CLINICAL BIOCHEMISTRY

(BMS 2143)

4TH BATCH 2ND YEAR 1ST SEMESTER

By

Dr Jagath Kasturiarachchi
PhD (UK), MSc (UK), BSc (Colombo)
 Module content

1) Introduction & submission of specimens

2) Specimen analysis
3) Results Recording
4) Specificity and sensitivity of testing
5) Clinical biochemistry analysis of blood
6) Haemoglobin
7) Blood gas analysis
8) Serum enzymology
9) Measurement of metabolites
10)Serum electrolytes & Lipid profiles
 Learning Objectives

• Rationale and principles of measurements of metabolites.

• The principal behind the metabolites which are used in clinical diagnosis.

 Blood urea
 Uric acid
 Creatinine in blood.
 Metabolites

 Metabolites are the small biological molecules involved in energy conversion

and biosynthesis.

 Studying metabolism is inherently challenging due to metabolites’ reactivity,

structural diversity, and broad concentration range.

 It can evaluate one's health condition.

 The central dogma of biology

• Showing the flow of information from DNA to the phenotype. Associated with
each stage is the corresponding systems biology tool, from genomics to
metabolomics.
 Clinical diagnosis

• The metabolite refers to the complete set of small-molecule (<1.5 kDa)

metabolites:

o Such as metabolic intermediates

o hormones
o other signalling molecules,
o secondary metabolites

• To be found within a biological sample, such as a single organism, can be

used for clinical diagnosis.
Blood Urea
 Blood Urea: normal value, clinical significance
and methods of estimation

• Urea is the chief nitrogenous waste formed during protein metabolism in

human.

• It is devised principally from the amino groups of amino acids.

• Liver is the main organ where urea is synthesized by a process called

ornithine cycle.

• After urea is formed in the liver, it passes into the blood and then excreted in
the urine.

• The concentration of urea in blood depends upon the relationship between

urea production and urea excretion.
 Normal value of blood urea

• The normal blood (serum) urea = 10-50 mg/100ml of blood.

• This value varies directly with the protein intake of the individual.

• The urea molecule contains two nitrogen atoms.

• So, the concentration of urea is expressed as blood urea nitrogen (BUN).

• The conversion of blood urea nitrogen (BUN) value to the blood urea is done
by the following formula.

• Value of blood urea = BUN X 2.14

• Hence the normal BUN = 6-22mg/100ml of serum.

 Method for estimation of blood urea

• Blood urea can be estimated by the following method.

Berthelot method:

• In this method to estimate blood urea, blood plasma or serum is used.

• It is based on the principle that urea is hydrolysed into carbonic acid and
ammonia by enzyme urease.

• The ammonia produced is measured photometrically after its reaction with

phenol in the presence of hypochlorite (Berthelot reaction).

• This blue color reaction product is determined photometrically.

• This method is widely used because of absolute specificity of enzyme

urease.
 Clinical significance blood urea:

• Increase in BUN = The value increase in kidney disease, shock,

dehydration, diabetes, acute myocardial infarction.

• Decrease in BUN = The value decreases in liver failure, impaired

absorption and overhydration (increased urinary outflow).
Uric acid
 Uric acid

• Uric acid is a waste product found in blood.

• Most uric acid dissolves in the blood, passes through the kidneys and leaves
the body in urine.

• Food and drinks high in purines also increase the level of uric acid.

• Food and drinks high in purines also increase the level of uric acid. These
include:

 Seafood (especially salmon, shrimp, lobster and sardines)

 Red meat
 Organ meats like liver
 Food and drinks with high fructose corn syrup, and alcohol
(especially beer, including non-alcoholic beer)
Structure of uric acid and its homeostasis.
 Hyperuricaemia

• The normal upper limit is 6.8mg/dL, and anything over 7 mg/dL is

considered saturated, and symptoms can occur.

• This elevated level is the result of increased production, decreased excretion

of uric acid, or a combination of both processes.
 Hyperuricaemia

• With lifestyle changes, hyperuricaemia has become common around the

world.

• However, 85–90% of hyperuricaemia patients have no clinical features.

• This stage is asymptomatic hyperuricaemia. Over time, long-term high

serum uric acid (SUA) may cause many complications.
 Hyperuricaemia

• Hyperuricaemia occurs due to alterations in urate production or excretion.

• UA is the final metabolite of purines and mainly excreted in the body by the
kidney and intestine.
• The kidney excretes about two-thirds while the gastrointestinal tract excretes
one-third of the UA load.
• Most UA is filtered from glomerular, while renal tubules reabsorption and
secretion regulate the amount of urate excretion.
• The proximal tubule is the site of UA reabsorption and excretion. About 90%
UA is reabsorbed into blood.
• Urate transporters are mostly located in the proximal tubules of the kidney and
play key roles in reabsorption and excretion of UA.
• In this review, we discuss the molecular mechanisms of urate transports and
their inhibitors on hyperuricaemia-associated diseases.
• This study not only shows that urate transports play considerable roles in the
progression of hyperuricaemia-associated diseases but also indicates that they
may be used as therapeutic targets.
 Hyperuricaemia

• Disorders of uric acid metabolism may be associated with pathological processes

in many diseases, including diabetes mellitus, cardiovascular disease, and kidney
disease.

• These diseases can further promote uric acid accumulation in the body, leading to a
vicious cycle.

• Preliminary studies have proven many mechanisms such as oxidative stress, lipid
metabolism disorders, and rennin angiotensin axis involving in the progression of
hyperuricaemia-related diseases.

• In summary, hyperuricaemia has become a key risk factor for development of many
serious diseases.

• However, there is still lack of effective clinical treatment for hyperuricaemia.

 Hyperuricaemia

• At present, two sources of UA are recognized:

1) Uptake of foods containing a high level of purines;
2) Catabolism of proteins and other compounds in the human body.

• UA, as scavenger of oxygen radical, contributes to approximate 60% of plasma

antioxidant activity and maintains the stability of blood pressure and
antioxidant stress.

• In addition, it prevents the oxidation of low-density lipoproteins and the

inactivation of superoxide dismutase.

• This antioxidant activity displays the protective roles of UA action under

physiological environment.
•
• However, the abnormal UA level may be is correlative with many diseases.
 Mainly physiological progression of uric acid in the body.

• Serum uric acid is original

from uptake of foods
containing a high level of
purines as well as
catabolism of proteins and
other compounds in the
human body.

• About 60% uric acid

involves in metabolism
process and the rest of uric
acid is excreted through the
gut and urethra.

• Urethral excretion is the

main way.

• A series of urate transporters

including SLC and ABC
transporters expressed in
urethra, especially the
proximal convoluted tubules,
maintain urate homeostasis.
Creatinine in blood
 Creatinine in blood

• Creatinine is a breakdown product of creatine phosphate from muscle and

protein metabolism.
• A creatinine test is a measure of how well your kidneys are performing
their job of filtering waste from your blood.
• Creatinine is a chemical compound left over from energy-producing
processes in your muscles.
• Healthy kidneys filter creatinine out of the blood. Creatinine exits your
body as a waste product in urine.
• Its main role is to facilitate recycling of ATP, the energy currency of the
cell, primary in muscle and brain tissue.
• Naturally produced in the human body from the amino acids glycine and
arginine.
 Creatine

• About 95% of creatine is stored in the skeletal muscle of your body and is
used during physical activity.
• Creatine helps to maintain a continuous supply of energy to working
muscles by keep production up in working muscles. Small amounts are also
found in your heart, brain and other tissues.
• Creatine is an amino acid (protein building block). We get some creatine
from our diet, mainly from animal products such as meat, fish, and poultry.
Our bodies manufacture the rest. Creatine can also be made synthetically as
a supplement.
Creatinine has been found to be a fairly reliable indicator of
kidney function
 Creatinine level signifies impaired kidney function

• Abnormally high levels of creatinine thus warn of possible malfunction

or failure of the kidneys. It is for this reason that standard blood tests
routinely check the amount of creatinine in the blood.

• A more precise measure of the kidney function can be estimated by

calculating how much creatinine is cleared from the body by the
kidneys.

• This is referred to as creatinine clearance and it estimates the rate of

filtration by kidneys (glomerular filtration rate, or GFR).

• The creatinine clearance can be measured in two ways. It can be

calculated (estimated) by a formula using serum (blood) creatinine
level, patient's weight, and age.
 Creatinine level signifies impaired kidney function

• Blood urea nitrogen (BUN) level is another indicator of kidney function.

Urea is also a metabolic byproduct which can build up if kidney function is
impaired.

• The BUN-to-creatinine ratio generally provides more precise information

about kidney function and its possible underlying cause compared with
creatinine level alone. BUN also increases with dehydration.

• Recently, elevated creatinine levels in infants were associated with

bacteraemia while elevated levels in adult males have been linked to
increased risk of prostate cancer.
 What are normal blood creatinine levels?

• Normal levels of creatinine in the blood are approximately 0.6 to 1.2

milligrams (mg) per deciliter (dL) in adult males and 0.5 to 1.1 milligrams
per deciliter in adult females.

• A person with only one kidney may have a normal level of about 1.8 or 1.9.

• Creatinine levels that reach 2.0 or more in babies and 5.0 or more in adults
may indicate severe kidney impairment.

• The need for a dialysis machine to remove wastes from the blood is based
upon several considerations including the BUN, creatinine level, the
potassium level and how much fluid the patient is retaining.
 Symptoms associated with high creatinine levels

• The symptoms of kidney dysfunction (renal insufficiency) vary widely.

• They generally do not correlate with the level of creatinine in the blood.

• Some people may have an incidental finding of severe kidney disease and
elevated creatinine on routine blood work without having any symptoms.
• In others, depending on the cause of the problem, different symptoms of
kidney failure may be present including:
 feeling dehydrated,
 fatigue,
 swelling (edema),
 shortness of breath,
 confusion, or
 many other nonspecific symptoms (for example, nausea, vomiting,
neuropathy, and dry skin).
 What causes high creatinine levels in the blood

• Any condition that impairs the function of the kidneys is likely to raise the
creatinine level in the blood. Is it longstanding or recent? Recent elevations
may be more easily treated and reversed.

• The most common causes of longstanding (chronic) kidney disease in adults

are
 high blood pressure and
 diabetes.
• Other causes of elevated blood creatinine levels are:

 Certain drugs (for example,cimetidine) can sometimes cause

abnormally elevated creatinine levels.
 Serum creatinine can also transiently increase after ingestion of a
large amount of dietary meat; thus, nutrition can sometimes play a
role in creatinine measurement.
 Kidney infections, rhabdomyolysis (abnormal muscle breakdown)
and urinary tract obstruction may also elevate creatinine levels.
 Who has low or high blood creatinine levels?

• Muscular young or middle-aged adults may have more creatinine in their

blood than the norm for the general population.

• Elderly persons may have less creatinine in their blood than the norm.
Infants have normal levels of about 0.2 or more, depending on their
muscle development.

• In people with malnutrition, severe weight loss, and long standing

illnesses, the muscle mass tends to diminish over time and, therefore,
their creatinine level may be lower than expected for their age.
 Summary

• Urea, uric acid and creatinine typically employed in clinical

and medical settings for the monitoring of renal function.