Hematology

Coagulation test
Liver function test
Hematology
Blood is made of two major components-plasma and cells.
• complete blood count (CBC) and differential (diff).
• CBC tests for the amount of :
1. RBC, hemoglobin, hematocrit, Indices includes (MCV),(MCH),
(MCHC),(RDW)
2. platelets(thrombocytes)
3. WBCs(leukocytes)
• The differential segments includes neutrophils, bands, eosinophils,
monocytes and lymphocytes
• Hematology:
Blood: Physical characteristics
Average amount: 8% body weight
(70 kg man‐ 5.6L)
Specific gravity: 1055‐1065 (viscosity is 5 times
that of water)
pH: 7.35‐7.45
Osmolarity: 300 mOsm
Colour: Bright red to deep red
• Functions of blood
Distributive
o Carries O2 (from lungs) and nutrients (from GIT and body stores) to all
cells
o Carries wastes from all cells to elimination sites (lungs for CO2, liver
for bilirubin and kidneys for nitrogenous wastes)
o Carries hormones (chemical signals) from endocrine organs to target
tissues
Regulatory functions
o Body T° by absorbing and distributing heat
o pH by virtue of its many buffers
o Maintains adequate fluid volume in the body
Protective functions
o Prevents blood loss by initiating clotting mechanisms in response to
blood vessel damage
o Prevents infection via WBCs and plasma immune proteins
• Components of Whole Blood
Plasma protein:
• α1 zone(globulins): α1 anti trypsin, TBG
• α2 zone(globulins): α2 macroglobulin, caeruloplasmin, haptoglobin
• β zone(globulins): Transferrin, fibrinogen, C3 & C4 complement
• γ zone(globulins) : Immunoglobulins, Factor VIII, C‐reactive proteins, α
feto protein

Origin of plasma proteins:

1. Liver: albumin, α and β globulin , fibrinogen
2. B lymphocytes in lymph nodes, bone marrow: γ
globulins(immunoglobulins)
Albumin
• 60% of total plasma proteins(3.4‐4.7 g/dL)
• T1/2 = 19 days
Functions of albumin:
• Regulates blood volume & body fluid balance
• Viscosity: One of the determinants of resistance to blood flow
• Blood pressure maintenance
• Protein reserve
Binding to various ligands helps in transport of free fatty acids, bilirubin, calcium
• Secondary carrier for thyroxin, cortisol & heme
• Drug binding eg. Sulfonamides, penicillin G, aspirin
• Buffering action: Helps maintain pH of blood
Variations in plasma albumin:

• Increase
• Secondary to burns , dehydration

• Decrease
• Infants and newborns
• Pregnancy
• Hepatitis
• Cirrhosis
• Nephrosis
• Protein losing enteropathies
Functions of alpha & beta globulins:

• TBG: Carrier protein for thyroid hormone in blood

• α 1‐ ANTITRYPSIN: Principal plasma inhibitor of serine

protease(inhibits trypsin, elastase)
Deficiency has a role in emphysema
• Caeruloplasmin: Transports copper
• Haptoglobin: Transports free hemoglobin
• Transferrin: Transports iron
• Fibrinogen: Precursor of fibrin
• α feto protein: Osmotic regulation, carrier protein
Ceruloplasmin:
• Carries 90% of copper in plasma (copper cofactor for a variety of
enzymes);
• binds copper more tightly than albumin that carries other 10%
of copper
• albumin may be more important in copper transport (donates copper
to tissues more readily)
Wilson’s disease
• accumulation of copper in liver, brain, kidneys
• Liver disease, neurologic symptoms
Haptoglobin:

• Binds free hemoglobin and delivers it to the reticuloendothelial cells

• complex Hb‐Hp is too large to pass through glomerulus prevention of
loss of free Hb
• Free Hb passes through glomeruli, enters tubules and precipitates
leading to kidney damage
Variations in gamma globulins:

• Increase
TB
Leukemia
Cirrhosis and acute hepatitis
Nephritis
• Decrease
Immune deficiency
Variations in fibrinogen

• Increase
o Pregnancy
o Menstruation
o Malaria
o Tissue injury
• Decrease
o Congenital
o Carcinoma prostate
o Intravascular coagulation
Acute phase proteins:

• α1 antitrypsin
• Fibrinogen
• Haptoglobin
• C‐reactive protein
Formation of cellular elements
of blood:
Hematopoiesis
Bone marrow is the site of synthesis
of all formed elements of blood after
birth
Erythropoiesis: Formation of RBCs
This development takes about 7 days and involves three to four mitotic
cell divisions, so that each stem cell gives rise to 8 or 16 cells.
Anisocytosis: Variations in erythrocyte size

• Microcytic : MCV = = <80 fL & size = <6 μM

Eg.iron‐deficiency anemias.
• Normocytic : MCV = 80 ‐ 100 fL & size = 6 ‐ 9μM
• Macrocytic: MCV = >100 fL & size = >9 μM
Eg. hepatic diseases & vitamin B12 and folic acid deficiency anemias
Heinz bodies
• Appear inside the RBC when it has been subjected to oxidative stress
as a result of oxidation and subsequent precipitation of –SH groups of
hemoglobin
• Heinz bodies are denatured hemoglobin, which occurs in G6PD
deficiencies and in unstable hemoglobin disorders. Abdominal
ultrasound may be useful in assessing for splenomegaly and gallstones
• Spherocyte
• Observed in immune induced hemolysis,post blood transfusions, and
congenital anemia
• Poikilocytosis:
Variation in the shape of erythrocytes Due to chemical or physical
alteration in the red blood cell membrane or the actual contents of the
cell
Anemia
Definition Deficiency of hemoglobin in blood as a result of
• too few RBCs(< 4million/cumm)
• too little hemoglobin:
o Hb < 7.0 g/dl severe anemia
o 7.0 –9.9 g /dl moderate anemia
o 10.0 – 10.9 g/dl mild anemia in pregnant women and 10.0 –11.9g% for
non‐pregnant women
• Manifestations of anemia:??
o Cardiac signs (In severe anemia)
Hyper dynamic circulation:tachycardia, flow murmurs, and cardiac
enlargement. There may be signs of heart failure
Atrial fibrillation
Classification of anemia: Based on underlying mechanism
• Blood loss
Acute: Trauma
Chronic: Lesions of GIT,Bleeding, gynaecological
• Hemolytic anemia
Membrane defect, Enzyme defect, Hb defect,Antibody
mediated,infections, e.g.: Spherocytosis Thalassemia Sickle cell
anemia
• Impaired production
Disturbance of proliferation & maturation
e.g.: Aplastic anemia, anemia of renal failure, anemia of endocrine
disorders, iron deficiency, Megaloblastic anemia
Reticulocytes VS mature RBC

 Reticulocytosis
Physiological causes: Newborn
Pathological causes: anemia, After hemorrhage
Polycythemia/Erythrocytosis
Increase RBC & Hb levels
Classification
Primary: Abnormal proliferation of myeloid stem cells(polycythemia vera)
Secondary: Lung disease, high altitude, erythropoietin secreting tumour

 Reticulocytopenia
Aplastic anemia
Post spleenectomy
Peripheral Blood Smear(PBS)
The examination of blood films stained with Wright's stain frequently
provides important clues in the diagnosis of anemias and various
disorders of leukocytes and platelets.
A microscopic view of your cells may help your healthcare provider
find out how and/or why your blood cells look abnormal or you have
an abnormal number of cells.
• What diseases require a peripheral blood smear test?
Leukemia, Myelodysplastic syndrome, Anemia, Lymphoma,…
RBC indices
• MCV (gives you the average volume of erythrocytes).
This measures the average size of the RBC and can be calculated by dividing
hematocrit X10 by RBC count. Normal values are 80-100 fL.
• MCH (gives you the average weight of hemoglobin per erythrocyte).
Normal level is 27 to 311 picograms (pg) or 28-33 pg, depending on the
reference
• MCHC (gives you the average hemoglobin concentration per erythrocyte).
• RDW (This index is a quantitative estimate of the uniformity of individual
cell size)
Elevated levels may indicate iron deficiency or other conditions with a wide
distribution of various cell sizes. Normal levels are 11.5 percent to 14.5
percent
Hemoglobin:
Characteristics of oxygen combination with hemoglobin
•Oxygen is carried in molecular form
•Forms coordinate bond with iron atom
Hemoglobin types:

1. HbA IC: Glycated hemoglobin(Glucose attached to terminal valine in each beta chain

2. Meth Hb: Fe++ changed to Fe+++

3. Car boxy hemoglobin & Oxy hemoglobin

o Haemoglobin binds with CO , 240 times more readily than with oxygen.
o The presence of carbon monoxide on one of the 4 heme sites causes the oxygen on the
other haem sites to bind with greater affinity.
o This makes it difficult for the hemoglobin to release oxygen to the tissues.
o With an increased level of carbon monoxide, a person can suffer from severe
hypoxaemia while maintaining a normal pO2.
Hemoglobin A1C
• 4-6% (target for patients without diabetes)
• <7% (target for patients with diabetes)
Erythrocytes hemoglobinization

• Normochromic RBC normal amount of hemoglobin which stains uniformly MCH =

27 to 32 pg & MCHC = 31 to 37%.

• Hypochromasia / hypochromia MCH = <27 pg & MCHC = <31

Eg.iron‐deficiency anemia and thalassemia,any hemoglobinopathy
Hematocrit/ Packed cell volume:
the test for hematocrit measures the volume of cells as a percentage of the
total volume of cells and plasma in whole blood.
This percentage is usually three times greater than the hemoglobin.
After hemorrhage or excessive intravenous fluid infusion, the hematocrit will
be low. If the patient is dehydrated, the hematocrit will be increased.

Normal values are as follows:

• Adult male = 42% to 53%
• Adult female = 36% to 46%
• Newborn = 50% to 62%
• One year = 31% to 39%
Hematocrit:

• Increased
Polycythemia
Shock associated with surgery, burns, or traumas
Dehydration
• Decreased
Anemias
Pregnancy
receiving IV fluids
Cardiac decompensation (a failure to maintain a good blood
circulation)
Hemoglobin & hematocrit(1:3 ratio)
condition HCT Hg
Hemorrhage, anemia decrease Decrease
Pregnancy, over hydration decrease normal
dehydration increase normal
Low O2 available state increase increase
)…,e.g. COPD, fibrosis (

Reticulocyte:
 These are the new cells released by the bone marrow. The reticulocyte count is therefore used to
assess bone marrow function and can indicate the rate and production of RBCs.
Normal to slightly elevated reticulocyte counts may occur with anemia demonstrating an
underproduction of red cells (such as with iron or folate deficiencies), depending on the staging
of the disease. Elevated levels may indicate blood loss or hemolysis.
 Normal levels are 0.5 percent to 1.5 percent.
White Blood Cells
• WBCs, also known as leukocytes, are larger in size and less numerous than red
cells.
• They develop from stem cells in the bone marrow.
• WBC function involves the response to an inflammatory process or injury.
• Normal levels of WBCs for men and women are 4,500-10,500/cubic mm.
• When the white count is abnormal, the differential segment can measure the
percentage of the various types of white cells present.
• Differential counts add up to 100 percent. The differential usually includes
neutrophils, bands, eosinophils, monocytes and lymphocytes.
• Decrease WBC:??
• Increase WBC:??
Neutrophils
The function of neutrophils is to destroy and ingest bacteria. Neutrophils arrive
first at the site of inflammation; therefore their numbers will increase greatly
immediately after an injury or during the inflammatory process.
Their life span is approximately 10 hours, then a cycle of replenishing neutrophils
must occur.
neutrophils increase with such conditions as stress, acute infection, necrosis from
burns and heart attack and decrease with such condition as
chemotherapy(Neupogen (filgrastim)), radiotherapy, infection(measles, rubella,…)
Normal levels range from 45 percent-74 percent.

Bands: These are immature neutrophils which are released after injury or
inflammation.
The presence of bands indicates that an inflammatory process is occurring.
Normal level ranges from 0 percent-4 percent.
Basophils
Basophils Called basophils when found in the blood, these cells are also known as “mast”
cells when found in the tissues. Tissue basophils are found in the gastrointestinal and
respiratory tracts and the skin. They contain heparin and histamine and are believed to be
involved in allergic and stress situations. Basophils may contribute to preventing clotting in
microcirculation.
Normal blood levels range from 0 percent-2 percent.
Decrease level: pregnancy, hyperthyroidism
Increase level: leukemia, Polycythemia Vera, Hodgkin lymphoma

Eosinophil's
These are found in such areas as skin and the airway in addition to the bloodstream.
Increase level: allergic and inflammatory reactions and parasite infections.
Decrease level: crushing's syndrome, stress related to trauma or surgery
Normal blood levels range from 0 percent-7 percent.
Lymphocytes
Lymphocytes fight viral infections; B cells and T cells are two major types.
Lymphocytes have a key role in the formation of immunoglobins (humoral immunity) and
also provide cellular immunity.
Normal levels range from 20 percent-25percent.
Decrease level: heart failure, renal failure, corticosteroids
Increase level: infection(TB, syphilis, pertussis, auto immune disease)
Monocytes
These cells arrive at the site of injury in about five hours or more. The monocytes are
phagocytic cells that remove foreign materials such as injured and dead cells,
microorganisms and other particles from the site of injury, particularly during viral or
bacterial infections.
Normal levels range from 2 to-10 percent.
Decrease level; bacterial endocarditis, TB, auto immune disease
• Platelets
Platelets, also known as thrombocytes, are small elements formed in the red bone
marrow.
They are actually fragments of megakaryocyte cytoplasm (precursor cell to the
platelet.) Platelets help to control bleeding.
There are two means by which platelets are able to do this: one is by forming an
occlusion at small injurious openings in blood vessels; and the second by a
thromboplastic function which stimulates the coagulation cascade.
Both platelet number (measurable by platelet count) and platelet function (not
measurable by platelet count) play a role in the effectiveness of the platelet in
controlling bleeding. Note that platelet count measures only platelet number, not
function.
• Thrombocytopenia: aplastic anemia(in which the patient experiences loss of bone
marrow function), drug-induced, leukemia
• Thrombocytosis: chronic leukemia (depending on stage and therapy),post-
splenectomy, iron deficiency anemia, malignancy, and chronic infection or
inflammation
 ‫در لوله ‪ CBC‬می توان این ازمایشات رو گرفت‪:‬‬

‫نمونه ی ‪ CBC diff‬شامل‪:‬‬

‫‪Hb_ Hct_ Plt_ MCV_ MC_MCH_MCHC-RWD- WBC-RBC‬‬

‫ازمایش ‪PBS‬‬
‫ازمایش ‪Retic count‬‬
‫ازمایش ‪BGRH‬‬
‫ازمایش ‪HbA1C‬‬
‫ازمایش ‪G6PD‬‬
‫ازمایش ‪Direct coombs‬‬

‫در شرایط اورژانسی و نیاز به جواب فوری "‪:‬‬

‫‪Bill -۱‬‬
‫‪۲- Cross match‬‬
‫‪۳- Fbs‬‬
‫لول‪9‬ه ب‪9‬ا در ن‪9‬ارنجی ی‪9‬ا لول‪9‬ه شیش‪9‬ه ای ب‪9‬ا در مش‪9‬کی ن‪9‬یز ب‪9‬رای انج‪9‬ام آزم‪9‬ایش ‪ ESR‬اس‪9‬تفاده می ش‪9‬ود‪ .‬ب‪9‬ه م‪9‬یزان‬
‫‪ 1/6‬س‪9‬ی س‪9‬ی خ‪9‬ون وارد لول‪9‬ه ریخت‪9‬ه می ش‪9‬ود و ب‪9‬ه آرامی تک‪9‬ان داده می ش‪9‬ود ت‪9‬ا ب‪9‬ا س‪9‬یترات درون لول‪9‬ه آزم‪9‬ایش‬
‫آغشته شود و مانع از تشکیل لخته گردد‪.‬‬

‫لول‪9‬ه ب‪9‬ا درب بنفش‪/‬آبی‪ /‬زرد ب‪9‬رای انج‪9‬ام آزمایش‪ PTT,PT,INR, D- dimer, fibrinogen,TEG‬ک‪9‬اربرد دارد‪/‬‬
‫حاوی ماده ضدانعقاد می باشد باید به آرامی تکان داده شود‪.‬‬

‫لول‪9‬ه لخت‪9‬ه ب‪9‬ا ی‪9‬ا ب‪9‬دون ‪ CLOT activator‬ک‪9‬ه ب‪9‬ا رن‪9‬گ ه‪9‬ای متف‪9‬اوتی در بخش موج‪9‬ود ان‪9‬د‪ .‬آزمایش‪9‬اتی مانن‪9‬دتمام‬
‫الکترولیته‪9‬ای موج‪9‬ود (س‪9‬دیم‪،‬پتاس‪9‬یم‪،‬کلس‪9‬یم و‪ ،)....‬آن‪9‬زیم ه‪9‬ای کب‪9‬دی(‪ )Ast_Alt‬و‪،)...‬آن‪9‬زیم ه‪9‬ای قل‪9‬بی‬
‫‪،))Cpk_troponin_Myoglobin‬تس‪9‬ت ه‪9‬ای عملک‪9‬ردی کلیه‪،))Bun_cr‬تس‪9‬ت ه‪9‬ای تیرویی‪9‬د(‪Tsh‬و ‪))T3,T4‬‬
‫در این لوله ریخته می شود‪.‬‬
Complete Blood Count
RBC: 4.5–5.5 million
WBC: 5,000–10,000
Platelets: 150,000–400,000
Hemoglobin:
• 12–16 g/dL (women)
• 14–18 g/dL (men)
Hematocrit:
• 37 – 47% (women)
• 42 – 52% (men)
Coagulation
 Coagulation test(PTT, PT, INR,…)
Coagulation screen
The main reasons for performing a coagulation screen are:
• To confirm a suspected coagulopathy.
• To monitor the coagulation status of a patient on long/short term
anti-coagulants.
• To assess a patients coagulation status prior to surgery.
• To assess the synthetic function of the liver.
How does coagulation work?
The coagulation screen assesses the function of the clotting cascade and the body’s
ability to create a platelet plug. First, we shall look at how platelets work.
• Platelets
In response to vascular injury, the following steps lead to a platelet plug:
1. von Willebrand’s Factor (vWF) adheres to the vascular injury.
2. vWF then binds to GpIb receptors on surrounding platelets.
3. After binding, the ADP (P2Y12) receptor on the platelet is activated leads to
increased expression of GpIIb/IIIa.
4. These newly expressed receptors then finally bind to fibrinogen, which leads to
further platelet aggregation.
Now, let’s look at how the clotting cascade works
• Clotting cascade
• The clotting cascade is comprised of many different factors, ranging from I through
to XIII. These factors form 3 groups: the intrinsic pathway, the extrinsic pathway, and
the combined pathway.
• Key features of each pathway are shown below.
• Intrinsic pathway
The intrinsic pathway is activated by contact with a damaged surface and goes as follows:
Factor XII → Factor XI → Factor IX (+ Factor VIII + vWF) → Common pathway
• Extrinsic pathway
The extrinsic pathway is activated by the release of tissue factors and goes as follows:
Factor VII → Common pathway
• Combined pathway
The combined pathway then proceeds the intrinsic/extrinsic pathways and goes as follows:
Factor X (+ Factor V) → Factor II → Factor I (+ Factor XIII → Fibrin mesh)
• How are clots later dissolved?
Fibrin clots can then be dissolved through a separate pathway
whereby plasminogen becomes its activated form, plasmin, via tPA.
This plasmin then breaks down the fibrin mesh
Medication
1. Antiplatelet include:
A. ASA, also called acetylsalicylic acid (Aspirin)
B. Clopidogrel (Plavix, osevix, zilt), ticlopidine,Prasugrel
C. Abciximab,ephibatide, tirofiban
D. Diprydamole, cilostazol

2. Anticoagulants include: monitor the coagulation status

of a patient on long/short term
E. Heparin& enoxaparin
anti-coagulants.
F. Rivaroxaban & apixaban
G. Argatroban & dabigatrin
H. Bivalirudin & desirudin Ptt, Pt, INR
I. warfarin
3. thrombolytic agents include:
J. Streptokinase & urokinase
K. Alteplase& Reteplase &Tenecteplase.
warfarin Heparin
Name: vit K antagonist(2,7,9,10, C,S) Name: Indirect thrombin inhibitor
Function: Prevent clotting Function: Prevent clotting
Why clot is important? Why DVT/VTE is important?
Used for? Used for?
pregnancy? no pregnancy? yes
Administered oral Administered SC or IV/iv infusion
Check PT/INR (ex: atrial fibrilation) Check PTT (heparin therapy)
Monitor for bleeding Monitor for bleeding, CBC( decrease Plt ,…)
Antidote:?? Heparin-induced thrombocytopenia(HIT)
Patient Education:? Antidote:?
Patient Education:?
APTT (35-45 seconds)
• The activated partial thromboplastin time (APTT) is a measure of the time taken
for blood to clot via the intrinsic pathway.
• Like with PT, APTT time will be affected by overall clotting factor
synthesis or consumption (it can also be affected by DIC, liver failure, vitamin K
deficiency and warfarin levels).
• APTT, however, can indicate issues with factors VIII (and vWF), IX,
and XI specifically.
• The main conditions that could result in an abnormal APTT include:
Haemophilia
von Willebrands disease
Increase PTT: vit K deficiency, liver disease, anticoagulant
Decrease PTT: DIC, massive bleeding, cancer
Critical point: more than 100 second
Tests
• PT/INR (12-13 seconds/0.8-1.2)
• The prothrombin time (PT) is a measure of the time taken for blood
to clot via the extrinsic pathway .
• International normalised ratio (INR) is a standardised version of this
test, commonly used with patients on anticoagulants.
• Since the only factor in the pathway is VII.these tests are a measure
of overall clotting factor synthesis or consumption.
• Increase PT/INR: liver disease, disseminated intravascular
coagulation (DIC), vitamin K deficiency, massive
tranfusion and warfarin levels.
• Decrease PT/INR: FFP transfusion, vit K supplement
• INR Critical point: more than 5
Fibrinogen
• fibrinogen is a soluble protein in the plasma that is broken down to
fibrin by the enzyme thrombin to form clots.
• Fibrinogen reference range is 200-400 mg/dL or 2-4 g/L (SI units).
Increase Fib: inflammation, trauma
Decrease Fib: DIC, massive transfusion, liver disease
Critical point: less than 100 mg/dl.
if suspect to DIC or PTT,PT/INR are abnormal: check fibrinogen

DIC: Decrease PPT, Increase PT/INR, Decrease Fibrinogen

Bleeding time
• bleeding time assesses overall platelet function and levels. It is therefore worth
noting the time it takes for a patient to stop bleeding from any cuts.
• As such, platelet specific disorders will increase the overall bleeding time.
• Some examples of such disorders that will increase bleeding time include:
• von Willebrand’s disease (vWF deficiency – autosomal dominant)
• Bernard-Soulier syndrome (GpIb deficiency)
• TTP/ITP/DIC
• Thrombocytopaenia
• Extra tests
• Further tests can be ordered to work out the exact pathology. These can provide levels
of specific factors, antibodies, thrombophilia screens, ADAMTS13 (for TTP) and many
more.
Thrombin time (10-15 seconds)
• This is a test of how fast fibrinogen is converted to fibrin by thrombin.
• In cases of a prolonged time, the cause is either a synthetic issue or consumption
issue.
• Similar to prolonged PT, this can be due to DIC, liver failure, malnutrition, abnormal
fibrinolysis and many other conditions.

• It is also worth ordering a full blood count (to assess platelet

levels), liver function tests (to assess for general liver function
abnormalities), albumin (to assess the liver’s synthetic function/malnutrition) and D-
dimer.
D-dimer
D-dimer is the degradation product of cross-linked fibrin; therefore, it
reflects ongoing activation of the hemostatic system. healthy
individuals have a minimal D-dimer level.
The reference concentration of D-dimer is < 250 ng/mL, or < 0.4 μ/mL.
Elevated D-dimer levels reflect ongoing activation of the hemostatic
and thrombolytic system, providing clinical utility in the following:
• Evaluation of thrombus formation
• Ruling out DVT
• Monitoring anti coagulative treatment (a decreasing value indicates
effective treatment)
• Disseminated intravascular coagulation (DIC)
• Snake venom poisoning
• D-dimer levels may be elevated in the setting of pregnancy,
inflammation, malignancy, trauma, postsurgical treatment, liver
disease (decreased clearance), and heart disease.

• a high triglyceride level, an elevated bilirubin level, an elevated serum

rheumatoid factor level, or hemolysis may falsely increase the D-
dimer level.
Coagulation Levels
• INR/PT:
• PT (prothrombin time): 10-12 seconds (normal level for patients not on
Warfarin)
• INR (international normalized ration): Less than 1 (normal level for
patients not on Warfarin).
• When a patient is taking the anticoagulant Warfarin the INR should be 2-3.
• The INR level is calculated from the PT level.
• aPTT (activated partial thromboplastin time):
Normal 30-40 seconds (not on Heparin)
• If the patient is on Heparin, the aPTT needs to be 1.5 to 2.5 times the normal range.
Liver Function Test
Liver functions:
 Synthetic Function
Plasma proteins (albumin, globulins), cholesterol, triglycerides and
lipoproteins
 Detoxification and excretion
Ammonia to urea (urea cycle), bilirubin, cholesterol, drug metabolite
 Storage Function
Vitamins A, D, E, K and B12
 Production of bile salts
Liver function tests (LFTs)
LFTs are requested for two primary reasons:
• To confirm a clinical suspicion of potential liver injury or disease.
• To distinguish between hepatocellular injury (hepatic jaundice) and cholestasis (post-
hepatic or obstructive jaundice).
• What blood tests are used to assess liver function?
1. Alanine transaminase (ALT)
2. Aspartate aminotransferase (AST)
3. Alkaline phosphatase (ALP)
4. Gamma-glutamyltransferase (GGT)
5. Bilirubin
6. Albumin
7. Prothrombin time (PT)

Hint: ALT, AST, ALP and GGT are used to distinguish between hepatocellular damage and
cholestasis. Bilirubin, albumin and PT are used to assess the liver’s synthetic function.
reference ranges for LFTs:

ALT (alanine transaminase) 4to 46 U/L

AST (aspartate transaminase) 6-40 U/L

ALP (alkaline phosphatase) 40-120 U/L

GGT 8-60 u/l

Bilirubin <1 mg/dl

Albumin 3/5-5/5 g/l

PT 10-12 seconds
• AST and ALT is found in high concentrations within hepatocytes and enters
the blood following hepatocellular injury. It is, therefore, a useful marker
of hepatocellular injury.
• Alt is more specific than AST for liver function.
• ALP is particularly concentrated in the liver, bile duct and bone tissues. ALP
is often raised in liver pathology due to increased synthesis in response
to cholestasis. As a result, ALP is a useful indirect marker of cholestasis.

Compare ALT and ALP levels

Assess if ALT and/or ALP is raised:
• If the ALT is raised, decide if this is a more than a 10-fold rise (↑↑) or less
than a 10-fold rise (↑).
• If the ALP is raised, decide if this is a more than a 3-fold rise (↑↑) or less
than a 3-fold rise (↑).
• A greater than 10-fold increase in ALT and a less than 3-fold increase in
ALP suggests a predominantly hepatocellular injury.
• A less than 10-fold increase in ALT and a more than 3-fold increase in
ALP suggests cholestasis.
• It is possible to have a mixed picture involving
both hepatocellular injury and cholestasis
• ERRCP& MRCP

• What about Gamma-glutamyl transferase?

If there is a rise in ALP, it important to review the level of gamma-glutamyl transferase
(GGT). A raised GGT can be suggestive of biliary epithelial damage and bile flow
obstruction. It can also be raised in response to alcohol and drugs such as phenytoin.
A markedly raised ALP with a raised GGT is highly suggestive of cholestasis.
Isolated rise of ALP
• A raised ALP in the absence of a raised GGT should raise your suspicion
of non-hepatobiliary pathology. Alkaline phosphatase is also present in
bone and therefore anything that leads to increased bone breakdown
can elevate ALP.
Causes of an isolated rise in ALP include:
• Bony metastases or primary bone tumours (e.g. sarcoma)
• Vitamin D deficiency
• Recent bone fractures
• Renal osteodystrophy
Bilirubin is a breakdown product of hemoglobin. Unconjugated bilirubin is taken
up by the liver and then conjugated. Hyper bilirubinemia may not always cause
clinically apparent jaundice (usually visible > 2/5 mg/dl). The patient’s
symptoms and clinical signs can help differentiate between conjugated and
unconjugated hyper bilirubinemia.
the color of the urine and stools can be used to differentiate the causes of
jaundice
• Bilirubin excreted into the intestine is metabolized by bacteria and forms
urobilinogen.
Urobilinogen is reabsorbed via the portal circulation and a small amount is
excreted in the urine.
Increased urobilirubin levels are associated with excessive hemolysis, liver
parenchymal diseases, constipation, and intestinal bacterial overgrowth.
Decreased urobilirubin levels are associated with obstructive biliary disease
and severe cholestasis.
The combination of the color of urine and stools can give an indication as to
the cause of jaundice:
• Normal urine + normal stools = pre-hepatic cause
• Dark urine + normal stools = hepatic cause
• Dark urine + pale stools = post-hepatic cause (obstructive)

Causes of unconjugated hyperbilirubinaemia include:

• Haemolysis (e.g. haemolytic anaemia)
• Impaired hepatic uptake (e.g. drugs, congestive cardiac failure)
• Impaired conjugation (e.g. Gilbert’s syndrome)

Causes of conjugated hyperbilirubinaemia include:

• Hepatocellular injury
• Cholestasis
Jaundice
Definition : Yellowish discoloration of skin and eyes due to an elevation
in the concentration of bilirubin in blood.
Clinically detected only when bilirubin > 2.5 mg/dL.
First site where it is detected : sclera
Types:
• Hemolytic
• Hepatic
• Obstructive
Types of jaundice
Van den Berg test: Principle
Mechanism of red cell destruction
Average life span 120 days/
Heme oxygenize system responsible for hemoglobin degradation is
located in the phagocytic cells of Liver, Spleen& Bone marrow.
Sites of erythrocyte destruction
• Extravascular hemolysis(80‐90 %) Spleen, Liver, Macrophages, Lymph
node and Bone marrow
• Intravascular hemolysis Hemoglobin is discharged directly into the
circulation & is removed by several mechanisms
Common patterns of LFT derangement
Acute hepatocellular Chronic Cholestasis
damage hepatocellular damage

ALT ↑↑ Normal or ↑ Normal or ↑

ALP Normal or ↑ Normal or ↑ ↑↑
GGT Normal or ↑ Normal or ↑ ↑↑
Bilirubin ↑ or ↑↑ Normal or ↑ ↑↑
Albumin
• Albumin is synthesized in the liver and helps to bind water, fatty acids and
bilirubin. It also plays a key role in maintaining the oncotic pressure of
blood.
Albumin levels can fall due to:
• Liver disease resulting in a decreased production of albumin (e.g. cirrhosis).
• Inflammation triggering an acute phase response which temporarily
decreases the liver’s production of albumin.
• Excessive loss of albumin due to protein-losing enteropathies or nephrotic
syndrome.
Pro thrombin time
• Pro thrombin time (PT) is a measure of the blood’s coagulation
tendency, specifically assessing the extrinsic pathway. In the absence
of other secondary causes such as anticoagulant drug use and vitamin
K deficiency, an increased PT can indicate liver disease and
dysfunction. The liver is responsible for the synthesis of clotting
factors, therefore hepatic pathology can impair this process resulting
in increased prothrombin time
Extra test for liver screen includes:

• Hepatitis serology (A/B/C)

• LDH
• Epstein-Barr Virus (EBV)
• vit K
• Cytomegalovirus (CMV)
• Alpha1-Fetoprotein (Tumor marker)
• Anti-mitochondrial antibody (AMA): used to diagnose primary biliary cholangitis, formerly
called primary biliary cirrhosis (PBC)
• Anti-nuclear antibody (ANA)
• Immunoglobulin's – IgM / IgG
• Serum Copper (to rule out Wilson’s disease)
• Ceruloplasmin (to rule out Wilson’s disease)
• Ferritin (to rule out hemochromatosis)
Labs to Know for NCLEX and as a Nurse
Metabolic Panel

Glucose: 70–100 mg/dL Sodium: 135-145 mEq/L

Serum creatinine: 0.6–1.2 mg/dL Potassium: 3.5-5 mEq/L

BUN: 5-20 Magnesium: 1.5-2.5 mg/dL

Total Protein: 6.2–8.2 g/dL Calcium: 8.5–10.5 mg/L

Albumin: 3.4–5.4 g/dL Phosphorus:2.5–4.5 mg/dL

Bilirubin: 0.1-1 mg/dL (less 1) Chloride: 95-105 mEq/L

Arterial Blood Gases (ABG)& Venous Blood Gas(VBG)

pH: 7.38-7.42 pH: 7.35-7.45

pCO2: 41-57 mmHg pCO2: 35-45 mmHg
HCO3: 24-28 mEq/L HCO3: 22-26 mEq/L
pO2: 40-50% pO2: 80-100%
O2 sat: 75% O2 sat: 95-100%
Lipid Panel (risk for cardiovascular disease)

LDL (low density lipoprotein): <100 mg/dL (want it LOW)

HDL (high density lipoprotein): >60 mg/dL (want it HIGH)

Total Cholesterol: <200 mg/dL

Triglycerides: <150 mg/ dL

Drug Level Ranges
• Digoxin: 0.5-2 ng/mL
• Carbamazepine: 4-10 mcg/mL
• Dilantin: 10-20 mcg/mL
• Theophylline: 10-20 mcg/mL
• Phenobarbital: 15-40 mcg/mL
• Lithium: 0.5-1.2 mmol/L
Urine Analysis(U/A)
Urinalysis(U/A) reference:
RBCs : ≤2 RBCs/hpf Color : Yellow (light/pale to dark)

WBCs : ≤2-5 WBCs/hpf Clarity/turbidity :Clear or cloudy

Casts : 0-5 hyaline casts/lpf pH : 4.5-8

epithelial cells : ≤15-20 squamous Specific gravity : 1.005-1.025

epithelial cells/hpf
Crystals : Occasionally Ketones : None

Bacteria : None Nitrites : Negative

Yeast : None Leukocyte esterase : Negative

 visual examination
Highly concentrated urine has a darker yellow appearance. This may be
seen in patients who are volume depleted.
dilute urine has a lighter yellow appearance. This may be seen in patients
with diabetes insipidus, due to impaired urine concentrating ability.
Urine color may vary due to certain medications, foods, and medical
conditions.
Red urine may indicate the following:
• Foods – Beets, blackberries
• Drugs – Propofol, chlorpromazine
• Medical conditions – Urinary tract infections (UTIs), nephrolithiasis,
hemoglobinuria (rhabdomyolysis),
Orange urine may indicate the following:
• Foods – Carrot, vitamin C
• Drugs – Rifampin, phenazopyridine
Green urine may indicate the following:
• Drugs – Vitamin B, methylene blue, propofol, amitriptyline
• Medical condition – UTI
Blue urine may indicate the following:
• Drugs – Methylene blue, amitriptyline, cimetidine (intravenous),
promethazine (intravenous)
White urine may indicate the following:
• Medical conditions – pyuria
Chemical examination
• Urinary pH levels are particularly useful in the evaluation of stones,
infection, and renal tubular acidosis (RTA).
Calcium oxalate/calcium phosphate, magnesium-ammonium phosphate,
and staghorn calculi are associated with alkaline urine. Conversely, uric
acid and cystine calculi are associated with acidic urine
patients with a UTI due to urea-splitting organisms, such as proteus and
klebsiella, typically have alkaline urine.
• Specific gravity is a measurement of urine concentration and is
representative of the kidney’s ability to concentrate urine.
• Low specific gravity is seen in patients with impaired urinary
concentrating ability (eg, diabetes insipidus,nephropathy, acute tubular
necrosis).
• Glucose present in the urine is termed glucosuria. Most commonly,
this indicates diabetes mellitus but is also often seen in pregnancy.
• It is due to either a high blood glucose level or a decreased kidney
threshold concentration. When blood glucose levels exceed
approximately 180 mg/dL, the proximal tubules become
overwhelmed and cannot reabsorb the excess glucose.
• Ketones in the urine are abnormal. Ketones accumulate when
carbohydrates are insufficient and the body must get its energy from
fat metabolism. [2] Acetone, acetoacetic acid, and B-hydroxybutyric
acid are the common ketones formed.
• Ketonuria may be seen with uncontrolled diabetes, diabetic
ketoacidosis, severe exercise, starvation, vomiting, and pregnancy.
• Nitrite testing is sensitive, but not specific, in detecting UTIs.
Normally no nitrites are detected in the urine. Urinary nitrates are
converted to nitrites by bacteria in the urine.
• A positive nitrite result signifies that bacteria capable of this
conversion (eg, Escherichia coli, Klebsiella, Proteus, Enterobacter,
Citrobacter, Pseudomonas) are present in the urinary tract.
• However, some bacteria are not capable of converting nitrates to
nitrites (eg, Staphylococcus, Streptococcus, Haemophilus), and these
bacteria may still be present in the urinary tract despite a negative
test result. Therefore, a positive test suggests a UTI (typically due to
Enterobacteriaceae), but a negative test result does not rule out a
UTI.
• WBCs contain an enzyme known as leukocyte esterase, which is
released when WBCs undergo lysis. Normally, too few WBCs are
present in the urine for the test to be positive.
• when the number of WBCs in the urine increases, the result
becomes positive. [1] A positive leukocyte esterase test result
indicates pyuria. Pyuria typically implies a UTI.
• Bilirubin should not be present in the urine. In obstructive
hepatobiliary conditions and in certain liver diseases, such as
hepatitis, conjugated (water-soluble) bilirubin is excreted in the urine.
Often, this may occur prior to the development of clinical symptoms
(ie. jaundice)
• Normal urinary proteins values are less than 150 mg/d and are
undetectable using urinary dipstick. The urinary dipstick only detects
the presence of albumin and no other proteins.
When urinary protein values exceed 300-500 mg/d, the dipstick test
result becomes positive. Thus, it is a very specific, but not sensitive, test
for proteinuria. This is especially important to note in patients with
diabetes because the urine dipstick is insensitive for microalbuminuria.
The urine should not be tested within 24 hours after a contrast study
because contrast (many iodinated radiocontrast agents) may produce
false-positive results.
• Trace proteinuria - Approximately 10-30 mg/dL, as follows:
• 1+ - Approximately 30 mg/dL
• 2+ - Approximately 100 mg/dL
• 3+ - Approximately 300 mg/dL
• 4+ - 1000 mg/dL or more
Because the urinary dipstick protein results can be inaccurate for the
above stated reasons, a more accurate test is the sulfosalicylic acid test
(SSA). This test detects all proteins in the urine at any amounts,
including albumin, globulin, and Bence Jones proteins.
Patients with significant or persistent proteinuria should undergo a
quantitative measurement of protein excretion. This can be
accomplished by performing a 24-hour urine collection or by
calculating the total urine protein to creatinine ratio using a single
random urine specimen.
A 24-hour urine collection can be difficult for elderly patients or those
with incontinence and is especially cumbersome in the outpatient
setting. Hence, the urine protein to creatinine ratio is typically the
preferred method and has been shown to have a good correlation with
the 24-hour urine protein determination.
• Proteinuria is typically classified as transient or persistent.
Transient proteinuria due to transient changes in glomerular
hemodynamics (increased excretion of urinary protein) may have the
following etiologies:
• Fever
• cognitive heart failure
• Strenuous exercise
• Seizure disorders
• Stress
 Persistent proteinuria is then further classified into glomerular, tubular, or
overflow.
• Glomerular proteinuria due to disruption of filtration barrier (an increased filtration of
albumin across the glomerular capillary wall) may have the following etiologies:
Nephrotic syndrome (ie, diabetic nephropathy)
Glomerulonephritis

• Tubular proteinuria due to defective absorptive capacities in the proximal tubules of freely
filtered proteins, mostly low&molecular weight proteins such as immunoglobulin light chains
(excretion of normally reabsorbed proteins), may be caused by tubulointerstitial diseases.
ATN, acute interstitial nephritis, Fanconi syndrome
• Overflow proteinuria due to overproduction of immunoglobulin light chains in multiple
myeloma (amount produced exceeds maximum amount for reabsorption in the tubules) may
have the following etiologies:
Multiple myeloma
Myoglobinuria
• The dipstick test for blood detects the peroxidase activity of RBCs. [1] If
more than 3 RBCs are present, then the urinary dipstick test result is
positive for blood.
• A positive blood result on the urine dipstick can represent hematuria,
hemoglobinuria, myoglobinuria, false-positive results, or contamination.
False-positives may be seen with alkaline urine (pH >9), semen in the
urine. In addition, positive results can also represent contamination with
blood from a non urinary source, such as hemorrhoids or vaginal bleeding.
• if the urinary dipstick is positive for blood and urine microscopy is
positive for RBCs, hematuria is confirmed.
• If the dipstick result is positive for blood but no RBCs are found in the
urinary sediment when analyzed on urine microscopy, then that indicates
myoglobinuria (caused by rhabdomyolysis or myoglobinuric renal failure)
or hemoglobinuria (caused by infections such as Plasmodium falciparum,
transfusion-related reactions, or paroxysmal nocturnal hemoglobinuria)
Microscopic examination
WBCs, RBCs, epithelial cells, and, rarely, tumor cells are the cellular
elements found in the urinary sediment.
• The number of WBCs considered normal is typically 2-5 WBCs/hpf or
less. A high number of WBCs indicates infection, inflammation.
• most of the WBCs found are neutrophils.
• If found, urinary eosinophils may help diagnose acute interstitial
nephritis (AIN).
• Urinary lymphocytes are often associated with tubulointerstitial
diseases.
• Presence of any RBCs
Normally, less than 2 RBCs/hpf are observed.
Hematuria can be gross or microscopic. Gross hematuria is the
presence of red/brown urine. As little as 1 mL of blood per liter of
urine can produce a visible color change; therefore, gross hematuria
does not automatically indicate a large amount of blood.
Microscopic hematuria is defined as the presence of 3 RBCs/hpf or
more in 2 of 3 urine samples.
Hematuria may also be transient or persistent.
Transient hematuria in young patients is fairly common and is typically
benign. However, in older patients (>50 y), hematuria, even when
transient, can be serious and warrants a full workup for possible
underlying malignancy.
Persistent hematuria should always warrant a full evaluation.
The causes of hematuria are often categorized as renal versus extra
renal.
If the cause is thought to be renal, it is further categorized into
glomerular versus nonglomerular. The hallmark findings of hematuria
of glomerular origin include:
red cell casts, proteinuria (>500 mg/d), dysmorphic RBCs.
Hematuria of glomerular origin is also commonly described as "cola-
colored.
The first step in the evaluation of a patient with hematuria is a detailed
history. This may provide the clinician with important diagnostic clues.
For example, hematuria with acute onset flank pain radiating to the
ipsilateral groin with nausea/vomiting suggests nephrolithiasis,
whereas dysuria suggests a UTI or pyelonephritis, if fevers/chills are
also present.
A patient who notes a recent upper respiratory infection should be
evaluated for possible post infectious glomerulonephritis or
immunoglobulin (Ig)A nephropathy.
A patient’s family history is also important to gather because hematuria
may also be due to familial disorders (ie, polycystic kidney disease,
Alport syndrome, sickle cell nephropathy,benign familial hematuria).
Causes of non glomerular-based hematuria include the following:
• Tubulointerstitial nephritis
• Pyelonephritis
• Polycystic kidney disease
• Renal cell carcinoma
• Renovascular disease (eg, atheroembolic renal disease, renal vein
thrombosis, arteriovenous malformations)
Extrarenal-based hematuria may be caused by the following:
• Tumors/malignancies (prostate, ureteral, bladder)
• Stones (kidney, bladder)
• Benign prostatic hyperplasia
• Infections (pyelonephritis, cystitis, prostatitis, urethritis)
• Foley trauma
• Anticoagulants
• Chemotherapeutic agents (mitotane, ifosfamide, cyclophosphamide)
Epithelial cells that may be found in the urinary sediment include
squamous epithelial cells (from the external urethra) and transitional
epithelial cells (from the bladder). [2] Generally 15-20 squamous
epithelial cells/hpf or more indicates that the urinary specimen is
contaminated.

Casts are cylindrical particles that are formed from coagulated protein
secreted by tubular cells.
Hyaline casts may be seen in healthy individuals.
Other types of casts are not normally found and are suggestive of
renal disease. In particular, the finding of cells within a cast is
diagnostic of an intrarenal origin.
Hyaline casts are found in healthy individuals and are relatively
nonspecific. They may be increased after strenuous exercise. They are
often seen in small volumes of concentrated urine or with diuretic
therapy.
Red cell casts are nearly diagnostic of glomerulonephritis or vasculitis.
White cell casts and pyuria are most commonly seen with
tubulointerstitial nephritis and acute pyelonephritis. WBC casts are
also seen with renal tuberculosis and vaginal infections.
"Muddy-brown" granular casts are diagnostic of acute tubular
necrosis(ATN).
Waxy and broad casts are consistent with advanced renal failure.
Fatty casts and lipiduria, are commonly seen with nephrotic
syndrome.
Crystals are solid forms of a particular dissolved substance in the urine.
Crystal formation is determined by the urine pH, the super saturation of
the molecules, and the presence of possible inhibiting factors.
the observation of certain urinary crystals can diagnostically significant.
• calcium oxalate crystals and acute kidney injury is seen with
ethylene glycol ingestion.
• The presence of large amounts of uric acid crystal and acute kidney
injury is seen in tumor lysis syndrome.
• Uric acid crystals may also be seen with other causes of
hyperuricosuria, such as gout.
• triple phosphate crystals are seen with UTIs caused by urea-splitting
organisms (ie, Proteus, Klebsiella).
Bacteria in the urine sediment are generally due to infection or
contamination.
Normally no bacteria should be seen in the urinary sediment.
bacteria multiply rapidly if the urine specimen is left standing for too
long in room temperature.
A urinalysis with positive tests for nitrites, leukocyte esterase, and
bacteria is highly suggestive of a urinary tract infection. However, if a
significant amount of squamous epithelial cells (≥15-20/hpf) are present
as well, these findings may primarily indicate a contaminated specimen
and the urinalysis should be repeated.
even if no squamous cells are present and true bacteriuria is found,
these findings should be correlated clinically with the presence of
symptoms consistent with a urinary tract infection. [1] If the patient does
not have concomitant symptoms consistent with a UTI, then it is termed
asymptomatic bacteriuria.
If bacteriuria is found and a UTI is suspected, a urine culture with
sensitivities is recommended. In catheterized patients or with urine
obtained from a suprapubic tab, any organism on the urine culture is
considered significant. Otherwise, generally, 100,000/mL or more of a
single organism reflects significant bacteriuria.

Yeast cells are not normally found in the urine specimen. They can be
distinguished from red cells and amorphous crystals by their tendency
to bud. Commonly the yeast cells are of the Candida species, which can
colonize the vagina, urethra, or bladder. Yeast cells may signify true
infection or contamination (often due to contamination by vaginal
secretions in women with a yeast infection)