Chemical Pathology

Jordan McLeod
 CHEMICAL PATHOLOGY
Fluid and Electrolytes I [L2]
Fluid Balance
• Work out net fluid intake = total intake – total
total losses
• Is it sufficient enough to balance the insensible
losses?

1. Water Regulation
• Water Loss = ↑ ECF osmolality
1. Stimulation of vasopressin release = renal water retention
2. Stimulation of hypothalamic thirst centre = ↑ water intake
3. Redistribution of water from ICF = ↑ ECF water potential
= restoration of ECF osmolality

Vasopressin also affected by angiotensin II baroreceptors and volume receptors

• Falls in BP (blood loss) = massive ↑↑ vasopressin secretion

• Osmolar controls overidden

Fluid Loss
HYPOTONIC FLUID LOSS
Low osmotic pressure + high water potential lost = Water content
in relation to sodium is greater
• ↑ Osmolality of ECF
• movement of water from ICF to ECF
• Signs of reduced ECF vol minimal = circulatory failure is
late sign
Causes
1. Diabetes Insipidus
2. Diabetes Mellitus - Osmotic diuresis
3. Excessive sweating
4. Cessation of water intake with ongoing obligatory water loss
5. Hyperventilation or assisted ventilation

ISOTONIC FLUID LOSS

Equivalent amount of sodium lost
• no change in ECF[Na+] hence
• no change in ECF osmolality = no change in ICF volume
• ECF volume ↓↓ = circulatory collapse pronounced
• Progressive rise in plasma [urea] and [creatinine]

Causes
1. Haemorrhage
2. Burns
3. GIT loss – diarrhoea, vomiting
 4. Renal loss – diuretics
5. Effusion of ECF into body spaces – hematoma, ascites

2. Sodium Distribution
[Na+]:
• ECF = 135-145 mmol/L
• ICF = 4-10 mmol/L
• intake = 100-200 mmol/24h
• obligatory sodium loss < 20mmol/24h
• maintained by active pumping of Na+ (out of cell) from ICF → ECF by Na+,K+-ATPase

Understand the concept of osmolality and osmolarity and how they can be useful in the patient
management

• Osmolality
o physical property of a solution
o [solutes] millimoles
kg of solvent (w/w)
o parameter to which the hypothalamus responds
o Exclusion of pseudohyponatraemia
• Osmolarity
o Measure of solutes reported in milliosmoles per liter (w/v)
o 2[Na+] + [urea] + [glucose]
• Osmolal gap (OG)
o Osmolality – osmolarity
o OG elevated with ↑ in other osmoles
▪ Renal Failure
▪ DKA
▪ Lactic acidosis (OG > 10)
▪ Ethanol, methanol, ethylene glycol (OG > 15)

Know the basis to the understanding of sodium disorders

Know the APPROACH to Hypo and Hypernatremia and their complications

Hyponatraemia
• Most common
• < 130mmol/L = clinically significant
• Assess:
1. Serum [Na+]
2. Serum Osmolality
3. Volume Status
4. urine [Na+]

>> THINK:
• Losing Sodium vs Gaining Water
Approach

Hypertonic Pseudo Hypotonic Hyponatraemia

Hyponatraemia hyponatraemia
(Isotonic)
↑ Osmolality Measurement ↓ Osmolality (most common)
Artefact → Common = inability to suppress secretion of ADH (↑ renal
Dilutional proteins and water retention)
Hyponatraemia triglycerides
interfere*
= confirm with
plasma osmolality
Interference
removed by
ultracentrifugation
CAUSES:
1. Hyperglycaemia, 1. Hyper Hypervolaemic Euvolaemic Hypovolaemic
Poorly triglyceridemia
Controlled DM
impaired 2. Para
movement of proteinemia
glucose into cells *large ↑ H2O *↑ in H2O *small ↓ H2O
small ↑ Na+ Normal Na+ large ↑ H2O
2. Mannitol
therapy for brain *edema → lower No fluid → into → losing more
oedema draws fluid circulating volume interstitial space = sodium than
out of cells which stimulates: no signs of water
↑ aldosterone hypervolaemia
(Na+H20 retention) Mostly dilute urine
↑ ADH
(H20 retention)
NET ↑ H2O
 Oedematous u-[Na+] > 40 u-[Na+] > 40
Disorders
1. Psychogenic Renal Losses
u-[Na+] > 40 polydipsia 1. Diuretics
(u-osmol 2. Osmotic
1. Renal Failure < 100) Diuresis
2. Cortisol 3. Addisons
u-[Na+] < 25 deficiency due disease
to deficient (↓ cortisol
↓ aldosterone)
1. CHF ACTH/CRH
3. Hypothyroidism 4. Cerebral
2. Nephrotic
4. SIADH ↑ u-osm salt wasting
Syndrome
syndrome
3. Liver Cirrhosis 5. Drugs stimulate
ADH release (↑ BNP)
*meningitis

u-[Na+] < 25

Extrarenal
Losses
1. Diarrhoea
2. Hypotonic
skin losses
3. 3rd space
losses
NB: skeletal
#, GIT
obstruction
TREATMENT:
1. Diuretics 1. Replace 1. Rehydration
2. Fluid Restriction deficient using NaCl
3. Dialysis for hormones
renal failure 2. Fluid restriction /
vaptans (ADHR
antagonist)
3. SIADH =
Demeclocycline

SIADH Syndrome of Inappropriate ADH secretion

Ectopic ADH secretion

Causes
1. Carcinoma [NB]
a. Bronchus
b. Carcinoid
c. breast pancreatic
2. Pulmonary
a. TB
b. Pneumonia
c. Aspergillosis
3. CNS disorders
a. Encephalitis
b. Meningitis
c. Brain tumour / abscess / haemorrhage
Diagnostic Criteria
1. Hyponatraemia (<135 mmol/L) *follow the approach
2. ↓ s-Osmolality (<270 mOsm/kg)
3. Clinically euvolemic
4. u-[Na+] > 40 mmol/L
5. u-osmolality > 100 mOsm/kg
6. No evidence of renal, cardiac, adrenal, pituitary or thyroid disease and pt not taking diuretics

Hypernatremia
• > 160mmol/L = clinically significant
• less common
o Hypernatraemia seldom occurs in:
▪ Alert patients
▪ Intact thirst mechanism
▪ Access to water
▪ ability to drink water
• Assess
1. Serum [Na+]
2. Volume status
3. Urine [Na+]

>> THINK
• Losing water vs gaining sodium

Hypervolaemic Hypernatraemia Euvolaemic Hypernatraemia Hypovolaemic Hypernatraemia

u-[Na+] > 40 mmol/L *acute

CAUSES
1. Iatrogenic u-osmolality < 500 u-[Na+] > 40
- Hypertonic NaCl Renal Losses Renal Losses
- Dialysis 1. Diabetes Insipidus: 1. Osmotic Diuresis
 - NaHCO3 - Central: ADH deficiency
2. Sea water ingestion - Nephrogenic: resistance
[Na+] = 350 – 500 mmol/L to ADH
3. Overconcentrated milk
formula u-osmolality > 500
Extra-renal losses
1. Insensible Losses
2. Polyuric phase of acute
tubular necrosis
u-[Na+] < 25
Extra-renal causes
1. Osmotic diarrhoea
2. Insensible losses

Rx: Rx: Rx:

1. Diuretics 1. 5 % dextrose IVI 1. 0.45% NaCl IVI
2. 5% dextrose IVI 2. or H2O orally/ NG tube

The mechanisms of the cerebral adaptation of sodium disorders

Cerebral Adaptation
Hyponatraemia
• Hyponatraemia in ECF = ↑ water potential therefore water will move into ICF
• Influx of water and swelling of brain cells → Cerebral Oedema
• within hrs → ADAPTATION starts → 2-3 days established
o Secreting osmolytes out of brain cells into ECF to ↑ its water potential in order to prevent
influx of water
o RAPID CORRECTION → Central pontine myelinolysis

Hypernatraemia
• Hypernatraemia in ECF = ↓ water potential therefore water will move into ECF
• efflux of water and dehydration of brain cells
• ADAPTATION Established by 2-3d
o Accumulating intracellular osmolytes to ↓ its water potential and avoid water moving out
of the cell
o RAPID CORRECTION → Brain Oedema

Cerebral Complications
1. Acute Hypernatraemia
a. Cerebral dehydration causes the brain to pull away from the meninges → rupturing
meningeal vessels
2. Cerebral Pontine Myelinosis
a. spastic quadriplegia
b. pseudobulbar palsy
c. cognitive changes
3. Cerebral Oedema
a. compression of the brain against the rigid vault of the skull
Fluid and Electrolytes II [L4]
Identify the FACTORS driving the redistribution of potassium between extracellular and intracellular
compartments

1. pH effect
a. Acidosis = HYPERkalaemia
i. H+ ions displace K+ into ECF
ii. Competition between K+ and H+ ions for
renal excretion = ↑↑H+ will be excreted and
the less K+ will be excreted
b. Alkalosis = HYPOkalaemia
i. Metabolic alkalosis
ii. In attempt to correct alkalosis → H+ shifts
into ECF in exchange for K+ (into cell)
c. *Exception: Acidosis with HYPOkalaemia
i. Diarrhoea
ii. Renal Tubular Acidosis
2. Temperature effect
a. Na/K ATPase pump is energy dependent ↓pH = ↑ K+ ↓temp = ↑K+
b. Recommended storing temp = 25°
c. ↓ temp inhibits glycolysis = HYPERkalaemia ↑pH = ↓K+ ↑temp = ↓K+
d. ↑ temp at 37° glycolysis occurs = HYPOkalaemia
↑ glycolysis = ↑ energy = ↑ pump activity = ↑ INTRACCELLULAR K+ = HYPOkalaemia
3. Insulin
a. K+ INTO cells = HYPOkalaemia
i. ↑ activity of Na/K pump
ii. K+ phosphorylated to glucose-6-phophate
4. B adrenergic agonists
a. enhance uptake INTO cells by stimulating
glycogenolysis = HYPOkalaemia
5. Digoxin
a. Na+K+ATPase pump inhibition = HYPERkalaemia

6. Hypokalaemia
a. enhances K+ efflux
b. Hyperpolarizes cells → difficult to initiate action
potential → SLOWS / BLOCKS nerve conduction
i. muscle weakness
ii. diastolic cardiac arrest
7. Hyperkalaemia
a. Opposes K+ efflux
b. Depolarises cell → Hyperexcitable state
i. Ectopic beats
ii. Ventricular fibrillation
iii. Asystole
Hypokalaemia Causes:
• s-K+ <3.5 mmol/L • Metabolic Alkalosis
• Insulin
Pseudohypokalaemia
• Catecholamines: B adrenergic
• Leukemia
agonists and alpha antagonists
o uptake of K+ by abn leucocytes
• Seasonal Hypokalaemia
o temperature effects → high temperature

Causes
1. Excess losses from GIT or kidney >> most common
GIT losses
s-[K+] ↓
• Chronic Diarrhoea → more direct loss → metabolic acidosis
• Chronic laxative abuse u-[K+] ↓↑
• Vomiting → metabolic alkalosis → hypokalaemia
metabolic alk / acidosis
• Gastric suction
• Fistula – discharge small intestinal contents u- [Cl-] ↓
• Villous adenoma of colon (massive K+ loss) → rare

Renal losses
• Direct mineralocorticoid effects on K+ secretion by DCT
o Primary hyperaldosteronism
s-[K+] ↓
o Cushing syndrome
o CAH u-[K+] ↑
o Renin-secreting tumour
metabolic alkalosis
• Congenital and acquired renal tubular diseases
o Renal Tubular Acidosis u- [Cl-] ↑
o Fanconi Syndrome (wasting K+, glucose, UA, amino acid and
phosphorous)
• Drugs
o Diuretics >> most common
o Amphotericin B

2. Inadequate dietary K+
• Severe malnutrition
o starvation
o alcoholism
• Pareneral nutrition without adequate K+ supplementation
o TPN ++ glucose → release insulin → ↓ K+

3. Abnormal movement of K+ into cells

• Treatment of DKA → Insulin if given without K+ will draw all the K+ into the cell leading to severe
hypokalaemia
• Refractory hypokalaemia from MAGNESIUM deficiency
o impaired proximal Na+ absorption
o promoting urinary loss of K+
o enhances ALDOSTERONE secretion
• After abdominal surgery → ileus → K+ malabsorption
 • After surgery → ANABOLIC state = ↑ body’s requirements

Clinical Manifestations
Mild hypoK+ (3-3.5) rarely causes symptoms

<3.0 mmol/L:
1. Muscle weakness, cramps, fasciculation → risk of paralysis and respiratory failure
2. Polyuria dt impairment of renal concentration (can’t reabsorb water)
3. Cardiac block

ECG Changes
1. Prolonged PR interval
2. T-wave flattening / low ST segment
3. U-waves

Treatment
• K+ administration
o replace
▪ orally ideally
▪ slowly IVI < 20mmol/hr in dilute solution < 40 mmol/L
o monitor plasma K+ regularly
• ± Continuous ECG monitoring
• Treat the cause

Approach
1. s-K+ levels
2. u-K+ levels
3. pH – metabolic alkalosis or acidosis?
4. u-Cl- levels

Conn’s Syndrome – primary aldosteronism

• Autonomous secretion of aldosterone
• Adrenal adenoma or hyperplasia
• Excessive Na+ and H2O reabsorption
 • Concomitant loss of K+ and H+
• Hypernatraemia + Hypokalaemic alkalosis
• Diagnosis:
o HIGH plasma aldosterone levels
o Plasma renin levels SUPPRESSED
o Visualize adrenal gland to exclude tumour

Hyperkalaemia
• plasma K+ > 5.5 mmol/L

Pseudohyperkalaemia >> more common than pseudohypokalaemia

*Check the sample
• Extravascular haemolysis
• Old specimen → leakage of K+ from RBC
• High plt count → release of K+ from platelet during clotting
• Forearm exercise during venepuncture (skeletal mm cells release K+)

Causes
1. From excess total body K+ stores / intake
a. rarely occurs unless
i. In renal impairment
ii. K+ sparing diuretics
2. Abnormal movement of K+ out of cells
a. Metabolic acidosis
b. Hyperglycemia dt insulin deficiency
c. Moderately heavy exercise
d. Digoxin intoxication
e. Cell damage from trauma → K+ leaks
f. Acute intravascular hemolysis *lysis of cells release K+
g. Rhabdomyolysis
h. Tumour lysis syndrome
3. Impairment of renal K+ excretion → OLIGURIA *↑s-creat ↑s-urea
a. Acute RENAL FAILURE
i. Hypovolaemic shock → ↓ renal perfusion → acute tubular necrosis → ↓ excretion of
K+
b. Chronic Renal Failure
c. K+ sparing diuretics – Spironolactone: inhibit aldosterone action (inhibits sodium retention
therefore excretion of sodium and spares K+)
d. Adrenal insufficiency – aldosterone deficiency
i. Addisons Disease
1. Orthostatic hypotension → ↓ ECF volume due to Na+ and H2O loss
2. Pigmentation of buccal mucosa, palmar creases and scars
3. ACTH stimulation test +ve
4. Anti-adrenal antibodies detected
e. Hyporeninaemic hypoaldosteronism – DM
4. Drugs
a. ACE inhibitors – inhibits conversion of Angiotensin I → Angiotensin II therefore aldosterone
not stimulated to retain Na+ and excrete K+
b. B blockers - ↓ uptake of K+ during glycogenolysis
 c. Spironolactone - K+ sparing diuretics
d. Digoxin – NA/K ATPase inhibitor
e. NSAIDs
f. Cyclosporine
g. Lithium
h. Heparin
i. Succinylcholine

Clinical Manifestations
EMERGENCY!!
• Muscle Weakness, tingling, numbness
• Mental confusion*
• Cardiac Toxicity
o ventricular fibrillation
o Asystole in marked hyperK+ > 6.5

ECG Changes
1. Absent P waves
2. Prolonged PR interval
3. Widened QRS complex
4. ST depression
5. Peaked T wave

Approach

1. Exclude pseudohyperkalaemia → check the sample

2. Review of drugs
3. Measurement of electrolytes, BUN, creatinine
4. ECG
5. If renal failure present
a. Renal US to exclude obstruction
Treatment
• Cation exchange resin
• In EMERGENCIES:
1. Ca gluconate NB NB
i. cardio-protective
ii. ↓ threshold potential of myocardial cells
2. Beta adrenergic agonists
i. Salbutamol nebs
3. Insulin with glucose
4. Kayexelate enemas – binds to K+ secreted in colon
5. Refractory → Hemodialysis

Know the endocrine (RAAS) regulation on potassium balance

• Principal cells → excretion, alpha-intercalated cells → reabsorption

• Stretch receptors in afferent arteriole respond to fall in BP
• RENIN secretion
o stimulated by ↓ renal perfusion
o converts angiotensinogen → angiotensin I
o Angiotensin I – ACE→ Angiotensin II
• ALDOSTERONE ↑Na+ ↓K+
o Stimulated by Angiotensin II
o AND directly stimulated by extracellular K+
o stimulate the reabsorption of sodium and the
excretion of K+ and H+ in DCT
Lab Evaluation of GI conditions [L5]
Localize the GI condition either in the stomach or in the intestine based on signs and symptoms

Gastric Disorders Bowel Disorders

1. Gastric Ulcer 1. Coeliac Disease
2. Duodenal Ulcer 2. Diarrhoea – malabsorption disorders
3. Zollinger Ellison Syndrome - IBD: Chrons
- IBS

Know the pathophysiology of Zollinger Ellison syndrome and what diagnostic lab test to use

Zollinger Ellison
• Caused by gastrin secreting tumour → often malignant
o Pancreatic
o Bowel wall
• Severe duodenal ulceration with diarrhoea
• s-[Gastrin] > 500 ng/L 40% have 100 - 500
• 20% have parathyroid and pituitary adenomas → MEN I (3Ps: pancreatic, parathyroid, pituitary)
• Treatment:
o Surgical
o H2 receptor antagonists

Identify the differential diagnoses of ELEVATED PLASMA GASTRIN LEVELS

1. Zollinger Ellison Syndrome

2. Antral G-cell hyperplasia *gastrin secreted by antral mucosa
3. Vagotomy without antrectomy
4. Atrophic gastritis
5. Pernicious anaemia (↓B12)
6. Antacids
7. H2 blockers
8. PPIs

Low s-[gastrin] → antrectomy with vagotomy, hypothyroidism

Select the appropriate diagnostic lab test for coeliac disease Autoimmune intestinal disorder
• epithelial damage → tissue
Coeliac Disease transglutaminase
• sensitivity to gliadin in gluten in wheat → • immune response by gut derived T
cells
Clinical Picture • Inflammation of small intestine
• Chronic Diarrhoea with malabsorption
• Malabsorption
• Weight Loss Anaemia Workup:
• Failure to thrive • MCV and MCH
• Abdominal Distension • Reticulocytes Production Index
• Fe deficiency anaemia → Workup • Peripheral Smear
• A/w: Type 1 DM and other autoimmune d/o • Iron, folate + B12
Diagnosis
• Serology while on gluten-containing diet
o Antibodies:
▪ IgA EMA = IgA endomysial antibody → mostly IgA because it is the mucosal Ab
▪ IgA tTG = IgA tissue transglutaminase antibody
▪ (Anti-gliadin Ab no longer advised)
▪ In selective IgA deficiency → IgG tTG or EMA
• Confirm Diagnosis
o At least 3 jejunal biopsies
▪ Villous Atrophy
▪ ↑ intraepithelial lymphocytes
▪ Hyperplasia of the crypts
• Treatment
o Gluten free diet

Diarrhoea
Secretory Diarrhoea
• input exceeds reabsorption of fluids in colon → solutes derived from GIT secretions

Causes
1. Bacterial toxins (cholera, salmonella)
2. Tumour secreting peptide hormones eg. VIPoma, carcinoid tumour
a. U-5-hydroxy indoleacetic acid excretion*
b. Look for liver mets → ↑ ALP + GGT
3. Irritant laxatives (senna)
4. Malabsorption of BA and their conjugation to potent cathartics by bacterial flora (morning diarrhoea)

Osmotic Diarrhoea
• Diet-derived osmotically active particle

Causes
1. Osmotic laxatives (lactulose)
2. Impaired digestion of normal food constituents eg lactase deficiency, gastrinoma
3. Impaired absorption of digested food products
a. Mucosal damage → IBD
b. Rapid food transit through small bowel (IBS)

Know the difference between acute and chronic diarrhoea

Acute Chronic
• ≤ 1 wk • ≥ 4 wks
• typically dt infectious causes • requires investigation
• self-limiting or easily managed with
antimicrobials

Endocrinopathies
• Hyperthyroidism
• Carcinoids
• VIPoma
• Pheochromocytoma
Steatorrhoea
• pale, loose, floating, foul smelling stool
• Fat maldigestion / absorption
o pancreatic insufficiency
▪ Cx: Hyperglycaemia
o Lack of bile salts → obstructive jaundice

Investigations:
• Microscopic inspection of stool stained with lipohilic stain (sudan III)
• CONFIRMATION TEST: Low fecal elastase and ↑ fecal fat

Assess the severity of diarrhoea by the use of lab tests

Know how to calculate stool OSMOLAR GAP and its utility in the evaluation of chronic diarrhoea

1. Fast the patient + give IV fluid requirements

a. Osmotic Diarrhoea clears up BECAUSE → secretory diarrhoea
b. Secretory Diarrhoea will remain contains osmotically active
2. Osmotic Gap = measured fecal osmolality – 2([Na+] + [K+]) particles:
a. < 50 mOsm/kg = secretory diarrhoea • Na+
b. > 50 mOsm/kg = osmotic diarrhoea • K+
3. Investigations: • HCO3-

a. OSMOTIC DIARRHOEA
i. Fecal pH: < 5.6 suggests carbohydrate malabsorption
1. H2 breath test – lactose
2. Lactase assay
ii. Fecal laxative Screening
1. High Mg output = inadvertent ingestion / laxative abuse

b. SECRETORY DIARRHOEA
i. Exclude Infection = Fecal MC&S
ii. Imaging Studies
1. Chron’s
a. narrowing and ulceration of terminal ileum with an ileo-ileal fistula
iii. Selective testing:
1. Gastrin
2. Calcitonin
 3. VIP
4. Somatostatin
5. Urine: 5-HIAA, metanephrine, histamine
6. TSH
7. ACTH stimulation
8. Serum protein electrophoresis
9. Immunoglobulins
iv. Trial of bile-acid-binding resin for BA diarrhoea
c. OTHER TESTS:
i. Fecal occult blood
1. IBD
2. Colon ca
d. Fecal fat & fecal elastase
e. Deficiency in:
i. Folate, Vit B12, Fe
Pernicious Anaemia
↓ Vit B12
Antiparietal Cell Antibodies
ii. Ca2+, Mg, PO4, total protein, pre-albumin & albumin
iii. Zinc
iv. Vit A, D, E, K (fat soluble)

Select the appropriate a in the assessment of malnutrition caused by chronic diarrhoea

• ANION GAP = K+ + Na+ - [Cl- + HCO3-]

Know the relevant biochemical abnormalities associated in severe acute or chronic diarrhoea

o Acute diarrhoea = NORMAL anion gap

 ▪ predominant loss of Na+, HCO3- and water → no time for reabsorption
▪ dehydration in ECF compartment
▪ Hypokalaemia if not resolved promptly
o Chronic diarrhoea
▪ time for more water and Na+/k+ exchange, hyperchloraemic metabolic acidosis
(loss of bicarb, high Cl)
▪ Dehydration less obvious
▪ emphasis on hypokalaemia
Calcium, Magnesium and Phosphate [L9-10]
Calcium
Calcium Flux / Turnover

Calcitriol*

PTH*

PTH*

Key Hormones regulating calcium homeostasis

1. PTH ↑Ca+ ↓PO4
a. bone → stimulate resorption and release Ca+ into ECF = ↑ osteoclast activity
b. kidney → ↑ Ca+ reabsorption and phosphate excretion
c. also in kidney → stimulates 1alphahydrocylase for Vit D activation in the kidney
d. Gut → ↑ calcium and phosphate absorption from gut
* Phophaturia
Hypercalciuria
Mild acidosis
2. Vit D (CALCITRIOL) ↑Ca+
a. ↑ Ca+ and phosphate absorption
3. Calcitonin ↓Ca+
a. ANTAGONIST of PTH
b. Inhibits osteoclast activity
c. Increases urinary excretion of Ca+
d. Prevents intestinal absorption

Q: What is effect of PTH on URINE calcium?

NB → must know effects of PTH

Vit D
PTH and Vit D
• Total Vit D = D2 + D3
o D2 = diet
o D3 = skin, activated UV light
• calcitriol = active VitD
o ↑ with ↑ PTH
o stimulates resorption in bone and
absorption in the gut = ↑ Ca+
plasma
o forms negative feedback pathway

Describe the METABOLISM of vitamin D.

1. In the skin: 7-dehydrocholesterol is

converted to Calciferol (Vit D3) on
exposure to sun
2. Calciferol is converted to 25(OH)D 25
hydroxycholecalciferol in the liver
3. It is then converted to 1,25 dihydroxy
cholecalciferol or CALCITRIOL
(1,25(OH)2D) in the kidney

Describe biochemical FEATURES of primary, secondary and tertiary hyperparathyroidism.

Primary Hyperparathyroidism
• Sporadic
• Familial

Secondary Hyperparathyroidism
• Malignant disease
o humoral hypercalcaemia of malignancy (PTHrP)
o Widespread skeletal metastases (breast ca common)
o Haematological malignancy (multiple myeloma, adult T cell leukemia, lymphoma)

Tertiary Hyperparathyroidism
Occasionally the parathyroid glands become AUTONOMOUS → tertiary hyperparathyroidism
• massively elevated [PTH] → severe hypercalcaemia
• Rx: calcimimetic drugs or parathyroidectomy

SUMMARY
Calcium PTH
Primary ↑ ↑
Secondary ↓/N ↑
 (hyperparathyroidism dt
hypocalcaemia = could be
corrected)
Tertiary ↑↑ ↑↑

Describe how you would investigate hypercalcaemia

Clinical Features
*be able to recognise clinical picture for case scenarios
Describe important considerations in MEASURING plasma calcium.

Consideration Effect Explanation

↑ pH (alkalosis) ↓ ionised (free) Ca+ H+ dissociate from albumin = free Ca+ BIND to vacant
HYPOcalcaemia sites on albumin
↓ pH (acidosis) ↑ free ionised Ca+ Lesser binding → H+ bind to albumin
HYPERcalcaemia
Plasma albumin Exclusion of air from the sample to avoid changes in binding of calcium to alumin in
concentration response to pH
Pre-analytical 1. Stasis-free collection into evacuated SST
variables 2. Transport on ice
3. Reach lab within 30 mins for centrifugation within 1 hr
4. Tube should be kept sealed to avoid changes in pH and false
measurement

Write a formula for calculating adjusted plasma calcium concentration

What are we adjusting for? - Ca usually complexes albumin forming large molecules that can’t be excreted or enter
cells. Abnormal protein levels can cause falsely abnormal Ca levels
• plasma albumin concentration is [alb] g/L and measured TOTAL ca is [Ca] mmol/L
• [alb] < 40
o [Ca] + 0.02 x (40 – [alb]) mmol/L
• [alb] > 45
o [Ca] – 0.02 x ([alb] - 45) mmol/L

Describe CAUSES of hypocalcaemia.

1. Hypoalbuminaemia
2. Renal Impairment
3. Hypomagnesaemia
4. Hypoparathyroidism
5. Vit D deficiency
6. VDDR type I and II
7. Osteoblastic mets
8. acute pancreatitis
9. multiple blood transfusions
10. inhibitors of bone resorption
11. Hyperphosphataemia
12. Cell lysis
13. Pseudohypoparathyroidism

Phosphate
• Fibroblast growth factor 23 → FGF23
o hormone secreted by OSTEOCYTES
when circulating concentrations of calcitriol and phosphate are INCREASED
o does NOT affect plasma calcium directly
o produced in hyperphosphataemia
o ↑ LOSS of phosphate through the kidneys by inhibiting the sodium-phosphate cotransporter
o Inhibits renal 1 alpha hydroxylase
o NET EFFECT → ↓ serum phosphate, phosphaturia and ↓ serum calcitriol
Describe CAUSES of hyperphosphataemia and hypophosphataemia.

Hyperphosphataemia
1. Chronic Kidney Disease → renal insufficiency
2. Catabolic states: tumour lysis syndrome
3. Hypoparathyroidism / pseudohypoparathyroidism
4. Acromegaly
5. excessive phosphate intake / administration
6. Vit D intoxication

Hypophosphataemia
*COMMON

Causes:
*↓ intestinal absorption, ↑ renal excretion or redistribution from ECF to ICF

1. Redistribution
a. DKA in recovery phase: increased uptake of phosphate into recovering tissues
b. Malnourished patients are given high energy intake
2. Renal Loss
a. primary hyperparathyroidism
b. renal tubular disease
c. diuretics
3. Decreased intake or absorption
a. vit D deficiency
b. alcohol withdrawal (and renal loss, alkalosis and refeeding)
c. Respiratory alkalalosis = formation of phosphorylated glycolytic intermediates

Clinical Effects
• SEVERE cases < 0.3 mmol/L
o muscle cells: muscle weakness or rhabdomyolysis
o red and white blood cells
o platelets
by limiting the formation of essential phosphate containing compounds such as ATP*
• Chronic hypophosphataemia: rickets and osteomalacia

Magnesium
• essential cofactor for many enzymes
• urinary excretion regulates its [] in ECF

Hypomagnesaemia
Describe clinical and biochemical FEATURES of magnesium deficiency.

• similar to those of hypocalcaemia and indeed can cause hypocalcaemia because the secretion
of PTH is magnesium dependent
• Causes:
o prolonged diarrhoea, malnutrition and malabsorption
o alcoholis
o cirrhosis
o Hypoalbuminaemia leads to low plasma [Mg] → Mg binds albumin
Porphyrias [L8]
• Partial DEFICIENCY of one of the enzymes of porphyrin synthesis = ↓ HAEM
• ↑ metabolites before the enzyme block
• Result = excessive quantities of porphyrin precursors = ALA and PBG or porphyrins

Porphyrin Pathway
Need to know this pathway = Enzymes!!

H2O soluble → urine

ACUTE

→ Neuro-visceral manifestations

Negative feedback

CHRONIC

→ Cutaneous manifestations

* ↑ Porphyrins = photosensitivity

H2O insoluble → faeces

- coproporphyrinogen
- protoporphyrinogen
- protoporphyrin

Porphyrias
• Major site of abnormal metabolism = hepatic or erythropoietic

Classification Clinical Site of

Picture abnormal
metabolism
Acute 1. Acute Intermittent Porphyria
→ most common inherited
Neuro-visceral
2. Hereditary Coproporphyria
Hepatic
3. Variegate Porphyria
Chronic 1. Cutaenous Hepatic Porphyria (Porphyria
cutanea tarda) → most common acquired
Cutaneous
2. Congenital erythropoetic porphyria
Erythropoietic
3. Erythropoeitc protoporphyria
ACUTE
1. Acute Intermittent Porphyria
• PBG deaminase
o ↑↑ ALA and PBG
• Neurovisceral Manifestations → photosensitivity NEVER a feature
o Abdominal pain, vomiting, constipation
o psychiatric disturbances
o peripheral and autonomic neuropathy
• Precipitants:
o fasting, barbiturate, sulphonamides, oral contraceptives, alcohol

2. Variegate Porphyria
• Protoporphyrinogen oxidase
o Cutaneous photosensitivity
o ↑↑ Protoporphyrinogen IX
• BUT protoporphyrinogen IX inhibits PBG deaminase
o ALSO get neuro-visceral manifestations

3. Hereditary Corporphyria
• Coproporphyrinogen oxidase
o Cutaneous photosensitivity
o ↑↑ Coproporphyrinogen IX
• BUT Coproporphyrinogen oxidase inhibits PBG deaminase
o ALSO get neuro-visceral manifestations
CHRONIC
• ONLY present with cutaneous manifestations

1. Porphyria Cutanea tarda

• Uroporphyrinogen decarboxylase
o ↑ uroporphyrinogen I + III in urine

2. Erythropoietic protoporphyria and 3. Congenital erythropoietic porphyria

• RARE

Clinical Picture
• Shortly after birth with red-brown urine staining of nappies
• SEVERE photosensitivity
o extensive blistering + tissue destruction
o mutilation of digits and fcaes
• Abn hair growth – HYPERtrichosis

Secondary Porphyrias
1. Liver disease
a. impaired excretion of porphyrins
2. Bleeding ulcers may cause ↑ faecal porphyrins
a. breakdown of Hb in the gut
3. Lead poisoning
a. inhibits ALA dehydratase
b. inhibits Coproporphyrinogen oxidase and ferrochelatase
c. ↑↑ ALA, coproporphyrins AND red cell zinc protoporphrin

INVESTIGATIONS
• ALA, PBG + uroporphyrin → WATER SOLUBLE
• Coproporphyrin is BOTH WATER and FAT soluble → urine AND feces
• Prorporphyrin is only FAT soluble → feces

1. Urine PBG screening test

2. QUANTATION of u-PBG
3. Total porphyrins quantitation
4. Porphyrin fractionation
5. Measure the defective enzyme
6. Genetic studies

Management
1. Removal of precipitating factors
2. Supportive:
a. Maintenance fluids and electrolyte balance
b. adequate carb intake
c. IV haem arginate
d. Pain relief and anti-emetic
3. Avoid precipitants
4. Avoid direct sunlight
Therapeutic Drug Monitoring and Toxicology[L13]
TDM
The Purpose of TDM

• TDM suitable for drugs of narrow therapeutic index

• good correlation between plasma concentration and pharmacological effect

Measuring plasma concentration

• Measure total plasma concentration
o assay must be specific for the drug or its ACTIVE metabolite
o inactive metabolite should not be measured
o should not be affected by other drugs pt taking*
• Protein bound drugs* → hypoalbuminaemia will change result
• bloods taken at steady state → after 5 ½ lives
• most drugs trough levels are measured

Some Specific Drugs

1. Phenytoin:
• Anticonvulsant
• Signs of Toxicity:
o Mimic neurological disease!! → seizures
• Enzyme responsible for metabolism → fully saturated at therapeutic dose*
o elimination decreases at higher concentration
• Diff patients require different doses to reach desired effect
• Presence of drugs metabolised through SAME enzyme may alter phenytoin kinetics
o CYTP450

2. Digoxin
• Mx of atrial fibrillation
• Renal Clearance*
• Acts by inhibiting the Na/K-ATPase pump
o Hypokalaemia potentiates digoxin
• Signs of Toxicity
o Dysrythmias* → confused with Cx of disease
• Assay Interference
o Digoxin toxicity → Rx antidigoxin antibodies → interfere with assay (endogenous substances
which bind to Ab used in immunoassays)

3. Lithium
• Rx: Hypomania, Mania, Prophylaxis in bipolar d/o
• Variable optimum therapeutic range
• Nephrotoxic* → diabetes insipidus
o excreted through kidneys
• Toxicity Rx → ↑ urinary excretion = Dialysis may be necessary
Toxicology
Metabolic Derangement of substances commonly assessed for toxicity

Typical Q: Clinical scenario

• which drug test would you like to order? or

• which drug Is most likely cause of the clinical picture

1. Paracetamol
• Metabolised→ glucuronidation and sulphation = harmless metabolites excreted in urine*
o NAPQI (N-acetyl-p-benzoquinone imine) formed and DETOXIFIED by conjugation with
glutathione
o BUT glucuronidation and sulphation are saturable → excessive paracetamol intake =
↑ NAPQI → hepatotoxic and nephrotoxic

Signs of Toxicity
• < 24 h
o anorexia, nausea, vomiting
• 24-48h
o abdominal pain
o hepatic tenderness
o prolonged PT
o ↑ plasma aminotransferases and bilirubin
• > 48 h
o Jaundice
o Encephalopathy (NH3)
o Liver Failure
o AKI

Management:
1. Acetaminophen levels sample < 4 hrs after ingestion
2. ↑ Prothrombin time → marker of severity
3. ↑ s-creat and metabolic acidosis → poor prognosis > 24 hrs after overdose
4. Always Test: acetaminophen levels, liver and renal function
5. Antidote: N acetylcysteine (promotes hepatic glutathione synthesis)

2. Salicylates
• Aspirin → hydrolysed to active metabolite *salicylic acid* excreted unchanged in urine
• ULN therapeutic range = 350 mg/L (higher doses → toxicity)

Signs of Toxicity
• Tinnitus → early sign
• Metabolic disturbances:
o Stimulation of resp centre → Respiratory Alkalosis
o Metabolic Acidosis
o Uncoupling of oxidative phosphorylation
o Stimulation of central emetic effect → vomiting → electrolyte disturbances
Management
• Alkalanise urine → ↑ excretion in urine = salicylic acid is not ionized in an acidic environment and
unionized salicylic acid can be reabsorbed through tubular cells
o NaHCO3
o Urine pH > 7.5 but < 8.0
• Plasma Salicylic levels measured

3. Lead
• Common in children – ingestion of paint
• Adults – occupational inhalation

Approach
• Levels > 0.5 umol/L warrant further investigation
• Factory workers > 2.9 umol/L
• Symptoms at > 5 umol/L → in children MUCH lower

Signs of toxicity
• N+V
• Abdominal colic
• Severe → encephalopathy
• Convulsions
• Coma
• Intereferes with several steps of the porphyrin synthesis

Management
1. Tests:
a. U-coporphyrin III
b. U-aminolaevulinic acid
c. Protoporphyrin in RBC
2. Rx: chelatin therapy - DMSA

4. Iron
• Toxicity → necrosis of GIT mucosa = haemorrhage, fluid and electrolyte loss

Signs of Toxicity
• Encephalopathy
• Circulatory Collapse
• Renal Failure
• Liver Necrosis

Management
• Desferroxamine – iron chelating agent
• Hydration and avoid hypoglycaemia

5. Ethanol
• CNS depressant

Clinical Picture:
• metabolism ↑ lactate/pyruvate ratio
• hyperlactaemia
 • inhibits gluconeogenesis → hypoglycaemia
• Chronic Ingestion:
o Ketoacidosis
o Hypertriiglyceridaemia
o Hypoglycaemia
o Hypogonadism
o Hyperuricaemia
o Pseudocushings
o Pophyria cutanea tarda

Tests:
1. ↑ ethanol levels
2. ↑ GGT and ↑ mean cell volume
3. ↑ carbohydrate deficient transferrin → gold stnd for chronic ingestion

Treatment:
1. Alcohol dehydrogenase

NB:

Common prescription drugs abused: Opioids, Benzos

Disorders of Carbohydrate Metabolism [L14]
Carbohydrate Metabolism
• Glucose is most nb energy source → carbohydrates dietary source

Hormone functions:
• ↓ blood glucose
o insulin
• ↑ blood glucose
o glucagon
o cortisol
o catecholamines
o growth hormone

Insulin
• Pancreatic B-cells when BG ↑
• Incretins also stimulate release (stimulated by food)
++
o GLP-1
• glycogen
o GIP (glucose dependent insulinotropic peptide)
• glucose → pyruvate
• ACTION:
• lipids
o GLUT4 transporters and ↑ glucose uptake
• protein
o Glycogen synthesis → ↑ glycogen synthase
o Glycolysis = glucose → pyruvate --
(glucokinase, pyruvate kinase and • Glucose
phosphofructokinase) • Ketones
o Lipid synthesis → glycerol and fatty acids • Breakdown of glycogen,
o Protein synthesis → aa from Krebs cycle lipids, proteins
o ↓ Glycogenolysis, lipolysis, proteolysis
o ↓ Gluconeogenesis, ketogenesis

Glucagon ↑circulating glucose

• ᾳ cells when BG ↑ ++
• ACTION: opposes insulin • Glucose
o Liver glycogenolysis (glycogen phosphorylase) • Ketones
o Gluconeogenesis, Lipolysis, ketogenesis • Breakdown:
o ↓ Glycogen synthesis o glycogen, lipids,
o ↓ Glycolysis = glucose → pyruvate proteins
o ↓ Lipid synthesis
--
o ↓ Protein synthesis
• glycogen
Disorders of Carbohydrate Metabolism • lipids
• proteins
1. Hyperglycaemia (↑BG)
Diabetes Mellitus
Type 1 Type 2
Autoimmune destruction of B cells → rapid loss Insulin resistance → gradual B cell exhaustion
of insulin
• Children + Young adults • Overweight (metabolic syndrome) , older
pts
• Develops ketones ++ → DKA • NO ketone formation
 • Autoantibodies → Islet cell, GAD, Insulin • No antibodies
• Genetic susceptibility • Strong familial inheritance – polygenic, no
HLA association
• Treated with INSULIN • Treated with DIET and DRUGS
Secondary Diabetes
• Diabetes resulting due to pancreatic damage
o Chronic pancreatitis, haemochromatosis, cystic fibrosis
• Secondary to disease with ↑ counter regulatory hormones
o Cushing syndrome → CORTISOL
o Acromegaly → GROWTH HORMONE

DIAGNOSIS
WHO guidelines:

• Normal fasting BG < 6.1 mmol/L

grey top (sodium fluoride)
• Normal 2hOGTT glucose < 7.8
• Impaired fasting glucose - glycolysis INHIBITOR
o fasting BG = 6.1-6.9
o 2h-OGTT glucose < 7.8
• Impaired glucose tolerance
o fasting BG < 7
o 2hOGTT glucose 7.8-11.1
• Confirmed diabetes: any one of the following:
o Fasting BG > 7
o 2hOGTT glucose > 11.1
o random BG > 11.1
o HbAc > 6.5 % (shows glycaemic control of 2-3 months)

Oral Glucose Tolerance test

• Detects pre-diabetes
• overnight fast → 75g oral glucose → blood glucose measured @ baseline and after 2h
• used to evaluate GLUCOSE METABOLISM in patients NOT MEETING THE DIABETIC CUTOFFS
• NB
o recommended in Gestational Diabetes
o opportunity for early detection

HbA1c
• Shows glycaemic status → over 2-3months
• Normal HbA1c < 42 mmol/mol
• Diabetes likely > 48 mmol/mol
• Levels dependant on RBC lifespan and average BG

Situations where NOT indicated:

1. Hyperglycaemia developed RAPIDLY

2. Pregnancy → OGTT and fasting BG
3. Abnormal Haemoglobin → HbS, HbF
4. Abnormal RBC lifespan
a. haemolytic anaemia
b. iron/B12 deficiency
 c. CLD
d. CKD
e. post splenectomy / splenic disease
*IF HbA1c does NOT make sense → do an OGTT

MONITORING TREATMENT
• 3 monthly HbA1c
o AIM < 53
• SELF monitoring with glucometer
o 5-7 mmol/L in morning
o 4-7 mmol/L before meals
o 5-9 mmol/L after meals
• Measure Urine or plasma ketones
o Urine Dipstick = may underestimate ketone load and severity of DKA
o Better → Plasma 3-OH-buturate at bedside with point of care ketone meter
(3-OH-B > acetoacetate in DKA because acetoacetate converts to 3-OH-B in acidosis)
• Screen for hyperlipidaemia
o ↑ LDL ↑ Triglycerides ↑ VLDL ↑ Chylomicrons
o ↓ Lipoprotein lipase
o ↓ Hormone sensitive lipase
o All diabetics should get STATINS
• Screen for diabetic nephropathy
o Urine albumin:creatinine ratio > 3 mg/mmol
o Serum creatinine and eGFR
• Screen for retinopathy and neuropathy → clinically

DKA – Acute metabolic disturbance

Management
1. Replace insulin with short acting IV insulin
2. Replace lost electrolytes: Na+ and K+
3. Support kidney function
4. Maintain tissue perfusion
5. Treat precipitating cause

Monitoring

• 6 hrly U+E, glucose, ketones

2. Hypoglycaemia
• blood glucose < 3 mmol/L
• Neurological and adrenergic features

1. Reactive Hypoglycaemia
• Follows a stimulus
o Drugs
▪ Insulin
▪ Anti-diabetic
▪ B-blocker
▪ Salicylates
o Stress or illness
o Alcohol
o 90-150 min after a meal in post gastric surgery pts → dumping syndrome
o galactosaemia → inborn metabolic disease

2. Fasting Hypoglycaemia
• Insulinoma → tumour of pancreatic B cells
o BG < 3 with ↑ serum insulin, ↑ serum C-peptide and ↓ ketones
• MUST collect blood when pt has symptoms
o try after overnight fast or 6hrly during a 72 hr fast
• MUST exclude surreptitious use of anti-diabetic drugs
o urine sulphonylurea screen
o c-peptide ↓ if pt is secretly injecting insulin

3. Neonatal / childhood Hypoglycaemia

Any serious illness, cancer or disease affecting counterregulatory hormones can cause hypoglycaemia

• Alcohol, drugs, toxins

• Sepsis
• Liver disease (↓ gluconeogenesis, glycogenolysis)
• Kidney (↓ gluconeogenesis, ↓ breakdown of insulin)
• Adrenal disease (↓ catecholamines, cortisol)
• Pituitary disease (↓ ACTH, growth hormone)
• Solid organ malignancies or metastatic cancer (glucose consumption, ?IGFs)
Liver Function Tests [L15]
Describe common causes of liver disease.

1. Hepatitis
2. Liver Cirrhosis → hypertension in portal venous system and cholestasis
3. Tumours

Identify the components of the LFT.

Identify and discuss markers of synthetic function.

1. Albumin
a. Causes:
i. Chronic liver disease
ii. Negative acute phase reactant – decrease in [albumin] in inflammation
b. Serum Ascites Albumin Gradient
i. SAAG = serum albumin – ascites albumin
1. HIGH gradient > 1.1g/dL = PHTN and non-peritoneal cause of ascites
2. Low SAAG <1.1 g/dL = peritoneal cause
2. Clotting Factors
a. Prothrombin time → reflects activity of vit K dependent clotting factors synthesized by the
liver: II, VII, IX, X
i. Acute liver disease ↑ PT
ii. Vit K deficiency ↑ PT
iii. Malabsorption of fat
iv. ↓ BA synthesis

Identify and discuss markers of hepatocellular damage. Aminotransferases increased levels:

1. ↑ ALT / AST • Mild: < 5x ULN
a. ALT more specific for liver damage • Moderate: 5–10x ULN
2. ↑ UNconjugated bilirubin • Severe: > 10x ULN
Isolated Increased aminotransferases: • Acute hepatitis: >5-10 xULN
• Chronic hepatitis: 10-100 xULN
1. Hepatitis – viral or autoimmune
2. NAFLD
3. Drugs

Identify and discuss markers of cholestasis.

1. ↑ ALP / GGT
a. dt hepatocyte swelling compressing intra-hepatic bile ducts →
2. ↑ conjugated bilirubin

Which 2 enzymes are nb in identifying cholestasis?

1.Alkaline Phosphatase (ALP)
• Sources: Liver, Bone, GIT, placenta, tumours
• T1/2 = 10d → serial progression repeat every 2 weeks

>> Hepatocellular damage = 3 x increase URL

 >> ISOLATED ALP increase → bone / GIT / germ cell tumour

• Remember* total ALP is measured NOT liver-specific ALP

o Cholestasis stimulated increased production of ALP by biliary epithelium
o Levels are proportional to bile duct obstruction

2. γ-glutamyltransferase (GGT)
• T1/2 = 4 days

>> Hepatocellular damage = 5x increase

>> Biliary obstruction or space occupying lesion = > 25 fold increase

>> ISOLATED GGT increase → usually dt enzyme induction (ethanol or drugs) NOT liver damage

• Increased GGT is found in both

o Cholestasis
o Hepatocellular damage
>> Therefore this enzyme is VERY SENSITIVE indicator of hepatobiliary disease but is NON-
specific

Intra-hepatic OR extra-hepatic obstruction causes significant increase in ALP and GGT

Describe the detoxification function of the liver.

Describe markers important in the detoxification function of the liver.

• In the gut: Dietary protein → ammonia
• In the liver: Ammonia → urea *urea cycle

Causes of elevated urea:

1. High protein meals

2. GIT bleeding
3. Renal failure

NB: Urea cycle is impaired in patients with liver cirrhosis → AMMONIA enters the systemic circulation
• Porto-systemic shunting delivers ammonia straight into the systemic system
• HEPATIC ENCEPHALOPATHY

Describe markers of specific liver diseases.

Alcoholic Liver Disease

• No specific biochemical DIAGNOSTIC markers
• Surrogate markers include:
o ↑ γGT *disproportionate to any increases in other liver enzymes
o AST:ALT > 2
o Hypertriglyceridaemia
o ↑ s-IgA
o red call macrocytosis
Hyperbilirubinaemia *use surgery notes rather*
1. Pre-hepatic jaundice and Unconjugated hyperbilirubinaemia
• Causes:
o Liver disease
o Haemolysis
o Gilbert Syndrome
o Physiological Jaundice in neonates
• Metabolic picture:
o ↑ unconjugated bilirubin
o ↑ bilirubin in stool
Haemolysis
o ↑ urinary urobilinogen
• Complications:
o Kernicterus: unconjugated hyperbilirubinaemia is fat soluble fraction and can cross BBB

Lab Findings:

2. Conjugated Hyperbilirubinaemia
• Dark urine and pale stools
o ↑ urobilinogen into circulation
o ↓ stercobilin – obstruction does not allow bilirubin to reach gut

3. Delta Bilirubin
• Conjugated bilirubin covalently bound to albumin
o Longstanding CONJUGATED hyperbilirubinaemia
o ½ life similar to that of albumin therefore explaining why jaundice persists even with absence
of bilirubinuria
Interpret the biochemical patterns in liver disease.

Analyse and interpret a patient case study in conjunction with a LFT result.

Describe the clinical utility of catabolic and anabolic markers produced by the liver.

List characteristics of protein markers synthesised in the liver.

Summary
1. Jaundice?
a. Unconjugated or conjugated bilirubin?
2. Protein
a. Albumin – synthetic function
b. Total protein
c. Gamma globulin gap = If HIGH IGs
3. Clotting factors
a. prolonged PT – synthetic function
4. Hepatocyte damage
a. ALT predominantly
5. Cholestatic jaundice
a. mostly ALP and GGT
b. *malignancy → GGT shows hepatic origin
6. Haemolytic jaundice
a. LDH ↑
b. Haptoglobulin ↓
7. Acute liver failure
a. ↑ NH3
Renal Function Tests [L17]
Common Laboratory Tests
Urinalysis 1. Protein
2. Blood glucose
3. Ketones
4. Bilirubin
5. Hb
6. pH
7. SG
8. Nitrite
Routine Lab Tests 1. Blood urea and creatinine
2. Electrolytes
Others 1. Creatinine clearance and eGFR
2. Beta- 2 microglobulin

1. Proteinuria
3 choices to measure Proteinuria
1. Disptick
2. Total protein corrected for creatinine
3. Microalbuminaemia

Dipstick:
• Dipstick → mostly +ve tests are benign
• GRADING of proteinuria is nb
• N urine protein < 150mg/day
o 20 % LMW → Igs
o 40 % HMW → albumin
o 40 % tubular mucoproteins

Categories
• Persistent proteinuria ≥ 1+
o Early sign of CKD
▪ diabetes nephropathy
▪ HT
▪ GN
• Proteinuria > 300 mg /day
o Random fresh urine sample
o Correction using creatinine
• Benign

Microalbuminaemia
• ↑ SENSITIVE test compared to dipstick
• detects low [albumin] in urine
• 30-300 mg/day or 20-200 ug/min
• Indication of EARLY nephropathy → used in screening for diabetic nephropathy

Sites of damage determines constituents of protein lost

1. Overflow Proteinuria
a. high presence in plasma > tubular reabsorptive capacity
b. LMW proteins
i. Bence Jones protein
 ii. Immunoglobulin light chains in myeloma
2. Glomerular proteinuria: 2-3 g/day
a. Heavy proteinuria → indication of CKD!!! DM, glomerular disease, HT
i. Albumin!!!
ii. Immunoglobulins
3. Tubular Proteinuria: < 2g / day
a. LMW proteins
i. RBP: retinol-binding protein
ii. ᾳ-1 microglobulin
iii. B2 microglobulin
4. Secretory
a. Tamm Horsfall protein
b. Immunoglobulins
c. UTI / bladder tumours

Tests Used
1. Urine Protein Electrophoresis
2. Electophoresis coupled with Immunofixation

2. Creatinine
• More SENSITIVE and SPECIFIC test of renal function than urea
o mainly filtered by the kidney
o small amount actively secreted too
o NO tubular reabsorption
• Dependant on muscle mass:
o Female = 45 - 90 umol/L
o Male = 60 – 110 umol/L

Causes of elevated plasma creatinine

1. Severe damage to nephrons → acute kidney injury
2. Consider other causes besides AKI:
a. Massive rhabdomyolysis / crush injury
b. Diet – red meat
c. Pt stature → body builder, adult men = higher baselines
d. Drugs: probenecid, cimetidine…
e. Cephalosporins and ketone bodies cause interference with the lab assay → analytical
interference

Causes of low plasma creatinine

Factors impacting creatinine measurement:

1. Elderly and Infants

2. Chronic illness
3. High bilirubin levels → make falsely low
4. Vegetarians: no creatinine in diet
Creatinine Clearance

• Varies based on age, gender and body size

o Adult males = 90-140 ml/min
o Adult females = 80-125 ml/min
• Clearance can be corrected for BSA
o ml/min/m2

Impaired CrCl values

eGFR
• alternative to CrCl → calculate estimate of the clearance from the s-creatinine
• Formula = MDRD (modification of diet in renal disease)→ 4 variables
o creatinine
o age
o corrective factors for:
▪ ethnicity
▪ gender

Midleading eGFRs
1. AKI
2. increased vol of distribution for creatinine → oedema of heart failure or nephrotic syndrome
3. pregnancy
4. ↑/↓ in muscle mass
5. extremes of age
6. ethnic groups
7. malnutrition and obesity
8. meat rich meal
9. drugs interfere with renal secretion of renal tubules

3. Cystatin C
>>Provide better estimated of GFR than those based on creatinine alone

• improved accuracy over creatinine

 o small protein freely filtered by the glomerulus and completely* reabsorbed by the PCT cells
o *not influenced by sex or muscle mass
o BUT may be increased in malignancy, hyperthyroidism and steroids
• not routinely available*
• SENSITIVE SCREENING test
• single RR for male and female above 50
• useful in paeds

4. CKD-EPI
• Correlates better with measured GFR than original MDRD formula esp for values > 60mL/min
• Variables: serum creatinine, sex, race
• Addition of [cystatin C] to the CKD-EPI improves the accuracy of eGFR BUT high cost restricts
use
• MAJOR USE of CKD-EPI: Screening Tool for CKD

5. B2-Microglobulin (B2M)
• good as a measure of GFR → similar to creatinine
• VERY SENSITIVE INDICATOR OF RENAL TUBULAR DISEASE
• Prognostic marker in multiple myeloma

6. Urea
• Less specific than s-creat in assessing renal function:
o ECF vol
o protein intake and catabolism
o renal blood flow
• Plasma urea and creatinine more complete estimation* → urea:creatinine ratio
o HIGH urea>creat = pre-RF
▪ dehydration

Extra-renal influences on [urea]

↑↑

• high protein intake

• GI bleeding
• dehydration
• hypercatabolic state
• congestive cardiac failure
• urinary stasis
• muscle wasting/amputation

↓↓

• low protein intake

• dialysis
• severe liver disease

Biochemical Indices
• Fractional excretion of Na (FENa)
o 100 x (uNa x PCr)
(PNa x UCr)
 • Renal function index (RFI)
o (UNa x PCr)
UCr
• Urea:Creat
• Urinary Na: mmol/L
• Urinary Osmolality: mosmol/kg

Interpretation of indices for ARF

Limitations:
• Urea:Creat ratio > 70
o Common in elderly
o Marker of ill health
• FE Na < 1 %
o diuretics increase excretion Na
o Secondary hyperaldosteronism (cirrhosis) → Na excretion is decreased

Renal Pathologies
Acute Kidney Injury
Causes
Pre-renal Intrinsic renal Post-renal
↓ renal blood flow Damage to kidneys Urinary tract obstruction
• Dehydration • glomerulonephritis • bilateral obstructing
• Hypotension • SLE kidneys tones
• Haemorrhage • Vasculitis • prostatic enlargement
• Septiceamia • Nephrotoxins: NSAIDs, • other urinary tract
• ↓ CO aminoglycosides, xray neoplasms
• Burns contrast • retroperitonela fibrosis
• Intra-renal obstruction: • neurogenic bladder
Bence Jones protein
Staging
• The higher the level of creatinine and the longer the
duration of oliguria = the worse the prognosis of AKI
• don’t need to memorise

Biochemical Changes in plasma

Increased Decreased
• Potassium • Sodium → Hyponatraemia
• urea • Bicarbonate → metabolic acidosis
• creatinine • Calcium → hypocalcaemia
• phosphate
• magnesium
• H+
• urate

NB: Measurement of urine kidney injury molecule-1 or neutrophil gelatinase-associated lipocalin

helps to identify patients at high risk of developing intrinsic kidney injury → their concentration rise before
that of plasma creatinine

Post-renal AKI
• obstruction to flow of urine = ↑ hydrostatic pressure in collecting ducts → secondary renal
tubular damage
• Obstruction that occurs above the level of urethral insertions in the bladder must be bilateral to
have a major effect on urine flow
• Complete anuria is rare with AKI from other causes and thus is strongly suggestive of obstruction
• More often, obstruction is either intermittent or incomplete, and urine production may even be
normal in obstruction with overflow
• The degree of reversibility of renal damage in obstructive kidney injury depends to some extent on
how longstanding the obstruction is
• More likely to be reversible if obstruction is acute

Chronic Kidney Failure

• Neurological
o lethargy
o peripheral neuropathy
• Genitourinary
o nocturia
o impotence
• Cardiovascular
o anaemia
o hypertension
o pericarditis
• Musculoskeletal
 o growth failure Kidney Failure:
o bone pain
o myopathy • GFR < 15
• Gastrointestinal
o anorexia
o N+V
o GI bleeding
• Dermal
o pruritis
o pallor

Diagnosis
• ↓ eGFR
• ↑ albumin:creatinine ratios

CKD and endocrine effects

• Calcitriol synthesis
• ↓ testosterone and oestrogen
• Abnormal thyroid function
• Abnormal glucose tolerance with hyperinsulinaemia (insulin resistance)

List 4 hormones affected by established kidney disease:

1. ↓ Erythropoeitin
2. Calcitriol
3. Thyroid functions ± clinical abnormalities
4. Insulin

CKD and Anaemia

• normochromic normocytic anaemia
• ↓ erythropoietin
• Iron deficiency may contribute to anaemia

CKD and dyslipidaemia

• hypertriglyceridaemia
• increased plams concentration of remnant particles
• High risk of CVD which is common in advanced CKD
Acid-Base Disorders [L20]
Normal Values
• pH 7.35-7.45
• [H+] 35–45 nmol/L
• PaCO2 35-45mmHg
• HCO3- 22-26 mmol/L
• Anion gap 14 –18mmol/L

Mechanisms of regulation of acid-base homeostasis; Compensatory mechanism for acid base

disturbances → Buffer systems in blood and urine; Henderson-Hasselbalch equation

1. Principle buffer system in all cells: Henderson-Hasselbach equation

a. H++ HCO3- ↔ H2CO3 ↔ H2O + CO2
>> Carbonic Anhydrase
2. Urinary Buffers:
a. HPO4- + H+ ↔ H2PO4-
b. NH3+ H+ ↔ NH4+
3. Red blood cell
a. Hb- + H+ ↔ HHb

Interpretation of blood gas results → be able to identify simple acid base abnormalities

Approach to diagnosis of acid base disorders

1. pH – is there acidosis or alkalosis?

2. Is the disturbance metabolic or respiratory?
a. Look at PaCO2 and HCO3
3. Is there APPROPRIATE compensation?
a. Compensatory Mechanisms
 4. Some aids in interpretation of acid-base disorders

Common clinical conditions giving rise to metabolic or respiratory acidosis or alkalosis →

Differentiate respiratory from metabolic causes

Metabolic Acidosis AG = [K+ + Na+] – [HCO3- - Cl-]

High Anion Gap • Normal = 14-18 mmol/L
• “MUDPILES”
o Methanol
o Uremia – Renal Failure
o DKA
o Profound Hypoxemia
o Iron, Isoniazid
o Lactic Acidosis
o Ethylene glycol
o Salicylates, Shock, Septicaemia

Normal Anion Gap

• Renal Tubular Acidosis:
o Failure to reabsorb bicarb by the kidney (RTA 2)
o Failure to secrete H+ ions by the kidney (RTA 1)
• Failure to regulate bicarb
• Extra-renal loss of bicarb
o Diarrhoea
o Ileostomy

TEST Q: Case of child with metabolic acidosis w NORMAL anion gap:

• RTA
• Diarrhoea

Metabolic Alkalosis
Causes:
• Volume depletion
o VOMITING
o pyloric stenosis
• Chronic alkali intake
 • Potassium depletion
o inadequate intake
o mineralocorticoid EXCESS
▪ Conn syndrome
▪ Cushing’s syndrome

Respiratory Acidosis
“retaining CO2”

• Airway Obstruction
o COPD
o Bronchospasm → asthma
o Aspiration
• Pulmonary disease
o Pulmonary fibrosis
o Severe pneumonia
• Depression of respiratory centre
o Anaesthetics
o Cerebral trauma
• Neuromuscular disease
o Guillian Barre syndrome
o Motor Neuron disease

Respiratory Alkalosis
“breathing off too much CO2”

• Increased respiratory drive Salicylates:

o high altitude
• Resp Alkalosis: initial
o severe anaemia
presentation dt HYPER
o pulmonary disease → PE, pulmonary oedema
ventilation
o Respiratory stimulants eg salicylates
• Later metabolic acidosis
• Voluntary hyperventilation → anxiety
• Mechanical overventilation (in anaesthetics)
Thyroid Functions Tests [L22]
*includes surgery notes

Regulation of Thyroid Hormone Synthesis and Metabolism

Understand the biosynthetic pathways involved in thyroid hormone synthesis and their action:

Need to know basic physiology to work out scenarios

Synthesis of Thyroid Hormones

1. Follicle = Colloid + surrounding cuboidal cells → Thyroid Hormones
2. Parafollicular cells = “C-cells” → Calcitonin
3. Parathyroid chief cells → PTH

Tyrosine residues

1
2 TPO

5
4
DIT T4
T4
3

T3
6
MIT

Process
1. Trapping Iodine “trapped” → pumped into cell via Na/I transporter
• Activated: TSH ++ binds to TSH receptor, Graves Ab
• Inhibited: Iodine (-ve feedback), ClO4-
2. Iodide Oxidation TPO (thyroid peroxidase)
+ Organification → oxidises iodide
→ binds it to tyrosine residues in thyroglobulin Thyroglobulin:
→ Iodotyrosine: Protein made in
2 iodines = DIT ER + produced in
1 iodine = MIT vesicles →
TPO: exocytosed: ↑
Activated: TSH thyroglobulin in
Inhibited: Carbimazole, Propylthiuracil, Methimazole colloid
(Thioamides)
Iodides (Lugol’s solution) → interferes with
organification
3. Coupling TPO catalyses → Iodotyrosines couple up: TPO catalyses:
DIT + DIT = 4 iodines → T4 • Oxidation
MIT + DIT = 3 iodines → T3 • Organification
• Coupling
4. Endocytosis Thyroglobulin + conjugated iodotyrosines
 5. Proteolysis Thyroglobulin molecule is degraded
• Triiodothyronine (T3)
• Thyroxine (T4)
6. Secretion Activated: TSH
Inhibited: Iodine (Iodides: Lugol’s solution), Lithium
Taken up by carrier proteins:
1. Thyroxine Binding Globulin (TBG) –
↑↑ affinity: 70% + has 1 binding site
++ : estrogen → ↑ total T3 T4 but still euthyroid
- - : congenital TBG deficiency → ↓ total T3 T4 but still euthyroid
2. Transthyrotine
Rapid
3. Albumin
Metabolism: Deiodinase
• T4 → T3

Control of Thyroid Function

Mechanisms that regulate the hypothalamic-pituitary-thyroid
axis:

Hypothalamus ++ TRH → ant pituitary ++ TSH → Thyroid ++ T3/T4

Regulation of thyroid hormone synthesis and metabolism:

1. TRH
2. TSH
3. Negative feedback of T4 and T3
4. Conversion of T4 → T3

Physiological Function of Hormones

Thyroid Hormones (T3 & T4)
↑ BMR
Heat Generation:
• ↑ Na+/K- pumps, mitochondria
• Except: brain, testes, uterus, LN, spleen, ant pituitary
Metabolic
• ↓ cholesterol production + ↑ catabolism FA
• ↑ absorption of glucose, gluconeogenesis, glycolysis
• ↑ synthesis + catabolism of proteins
CVS:
• ↑ alpha MHC ↓ beta MHC
• ↑ beta receptors (↑sensitivity to catechlamines)
• ↑HR, ↑ CO, ↑ pulse pressure, ↓PVR (vasodilation)
↑erythropoiesis
Resp
• ↑ RR
GI
• ↑ motility + secretion
CNS
• ↑ CNS activity + alertness
• N neuronal function
Growth + Developme nt
Thyroxine potentiates growth hormone
• Normal myelination + axonal development
• Stimulate skeletal growth
 • Promote bone mineralization

Causes and features of thyroid dysfunction and the INVESTIGATIONS that should be performed
when thyroid disease is suspected

Features
Hypothyroidism vs
CNS 1. Tiredness/lethargy
2. Mood changes (depression)
3. Cold intolerance
4. Bradycardia
CVS
5. Weight gain despite
Resp
6. ↓ appetite
GI 7. Constipation
8. Menorrhagia
9. Muscle weakness
GU
Inspection
1. Facial and eyelid oedema
Msk 2. Obesity
3. Dry thin hair
4. Loss of outer 1/3 of eyebrow
5. “Peaches & cream” complexion
Palpation
6. Muscle weakness
7. Cold peripheries
8. Oedema
9. Hyporeflexia
10. Carpal Tunnel Syndrome
Auscultation
11. Bradycardia
Hyperthyroidism
1. Hyperactive
2. Mood changes (anxiety, irritability)
3. Heat intolerance
4. Tachy, Palpitations
5. Dyspnoea (CF)
6. Weight loss despite
7. ↑ in appetite
8. Diarrhoea
9. Oligomenorrhoea
10. ↓libido
11. Tremors
12. Proximal weakness
Inspection
1. Staring/ unblinking
2. Eye Sx:
[5] Lid retraction, Exopthalmos,
chemosis, opthalmoplegia,
proptosis
3. Thin (↓BMI)
4. Alopecia
5. Face appears flushed
Palpation
6. Proximal myopathy
7. Warm + sweaty palms
8. Tremors
9. Clubbing / onycholysis
10. Pre-tibial myxoedema
11. Hyperreflexia
Auscultation
12. Tachycardia @ rest ± Afib

Causes Hypothyroidism
1° Hypothyroidism
Acute Sub-acute Subacute Hashimoto’s Reidels
Granulomatous Lymphocytic Thyroiditis
Bacterial infection Viral infection Autoimmune Autoimmune Fibrous tissue
- staph - coxsackie / (atrophic) inflammation – replaces thyroid
mumps ± postpartum dense lymphocytic tissue (rare)
infiltrate
De Quervain’s Microsomal Microsomal auto-Ab
disease autoantibodies - anti-TG
- anti-TPO
Initially = Thyroid Damage and inflammation→ ↑ thyroxine release –
HYPERthyroidism
Later = Hypothyroidism as the gland is progressively destroyed
Therefore: Hypothyroidism is preceded by hyperthyroidism
Pain ++ URTI → painful a/w: a/w
Fever thyroid - vitiligo other sclerosing
conditions
Cervical - pernicious
Lymphadenopathy anaemia
- Addisons
- Down Syndrome
- Turners
- Klinefelter
PAINFUL painless
↓ Iodine uptake Mutinucleated Microsomal auto-
giant cells Ab
- lacks germinal
follicles
Rx: penicillin / Self limiting ↑↑ risk of B cell Rx:
ampicillin malignant corticosteroids
lymphoma with Tamoxifen
longstanding Surgery
Hashimoto’s

Other Causes:
• Drugs
o Amiodarone → inhibits D1 → ↓ uptake of iodine by the cell
o Lithium → ↓ secretion
o Sulphonylureas
• Iodine deficiency → most common cause of goitre
• Neoplasms
• Iatrogenic → post-thyroidectomy + irradiation

2° Hypothyroidism
• Hypopituitarism
• Hypothalamic Dysfunction
• Isolated TSH deficiency

Causes Hypethyroidism
1° Hyperthryoidism
Graves Disease
Autoimmune disease
Antibody (thyroid stimulating IgG
antibody) targets TSH receptor
(anti-TSH)→ activates it and
STIMULATES ++ TSH
o Exophthalmos: adipose +
glycosaminoglycan
deposition behind eye
- proptosis + mm weakness
o Myxoedema: deposition of
multipolysaccharides in
dermis
o Thyroid acropathy: ↑
deposition in extremities
(clubbing)
o Bruit: vascularity
Toxic Multinodular Goitre Toxic Adenoma
IODINE deficiency Solitary secreting adenoma,
Longstanding non-toxic goitre→ TSH secretion + the remainder
constant hyperplasia + evolution of the gland is suppressed
→ autonomous nodules become
hyperactive and function
independently of TSH levels
“Plummer’s Disease”: single
toxic nodule (adenoma) present
with the b/g of a suppressed
multinodular goitre
Eye signs are rare in these pts
↓ TSH ↑ iodine uptake: hot nodules – ↑ iodine uptake: 1 hot nodule
↑ T4 multiple patchy areas and remainder of the gland is
↑ iodine uptake: cold
diffuse

Treatment:
1. Medical
o Antithyroid Drugs → Thioamides: Carbimazole, Propylthiuracil, Methimazole
➔ Inhibit TPO: oxidation, organification, coupling
➔ PTU also inhibits D1 which inhibits T4 → T3 conversion
S/E: AGRANULOCYTOSIS
Hypersensitivity reaction: rash
Cholestatic hepatitis
MMI not used in pregnancy → cretinism
PTU can be used “p for pregnancy”
o Iodine
o Destroy gland using radioactive iodine
→ Pt rendered euthyroid then:
2. Surgical
o Thyroidectomy
o Toxic adenoma – hemithyroidectomy
o + adjuvant radioactive radio-iodine ablation

Thyroid storm:
1. Propanolol: Beta blocker + blocks deidonase
2. Lugol’s solution
3. Thioamides
4. Glucocorticoids
5. Diltiazem (CCB)

2° Hyperthyroidism
• TSH secreting pituitary adenoma – TSH ↑ despite ↑ T3 + T4
• Gestational thyrotoxicosis - ↑ HCG stimulates TSH receptors
• Neoplasms – metastatic thyroid ca

Investigations of Thyroid Function

1. GOLD STANDARD
Serum TSH → followed by free T4, T3
a. LOW → Hyperthyroidism (↑T4 + T3 ± anti-TSH)
b. HIGH → Hypothyroidism (↓T4 + T3 ± anti-TPO, anti-TG)

When is TSH first line okay?

• Monitoring pts on thyroxine
• Screening at risk pts who are symptomatic

When is TSH first line not ideal? (should do more tests – not TSH alone)
• Symptomatic pt on first presentation
• Optimising treatment
• Screening and monitoring in pregnancy
• Dx and monitoring of hypopituitarism
• Dx of TSHoma and thyroid hormone resitance
Other tests:
1. Thyroid ca – follicular ca: thyroglobulin used as a marker
2. TRH test – secondary hyperthyroidism
a. TSH oma or thyroid hormone resistance
b. TRH injected and assess TSH level
3. Antithyroid peroxidase antiobodies: auto-immune thyroiditis
4. TSH receptor antibodies: Graves disease

Who should have a thyroid function test done?

1. Symptomatic patient
a. ft of thyroid disorder
b. family hx
c. elderly pt with nonspecific sx
d. women presenting in menopause with non-speficic sx
e. taking thyroxine
2. Pts at risk of developing thyroid disease
a. presenting with diabetes
i. Type 1 → annual check
ii. Type 2 → at diagnosis
b. Annual check
i. autoimmune disease
ii. treated hyperthyroidism → at risk of HYPOthyroidism
iii. Downs and Turners
iv. Post neck irradiation
c. Before Rx and 6 monthly check ups:
i. Lithium or amiodarone

How to interpret the results of thyroid function tests both for diagnosis and monitoring the patient

Hypothyroidism

Management:
1. T4 replacement therapy
2. Once stabilised annual check*
Hyperthyroidism

*Measurement of TSH not reliable in first 4-6 mo

Biochemical patterns in thyroid / non-thyroid disease

Subclinical Disease
The concept of subclinical thyroid disease and when treatment should be implemented in such pts

When to treat Subclinical hypothyroidism:

• Only if TSH REMAINS > 10 mU/L
o If TSH 4.5-10 mU/L → no Rx unless
▪ + anti-TPO antibodies
▪ goitre
▪ pregnancy
Causes of abnormal TSH in clinically euthyroid patients
Low TSH in euthyroid pt (no signs / symptoms) High TSH in euthyroid patient
1. Subclinical hyperthyroidism 1. Subclinical Hypothyroidism
2. Treated hyperthyroid patients (first 6 2. Recovery phase of nonthyroidal illness
months)
3. Pregnancy (first 20 wks)
4. Opthalmic Graves disease
5. Rx with dopaminergic drugs or high dose
glucocorticoids

Must recognise medullary carcinoma of the thyroid

• Calcitonin + CEA
• Screen: serum / urine metanephrines / normetanephrines

Laboratory tests affected by changes in thyroid function

Hyperthyroidism
• Hypocholesterolaemia
• Hyperglycaemia / impaired glucose tolerance
• Hypercalcaemia
• ↑ SHBG
• Abnormal liver function tests

>> Severe hyperthyroidism can cause cardiomyopathy

Hypothyroidism
• Hypercholesterolaemia
• Hyperprolactinaemia
• ↑ CK
• Hyponatraemia
• ↓ SHBG

When may TFTs be unreliable?

• Nonthyroidal illness / sick euthyroid syndrome
• Recovery from illness → elevated TSH = nonthyroidal illness just as likely as primary
hypothyroidism
• Neonate → normalise after few days – influence of mothers hormones
• Pregnancy

Thyroid function testing in non-thyroidal illness

• abnormal thyroid function tests are commonly found in pts with NTI:
o thyroid testing should only be performed if thyroid possible contributor
o ↓ T3 = common finding
o ↓ TSH 2x as likely to be due to NTI as the hyperthyroidism
▪ NTI mostly > 0.01 mU/L
▪ Hyperthryoid mostly < 0.01 mU /L
o ↑ TSH is as likely to be due to recovery from illness as to hypothyroidism
o No persuasive evidence for use of T4 / T3 therapy

Causes of abnormal results in euthyroid pts: (these are rare)

• abn TBG
 • Genetic variants of albumin – familial dysalbuminaemic hyperthyroxinaemia
• Assay interference – pts with endogenous antibodies that interfere with assays

Drugs that affect thyroid Function

The drugs that commonly give rise to abnormal thyroid function tests and the various mechanisms
by which these drugs produce such effects

Consider these drugs if you get an abnormal result

↓ in thyroid hormone Induce ↓ thyroidal Impaired T4 → Modified

secretion = Hyperthyroidism synthesis T3 conversion thyroid
hypothyroidism hormone
action
• Lithium • Lithium Lithium Amiodarone Amiodarone
• Amiodarone • Amiodarone
• Iodide • Iodide

*BIOTIN SUPPLEMENTS → can affect immunoassay lab results – think of it if you get an abnormal result
that doesn’t match the clinical picture
Bones and Joints [L23]
Metabolic Bone Disease
**NB: alkaline phosphatase

1. Osteomalacia and Rickets

• Defective mineralization of osteoid

Causes
Calciopenic rickets
• Dietary deficiency
• Lack of sunlight
• Malabsorption of Vit D
o Vit D dependent type I = ↓ 1 ᾳ hydroxylase Inheritance of type I
o Type II – resistance to calcitriol actions and II = AR
▪ Impaired production of calcitriol or resistance to its
actions
• In CKD → impaired production of calcitriol
• Anticonvulsants

Phosphopenic
• Fanconi syndrome
• RTA type 1
• Hypophosphataemic “vit D resistant” rickets

>> these disorders activate fibroblast growth factor 23 (FGF23) → NB stimulator of renal phosphate loss
and ↓ calcitriol formation
• Measurement of plasma FGF23 and tubular reabsorption of phosphate:
o tumour induced osteomalacia
o genetic disorders
• Ddx: Hypophosphatasia
o rare inherited d/o → resembles rickets
o ↓↓ ALP

Features
List clinical and biochemical features of rickets and osteomalacia

Clinical
• Bone pain and tenderness + skeletal deformities
 • proximal muscle weakness

Biochemical
• 50% Hypocalcaemia
• 50% Normal [calcium] dt secondary hyperparathyroidism

Management
• Biochemical monitoring is through measurement of
o plasma calcium
o plasma phosphate
o ALP
o PTH
o For rare inherited disease: plasma 25 hydroctcholecalciferol or calcitriol

2. Osteoporosis
• reduced bone mass and abnormalities of bone
microarchitecture
• defined as a bone mineral density > 2.5 standard deviations
below mean for young people or by the occurrence of atypical
fracture
o vertebral, neck
o colles fracture of distal radius
o femoral neck
• bone loss as a result of ↓↓ in osteoblastic activity in relation
to osteoclastic activity

Risk Factors
• Ageing
• Postmenopausal oestrogen deficiency

Diagnosis
Provide an approach to the biochemical work-up of a patient with osteoporosis.

1. Bone Density – DEXA scan

2. WHO-sponsored FRAX tool: Combine clinical risk factors with measurements of bone mineral
density in algorithms that estimate future fracture risk → preferred
3. Plasma calcium and phosphate are NORMAL
4. ALP activity is normal
a. unless # occurred or osteomalacia is also present

Markers of bone turnover

• identify pts at risk of development of osteoporosis
• monitor effects of treatment
Markers of bone resorption
• substances derived from collagen
o urine- pyridinium cross-links of collagen
o serum – cross-linking telopeptides of type I collagen (eg CTX)
• Clinical use?
o can improve monitoring medical therapy
o failure to respond → non-adherence
o changes in concentration of these markers larger correlation with reduction in risk of
fracture than changes in bone mineral density
>> therefore: predominantly in monitoring treatment rather than identification of pts at risk of
developing osteoporosis, for which DEXA scanning and risk scored are preferred

Markers of bone formation

• plasma osteocalcin
• bone-specific ALP
• procollagen type I terminal peptides (P1NP)

*International osteoporosis foundation → endorsed use of CTX and P1NP in clinical trials

Management:
1. RF management
2. Oral cholecalciferol
3. Dietary calcium > calcium supplements (increase cardiovascular risk)
4. Bisphosphonates → reduce osteoclastic activity

3. Pagets Disease
• unknown aetiology → ?paramyxovirus
• ↑↑ osteoclastic activity
• new bone formed is abnormal and laid down in disorganized fashion
• Bones become thickened, deformed and painful
o Pelvis, spine, skull, femurs
• Disease of the elderly

Clinical Picture
List features of Paget’s disease.

1. Deformity
2. Pathological #
3. Compression of adjacent tissues → auditory nerves = deafness
4. Steal syndrome: increased vascularity of abnormal bone diverts blood from tissues → ischaemia
5. Osteosarcoma

Metabolic Picture
1. Plasma ALP is ↑↑ → markedly (10 x ULN)
2. Plasma calcium and phosphate are usually normal
a. ± Hypercalcaemia if pt is immobilized

>> Relatively common → unexpectedly ↑ s-ALP activity in elderly subjects

• if s-Ca and s-phosphate and LFTs are all normal → Pagets disease is frequent cause
4. Osteogenesis Imperfecta
• Brittle bone disease
o Typically in children with # and bone deformities
o NB: differentiate from non-accidental injury
o FRAGILE BONES
o BLUE SCLERA
• Biochemical:
o no tests**
• Keep in mind for differential for deformed bones* along with Osteopetrosis

5. Osteopetrosis
• affects number or function of osteoclasts
• present in infancy with poor growth ad blindness or deafness → CN entrapment

Articular Disease
• OA, RA and GOUT
o role of biochemistry in Mx is limited
▪ Measurement of CRP to monitor inflammatory conditions

Acute Phase Proteins and the Acute Phase Response

Acute Phase Response
• haemodynamic changes
• increases in activity of coagulation and fibrinolytic systems
• leucocytosis
• changes in concentrations of many plasma proteins
• systemic effects → pyrexia

>> mediated by a host of cytokines (eg. IL-6), tumour necrosis factor and vasoactive substances

→ increased synthesis positive acute phase proteins

↑↑ in plasma [CRP]
↑↑ plasma [procalcitonin]
↑↑ protease inhibitors
↑↑ caeruloplasmin
↑↑ ᾳ1 acid glycoprotein
↑↑ fibrinogen
↑↑haptoglobins

→ at the same time there are decreases in negative acute phase proteins
↓↓ albumin

↓↓ prealbumin

↓↓ transferrin
as a result of ↑ vascular permeability, mediated by prostaglandins and histamine

CRP
• can ↑↑ 30 fold from normal value of < 5 mg/L during acute phase response. → valuable marker
o esp in monitoring pts with inflammatory conditions such as RA and Crohns Disease
• more sensitive and more specific than ESR and plasma viscosity
• begins to rise at about 6hr after the initiation of an acute phase response
• reaches peak after 48hr
• then falls if inflammatory stimulus remits
• Raised CRP:
o Evidence of an inflammatory response!!
▪ NOT viral infections or autoimmune
o “High sensitivity CRP” (measuring lower concentrations] → useful marker of cardiovascular
risk

Procalcitonin is an APR
• plasma concentration increases to particularly high levels in response to infection
• NOT a substitute for CRP BUT
o can provide additional information because higher sensitivity and specificity for bacterial
infection than CRP and to be a better prognostic indicator

Gout
List biochemical features of gout and other crystal arthropathies.

• Tests to confirm diagnosis:

1. Hyperuricaemia
a. serum urate
2. Aspiration of synovial fluid
a. GOUT = Monosodium urate crystals
i. Needle shaped
ii. Negatively birefringent
b. Pseudogout = Calcium Pyrophosphate crystals
i. Rhomboid shaped
ii. Positively birefringent

Differential Diagnosis of Gout

1. Crystalline Arthropathies
a. Pseudogout – calcium pyrophosphate
i. Chondrocalcinosis may be present
b. Hydroxyapatite crystals
2. Septic Arthritis
CKD-MBD
Describe biochemical features of chronic kidney disease metabolic bone disease. (CKD-MBD)

• Most pts with CKD → hypocalcaemic → may develop CKD-MBD

o secondary hyperparathyroidism or osteomalacia or mixed or adynamic bone disease

• CKD → retention of phosphate → hyperphosphatemia inhibiting calcitriol synthesis (mediated by ↑

FGF23) and leading to HYPOcalcaemia through a reduction in intestinal calcium absorption
• PTH concentrations are elevated in CKD secondary to hypocalcaemia, low calcitriol concentrations
and down-regulation of the calcium-sensing and vit D receptors
• PTH → decrease the reabsorption of phosphate from each nephron → BUT the falling GFR
becomes a limiting factor in phosphate excretion and PERSISTENT hyperphosphataemia*
• If the concentration of phosphate becomes so high that the solubility product of calcium and
phosphate ([Ca2+] x [Pi]) is exceeded → metastatic calcification
• Advanced kidney failure = ↓ functioning renal tissue also contributes to ↓ calcitriol production
• Buffering of H+ → demineralisation of bone

Management
1. Monitored:
a. plasma calcium, phosphate, PTH, Alkaline phosphatase
2. Avoid Hyperphosphatemia and Hypocalcaemia
a. oral phosphate binder
b. oral calcitriol

NB: Occasionally the parathyroid glands become AUTONOMOUS → tertiary hyperparathyroidism

• massively elevated [PTH] → severe hypercalcaemia
• Rx: calcimimetic drugs or parathyroidectomy

Interpretation, analysis and evaluation of clinical cases and biochemical data in case-based format
Acute Coronary Syndrome [L24]
Physiology
Draw an annotated diagram describing the processes involved an atherosclerosis

1. LDL cholesterol trapped and oxidised

2. Attracts monocytes and tissue macrophages
3. Macrophages take up oxidised LDL → foam cells
4. Foam cells:
a. secrete pro-inflammatory cytokines → ++ attract more leucocytes = endothelial dysfunction
b. Ag presenting cells → activate Th1 cells → produce inflammatory cytokines
c. enzymes erode fibrous cap of plaque and increase risk of plaque rupture
d. secrete tissue factor → stimulates thrombosis when plaque ruptures

Diagnosis
Give 3rd universal definition of acute myocardial infarction.

• Typical rise and fall in troponin with at least 1 value > 99th percentile measured with highly
sensitive assay

List all criteria required for diagnosis of MI

>> At least 1 of the following:

1. Symptoms of ischaemia
2. New significant ST-T changes or new LBBB
3. Development of pathological Q waves
4. Imaging evidence of new loss of viable myocard or new regional wall motion abnormality
5. Identification of an intracoronary thrombus by angiography or autopsy

Know the different investigations and diagnostic tests used in the assessment of patients
presenting with an acute coronary syndrome.

1. ECG!!
a. do ECG on any pt > 45yr with thoracoabdominal discomfort
b. Confirms STEMI > 80% BUT not a good rule out test →need cardiac biomarkers to rule out
ACS if ecg is unremarkable
2. Cardiac Troponin is the ONLY biomarker to be tested in pts with suspected MI

List the reasons why troponin is the only recommended biochemical test used to diagnose acute
myocardial infarction.
 1. Superior sensitivity and accuracy
2. Cardio-specific, heart is the only source
3. Serum levels start increasing within 3-12 hrs of onset of chest pain, peak at 24-48hrs and normalize
over 7-14 days
a. elevation in troponin visible 2-4 hrs after initial occlusion event
b. 80% pts with ACS have elevated troponin within 2-3 h of emergency department arrival
c. can be diagnosed in late presenters → remains elevated for 7-10 d

Classify the different acute coronary syndromes using ECG and troponin results

Troponin ECG
Unstable Angina N Non-specific
Non ST-elevation MI ↑ ST depression
ST-elevation MI ↑ ST elevation

Cardiac muscle and troponin

Describe the functional unit of cardiac muscle.

• Actin-Myosin Complex

Name the different troponins and describe how they are associated with the contractile apparatus.

• Troponin T → bound to tropomyosin*

• Troponin I → binds tropomyosin to actin* →*ONLY IN MYOCARDIUM
• Troponin C → recruits calcium during contraction → non-specific

Indicate which troponins are routinely used for testing.

• TnT

Understand that there are different troponin assays each with their own advantages and disadvantages.

What is the 99th percentile and why is it important when looking at troponin results?

Describe the features of a high sensitivity troponin assay.

• very low detection limit → high analytical sensitivity

• can detect troponin in 50% healthy subjects with no heart disease
• reflects normal turnover of troponin in working heart
• < 10 % variation at the 99th percentile

Describe a common point-of-care troponin assay in use.

• Roche Trop T “dipstick” /Roche Cardiac Reader

List the advantages and limitations of point-of-care troponin tests.

• Qualitative result – above or below cutoffs

• Can’t monitor trends
• Useful in established MI where levels ↑↑↑
• comparable to 2nd gen trop assays

Discuss why it is important for a doctor to know which assay is being offered in his/her local laboratory.

Understand how to use ECG and troponin testing to diagnose and manage patients with acute
coronary syndromes.
 • ECG:

o STEMI:
▪ Pathalogical Q-wave
▪ ST elevation
o NSTEMI:
▪ ST depression → followed by:
▪ T inversion
▪ *no development of Q wave
• Troponin:
o ↑

Draw a diagram of the recommended testing algorithm to be followed when evaluating a patient
with an acute coronary syndrome

Troponin Testing:

Understand the different mechanisms that may be responsible for symptoms in patients presenting with an

acute coronary syndrome.

Describe the troponin kinetics seen in acute coronary vaso-occlusion.

• Characteristic rising and falling trend on 3-6 hrly repeat testing

Give a differential diagnosis for persistently elevated troponin levels.

1. Heart Diseases
 a. Myocarditis
b. Pericarditis
c. Tachyarrythmia
d. Acute heart failure
e. LVH
f. Cardiomyopathy
g. Endocarditis
2. Others:
a. Hypotension / Shock
b. PE
c. Stroke
d. Acute aortic dissection
e. Sepsis
f. Pulmonary hypertension
g. Chronic Kidney Disease

What is the mechanism of injury in patients diagnosed with STEMI?

• abrupt total occlusion of a major coronary artery causing transmural

ischaemia / necrosis

What is the mechanism of injury in patients diagnosed with NSTEMI?

• partial occlusion of a major artery or total occlusion of a minor artery causing

partial thickness or subendocardial necrosis

What is the mechanism of injury in patients diagnosed with myocarditis?

What is the mechanism for troponin elevation in patients with chronic renal
failure?

• Troponin levels are elevated due to decreased renal clearance

Describe how acute myocardial infarction should be ruled out in patients with persistent troponin
elevation.

1. If baseline troponin is elevated → mechanism must be confirmed with serial testing

a. Rising/falling trend → ischaemic disease
b. Stable trend → non-occlusive disease
i. Further investigated for structural heart disease and renal disease
1. Wall motion anomalies on U/S
2. Coronary Angiography

Give a differential diagnosis for troponin elevation with normal/non-specific ECG

Dyslipidaemias [L25]
ONLY MCQs

Understand the exogenous and endogenous pathways involved in transportation of lipids in the body.

Functions of apoproteins

Summary
• ApoA I-II structural protein for HDL
▪ Apo I activates LCAT
• ApoB 48 structural protein for CM
• ApoB 100 structural protein for VLDL, LDL, IDL, Lp
▪ Binding ligand to LDL receptor
• Apo C II Cofactor for LPL
• Apo E Ligand for binding to LDL → CM, IDL, HDL

List the atherogenic lipoproteins and their associated apolipoproteins.

Understand how HDL is formed and metabolised.

List the apolipoprotein markers of HDL.

• ApoA-I
• ApoA-II
• ApoC-I
• ApoC-II
• ApoE

Describe the function of LCAT.

• converts free cholesterol into cholesterol esters

Describe the function of CETP.

• Cholesterol ester transfer protein

Understand how LDL is cleared from the circulation.

Describe the function of PCSK9.

• reduces LDLR levels on the plasma membrane. Reduced LDLR levels result in decreased
metabolism of LDL-particles, which could lead to hypercholesterolaemia

Know the components of a fasting lipogram.

Describe what is tested in a lipogram.

1. Total Cholesterol
 2. Triglycerides
3. HDL cholesterol
4. LDL cholesterol

*12h fast for reliable trig and calculated LDL

• Calculated LDL = TC – [HDL + TG/2.2]
o can’t calculate if TG > 4.5 mmol/L

List the indications for requesting a fasting lipogram.

1. Primary prevention in patients with CVS risk factors

a. Smokers, HT, Obesity, DM, family hx
2. Secondary prevention in pts who have already suffered a CVS event
3. Pts with signs of genetic dyslipidaemia
4. Routine care in:
a. DM, hypothyroidism, CKD, nephrotic syndrome, drugs (COC, steroids, ARVs)

Describe how the lipogram results should be used to determine a patient’s 10-year risk of an
adverse cardiac event.

• Framingham risk score

o calculation includes: gender, age, systolic BP, TC, HDL, smoker status

Describe what an atherogenic lipid profile looks like.

• ↑ Chol
• ↑ TGs
• or both

Causes
Know how to diagnose the primary dyslipidaemias.

1. FIRST: exclude secondary causes before diagnosing primary dyslipidaemia

a. secondary causes are more common

Know the common secondary causes of dyslipidaemia and how to diagnose them.

List the medical conditions that can result in secondary dyslipidaemia, and indicate which
lipoprotein fractions are elevated in each.
 1. Hypothyroidism ↑ LDL TG
2. Insulin resistance ↑ LDL TG
3. Uncontrolled DM ↑ LDL TG
4. Obesity ↑ LDL TG
5. Alcohol abuse ↑ TG
6. Obstructive liver dis ↑ LDL TG
7. CKD ↑ LDL
8. Nephrotic Syndrome ↑ LDL

List the medications that can result in secondary dyslipidaemia and indicate which lipoprotein
fractions are elevated in each.

1. Thiazide diuretics
2. B blockers
3. Anticonvulsants
4. HAART
5. COC
6. glucocorticoids
7. Anabolic steroids, androgen
8. Retinoids
9. Immunosuppresants

Management
1. Control cause of secondary hypercholesterolaemia
2. diet and lifestyle counselling
3. address other risk factors
4. primary prevention of atherosclerotic heart disease
a. establish treatment targets based on Framingham score

List the primary dyslipidaemias and indicate which lipoprotein fractions are elevated in each.

1. ↑ LDL
a. Familial hypercholesterolaemia
b. Familial defective apoB-100
c. FH dt PCSK9 activating mutations
d. Familial combined hyperlipidaemia (VLDL + LDL)
e. Polygenic hypercholesterolaemia
2. ↑ VLDL and CM
 a. Familial hypertriglyceridaemia
b. Familial hyperchylomicronaemia
c. Familial combined hyperlipidaemia (VLDL + LDL)
3. IDL and CM remnants
a. Familial dysbetalipoproteinaemia

List the 3 primary dyslipidaemias that are commonly found in South Africa.

1. Familial Hypercholesterolaemia
Describe the pathogenesis of familial hypercholesterolaemia.

List the genetic defects involved in the pathogenesis of familial hypercholesterolaemia.

Monogenic Disorder: defect in one of 3 genes

1. ApoB100 (5%) = ↓ binding of LDL or LDLR

2. LDL receptor (93%) = ↓ LDL clearance, ↑ oxidation, ↑ uptake of oxidised LDL by foam cells
3. PCSK9 (2%) = ↓ LDL receptor cycling

Describe the clinical presentation and lipogram findings of patients with familial
hypercholesterolaemia.

*Red flag if young person*

1. Clinical Presentation
a. Chronic xanthelasma
b. Tendon xanthomas
c. Arcus cornealis
2. Heterozygous more common
a. symptomatic CAD from early 20’s
b. total cholesterol 8 – 15 mmol/L
3. Homozygotes
a. childhood onset CAD
b. total cholesterol 20 – 26 mmol/L

List the diagnostic criteria of familial hypercholesterolaemia.

Simon Broome criteria

1. TC > 6,7 mmol/L in child < 16 yr pretreatment

2. TC > 7.5 mmol/L in adult pretreatment

PLUS

3. Tendon xanthomas in pt or family member (parent, sibling, child, grandparent, aunt, uncle)

OR

4. DNA evidence of LDLR, apoB100 or PCSK9 mutation

2. Familial Combined Hyperlipidaemia

• Most common diagnosis made in CAD disease
• Obesity and insulin resistance common
• Atherogenic lipid profile:
o ↑ LDL, VLDL or both
o ↓ HDL
 • CAD in 40 – 50’s

3. Familial hypertriglyceridaemia
• ↑ chylomicorns with
1. eruptive xanthomas,
2. retinal lipaemia
3. acute pancreatitis
• lipid-laden foam cells

4. Familial Hyperchylomicronaemia
• lipoprotein lipase or apoC-II deficiency
• Clinical picture
o eruptive xanthomas,
o retinal lipaemia,
o acute pancreatitis,
o hepatosplenomegaly
• Lipaemic plasma
• plasma TG > 10 mmol/L

5. Familial Dysbetalipoproteinaemia
• defective apoE causing remnant hyperlipoproteinaemia (IDL and CM remnants)
• Clinical picture:
o fatty palmar streaks
o eruptive xanthomas
• Additional test:
o lipid electrophoresis
o ApoE genotyping

Understand the role of laboratory testing in the therapeutic monitoring of patients receiving statin treatment.

List the two major side-effects of statin treatment.

1. Myopathy
2. Hepatopathy

List the biochemical tests used to monitor for statin toxicity.

1. CK

2. LFT

Myopathy
1. Document pre-treatment muscle complaints
2. Baseline CK must be normal
3. Test CK during Rx if pt develops myalgia
4. TAKE STATIN in morning (worse myopathy at
night)
5. ↑ CK < 5 x ULN = MONITOR
6. ↑ CK > 5 x ULN or intractable pain =
change to alternative Rx
Hepatopathy
1. Document baseline LFT
2. Baseline ALT must be < 3 x ULN
3. ↑ ALT < 3 x ULN: monitor
4. ↑ ALT > 3 x ULN = change to alternative Rx
5. Can try to re-introduce later if unrelated liver
disease
Disorders of the adrenal gland [L28]
1. Glucocorticoid Excess

• Cholesterol
o Aldosterone synthase → Aldosterone
o 17a hydroxy-progesterone → Cortisol
o DHEA → Testosterone → Oestradiol

Feedback Mechanisms
• Excess cortisol from adrenals → neg feedback to Hypothalamus to ↓ CRH

Causes:
1. ACTH dependent
a. Cushings Disease (pituitary) ↑ ACTH
b. Ectopic ACTH secretion
c. Ectopic CRH
d. ACTH therapy
2. ACTH independent (adrenal cause) ↓ ACTH
a. Adrenal adenoma / ca
b. Glucocorticoid therapy
c. Hyperplasia

Tests for Cushing’s syndrome

Name 1 test useful for screening for Cushings
1. Low-dose dexamethasone suppression test
2. 24 hr Urinary free cortisol
3. Late night salivary cortisol

Approach
1. Screening test = ↑ cortisol
2. ACTH level = ↑/↓
a. ↑ = ACTH dependent cause
b. ↓ = adrenal cause
3. if ACTH dependent = CRH test
 a. if ACTH ↑ → pituitary cause = Cushings disease
b. if no response → ECTOPIC source

Other tests:
1. Hypokalaemic alkalosis
a. ↑ aldosterone
2. Selective venous sampling
3. Pituitary function tests
4. Tumour markers
5. Glucose intolerance → steroid induced diabetes = why? glucocorticoids ↑ gluconeogenesis
2. Adrenal Insufficiency
• ↓ cortisol
• ↑ ACTH

Causes
Primary Secondary
1. Autoimmune – hashimotos 1. Congenital
thyroiditis 2. tumours
2. Infective 3. infection
3. Secondary tumour 4. secondary tumour deposits
4. Infiltrative 5. trauma
5. CAH 6. iatrogenic
6. Adrenoleukodystrophy 7. Secondary to hypothalamic disease
7. Drugs

Diagnosis
1. Confirm adrenocortical insufficiency
a. Morning cortisol
i. at a time when it is expected to
be high = therefore +ve test
result if LOW
b. Short synacthen test
i. Synthetic ACTH stimulation (no
response +ve test)
c. Urea and electrolytes
2. ACTH levels
a. HIGH
i. Adrenal insufficiency
b. LOW
i. Secondary
– pituitary function tests

3. Secondary Hypertension
List 2 causes of secondary HT

1. Hyperaldosteronism
2. Phaeochromocytoma

1. Hyperaldosteronism
1. Bilateral adrenal hyperplasia
2. Unilateral adenoma – Conns syndrome

Investigations
1. Plasma aldosterone: renin ratio ↑
a. ↓ renin if primary hyperaldosteronism
2. Urine 18 hydroxycortisol
3. Genetic testing CYP11B2 → Conns syndrome

Secondary Hyperaldosteronism
• high renin → diuretic therapy
2. Phaeochromocytoma
Investigations
1. Demonstrate excessive production of catecholamines:
a. plasma free or urinary fractioned metanephrines
b. OR less sensitive:
i. urine catecholamines
ii. urine total metanephrine
iii. urinary VMA
2. Clonidine suppression test

SUMMARY OF TESTS
Metabolic Aspects of Malignant Disease [L38]
Neuroendocrine Tumours
• Different types BUT all have prominent secretory granules and
secreting biogenic amines and peptide hormones Net Clinical Syndrome:
• Remember hormone secretion by tumours does NOT always 1. Hormone combination
cause and endocrine syndrome. → dominant hormone
o may not be sufficient secretion to cause persistently raised 2. Biological activity
concentration 3. Concentration
o secretory product may be an inactive precursor of
hormone

List common endocrine paraneoplastic syndromes and associated hormone secretion.

Tumour Hormone Syndrome

Small Cell carcinoma of 1. ACTH 1. Cushing syndrome
bronchus 2. ADH - Vasopressin 2. Dilutional hyponatraemia
3. hCG 3. Gynaecomastia
Carcinoid tumours 1. ACTH 1. Cushing syndrome
2. ADH - Vasopressin 2. Dilutional hyponatraemia
Squamous cell ca of bronchus PTHrP Hypercalcaemia
RCC
Breast ca Calcitonin *common but > None- clinically silent
Mesenchymal tumours Insulin like growth factor Hypoglaycaemia

What are the most frequently encountered paraneoplastic endocrine syndromes?

1. Cushing Syndrome
2. SIADH
3. Hypercalcaemia

1. Cushing Syndrome
• High circulating levels of glucocorticoids
o Adrenal carcinomas
o Non-adrenal carcinomas
▪ Ectopic ACTH secretion: functions
autonomously → consistent outflow of
ACTH from tumour regardless of
levels of cortisol in body
• ↑ ACTH
• ↑/↓ cortisol

Clinical Picture
*classical picture not always seen → usually seen in
longstanding disease (concentration and activity of hormone)

Screening Tests
1. CORTISOL MEASUREMENT
1. 24h urinary cortisol excretion
2. 48h low dose dexamethasone suppression test
 3. midnight salivary cortisol

*Loss of diurnal variation of cortisol secretion → early feature (Dx can be excluded if N plasma cortisol
concentration at 11pm or midnight*
• Plasma levels → false positives because stressful event*
• replaced by salivary cortisol on a midnight sample which pt can do at home

Dynamic Function testing: DMST

• Dexamethasone (synthetic glucocorticoid) → should suppress ACTH in normal person to <
50nmol/L
• Failure of suppression is characteristic of Cushing Syndrome (or false +ve: pseudo-cushing or
stress)
• Fewer false positives with low dose dexamethasone than high dose

2. ACTH MEASUREMENT
• With confirmed ↑ cortisol secretion
o ↓ ACTH = Adrenal cause
o ↑ ACTH = pituitary-dependent Cushing disease
o ↑↑↑ ACTH = Ectopic secretion

3. CORTICOTROPIN RELEASING HORMONE TEST

• to differentiate between Cushing Disease and ectopic ACTH secretion
o Cushing disease = ↑ plasma ACTH by ± 50% AND cortisol concentration by 20%
o Ectopic ACTH secretion or adrenal tumour = NO RESPONSE

Ectopic ACTH biochemical findings:

• ↑↑ cortisol
• ↑↑ ACTH
• no response/suppression by dexamethasone
• metabolic sequalae of excessive cortisol secretion:
o Hypokalaemia with alkalosis
o glucose intolerance
o Hypertension

2. Dilutional Hyponatraemia
Tumours that ↑ ADH secretion
1. Small cell carcinoma of bronchus
2. Carcinoid tumours
3. Breast cancers
4. Pancreatic adenocarcinomas

• Ectopic Vasopressin secretion → SIADH

o secretion of ADH by the tumour is UNREGULATED and exceeds the body’s requirement for
osmotic homeostasis
→ Water retention with dilutional hyponatraemia
↑↑ water retained than Na+

List features of ectopic vasopressin secretion.

1. Clinical Features:
a. CNS effects
 i. drowsiness, confusion, fits, coma
2. Dilutional Hyponatraemia
a. ↓s-Na+
b. ↓s- urea
c. ↓s-proteins
3. ↓ s-osmolality
4. Euvolaemic
5. Highly concentrated urine
a. SIGNIFICANTLY ↑ ADH secretion occurs only with more severe ECF volume depletion
b. ectopic production of vasopressin is NOT regulated by ECF osmolality → secretion is
unregulated
6. Urine Na ↑
7. Normal renal function, adrenal function

3. Hypercalcaemia of Malignancy
Pathophysiology
*Parathyroid hormone related peptide

1. Driving HYPERCALCAEMIA dt osteoclastic activation by:

• prostaglandins produced by bone mets
• OR osteoclast-activating cytokines by haematological tumours
2. High levels of calcium will suppress Normal PTH secretion (attempt to ↓ renal tubular reabsorption
of calcium = allowing excretion of Ca+)
3. BUT PTHrP will remain ↑↑ which has same biological activity as PTH → therefore Hypercalcaemia
remains*

Describe features of hypercalcaemia of malignancy.

• ↑ s-[Ca]
• ↓s-[Pi]
• BUT
• ↓ PTH → what is driving hypercalcaemia?
• ↑PTHrP

4. Tumour-associated Hypoglycaemia
• Primary Insulinoma → most common cause
• Rarely due to ectopic insuling secretion by non-B-cell tumours
o Mesenchymal tumours
o HCC
o Adrenal
o Carcinoid
• What are the factors driving insulin release?
o Insulin-like-growth factors – IGFs / somatomedins
▪ Specifically IGF-2 = IGF-1 / IGF-2 ratio is decreased
o Cytokines: TNFᾳ

List (other) metabolic complications of malignant disease.

1. AKI or CKD
Tumour Lysis Syndrome
 a. Hyperkalaemia
b. Hyperuricaemia → false -ve result (↓uric acid) with some drugs eg rasburicase
c. Hyperphosphataemia
d. Hypocalcaemia
>> Mx: maintain adequate hydration, give ALLOPURINOL to inhibit uric acid synthesis
2. Hypomagnesaemia
3. Hypokalaemia → cytotoxic drugs

Cancer Cachexia
• COMMON feature of malignant disease
• Causes
o Malabsorption (pancreatic, biliary obstruction)
o Infection (immunosuppressed)
o Tumour consumes nutrients
o Secretion of cachetin (TNFᾳ) → ↑ metabolic rate
o Obstruction* → early satiety and ↓ food intake
o Loss of protein (from ulcerated mucosa)
o Treatment with cytotoxic drugs

Carcinoid Tumours
• Gastroenteropancreatic neuroendocrine tumours (GEP-NET)
o arise from neuroendocrine cells derived from the embryological gut
o low -grade malignancy
o 50% are CARCINOID tumours
o Non-carcinoid types mostly pancreatic* but anywhere along GIT
o Chromogranins → useful tumour markers because many GEP-NETs produce it

Describe biochemical and clinical features of the carcinoid tumours.

Hormone Clinical Features

5-hydroxytryptamine Carcinoid syndrome
Insulin Hypoglycaemia
Gastrin Zollinger Ellison: peptic ulcers, diarrhoea
Glucagon DM
Somatostatin DM, steatorrhoea
Vasointestinal polypeptide Werner-Morrison syndrome: watery diarrhoea
Pancreatic polypeptide None
Neurotensin
 • Dietary Tryptophan → metabolised to → Serotonin: 5-
hydroxytryptamine (5-HT)
o in pts with carcinoid syndrome → 50% of dietary tryptophan
may be metabolized by this pathway – INSTEAD of usual
1% = SHUNTING tryptophan away from protein and nicotinic
acid synthesis*
▪ Pellagra-like skin lesions → nicotinic acid deficiency

Biochemistry:
1. Screening test:
a. 24h urine 5-hydroxyindoleacetic acid (5-HiAA) ↑
i. > 2 x ULN
2. Chromogranin A ↑
a. more sensitive but less specific
3. Whole blood serotonin ↑ → bronchial carcinoid but N 5-HIAA
secretion

NB clinical features:
• Diarrhoea + colicky
pain (GI sx)
• Flushing
• Bronchospasm
• Pellegra

List the glands involved in multiple endocrine neoplasia.

MEN I MEN IIa MEN IIb

1. Parathyroids 1. Phaeochromocytoma – adrenal 1. Phaeochromocytoma
2. Pancreatic islets medulla 2. Parathyroids
3. Pituitary (ant) 2. Parathyroids 3. Thyroid
3. Thyroid (medullary cell ca) 4. Somatic abnormalities:
*3 Ps *APT - marfanoid habitus
- mucosal neuroma
- pigmentation
- café au lait spots
Tumour Markers
Describe the use of tumour markers in cancer using common clinical examples.

Can be used for:

1. Screening
2. Diagnosis
3. Prognosis
4. Treatment monitoring
5. F/U detect recurrence

BUT:
• not helpful in dx of pts with non-specific sx
• concentrations are raised in variety of cancers and can even be raised in BENIGN conditions
o ↓ Specificity
• Normal plasma concentrations do NOT exclude ca
• Most appropriate use = SERIAL MONITORING of treatment

ᾳ-Fetoprotein
• Valuable marker in:
o HCCs
o Testicular germ cell tumours

1. HCC
• The concentration is predictive of tumour mass and probability of having cancer
• BUT:
o Lacks specificity:
▪ high concentrations can occur in cirrhosis in the absence of malignancy
o BUT in histologically confirmed HCC → serial measurements of AFP are valuable
▪ normal hepatic regeneration that occurs after partial hepatic resection may cause
transient ↑AFP

2. Non-seminomatous germ cell tumours of testes

• AFP measurements are valuable in assessing:
o prognosis → staging (high concentration = poorer prognosis)
o monitoring therapy
Carcinoembryonic antigen (CEA) Post surgical resection: expected fall,
• Can be raised in:
o Colorectal ca although a subsequent rise suggests
o other malignancies: recurrence… recurrence is no
▪ pancreatic, breast, lung ALWAYS heralded by a rise – tumours
o non-malignant: may lose the ability to secrete CEA
▪ liver disease
▪ pancreatitis
▪ IBD
▪ smokers
• THEREFORE: neither sufficiently specific or sensitive to be used in screening for colorectal ca
o concentrations correlate poorly with tumour bulk

Human Chorionic Gonadotrophin

• normal placenta during pregnancy* produces this hormone
o ᾳ and B subunit
• The presence of hCG at ANY OTHER TIME than pregnancy indicates:
o abnormal trophoblastic tissue OR
o tumour secreting the hormone ectopically
• Assays: must measure intact hCG and its free B-subunit – some tumours produce more of latter
• Extremely SENSITIVE – monitoring treatment

What are the limitations of PSA in screening for prostate cancer?

1. Low sensitivity
2. Low specificity
a. ↑ in prostate ca
b. ↑ with age
c. ↑ with age
d. ↑ BPH
e. DRE
f. acute urinary retention
3. Efforts to improve S+S
a. age related ranges
b. relating pSA to prostatic volume
c. rate of change of concentration with time
d. free vs bound psa → free:total PSA
i. BOUND proportion is higher in prostate cancer
1. Free PSA > 25 % → more likely to have beign condition = biopsy NOT
indicated
2. Free PSA < 10 % → indication for biopsy

1. Be able to think about clinical utility of tumour markers: pros vs cons

2. Be able to illustrate using the 3 examples given
3. Multiple utilities
4. Sensitivity and specificity concept
5. ability of tumour markers to guid an prognosticate Mx
6. Tumour markers can be produced by other cancers as well as other pathologies
7. Adv and Disadv?
Evaluation of gonadal function [L42]
Male Gonadal Function
Physiology
• Hypothalamus → GnRH → ant pituitary:
• LH → leydig cells → testosterone
o wollffian duct development
o Sertoli cell and sperm development
o sexual characteristics (masculinization)→
DIHYDROTESTOSTERONE by 5 alpha
reductase
• FSH → Sertoli cells → support sperm division and
growth
o INHIBIN exerts negative feedback on FSH
o Androgen binding protein → concentrates T

Testosterone
• 97% PROTEIN BOUND
o to SHBG → high affinity
o albumin
o free → bioavailable

Hypogonadism in males
• PRIMARY (testes)
o ↓T
o ↑ LH FSH
• SECONDARY (pituitary)
o ↓T
o ↓LH FSH
• *Seminiferous tubule dysfunction
o ↑ FSH
o ↓ Sperm count
• Leydig cell dysfunction
o ↑LH
o ↓ Sperm count AND masculinization

Diagnosis
• 1st line tests
o TOTAL T *highest level @ 9am → measure FASTING
▪ Normal = >12.1
o LH and FSH
• Free T in men with:
o low end T 6.9-13.1
o ABNORMAL SHBG
• BEST PREDICTOR OF HYPOGONADISM
o 3 sexual symptoms
o Total T < 8-11
o Free T < 0.22
 • 2nd line tests:
o HCG stimulation test
▪ DISTINGUISHES primary from
secondary*
• PRIMARY: no response
• SECONDARY: normal
response
o Semen analysis
• To distinguish pituitary cause from
hypothalamic cause = GnRH stimulation test
o Normal response = DOUBLES
o If minimal response → PRIME the pituitary gland and then repeat the test

Conditions associated with ↓SHBG

• Obesity
• DM
• Nephrotic syndrome
• Hypothyroidism

Conditions associated with ↑ SHBG *↓free fraction T

• Ageing
• HIV
• Cirrhosis
• Hyperthyroidism
Approach

Hypogonadism top Ddx

1. Kleinefelter syndrome
a. Primary*
b. Karyotype 47 XXY
2. Kallmann syndrome
a. Hypothalamic development disorder
b. Anosmia
3. Hypothalamopituitary disease
a. IGF1 → marker for GH
b. LH FSH
c. ACTH
d. TSH
4. Androgen insensitivity
5. 5 alpha reductase

Kallman Syndrome
• abn migration of OLFACTORY and GnRH neurons from olfactory bulb*
• HYPOGONADOTROPHIC HYPOGONADISM with ANOSMIA
o Gynaecomastia
o Osteoporosis
o Genital Infantilism

↓↓ GnRH FSH LH Testosterone

Klinefelter syndrome
• Genetic disorder AFFECTING THE TESTES
o testicular dysgenesis ↓ Leydig and seminiferous tubule function
o TALL stature
o feminization – gynaecomastia / female body hair
• HYPERGONADOTROPHIC HYPOGONADISM
↑ LH FSH ↓T ↑E

Female Gonadal Function

• LH → ovulation + progesterone
o IMPLANTATION = prog ↑
▪ Day 21 HIGHEST
o ↓ maternal immune response
o ↓ contractility of uterine smooth muscle
• estrogens ↑SHBG = ↓ free T

Female Hypogonadism
• PRIMARY
o ↓ 17B estradiol
o ↑ LH FSH
• SECONDARY
o ↓ 17 B estradiol
o ↓LH FSH

1. Oligo/amenorrhoea
1. ALWAYS start with pregnancy test
2. Signs of hyperandrogenism? – hirsutism
3. Measure: (hypothalamic / pituitary route)
a. Prolactin
b. FSH LH

↑ FSH FSH N FSH, LH PROLACTIN ↑

LH ↑ / N N/↓
Ovarian Failure PCOS Oestradiol* Hyperprolactinaemia?
• LH>FSH • PITUITARY!!
PRIMARY- Karyotype ↓ = PITUITARY or
HYPOTHALAMIC
= dynamic function test
Secondary- tumour, N = progesterone
surgery, infiltration challenge test
No withdrawal bleed =
uterine disease
2. Menopause
• PRIMARY hypogonadism
o ↓ estradiol
o ↑↑ FSH
o ↓AMH, ↓follicle number, ↓inhibin

3. Hirsutism
• HYPERandrogenism, ↓SHBG
• PCOS!!! COMMON
o produce excessive androgens
▪ DIAGNOSTIC!! T = 2.5-5 nmol/L
▪ BUT = normal T does NOT
exclude PCOS
• FAI: free T:estrogen ratio
• FAI>4.97
o NB: test for metabolic syndrome

Diagnostic Tests PCOS

1. Fasting insulin, OGTT, lipogram → metabolic syndrome
2. LH > FSH
3. ↑ 17-OHP in late onset CAH
4. ↑FAI, free T > 2.5-5, BAT
5. Ovarian morphology
 VIROLOGY
MCQs + tips given

Laboratory Diagnosis of Viral Syndromes [L3]

3 Questions submitted*

Diagnostic Approach
2 ways to detect a virus:

1. Direct demonstration virus / part of virus 2. Detection of antibodies in serum (serology)

NO LONGER USED USED IN PRACTICE: detection of a pts specific
immune response: IgG or IgM Ab to a specific
pathogen
1. Electron microscopy (virus) • Usually tested by an enzyme-linked
immunosorbent assay (ELISA) technique
2. Antigen testing • Also used for some rapid point of care tests
• ELISA
• Immunoflourescence
3. Viral Nucleic acid RNA/DNA • Can get FALSE POSITIVES with non-
• molecular assays / nucleic acid specific Ab
amplification tests (NAATs)
a. eg. PCR – polymerase chain
reaction
*Molecular testing (multiplex PCR) has replaced
viral isolation, IF testing and rapid Ag testing in
most labs*

Serology
IgM IgG
• First to rise *7-10d • *10-14d → TEST QUESTION
• NB: repeat IgM after a few days if -ve • Persists indefinitely
initially
• Persists 3 months
• Indicates: • Indicates:
• ACUTE infection • PAST infection / exposure or
• Reactivation / re-infection immunization
• Titre ↑ > 4 x in acute infection
• Prone to non-specific / cross reactions • Can cross the placenta
→ may cause false positives (usually low Q: +ve in newborn does NOT indicate infection
values) • Can test avidity : because increases over T
• LOW = primary infection
• HIGH = past infection
 ADVANTAGES
1. Test for immunity (Total / IgG)
• vaccinated
• before / during pregnancy
• contacts after exposure
• sexual partner
2. Diagnosis of acute disease
• IgM
• IgG Avidity
3. Diagnosis of chronic disease
• HIV, HTLV, HBV, HCV
4. Relatively cost effective
5. Rapid assays available
DISADVANTAGES
1. “False” negative results
• early after exposure
• SEVERE immunosuppression
• No Ab stimulation = HPV
2. False positive results
• Cross reactions = esp herpes viruses
like EBV
• Serum factors = rheumatoid factor,
auto-immune disease, pregnancy
• Recipients of blood products
3. Maternal IgG cross the placenta =
present in newborn ≤ 18mo of age
→ ONLY confirms exposure

NAAT/Molecular testing eg PCR

ADVANTAGES DISADVANTAGES
1. HIGH sensitivity 1. May be more expensive
• able to detect low copy numbers in 2. Result interpretation may be
clinical samples complicated??
2. Use low sample volumes • Pathogen vs passenger/latency
3. Can be automated 3. Interpret in conjunction with serology for
4. Fast turn-around time certain disease
5. Can measure (quantify) the amount of 4. False negative results due to genetic
virus “viral load” variability of viruses (rare)
6. Multiplex PCR used for syndromic/panel 5. False positive results (rare)
based diagnosis • contamination improper sampling + lab
7. Point of care assays eg. GeneXpert, technique
BIofire
Indications for the use of qualitative NAAT/molecular assays
1. Diagnosis of viruses that cannot easily be detected by another method – HPV, resp viruses,
BK virus
2. Where antibody testing “fails”
a. HIV PCR for early dx of HIV in babies born to HIV +ve mothers where maternal Abs may
persist → mainly used for infant diagnosis
b. HIV PCR for suspected acute HIV infection in the window period
c. Immunosuppressed pts → parvovirus B19 PCR
d. Viruses with problematic serology interpretation eg HCV
3. Pre-natal (foetal) dx of congenital infections
a. rubella or CMV PCR on amniotic fluid
4. To exclude infectivity
a. SANBS: HIV, HBV + HCV in blood products before transfusion

TEST QUESTION:
• Suspect disease in mother? → serology testing
• Suspect disease in infant <18mo? → PCR
o because detection of HIV specific antibodies in a child <18mo old does NOT = infection it
only confirms exposure
• Aplastic crisis (severe immunosuppression)→ PCR
Indications for the use of quantitative NAAT/molecular assays
1. Mainly to guide or monitor treatment
a. assess progression of viral disease, indication for Rx and prognosis
b. Monitor efficacy of antiviral Rx and identifyy Rx failure or emergence of drug-resistant
viruses
2. To identify the most likely pathogens that are causing disease
a. distinguish active “pathogen” vs latent “passenger” disease
3. High viral load may be an indication of a poorer prognosis

Indications for the use of genotyping of viruses

1. Molecular epidemiology
a. polio + measles surveillance and outbreak investigations
2. Resistance testing
a. HIV genotypic resistance testing to guide treatment regimen after ART failure
3. Identification of pathogenic genotypes that respond to specific therapies
a. HCV genotype 1 are less likely to respond to traditional treatment
4. Identification of high risk genotypes that necessitate different Mx
a. high risk HPV typing as part of cervical ca screening
5. Research tool

MULTIPLEX PCR
• Simultaneous detection of > 1 type of specimen
• Particularly useful for dx in case of SYNDROMES (similar signs and symptoms) where it may be
difficult to distinguish between causative pathogens clinically
• across disciplines, not just virology --> bacteria and fungi too: do multiplex --> most often used for respiratory
pathogens

Examples:
• Respiratory infections (respiratory swab, others)
• Aseptic meningitis/encephalitis (cerebrospinal fluid)
• Gastroenteritis/infectious diarrhea (stool)
• Sexually transmitted infections (swab/urine)
• Viral haemorrhagic fever & arboviruses (blood)

✓ Faster detection of a larger number of microorganisms → promise to improve health care & expand
knowledge
• Challenges include cost, ideal test utilization strategies (ie optimal ordering) & test
interpretation

Saves Cost Costly

1. ↑ infection control + prophylaxis 1. Simplified test ordering
2. ↓ unnecessary investigations 2. Accurate testing
3. ↓ hospital admission and duration of 3. Faster results → earlier dx
stay 4. Testing multiple pathogens
4. antimicrobial stewardship 5. ↑ detection rate
5. effective customized treatment 6. ↓ sample volume
6. epidemiological information 7. Epidemiological information
Influenza lab testing:
Who?
• Lab diagnosis of uncomplicated illness is not routinely recommended
• Consider testing for the following:
o Pts who meet the criteria for COMPLICATED or SEVERE influenza, where a lab
diagnosis will ASSIST in patient management
o Pts at HIGHER RISK of complications / severe disease
o Cluster of cases where a sx of the cause of the outbreak is needed (healthcare facilities and
nursing homes)

What test?
• Molecular diagnostics → real-time multiplex PCR or GeneXpert for influenza A + B
o GeneXpert → 3 targets
o FastTrack→ 18targets
o Biofire → 20-21 targets
• rapid point of care or IF tests for influenza A are NOT recommended
• Lab testing should NOT delay administration of treatment when indicated*

Interpretation of results
• Significantly ↑ proportion of pts in whom an aetiological agent can be found =80% → mainly viral
and atypical pathogens
• CAUSALITY → passenger vs pathogen
o up to 15% of HEALTHY PERSONS harbour resp tract virus at ANY point of time
• URTI vs LRTI
o sampling site nb
o contamination of URT when sampling LRT
• interpret all results in the context of clinical observations
• ALWAYS consider disease pathogenesis

TEST QUESTION:
• If you identify a pathogen on multiplex PCR it ALWAYS indicates disease? → FALSE
o Passenger* vs pathogen
New Developments in Virology and virus
vaccines [L7]
HIV Pre-exposure Prophylaxis (PrEP)
• The use of ARVs by HIV -ve people BEFORE POTENTIAL EXPOSURE to prevent acquisition
of HIV
o SHOULD be considered for people who are at significant risk of acquiring HIV infection
as part of a combined HIV prevention strategy (with condoms, abstinence, circumcision)
• TRUVADA
o 1 tablet once a day
o FDC of 300 g tenofovir (TDF) and 200 mg of emtricitabine (FTC)

TEST Q
Who gets PrEP?
• High risk (sex workers, men who have sex with men, any other at risk)

Before initiation of PrEP

1. Screening
a. HIV ELISA neg
b. eGFR >60ml/min (tenofovir can cause renal impairment)
c. HBsAg, HBsAb → if negative MUST vaccinate
d. STI screen → treat appropriately
e. BhCG
2. PrEP initiation visit Adequate tissue levels:
a. HBV vaccine, STI Rx, educate, prevention • anal sex = 7 days
3. 1-month F/U • vaginal sex = 20 days
a. creatinine clearance
4. 3 monthly maintenance visits Discontinue PrEP
a. HIV testing, STI screening ext • Continue for 28d after
last exposure
Post-Exposure Prophylaxis
1. Preferred backbone: TDF + 3TC / FTC
2. Preferred 3rd drug: DTG
3. Alternative 3rd drug options: ATV/r, DRV/r, LPV/r & RAL

How to make more aware of HIV status

1. HIV counselling & testing (HCT) using rapid Ab test (adolescents/adults incl. pregnant /
breastfeeding)
2. Regular testing for pregnant / breastfeeding
3. Birth PCR for HIV exposed infants

TEST QUESTION
- Is acceptable to use rapid test at clinic according to DOH guidelines
- Pregnant/breastfeeding is high risk for seroconversion thus regular test 3 monthly
- Birth PCR FNB

If HIV test is negative → When to repeat HCT?

TEST QUESTION
When to test in pregnancy and HIV exposed babies
 1. Pregnant / breastfeeding women
a. every 3 months throughout pregnancy
b. at labour / delivery
c. at the 6 week EPI visit
d. Every 3 months throughout breastfeeding
2. HIV-exposed babies
a. Birth
b. 10 or 18 weeks
c. 18 months
d. When sick
e. test 6 weeks after last exposure
i. PEP for 4 weeks if low risk exposure thus test at 10 weeks
ii. high risk babies, 12 weeks PEP thus test at 18 weeks

Recommended intervals for infant and child testing Can test with rapid after 18 months

HIV PCR TEST RAPID HIV ANTIBODY TEST

At birth At 18 months
- all HIV exposed babies - all HIV exposed infants
IF BIRTH TEST HIV -ve / NO PRIOR TESTING:
At 10 weeks Breastfed Infants
- all HIV exposed babies - 6 weeks post cessation of bf if > 18 mo of
age
At 18 weeks Family and social history (at all times)
- all infants who received 12 weeks of NVP - parental request to test the child
prophylaxis - Father or sibling with HIV infection
Breastfed Infants: - Death of mother, father, sibling
- 6 weeks post cessation of breastfeeding if < - Mothers HIV status unknown or she is
18 mo of age unavailable to be tested
< 18 months: All children (at all times) with:
- when clinically indicated - Clinical features suggestive of HIV
Any infant with a +ve HIV PCR should be urgently - Acute, severe illness
referred / discussed telephonically for ART - TB
intitiation by a paediatric HIV expert - Exposure eg sexual assault / breastfed by
other F
- Considered for fostering / adoption

HIV self-testing
• HIV self-testing or self-screening is a process in which a person collects his/her own specimen (oral fluid/blood) & then
performs an HIV test & interprets the result, often in a private setting, either alone or with someone he/she trusts.
• Recommended to reach key & under-tested populations as a complementary approach to existing HIV testing services
• HIVST does NOT provide a definitive diagnosis: a reactive (positive) result always requires
further confirmatory testing from a trained health professional using relevant validated national HIV
testing algorithm, typically performed at a clinic

SA self testing policy:

• Start life-long ART regardless of CD4 count or clinical staging as soon as possible after
diagnosis

Indications for initiating ART

• Start in ALL individuals diagnosed with HIV
o CD4 < 200 = initiate within 1 wk
 o Pregnancy = initiate on SAME DAY as diagnosis
• Exceptions: delay ARVs to avoid IRIS
o TB
o TB meningitis
o Cryptococcal meningitis
o pts receiving rx for other acute or opportunistic infections: rx opportunistic infection 1st

Defining ART failure: HIV VL

Definitions form part of a test question
• Successful Treatment
o a decline in VL to <50 copies / mL within 6 months of commencing ART & sustained
thereafter
• Treatment failure
o VL of > 1000 copies / mL on 2 measurements taken 2-3 months apart
▪ NB: intensive adherence counselling after result

Most common reasons for treatment failure:

1. inadequate patient adherence to prescribed regimen
2. Drug interactions that decrease ART concentrations
3. Prior use of single dose NVP for PMTCT
4. Transmitted drug resistance – estimated 5-15% & increasing

Indications for changing ART

1. Toxicity – substitution if:
a. VL is supressed
b. ART was initiated within last 6 months
2. Resistance (failure)
a. SWITCH
i. 1st line → 2nd line → 3rd line
ii. Switching ↑ cost, ↓tolerable, ↑doses BUT
→ a delay will cause a progressive ↑ in the accumulation of resistance mutations
THUS
1. Switch WITHOUT delay if virological criteria for treatment failure are met →
expedite if CD4 < 100
a. VL > 1000 copies/mL on 2 measurements taken 2-3 mo apart
b. Low level viraemia (detectable ut < 1000 copies / mL) for > 1 year
c. Low level viraemia with persistently CD4 counts < 100 cells/uL
DESPITE ADHERENCE INTERVENTIONS

2nd & 3rd line ART regimens

• NEVER switch ONLY 1 drug if a failing regimen
• Do NOT continue therapy with a failing NNRTI regimen for prolonged periods = ↑ risk of
accumulating NRTI resistance mutations
 MICROBIOLOGY
Lab Aspects and diagnosis [L26]
Principles of Hospital Infection Prevention and
Control [L41]
1.Understand the principle behind infection prevention and control (IPC) in the context of hospital
acquired infection

• processes and activities (quality improvement processes) that identify and reduce the risks of
acquiring and transmitting infections among individuals (healthcare workers, pts and others) in the
healthcare setting and community
• Pathogens may be transmitted from other pts, hospoital personnel, hospital environemnt

2.Understand the cycle of infection

WANT TO BREAK THE CYCLE

- at reservoir: wash hands, clean

environment, isolation areas
- infectious agents: ABs +
sufficient treatments

3.List the Standard Precautions

1. Hand Hygiene – before and after every pt contact

2. Personal Protective Equipment (PPE)
3. Safe disposal or cleaning of instruments and linen
4. Safe injection practices and disposal of needles and sharps
5. Cough etiquette

4. Transmission Based Precautions

1. Contact precautions
a. DIRECT – hands, injection, ingestion
b. INDIRECT – equipment, environment
2. Droplet precautions
a. 1-2m*
3. Airborne precautions
a. remain suspended in the air for extended periods → MASK
i. Confirmed TB
ii. Measles
iii. Varicella
iv. Smallpox
v. Severe acute respiratory syndrome

5.Understand the 5 moments for Hand Hygiene and the recommended technique
6.Differentiate the types of transmission based precautions
 IMMUNOLOGY
MCQs
• choose the correct set of test to verify or eliminate said conditions

Outcomes:
• what laboratory tests to requisition should he/she suspect Autoimmune diseases, Primary
Immunodeficiency Diseases, or Infectious Diseases
• clinical picture
• successful interpretation of the reported results.

Serodiagnosis of Allergy & Infectious Diseases [L12]

Allergic Sensitivity
• Total IgE in serum
• Measurement of Allergen-specific IgE in serum using the Immunocap / RAST system
o single allergen or groups
o Screen using allergen mixes → then test for specific sensitivites
• Specialised Allergy testing → not practiced in gvnmnt
o Allergen microassays 130 diff allergens
o CAST-ELISA → release of cysteinul leukotrienes C4 and D4 from allergen treated blood

Immunocap Allergen Mixes

Aeroallergen mix Food mix
1. House dust mites 1. Cows milk
2. Cat dander 2. Fish
3. Dog dander 3. Peanut
4. Cockroach 4. Wheat
5. Grass 5. Soya Bean
6. Aspergillus fumingatus 6. Egg white
7. Alternaria alternata
>> IF POSITIVE → test reactivity for specific allergens

Management of peanut allergic patients

• How can you differentiate between a ‘true’ peanut allergy or symptoms of cross-reactivity?
o Presence of specific IgE (Ara h 1,2,3) → “true” peanut allergy + high risk of severe reaction
o Cross-reactive allergen components (Ara h 8,9) which also present in pollen and plant foods
→ varies depending on exposure
o Several peanut allergen components → higher risk of severe reaction
Immunodeficiency
Definition:
• Immunodeficiency is the result of a diverse group of abnormalities of the immune system resulting in
primarily an increased incidence of infection

Primary Immunodeficiency Syndromes

• Congenital + hereditary

Lab Investigations
Indications:

SPUR

• Serious Infections requiring IV antibiotics

• Persistent infections
• Unusual organisms at unusual sites
• Recurrent Infections

Screening Procedures:
1. FBC and differential
2. Total serum Igs
a. IgG, IgA, IgM, total IgE
b. → IgG subclasses
3. Total haemolytic complement
a. C3 and C4
4. Flowcytometric analysis of:
a. T cells / subsets (CD3, CD4, CD8)
b. Circulating B cells (CD19)
c. NK cells (CD56)

Follow-Up Procedures:
• Neutrophil functions – antimicrobial activity
• Monocyte / macrophage functions – production of
cytokines
• T-lymphcytes functions – proliferations, cytokine production

Secondary Immunodeficiency
• Acquired on a transient ot permanent basis
Infectious Diseases
• detection of SPECIFIC ANTIGEN is definitive and preferable to serological procedures
o isolation and culture
o observation by microscopy
o Detection of pathogen-specific nucleic acid (PCR)

Serology
Limitations of Serological Procedures
1. Many antigenic sub-types
2. High pre-existing levels of Abs
3. Ab production compromised
a. immunodeficiency / immunosuppressive therapy
b. acute phase disease precedes production of specific Abs

Serodiagnosis if of VALUE in:

1. Syphilis “Bruce has syphyllis and pneumonia but rick ate
2. Brucellosis a toxic chlam”
3. Pneumonia by mycoplasma pneumonia
4. Chlamydial diseases
5. Rickettsial diseases
6. Toxoplasmosis
7. HIV and HV infections

Acute vs Chronic Infection

ACUTE CHRONIC
1. IgM • IgG: significant increase in titer (4 x basal)
– detectable within days + peak at 7-10 d *Chlamydial serology: IgG, IgA, IgM
2. IgG
- detectable 7-14 days + STAY in circulation
for months
*↑ titres must be shown in FU samples to
CONFIRM active infection – retest in 4-6wks

Serological Procedures which can detect different types of Ab

• Indirect Immunofluoresence
• ELISA – enzyme linke immunoassay
1. Syphilis
Know when to initiate treatment

• Serology effective for diagnosis and monitoring treatment → MAINSTAY

→ false +ve
→ +ve test = TREATMENT
→ Latent Syphilis: prev Rx
→ No evidence of syphilis

2. Chlamydia
• C. psittaci, C.trachomatis, C.pneumoniae

EXAM Q:
Can get a question like this without the normal values

Normal Values:
• IgG < 1:64
• IgA < 1:16
• IgM < 1:10

3. Tick byte fever

• R. conorrii, R.typhi, R. ricketsii, C. burnetti

Rickettsia
C. Burnetti
EXAM Q:
• Acute vs Chronic
Serodiagnosis of Autoimmune Diseases [L19]
Extractable Nuclear Antigens and Associated Diseases
DIAGNOSTIC ANTIGENS

Antigen Disease Associations

(DIAGNOSTIC)
dsDNA SLE
SmDP SLE
Ribosomal P Neuropsychiatric SLE
Jo-1 Polymyositis
Scl-70 Progressive systemic sclerosis
(topoisomerase 1)
Centromere P CREST Syndrome
CENP Scleroderma. CREST

TEST Questions:

• Serological Picture of SLE

1. ds DNA → diagnostic
2. Sm → diagnostic
3. Ribosomal P → diagnostic
▪ Supportive:
• SS-A, SS-B, U1RNP
4. ANA → most likely positive
5. Homeogenous pattern
Rheumatoid Arthritis
• Rheumatoid factor
• Anti-CCP antibodies

Anti-Phospholipid Syndrome
>> NEVER BEEN ASKED

• Clinical Picture
o Arterial / venous thrombosis
o recurrent foetal loss
o thrombocytopenia
o F>M
• Anti-Cardiolipin Antibodies (ACLA)

Neurological Diseases
• Classic paraneoplastic neurological syndrome
• Autoimmune encephalitis
• Neuromyelitis optica
• Polyneuropathies
• Myasthenia gravis
• Alzheimers? theorise

When do we send serum and when do we send CSF?

• Mostly serum
• NMDA → Serum + CSF
• VGKC → Serum + CSF
 HAEMATOLOGY
Most likely MCQs*

The FBC and making a haematological

diagnosis [L6]
Haematopoiesis
Where does it occur?
• Red bone marrow
o ribs, vertebrae, sternum, pelvis, procimal
humeri and proximal femurs

How is it regulated?
• Rate is controlled by erythropoietin produced by the
kidneys
• Homeostasis is maintained by negative feedback
from blood oxygen levels

Anaemia
Structure of Hb and the Hb/O2 dissociation curve

How is energy generate by the RBC

Describe the RBC membrane structure

Pathophysiological and morphological classifcation systems

Pathophysiological Morphological
Increased Red Cell Loss (↑reticulocytes) ↓MCV ↓MCH
- Blood Loss Hypochromic, microcytic anaemia
- Haemolysis - Fe deficiency
- Anaemia of Chronic Disease
- Thallasaemia
Decreased red cell production (↓reticulocytes) N MCV N MCH → MOST COMMON
- Stem cell abn = aplasia Normochromic Normocytic
- ↓ erythropoetin (renal failure) - Anaemia of chronic disease
- Defective DNA synthesis (↓B12/folate) - Acute blood loss
- Defective haemoglobin synthesis (↓Fe, - Chronic renal failure
thalassaemia)
- Displacement of normal progenitor cells
Malignancy, fibrosis, granulomas
Multifactorial ↑ MCV
- Anaemia of chronic disease Macrocytic Anaemia
- HIV MEGALOBLASTIC NON-
(oval macrocytes, MEGALOBLASTIC
hypersegmented (round macrocytes)
neutrophils) - reticulocytosis
- Vit B12 / folate - liver disease
deficiency - alcohol
- drugs
 - pregnancy
- hypothyroidism
- myelodysplasia

How does a patient with anaemia present

Be able to understand and interpret every component of the FBC

How is erythropoiesis measured

When would you do a bone marrow examination on a patient

Hypochromic Anaemia
What is the role of Fe in the RBC

How is Fe absorption controlled

What are the causes of iron deficiency

What is anaemia of chronic disease and how is it differentiated from iron deficiency

Anaemia of Chronic Disease

• Develops after 2 mo
• NON-progressive
• Pathogenesis
o Iron transfer block
o ↓ EPO production
o impaired response to EPO by erythroid precursors
• Lab Features
o Initially NORMOCYTIC → later MICROCYTIC
o Inappropriately RAISED ferritin

Causes of Reticulocytosis
1. Haemorrhage
 2. Hamatinic Therapy
3. Erythropoetin therapy
4. Haemolysis

Haemolytic Anaemia → lecture 35

Granulocytes and monocytes, benign disorders

How do neutrophils fight infection

What are the causes and mechanisms of a low neutrophil count

Neutropenia
1. Decreased production
a. General bone marrow failure
i. aplastic anaemia
ii. myelodysplasia
iii. acute leukemia
iv. chemotherapy
b. Specific failure of neutrophil production
i. Congenital
ii. cyclical
iii. drug induced
2. Increased Destruction
a. General: hypersplenism
b. Specific: Auto-immune

What causes a high neutrophil count?

Neutrophil Leucocytosis
1. Bacterial Infection!!!
2. Tissue Necrosis
3. Metabolic Disorders
4. Neoplasms
5. Acute Haemorrhage or Haemolysis
6. Steroid Therapy
7. Myeloproliferative disease

what is a leukemoid reaction and what causes it

Causes of raised monocyte count

• Chronic Infections
o eg TB

Causes of a raised eosinophil count

• Allergy
• Parasitic infestation
• Chronic skin disease

Lymphocytes, benign disorders

define each of the lymphocyte subsets

Causes of lymphopenia
1. Inherited and acquired IMMUNODEFICIENCY (HIV)
 2. Irradiation
3. Acute stress (trauma, surgery, burns)
4. Drugs → ATG, steroids
5. Auto-immune disease → SLE

Causes of lymphocytosis
1. Infection – viral /bacterial
2. Lymphoproliferative disease

effect of HIV infection on the haemopoietic system

Vascular and platelet abnormalities

Approach to a patient with a low plt count →
Thrombocytopenia

1. Decreased production
2. Increased destruction / consumption → most common
a. ITP + HIV associated thrombocytopenia
b. DIC
c. HUS / TTP
3. Hypersplenism
4. Dilution (post transfusion)

Diagnosis – Evaluation of bleeding

History Taking – more valuable than lab investigations
1. Onset of bleeding
2. nature of bleeding
3. drugs used
4. family history
5. spontaneous or following trauma

Thrombocytopenia
>> Platelets < 10 x 109/L

1. Spontaneous bleeding
2. Mucosal bleeding
3. Ecchymoses and petechiae

Clotting Factor Deficiency

>> abnormal clotting screen

1. Bleeding after surgery

2. Bleeding into joints or muscles
3. Delayed bleeding
4. Family history

Pt who is bleeding with normal platelet count and normal coagulation screen
1. Bleeding time / PFA – 100
2. Platelet function defect
a. Von Willebrand disease
 b. ASPIRIN

Diagnosis and management of ITP

Inherited and acquired plt function disorders

Haematological malignancy
What modalities are available for the lab investigation of haematological malignancy

How is clonality established in the lab

1. Recurring cytogenetic abnormality eg Ph+

2. Light chan restriction ie kapp or lambda
3. IgH gene rearrangement
4. T cell receptor rearrangement

Interpretation of Clotting Tests

Condition Prothrombin APTT (activated Bleeding Time Platelet Count
Time partial thromplastin
time)
Haemophilia N ↑ N N
Von Willebrand N ↑ ↑ N
Liver Disease ↑ ↑ N N
DIC ↑ ↑ N ↓
Hypercoagulability and Thrombophilia [L16]
1. Arterial Thrombosis
Pathogenesis
• atherosclerosis of arterial wall → plaque formarion
• endothelial injury
• platelet nidus
• Adhesion: plt adheres to something else → collagen / vessel wall
• Aggregation: platelets adhere to each other
• PDGF→ intimal proliferation
• Endothelial regrowth → thrombus incorporated
• Obstruction of lumen → symptoms

Antithrombotic properties of vascular endothelium

• Modulation of thrombin activity
o Heparin sulphate
o Thrombomodulin
• Modulation of platelet reactivity and release of vasodilators
o Prostaglandin I2
o Nitric oxide
• Activation and localization of fibrinolytic activity
o generation of tPA
o Affinity for tPA and plasminogen

Risk Factors
• Family Hx
• Male
• Hyperlipidaemia → lipogram
 • HT → BP
• Smoking
• DM → glucose
• Gout → uric acid
• Polycythaemia → FBC

Homocysteine
• ↑↑ HOMOCYSTEINE = acts like
cholesterol
• NB to treat with Vit B12 + B6
• Common clinical picture = heart
attack in young person

2. Venous Thrombosis
Pathogenesis
• Virchows Triad
o Stasis
o Hypercoagulability
o Vessel wall damage

Clinical Signs and Symptoms

• Leg pain + tenderness
• Ankle oedema
• Calf swelling → measure
• Dilated veins
• Homan’s sign (sharp pain in calf on dorsiflexion of the foot)

Risk Factors
List the genetic risk factors

Deficiency of Antithrombin
anticoagulant Protein C
Protein S
Abnormal protein Factor V Leiden
Dysfibrinogen
Increased Prothrombin G20210A
PROcoagulant Factor VIII
Abnormal metabolism Homocystinuria
Putative Mechanisms Thrombomodulin defects
Fibrinolytic defects
Coagulation Cascade *look at surgery notes

Anticoagulation Pathway:
1. Protein C → protein S
2. Antithrombin
3. Plasmin

Inherited
1. Antithrombin Deficiency
• Inactivates Factors
o IIa, VIIxa, IXa, X, XIa → 2, 7, 9, 10, 11
o esp in presence of heparin*
• Pts may be resistant to heparin therapy
• Inherited
• TEST: Antithrombin level

2. Protein C + S deficiency
• C: Vit K dependant protein
o Inactivates Factors:
▪ Va and VIIIa →5+8
▪ In the presence of PROTEIN S
• Inherited but can also be acquired → Liver pathology*
• TEST: protein C+S levels
o Prove abnormal levels 3 times before making a diagnosis

3. Factor V Leiden
• most common thrombophilic factor*
• FV → resistant to inactivation by protein C
• TEST:
 o APC-R
o PCR test for FV Leiden

4. Prothrombin G20210A
• Overproduction of thrombin*
• TEST:
o prothrombin level
o PCR testing

Significance of a 2nd abnormality

Antibody Mediated Thrombosis
Antiphosphospholipid Antibody Syndrome
• Acquired
• Directed against phospholipids of the cascade* → antibodies form clots

Patients to be tested:
• Recurrent thrombosis
• Thrombosis while ON anticoagulant therapy
• Thrombosis at young age < 50y
• Children
• +ve Fam Hx
• Recurrent foetal loss
• Thrombosis at unusual site

Screening Tests for Hypercoagulability

1. FBC, ESR
2. Blood film examination
3. PT/PTT
4. Fibrinogen
5. Factor V Leiden: APC-R/PCR
6. Prothrombin G20210A
7. Antithrombin
8. Prot C + Prot S
9. Homocysteine
10. Acid lysis test / flow cytometry for PNH
11. Factor level determinations: FV, VII, XII
12. Exclude malignancy
Haemostasis [L21]
Indications for ordering Haemostatic Tests
1. Identify which pts with acute bleeding have a correctable bleeding tendency
2. Identify which pts with acute clots have a correctable clotting tendency
3. Monitoring pt response to anticoagulant rx
4. Prognostication in pts with liver failure
5. Screening for DIC

Conventional Tests
1. Platelet count → Thrombocytopenia/cytosis
2. PT/INR →
3. aPTT – activated partial thromboplastin time
4. Fibrinogen
5. D-dimer

Common Aetiologies
1. Platelet Count
Thrombocytopenia
Decreased production Bone marrow disease
Nutritional deficiencies
Increased Destruction Medications
Alcohol
Autoimmune disease
DIC
Hypersplenism
Thrombocytosis
Reactive Infection
Post surgery
Post splenectomy
Malignancy
Acute blood loss
Myeloproliferative
disorders

2. Prothrombin Time and aPTT

Isolated Prolonged PT Which test measures what?
• Vit K deficiency
• Liver disease • PT
• malabsorption o Extrinsic Pathway
• Heparin ▪ TF, VII
• Multiple clotting factor deficiencies • aPTT
o Intrinsic Pathway
Isolated prolonged aPTT ▪ VIII, IX, XI, XII
• Deficiencies of XII, XI, IX, VII • Common
• Acquired clotting factor inhibitors o II, V, X, fibrinogen

Prolonged aPPT and prolonged PT

• Vit K deficiency
 • Liver disease
• DIC
• Dilutional coagulopathy
• multiple clotting factor deficiencies

Increased aPTT ± prolonged PT

• UFH
• antiphopholipid pts
• Acquired clotting factor inhibitors

3. Fibrinogen
• formation of plt plug → ultimate step in coagulation

High levels
• Acute phase reactant
• pregnancy

Low levels
• liver failure
• DIC

4. D-Dimer
• degradation product of cross-linked thrombin
• *not specific outside clinical context

Causes of HIGH D-dimer

1. VTE
2. Arterial clot
3. DIC
4. Severe sepsis
5. Malignancy
6. Surgery / trauma
7. Liver disease
8. pregnancy

Interpretation of the results

both pathways

both pathways

intrinsic pathway

intrinsic pathway
Blood Transfusion [L40]
Informed consent!!

Products:
1. Red cell concentrate
a. acute blood loss
b. surgery
c. symptomatic anaemia
2. Washed red cell
a. for pts allergic reaction to transfusion before
3. Irradiated red cells
4. Leucodepletion
a. Pts on chronic transfusion regimens
b. risk of CMV infection
c. organ and stem cell transplant pts
d. infants <1y
e. pts undergoing cardiac surgery
5. Gamma irradiation
a. transfusion from relatives
b. HLA matched platelets
c. Hodgkins disease
d. pts treated with purine analogues
6. Platelets
a. bone marrow failure
b. massive transfusion
c. acute DIC
d. congenital d/o of platelets
e. C/I
i. ITP
ii. TTP
iii. HIT
7. Plasma products
a. FFP
i. coagulation deficiency
ii. Vit K def
iii. reversal of warfarin

Complications of blood transfusion

Early Late
1. Haemolytic reactions 1. Transfusion associated graft vs host
2. Bacterial contamination disease
3. Anaphylactic reaction 2. Transmission of infection
4. Febrile non haemolytic transfusion 3. Post-transfusion purpura
reaction 4. Alloimmunisation
5. TRALI
6. Allergic Reaction
7. Electrolyte imbalances (hyperK)
Management of Transfusion Reaction
1. STOP transfusion
2. Repeat ID and verification of pt and unit
3. Specimens
a. blood – post transfusion pt sample → 1 clotted and 1 anticoagulated
b. urine sample
4. Lab
a. repeat ABO and Rh of pretransfusion, repeat ABO and Rh of posttransfusion,
b. DAT,
c. crossmatch using pre and post samples,
d. check for haemolysis
e. Blood cultures, haptglobin, FBC, urine haemosiderin
5. Complete reaction report form
 RADIOLOGY
>> MCQs

Which cost effective radiological modality should be chosen for a

specific case scenario.
• An adult patient with suspected intracranial bleed.
o Uncontrasted CT
• A neonate with suspected intracranial bleed.
o U/S
• An adult patient with suspected gallstones.
o U/S
• Paeds – any solid organ examination
o U/S
• A patient with suspected intracranial aneurysm.
o CT Angio
• A patient known with breast carcinoma presenting with acute confusion.
o Contrasted CT
• A patient with sudden paraparesis and loss of bladder and rectal sphincter control.
o MRI lumbar spine and sacrum
• Patient with suspected interstitial lung disease on cxr.
o High-risk CT
• Post trauma patient to exclude free fluid in the abdomen.
o FAST - U/S
• An adult patient with suspected hip dislocation.
o XRAY pelvis
o or Muscle: MRI
• Neonate with suspected hip dislocation.
o U/S
• An adult patient with suspected intra peritoneal abscesses.
o CT contrast
• A patient with a suspected hyper acute infarct and a normal brain CT scan.
o MRI brain
• A renal failure patient with query brain abscess or brain metastasis.
o CT followed by dialysis OR straight to MRI
• A teenager with bilateral, multiple, mobile breast lumps.
o U/S
• Adult patient with suspected diverticulitis.
o Barium enema
• A patient with suspected gastric outlet obstruction.
o Barium meal
• In a patient wth a pacemaker the risk of MRI investigation far outweighs the befit as the MR
machine can rip off the pacemaker → death
o If you need imaging of the spine:
▪ CT myelogram: contrast injected into spinal column
 • Case 1: A 25 year old patient fell and presents with a suspected knee dislocation and cold limb.
Orthopaedic vs Vascular injury
o → Doppler: absent pulses
o CT angio
• Case 2: An unstable hypotensive patient with abdominal and head injuries.
Abdominal Vascular injury vs Head injury-?
Commonly result in hypotension?
o ABCDE
o US abd
o CT abd
o THEN only CT brain
• Case 3: In a patient with blunt abdominal trauma and a known or suspected hemorrhagefrom pelvic
fractures. Abdominal vascular Injury vs Pelvic injury-? Arterial ? Venous
o CT Angio of abd and pelvis
• Case 4: 49 years old female patient-right upper quadrant pain radiating to the right back, fever
nausea and vomiting post prandial. ?Cholecystitis-U/S or CT
o Abd U/S
• Case 5: A 19 year old male patient complaining of severe right lower quadrant pain with guarding,
high white cell count with no history of trauma. ? Appendicitis-U/S or CT
o U/S abdo
o IF PT OBESE → CT abdo

Which modalities use radiation and which does not use radiation.
• Does NOT use radiation
o Ultrasound
o MRI
• Uses radiation
o Xrays (small amount)
o Fluoroscopy
o CT scan (more radiation through bone vs other tissue)
o Mammography
o Interventional radiation (loots of radiation)

Know what to put on referral letter.

• All the relevant clinical history, presenting symptoms, relevant laboratory findings, the
number one clinical diagnosis and differential diagnosis.
• Without the above information, the clinical question might not be answered after imaging.
• Radiologist might end giving clinicians a long list of differential diagnosis instead of simply giving the
diagnosis.
• Radiologists are Clinical Radiologist

Cost Effective Radiology:

Know definition of cost effective radiology.

• Does NOT mean doing cheapest investigation first

• does NOT mean doing the most accurate test first
 • Balance between: most accurate, expensive procedure AND less accurate, less expensive
procedure.
• Moderately expensive procedure that are highly accurate, should always precede expensive
procedures that are slightly accurate
• Referrer (clinician) has a responsibility to provide sufficient medical information so that the
radiologist can decide if the exposure can be justified

cost - just know US < x-ray < CT < MRI

CT Scan
Contrasted CT SCAN Pre-requisite
• allergy to iodine
• allergy to penicillin
• have they taken Glucophage prior to examination? → LACTIC ACIDOSIS

CT scan pre-requisites
• U+E creatinine*

To exclude tumour or abscess use contrast

MRI
• good for soft tissue imaging
o If you want to see spine or nerves - do MRI
• no radiation, therefore safe to use in pregnancy and paeds
• Lie very still → movement blurs or distorts pics
• claustrophobic sensation

Contraindications
1. Pacemakers
2. Metal implants/chips/clips

Mammogram
Mammogram is low radiation and us for older than 40. If younger than 40 do U/S.

FAST
know what fast stands for and what a positive fast means.

• Focused Assessment with Sonography in Trauma

o +ve FAST = free fluid in the abdomen

Fluoroscopy
uses will just help with when to order what

Radiation
Radiation Dose
• tells us about the effect the radiation has on a tissue
 • different tissues have varying sensitivity to radiation exposure → the actual radiation risk to
different parts of the body varies
• an exposure to low-dose radiation may not cause immediate harm to patients but may potentially
have long term biological effects
• Females are more sensitive to develop radiogenic cancer than males

Effects of Radiation
What is Stochastic effect and Deterministic effect.
• STOCHASTIC EFFECT
o likelihood that an effect/cancer will occur in the long term – there is no threshold below
which the effect does NOT occur
• DETERMINISTIC EFFECT
o Varies with the dose, there is a threshold below which the effect does not occur

ALARA Principle
What is ALARA principle?

• “as low as reasonably achievable”

o By the radiographer
▪ controlling the exposure in majority of dx examinations
▪ limiting irradiation of gonads → gonad shielding and rubber
▪ 10 day rule in pregnancy:
•
women of child bearing age, non urgent diagnostic radiography of the
abdomen should be confined to the pre-ovulatory phase of the menstrual
cycle → 10 days following the 1st day of the last menstrual period
▪ ordered investigation appropriate for pts clinical presentation
▪ guiding the physician if ordered investigation will not help finding correct dx
• How can physicians reduce radiation dose?
o By clinicians
▪ Order the appropriate investigations for the relevant clinical presentation
▪ do NOT unnecessarily repeat investigations
▪ Always check previous imaging BEFORE ordering any investigation
▪ Have all pre CT scan pre-requisites CHECKED before requesting an investigation
▪ Have relevant blood results ready (U+E in renal failure) in case of post
contrasted imaging or angiography
▪ Is pt allergic to iodine, penicillin or other allergy and prep the pt for imaging
▪ Benefit of these exams should far outweigh any risk the pt receives form the
amount of radiation received

Emergency cases
Radiological approach to emergency cases - A trauma patient, acute abdomen, widened mediastinum,
blunt abdominal trauma, vascular injury, head, cervical spine injury and chest trauma.
1. A. AP Chest Radiograph
a. to exclude: tension pneumo, widened mediastinum
2. B. AP pelvic radiograph
a. #
3. C. FAST
a. free fluid in pericardium, peritoneal cavity, hemopneumothorax
 b. +ve FAST must be followed by CT scan
4. D. long bone XR
a. #
5. E. Doppler
a. vascular injury
6. F. CTA
a. vascular injury
b. if in doubt and PATIENT IS STABLE
7. G. neuro examination
a. head injury / intracranial injury TRAUMA → Pre-contrast CT brain
b. C-spine injury: XR order whenever chance of cervical injury, high risk and signs of
neurologic injury require CT and possibly MRI
c. If neurological fallout but no xr or ct findings → do the mri!
i. MRI is most sensitive method for detecting this type of ST injury

Acute Abdomen
• Clinician and the radiologist have to be familiar
with all the diagnoses listed in the table to be able
to recognise them (clinically or radiologically)
• Focus on the most common disease and make a
firm diagnosis to exclude them
• 1st cost effective investigation: U/S
• if inconclusive → CT scan
• XR only indicated for:
o kidney stone detection
o pneumoperitoneum
• NB NB:
o RLQ: appendicitis → U/S → CT
▪ appendiceal abscess → U/S
o LLQ → Diverticulitis → barium enema
o RUQ → cholecystitis → U/S
o Ureteric stones → CT scan pre-contrast BEST for small stones

Free intraperitoneal air

• Common causes:
o Perforated gastric ulcer
o Perforated colonic diverticuli
• free air under diaphragm

Ruptured abdominal aortic aneurysm

• aortic aneurysm:
o first U/S → angiogram
• Ruptured
o CT more specific

Pancreatitis
• U/S
• CT
Blunt Trauma
1. CXR: evaluate for penumo and widened mediastinum
2. AXR: pneumoperitoneum
3. FAST: free fluid
a. CT scan abdomen and pelvis
4. Cystogram / CT cystogram: bladder injury
5. U/S: pericardial effusion

Widened mediastinum
• CXR → CT scan → Angiography

Xrays
• Haemothorax
• Pneumothorax
• C-spine
• widened mediastinum
Acid-Base Disorders
Acid-Base Homeostasis
Buffers
Buffer systems in blood and urine
Henderson-Hasselbalch equation
1. Principle buffer system in all cells: Henderson-Hasselbach equation
a. H++ HCO3- ↔ H2CO3 ↔ H2O + CO2
>> Carbonic Anhydrase
2. Urinary Buffers:
a. HPO4- + H+ ↔ H2PO4-
b. NH3+ H+ ↔ NH4+
3. Red blood cell
a. Hb- + H+ ↔ HHb

Compensation
Normal Values
• pH 7.35-7.45
• PaCO2 35-45mmHg
• PaO2 80-100 mmHG
• HCO3- 22-26 mmol/L
• Anion gap 14 –18mmol/L
• [H+] 35 –45 nmol/L

Acidosis Alkalosis
Approach
pH  
1. Is PaO2 and O2 saturation normal?
CO2  
2. Is pH Normal?
PO2  = Hypoxia  = O2 Therapy
3. Is PaCO2 Normal?
4. Is HCO3- Normal? HCO3-  
5. Match PaCO2 or HCO3-to pH RO-ME
6. Compensation: Does CO2 or HCO3- go in opposite direction to pH Respiratory = Opposite to pH
Metabolic = Equal to pH

1. PaO2 = Oxygenation
• Transfer of adequate Oxygen from a;veoli to Blood
•  PaO2 = Hypoxia

 as O2  PaO2
1. Hypoventilation 1. Hyperventilation
2. R –> L Shunt 2. O2 Therapy
3. Alveolar Capilary Block
4. VQ Mismatch

Type 1 Respiratory Failure : Hypoxemia WITHOUT CO2 Retention

• Pure O2 Problem = Lung Disease
o Chest Infection: Pneumonia
o Asthma
o Pulmonary Edema: Shunt
• Rx:
o O2 Suplementation
o PEEP

Type II Respiratory Failure: Hypoxemia WITH CO2 Retention

• Ventilatory Problem =  Respiratory Effort
• Associated Lung Diseases
o COPD
o Head Injury
o Opioids
• Rx
o Assist Ventilation

NB: Pulmonary Embolism:

 PaO2 and  PaCO2
= Pt is hypoxic AND CO2 is low → hypoxia stimulates alveolare ventilation = tachypnoea = breath out more CO2
2. pH: Acidosis or Alkalosis
• Normal: 7.35 – 7.45
• CO2 + H2O > H2CO3 -> HCO3- + H+

 pH   HCO3 (Kidney)
 PaCO2 (Lung)

Compensation
• Respiratory: Fast (minutes)
• Renal: Slow (8-24hrs)

Some aids in interpretation of acid-base disorders

3. PaCO2 : Ventilation
Respiratory Acidosis
Acute Respiratory Acidosis
 PaCO2
 pH
N HCO3 → Not enough Time for kidneys to compensate

Compensation

Causes
1. Respiratory
a. Airway obstruction
b. Bronchospasm → asthma
c. Aspiration
d. Chest Trauma
e. Pneumothorax
2. Depression of respiratory centre
a. Anaesthetics: sedatives, narcotics
b. Cerebral trauma
3. CNS
a. Head Trauma
Chronic Respiratory Acidosis
 PaCO2
N pH
 HCO3- → Kidneys have compensated

Compensation

Causes
“retaining CO2”
1. Chronic Lung Disease
a. COPD
2. Pulmonary disease
a. Pulmonary fibrosis
b. Severe pneumonia
3. Neuromuscular disease
a. Guillian Barre syndrome
b. Motor Neuron disease
4. Chest Wall Deformity
a. Kyphosis
5. Extreme Obestiy

Respiratory Alkalosis
“breathing off too much CO2”
 PaCO2
 pH
N HCO3- → Kidneys have not compensated

Compensation

Causes
1. Hyperventilation
a. Anxiety
b. Pain
2. Over-aggressive Mechanical Ventilation
3.  Lung Volume Salicylates:
a. Restrictive Lung Disease, • Resp Alkalosis: initial presentation
b. Pregnancy dt HYPER ventilation
4. Fever, Sepsis
• Later metabolic acidosis
5. Increased respiratory drive
o high altitude
o severe anaemia
o pulmonary disease → PE, pulmonary oedema
o Respiratory stimulants eg salicylates
4. HCO3 : Renal Acid Excretion
Metabolic Acidosis
 pH
 HCO3-
 PaCO2 → Lungs have compensated

Compensation

Causes
High Anion Gap:
1. Lactic Acidosis →  perfusion–  O2 M ethanol
2. Ketoacidosis: U remia
a. DKA D KA
b. Starvation
  H+ Production
3. Ingestions P ropylene glycol
a. Ethylene Glycol I ngestions: Cocaine, excstacy
b. Methanol L actic Acidosis
c. Salicylates E thylene Glycol
4. Renal failure S alysalites
 H+ Excretion

Normal Anion Gap: (Hyperchloremic Metabolic Acidosis)

1. Renal Tubular Acidosis
o Failure to reabsorb bicarb by the kidney (RTA 2)
o Failure to secrete H+ ions by the kidney (RTA 1)
2. Failure to regulate bicarb
3. Extra-renal loss of bicarb
o Diarrhoea
o Ileostomy

TEST Q: Case of child with metabolic acidosis w NORMAL anion gap:

• RTA
• Diarrhoea
Anion Gap
• Helps determine Source of Acidosis
AG = [K+ + Na+] – [HCO3- - Cl-] ( Na + K ) - ( Cl- + HCO3- )
• Normal = 14-18 meq/L (140 + 4) - (105 + 27)
• High: > 15 = 144 – 132
• Low < 10 = 12 meq/L

Cations Anions
- Na+ = 140 - Cl- = 105 • Na represents majority of of +ve ions
- K+ =4 - HCO3- = 27 • But there are many other CATIOJS other than
Cl- and HCO3-than are being measures
- Ca = 4.5 - Protein = 15 • + 12 = Represents all of the unmeasured -ve
- Mg = 1.5 - PO4- =2 charges in the blood
- Proteins - SO4- =1
- Acid =5
High Anion Gap Metabolic Acidosis
•  Organic Acids
o = release H+ which bind to HCO3-
o HCO3 gets used up
o CALCULATED -- ve anions 
=> (Na+ + K+) - (Cl- +   HCO3-)
o Therefore Anion Gap gets more positive

•  of UNMEASURED anions
o Causes:
▪ Hyperphosphatemia =  PO4-
▪ Hyperalbuminemia =  Albumin
▪ Iga producting multiple myeloma =  Immunoglobulins
o To keep total charge in balance Cl- and HCO3- decrease
o = Anion Gap goes up

Normal Anion Gap

• Bicarbonate is lost due to vomiting or diarrhoea
• Kidney Compensated by absorbing Cl- Ions
• Cl- is a CALCULATED anion, therefore AG doesn’t change

Low Anion Gap (rare)

• Decreased Unmeasured Anions (Eg Albumin )
o To compensate and maintain elctroneutrality HCO3-and Cl- (measured anions) increase

Metabolic Alkalosis
 pH
 HCO3-
 PaCO2 → Lungs have compensated

• Rare
• Loss of H+ and gain in HCO3-→ lose H therefore no H to bind HCO3- which s
→ in vomiting pt is volume depleted =  Aldosterone =  HCO3- reabsorbtion by kidneys
Compensation

Causes
1. Volume depletion
a. VOMITING
b. pyloric stenosis
c. Excessive NG Suctio
2. Chronic alkali intake or Alkali Administration
3. Potassium depletion
a. inadequate intake
b. mineralocorticoid EXCESS
i. Conn syndrome
ii. Cushing’s syndrome
4. Contraction Alkalossi:  ECF Vomume
Base Excess
• Magnitude of Metabilic Component of Acid Base Imbalance
• Measure Total Body bases
o Haemoglobin
o Cl-, PO4, SO4
o Albumin
• Normal = -2 - +2

 = Alkalosis (with  HCO3-)

 = Acidosis → - 10 = significant portion of acidosis is coming from metabolic system

Common clinical conditions giving rise to metabolic or respiratory acidosis or alkalosis → Differentiate respiratory
from metabolic causes