Chemistry Flashcards

1
Q

Major analytical methods used in the clinical chemistry laboratory include:

A

Major analytical methods used in the clinical chemistry laboratory include:

  • spectrophotometry
  • chemical sensors
  • gas chromatography with various detectors
  • gas chromatography combined with mass spectrometry
  • high-performance liquid chromatography
  • liquid chromatography combined with mass spectrometry or tandem mass spectrometry
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2
Q

Detection Method - Various Assays/Analytical Instrument

  • Spectrophotometric detection
  • Chemical sensors
  • Flame ionization detection
  • Mass spectrometric detection
A

Detection Method - Various Assays/Analytical Instrument

  • Spectrophotometric detection
    • Colorimetric assays
    • Atomic absorption
    • Enzymatic assays
    • Various immunoassays
    • High-performance liquid chromatography with ultraviolet (HPLC-UV) or fluorescence detection
  • Chemical sensors
    • Various ion-selective electrodes and oxygen sensors
  • Flame ionization detection
    • Gas chromatography
  • Mass spectrometric detection
    • Gas chromatography/mass spectrometry (GC/MS)
    • High-performance liquid chromatography (HPLC)/mass spectrometry (LC/MS)
    • Handem mass spectrometry (LC/MS/MS)
    • Inductively coupled plasma mass spectrometry (ICP-MS)
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3
Q

Spectrophotometric measurements

  • based on __ Law
  • __ measured as __ because there is a linear relationship between __ and concentration of the analyte in the solution
  • scale of absorbance __ to __, __ = “no absorbance”
  • __of light depends on the concentration of the analyte in the solvent and __
A

Spectrophotometric measurements

  • based on Beer’s Law (BeerLambert Law)
  • transmittance measured as absorption (“A”) because there is a linear relationship between absorbance and concentration of the analyte in the solution
  • scale of absorbance 0 to 2, 0 = “no absorbance”
  • Absorption of light depends on the concentration of the analyte in the solvent and length of the cell path
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4
Q

Atomic absorption spectrophotometry

  • used for analysis of __
  • components of gaseous samples are converted into __ by __ using a graphite chamber that can be heated after application of the sample
  • hollow cathode lamp containing __ at a very __ pressure is used as a light source
  • __ cathode contains the analyte of interest
  • Atoms in the ground state then __ part of the light emitted by the __ to boost them into __
  • part of the light beam is __ –> net __ in the intensity of the beam that arrives at the detector
  • __ Law to measure concentration of the analyte of interest
  • __ correction in flameless to correct for background noise
  • __is vaporized at room temperature –> “cold vapor atomic absorption” can be used only for analysis of __
A

Atomic absorption spectrophotometry

  • used for analysis of various elements, including heavy metals
  • components of gaseous samples are converted into free atoms by flame or flameless manner using a graphite chamber that can be heated after application of the sample
  • hollow cathode lamp containing an inert gas like argon or neon at a very low pressure is used as a light source
  • metal cathode contains the analyte of interest
  • Atoms in the ground state then absorb a part of the light emitted by the hollow cathode lamp to boost them into the excited state
  • part of the light beam is absorbed –> net decrease in the intensity of the beam that arrives at the detector
  • Beer’s Law to measure concentration of the analyte of interest
  • Zimmerman’s correction in flameless to correct for background noise
  • Mercury is vaporized at room temperature –> “cold vapor atomic absorption” can be used only for analysis of mercury
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5
Q

Inductively coupled plasma mass spectrometry (ICP-MS)

  • Is it a spectrophotometric method?
  • Used for analysis of __, especially __ found in small quantities in __ specimens
A

Inductively coupled plasma mass spectrometry (ICP-MS)

  • not a spectrophotometric method, but is a mass spectrometric method
  • used for analysis of elements, especially trace elements found in small quantities in biological specimens
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6
Q

Chemical sensors

  • capable of detecting __ present in __ matrix
  • those capable of detecting __ are classified under three broad categories:
A

Chemical sensors

  • capable of detecting various chemical species present in biological matrix
  • those capable of detecting selective ions are classified under three broad categories:
    • ion-selective electrodes
    • redox electrodes
    • carbon dioxide-sensing electrodes
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7
Q

Gas chromatography

  • Used for separation of __
  • Compounds identified by __
    • __ depends on the flow rate of __ through the column, nature of the column, and __ of analytes
  • After separation by GC, compounds can be detected by:
    • __, __, __
    • __ is the most specific detector for GC
  • Drawback:
    • only for analysis of __
A

Gas chromatography

  • used for separation of relatively volatile small molecules
    • compounds with higher vapor pressures (low boiling points) will elute faster than compounds with lower vapor pressures (high boiling points)
  • Compounds identified by the retention time (RT)
    • travel time needed to pass through the GC column
    • RT depends on the flow rate of gas (helium or an inert gas) through the column, nature of the column, and boiling points of analytes
  • After separation by GC, compounds can be detected by:
    • flame-ionization detector (FID)
    • electron-capture detector (ECD)
    • nitrogen-phosphorus detector (NPD)
    • Mass spectrometer is the most specific detector for GC
  • Drawback:
    • only for analysis of relatively volatile compounds or compounds that can be converted into volatile compounds using chemical modification of the structure (derivatization)
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8
Q

High-performance liquid chromatography (HPLC)

  • Capable of analyzing __
  • Common detectors include: __
  • HPLC + __ is a superior technique
  • __ ionization is commonly used in liquid chromatography + __ or __
A

High-performance liquid chromatography (HPLC)

  • Capable of analyzing polar and non-polar compounds
  • Common detectors include: ultraviolet (UV) detectors, fluorescence detectors, or electrochemical detectors
  • HPLC + mass spectrometry is a superior technique
  • Electrospray ionization is commonly used in liquid chromatography + mass spectrometry or tandem mass spec (MS/MS)
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9
Q

Immunoassays

  • __
    • only one antibody is used
    • for assays of __ such as __
  • __
    • two antibodies are used
    • for assays of __
A

Immunoassays

  • Competitive immunoassays
    • only one antibody is used
    • for assays of small molecules such as a therapeutic drugs or drugs of abuse
  • Immunometric (non-competitive, aka sandwich)
    • two antibodies are used
    • for assays of relative large molecules
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10
Q
  • Homogenous immunoassay format:
  • Heterogenous immunoassay format:
A
  • Homogenous immunoassay format:
    • After incubation, no separation between bound and free label is necessary.
  • Heterogenous immunoassay format:
    • The bound label must be separated from the free label before measuring the signal.
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11
Q

EMIT (enzyme multiplied immunoassay technique)

  • __, __ immunoassay, __ molecules (__ Daltons)
  • antigen is labeled with __
    • enzyme that reduces __ to __
    • __ = no signal at __ nm
    • __ = absorbs at __ nm
  • absorbance is monitored at __ nm
  • labeled antigen binds with the antibody molecule –> enzyme label becomes __ and __ signal is generated
  • signal intensity is proportional to analyte __
A

EMIT (enzyme multiplied immunoassay technique)

  • homogenous competitive immunoassay, small molecules (<1000 Daltons)
  • antigen is labeled with glucose 6-phosphate dehydrogenase
    • enzyme that reduces NAD to NADH
    • NAD = no signal at 340 nm
    • NADH = absorbs at 340 nm
  • absorbance is monitored at 340 nm
  • labeled antigen binds with the antibody molecule –> enzyme label becomes inactive and no signal is generated
  • signal intensity is proportional to analyte concentration
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12
Q

The Cloned Enzyme Donor Immunoassay (CEDIA)

  • method is based on __ technology
  • bacterial enzyme __ is genetically engineered into two inactive fragments
  • when both fragments __, a signal is produced that is proportional to __
A

The Cloned Enzyme Donor Immunoassay (CEDIA)

  • method is based on recombinant DNA technology
  • bacterial enzyme beta-galactosidase is genetically engineered into two inactive fragments
  • when both fragments combine, a signal is produced that is proportional to the analyte concentration
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13
Q

Kinetic interaction of microparticle in solution (KIMS)

  • In the absence of __ molecules free antibodies bind to __ to form particle aggregates
  • results in __ in absorption that is __ measured at various visible wavelengths (_-_ nm)
A

Kinetic interaction of microparticle in solution (KIMS)

  • In the absence of antigen molecules free antibodies bind to drug microparticle conjugates to form particle aggregates
  • results in an increase in absorption that is optically measured at various visible wavelengths (500-650 nm)
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14
Q

Luminescent oxygen channeling immunoassays (LOCI)

  • immunoassay reaction is __with light to generate __ molecules in microbeads (“Sensibead”) coupled to the __
  • when bound to the respective antibody molecule, also coupled to another type of bead, it reacts with __
  • __ signals are generated, proportional to the concentration of __
A

Luminescent oxygen channeling immunoassays (LOCI)

  • immunoassay reaction is irradiated with light to generate singlet oxygen molecules in microbeads (“Sensibead”) coupled to the analyte
  • when bound to the respective antibody molecule, also coupled to another type of bead, it reacts with singlet oxygen
  • chemiluminescence signals are generated, proportional to the concentration of the analyte-antibody complex
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15
Q

Bilirubin interference

  • total bilirubin concentration > __ mg/dL may cause problems
  • interference of bilirubin is mainly caused by its absorbance at __or __ nm
A

Bilirubin interference

  • total bilirubin concentration < 20 mg/dL does not cause interferences
  • concentrations > 20 mg/dL may cause problems
  • interference of bilirubin is mainly caused by its absorbance at 454 or 461 nm
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16
Q

Heterophilic antibodies

  • May arise in a patient with:
    • __, __, __
  • Interference
    • most commonly with __ used for measuring __
    • rarely with __ assays
    • causing mostly false __results
A

Heterophilic antibodies

  • May arise in a patient with:
    • exposure to certain animals or animal products
    • infection by bacterial or viral agents
    • use of murine monoclonal antibody products in therapy or imaging
  • Interference
    • most commonly with sandwich assays used for measuring large molecules
    • rarely with competitive assays
    • causing mostly false positive results
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17
Q

Heterophilic antibodies

  • __in urine
  • If a __ specimen is positive for an analyte, but it cannot be detected in the __ specimen, it indicates interference from a heterophilic antibody in the __
  • Another way to investigate heterophilic antibody interference is __ dilution of a specimen
    • if serial dilution produces a __ result, it indicates interference in the assay
  • Interference can also be blocked by adding __
A

Heterophilic antibodies

  • Absent in urine
  • If a serum specimen is positive for an analyte (e.g. hCG), but beta-hCG cannot be detected in the urine specimen, it indicates interference from a heterophilic antibody in the serum
  • Another way to investigate heterophilic antibody interference is serial dilution of a specimen
    • if serial dilution produces a non-linear result, it indicates interference in the assay
  • Interference can also be blocked by adding commercially available heterophilic antibody blocking agents to the specimen prior to analysis.
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18
Q

Autoantibodies

  • interfere with an immunoassay to produce false __results
  • __ will conjugate with immunoglobin or other antibodies to generate __, which can falsely __ a result
  • example: __ and __ can produce falsely __ results in amylase and prolactin assays
  • interference can be removed by __
A

Autoantibodies

  • interfere with an immunoassay to produce false positive results (rarely false negative)
  • endogenous analyte of interest will conjugate with immunoglobin or other antibodies to generate macro-analytes, which can falsely elevate a result
  • Example: macro-amylasemia and macro-prolactinemia can produce falsely elevated results in amylase and prolactin assays
  • interference can be removed by polyethylene glycol precipitation
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19
Q

Prozone (“hook”) effect

  • __ levels of antigen can __ the concentrations of “sandwich” (Ab1:antigen:Ab2) complexes responsible for generating the signal by forming mostly __ complexes
  • mostly causes __ interference (falsely __ results)
  • best way to eliminate the hook effect is __
A

Prozone (“hook”) effect

  • Very high levels of antigen can reduce the concentrations of “sandwich” (Ab1:antigen:Ab2) complexes responsible for generating the signal by forming mostly single Ab:antigen complexes
  • negative interference (falsely lower results)
  • best way to eliminate the hook effect is serial dilution
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20
Q

Hemoglobin

  • 6 Globin Chains?
  • Embryonic
    • Gower-1 Two __, two __
    • Gower-2 Two __, two __
    • Portland-1 Two __, two __
    • Portland-2 Two __, two __
  • Fetal
    • Hemoglobin F Two __, two __
  • Adult
    • Hemoglobin A Two __, two __ (__%)
    • Hemoglobin A2 Two __, two __ (
    • Hemoglobin F Two __, two __ (
A

Hemoglobin

  • Globin Chains
    • alpha chain (α-chain)
    • beta chain (β-chain)
    • gamma chain (γ-chain)
    • delta chain (δ-chain)
    • epsilon chain (ε-chain)
    • zeta chain (ζ-chain).
  • Embryonic
    • Gower-1 Two zeta, two epsilon
    • Gower-2 Two alpha, two epsilon
    • Portland-1 Two zeta, two gamma
    • Portland-2 Two zeta, two beta
  • Fetal
    • Hemoglobin F Two alpha, two gamma
  • Adult
    • Hemoglobin A Two alpha, two beta (92-95%)
    • Hemoglobin A2 Two alpha, two delta (
    • Hemoglobin F Two alpha, two gamma (
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21
Q

Newborn babies and infants up to __ old do not depend on HbA synthesis

  • switch from Hb F (2__, 2__) to Hb A (2__, 2__) occurs around __
  • disorders due to __chain defects manifest clinically after 6 mo
  • diseases due to __chain defects are manifested in utero or following birth
A

Newborn babies and infants up to 6 months old do not depend on HbA synthesis

  • switch from Hb F (2alpha, 2gamma) to Hb A (2alpha, 2beta) occurs around 3 mo
  • disorders due to beta chain defects (SS) manifest clinically after 6 mo
  • diseases due to alpha chain defects are manifested in utero or following birth
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22
Q

Location of Globin Genes

A

Location of Globin Genes

  • Chromosome 16
    • alpha chain
  • Chromosome 11
    • beta chain
    • gamma chain
    • delta chain
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23
Q

Heme synthesis

  • Involves enzymes in both the mitochondrion and cytosol
  • In mitochondria __+ __ –> delta-aminolevulinic acid –> cytoplasm –> __ –> coproporphyrinogen III –> mitochondria –> __–> protoporphyrin IX –> heme –> cytosol –> heme combines with __ –> hemoglobin molecule
A

Heme synthesis

  • In mitochondria glycine + succinyl-CoA –> delta-aminolevulinic acid –> cytoplasm –> porphobilinogen –> coproporphyrinogen III –> mitochondria –> protoporphyrinogen III –> protoporphyrin IX –> heme –> cytosol –> heme combines with globulin –> hemoglobin molecule

​Heme synthesis

  • mitochondria
    • glycine + succinyl-CoA
    • delta-aminolevulinic acid
  • cytoplasm
    • porphobilinogen
    • coproporphyrinogen III
  • mitochondria
    • protoporphyrinogen III
    • protoporphyrin IX
    • heme
  • cytosol
    • heme + globulin
    • hemoglobin molecule

With enzymes

  • In mitochondria glycine + succinyl-CoA –> delta-aminolevulinic acid –> cytoplasm –> converted into porphobilinogen (enzyme: aminolevulinic acid dehydrogenase) –> coproporphyrinogen III (multiple steps & enzymes) –> mitochondria –> protoporphyrinogen III (enzyme: coproporphyrinogen III oxidase) –> protoporphyrin IX (enzyme: protoporphyrinogen III oxidase) –> heme (enzyme: ferrochelatase) –> cytosol –> heme combines with globulin –> hemoglobin molecule
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24
Q

Hemoglobinopathies can be divided into 3 major categories:

A

Hemoglobinopathies can be divided into 3 major categories:

  • Quantitative disorders of hemoglobin synthesis:
    • Production of structurally normal globin chains, but in decreased amounts
    • thalassemia syndrome
  • Qualitative disorders of hemoglobin structure:
    • Production of structurally abnormal globulin chains
    • hemoglobin S (most common), C, O, or E
  • Failure to switch globin chain synthesis after birth:
    • Hereditary persistence of fetal hemoglobin (HbF)
      • relatively benign condition
      • can co-exist with thalassemia or sickle cell disease, result in decreased severity (protective effect)
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25
Q

Hemoglobinopathies

  • Ineritance pattern
  • Caused by inherent mutations of genes coding for __ synthesis
    • Thalassemias:
    • Hemoglobin variants:
A

Hemoglobinopathies

  • Autosomal recessive
    • carriers with 1 affected and 1 normal chromosome are usually healthy/slightly anemic
    • both parents are carriers, children have
    • 25% chance of being normal
    • 25% chance of being severely affected by the disease
    • 50% chance of being mostly normal
  • Caused by inherent mutations of genes coding for globin synthesis
    • Thalassemias: mutations disrupt gene expression –> reduced production of alpha/beta globin chain
    • Hemoglobin variants: point mutations of gene in coding region (exons) –> production of defective globin –> formation of abnormal hemoglobin
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26
Q

ALPHA-THALASSEMIA

  • Chromosome _
  • _ genetic loci for the alpha gene –> __ alleles for alpha-hemoglobin
  • _ alleles inherited from each parent
  • Alpha-thalassemia occurs when __

Alpha-thalassemia can be divided into four categories:

A

ALPHA-THALASSEMIA

  • Chromosome 16
  • 2 genetic loci for the alpha gene –> 4 alleles for alpha-hemoglobin (α/α, α/α)
  • 2 alleles inherited from each parent
  • Alpha-thalassemia occurs when there is a defect/deletion in one or more of the 4 alleles

Alpha-thalassemia can be divided into four categories:

  • Silent Carriers:
    • 1 defective/deleted gene, 3 functional genes
    • (-/α,α/α)
    • no health problems, +/- low MCV/MCH
  • Alpha-Thalassemia Trait:
    • 2 deleted/defective genes, 2 functional genes
    • alpha thal 1 (-/-,α/α) or alpha thal 2 (-/α,-/α)
    • +/- mild anemia
  • Alpha-Thalassemia Major (Hemoglobin H Disease):
    • 3 deleted/defective genes, 1 functional gene
    • (-/-,-/α)
    • persistent anemia & significant health problems
    • Hb H disease + Hb Constant Spring = severity greater than Hb H disease alone
  • Hydrops Fetalis:
    • no functional alpha gene
    • have hemoglobin Bart
    • life-threatening unless an intrauterine transfusion is initiated
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27
Q

Alpha-Thalassemia Major (Hemoglobin H Disease):

  • Genes?
  • What is Hb H
  • What are Heinz bodies?
  • Clinical?
A

Alpha-Thalassemia Major (Hemoglobin H Disease):

  • 3 deleted/defective genes, 1 functional gene, (-/-,-/α)
  • only 1 alpha gene –> decreased production of alpha-globin
  • high β-globin-to-α-globin ratio (a 2- to 5-fold increase in β-globin production)
  • Hb H formation: tetramer containing only 4 β chains
    • cannot deliver oxygen in peripheral tissues 2/2 very high oxygen affinity
  • microcytic hypochromic anemia with target cells and Heinz bodies (precipitated HbH)
  • Chronic hemolytic anemia (variable)
    • red cells that contain hemoglobin H are sensitive to oxidative stress and more susceptible to hemolysis, especially with oxidants such as sulfonamides
    • mature erythrocytes contain more precipitated hemoglobin H and are removed from the circulation prematurely
    • Subsequent increase in erythropoiesis –> erythroid hyperplasia
      • bone structure abnormalities with marrow hyperplasia
      • bone thinning
      • maxillary hyperplasia
      • pathologic fractures
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28
Q

BETA-THALASSEMIA

  • Chromosome __
  • __ genetic locus for the beta gene –> __ alleles for beta-hemoglobin
  • due to deficit/absent production of beta-globin –> excess production of __

Beta-thalassemia can be broadly divided into 3 categories:

  • What’s decreased?
  • What’s increasd?
A

BETA-THALASSEMIA

  • Chromosome 11
  • 1 genetic locus for beta gene –> 2 alleles for beta-hemoglobin
    • β0 - a defective gene is incapable of producing any beta-globin
    • β+ - mutated gene can retain some function
    • β0 or β+ does not predict the severity of disease
  • due to deficit/absent production of beta-globin –> excess production of alpha-globin
  • >200 point mutations have been reported
  • deletion of both genes is rare

Beta-thalassemia can be broadly divided into 3 categories:

  • Beta-Thalassemia Trait:
    • 1 defective and 1 normal gene, β0/β or β+
    • mild anemia, not be transfusion-dependent
    • low MCV/MCH
    • HbA2 increased
    • HbF +/- elevated
  • Beta-Thalassemia Intermedia:
    • 2 defective genes, β++ or β+0
    • some beta-globin production is still observed
    • +/- significant health problems that require intermittent transfusion
  • Beta-Thalassemia Major (Cooley’s Anemia):
    • 2 defective genes, β00 or β+0
    • no synthesis of beta-globin
    • severe form of disease, requires lifelong transfusions, +/- shortened lifespan
    • elevated HbA2 and HbF
    • excess alpha-globin chain precipitates, leading to hemolytic anemia
    • due to HbF, no symptoms prior to 6 months of age
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29
Q

Sickle Cell Diseases

  • HbAS
    • HbS:
    • HbA2:
    • Hgb:
  • HbSS
    • HbS:
    • HbA2:
    • HbA:
    • Hgb: g/dL
  • HbSβ0
    • HbS:
    • HbA2:
    • HbA:
    • Hgb: g/dL
  • HbSβ+
    • HbS:
    • HbA2:
    • HbA:
    • Hgb: g/dL
  • HbS/α-thalassemia
    • HbS:
    • HbA2:
    • HbA:
    • Hgb:
  • HbSC
    • HbS:
    • HbC:
    • Hgb:
  • HbS/HPFH
    • HbS:
    • HbA2:
    • HbF:
    • HbA:
    • Hgb: g/dL
A

Sickle Cell Diseases

  • HbAS
    • HbS: 35-40%
    • HbA2: < 3.5%
    • normal Hgb; no apparent illness
  • HbSS
    • HbS: >90%
    • HbA2: +/-3.5%
    • HbA: none
    • Hgb: 6-8 g/dL; severe disease, chronic hemolysis
  • HbSβ0
    • HbS: >80%
    • HbA2: >3.5
    • HbA: none
    • Hgb: 7-9 g/dL; severe sickle cell disease
  • HbSβ+
    • HbS: >60%
    • HbA2: >3.5%
    • HbA: 5-30%
    • Hgb: 9-12 g/dL; variable mild-moderate sickle cell disease
  • HbS/α-thalassemia
    • HbS: 35-40%
    • HbA2:
    • HbA: 60%
    • Hgb: microcytosis
  • HbSC
    • HbS: 50%
    • HbC: 50%
    • Hgb: 10-12 g/dL; moderate sickling disease, +/- chronic hemolytic anemia
  • HbS/HPFH
    • HbS: 60%
    • HbA2:
    • HbF: 30-40%
    • HbA: none
    • Hgb: 11-14 g/dL; mild sickling disease
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30
Q

HEREDITARY PERSISTENCE OF FETAL HEMOGLOBIN

HPFH is divided into two major groups:

A

HEREDITARY PERSISTENCE OF FETAL HEMOGLOBIN

HPFH is divided into two major groups:

  • Deletional HPFH
    • caused by a variable length deletion in the beta-globin gene cluster
    • leads to decreased (or absent) beta-globin synthesis and a compensatory increase in gamma-globin synthesis
    • pancellular/homogenous distribution of HbF in red blood cells
  • Non-deletional HPFH
    • broad category of related disorders with increased HbF
    • Heterocellular distribution of HbF in RBCs
    • also seen in beta-thalassemia and deltabeta-thalassemia
  • HbA2 is normal
  • Both homozygous and heterozygous HPFH are asymptomatic with no clinical or significant hematological change
    • homozygous HPFH, up to 100% HbF
    • heterozygous, 20-28% HbF
  • If HPFH is associated with sickle cell, it can reduce the severity of the disease.
    • HbS/HPFH: high levels of HbF, few (if any) sickle cell disease-related complications
  • If HPFH is associated with thalassemia, less severe disease complications
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31
Q

HbS

  • __% prevalence of S trait in African Americans
  • Genetics
  • Under deoxy conditions
  • shortened RBC survival, average lifespan __days (normal __days)
  • Cells that remain sickled despite re-oxygenation
  • Splenic sequestration crisis
  • Hyperhemolytic crisis
  • Infections are a major source of morbidity/mortality, made worse by __
    • __most common
    • Others:
  • Neurologic complications are frequent
    • 1 in 3 patients will have angiographic appearance of __ disease
  • Acute hepatic cell crisis (right upper quadrant syndrome)
  • Pregnancy
  • 7 classic sickle cell nephropathies
  • Priapism in up to __% of male
  • Ocular complications
A

HbS

  • 10% prevalence of S trait in African Americans
  • Genetics
    • Chromosome 11
    • sub thymine for adenine in the sixth codon of the beta-chain gene, GAG to GTG
    • (β6glu→val) coding of valine instead of glutamate in position 6 of the Hb beta chain
  • Under deoxy conditions
    • decreased solubility, increased viscosity, and polymer formation at concentrations exceeding 30 g/dL
    • forms a gel-like substance containing Hb crystals called tactoids
    • gel-like form of Hb is in equilibrium with its liquid-soluble form
      • factors influence equilibrium: oxygen tension, concentration of Hb S, presence of other hemoglobins
  • shortened RBC survival, average lifespan 17 days (normal 120 days)
  • Cells that remain sickled despite re-oxygenation—irreversibly sickled cells (ISCs) in PB smears
    • sickled cells should return to their normal shape upon exposure to atmospheric oxygen
    • sickled forms on the PB smear are by definition ISCs
    • ISC percent is more or less constant in an individual and does not appear to predict or reflect episodic crises
    • seem to be correlated inversely with that patient’s red cell survival.
  • Splenic sequestration crisis presents as worsening of anemia a/w enlarged, tender spleen
    • often occur during a viral illness
    • Children (whose spleens have not yet undergone fibrosis) and adults with SC disease or sickle cell-β+-thalassemia are most susceptible
  • Hyperhemolytic crisis
    • sudden exacerbation of anemia in association with profound reticulocytosis and hyperbilirubinemi
    • has been a/w concomitant G6PD deficiency
  • Infections are a major source of morbidity/mortality, made worse by functional asplenia
    • S. pneumoniae most common
    • Others: Salmonella, Haemophilus (HITB), and M pneumoniae
  • Neurologic complications are frequent
    • 1 in 3 patients will have angiographic appearance of moyamoya disease (segmental arterial stenoses with ‘puff of smoke’ collaterals)
  • Acute hepatic cell crisis (right upper quadrant syndrome)
    • progressive jaundice, elevated LFTs, and a tender, enlarged liver
    • usually resolves within 2 weeks, but it may progress to liver failure
  • Pregnancy
    • increased rate of both maternal and fetal death
    • increased risk of pregnancy-induced hypertension (preeclampsia)
    • increased incidence of intrauterine growth retardation, intrauterine fetal demise, and prematurity
  • 7 classic sickle cell nephropathies: gross hematuria, papillary necrosis, nephrotic syndrome, renal infarction, isosthenuria, pyelonephritis, and renal medullary carcinoma (also increased in AS and SC)
  • Priapism in up to 40% of male
  • Ocular complications (proliferative retinopathy)
    • more common in SC and S/β+ than SS
  • Osteonecrosis
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32
Q

HbA2’ (hemoglobin A2 prime)

  • clinically __, __-chain variant
  • __% of African Americans
  • heterozygotes gel electrophoresis, A2’ __
    • may underestimate __ –> underdiagnosis of _
    • __ and HbA2’ levels must be added
  • easily detectable by __, minor peak in __area

HbC (β6glu→lys)

  • AC
    • __% of hemoglobin in the in C band (__ + HbC)
    • generally asymptomatic, __ target cells
  • CC
    • __% HbC, __% HbF, __% HbA2, __% HbA
    • __ hemolytic anemia, splenomegaly, and __target cells
    • __-shaped crystals in the red cells, esp after __

HbE (β26glu→lys)

  • common in __
  • __indices, __target cells

HbD & G

  • clinically __
  • cellulose acetate - runs with __
  • citrate - runs with __
  • D & G distinguished
    • HbD is a __-chain defect, HbG is an __-chain defect
    • HbG: two __ bands (1 normal, 1 abnormal) separated by a distance equal to that separating __ from HbG

HbLepore

  • Common in __
  • Suspect if < __% (~__%) HbS on electrophoresis
    • Actual HbS rarely this low (RBC exchange)
  • result of fusion between _ and _ genes
  • cellulose acetate - runs with __
  • inefficiently produced, __% of total Hb
  • HbF up to __%

Hb Constant Spring (CS)

  • __indices
  • mutation in _ gene stop codon
  • produces __ transcript, unstable
  • __ gene is inefficient –> __
  • heterozygote hemoglobins produced:
    • __
    • adult: cellulose acetate - _ bands
    • newborn: also have __

High oxygen affinity hemoglobins

  • A group of hemoglobins with __
  • Ex:
  • Most cannot be resolved on __
  • Clue to their Dx is __ on the CBC
  • __ is diagnostic

Unstable hemoglobins

  • A group of hemoglobins a/w __ on PB
  • __ may precipitate hemolytic crisis
  • Screening: incubating __ with 17% __–> precipitation of __
  • Ex: __, only Hb __ a/w severe hemolysis
A

HbA2’ (hemoglobin A2 prime)

  • clinically insignificant δ-chain variant
  • 1–2% of African Americans
  • heterozygotes gel electrophoresis, A2’ barely detectable
    • may underestimate A2 –> underdiagnosis of β-thalassemia trait
    • HbA2 and HbA2’ levels must be added
  • easily detectable by HPLC, minor peak in S area

HbC (β6glu→lys)

  • AC
    • 40-50% of hemoglobin in the in C band (HbA2 + HbC)
    • generally asymptomatic, scattered target cells
  • CC
    • 90% HbC, 7% HbF, 3% HbA2, 0% HbA
    • mild hemolytic anemia, splenomegaly, and numerous target cells
    • hexagonal/rod-shaped crystals in the red cells, esp after splenectomy

HbE (β26glu→lys)

  • common in Southeast Asia
  • thalassemic indices, numerous target cells

HbD & G

  • clinically normal
  • cellulose acetate - runs with HbS
  • citrate - runs with HbA
  • D & G distinguished
    • HbD is a β-chain defect, while HbG is an α chain defect
    • HbG: two HbA2 bands (1 normal, 1 abnormal) separated by a distance equal to that separating HbA from HbG

HbLepore

  • Common in Mediterranean, esp Italy
  • Suspect if < 30% (~15%) HbS on electrophoresis
    • Actual HbS rarely this low (RBC exchange)
  • result of fusion between δ and β genes
  • cellulose acetate - runs with HbS
  • inefficiently produced, 8 - 15% of total Hb
  • HbF up to 20%

Hb Constant Spring (CS)

  • thalassemic indices
  • mutation in α gene stop codon
  • produces abnormally long transcript, unstable
  • αcs gene is inefficient –> thalassemia
  • heterozygote hemoglobins produced:
    • α-β (HbA), αcs-β (HbCS), α-δ (HbA2), αcs-δ
    • adult: cellulose acetate - 4 bands
    • newborn: also have α-γ (HbF), αcs-γ

High oxygen affinity hemoglobins

  • A group of hemoglobins with left-shifted oxygen dissociation curves
  • Ex: HbChesapeake and HbDenver
  • Most cannot be resolved on gel electrophoresis or HPLC
  • Clue to their Dx is erythrocytosis on the CBC
  • HbO2 dissociation curve (P50) is diagnostic

Unstable hemoglobins

  • A group of hemoglobins a/w Heinz bodies and bite cells on PB
  • Oxidative stresses may precipitate hemolytic crisis
  • Screening: incubating lysed red cells with 17% isopropanol –> precipitation of unstable Hbs
  • Ex: Hbs Hasharon, Koln, & Zurich, only Hb Hammersmith a/w severe hemolysis
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33
Q

Methemoglobin (Hi, hemiglobin)

  • form of hemoglobin in which iron is in the __ ___ (Fe?) state instead of __ (Fe?)
  • results from __of hemoglobin
  • incapable of combining with __
  • Under normal circumstances, small degree of hemoglobin oxidation
    • Hi up to __% of total Hb
    • reduced in the erythrocyte by the __
  • Cyanosis results when Hi reaches __% of total Hb or around __g/dL
    • blood is grossly __
  • __ is capable of measuring methemoglobin directly
  • pulse oximetry and arterial blood gas analyzers
    • estimate O2 sat by emitting a __light (wavelength of __nm) absorbed mainly by reduced hemoglobin and an __light (wavelength of __nm) absorbed by oxyhemoglobin
    • Hi absorbs _
    • increasing levels of methemoglobin result in __ measured oxygen saturation towards __%, form of oxygen saturation gap
  • Hereditary methemoglobinemia can result from either
    • __ or __
  • Hb M: __
  • Cyanosis appears at __ age, unless there is M fetal hemoglobin in which case cyanosis abates at __
  • Most M hemoglobins run with __ on routine gels.
  • Acquired methemoglobinemia results from __ that increase formation of Hi
    • Ex:
    • Hi has a very high affinity for __, Tx for __toxicity involves giving __to generate Hi to chelate __
  • Treatment: methylene blue, reduces Hi to Hb
A

Methemoglobin (Hi, hemiglobin)

  • hemoglobin in which iron is in the oxidized ferric (Fe+++) state instead of ferrous (Fe++)
  • results from oxidation of hemoglobin
  • incapable of combining with oxygen
  • Under normal circumstances, small degree of hemoglobin oxidation
    • Hi up to 1.5% of total Hb
    • reduced in the erythrocyte by the NADH-dependent methemoglobin reductase system
  • Cyanosis results when Hi reaches 10% of total Hb or 1.5 g/dL
    • blood is grossly chocolate brown
  • co-oximeter is capable of measuring methemoglobin directly
  • pulse oximetry and arterial blood gas analyzers
    • estimate O2 sat by emitting a red light (660 nm) absorbed by reduced hemoglobin and an infrared light (940 nm) absorbed by oxyhemoglobin
    • Hi absorbs equally at both wavelengths, essentially undetectable
    • increasing levels of methemoglobin result in decreased measured oxygen saturation towards 85%, form of oxygen saturation gap
  • Hereditary methemoglobinemia can result from either
    • deficiency in the reductase system
    • abnormal Hbs (HbM) upon which this enzyme cannot act
  • Hb M: group of Hbs that prefer the ferric (methemoglobin) state
    • 2/2 various aa subs
    • cyanosis appears at 6 mo
    • M fetal Hb, cyanosis abates at 6 mo
    • Most M hemoglobins run with A on routine gels
  • Acquired methemoglobinemia results from exposure to drugs/chemicals that increase formation of Hi
    • Ex: nitrites, quinones, phenacetin, and sulfonamides
    • Hi has a very high affinity for cyanide, Tx for cyanide toxicity involves giving nitrites to generate Hi to chelate cyanide
  • Treatment: methylene blue, reduces Hi to Hb
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34
Q

HbA2’ (hemoglobin A2 prime)

  • clinically __, __-chain variant
  • __% of African Americans
  • heterozygotes gel electrophoresis, A2’ __
    • may underestimate __ –> underdiagnosis of _
    • __ and HbA2’ levels must be added
  • easily detectable by __, minor peak in __area
A

HbA2’ (hemoglobin A2 prime)

  • clinically insignificant δ-chain variant
  • 1–2% of African Americans
  • heterozygotes gel electrophoresis, A2’ barely detectable
    • may underestimate A2 –> underdiagnosis of β-thalassemia trait
    • HbA2 and HbA2’ levels must be added
  • easily detectable by HPLC, minor peak in S area
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35
Q

HbC (β6glu→lys)

  • AC
    • __% of hemoglobin in the in C band (__ + HbC)
    • generally asymptomatic, __ target cells
  • CC
    • __% HbC, __% HbF, __% HbA2, __% HbA
    • __ hemolytic anemia, splenomegaly, and __target cells
    • __-shaped crystals in the red cells, esp after __
  • Identification
    • Alkaline gel:
    • Acid gel:
    • HPLC:
    • Capillary electrophoresis:
A

HbC (β6glu→lys)

  • AC
    • 40-50% of hemoglobin in the in C band (HbA2 + HbC)
    • generally asymptomatic, scattered target cells
  • CC
    • 90% HbC, 7% HbF, 3% HbA2, 0% HbA
    • mild hemolytic anemia, splenomegaly, and numerous target cells
    • hexagonal/rod-shaped crystals in the red cells, esp after splenectomy
  • Identification
    • Alkaline gel: Band in C lane; possibilities - C, E, or O.
    • Acid gel: Band in C lane
    • HPLC: peak @ 5 min, small peak just before main peak (HbC1d)
    • Capillary electrophoresis: peak Zone 2
36
Q

HbE (β26glu→lys)

  • common in __
  • __indices, __target cells
  • Identification
    • Alkaline gel:
    • Acid gel:
    • HPLC:
    • Capillary electrophoresis:
A

HbE (β26glu→lys)

  • common in Southeast Asia
  • thalassemic indices, numerous target cells
  • Identification
    • Alkaline gel: Band in C lane; possibilities are C, E, or O
    • Acid gel: Band in A lane
    • HPLC: peak at 3.5 minutes
    • Capillary electrophoresis: peak in Zone 4
37
Q

HbD & G

  • clinically __
  • cellulose acetate - runs with __
  • citrate - runs with __
  • D & G distinguished
    • HbD is a __-chain defect, HbG is an __-chain defect
    • HbG: two __ bands (1 normal, 1 abnormal) separated by a distance equal to that separating __ from HbG
  • Identification
    • Alkaline gel:
    • Acid gel:
    • HPLC:
    • Capillary electrophoresis:
A

HbD & G

  • clinically normal
  • cellulose acetate - runs with HbS
  • citrate - runs with HbA
  • D & G distinguished
    • HbD is a β-chain defect, while HbG is an α chain defect
    • HbG: two HbA2 bands (1 normal, 1 abnormal) separated by a distance equal to that separating HbA from HbG
  • Identification of D
    • Alkaline gel: Band in S lane; possibilities are S, D, G, Lepore
    • Acid gel: Band in A lane
    • HPLC: peak at 3.9-4.2 minutes; no additional peak
    • Capillary electrophoresis: peak in Zone 6.
  • Identification of G
    • Alkaline gel: Band in S lane; possibilities are S, D, G, Lepore
    • Acid gel: Band in A lane
    • HPLC: peak at 3.9-4.2 minutes; small additional peak (G2)
    • Capillary electrophoresis: peak in Zone 6.
38
Q

HbLepore

  • Common in __
  • Suspect if __
  • result of fusion between _ and _ genes
  • cellulose acetate - runs with __
  • inefficiently produced, __% of total Hb
  • HbF up to __%
  • Identification
    • Alkaline gel:
    • Acid gel:
    • HPLC:
    • Capillary electrophoresis:
A

HbLepore

  • Common in Mediterranean, esp Italy
  • Suspect if < 30% (~15%) HbS on electrophoresis
    • Actual HbS rarely this low (RBC exchange)
  • result of fusion between δ and β genes
  • cellulose acetate - runs with HbS
  • inefficiently produced, 8 - 15% of total Hb
  • HbF up to 20%
  • Identification
    • Alkaline gel: Band (faint) in S lanel; possibilities - S, D, G, Lepore
    • Acid gel: Band in A lane
    • HPLC: peak at 3.7 min (A2 peak); quantity is lower than D, G, or E; small increase in % HbF
    • Capillary electrophoresis: peak in Zone 6
39
Q

Hb Constant Spring (CS)

  • __indices
  • mutation in _ gene stop codon
    • produces __ transcript, unstable
    • __ gene is inefficient –> __
  • heterozygote hemoglobins produced:
    • __
    • adult: cellulose acetate - _ bands
    • newborn: also have __
A

Hb Constant Spring (CS)

  • thalassemic indices
  • mutation in α gene stop codon
  • produces abnormally long transcript, unstable
  • αcs gene is inefficient –> thalassemia
  • heterozygote hemoglobins produced:
    • α-β (HbA), αcs-β (HbCS), α-δ (HbA2), αcs
    • adult: cellulose acetate - 4 bands
    • newborn: also have α-γ (HbF), αcs
40
Q

High oxygen affinity hemoglobins

  • A group of hemoglobins with __
  • Ex:
  • Most cannot be resolved on __
  • Clue to their Dx is __ on the CBC
  • __ is diagnostic
A

High oxygen affinity hemoglobins

  • A group of hemoglobins with left-shifted oxygen dissociation curves
  • Ex: HbChesapeake and HbDenver
  • Most cannot be resolved on gel electrophoresis or HPLC
  • Clue to their Dx is erythrocytosis on the CBC
  • HbO2 dissociation curve (P50) is diagnostic
41
Q

Unstable hemoglobins

  • A group of hemoglobins a/w __ on PB
  • __ may precipitate hemolytic crisis
  • Screening: incubating __ with 17% __–> precipitation of __
  • Ex: __, only Hb __ a/w severe hemolysis
A

Unstable hemoglobins

  • A group of hemoglobins a/w Heinz bodies and bite cells on PB
  • Oxidative stresses may precipitate hemolytic crisis
  • Screening: incubating lysed red cells with 17% isopropanol –> precipitation of unstable Hbs
  • Ex: Hbs Hasharon, Koln, & Zurich, only Hb Hammersmith a/w severe hemolysis
42
Q
A
43
Q
A
44
Q
A
45
Q

What runs with S on cellulose acetate gel?

A

On Cellulose Acetate gel at pH 8.6

  • S, D, G, Lepore
46
Q

What runs with C on cellulose acetate gel?

A

Cellulose Acetate gel at pH 8.6

  • C, E, O and A2
47
Q

What runs with A on cellulose acetate gel?

A

Cellulose Acetate gel at pH 8.6

  • A, M
48
Q

What runs past A (+) on cellulose acetate?

A

Cellulose Acetate at pH 8.6

  • H & Bart run at the (+) end of the gel, past A
49
Q

What runs with A on citrate agar?

A

Citrate Agar at pH 6.2

  • A, A2, D, G, E, M
50
Q

HPLC

A
51
Q

HPLC

A
52
Q

Capillary Electrophoresis

A
53
Q

Identification of HbS

  • Alkaline gel:
  • Acid gel:
  • HPLC:
  • Capillary electrophoresis:
A

Identification of HbS

  • Alkaline gel: Band in S lane; possibilities: S, D, G, Lepore
  • Acid gel: Band in S lane
  • HPLC: peak at 4.5 minutes
  • Capillary electrophoresis: peak in Zone 5
54
Q

Urine Electrophoresis

A
55
Q

CSF Electrophoresis

A
56
Q

Protein Capillary Electrophoresis

A
57
Q

Cytochemical stains for typing blasts

  • Myeloperoxidase (MPO)
  • Sudan black B (SBB)Chloroacetate esterase (CAE)
  • Nonspecific esterases (NSE)
    • Monocyte NSE activity is inhibited by __
  • Periodic acid Schiff (PAS)
  • Oil red O
A

Cytochemical stains for typing blasts

  • Myeloperoxidase (MPO)
    • stains the primary (azurophilic) granules indicative of granulocytic differentiation
    • negative in lymphoblasts, erythroblasts, monoblasts, and megakaryoblasts
    • fine dusty positivity may be seen in monoblasts
    • degrades quickly in wet specimens, but is stable in smears for up to a month
  • Sudan black B (SBB)
    • stains lipid material found in granulocytic and monocytic cells
  • Chloroacetate esterase (CAE)
    • found only in the granulocytic series
    • monocytes and lymphocytes are negative
  • Nonspecific esterases (NSE)
    • include alpha naphthyl acetate esterase and alpha naphthyl butyrate esterase
    • stain cells of the monocytic series and +/- megakaryocytic, lymphocytic, granulocytic, and erythroid series
    • Monocyte NSE activity is inhibited by sodium fluoride (NaF)
  • Periodic acid Schiff (PAS)
    • positive in most lymphoid and some myeloid blasts
    • In ALL, it shows “block” positivity, often encircling the nucleus in a “rosary bead” fashion
    • In AML, when positive, it is usually a diffuse, granular hue of positivity
  • The vacuoles in the blasts of L3 ALL stain positively with the oil red O stain
58
Q

Substance Abuse and Mental Health Services Administration (SAMHSA) guidelines for federal workplace drug testing

Require testing for 5 abused drugs:

A

Substance Abuse and Mental Health Services Administration (SAMHSA) guidelines for federal workplace drug testing

Require testing for 5 abused drugs:

  1. amphetamines (amphetamine, methamphetamine, and 3,4-methylenedioxymethamphetamine; MDMA, ecstasy)
  2. cocaine (tested as benzoylecgonine)
  3. opiates
  4. marijuana (tested as marijuana metabolites)
  5. phencyclidine (PCP)
59
Q

In urine, most drugs can be detected for only 2-3 days after abuse, except for

PCP (__ days) and marijuana (up to __ days, from chronic abuse).

A

In urine, most drugs can be detected for only 2-3 days after abuse, except for

PCP (__ days) and marijuana (up to __ days, from chronic abuse).

60
Q

Abuse of cocaine and ethanol (alcohol) is dangerous because:

A

Abuse of cocaine and ethanol (alcohol) is dangerous because:

  • ethanol and benzoylecgonine (inactive metabolite of cocaine) = cocaethylene
  • cocaethylene: active metabolite with a long half-life
61
Q

Plasma osmolality =

Osmolar gap =

High osmolar gap can be due to?

A

Plasma osmolality = 2 x [Na in mmol/L] + [Glucose mg/dL]/18 + [BUN mg/dL]/2.8

Osmolar gap = Observed osmolality - Calculated osmolality

  • High osmolar gap can be due to:
  • ethanol, methanol, and ethylene glycol (overdosed patients)
  • reduced fractional water content of plasma 2/2 hyperlipidemia or paraproteinemia
62
Q

Diabetes insipidus

SIADH (syndrome of inappropriate ADH secretion)

A

Diabetes insipidus

  • Central/cranial: due to lack of secretion of ADH
  • Nephrogenic: due to the inability of ADH to work at the collecting duct of the kidney

SIADH (syndrome of inappropriate ADH secretion)

  • hyponatremia (plasma sodium <131 mmol/L)
  • decreased plasma osmolality (<275 mOsm/kg)
  • urine osmolality >100 mOsm/kg
  • high urinary sodium (>20 mmol/L) with no edema
63
Q

Equilibrium equation

  • CO2
  • H2O
  • Carbonic acid
  • Bicarbonate
A

CO2 + H2O = H2CO3 = H+ + HCO3-

  • Carbonic acid: H2CO3
  • Bicarbonate: HCO3-
64
Q

Normal pH of arterial blood =

Normal bicarbonate level =

Normal pCO2 =

Normal chloride level =

A

Normal pH of arterial blood = 7.35-7.45

Normal bicarbonate level = 23-25 mmol/L

Normal pCO2 = 35-45 mmHg

Normal chloride level = 95-105 mmol/L

65
Q

pH, pCO2, bicarbonate

  • Metabolic acidosis
  • Respiratory acidosis
  • Metabolic alkalosis
  • Respiratory alkalosis
A
  • Metabolic acidosis
    • Decrease: pH, pCO2, bicarbonate
  • Respiratory acidosis
    • Decrease: pH
    • Increase: pCO2, bicarbonate
  • Metabolic alkalosis
    • Inrease: pH, pCO2, bicarbonate
  • Respiratory alkalosis
    • Increase: pH
    • Decrease: pCO2, bicarbonate
66
Q

Anion gap =

The normal value is __

A

Anion gap = sodium - (chloride + bicarbonate)

  • The normal value is 8-12 mmol/L (mEq/L)
67
Q

Causes of normal anion gap metabolic acidosis

Causes of increased anion gap metabolic acidosis

A

Causes of normal anion gap metabolic acidosis

  • loss of bicarbonate buffer from the gastrointestinal tract
    • chronic diarrhea, pancreatic fistula, and sigmoidostomy
  • renal loss of bicarbonate
    • renal tubular acidosis and renal failure

Causes of increased anion gap metabolic acidosis (MUDPILES)

  • Methanol
  • Uremia
  • Diabetic ketoacidosis
  • Paraldehyde
  • Isopropanol
  • Lactic acidosis
  • Ethylene glyco
  • Salicylate
68
Q

Metabolic alkalosis

A

Metabolic alkalosis

  • loss of hydrogen ion
  • gain of bicarbonate
  • alkali for any of the following reasons:
    • loss of acid from gastrointestinal tract issues (vomiting, diarrhea)
    • loss of acid from kidneys (glucocorticoid or mineralocorticoid excess, diuretics)
    • gain of alkali (e.g. “milk-alkali syndrome,” aka Burnett’s syndrome, excess milk intake and alkali leading to hypercalcemia)
69
Q

Respiratory acidosis

A

Respiratory acidosis

  • Increased CO2 due to type II respiratory failure (hypoventilation)
    • CNS disorders that damage or suppress the respiratory center (e.g. stroke, tumor, drugs, alcohol, neuropathy)
    • myopathy affecting muscles of ventilation (e.g. GuillainBarré syndrome, myasthenia gravis)
    • reduced movement of chest wall (e.g. flail chest, severe obesity)
    • airway obstruction (e.g. severe acute asthma)
70
Q

Respiratory alkalosis

  • Acute vs. Chronic respiratory disturbance
A

Respiratory alkalosis

  • Decreased CO2 (hyperventilation)
    • CNS stimulation due to drugs such as aspirin, ketamine,
    • hysteria
    • bronchial asthma (early stage)
  • Acute respiratory disturbance:
    • 10 mmHg pCO2 change –> 0.08 units change in pH
  • Chronic respiratory disturbance
    • 10 mmHg pCO2 change –> 0.03 units change in pH
71
Q
A
72
Q
  • What clotting factor is not produced in the liver?
  • What do low urea and glucose levels indicate?
A
  • Synthesis of clotting factors
    • Factor VIII is not produced in the liver
  • Significant Urea synthesis from ammonia and carbon dioxide
    • Low urea level in fulminant hepatic failure
  • Liver releases glucose by glycogenolysis and gluconeogenesis
    • Hypoglycemia in fulminant hepatic failure
73
Q
  • Pre-hepatic jaundice (hemolytic anemia)
  • Hepatocellular jaundice
  • Cholestatic jaundice
  • Acute liver disease
  • Chronic liver disease
  • Liver metastasis
  • Bone disease or metastasis
  • Alcoholic liver disease
A
  • Pre-hepatic jaundice (hemolytic anemia)
    • Total and unconjugated bilirubin is high
    • Liver enzymes (ALT, AST, ALP, and GGT) are normal
    • PT and proteins are normal
  • Hepatocellular jaundice
    • Total bilirubin is high
    • Liver enzymes are elevated
    • ALT and AST may be very high (in thousands)
    • ALP < 3x normal
    • Total protein and albumin may be normal
    • PT may be prolonged if liver damage is significant
  • Cholestatic jaundice
    • Total bilirubin and conjugated bilirubin is high
    • Liver enzymes are elevated (typically mildly)
    • ALP >3x normal
    • PT may be prolonged due to lack of absorption of fat-soluble vitamin K
  • Acute liver disease
    • PT is the best marker
    • Total protein and albumin are typically normal
  • Chronic liver disease
    • Albumin level is decreased
    • Total protein could be elevated if hypergammaglobulinemia is present
    • liver enzymes may or may not be elevated
  • Liver metastasis
    • Only ALP and GGT may be elevated
  • Bone disease or metastasis
    • Only ALP may be elevated
  • Alcoholic liver disease
    • Only GGT is elevated
74
Q

Congenital Hyperbilirubinemias

A

Congenital Hyperbilirubinemias

  • Gilbert’s syndrome
  • CriglerNajjar Type I
  • CriglerNajjar Type II
  • Dubin-Johnson
  • Rotor
75
Q

Congenital Hyperbilirubinemias

  • Gilbert’s syndrome
  • CriglerNajjar Type I
  • CriglerNajjar Type II
  • Dubin-Johnson
  • Rotor
A

Congenital Hyperbilirubinemias

  • Gilbert’s syndrome
    • Autosomal dominant
    • Reduced levels of UDP-glucuronyl transferase –> elevated unconjugated bilirubin
      • increases with fasting
  • CriglerNajjar Type I
    • Autosomal recessive
    • Total absence of UDP-glucuronyl transferase
    • Markedly elevated unconjugated bilirubin
    • may be fatal
  • CriglerNajjar Type II
    • Autosomal dominant
    • Reduced levels of UDP-glucuronyl transferase
    • Elevated unconjugated bilirubin
    • can be treated with enzyme inducer such as phenobarbital
  • Dubin-Johnson
    • Autosomal dominant
    • Impaired excretion of conjugated bilirubin, causing conjugated hyperbilirubinemia
    • Melanin pigment found within hepatocytes
  • Rotor
    • Autosomal dominant
    • Impaired excretion of conjugated bilirubin
76
Q

Autoimmune liver disease

  • a/w __
  • Extrahepatic:
  • Antibodies:
  • Polyclonal hypergammaglobulinemia may be present due to__
A

Autoimmune liver disease

  • a/w other autoimmune diseases
  • Extrahepatic: polyarthritis, pleurisy, and glomerulonephritis
  • ANA, anti-smooth muscle actin, anti-soluble liver antigen, and anti-liver/kidney microsomal antibodies
  • Polyclonal hypergammaglobulinemia may be present due to increased IgG
77
Q

Primary biliary cirrhosis

  • Gender?
  • Presenting symptom?
  • Antibody?
  • __ levels high
A

Primary biliary cirrhosis

  • primarily in women
  • pruritus precedes other features, +/- secondary hyperlipidemia
  • Anti-mitochondrial antibody
  • IgM levels high
78
Q

Wilson’s disease

  • Inheritance
  • __is deposited in the liver
  • age
  • __ ring is seen as greenish brown pigment at the sclera cornea junction
  • Low serum __
A

Wilson’s disease

  • autosomal recessive
  • copper is deposited in the liver
  • young age
  • Kayser-Fleischer ring is seen as greenish brown pigment at the sclera cornea junction
  • Low serum ceruloplasmin
79
Q

Alpha-1 antitrypsin deficiency

  • Serum alpha-1 antitrypsin level is __
  • Genetic variants are characterized by their electrophoretic mobility:
A

Alpha-1 antitrypsin deficiency

  • liver disease and panacinar emphysema
  • Serum alpha-1 antitrypsin level is low
  • Genetic variants are characterized by their electrophoretic mobility:
    • medium (M), slow (S), and very slow (Z)
    • Normal people are MM, homozygotes are ZZ, heterozygotes MZ or SZ
80
Q
  • HLA-B27 =
  • HLA-B46 =
  • HLA-B47 =
  • HLA-DR2 =
  • HLA-DR3 =
  • HLA-DR4 =
A
  • HLA-B27 = Ankylosing spondylitis, Reactive arthritis
  • HLA-B46 = Graves’ disease (Asian population)
  • HLA-B47 = 21-Hydroxylase deficiency
  • HLA-DR2 = Systemic lupus erythematosus
  • HLA-DR3 = Type 1 diabetes mellitus, SLE
  • HLA-DR4 = Myasthenia gravis, Rheumatoid arthritis
81
Q

Hypersensitivity reactions 4 types:

A

Hypersensitivity reactions 4 types:

  • immediate (type I)
  • antibody-mediated (type II)
  • immune complex-mediated (type III)
  • T cell-mediated (type IV)
82
Q

Hypersensitivity reactions 4 types:

  • immediate (type I)
  • antibody-mediated (type II)
  • immune complex-mediated (type III)
  • T cell-mediated (type IV)
A

Hypersensitivity reactions 4 types:

  • Immediate (type I) hypersensitivity reaction
    • host is exposed to an antigen, IgE antibodies are produced, which are bound to the surface of mast cells, that trigger mast cell degranulation
  • Antibody-mediated (type II) hypersensitivity disorder
    • antibodies directed against antigens, which are components of cells
  • Immune complex-mediated (type III) hypersensitivity disorder
    • large amounts of antigenantibody complexes are formed, may deposit in tissues and cause an inflammatory response
      • kidneys, joints, and skin
  • T cell-mediated (type IV) reactions
    • Delayed-type hypersensitivity (DTH)
      • classic example is the tuberculin reaction
    • T cell-mediated cytotoxicity
      • CD8+T cells are responsible for killing antigen-bearing target cells
      • cytotoxicity is important against viral infections and tumor cells
83
Q

Classical Complement Pathway

A
84
Q

Alternate Complement Pathway

A
85
Q

Complement Pathway

A

The complement pathways

  • Classic pathway
    • Activated by IgM and subclasses of IgG (IgG1, IgG2, IgG3)
    • Fc portion of the Ig interacts with C1q to initiate this process
    • Activated C1 catalyzes the association of C4 and C2 to make C4b2b (the C3 convertase of the classic pathway)
    • C4b2b is capable of converting C3 to C3b + C3a
    • C3b associates with C4b2b to make C4b2b3b (the C5 convertase of the classic pathway)
  • Alternate pathway
    • Can be activated in the absence of Ig by:
      • bacterial cell walls, venoms, or endotoxin
      • complexed IgA
    • These substances bind to C3b and prevent its degradation
    • C3b is present at low levels at all times in peripheral blood, minute amounts of C3 are constantly converted to C3a and C3b
    • Normally C3b is rapidly inactivated by factor I, unless a suitable surface is present to prevent it and promote the association of C3b with factor B to makeC3bBb (the C3 convertase of the alternate pathway)
    • C3bBb is capable of converting C3 to C3b + C3a
    • Abundantly available C3b associates with C3bBb to make C3bBb3b (the C5 convertase of the alternate pathway)
    • The whole point of both the alternate and classical pathways is to produce a C5 convertase (a molecule capable of converting C5 into C5b + C5a)
    • Once C5b is formed, it quickly complexes (on the surface of adjacent cells such as bacteria, transfused red cells, etc.) with C6, C7, C8 and C9 to form C5b6789 (the membrane attack complex or MAC)
  • C3a and C5a are formed as by-products
    • anaphylatoxins capable of increasing vascular permeability and causing vasodilation
  • C3b alone, like IgG, when fixed to the surfaces of cells, acts as an opsonin
    • interacts with receptors on phagocytic cells, leading to ingestion of the bound cell
86
Q
A