introduction to clinical pharmacy l-9 l-10 9...•bilirubin—total (0.1–1mg/dl) break down...
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Introduction to clinical pharmacy L-9
L-10
Interpretation of Clinical Laboratory Data
Presented by:
Kholod Hamad
Clinical Pharmacy- NUS
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Learning objectives
• State the clinical application of common general diagnostic procedures.
• Identify the clinical application of specific laboratory tests.
• Assess common laboratory and diagnostic test results.
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General principles
• Order test only if the results will affect decisions about the care of the patient
• Balance benefit to patient-specific outcomes with the economic cost and impact on the quality of life related to obtaining these data
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Factors Affecting the Test Result From the Time
the Test Is Ordered Until It Arrives at the Laboratory..
• Incorrect test ordered
• Sample incorrectly labeled
• Improper preparation for test
• Medication
• Improper timing of test
• Collection incomplete or improper
• Improper handling or storage
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Continue..
• Poor accuracy or precision
• Technical
• Sex
• Age
• Pregnancy
• Posture
• Exercise
• Normal physiologic fluctuations
• Medical procedures
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Blood Chemistry Reference Values Electrolytes
• Sodium (135–145mmol/L )
Low sodium is usually caused by excess water (e.g.,↑ serum antidiuretic hormone) and is treated with water restriction.
↑in severe dehydration, diabetes insipidus, significant renal and GI losses.
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• Potassium (3.5–5mmol/L)
↑with renal dysfunction, acidosis, K-sparing diuretics, hemolysis, burns, crush injuries.
↓by diuretics, alkalosis, severe vomiting and diarrhea, heavy NG suctioning.
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• CO2 (22–28mmol/L)
• Sum of HCO3– and dissolved CO2.
• Reflects acid–base balance and compensatory pulmonary (CO2) and renal (HCO3–) mechanisms.
• Primarily reflects HCO3–.
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• Chloride (95–105mmol/L)
Important for acid–base balance.
↓by GI loss of chloride-rich fluid (vomiting, diarrhea, GI suction, intestinal fistulas, over diuresis).
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• BUN (2.8–7.1mmol/L)
End product of protein metabolism, produced by liver, transported in blood, excreted renally.
↑in renal dysfunction, high protein intake, upper GI bleeding, volume contraction
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• Creatinine (0.6–1.2mg/dL)
Major constituent of muscle; affected by muscle mass(lower with aging); excreted renally.
↑in renal dysfunction. Used as a primary marker for renal function(GFR).
• CrCl (90–130mL/min)
Reflects GFR; ↓in renal dysfunction. Used to adjust dosage of renally eliminated drugs
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• Glucose(fasting)( 70–99mg/dL)
↑in diabetes or by adrenal corticosteroids
• Glycosylated hemoglobin HA1c (<4–5.6% )
Used to assess average blood glucose during 1–3 months. Helpful for monitoring chronic blood glucose control in patients with diabetes.
Values >8% seen in patients with poor glucose control.
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• Calcium—total (8.5–10.5mg/dL)
Regulated by body skeleton redistribution, parathyroid hormone, vitamin D, calcitonin.
Affected by changes in albumin concentration.
↓ by hypothyroidism, loop diuretics, vitamin D deficiency;
↑ in malignancy and hyperthyroidism
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• Calcium—unbound (4.5–5.6mg/dL)
Physiologically active form.
Unbound “free” calcium remains unchanged as albumin fluctuates.
Total calcium ↓ when albumin ↓.
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• Magnesium (1.5–2.4mEq/L)
↓ in malabsorption, severe diarrhea, alcoholism, pancreatitis, diuretics, hyper aldosteronism (symptoms of weakness, depression, agitation, seizures, hypokalemia, arrhythmias).
↑ in renal failure, hypothyroidism, magnesium-containing antacids
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• Phosphate (2.5–4.5mg/dL)
↑ with renal dysfunction, hyper vitaminosis D , hypocalcemia, hyperparathyroidism.
↓ with excess aluminum antacids, malabsorption, renal losses, hypercalcemia, refeeding syndrome
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• Uric acid (<7mg/dL)
↑ in gout, neoplastic, or myeloproliferative disorders
Drugs increase uric acid
• Diuretics
• Niacin
• low-dose aspirin
• cyclosporine
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Proteins
• Prealbumin (15–36mg/dL)
Indicates acute changes in nutritional status, useful for monitoring TPN
• Globulin (2.3–3.5g/dL)
Active role in immunologic mechanisms. Immunoglobulins ↑ in chronic infection, rheumatoid arthritis, multiple myeloma
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• Albumin (3.3–4.8g/dL)
Produced in liver; important for intravascular osmotic pressure.
↓ in liver disease, malnutrition, ascites, hemorrhage, protein-wasting nephropathy.
May influence highly protein-bound drugs (↑free drug)
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Cardiac Markers
• CK (<150units/L)
In tissues that use high energy (skeletal muscle, myocardium, brain).
↑ by IM injections, MI, acute psychotic episodes.
Isoenzyme
CK-MM in skeletal muscle
CK-MB in myocardium
CK-BB in brain.
MB fraction >5%–6% suggests acute MI.
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• LDH lactate dehydrogenase (<200units/L)
High in heart, kidney, liver, and skeletal muscle.
Five isoenzymes:
LD1 and LD2 mostly in heart, LD5 mostly in liver and skeletal muscle, LD3 and LD4 are nonspecific.
↑in malignancy, extensive burns, PE, renal disease
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• BNP blood natriuretic peptide (<100pg/mL )
BNP >500ng/L indicates left ventricular dysfunction.
Released from heart with ↑ work load placed on heart (e.g., CHF).
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• CRP C-reactive protein (0–1.6mg/dL)
Nonspecific indicator of acute inflammation. Similar to ESR, but more rapid onset and greater elevation.
CRP >3mg/dL increases risk of cardiovascular disease.
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Liver Function
• Aspartate aminotransferase AST (0–35units/L)
Large amounts in heart and liver; moderate amounts in muscle, kidney, and pancreas.
↑ with MI and liver injury. Less liver specific than ALT.
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• Alanine aminotransferase ALT (0–35units/L)
From heart, liver, muscle, kidney, pancreas.
↑ indicates parenchymal liver disease.
More liver specific than AST
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• Alkaline phosphatase ALP (30–120units/L)
Large amounts in bile ducts, placenta, bone.
↑ in bile duct obstruction, obstructive liver disease, rapid bone growth (e.g., Paget disease), pregnancy.
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• Bilirubin—total (0.1–1mg/dL)
Break down product of hemoglobin, bound to albumin, conjugated in liver. Total bilirubin includes direct (conjugated) and indirect bilirubin.
↑ with hemolysis, cholestasis, liver injury.
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Miscellaneous
• PSA (0–4ng/mL)
↑ in benign prostatic hypertrophy (BPH) and also in prostate cancer.
PSA levels of 4–10ng/mL should be worked up.
Risk of prostate cancer increased if free PSA/total PSA <0.25.
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• TSH (0.4–5 μunits/mL)
↑ TSH in primary hypothyroidism requires exogenous thyroid supplementation.
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• Procalcitonin (<0.5ng/mL)
↑ with bacterial infections
Low risk of sepsis if <0.5ng/mL;
High risk of severe sepsis if >2.0ng/mL.
May assist in when to start/stop antibiotic therapy