PART I SOURCE AND COMPOSITION OF BLOOD

Basic Principles and Practice of Clinical Chemistrv I 1

1 Basic Principles and Practices I 3 Eileen Carreiro-Lewando wski

UNITS OF MEASURE / 3 Electronic Reporting of Results 15

REAGENTS / 5 Chemicals / 5 Reference Materials 1 6 Water Specifications 1 6 Solution Properties / 7

rLINICAL LABORATORY SUPPLIES / 9 Thermometersflemperature / 9 Glassware and Plasticware 1 10 Desiccators and Desiccants 1 16 Balances / I 7

BASIC SEPARATION TECHNIQUES 1 18 Centrifugation / 18 Filtration / I 9 Dialysis / 19

LABORATORY MATHEMATICS AND CALCULATIONS / 19 Significant Figures / 19 Logarithms I 2 0 Concentration I 2 0 Dilutions / 23 Water of Hydration / 26 Graphing and Beer's Law I 2 6

SPECIMEN CONSIDERATIONS / 28 Types of Samples / 28 Sample Processing 130 Sample Variables 1 30 Chain of Custody / 31

Phlebotomy and Specimen Considerations 1 33 Ruth E. McCall, Cathee M. Tankersley

BLOOD COLLECTION PERSONNEL / 33 PUBLIC RELATIONS AND CLIENT INTERACTION I 3 4

Professionalism / 34 Patient Consent I 3 4 Confidentiality and the Health Insurance Portability

and Accountability Act / 35 LEGAL ISSUES / 35 INFECTION CONTROL / 35 THE VASCULAR SYSTEM I 3 9 PHLEBOTOMY-RELATED VASCULAR ANATOMY / 39

H Pattern Veins / 40 M Pattern Veins I 4 0 Other Veins I 4 1

SPECIMENS / 41 TYPES OF BLOOD SPECIMENS I 4 1 VENIPUNCTURE EQUIPMENT / 41

Tourniquet I 4 1 Needles / 41 Evacuated Tube System I 4 2 Syringe System 144 Butterfly System I 4 4 Tube Addltlves 144 Trace Element-Free Tubes I 4 6

ORDER OF DRAW AND ADDITIVE CARRY-OVER / 46

VENIPUNCTURE PROCEDURES / 47 Troubleshooting Failed Venipuncture I 4 7 Multiple Venipuncture Attempts / 60

PEDIATRIC VENIPUNCTURE / 60 Interacting with a Child I 6 0 Immobilizing a Child / 61 Pediatric Venipuncture Equipment / 61

GERIATRIC VENIPUNCTURE / 61 QUALITY ASSURANCE IN PHLEBOTOMY I 6 1 PREANALYTIC CONSIDERATIONS I 6 2

Problem Sites I 6 2 Vascular-Access Devices / 62 Procedural Error Risks / 62 Patient Conditions and Complications / 63

CAPILLARY SPECIMEN COLLECTION / 64 Alcohol, Gauze, Bandages / 64 Lancets / 64 Warming Devices I 6 4 Microcollection Tubes / 64 Microhematocrit Tubes / 65 Sealants / 65 Capillary Order of Draw I 6 5 Indications for Capillary Puncture 165

CAPILLARY PUNCTURE PROCEDURES / 65 Neonatal Bilirubin Collection / 70 Neonatal Screening I 7 0

SPECIMEN HANDLING AND PROCESSING / 71 Routine Handling / 71 Special Handling / 71

SPECIMEN PROCESSING / 71 Processing Safety I 7 2 Specimen Suitability / 72 Centrifugation I 7 2 Stopper Removal / 72 Aliquot Preparation / 72

3 Laboratory Safety and Regulations 1 74 Tolmie E. Wachter LABORATORY SAFETY AND REGULATIONS 1 74

Occupational Safety and Health Act (OSHA) I 7 4 Other Regulations and Gurdelrnes I 7 5

CONTENTS

SAFETY AWARENESS FOR CLINICAL LABORATORY PERSONNEL / 76 Safety Responsibility / 76 Signage and Labeling / 76

SAFETY EQUIPMENT / 76 Chemical Fume Hoods and Biosafety Cabinets / 76 Chemical Storage Equipment 177 Personal Protective Equipment 177

BIOLOGIC SAFETY / 78 General Considerations / 78 Spills / 78 Bloodborne Pathogens / 79 Airborne Pathogens 179 Shipping / 79

CHEMICAL SAFETY 179 Hazard Communication 179 Material Safety Data Sheet 179 OSHA Laboratory Standard / 80 Toxic Effects from Hazardous Substances / 80 Storage and Handling of Chemicals / 80

RADIATION SAFETY / 81 Environmental Protection / 81 Personal Protection 182 Nonionizing Radiation 182

FIRE SAFETY / 82 The Chemistry of Fire 182 Classification of Fires / 82 Types and Applications of Fire Extinguishers 183

CONTROL OF OTHER HAZARDS / 83 Electrical Hazards 183 Compressed Gases Hazards 1 84 Cryogenic Materials Hazards / 84 Mechanical Hazards 184 Ergonomic Hazards 184

DISPOSAL OF HAZARDOUS MATERIALS / 84 Chemical Waste / 85 Radioactive Waste / 85 Biohazardous Waste 185

ACCIDENT DOCUMENTATION AND INVESTIGATION / 85

4 Method Evaluation and Quality Management 188 5 Christopher R. McCudden, Mike Rogers, Jordan Erickson, Ronald Erickson, Monte 5. Willis

BASIC CONCEPTS 189 Descriptive Statistics: Measures of Center, Spread,

and Shape / 89 Descriptive Statistics of Groups of Paired

Observations / 92 Inferential Statistics / 95

REFERENCE INTERVAL STUDIES I 9 5 Establishing Reference Intervals / 97 Selection of Reference Interval Study Individuals / 97 Preanalytic and Analytic Considerations / 98 Determining Whether to Establish or Verlfy

Reference Intervals / 99 Analysls of Reference Values / 99 Data Analysis to Establ~sh a Reference Interval 199

Data Analysis to Verify a Reference Interval (Transference) / 99

DIAGNOSTIC EFFICIENCY / 101 Measures of Diagnostic Efficiency / 102

METHOD EVALUATION / 108 Regulatory Aspects of Method Evaluation

(Alphabet Soup) / 108 Method Selection 1 109 Method Evaluation / 109 First Things First: Determine lmprecision and

Inaccuracy / 1 10 Measurement of Imprecision / I 10 Measurement of Inaccuracy / 1 12 Recovery Studies / 1 12 Interference Studies / I I 2 Comparison-of-Methods Studies / I I 3 Allowable Analytic Error / 1 15

QUALITY CONTROL / 1 16 Quality Control (QC) Control Charts / 117 Operation of a Quality Control System / 11 7 Multi-Rules RULE! / 1 18 Proficiency Testing / 1 19

QUALITY MANAGEMENT / 120 Quality Improvement: Lean Six Sigma / 121 Improvement Methodology-DMAIC / 122 Metrics-Lean and Six Sigma / 123 Perspective: Patient Safety, Lean Six Sigma, and the

Laboratory 1 124 Practical Application of Six Sigma Metrics / 125

PRACTICE PROBLEMS / 126 Problem 4-1. Calculation of Sensitivity and

Specificity / 126 Problem 4-2. A Management Decision in Quality

Control / 126 Problem 4-3. Interdepartmental Communication / 126 Problem 4-4. Precision (Replication) / 127 Problem 4-5. Recovery / 127 Problem 4-6. Interference / 127 Problem 4-7. Sample Labeling / 127 Problem 4-8. QC Program for POCT Testing / 127 Problem 4-9. QC Rule Interpretation / 127

Analytical Techniques 1 i 30 Julia C. Drees, Alan H. B. Wu

SPECTROPHOTOMETRY AND PHOTOMETRY / 130 Beer's Law / 13 1 Spectrophotometric Instruments / 133 Components of a Spectrophotometer / 133 Spectrophotometer Quality Assurance / 136 Atomic Absorption Spectrophotometer / 136 Flame Photometry / 138 Fluorometry / 138 Chemiluminescence / 140 Turbidity and Nephelometry / 140 Laser Applications / 141

ELECTROCHEMISTRY / 141 Galvanic and Electrolytic Cells 1 141 Half-Cells / 141 Ion-Selective Electrodes / 142

CONTENTS xiii

pH Electrodes / 142 Gas-Senslng Electrodes / 144 Enzyme Electrodes / 145 Coulometric Chloridometers and Anodic Stripping

Voltametry / 145 ELECTROPHORESIS / 145

Procedure / 145 Support Materials / 146 Treatment and Application of Sample / 146 Detection and Quantitation / 147 Electroendosmosls / 147 lsoelectric Focuslng / 147 Capillary Electrophoresis / 147

CHROMATOGRAPHY / 147 Modes of Separation / 148 Chromatographic Procedures / 149 High-Performance Liquid Chromatography / 150 Gas Chromatography / 152

MASS SPECTROMETRY / 154 Sample Introduction and lonizatlon / 154 Mass Analyzer 1 156 Detector I 158 Applications of Mass Spectrometry In the Clinical

Laboratory / 158 INSTRUMENTATION FOR PROTEOMICS / 159

Two-d~mensional Electrophoresis / 159 MALDI-TOF and SELDI-TOF Mass Spectrometry 1 159

OSMOMETRY / 160 Freezing-Point Osmometer 1 160

ANALYTIC TECHNIQUES FOR POINT-OF-CARE TESTING / 163

'3 Mncipier of Clinical Chemistry Automation I 66 William L. Roberts HISTORY OF AUTOMATED ANALYZERS / 166 DRIVING FORCES TOWARD MORE

AUTOMATION / 167 BASIC APPROACHES TO AUTOMATION / 168 STEPS IN AUTOMATED ANALYSIS 1 168

Specimen Preparation and Identification / 170 Specimen Measurement and Delivery / 170 Reagent Systems and Delivery / 174 Chemlcal Reaction Phase / 174 Measurement Phase / 176 Signal Processing and Data Handllng 1 178

SELECTION OF AUTOMATED ANALYZERS / 179 TOTAL LABORATORY AUTOMATION 1 180

Preanalytic Phase (Sample Processing) / 180 Analytic Phase (Chemical Analyses) / 181 Postanalyt~c Phase (Data Management) / 182

FUTURE TRENDS IN AUTOMATION / 183

7 Immunoassays 1 18s Susan Orton

IMMUNOASSAYS / 185 General Considerations / 185 Unlabeled Immunoassays / 186 Labeled Immunoassays / 190

8 Molecular Theory and Techniques 1 202 Susan Orton NUCLEIC ACID-BASED TECHNIQUES I202

Nucleic Acid Chemistry / 202 Hybridization Techniques / 203 DNA Sequencing I 205 DNA Chip Technology / 206 Target Amplification / 206 Probe Amplification / 208 Signal Amplification / 208 Nucleic Acid Probe Applications / 209

9 Point-of-Care Testing / 21 I Elizabeth E. Porter ADMINISTRATION AND STRUCTURE / 21 1

CLlA License and Regulation / 21 1 Support Staff 1 21 3 Standardization / 21 5 Oversight Structure / 2 15

COMMUNICATION / 2 1 5 Handling a Request for New or Additional Point-

of-Care Testing / 21 5 Preliminary Selection of DevicesIMethods / 21 6 Validation / 21 6 Contract Negotiation / 2 16 Implementation / 2 16

PROFICIENCY TESTING / 2 18 POINT-OF-CARE APPLICATIONS /218

Point-of-Care Glucose /218 Point-of-Care Chemistries and Blood Gases / 21 8 Point-of-Care Coagulation / 21 9 Point-of-Care Hematology / 21 9 Point-of-Care Connectivity / 2 19

PART 2

Clinical Correlations and Analytic Procedures 1 221

10 Amino Acids and Proteins 1 223 Lynda L. Tymchak

AMINO ACIDS / 223 Overview / 223 Basic Structure / 223 Metabolism / 224 Essential Amino Acids / 224 Nonessential Ammo Aclds / 226 Two New Amino Acids? I 227 Aminoac~dopathies / 227 Ammo Acid Analysls / 233

PROTEINS I 233 Importance I233 Molecular Slze / 233 Synthesis I 233 Catabolism and Nitrogen Balance / 235 Structure / 235 Nitrogen Content / 236

CONTENTS

Charge and lsoelectric Point 1236 Solubility 1236 Classification 1237

PLASMA PROTEINS 1 238 Prealburnin (Transthyretin) I 238 Albumin 1 238 Globulins 1240

OTHER PROTEINS OF IMPORTANCE / 247 Myoglobin I 247 Troponin (cTn) / 248 Brain Natriuretic Peptide and N-Terminal-Brain

Natriuretic Peptide / 248 Fibronectin 1 248 Adiponectin 1249 @-Trace Protein 1 249 Cross-Linked C-Telopeptides 1249 Cystatin C 1249 Arnyloid 1249

TOTAL PROTEIN ABNORMALITIES 1250 Hypoproteinernia 1 250 Hyperproteinernia 1 250

METHODS OF ANALYSIS 1 252 Total Nitrogen 1252 Total Proteins / 252 Fractionation, Identification,and Quantitation of

Specific Proteins / 253 Serum Protein Electrophoresis I 256 High-Resolution Protein Electrophoresis / 258 Capillary Electrophoresis 1 258 lsoelectric Focusing 1259 lrnmunochernical Methods / 259

PROTEINS IN OTHER BODY FLUIDS I 259 Urinary Protein 1 260 Cerebrospinal Fluid Proteins I 262

11 Nonprotein Nitrogen Compounds I 266 Elizabeth L. Frank UREA 1266

Introduction 1266 Physiology I 267 Clinical Application 1267 Methods 1 267 Specimen Requirements and lnterfering

Substances I 268 Reference Intervals I 268 Pathophysiology I 268

URIC ACID 1 270 Introduction 1 270 Physiology 1 270 Clinical Application 1 270 Methods I 270 Specimen Requirements and lnterfering

Substances / 27 1 Reference Intervals / 271 Pathophyslology I 272

CREATININEICREATINE 1 273 Introduction 1 273 Physiology I 273

Cllnical Application 1273 Methods 1 274 Specimen Requirements and lnterfering

Substances I 275 Sources of Error I 275 Reference Intervals 1275 Pathophysiology I 276

AMMONIA I 277 Introduction 1277 Physiology I 277 Clinical Applications 1 277 Methods I 278 Specimen Requirements and lnterfering

Substances 1 278 Sources of Error I 279 Reference Interval / 279 Pathophysiology I 279

Enzymes 1281 Kamisha Johnson-Davis, Gwen A. McMi//in GENERAL PROPERTIES AND DEFINITIONS 1281 ENZYME CLASSIFICATION AND

NOMENCLATURE 1283 ENZYME KINETICS 1283

Catalyt~c Mechanism of Enzymes I 283 Factors That Influence Enzymatic Reactions / 284 Measurement of Enzyme Activity I 286 Calculat~on of Enzyme Activity I 287 Measurement of Enzyme Mass I 288 Enzymes as Reagents I 288

ENZYMES OF CLINICAL SIGNIFICANCE 1288 Creatine Klnase I 288 Lactate Dehydrogenase I 293 Aspartate Aminotransferase 1296 Alanine Arninotransferase 1296 Alkaline Phosphatase 1297 Acid Phosphatase I 299 y-Glutamyltransferase 1 300 Amylase / 301 Lipase 1303 Glucose-6-Phosphate Dehydrogenase I 304 Drug-Metabolizing Enzymes 1 305

13 Carbohydrates 1 309 Vicki 5. Freeman GENERAL DESCRIPTION OF CARBOHYDRATES I 309

Classification of Carbohydrates / 309 Stereoisomers I 3 10 Monosaccharides, Disaccharides, and

Polysaccharides I 31 0 Chemical Properties of Carbohydrates 131 1 Glucose Metabolism / 31 1 Fate of Glucose 131 1 Regulation of Carbohydrate Metabolism I 3 13

HYPERGLYCEMIA / 3 14 Diabetes Mellitus 1314 Pathophysiology of Diabetes Mellitus 1 3 16

CONTENTS

Criteria for Testing for Prediabetes ano Diabetes / 3 17

Criteria for the Diagnosis of Diabetes Mellitus / 318 Criteria for the Testing and Diagnosis of

Gestational Diabetes Mellitus / 31 9 HYPOGLYCEMIA / 320

Genetic Defects in Carbohydrate Metabolism / 321 ROLE OF LABORATORY IN DIFFERENTIAL

DIAGNOSIS AND MANAGEMENT OF PATIENTS WITH GLUCOSE METABOLIC ALTERATIONS / 321 Methods of Glucose Measurement / 321 Self-Monitoring of Blood Glucose / 323 Glucose Tolerance and 2-Hour Postprandial

Tests / 323 Glycosylated Hemoglobin/Hemoglobin Alc / 324 Ketones / 326 Microalbuminuria / 326 Islet Autoantibody and Insulin Testing / 327

14 Lipids and Lipoproteins I 328 Amar A. Sethi, G. Russell Warnick, Alan T. Remaley

LlPlD CHEMISTRY / 329 Fatty Acids / 329 Triglycerides / 330 Phospholipids / 330 Cholesterol / 330

GENERAL LIPOPROTEIN STRUCTURE / 33 1 Chylomicrons / 332 Very Low Density Lipoproteins / 333 Low-Density Lipoproteins / 333 Lipoprotein(a) / 333 High-Density Lipoproteins / 333

LIPOPROTEIN PHYSIOLOGY AND METABOLISM / 333 Lipid Absorption / 334 Exogenous Pathway / 334 Endogenous Pathway / 335 Reverse Cholesterol Transport Pathway / 335

LlPlD AND LIPOPROTEIN POPULATION DISTRIBUTIONS / 336

DIAGNOSIS AND TREATMENT OF LlPlD DISORDERS / 339 Arteriosclerosis / 339 Hyperlipoproteinemia / 341 Hypercholesterolemia / 341 Hypertriglyceridemia / 342 Combined Hyperlipoproteinemia / 343 Lipoprotein(a) Elevation / 343 Hypolipoproteinemia / 344 Hypoalphalipoproteinemia / 344

LlPlD AND LIPOPROTEIN ANALYSES / 344 Lipid Measurement / 344 Cholesterol Measurement / 344 Triglyceride Measurement / 345 Lipoprotein Methods / 346 High-Density Lipoprotein Methods / 347 Low-Density Lipoprotein Methods / 348

Compact Analyzers / 349 Apolipoprotein Methods / 349 Phospholipid Measurement / 349 Fatty Acid Measurement / 349

STANDARDIZATION OF LlPlD AND LIPOPROTEIN ASSAYS / 349 Precision / 349 Accuracy / 350 Matrix Interactions / 350 CDC Cholesterol Reference Method Laboratory

Network / 351 Analytic Performance Goals / 351 Quality Control / 351 Specimen Collection / 351

15 Electrolytes / 356 Joan E. Polancic

WATER / 356 Osmolality / 357

THE ELECTROLYTES / 359 Sodium / 359 Potassium / 363 Chloride / 366 Bicarbonate / 368 Magnesium / 369 Calcium / 373 Phosphate / 376 Lactate I378

ANION GAP / 380 ELECTROLYTES AND RENAL FUNCTION / 381

16 Blood Gases, pH, and Buffer Systems / 384 Sharon 5. Ehrmeyer, Ronald H. Laessig, John I. Ancy

DEFINITIONS: ACID, BASE, BUFFER / 384 ACID-BASE BALANCE / 385

Maintenance of H' / 385 Buffer Systems: Regulation of H' / 385 Regulation of Acid-Base Balance: Lungs and

Kidneys / 385 ASSESSMENT OF ACID-BASE HOMEOSTASIS / 388

The Bicarbonate Buffering System and the Henderson-Hasselbalch Equation / 388

Acid-Base Disorders: Acidosis and Alkalosis / 389 OXYGEN AND GAS EXCHANGE / 390

Oxygen and Carbon Dioxide / 390 Oxygen Transport / 392 Quantities Associated With Assessing a Patient's

Oxygen Status / 392 Hemoglobin-Oxygen Dissociation / 393

MEASUREMENT / 394 Spectrophotometric (Cooximeter) Determination of

Oxygen Saturation / 394 Blood Gas Analyzers: pH, pCOz, and p02 / 395 Measurement of p02 / 395 Measurement of pH and pCOz / 396 Types of Electrochemical Sensors / 397

CONTENTS

Optical Sensors / 397 Callbration / 398 Calculated Parameters / 398 Correction for Temperature / 398

QUALITY ASSURANCE / 398 Preanalytic Considerations / 398 Analytic Assessments: Quality Control and

Proficiency Testing / 401 Interpretation of Results / 402

17 Trace Elements 1 403 Alan L. Rockwood, Elzbieta (Ela) Bakowska INSTRUMENTATION AND METHODS 1404

Sample Collection and Processing I 4 0 4 Atomic Emisslon Spectroscopy / 404 Atomic Absorpt~on Spectroscopy / 405 Inductively Coupled Plasma Mass

Spectrometry / 406 Interferences / 407 Elemental Speclation I 4 0 8 Alternative Analytic Techniques 1408

ARSENIC / 409 Health Effects / 409 Absorption, Transport, and Excretion / 409 Toxicity / 409 Laboratory Evaluation of Arsenic Status / 41 0

CADMIUM / 410 Health Effects / 41 0 Absorption, Transport, and Excretlon I 4 1 0 Toxicity / 41 1 Laboratory Evaluation of Cadmium Status / 41 l

LEAD / 41 1 Health Effects / 41 1 Absorption, Transport, and Excretlon I 4 1 1 Toxicity / 41 1 Laboratory Evaluation of Lead Status / 412

MERCURY / 41 2 Health Effects / 41 2 Absorption, Transport, and Excretion / 41 2 Toxlcity / 41 3 Laboratory Evaluation of Mercury Status / 41 3

CHROMIUM / 41 3 Health Effects / 41 3 Absorption, Transport, and Excretion / 41 4 Deficiency / 414 Toxicity I 41 4 Laboratory Evaluat~on of Chromium Status I414

COPPER / 41 4 Health Effects I 4 1 5 Absorption, Transport, and Excretion / 41 5 Deficiency 141 5 Toxiclty / 41 5 Laboratory Evaluation of Copper Status / 41 5

IRON / 41 6 Health Effects / 41 6 Absorption, Transport, and Excretion I 4 1 6 Deficiency / 41 6 Toxicity / 41 6 Laboratory Evaluat~on of lron / 41 7 Total iron Content (Serum lron) I 4 1 7

Total Iron-Blnding Capaclty / 41 7 Percent Saturation / 41 7 Transferrin and Ferritin I 4 1 7

MANGANESE / 41 8 Health Effects / 41 9 Absorption, Transport, and Excretion I 4 1 9 Deficiency / 41 9 Toxicity / 41 9 Laboratory Evaluat~on of Manganese Status / 41 9

MOLYBDENUM I 4 1 9 Health Effects / 41 9 Absorption, Transport, and Excretlon I 4 1 9 Deficlency I 4 1 9 Toxiclty / 41 9 Laboratory Evaluation of Molybdenum Status I 4 1 9

SELENIUM I 4 2 0 Health Effects I 4 2 0 Absorption, Transport, and Excretion / 420 Deficiency / 420 Toxicity I 420 Laboratory Evaluat~on of Selenium Status I 421

ZINC / 42 1 Health Effects / 42 1 Absorption, Transport, and Excretion / 421 Deficlency / 421 Toxicity / 42 1 Laboratory Evaluation of Zinc Status / 421

18 Porphyrins and Hemoglobin 1 424 Louann W. Lawrence, Larry A. Broussard PORPHYRINS I 4 2 4

Role in the Body 1424 Chemistry of Porphyrins / 424 Porphyrin Synthesis I425 Clinical Significance and Disease Correlation / 425 Methods of Analyzing Porphyrins / 428

HEMOGLOBIN I 4 3 0 Role in the Body 1430 Structure of Hemoglobin / 430 Synthesis and Degradation of Hemoglobin / 431 Clinlcal Significance and Disease Correlation 1437 Methodology / 437 DNA Technology 1439

MYOGLOBIN / 440 Structure and Role in the Body 1440 Clinical Significance 1440 Methodology / 441

PART 3

Assessment of Organ System Functions I 443

19 Introduction to Hormones and Pituitary Function 1445 Robert E. Jones EMBRYOLOGY AND ANATOMY I445 FUNCTIONAL ASPECTS OF THE HYPOTHALAMIC-

HYPOPHYSIAL UNIT / 446

CONTENTS

HYPOPHYSIOTROPIC OR HYPOTHALAMIC HORMONES 1447

ANTERIOR PITUITARY HORMONES 1448 PITUITARY TUMORS 1448 GROWTH HORMONE I 449

Actions of Growth Hormone I 4 4 9 Testing 1450 Acromegaly / 450 Growth Hormone Deficiency 1451

PROLACTIN I 451 Prolactinoma 1452 Other Causes of Hyperprolactinemia 1452 Clinical Evaluation of Hyperprolactinemia 1452 Management of Prolactinoma 1452 Idiopathic Galactorrhea 1 453

HYPOPITUITARISM 1453 Etiology of Hypopituitarism 1454 Treatment of Panhypopituitarism 1 454

POSTERIOR PITUITARY HORMONES 1454 Oxytocin 1 455 Vasopressin 1455

20 Adrenal Function 1458 Ryan Hungerford, A. Wayne Meikle THE ADRENAL GLAND: AN OVERVIEW I 4 5 8 EMBRYOLOGY AND ANATOMY I 4 5 8 THE ADRENAL CORTEX BY ZONE / 459

Cortex Steroidogenesis / 459 Congenital Adrenal Hyperplasia 1461

DIAGNOSIS OF PRIMARY ALDOSTERONISM 1 462 Diagnosis Algorithm 1463

ADRENAL CORTICAL PHYSIOLOGY / 463 ADRENAL INSUFFICIENCY (ADDISON'S

DISEASE) 1463 Diagnosis of Adrenal Insufficiency 1464 Treatment of Adrenal lnsufficiency 1465

HYPERCORTISOLISM I 465 CUSHING'S SYNDROME I 465

When Endogenous Cushing's Syndrome Is Confirmed 1 465

Pituitary versus Ectopic Adrenocorticotropic Hormone Secretion 1 466

Adrenocorticotropic Hormone Source in Dexamethasone Nonsuppression Adrenocorticotropic Hormone Secretion 1 466

Inferior Petrosal Sinus Sampling 1466 Diagnosis of Cushing's Syndrome 1 466 When Cushing's Syndrome Is Confirmed,

Corticotropin-Releasing Hormone Stimulation Tests Help Determine Adrenocorticotropic Hormone Dependency (Typically Not Necessary) 1467

Localization Procedures 1 468 Algorithm for Cushing's Syndrome

Workup / 469 Treatment 1469

ANDROGEN EXCESS 1469 Diagnosis of Excess Androgen Production 1470 Treatment for Adrenal Androgen

Overproduction / 470

THE ADRENAL MEDULLA 1470 Development 1470 Biosynthesis and Storage of Catecholamines 1 471 Catecholamine Degradat~on / 471 Urine and Plasma Catecholamlne

Measurements 1 471 Causes of Sympathetic Hyperactivity 1472 Diagnosis of Pheochromocytoma 1 473 Treatment of Pheochromocytoma / 474 Outcome and Prognosis 1474

ADRENAL "INCIDENTALOMA" I 474

21 Gonadal Function / 477 Marissa Grotzke THE TESTES 1 477

Functional Anatomy of the Male Reproductive Tract 1 477

Physiology of the Testicles 1477 Disorders of Sexual Development and Testicular

Hypofunction 1 479 Diagnosis of Hypogonadism 1 480 Testosterone Replacement Therapy I 480 Monitoring Testosterone Replacement

Therapy 1 481 THE OVARIES I 481 Functional Anatomy of the Ovarles 1 482 Hormonal Production by the Ovar~es 1482 The Menstrual Cycle 1 482 Hormonal Control of Ovulation 1483 Pubertal Development In the Female 1483 Menstrual Cycle Abnormalities 1483 H~rsutlsm 1487 Estrogen Replacement Therapy 1 488

22 The Thyroid Gland 1490 Marissa Grotzke THE THYROID / 490

Thyroid Anatomy and Development 1490 Thyroid Hormone Synthesis 1490 Protein Binding of Thyroid Hormone / 492 Control of Thyroid Function / 492 Actions of Thyroid Hormone / 492

TESTS FOR THYROID EVALUATION 1 493 Blood Tests / 493

OTHER TOOLS FOR THYROID EVALUATION / 494 Nuclear Medicine Evaluation 1494 Thyroid Ultrasound 1495 Fine-Needle Aspiration 1495

DISORDERS OF THE THYROID / 495 Hypothyroidism 1495 Thyrotoxicosis 1496 Graves' Disease / 497 Toxic Adenoma and Multinodular

Goiter I 498 DRUG-INDUCED THYROID DYSFUNCTION / 498

Amiodarone-Induced Thyroid Disease / 498 Subacute Thyroiditis 1499

NONTHYROIDAL ILLNESS I 499 THYROID NODULES / 499

xviii CONTENTS

23 Calcium Homeostasis and Hormonal Regulation 1 501 Thomas P Knecht, Ryan Hungerford

CALCIUM HOMEOSTASIS 1 501 HORMONAL CONTROL OF CALCIUM

METABOLISM I 501 Vitamin D 1502 Parathyroid Hormone I 503

ORGAN PHYSIOLOGY AND CALCIUM METABOLISM 1504 Gastrointestinal Physiology / 504 Renal Physiology 1504 Bone Physiology I 5 0 4

HYPERCALCEMIA I 505 Signs and Symptoms of Hypercalcemia 1 505 Causes of Hypercalcemia I 505 Endocrine Causes of Hypercalcemia 1 505 Organ System Causes of Hypercalcemia / 507 Medications That Can Cause

Hypercalcemia 1508 HYPOCALCEMIA I 508

Signs and Symptoms of Hypocalcemia 1508 Causes of Hypocalcemia I 509 Endocrine Causes of Hypocalcemia / 509 Organ System Causes of Hypocalcemia 1510 Medications That Affect Calcium

Metabolism / 5 10 METABOLIC BONE DISEASES / 51 2

Rickets and Osteomalacia / 51 2 Osteoporosis / 5 12

24 Liver Function I 5 I 6 lanelle M. Chiasera, Xin Xu

ANATOMY / 5 16 Gross Anatomy I 5 1 6 Microscopic Anatomy 1 51 7

BIOCHEMICAL FUNCTIONS I 51 8 Excretory and Secretory I 5 18 Synthetic / 5 19 Detoxifrcatlon and Drug Metabollsm 1520

LIVER FUNCTION ALTERATIONS DURING DISEASE 1520 Jaundlce I 520 Crrrhosls / 522 Tumors I 523 Reye Syndrome I 524 Drug- and Alcohol-Related Drsorders 1 524

ASSESSMENT OF LIVER FUNCTIONILIVER FUNCTION TESTS 1525 Bll~rubln 1525 Urobllinogen rn Urrne and Feces I 526 Serum Brie Aclds 1 527 Enzymes I 528 Tests Measurrng Hepatic Synthetic

Ability 1 529 Tests Measuring Nitrogen Metabollsm 1 529 Hepatrtrs I 529

25 Cardiac Function I 541 lanelle M. Chiasera

ANATOMY AND FUNCTION OF THE HEART / 541 Anatomy / 541 Function 1541

PATHOLOGIC CONDITIONS OF THE HEART I 543 Cardiovascular Disease / 543 Congenital Cardiovascular Defects / 544 Heart Failure / 545 Acute Coronary Syndromes I 546 Hypertensive Heart Disease 1 547 Infective Heart Disease I 548

DIAGNOSIS OF HEART DISEASE / 549 Laboratory Diagnosis of Myocardial Infarction / 549 Markers of Inflammation and Coagulation

Disorders 1552 Markers of Congestive Heart Failure I 553 Patient-Focused Cardiac Tests I 554 Role of Laboratory in Monitoring Heart

Disease / 554

26 Renal Function 1557 Kara L. Lynch, Alan H. B. Wu

RENAL ANATOMY / 557 RENAL PHYSIOLOGY 1 558

Glomerular Filtration I 558 Tubular Function 1558 Elimination of Nonprotein Nitrogen Compounds1 561 Water, Electrolyte, and Acid-Base Homeostasis 1 561 Endocrine Function 1563 1,25-Dihydroxy Vitamin D3 1 564

ANALYTIC PROCEDURES / 564 Clearance Measurements I 564 Urine Electrophoresis I 565 p2-Microglobulin 1565 Myoglobin 1 565 Microalbumin I 5 6 6 Urinalysis / 566

PATHOPHYSIOLOGY / 570 Glomerular Diseases 1570 Tubular Diseases 1571 Urinary Tract Infection/Obstruction / 571 Renal Calculi I571 Renal Failure / 572

Pancreatic Function and Gastrointestinal Function 1578 Edward P. Fody

PHYSIOLOGY OF PANCREATIC FUNCTION / 578 DISEASES OF THE PANCREAS / 579 TESTS OF PANCREATIC FUNCTION I 581

Secretin/Cholecystokinin Test 1 581 Fecal Fat Analysls I 582 Sweat Electrolyte Determinations / 583 Serum Enzymes I 583

CONTENTS xix

PHYSIOLOGY AND BIOCHEMISTRY OF GASTRIC SECRETION I 585

CLINICAL ASPECTS OF GASTRIC ANALYSIS 1 586 TESTS OF GASTRIC FUNCTION I 586

Measuring Gastric Acid in Basal and Maximal Secretory Tests / 586

Measuring Gastric Acid 1 586 Plasma Gastrin 1586

INTESTINAL PHYSIOLOGY / 587 CLINICOPATHOLOGIC ASPECTS OF INTESTINAL

FUNCTION 1 587 TESTS OF INTESTINAL FUNCTION / 587

Lactose Tolerance Test / 587 D-Xylose Absorption Test I 587 Serum Carotenoids / 588 Other Tests of Intestinal Malabsorption / 588

28 Body Fluid Analysis 1 591 Susan Strasinger AMNIOTIC FLUID I 59 1

Neural Tube Defects 1 592 Hemolytic Dlsease of the Newborn 1592 Fetal Lung Maturity 1593

PHOSPHADIDYLGLYCEROL I 596 FLUORESCENCE POLARIZATION 1 596

Lamellar Body Counts 1596 CEREBROSPINAL FLUID I 597 SWEAT / 599 SYNOVIAL FLUID I 600 SEROUS FLUIDS 1601

Pleural Fluid 1601 Pericard~al Fluid 1602 Peritoneal Fluid / 602

adecialtv Areas of Clinical Chemistrv~ 603

29 Therapeutic Drug Monitoring 1 605 David P. Thorne, Michelle E. Russell ROUTES OF ADMINISTRATION / 606 ABSORPTION / 606 FREE VERSUS BOUND DRUGS / 606 DRUG DISTRIBUTION 1607 DRUG ELIMINATION / 607

Metabolic Clearance I 609 Renal Clearance I 61 0

PHARMACOKINETICS 1 61 0 SAMPLE COLLECTION 1 61 2 PHARMACOGENOMICS I 61 2 CARDIOACTIVE DRUGS I 61 2

Digoxin I 61 2 Quin~dine / 61 3 Procainamide / 61 3 Dlsopyramide I 614

ANTIBIOTICS / 61 4 Aminoglycosides / 61 4 Vancomycin / 614

ANTIEPILEPTIC DRUGS 1 61 5 First-Generation Antiepileptic Drugs / 61 5 Second-Generation Antiepiletic Drugs /616

PSYCHOACTIVE DRUGS / 61 8 Lithium I 61 8 Tricyclic Antidepressants 1 619 Clozepine / 61 9 Olanzapine / 61 9

IMMUNOSUPPRESSIVE DRUGS I 61 9 Cyclosporine I 61 9 Tacrolimus / 620 Sirolimis 1620 Mycophenolic Acid 1620

ANTINEOPLASTICS I 620 Methotrexate / 621

30 Toxicology 1 622 David P. Thorne, Michelle E. Russell EXPOSURE TO TOXINS 1622 ROUTES OF EXPOSURE / 622 DOSE-RESPONSE RELATIONSHIP 1623

Acute and Chronic Toxicity / 623 ANALYSIS OF TOXIC AGENTS / 624 TOXICOLOGY OF SPECIFIC AGENTS I 624

Alcohol 1 624 Carbon Monoxide / 627 Caustic Agents 1627 Cyanlde 1 627 Metals and Metalloids I 628 Pesticides / 631

TOXICOLOGY OF THERAPEUTIC DRUGS I 631 Salicylates I632 Acetaminophen 1632

TOXICOLOGY OF DRUGS OF ABUSE I633 Amphetamines / 634 Anabolic Steroids / 635 Cannabinoids I 635 Cocaine 1635 Opiates / 636 Phencyclidine 1636 Sedatives-Hypnotics / 636

31 Circulating Tumor Markers: Basic Concepts and Clinical Applications I 637 Christopher R. McCudden, Monte 5. Willis TYPES OF TUMOR MARKERS I637 APPLICATIONS OF TUMOR MARKER

DETECTION / 638 Screening I 640 Prognosis I 640 Monitoring Effectiveness of Therapy and Disease

Recurrence 1642 RECOMMENDATIONS FOR TEST ORDERING I642 METHODS / 642

Immunoassays I 643 High-Performance Liquid Chromatography 1 644

CONTENTS

lmmunohistochemistry / 644 Enzyme Assays 1 644

FREQUENTLY ORDERED TUMOR MARKERS I 645 a-Fetoprotein / 645 Cancer Antigen 125 1 646 Carcinoembryonic Antigen 1 646 Human Chorionic Gonadotropin I 647 Prostate Specific Antigen 1648

32 Nutritional Assessment I 651 Linda 5. Gorman, Maria G. Boosalis NUTRITION CARE PROCESS: OVERVIEW I 651 NUTRITION ASSESSMENT I 651 BIOCHEMICAL MARKERS I 653

Macronutr~ents I 653 CARBOHYDRATES 1 656

Urlne Testlng 1656 Tests to Mon~tor Electrolyte

Disturbances 1656 MICRONUTRIENTS / 656

V~tamlns I 656 Fat-Soluble Vltamlns I 657 Water-Soluble Vrtamlns I 660

MINERAL METABOLISM--CALCIUM/ PHOSPHORUS I 665 Mlneral Tests to Monltor 1665

TRACE MINERALS I 6 6 6 Trace Elements to Monltor 1666

33 Clinical Chemistry and the Geriatric Patient 1673 Betty Wh~te

THE IMPACT OF GERIATRIC PATIENTS ON THE CLINICAL LABORATORY 1 673

THEORIES OF AGING 1674 BIOCHEMICAL AND PHYSIOLOGIC CHANGES OF

AGING / 675 Endocrine Functlon Changes 1676 D~abetes Mellitus and lnsulrn Resistance / 678 Renal Functlon Changes / 679 Hepat~c Funct~on Changes / 679 Pulmonary Functlon and Electrolyte

Changes I 680 Cardrovascular and Llpld Changes / 680 Enzyme Changes I 680

CLINICAL CHEMISTRY RESULTS AND AGING 1 680 Establlshlng Reference Intervals for the

Elderly I 681 Preanalytlc Variables, the Elderly, and Chemlstry

Results / 681 Therapeut~c Drug Mon~tor~ng In the Elderly 1682 Effects of Exerclse and Nutrition on the Elderly and

Chemlstry Results 1 682

34 Clinical Chemistry and the Pediatric Patient 1 685

Dean C. Carlow, Michael I. Bennett

DEVELOPMENTAL CHANGES FROM NEONATE TO ADULT I 685 Respiration and Circulation 1686 Growth I 6 8 6 Organ Development 1686 Problems of Prematurity and Immaturity 1686

PHLEBOTOMY AND CHOICE OF INSTRUMENTA- TION FOR PEDIATRIC SAMPLES I 686 Phlebotomy 1686 Preanalytic Concerns 1687 Choice of Analyzer I 687

POINT-OF-CARE ANALYSIS IN PEDIATRICS I 688 REGULATION OF BLOOD GASES AND pH IN

NEONATES AND INFANTS 1 688 Blood Gas and Acid-Base Measurement / 689

REGULATION OF ELECTROLYTES AND WATER: RENAL FUNCTION I 689 Disorders Affecting Electrolytes and Water

Balance 1 690 DEVELOPMENT OF LIVER FUNCTION 1 691

Physiologic Jaundice I 691 Energy Metabolism / 691 Diabetes 1 692 Nitrogen Metabolism / 692 Nitrogenous End Products as Markers of Renal

Function / 693 Liver Function Tests 1693

CALCIUM AND BONE METABOLISM IN PEDIATRICS I 6 9 3 Hypocalcemia and Hypercalcemia I 693

ENDOCRINE FUNCTION IN PEDIATRICS I 694 Hormone Secretion 1 694 Hypothalamic-Pituitary-Thyroid System / 694 Hypothalamic-Pituitary-Adrenal Cortex System 1695 Growth Factors / 695 Endocrine Control of Sexual Maturation 1696

DEVELOPMENT OF THE IMMUNE SYSTEM 1 696 Basic Concepts of Immunity 1696 Components of the Immune System 1 697 Neonatal and Infant Antibody Production 1698 Immunity Disorders I 698

GENETIC DISEASES 1 698 Cystic Fibrosis I 699 Newborn Screening for Whole Populations I 699 Diagnosis of Metabolic Disease in the Clinical

Setting I 7 0 0 DRUG METABOLISM AND

PHARMACOKINETICS I 701 Therapeutic Drug Monitoring 1701 Toxicologic Issues in Pediatric Clinical Chemistry I 702

Index I 705