the quaternary
structure refers to the spatial relationships between the subunits.
--Each enzyme contains an active site, often a water-free cavity, where
the substance on which the enzyme acts (the substrate) interacts with
particular charged amino acid residues.
--An allosteric site—a cavity other than the active site—may bind
regulator molecules and, thereby, be significant to the basic enzyme
--The ES complex is a physical binding of a substrate to the active site of
structure.
an enzyme.
--In addition to naming enzymes, the IUB system identifies each enzyme
--The structural arrangement of amino acid residues within the enzyme
by an EC numerical code containing four digits separated by decimal
makes the three-dimensional active site available.
points. The first digit places the enzyme in one of the following six
--At times, the binding of ligand drives a rearrangement to make the
classes:
active site. The transition state for the ES complex has lower energy of
activation than the transition state of S alone, so that the reaction
proceeds after the complex is formed. An actual reaction may involve
several substrates and products.
Factors That Influence Enzymatic Reactions
Substrate Concentration
--The reaction rate steadily increases when more substrate is added, with
the amount of enzyme exceeding the amount of substrate.
--When this occurs, the reaction is following first-order kinetics because
the reaction rate is directly proportional to substrate concentration.
--Eventually, when the substrate concentration is high enough to saturate
all available enzyme, the reaction velocity has reached its maximum.
--When product is formed, the resultant free enzyme immediately
combines with excess free substrate. The reaction is in
zero-order kinetics, and the reaction rate depends only on enzyme
concentration.

--The Michaelis-Menten constant (Km), derived from the theory of

Michaelis and Menten, is a constant for a specific enzyme and substrate
under defined reaction conditions and is an expression of the
relationship between the velocity of an enzymatic reaction and substrate
concentration.
--The assumptions are made that equilibrium among E, S, ES, and P is
established rapidly and that the E + P→ ES reaction is negligible. The
rate-limiting step is the formation of product and enzyme from the ES
complex.
--Then, maximum velocity is fixed, and the reaction rate is a function of
only the enzyme concentration. Km is specifically the substrate
concentration at which the enzyme yields half the possible maximum
velocity.
--Therefore, Km indicates the amount of substrate needed for a particular
enzymatic reaction.
Enzyme Concentration
--Because enzymes catalyze physiologic reactions, the enzyme
concentration affects the rate of the catalyzed reaction.
--As long as the substrate concentration exceeds the enzyme
concentration, the velocity of the reaction is proportional to the enzyme
concentration.
--The higher the enzyme level, the faster the reaction will proceed
because more enzyme is present to bind with the substrate.

This material was developed for students enrolled in MTAP/SEMR421. Our Lady of Fatima University-Quezon City – College of Medical Laboratory Science, August 2022. The
information in this material is solely intended for educational purposes only and does not guarantee accuracy, completeness, or timeliness and without any warranties
implicated. SUPPLEMENTARY NOTES ONLY; PLEASE REFER TO YOUR BOOKS. Obtain permission prior to use. For questions and corrections: Lara Melisa R. Olguera, RMT,
MSMT© | lrolguera@fatima.edu.ph.
 pH --One of two general methods may be used to measure the extent of an
--Enzymes are proteins that carry net molecular charges. Changes in pH enzymatic reaction:
may denature an enzyme or influence its ionic state, resulting in (1) fixed-time
structural changes or a change in the charge on an amino acid residue in (2) continuous monitoring or kinetic assay
the active site. --In the fixed-time method, the reactants are combined, the reaction
--Hence, each enzyme operates within a specific pH range and maximally proceeds for a designated time, the reaction is stopped (usually by
at a specific pH. inactivating the enzyme with a weak acid), and a measurement is made of
--Most physiologic enzymatic reactions occur in the pH range of 7.0 to the amount of reaction that has occurred.
8.0, but some enzymes are active in wider pH ranges than others. --The reaction is assumed to be linear over the reaction time; the larger
--In the laboratory, the pH for a reaction is carefully controlled at the the reaction, the more enzyme is present.
optimal pH by means of appropriate buffer solutions. Enzymes as Reagents
Temperature --Immobilized enzymes are chemically bonded to adsorbents, such as
--Increasing temperature usually increases the rate of a chemical reaction agarose or certain types of cellulose, by azide groups, diazo, and
by increasing the movement of molecules, the rate at which triazine.
intermolecular collisions occur, and the energy available for the reaction. --The enzymes act as recoverable reagents. When substrate is passed
--This is the case with enzymatic reactions until the temperature is high through the preparation, the product is retrieved and analyzed, and the
enough to denature the protein composition of the enzyme. enzyme is present and free to react with more substrate. Immobilized
--For each 10 degree increase in temperature, the rate of the reaction enzymes are convenient for batch analyses and are more stable than
will approximately double until, of course, the protein is denatured. enzymes in a solution.
--Each enzyme functions optimally at a particular temperature, which is --Enzymes are also commonly used as reagents in competitive and
influenced by other reaction variables, especially the total time for the noncompetitive immunoassays, such as those used to measure human
reaction. immunodeficiency virus (HIV) antibodies, therapeutic drugs, and cancer
--The optimal temperature is usually close to that of the physiologic antigens.
environment of the enzyme; however, some denaturation may occur at →Commonly used enzymes include horseradish peroxidase, alkaline
the human physiologic temperature of 37°C. phosphatase (ALP), glucose-6-phosphate dehydrogenase, and β
--The rate of denaturation increases as the temperature increases and is galactosidase.
usually significant at 40°C to 50°C. →The enzyme in these assays functions as an indicator that reflects
Cofactors either the presence or absence of the analyte.
--Cofactors are nonprotein entities that must bind to particular enzymes
before a reaction occurs.
--Common activators (inorganic cofactors) are metallic (Ca2+, Fe2+,
Mg2+, Mn2+, Zn2+, and K+) and nonmetallic (Br− and Cl−).
--The activator may be essential for the reaction or may only enhance the
reaction rate in proportion with concentration to the point at which the
excess activator begins to inhibit the reaction.
--Activators function by alternating the spatial configuration
of the enzyme for proper substrate binding, linking substrate to the
enzyme or coenzyme, or undergoing oxidation or reduction.
Inhibitors
--Competitive inhibitors physically bind to the active site of an enzyme
and compete with the substrate for the active site.
→With a substrate concentration significantly higher than the
concentration of the inhibitor, the inhibition is reversible because the
substrate is more likely than the inhibitor to bind the active site and the
enzyme has not been destroyed.
--A noncompetitive inhibitor binds an enzyme at a place other than the
active site and may be reversible in the respect that some naturally
present metabolic substances combine reversibly with certain enzymes.
→Noncompetitive inhibition also may be irreversible if the inhibitor
destroys part of the enzyme involved in catalytic activity.
→Because the inhibitor binds the enzyme independently from the
substrate, increasing substrate concentration does not reverse the
inhibition.
--Uncompetitive inhibition is another kind of inhibition in which the
inhibitor binds to the ES complex—increasing substrate concentration
results in more ES complexes to which the inhibitor binds and, thereby,
increases the inhibition. Creatine Kinase
→The enzyme–substrate–inhibitor complex does not yield product.
Lastly, a mixed inhibitor has the ability to bind to either the E or ES --CK is an enzyme with a molecular weight of approximately 82,000 that
complex at a different site from the substrate active site. is generally associated with ATP regeneration in contractile or transport
systems.
--Its predominant physiologic function occurs in muscle cells, where it is
involved in the storage of high-energy creatine phosphate.
Every contraction cycle of muscle results in creatine phosphate use, with
the production of ATP.
--This results in relatively constant levels of muscle ATP.

--CK is widely distributed in tissue, with highest activities found in

skeletal muscle, heart muscle, and brain tissue.
--CK is present in much smaller quantities in other tissue sources,
including the bladder, placenta, gastrointestinal tract, thyroid, uterus,
kidney, lung, prostate, spleen, liver, and pancreas.

Measurement of Enzyme Activity

--If the amount of substrate and any coenzyme is in excess in an
enzymatic reaction, the amount of substrate or coenzyme used, or
product or altered coenzyme formed, will depend only on the amount of
enzyme present to catalyze the reaction.
--Enzyme concentrations, therefore, are always performed in zero-order
kinetics, with the substrate in sufficient excess to ensure that no more
than 20% of the available substrate is converted to product.
--Any coenzymes also must be in excess.
--NADH is a coenzyme frequently measured in the laboratory.
--NADH absorbs light at 340 nm, whereas NAD does not, and a change
in absorbance at 340 nm is easily measured.

This material was developed for students enrolled in MTAP/SEMR421. Our Lady of Fatima University-Quezon City – College of Medical Laboratory Science, August 2022. The
information in this material is solely intended for educational purposes only and does not guarantee accuracy, completeness, or timeliness and without any warranties
implicated. SUPPLEMENTARY NOTES ONLY; PLEASE REFER TO YOUR BOOKS. Obtain permission prior to use. For questions and corrections: Lara Melisa R. Olguera, RMT,
MSMT© | lrolguera@fatima.edu.ph.
 Reference Range

Lactate Dehydrogenase
--LDH is an enzyme that catalyzes the interconversion of lactic and
pyruvic acids.
--It is a hydrogen transfer enzyme that uses the coenzyme NAD+.
--LDH is widely distributed in the body. High activities are found in the
heart, liver, skeletal muscle, kidney, and erythrocytes; lesser amounts are
found in the lung, smooth muscle, and brain.

Assay for Enzyme Activity

Source of Error
--Erythrocytes contain an LDH concentration approximately 100 to 150
times that found in serum. Therefore, any degree of hemolysis should
render a sample unacceptable for analysis.
--LDH activity is unstable in serum regardless of the temperature at
which it is stored. If the sample cannot be analyzed immediately, it
should be stored at 25°C and analyzed within 48 hours.
--LDH-5 is the most labile isoenzyme. Loss of activity occurs more
quickly at 4°C than at 25°C.
--Serum samples for LDH isoenzyme analysis should be stored at 25°C
Assay Enzyme Activity and analyzed within 24 hours of collection.
Reference Range

Aspartate Aminotransferase
--Aspartate aminotransferase (AST) is an enzyme belonging to the class
of transferases. It is commonly referred to as a transaminase and is
involved in the transfer of an amino group between aspartate and α-keto
acids. The older terminology, serum glutamic-oxaloacetic transaminase
(SGOT, or GOT), may also be used. Pyridoxal phosphate functions as a
coenzyme.

Source of Error
Hemolysis of serum samples may be a source of elevated CK activity.

This material was developed for students enrolled in MTAP/SEMR421. Our Lady of Fatima University-Quezon City – College of Medical Laboratory Science, August 2022. The
information in this material is solely intended for educational purposes only and does not guarantee accuracy, completeness, or timeliness and without any warranties
implicated. SUPPLEMENTARY NOTES ONLY; PLEASE REFER TO YOUR BOOKS. Obtain permission prior to use. For questions and corrections: Lara Melisa R. Olguera, RMT,
MSMT© | lrolguera@fatima.edu.ph.

--The clinical use of AST is limited mainly to the evaluation of
hepatocellular disorders and skeletal muscle involvement. In AMI, AST
levels begin to rise within 6 to 8 hours, peak at 24 hours, and generally
return to normal within 5 days.
--However, because of the wide tissue distribution, AST levels are not
useful in the diagnosis of AMI.
--AST elevations are frequently seen in pulmonary embolism.
--Following congestive heart failure, AST levels also may be increased,
probably reflecting liver involvement as a result of inadequate blood
supply to that organ.
--AST levels are highest in acute hepatocellular disorders. In viral
hepatitis, levels may reach 100 times ULN. In cirrhosis, only moderate
levels—approximately four times ULN—are detected. Skeletal muscle
disorders, such as the muscular dystrophies, and inflammatory conditions
also cause increases in AST levels (4 to 8× ULN).
Alanine Aminotransferase
--Alanine aminotransferase (ALT) is a transferase with enzymatic activity
similar to that of AST. Specifically, it catalyzes the transfer of an amino
group from alanine to α-ketoglutarate with the formation of glutamate
and pyruvate.
--The older terminology was serum glutamic-pyruvic transaminase (SGPT,
or GPT).
Diagnostic Significance
→confined mainly to evaluation of hepaticdisorders. Higher elevations
are found in hepatocellular disorders than in extrahepatic or intrahepatic
obstructive disorders.
--In acute inflammatory conditions of the liver, ALT elevations are
frequently higher than those of AST and tend to remain elevated longer
as a result of the longer half-life of ALT in serum (16 and 24 hours,
respectfully).
--Cardiac tissue contains a small amount of ALT activity, but the serum
level usually remains normal in AMI unless subsequent liver damage has
occurred. ALT levels have historically been compared with levels of AST
to help determine the source of an elevated AST level and to detect liver
involvement concurrent with myocardial injury.
Reference Range
This material was developed for students enrolled in MTAP/SEMR421. Our Lady of Fatima University-Quezon City – College of Medical Laboratory Science, August 2022. The
information in this material is solely intended for educational purposes only and does not guarantee accuracy, completeness, or timeliness and without any warranties
implicated. SUPPLEMENTARY NOTES ONLY; PLEASE REFER TO YOUR BOOKS. Obtain permission prior to use. For questions and corrections: Lara Melisa R. Olguera, RMT,
MSMT© | lrolguera@fatima.edu.ph.
Alkaline Phosphatase
Diagnostic Significance
--Elevations of ALP are of most diagnostic significance in the evaluation
of hepatobiliary and bone disorders. In hepatobiliary disorders,
elevations are more predominant in obstructive conditions than in
hepatocellular disorders; in bone disorders, elevations are observed
when there is involvement of osteoblasts.
--In biliary tract obstruction, ALP levels range from 3 to 10 times ULN.
--Increases are primarily a result of increased synthesis of the enzyme
induced by cholestasis.
--In contrast, hepatocellular disorders, such as hepatitis and cirrhosis,
show only slight increases, usually less than three times ULN.
--Because of the degree of overlap of ALP elevations that occurs in the
various liver disorders, a single elevated ALP level is difficult to interpret.
--It assumes more diagnostic significance when evaluated along with
other tests of hepatic function.
--Elevated ALP levels may be observed in various bone disorders.
--Perhaps the highest elevations of ALP activity occur in Paget's disease
(osteitis deformans).
--Other bone disorders include osteomalacia, rickets,
hyperparathyroidism, and osteogenic sarcoma.
--In addition, increased levels are observed in healing bone fractures and
during periods of physiologic bone growth.
--In normal pregnancy, increased ALP activity, averaging approximately
11⁄2 times ULN, can be detected between weeks 16 and 20 and 2 to 3
time the ULN during the third trimester.
--ALP activity increases and persists until the onset of labor.
Activity then returns to normal within 3 to 6 days.
--Elevations also may be seen in complications of pregnancy such as
hypertension, preeclampsia, and eclampsia, as well as in threatened
abortion.
--ALP levels are significantly decreased in the inherited condition of
hypophosphatasia. Subnormal activity is a result of the absence of the
bone isoenzyme and results in inadequate bone calcification.
--ALP exists as a number of isoenzymes, which have been studied by a
variety of techniques.
--The major isoenzymes, which are found in the serum and have
been most extensively studied, are those derived from the liver, bone,
intestine, and placenta.
--The bone isoenzyme increases due to osteoblastic activity and is
normally elevated in children during periods of growth and in adults
older than age 50.
--In these cases, an elevated ALP level may be difficult to interpret.
--The presence of intestinal ALP isoenzyme in serum depends on the
blood group and secretor status of the individual.
--Individuals who have B or O blood group and are secretors are more
likely to have this fraction. Apparently, intestinal ALP is bound by
erythrocytes of group A.
--In these individuals, increases in intestinal ALP occur after consumption
of a fatty meal.
--Intestinal ALP may increase in several disorders, such as diseases of the
digestive tract and cirrhosis.
--Increased levels are also found in patients undergoing chronic
hemodialysis.
--Heat inactivation is an imprecise method for differentiation because
inactivation depends on many factors, such as correct temperature
control, timing, and analytic methods sensitive enough to detect small
amounts of residual ALP activity.
--In addition, there is some degree of overlap between heat inactivation
of liver and bone fractions in both liver and bone diseases.
--A third approach to identification of ALP isoenzymes is based on
selective chemical inhibition.
--Phenylalanine is one of several inhibitors that have been used.
→ inhibits intestinal and placental ALP to a much greater extent than
liver and bone ALP. With phenylalanine use, however, it is impossible to
differentiate placental from intestinal ALP or liver from bone ALP.
 Assay for Enzyme Activity g-Glutamyltransferase
--γ-Glutamyltransferase (GGT) is an enzyme involved in the transfer of the
γ-glutamyl residue from γ-glutamyl peptides to amino acids, H2O, and
other small peptides.
--In most biologic systems, glutathione serves as the γ-glutamyl donor.
The specific physiologic function of GGT has not been clearly established,
but it is suggested that GGT is involved in peptide and protein synthesis,
regulation of tissue glutathione levels, and the transport of amino acids
across cell membranes.

--The most widely accepted substrate for use in GGT analysis is γ-

Acid Phosphatase
Acid phosphatase (ACP) belongs to the same group of phosphatase
enzymes as ALP and is a hydrolase that catalyzes the same type of
reactions.
→The major difference between ACP and ALP is the pH of the reaction.
glutamyl-pnitroanilide.
--The γ-glutamyl residue is transferred to glycylglycine, releasing
pnitroaniline, a chromogenic product with a strong absorbance at 405 to
420 nm.
--The reaction, which can be used as a continuous monitoring or fixed-
point method.

Amylase

--The acinar cells of the pancreas and the salivary glands are the major
tissue sources of serum AMY. Lesser concentrations are found in skeletal
muscle and the small intestine and fallopian tubes. AMY is the smallest
enzyme, with a molecular weight of 50,000 to 55,000. Because of its
small size, it is readily filtered by the renal glomerulus and also appears
in the urine.
--Digestion of starches begins in the mouth with the hydrolytic action of
salivary AMY.
--Salivary AMY activity, however, is of short duration because, on
swallowing, it is inactivated by the acidity of the gastric contents.
--Pancreatic AMY then performs the major digestive action of starches
once the polysaccharides reach the intestine.
The diagnostic significance of serum and urine AMY measurements is in
the diagnosis of acute pancreatitis.
--Disorders of tissue other than the pancreas can also produce elevations
in AMY levels. Therefore, an elevated AMY level is a nonspecific finding.
→degree of elevation of AMY is helpful, to some extent, in the
differential diagnosis of acute pancreatitis. In addition, other laboratory
tests (e.g., measurements of urinary AMY levels, AMY clearance studies,
AMY isoenzyme studies, and measurements of serum lipase [LPS]
levels)
→when used in conjunction with serum AMY measurement, increase
the specificity of AMY measurements in the diagnosis of acute
pancreatitis.
--In acute pancreatitis, serum AMY levels begin to rise 5 to 8 hours after
the onset of an attack, peak at 24 hours, and return to normal levels
within 3 to 5 days. Values generally range from 250 to 1,000 Somogyi
units per dL (2.55 × ULN). Values can reach much higher levels.

This material was developed for students enrolled in MTAP/SEMR421. Our Lady of Fatima University-Quezon City – College of Medical Laboratory Science, August 2022. The
information in this material is solely intended for educational purposes only and does not guarantee accuracy, completeness, or timeliness and without any warranties
implicated. SUPPLEMENTARY NOTES ONLY; PLEASE REFER TO YOUR BOOKS. Obtain permission prior to use. For questions and corrections: Lara Melisa R. Olguera, RMT,
MSMT© | lrolguera@fatima.edu.ph.
 Glucose-6-Phosphate Dehydrogenase

Lipase

--Glucose-6-phosphate dehydrogenase (G-6-PD) is an oxidoreductase

that catalyzes the oxidation of glucose-6-phosphate to 6-
phosphogluconate or the corresponding lactone.
--The reaction is important as the first step in the pentosephosphate
shunt of glucose metabolism with the ultimate production of NADPH.
--Sources of G-6-PD include the adrenal cortex, spleen, thymus, lymph
nodes, lactating mammary gland, and erythrocytes.
--Little activity is found in normal serum.
Diagnostic Significance
--Lipase (LPS) is an enzyme that hydrolyzes the ester linkages of fats to
produce alcohols and fatty acids. Specifically, LPS catalyzes the partial
hydrolysis of dietary triglycerides in the intestine to the 2-monoglyceride
intermediate, with the production of long-chain fatty acids.
--The enzymatic activity of pancreatic LPS is specific for the fatty acid
residues at positions 1 and 3 of the triglyceride molecule, but substrate
must be an emulsion for activity to occur.
--The reaction rate is accelerated by the presence of colipase and a bile
salt.
--Clinical assays of serum LPS measurements are confined almost
exclusively to the diagnosis of acute pancreatitis.
--Serum LPS activity increases 4 to 8 hours after an attack of acute
pancreatitis, concentrations peak at 24 hours, and decrease within 8 to
14 days.
--LPS is similar in this respect to AMY measurements but is considered
more specific for pancreatic disorders than AMY measurement.
--Both AMY and LPS levels rise quickly, but LPS elevations persist for
approximately 8 days in acute pancreatitis, whereas AMY elevations
persist for only 2 to 3 days.
--The extent of elevations does not correlate with severity of disease.
--Elevated LPS levels also may be found in other intraabdominal
conditions but with less frequency than elevations of serum AMY.
--Elevations have been reported in cases of penetrating duodenal ulcers
and perforated peptic ulcers, intestinal obstruction, and Macroenzymes
acutecholecystitis.
→high-molecular-mass forms of the serum enzymes (ACP,
--In contrast to AMY levels, LPS levels are normal in conditions of salivary
ALP, ALT, amylase, AST, CK, GGT, LDH, lipase) that can be bound to
gland involvement.
either an immunoglobulin (macroenzyme type 1) or a nonimmunoglobulin
→LPS levels are useful in differentiating serum AMY elevation as a substance (macroenzyme type 2). Macroenzymes are usually found in
result of pancreatic versus salivary involvement. Of the three lipase patients who have an unexplained persistent increase of enzyme
isoenzymes, L2 is thought to be the most clinically specific and sensitive. concentrations in serum.
--The presence of macroenzymes can also increase with increasing age.
--Macroenzymes accumulate in the plasma because their high molecular
masses prevent them from being filtered out of the plasma by the
kidneys.
--The detection of macroenzymes is clinically significant because the
This material was developed for students enrolled in MTAP/SEMR421. Our Lady of Fatima University-Quezon City – College of Medical Laboratory Science, August 2022. The
information in this material is solely intended for educational purposes only and does not guarantee accuracy, completeness, or timeliness and without any warranties
implicated. SUPPLEMENTARY NOTES ONLY; PLEASE REFER TO YOUR BOOKS. Obtain permission prior to use. For questions and corrections: Lara Melisa R. Olguera, RMT,
MSMT© | lrolguera@fatima.edu.ph.
presence of macroenzymes can cause difficulty in the interpretation of
diagnostic enzyme results.
--The formation of high molecular weight enzyme complexes can cause
false elevations in plasma enzymes, or they can falsely decrease the
activity of the enzyme by blocking the activity of the bound enzyme.
--The principal method to identify enzymes that are bound to
immunoglobulins and nonimmunoglobulins is protein electrophoresis.
--The binding of enzymes to high molecular weight complexes can alter
the normal electrophoretic pattern of enzymes.
--Antienzyme antibodies can cause the formation of new enzyme bands
on a gel, they can alter the intensity of enzyme bands, and they can
cause band broadening on the gel.
--Other test methods used to determine the presence of macroenzymes:
→gel filtration,
→immunoprecipitation,
→immunoelectrophoresis,
→counterimmunoelectrophoresis,
→immunofixation.
--The immunoinhibition test can also be used to determine the presence
of macro-CK.
Drug-Metabolizing Enzymes

SUPPLEMENTAL NOTES:

---END OF LECTURE---
This material was developed for students enrolled in MTAP/SEMR421. Our Lady of Fatima University-Quezon City – College of Medical Laboratory Science, August 2022. The
information in this material is solely intended for educational purposes only and does not guarantee accuracy, completeness, or timeliness and without any warranties
implicated. SUPPLEMENTARY NOTES ONLY; PLEASE REFER TO YOUR BOOKS. Obtain permission prior to use. For questions and corrections: Lara Melisa R. Olguera, RMT,
MSMT© | lrolguera@fatima.edu.ph.
This material was developed for students enrolled in MTAP/SEMR421. Our Lady of Fatima University-Quezon City – College of Medical Laboratory Science, August 2022. The
information in this material is solely intended for educational purposes only and does not guarantee accuracy, completeness, or timeliness and without any warranties
implicated. SUPPLEMENTARY NOTES ONLY; PLEASE REFER TO YOUR BOOKS. Obtain permission prior to use. For questions and corrections: Lara Melisa R. Olguera, RMT,
MSMT© | lrolguera@fatima.edu.ph.