Clinical Chemistry 3 Lecture 5 Hormonal Control of Calcium Metabolism

CALCIUM HOMEOSTASIS AND HORMONAL REGULATION

Roles of Calcium
Signal transduction pathways
acts as a second messenger, in
neurotransmitter release from neurons
Contraction of all muscle cell types
Fertilization
Enzyme cofactor
blood-clotting cascade
Proper bone formation
HYPERCALCEMIA
PRINCIPAL ORGANS INVOLVED IN CALCIUM the state of blood calcium levels above the expected
HOMEOSTASIS normal range in a healthy population
Small Intestines ionized or free calcium—biologically active 50%
Bones (Skeletal System) bound calcium
Kidneys Albumin
Normal Total Calcium: 2.2-2.6 mmol/L (9-10.5 mg/dL) Citrate
Normal Ionized Calcium: 1.1-1.4 mmol/L (4.5-5.6 mg/dL). Phosphate
CALCIUM HOMEOSTASIS Signs and Symptoms of Hypercalcemia
Central nervous system
Altered central nervous system function
 Lethargy
 Decreased alertness
 Depression
 Confusion
 Forgetfulness
 Obtundation
HORMONAL CONTROL OF CALCIUM METABOLISM  Coma
Parathyroid Hormone GASTRO-INTESTINAL
Vitamin D  Anorexia
 A hormone  Constipation
 Structurally similar steroid hormones  Nausea and vomiting
 a metabolic product of the cholesterol synthetic Renal
pathway Calcium acts as a diuretic and impairs the kidneys’ ability
 Tissues involved in the synthesis: to concentrate urine
 Skin  Dehydration
 Liver  hypercalciuria
 Kidneys  increases the risk of calcium-
 Target Organs: containing kidney stone
 Gut Skeletal
 Bone Patients with most causes of hypercalcemia have
 Parathyroids increased bone resorption
VITAMIN D SYNTHESIS  increased bone
demineralization, leading to
increased fracture risk
Cardiovascular
Hypercalcemia may cause or exacerbate hypertension
 ECG: shortened QT interval
Endocrine Causes of Hypercalcemia

Primary Hyperparathyroidism
parathyroid adenoma/hyperplasia
Parathyroid Hormone MEN 1
secreted from four parathyroid glands in the region of  result in tumors of the parathyroids,
the thyroid gland pituitary, and pancreas
 loss of a tumor suppressor gene that
maps to human chromosome 11
MEN 2
  result in tumors of the parathyroids,  refers to the abnormal mineralization
medullary thyroid hyperplasia or of bone in adults, or after closure of
cancer, and pheochromocytoma the ephiphysial plates.
 activating mutation in the ret proto- Osteoporosis
oncogene, which resides on human  the most prevalent metabolic bone
chromosome 10 disease in adults.
Familial hyperparathyroidism
results in primary HPT, without other associated tumors
mapped to human chromosome 1.14
Familial hypocalciuric hypercalcemia (FHH)
result of a mutation in the calcium- sensing receptor and
thus an increased “set point” for calcium homeostasis
mild hypercalcemia and hyperparathyroidism

Parathyroid hormone–related protein (PTHrP)

-substance very similar in structure to PTH
-produced by a variety of benign and malignant tumors
Breast
Lung
Kidney
Lymphoma
-PTHrP shares the N- terminal sequence homology with
PTH, it acts similarly and can cause hypercalcemia.

Milk-alkali Syndrome (Burnett’s Syndrome)

results from the ingestion of large amounts of calcium
together with an absorbable alkali
patients being treated for peptic ulcers using carbonate
or bicarbonate salts with milk or cream
can lead to:
 Hypercalcemia
 Metabolic alkalosis
 Renal impairment
HYPOCALCEMIA
the state of blood calcium levels below the expected
normal range in a healthy population

Signs and Symptoms of Hypocalcemia

Neuromuscular
 Chvostek’s sign
 Numbness and tingling in the face,
hands, and feet may be seen
 Trousseau’s sign
Central nervous system
 Irritability
 Seizures
 Personality changes
 Impaired intellectual functioning
Cardiovascular
 Cardiac contractile dysfunction
METABOLIC BONE DISEASES
Rickets and Osteomalacia
Rickets
 refers to the disease state in growing
bone (in children).
Osteomalacia
Clinical Chemistry 3 Lecture 4 Protein Binding of Thyroid Hormone
THE THYROID GLAND Thyroxin-binding Globulin (TBG)
Thyroxin-binding Prealbumin
The Thyroid Gland Albumin
Produces 2 hormones:
Thyroid Hormones (T3 & T4) Control of Thyroid Function
produced by thyrocytes
 critical in regulating body
metabolism, neurologic development, and
numerous other body functions
Calcitonin
produced by parafollicular cells C
involved in calcium homeostasis

Thyroid Anatomy and Development

Location: Lower Anterior Neck
Shape: butterfly, consisting of 2 lobes and an isthmus
Weight: 16-30 grams in adults
Embryology: outpouching of the foregut at the base of the
tongue TESTS FOR THYROID EVALUATION
Thyroid Hormone Synthesis TSH
 most useful test for assessing thyroid
function is the TSH
T3 & T4
 usually measured by:
 radioimmunoassay
(RIA)
 chemiluminometric
assay
 similar
immunometric technique
Thyroglobulin
 measured by
Metabolism of Thyroxine  double- antibody RIA
 enzyme-linked immunoassay
(ELISA)
 immunoradiometric assay
(IRMA)
 immunochemilu- minescent
assay (ICMA) methods
INTERPRETATION OF THYROID TESTS
Three Forms Of Iodothyronine 5’-deiodinase
Type 1 iodothyronine 5’-deiodinase
 the most abundant form
 found mostly in the liver and
kidney
 responsible for the largest
contribution to the circulating T3 pool
Type 2 iodothyronine 5’-deiodinase
 found in the brain and
pituitary gland
 maintain constant levels of
T3 in the central nervous system
Type 3 iodothyronine 5’-deiodinase
 found in fetal tissues
 prevent the rise of serum T3
 they maintain high levels of
rT3 during intrauterine life
#PREVALENCE OF THYROID AUTOANTIBODIES  Causes:
 excessive thyroid hormone ingestion
 leakage of stored thyroid hormone
from storage in the thyroid follicles
 excessive thyroid gland production of
thyroid hormone
SIGNS AND SYMPTOMS OF THYROTOXICOSIS
Signs
Tachycardia
Tremor
Warm, moist, flushed, smooth skin
Hypothyroidism Lid lag, widened palpebral fissures Ophthalmopathy
 Decreased free T4 with normal to elevated TSH (Graves’ disease)
Goiter
Brisk deep tendon reflexes
Muscle wasting and weakness
Dermopathy/pretibial myexedema (Graves’ disease)
Osteopenia, osteoporosis
Symptoms
Nervousness, irritability, anxiety
Tremor
Palpitations
Fatigue, weakness, decreased exercise tolerance
Weight loss
Heat intolerance
Hyperdefecation
Menstrual changes (oligomenorrhea)
Prominence of eyes

TYPES OF HYPOTHYROIDISM Graves’ Disease

Primary the most common cause of thyrotoxicosis
 Thyroid gland dysfunction an autoimmune disease in which antibodies are
Secondary produced that activate the TSH receptor
 Pituitary dysfunction DISORDERS ASSOCIATED WITH THYROTOXICOSIS
Tertiary
 Hypothalamic dysfunction

CAUSES OF HYPOTHYROIDISM

Thyrotoxicosis
 constellation of findings that result when
peripheral tissues are presented with, and
respond to, an excess of thyroid hormone.
Clinical Chemistry 3 Lecture 6  Almost all proteins are
LIVER FUNCTION synthesized by the liver
Gross Anatomy Of The Liver except for the
Blood Supply of the Liver immunoglobulins and adult
Excretory System Of The Liver hemoglobin
Microscopic Anatomy DETOXIFICATION AND DRUG METABOLISM
BIOCHEMICAL FUNCTIONS  serves as a gatekeeper between substances
Four Major Functions: absorbed by the gastrointestinal tract and those
 Excretion/secretion released into systemic circulation
 Synthesis LIVER FUNCTION ALTERATIONS DURING DISEASE
 Detoxification JAUNDICE
 Storage  Upper normal limit of total bilirubin
EXCRETORY AND SECRETORY  1.0-1.5 mg/dL
 Transforms unconjugated to conjugated  Jaundice is noticeable at 3.0 mg/dL
bilirubin ICTERUS
 Ligandin  used in the clinical laboratory to refer to a serum
 responsible for transporting or plasma sample with a yellow discoloration
unconjugated bilirubin to the due to an elevated bilirubin level
endoplasmic reticulum, CLASSIFICATION OF JAUNDICE
where it may be rapidly
conjugated
METABOLISM OF BILIRUBIN

SYNTHETIC
Responsible for synthesizing:
 Carbohydrates
 use the glucose for its own
cellular energy requirements
 circulate the glucose for use
at the peripheral tissues
 store glucose as glycogen
(principal storage form of
glucose) within the liver itself
or within other tissues
 Lipids
 approximately 70% of the
daily production of
cholesterol (roughly 1.5–2.0
g)
 Proteins
GILBERT DISEASE
 reduced activity of the enzyme
glucuronyltransferase, which conjugates bilirubin
and a few other lipophilic molecules
CRIGLER-NAJJAR SYNDROME TYPE 1
 Mode of Inheritance:
 Autosomal Recessive
 characterised by:
 serum bilirubin usually above 345
µmol/L (310–755 mg/dL)
 no UGT1A1 (UDP
glucuronosyltransferase 1 family,
polypeptide A1) expression
 no response to treatment with
phenobarbital*
CRIGLER-NAJJAR SYNDROME TYPE 2
Type II differs from type I in several aspects:
 Bilirubin levels are generally below 345
µmol/L (100–430 mg/dL) and some
cases are only detected later in life.
 Because of lower serum bilirubin,
kernicterus is rare in type II.
 Bile is pigmented, instead of pale in
type I or dark as normal, and
monoconjugates constitute the largest
fraction of bile conjugates.
 UGT1A1 is present at reduced but
detectable levels (typically <10% of
 normal), because of single base pair
mutations.
 Therefore, treatment with
phenobarbital is effective, generally
with a decrease of at least 25% in
serum bilirubin. In fact, this can be
used, along with these other factors, to
differentiate type I and II.
 The inheritance pattern of Crigler–
Najjar syndrome type II has been
difficult to determine but is generally
[
considered to be autosomal recessive.
DUBIN-JOHNSON SYNDROME
 An autosomal recessive disorder
 Increase of conjugated bilirubin in the serum
without elevation of liver enzymes (ALT, AST)
 Defect in the ability of hepatocytes to secrete
conjugated bilirubin into the bile
 Diagnosis
 A hallmark of DJS is the unusual ratio
between the byproducts of heme
biosynthesis.
 Unaffected subjects have a
coproporphyrin III to
coproporphyrin I ratio of
approximately 3–4:1.
 In patients with DJS, this
ratio is inverted with
coproporphyrin I being 3–4x
higher than coproporphyrin
III.
ROTOR SYNDROME
CIRRHOSIS
 clinical condition in which scar tissue replaces
normal, healthy liver tissue
 scar tissue replaces the normal liver tissue
blocking the flow of blood through the organ and
prevents the liver from functioning properly
 Causes:
 Chronic Alcoholism
 Chronic Hepatitis B, C, D
 autoimmune hepatitis
 inherited disorders (e.g., α1-antitrypsin
deficiency, Wilson disease,
hemachromatosis, and galactosemia)
 nonalcoholic steatohepatitis
 blocked bile ducts
 Drugs
 Toxins
 infections
REYE SYNDROME
 a term used to describe a group of disorders
caused by infectious, metabolic, toxic, or drug-
induced disease found almost exclusively in
children
 Associted with:
 viral syndrome
 Varicella
 Gastroenteritis
 upper respiratory tract
infection such as influenza
 aspirin during a viral syndrome
ASSESSMENT OF LIVER FUNCTION/LIVER FUNCTION
TESTS
Review:
BILIRUBIN
Ehrlich’s (Diazo) Reaction
 diazotized Sulfanilic Acid +
Urine  colored product
(RED)= urobilinogen
Van den Bergh Reaction
 determines the amount of
conjugated bilirubin in the
blood
 the reaction produces
azobilirubin
 Principle: diazotised sulfanilic
acid + serum + stabilizer =
produce purple colored
azobilirubin
Malloy and Evelyn Reaction
 Principle: diazotised sulfanilic
acid + serum + 50% methanol
(accelerator)= RED PURPLE
Jendrassik and Grof
 Principle: diazotised sulfanilic
acid + serum + caffeine-
benzoate-acetate
(accelerator)= PURPLE
REFERENCE RANGES FOR BILIRUBIN IN
ADULTS AND INFANTS
 DETERMINATION OF UROBILINOGEN
(SEMIQUANTITATIVE)
Principle
Urobilinogen (Urine) + p-dimethyl
aminobenzaldehyde (Ehrlich’s reagent)
= red color
Reference Range (Urine)
 0.1–1.0 Ehrlich units every 2 hours
 0.5–4.0 Ehrlich units per day (0.86.8
mmol/day)
Reference Range (Fecal)
 75–275 Ehrlich units per 100 g of fresh
feces
 75–400 Ehrlich units per 24-hour
specimen
LIVER ENZYMES
Most Clinically Useful:
 Aminotranferases
 alanine amino transferase [ALT]
SGPT
 aspartate aminotransferase [AST])
SGOT
 Phosphatases
 alkaline phosphatase [ALP]
 5’- neucleotidase)
 Gamma -glutamyltransferase (GGT)
 Lactate dehydrogenase
AMINOTRANFERASES
 ALT a more “liver-specific” marker than AST
 the serum activity of both transaminases rises
rapidly in almost all diseases of the liver and may
remain elevated for up to 2–6 weeks
 Markedly increased in:
 viral hepatitis
 drug- and toxin-induced liver necrosis
 Hepatic ischemia
 Normal or only mildly elevated in:
 cases of obstructive liver damage
PHOSPHATASES
Alkaline Phosphatase
 zinc metalloenzymes
 widely distributed in all tissues
 marker of extrahepatic biliary obstruction
 stone in the common bile duct
 intrahepatic cholestasis
 drug cholestasis
 primary biliary cirrhosis
 moderate increase:
 hepatocellular disorders such as hepatitis and
cirrhosis
5’-Nucleotidase
 responsible for catalyzing the
hydrolysis of neucleoside-5’-phosphate
ester
 serum levels become significantly
elevated in hepatobiliary disease
 more liver specific compared to ALP
PHOSPHATASES
 membrane-localized enzyme found in
high concentrations in the kidney, liver,
pancreas, intestine, and prostate but
not in bone
 plays a role in differentiating the cause
of elevated levels of ALP
 highest levels of GGT are
seen in biliary obstruction
 hepatic microsomal enzyme
 ingestion of alcohol or
certain drugs elevates GGT
 Barbiturates
 Tricyclic
Antidepressants
 Anticonvulsants
 a sensitive test for cholestasis caused
by chronic alcohol or drug ingestion
 useful if jaundice is absent for the
confirmation of hepatic neoplasms
 an enzyme with a very wide
distribution throughout the body
 released into circulation when cells of
the body are damaged or destroyed
 serves as a general, nonspecific marker
of cellular injury
Tests Measuring Hepatic Synthetic Ability
SERUM PROTEINS
 Useful in quantitating the severity of hepatic
dysfunction
 Not sensitive to minimal liver damage
SERUM ALBUMIN
 correlates well with the severity of functional
impairment
 chronic rather than in acute liver disease
(decreased)
SERUM α-GLOBULINS
 decrease with chronic liver disease
 low or absent α-globulin suggests α-
antitrypsin deficiency as the cause of
the chronic liver disease
SERUM γ-GLOBULIN
 transiently increased in acute liver
disease
 elevated in chronic liver disease
 IgG and IgM levels chronic
active hepatitis
 IgM Primary Biliary
Cirrhosis
 IgA Alcoholic Cirrhosis
PROTHROMBIN
 Decreased
 Prothrombin Time is prolonged
 Indicates severe diffuse liver disease
and a poor prognosis
Tests Measuring Nitrogen Metabolism
PLASMA AMMONIA
  a reflection of the liver’s ability to SEROLOGICAL PROFILES OF CHRONIC HEPATITIS B VIRUS
convert ammonia to urea so that it can INFECTION
be excreted through the kidneys
 increase in the bloodstream and may
ultimately cause hepatic coma
HEPATITIS

Serology Of Hepatitis B Infection With Recovery

CLINICAL FEATURES OF HEPATITIS D VIRUS (HDV)
COINFECTION AND SUPERINFECTION IN HEPATITIS B
VIRUS (HBV) CARRIERS

Serology Of Chronic Hepatitis With Formation Of

Antibody To HBeAg

TYPICAL INTERPRETATION OF SEROLOGIC TEST RESULTS

FOR HBV INFECTION