Bahan Kuliah Pakar Blok 9 Dewasa & Masa Tua

LABORATORY TEST &

INTERPRETATION

Department/Division of Clinical Pathology Zainoel Abidin Hospital-Medical Faculty University of Syiah Kuala

Banda Aceh 2013

16 Desember 2014

Dr. Vivi Keumala Mutiawati, SpPK., MKes

Blok 9: Dewasa & Masa Tua

MEDICAL CHECK-UP/MCU

Persiapan Pemeriksaan Laboratorium untuk MCU:

1. Puasa selama 12 jam:

dimulai dari malam hari sebelum

pengambilan darah/sampling darah

2. Istirahat yang cukup:

dimulai ketika melaksanakan puasa

3. Tidak merokok

dimulai ketika melaksanakan puasa


Patient Preparation for Laboratory MCU 1. Fasting for 12 hours: Starting from one night before blood sample taken (stop eating after last night dinner at 8 pm) 2. Have enough rest and sleep: Starting same time with fasting 3. No smoking Starting same time with fasting

Laboratory MCU include:

1. Clinical Hematology

2. Clinical Chemistry

3. Urinalisis (Clinical Chemistry)

4. Clinical Immuno-serology


Clinical Hematology

Routine Blood Count

1. Hemoglobin/Hb

2. Hematocrit/Hct

3. Erythrocyte

4. Leucocyte

5. Thrombocyte

Complete Blood Count 1. Hemoglobin/Hb

2. Hematokrit/Hct

3. Erythrocyte

4. Leucocyte

5. Thrombocyte

6. Mean Corpuscular Volume/MCV

7. Mean Corpuscular

Hemoglobine/MCH

8. Mean Cospuscular

Hemoglobin Consentration/MCHC

9. Red Cell Distribution Width/RDW

10. Differential Counting/DC


Pagana KD, Pagana TJ. Mosby’s Diagnostic and Laboratory Test Reference. 9th ed. Mosby Elsevier. 2009.

Complete Blood Count

1. Hemoglobin/Hb

2. Hematokrit/Hct

3. Erythrocyte

4. Leucocyte

5. Thrombocyte


7. Mean Corpuscular

Hemoglobine/MCH

8. Mean Cospuscular

Hemoglobin Consentration/MCHC

9. Red Cell Distribution Width/RDW

10. Differential Counting/DC


Which one are RED BLOOD CELL

INDICES ???


Complete Blood Count Main Function: Provide information about Size (MCV & RDW) Weight (MCH) Concentration (MCHC)

Investigating ANEMIA How to calculate: Necessary need the results of Erythrocyte Hematocrit Hemoglobin

MEDICAL CHECK-UP/MCU RED BLOOD CELL

INDICES



Size (MCV & RDW) indicated the terms NORMOCYTIC : normal erythrocyte MICROCYTIC : smaller than normal MACROCYTIC : larger than normal Additional information Weight (MCH) indicated the terms about: NORMOCRHOMIC : color normal size, shape, color & HYPOCHROMIC : less than normal intracellular HYPERCHROMIC : larger than norma structure describe in Concentration (MCHC) BLOOD CELL SMEAR


INDICES



1. Mean Corpuscular Volume/MCV Hematocrit (%) x 10 = ______________________ Erythrocyte (million/mm3) 2. Mean Corpuscular Hemoglobin/MCH Hemoglobin (gr/dL) x 10 = ______________________ Erythrocyte (million/mm3) 3. Mean Cospuscular Hemoglobin Consentration/MCHC Hemoglobin (gr/dL) x 100 = ______________________ Hematocrit (%)


INDICES




Adult/Elderly/Child : 80-95 fL

Newborn : 96-108 fL

2. Mean Corpuscular Hemoglobine/MCH

Adult/Elderly/Child : 27-31 pg

Newborn : 32-34 pg

3. Mean Cospuscular Hemoglobin Consentration/MCHC

Adult/Elderly/Child : 32-36 gr/dL

Newborn : 32-33 gr/dL


INDICES


NORMOCYTIC NORMOCRHOMIC ANEMIA Iron Deficiency (detected early) Chronic Illnes (e.g: sepsis, tumor) Acute Blood Loss Aplastic Anemia (e.g: chloramphenicol toxicosis) Acquaired Hemolytic Anemia (e.g: from a prosthetic cardiac valve)

MYCROCYTIC HYPOCROMIC ANEMIA Iron Deficiency Anemia (late detection) Thalassemia Lead Poisoning

MYCROCYTIC NORMOCHROMIC ANEMIA Renal Disease (because of the loss of erythropoeitin)

MACROCYTIC NORMOCHROMIC ANEMIA Vitamin B12 or Folic Acid Deficiensy Hydantoin Ingestion Chemotherapy Some Myelodysplastic Syndromes Myeloid Leukemia Ethanol Toxicity Thyroid Dysfunction


RED BLOOD CELL/RBC (ERYTHROCYTE)

Normal Erythrocytes • Colour : Red • Shape : Biconcave, with central area of pallor • Size : 6.7-7.7 µm (± 8 µm) • Nucleus : Anucleated cells • Consist : Haemoglobins (Hbs)

IMPORTANT CLINICALLY


http://www.nature.com/leu/journal/v23/n5/images/leu200954f3.jpg

REFFERENCE VALUE OR

NORMAL RANGE

Different in Ages

1 day (Neonates) : 15.2-23.6 gr/dL 2-6 day (Newborn ) : 15.0-24.6 gr/dL 1- 4 weeks : 12.7-18.7 gr/dL 2-7 months : 10.3-12.9 gr/dL 8 months-10 years : 10.5-15.6 gr/dL Adult (Female) : 12.0-16.0 gr/dL Adult (Male) : 14.0-18.0 gr/dL


METHODS

• Manual: Talquis

Sahli

• Analyzer:

Hemocytometer

Autoanalyzer (Flow Cytometry)


= Anemia

• Hemoglobin lower than normal range (different in any of ages).

• Caused by: classified as, Nutritional deficiency Vitamin B12/Folate Blood Loss Hemorrhage Accelerated Destruction of RBCs Immune & Nonimmune hemolysis Bone Marrow Replacement by cancer Infection Toxicity Hematopietic Stem Cell Arrest or

Damaged Hereditary or Acquired Defect • Is a common disease

= Erythrocytosis

(e.g: policythemia)

• Hemoglobin higher than normal range.

• Caused by:

Myeloproliferative Disorders

Splenomegaly

Myeloid metaplasia

Myelofibrosis

• Is a rare disease

INTERPRETATION RED BLOOD CELL/RBC (ERYTHROCYTE)

Relative Erythrocytosis

• The red cell mass is absence,

but the Hematocrit is elevated

• Caused by:

Dehydration

Hypertensive

Obese

Heavy smoking

Extreme Alcohol Consumption

Diuretic Therapy

Absolute Erythrocytosis

• The red cell mass is elevated

• Caused by:

Compensatory Increase in erythropoietin in response to tissue hypoxia

Those resulting from an inappropriate or pathologic secretion of erythropoietin

Those resulting from defective oxygen transport

INTERPRETATION RED BLOOD CELL/RBC (ERYTHROCYTE)

MORPHOLOGY OF

RBC

ABNORMAL MORPHOLOGY OF

RBC

Hypochromic Microcytic

Iron Deficiency Anemia (late detection)

ANEMIA DEFISIENSI FE (berat)

Pencil cell

Tear drops

Mikrosit

RETICULOCYTE (= polychromatic erythrocyte)

One type of NORMOBLASTIC SERIES, Just seen in bone marrow (unusually seen in pheripheral) Morphologic findings, known as: NORMOBLAST Contain : Ribonucleic Acid/RNA Size : 8-10 µm Ratio of Cytoplasm: No nucleus Granules : No granules

RETICULOCYTE

1. Reticulocyte Count

• Also call as: Reticulocyte Index

• Manual

• Reagen

Bryliant Crecil Blue/BCB

• Refference Value

Newborn: 2.5-6.0%

Adult : 0.5-2.0%

2. Absolute Reticulocyte

• Calculation:

% Retic x RBC

• Refference Value

24.000-84.000/µL

METHODS

= Reticulositosis

1. Bleeding

2. Hemolytic Anemias

3. Hemoglobinopathy

4. Sickle Cell Anemias

5. Enzyme Deficiency (Erythrocyte)

6. Malaria

Interpretation

RETICULOCYTE

WHITE BLOOD CELL/WBC (LEUCOCYTE)

1. Granulocyte:

young cell: Blast, Promyelocyte,

Myelocyte, Metamyelocyte,

Band

old cell: Neutrophil, Eosinophil,

Basophil

2. Lymphocyte

3. Monocyte

METHODS

• Manual: Counting Chamber

• Analyzer:

Hemocytometer



REFFERENCE VALUE OR

NORMAL RANGE

1. Granulocyte Eosinophil : 2-6 % Basophil : 0-2 % Blast : Not seen in pheripheral blood Promyelocyte : Not seen in pheripheral blood Myelocyte : Not seen in pheripheral blood Metamyelocyte: Not seen in pheripheral blood Band : 2-4 % 2. Lymphocyte : 40-70 % 3. Monocyte : 20-40 %


Shift to the left/Sttl

• If the WBC in differential counting/DC mostly are young granulocytes series

Ex: Band, metamyelocyte,

myelocyte.

• Caused by:

Acute stress

Infection

Toxemia

Acute bleeding

• Morphology:

DOHLE BODIES

Shift to the right/Sttr

• If the WBC in differential counting/DC mostly are neuthrophil segmented and monocyte

• Caused by:

Liver disease

Megaloblastic anemias

Hereditary

• Morphology:

HYPERSEGMENTATION

INTERPRETATION WHITE BLOOD CELL/WBC (LEUCOCYTE)

= Leucocytosis

• Leucocyte higher than 4x109/L in circulation

• Caused by:

Physiology

Exercise

Late pregnancy

Labor

Neonates

Idiopathic (normal)

Infection

Bacteria

= Leucopenia • Leucocyte lower than 4x109/L in

circulation • Caused by: Agranulocitosis BM depression Aplastic Anemias Osteosclerosis Myelofibrosis Neoplasm infiltration Iradiation Toxic Benzene Urethane Auramine & others Cytostatic Drugs Infection Virus Imune


Neutrofils: Shift to the Left • Definition: Increased

number of the neutrofil batangs or presence of less mature neutrofils in darah.

• Keberadaan : normally tidak ada

• Pewarnaan: MGG

• Perbesaran: x1000

DITEMUKAN SEMUA SERI GRANULOSIT

DALAM DARAH TEPI PADA

MORFOLOGI DARAH TEPI/MDT

Keterangan: Marked shift to the left in granulopoiesis. Also anisocytosis of erithrosit. Platelets granulesless . 1.neutrofil segmen 2.neutrofil batang 3.Mielosit neutrofil 4.promielosit 5.eosinofil 6.monosit

EOSINOPHIL

Normal Eosinophil Size : 12-17 µm Colour : Pale Blue Ratio of Cytoplasmic: High Granules : Many, large & Rounded, Reddish- Orange Nucleus : Usually two segments Main Function : Effector cells for antibody-dependent damage to metazoal parasites Regulate immediate-type hypersensitivity reactions (inactivate histamine and heparin and proteases)

Rodak BF, Fritsma GA, Keohane EM. Hematology Clinical Principles and Applications. 4th ed. Elsevier Saunders. Missouri. 2008

INTERPRETATION

= EOSINOPHILIA • Eosinophilia is defined as an

absolute eosinophil count above 0.4x109/L

• Caused by: Allergic Reaction (Ex: Asthma, Hay Fever, Drug Sensitivity) Parasitic Infection Hypersensitivity Reaction (Ex: Looeffler Syndrome) Skin Disease (Ex: Dermatitis Herpetiformis) Tropical Eosinophilia Malignant Myeloproliferative Disorders Certain Infection (Ex: Scarlet Fever)

= EOSINOPENIA

• Eosinopenia is defined as an absolute eosinophil count below 0.4x109/L

• Caused by:

Thymoma

Hypogammaglobulinemia

Rare Inherited Forms

Autoimmune Disorders with

Antieosinophilia Antibodies

Unknown Causes

EOSINOPHIL


NORMAL MORPHOLOG OF EOSINOPHILS

Mature Eosinofils in Periferal darah • Ukuran sel: 15 - 25 m

• Bentuk sel: oval atau bulat

• Warna sitoplasma: pale, covered by granules

• Granularitas: abundant eosinofilik (orange-red)

• Bentuk inti: lobulated, semicircular

• Tipe kromatin: condensed

• Ratio inti/sitoplasma: low or veri low

• Nukleolus: not visible

• Keberadaan:

• darah: 2 - 4 %

• sumsum tulang: < 2 %

• Pewarnaan: MGG

• Perbesaran: x 1000

Keterangan: Single eosinofil leucosit with bi-lobulated nucleus. Also anisocytosis of erithrosit and ovalosit. Normal platelets.

BASOPHIL

Normal Basophil Size : 10-14 µm Colour : - Ratio of Cytoplasmic: High Granules : Several, large & rounded, dark purplis-black Nucleus : Usually two segments, granules overlie nucleus Main Function: • Mediate immediate-type hypersensitivity (IgE-coated basophilia react with spesific antigen and release histamine and leukotrines). • Modulate inflammatory response by releasing heparin and

protease.


INTERPRETATION

= BASOPHILIA • Basophilia is defined as an

absolute basophil count greater than 0.15x109/L

• Caused by: Malignant Myeloproliferative Disorders Non Malignant (Ex: Hypothyroidsm, Ulcerative Colitis, Bee stings, Some types of Nephrosis)

= BASOPENIA

• Basopenia is defined as an absolute eosinophil count less than 0.15x109/L

• Difficult to establish

• Has been reported by:

Chronic Urticaria

BASOPHIL


NORMAL MORPHOLOGY OF BASOPHILS

Basofils in Periferal darah • Ukuran sel: 12 - 18 m

• Bentuk sel: round or oval

• Warna sitoplasma: light-pink, mostly covered by granules and nucleus

• Granularitas: veri dark, basofilik, granules of various size. The amount varies

• Bentuk inti: oval shaped in not mature forms; lobular shaped in mature forms

• Tipe kromatin: condensed, pale



• Keberadaan:

• darah: < 1 %


• Pewarnaan: MGG


Basofils in Periferal darah • Ukuran sel: 12 - 18 m

• Bentuk sel: round or oval

• Warna sitoplasma: light-pink, mostly covered by granules and nucleus

• Granularitas: veri dark, basofilik, granules of various size. The amount varies

• Bentuk inti: oval shaped in not mature forms; lobular shaped in mature forms

• Tipe kromatin: condensed, pale



• Keberadaan:

• darah: < 1 %


• Pewarnaan: MGG


Keterangan: Single basofil leucosit. Also 3 schisosit

NEUTROPHIL SEGMENTED

Normal Neutrophil

In the blood are distributed between a marginated granulocyte pool.

When cell counts are determined on samples of periphera venous blood, only the circulating granulocytes are being studied.



Normal Neutrophil

Size : 9-15 µm

Colour : Slightly pink

Ratio of Cytoplasmic:

High

Granules : Numerous, very fine, faint purple

Nucleus : Usually two to five segments

Main Function :

Chemotaxis, Phagocytosis, Killing

of Phagocytososed Bacteria


INTERPRETATION

= NEUTROPHILIA

• Is defined as an absolute neutrophil count above 8.7x109/L.

• Caused by: Physiologyc (Ex: Sternous exercise) Acute Infections Inflammation (Ex: Burns, After Surgery, Myocardial Infarction) Intoxication (Ex: Uremia, Diabetic Acidosis, Poisoning, Insect Envenomation) Acute Hemorrhage or Hemolysis Response to Fast-Growing Tumors Malignant Myeloproliferative Disorders Certain Medications (Ex: Steroids)

= NEUTROPENIA

• Is defined as an absolute neutrophil count below 2.0x109/L.

• Caused by: Overwhelming Infection Hemodialysis Physical Agents/Drugs (Ex: Chemotherapy, Radiation, Chloramphenicol, any agent causing Aplasia) Decreased or Ineffective Production (Ex: Megaloblastic Anemia) Splenic Sequestratio Autoimmune Disorders Debilitated States (ex: Alcoholism) Hereditary Disorders (Ex: Cyclic Neutropenia)



= Neutrophilia

• Netrophil segmented higher than >70% counted in differential counting/DC.

• Caused by: Infection, after fagocitation

process Organ Injury Crush Injury Neoplasm Burn Intoxication (Ex: Co, Pb) Metabolic Disorder Eclampsia Acute Gout Diabetes (Ketosis) Cushing Syndrome Leukemias Granulocytic Policytemia Vera Myelosis (erythremic)

= Neutropenia

• Netrophil segmented lower than >70% counted in differential counting/DC.

• Caused by: Famial Idiophatic Chediac Higashi Syndrome Hypersplenism Anafilactic Syock Chirosis Hepatis PNH Tirotoxicosis Drugs Analgetic antipiretic (Ex: Amydopirine, Metampiron) Antityroid (Ex: Thiouracyl, methylthiouracyl) Antihistamine (Ex: Promethazine, Chlorpheniramine) Tranquilizer (Ex: Chlorpromazine,Meprobamate, Imipramine) Antibiotic (Ex: Ristocetin, Tethracycline, Salicyl- azo sulfa pyridien, Strepthomycine) Anticoagulant (Ex: Dicoumarol) Antituberculosis (Ex: INH, PAS) Antimalaria (Ex: Primaquine) Diuretic (Ex; Thiazide) Others (Ex: Metronidazole)


ABNORMAL

NORMAL MORPHOLOGY OF

NEUTROPHILS

LYMPHOCYTES

Normal Lymphocytes

Peripheral blood:

65-80% are T cells

10-30% are B cells

2-10% are non-T & non-B cells

Function:

Involved in immune responses and production of haemopoietic growth factors


Normal Lymphocytes

SMALL

Size :

Colour :

Ratio of Cytoplasmic:

Granules :

Nucleus :

• 12-16 µm

• Pale Blue

• Higher

• Several, Coarser, purplish-red

• Less Condensation of chromatin

• 7-12 µm

• Pale Blue

• Low or Very Low

• Few, Fine

• Rounded with large clumps of condensed chromatin

LARGE

INTERPRETATION

= LYMPHOCYTOSIS

• Young Children: Is defined as an absolute lymphocyte count greater than 10.0x109/L. Adults: Is defined as an absolute lymphocyte count greater than 4.8x109/L.

• Caused by:…

= LYMPHOCYTOPENIA

• Young Children: Is defined as an absolute lymphocyte count less than 2.0x109/L. Adults: Is defined as an absolute lymphocyte count less than 1.0x109/L.

• Caused by:…

LYMPHOCYTES


INTERPRETATION (Continue)

= LYMPHOCYTOSIS

• Caused by: Without Morphologic Alteration Bordetella pertusis infection Acute infectious lymphocytosis With Morphologic Alterations Infectious mononucleosis Infectious hepatitis Cytomegalovirus infection Viral influenza Lymphoid malignancies

= LYMPHOCYTOPENIA

• Caused by:

Steroid therapy

Sternous exercise

Morphine administration

Human Immunodeficiency

Virus Infection

Genetic Abnormalities

LYMPHOCYTES


NORMAL MORPHOLOGY

OF LYMPHOCYTES

Limfosit dalam darah tepi Catatan:

Limfosit reaktif

yang terlihat

selama infeksi,

khususnya

infeksi virus.

Namun bisa

juga dijumopai

dalam darah

normal. Terlihat

beberapa

stomatosit

MONOCYTES Normal Monocytes Size : 15-30 Colour : Pale, Greyish Blue, Cytoplasmic vacuole may be seen Ratio of Cytoplasmic: Moderately High to High Granules : Variabel number, fine, purplish-red (unussual) Nucleus : Various shapes (rounded, C or U shape, lobulated), skin-like or lacy chromatin Main Function : The precursor of tissue macrophage. Phagositosis of microorganisms and cells coated with antibody. Chemotaxis, Phagocytosis, Killing of some microorganisms, Antigen presentation (dendritic cells/antigen presenting cell), Release of Interleukin (IL) -1 and Tumor Necrozing Factor/TNF which stimulate bone marrow stromal to produce GM-CSF, G-CFS, M-CFS and IL-6


= Monocytosis

• Is defined as an absolute monocyte count above 1.1x109/L.

• Caused by: Bacterial Infection (Ex: Tbc, subacute bacterial endocarditis, syphillis) Recovery from Acute Infection Protozoal & Rickettsial Infection (Ex: malaria, typhus) Certain Carcinomas Granulomatous Disease Collagen Vascular Disease (Ex: SLE) Malignancies of Monocyte Cell Line

= Monocytopenia

• Is defined as an absolute monocyte count below 0.4x109/L.

• Caused by:

Overwhelming Infections in Immunocompromised

Patients

Hemodialysis

Epstein-Barr Virus Infection

Steroid Therapy


INTERPRETATION

= MONOCYTOSIS

• Is defined as an absolute monocyte count greater than 1.1x109/L. • Caused by: Bacterial Infections (Ex: Tuberculosis, Subacute Bacterial Endocarditis, Syphillis) Recovery from Acute Infection Protozoal & Rickettsial Infection (Ex: Malaria, Thypus) Certain Carcinomas Granulomatous Diseases Collagen Vascular Disease (Ex: SLE) Malignancies of monocytes cell line

= MONOCYTOPENIA

• Is defined as an absolute

monocyte count less

than 0.4x109/L.

• Caused by:

Overwhelming Infections in

Immunocompromised -

Patients

Hemodialysis

Epstein-Barr Virus Infection

Steroid Therapy

MONOCYTES


NORMAL MORPHOLOGY

OF MONOCYTE

PLATELETS / TROMBOCYTE

Size : 2-4 µm

Colour : Pale blue

Granules : Fine Azurophillic

Nucleus : Anucleated

Main Function:

Adhere to subendothelial connective tissue, Participate in Blood Clotting (Hemostasis & Thrombosis)

METHODS

• Manual: Counting Chamber

• Analyzer:

Hemocytometer


PLATELETS (TROMBOCYTE)

REFFERENCE VALUE OR

NORMAL RANGE

150.000-450.000 U/L

= Thrombocitosis

• Thrombocyte in circulation higher than refference value (>450.000).

• Caused by: Iron Deficiency Anemia Hyposplenism Postsplenectomy Malignancy Collagen Vascular Disease Inflamatory Bowel Disease Infection Hemolysis Hemorrhage Idiopatic Mielofibrosis Essential Thrombocytosis Chronic Myelocitic Leucemia Idiopathic Sideroblastic Anemia Myelodysplasia Post operation Rebound ( stop alcohol, post correction

from Vitamin B12 deficiency/Folate) Policythemia vera

= Thrombocitopenia

• Thrombocyte in circulation lower than refference value (<150.000).

• Caused by:

Lower Production ec:

BMP damage

Aplasia Drugs/Toxin

Hepatitis Carcinoma

Congenital Defect

Fanconi’s anemia TAR Syndrome

Rubella May-Hegglin Syndrome

Wiskott Aldrich Dominant Autosomal

Ineffective Production

B12/Folate Deficiency

Distribution ec:

Splenomegaly

Liver disease Myelofibrosis

Higher Destruction ec:

Non Imune

DIC HUS

TTP HELLP Syndrome

Imune

SLE Limphoproliferative Disease

AIDS ITP

INTERPRETATION PLATELETS

(TROMBOCYTE)

The clinical sign of spontaneous bleeding in small areas of the skin and mucous membranes (petechial bleeding), which on injury diffuses out to form medium-sized subcutaneous ecchymoses, is grounds for suspicion of thrombocyte (or vascular) anomalies.

NORMAL MORPHOLOGY

OF THROMBOCYTES

ABNORMAL MORPHOLOGY OF THROMBOCYTES

Catatan: Trombosit raksasa dengan granulasi sedikit berkurang. Juga terlihat dua ovalosit.

Giant platelet Ukuran: > 6 m Bentuk: bulat atau oval, dengan pinggir tidak rata Warna sitoplasma: biru Granularitas: granul ungu halus yang mengisi bagian tengah trombosit Pinggir tipis tanpa granul pada bagian tepi dari sel Distribusi: dalam film darah tepi hanya satu giant plateklet Pewarnaan: MGG Perbesaran: x1000

INFLAMATION MARKERS

Erythrocyte Sedimentation Rate/ESR

C-Reactive Protein/CRP

Serum Amiloid A/SAA

Procalcitonin/PCT

Known as

Acute Phase Reactan

Erythrocyte Sedimentation Rate/ESR Laju Endapan Darah/LED

Principle of examination,

have 3 phase:

1. Rouleaux phase

2. Sedimentation phase

3. Consolidation phase

Men

• < 50 years: <15 mm/1 hour

> 50 years: >20 mm/1 hour

Women • < 50 years: <20 mm/1 hour

> 50 years: <30 mm/1 hour

Refference Value


METHODS

Westergren

(Widely used in Indonesia) Wintrobe


Advantage

• Cheap

• Simply

• Usually:

monitoring therapy

(ex: Tuberculosis)

Disadvantage

• Time Consuming

• As screening test

METHODS

= ESR Higher

• Injury • Inflamation • Pregnancy • Acute Inflamatory Disease: Local Systemic • Chronic Disease Ex: Rheumatoid Arthritis • Dysproteinemia Ex: Multiple Myeloma • Solid Tumor • Collagen Disease Ex: SLE • Macroglobulinemia Ex: Waldenstrom Syndrome • Nefritis, Nefrosis • Tuberculosis • Carcinoma

= ESR Lower

• Polyglobulin

Ex: Polycythemia

Interpretation


Clinical Chemistry

SERUM GLUTAMIC OXALOACETIC TRANSAMINASE/SGOT = ASPARTATE AMINOTRANSFERASE/AST

Production: Cleared from the blood in a few days Become elevated 8 hours after cell injury Peak at 24-36 hours Return to normal in 3-7 days Main Function: Is used in the evaluation of patients with suspected hepatocellular disease. Very High Concentrations Highly metabolic tissue: Heart muscle Liver cells Skeletal muscle cells Lesser degree Kidneys Pancreas Red Blood Cells/RBCs Release by: When disease or injury affects the of the tissues, the lyse. If the cellular injury is chronic, levels will be persistently elevated.

Pagana KD, Pagana TJ. Mosby’s Manual of Diagnostic and Laboraotry Test. 4th ed. Mosby Elsevier. 2010.

The AST/ALT Ratio

Greater than 1:

Alcoholic cirrhosis

Liver Congestion

Metastatic Tumors of the liver

Less than 1:

Actue Hepatitis

Viral Hepatitis

Infectious Mononucleosis


SGOT/AST

= SGOT/AST

Increased Levels

• Liver Disease • Hepatits • Hepatic Chirrhosis • Drug-Induced Liver

Injury • Hepatic Metastasis • Hepatic Necrosis (Initial State Only) • Hepatic Surgery • Infectious

Mononucleosis with Hepatitis

• Hepatic Infiltrative (e.g: Tumor) • Skeletal Muscle

Disease • Skeletal Muscle

Trauma

= SGOT/AST

Increased Levels

(Cont...)

• Recent Non Cardiac Surgery

• Multiple Traumas

• Severe, Deep Burns

• Progressive Muscular Dystrophy

• Recent Convulsions

• Heat Stroke

• Primary Muscle Disease

• Other Disease

Acute Hemolytic Anemia

Acute Pancreatitis

INTERPRETATION SGOT/AST

= SGOT/AST


Decreased Levels

• Acute Renal Disease

• Beriberi

• Diabetec Ketoacidosis

• Pregnancy

• Chronic Renal Dialysis

SERUM GLUTAMIC PIRUVATE TRANSVERASE/SGPT = ALANINE AMINOTRANSFERASE/ALT

Production: made joundice Main Function: to identify hepatocellular disease of the liver. Predominanatly Found in: Liver Lesser Quantity found in: Kidneys Heart Skeletal Muscle Release by : Injury or disease affecting the liver parenchyma will cause a release of

this hepatocellular enzyme into bloodstream, thus elevating serum ALT level.


The ALT/AST Ratio

(RATIO DeRITIS)

Greater than 1:

Viral Hepatitis

Less than 1:

Other than Viral Hepatitis


SGPT/ALT

REFFERENCE VALUE OR

NORMAL RANGE

Elderly : may be slightly higher than adults values Adult/Child : 4-36 international unit/L at 37ºC Infant : may be twice as high as adults values

SGOT/AST-SGPT/ALT

Manual : Spectrophotometer

Analyzer : Autoanalyzer (Flow Cytometry)

METHODS


= SGPT/ALT

Mildly

Increased Levels

• Myositis

• Pancreatis

• Myocardial Infarction

• Shock

= SGPT/ALT

Moderately

Increased Levels

• Cirrhosis

• Cholestasis

• Hepatic Tumor

• Hepatotoxic Drugs

• Obstructive Jaundice

• Severe Burns

• Trauma to Striated Muscle

INTERPRETATION SGPT/ALT

= SGPT/ALT


Significantly

Increased Levels

• Hepatitis

• Hepatic Necrosis

• Hepatic Ischemia

UREA & BLOOD UREA NITROGEN/BUN CREATININE

UREA : direct from serum BUN : indirect from serum (calculation)

Production: Protein (exogenous/dietary or endogenous/tissue)

(Liver)

(metabolism & digestion)

(breakdown)

Amino Acid

(catabolized)

Ammonia

(deposited)

Blood

(transport)

Kidneys

(excretion)


RENAL FUNCTION STUDIES

Burtis CA, Ashwood ER. Tietz Fundamentals of Clinical Chemistry. 5th ed. Saunders An Imprint of Elsevier. Pennsylvania. 2001

ELEVATED • Have Azotemia or • Be Azotemia PRERENAL AZOTEMIA: • Shock • Dehydration • Congestive Heart Failure • Excessive Proteins Catabolism • Gastrointestinal Bleeding POSTRENAL AZOTEMIA: • Ureteral Obstruction • Urethral Obstruction

UREA-BUN


= BUN = BUN

DECREASED

• Severe Primary Liver Disease

• Combine Liver & Renal Disease

(BUN can be Normal)

INTERPRETATION

METHODS



UREA-BUN


REFFERENCE VALUE OR NORMAL RANGE (depend on the methods)

Adult : 6-20 mg/dL

Newborn : 3-25 mg/dL

Adult >60 years : 8-23 mg/dL

(Elderly)


CREATININE : synthesized in kidneys, liver, and pancreas

The amount of creatinine produces each day is related to muscle mass (body weight)

Production: Creatine

(Liver)

(creatine kinase)

(muscle cells)

Phosphocreatine

(catabolized)

Creatinine

(deposited)

Blood

(transport)

Kidneys

(excretion)




METHODS

Manual : Spectrophotometer Analyzer : Autoanalyzer (Flow Cytometry)

CREATININE


REFERENCE VALUE OR NORMAL RANGE (depend on the methods)

Adult Female : 0.5-1.1 mg/dL Male : 0.6-1.2 mg/dL Elderly : decrease in muscle mass may cause decreased values Adolescent : 0.5-1.0 mg/dL Infant : 0.2-0.4 mg/dL Newborn : 0.3-1.2 mg/dL Child : 0.3-0.7 mg/dL


= CREATININE

ELEVATED (suggest chronicity of the disease)

• Dehydration • Glomerulonephritis • Pyelonephritis • Acute Tubular Necrosis • Urinary Obstruction • Diabetic Nephrophaty • Rhabdomyolysis • Acromegaly • Gigantism

SLIGHTLY ELEVATED • After meals (specially large

quantities of meat) • Diurnals variations (at 7 am-peak

at 7 pm)

= CREATININE

DECREASED

• Debilitation

• Decreased Muscle Mass

(e.g: muscular dysthropy,

myasthenia gravis)

INTERPRETATION CREATININE




The Most Important ‘Renal Clearance’ as an Indicator

GLOMERULAR FILTRATION RATE/GFR (Calculation)

The rate in millimeters per minute that substances, such as urea and creatinine, are filtered through the kidney’s glomeruli; a measure of the number of functioning nephrons.

The formula as follow:





The Most Important ‘Renal Clearance’ as an Indicator

CREATININE CLEARANCE (Calculation)

The volume (V) of

The urine measured (mL)

Urine flow rate is calculated (mL/min)

Creatinine is measured in mg/dL or mmol/L in

Both of th urine (urine/U and serum/S)

The formula as follow:




REFERENCE VALUE OR NORMAL RANGE

CREATININE CLEARANCE

Adult

Female : 72-110 mL/min/1.73 m2

Male : 94-140 mL/min/1.73 m2


URIC ACID/UA

URIC ACID: Nitrogenous Compound Large Degree Excreted by: Kidney Small Degree Excreted by: Intestinal Tract Production: Dietary Nucleic Acid (Purine Catabolism) Uric Acid Directly



METHODS



URIC ACID


REFFERENCE VALUE OR NORMAL RANGE (depend on the methods)

Adult Female : 2.7-7.3 mg/dL Male : 4.0-8.5 mg/dL Elderly : values may be slightly increased Newborn : 2.0-6.2 mg/dL Child : 2.5-5.5 mg/dL Possible Critical Values : >12 mg/dL


= URIC ACID/UA

HYPERURICEMIA

• Gout • Increase Ingestion of Purines • Genetic • Metastatic Cancer • Multiple Myeloma • Leukemia • Cancer Chemotherapy • Hemolysis • Rhabdomyolisis (e.g: heavy exercise, burns, crush injury, epileptic seizure, or myocardial infarction) • Chronic Renal Disease • Hypothyroidism • Toxemia of pregnancy • Hyperlipoproteinemia • Alcoholism

= URIC ACID/UA

DECREASED

• Wilson’s Disease

• Fanconi’s Syndrome

• Lead Poisoning

• Yellow Atropy of the Liver

INTERPRETATION URIC ACID


LIPID PROFILE

Clinical Significant


Lipids, Lipoproteins, and Apolipoproteins

High Density Lipoproteins Low Density Lipoproteins Very Low Density Lipoproteins

Triglycerides

Fatty Acid

Glycerol (acylglycerols)

Cholesterol (Steroid Alcohol)

Cholesterol Total

Chylomicron

REMEMBER !!!

The purpose of cholesterol testing is:

To identify patients at risk for ATERIOSCLEROTIC

LIPID PROFILE


Required the for production of:

steroids, sex hormones, bile acid, and

cellular membranes

Main Function

REFFERENCE VALUE OR NORMAL RANGE

Adult/Elderly : <200 mg/dL Infant : 70-175 mg/dL Newborn : 53-135 mg/dL Child : 120-200 mg/dL

LIPID PROFILE




METHODS

= Hyperlipidemia

INCREASED LEVELS

• Hypercholesterolemia • Hyperlipidemia • Hypothyroidism • Uncontroled Diabetes Mellitus • Nephrotic Syndrome • Pregnancy • High-cholesterol Diet • Xanthomatosis • Hypertension • Myocardial Infarction • Atherosclerosis • Biliary Cirrhosis • Stress • Nephrosis

= Hypolipidemia

DECREASED LEVEL

• Malabsorption

• Malnutrition

• Hyperthyroidism

• Cholesterol-lowering medication

• Pernicious Anemia

• Sepsis

• Stress

• Liver Disease

• Acute Myocardial Infarction

INTERPRETATION LIPID PROFILE


=

INCREASED LEVELS

• Hypercholesterolemia • Hyperlipidemia • Hypothyroidism • Uncontroled Diabetes Mellitus • Nephrotic Syndrome • Pregnancy • High-cholesterol Diet • Xanthomatosis • Hypertension • Myocardial Infarction • Atherosclerosis • Biliary Cirrhosis • Stress • Nephrosis

=

DECREASED LEVEL

• Malabsorption

• Malnutrition

• Hyperthyroidism

• Cholesterol-lowering medication

• Pernicious Anemia

• Sepsis

• Stress

• Liver Disease

• Acute Myocardial Infarction

INTERPRETATION LIPID PROFILE


BLOOD GLUCOSE

• Product: Carbohydrates Metabolism Diets (e.g: grains, legumes) (breakdown) Glycogen (Body stores) (Adipose tissue, Liver, Muscle) Exceed Calorie Intake • Hormon: Insulin Glucagon


SEFL-MONITORING OF BLOOD GLUCOSE

1. Patients undergoing intensive insulin treatment programs (Their glucose levels should be measured at least 4 time/day) 2. Hypoglycemia-prone patients (Who may not experience the early warning signs) 3. Avoidance of severe hyperglycemia (Particularly in situations of increased risk) 4. Patients with unstable diabetes 5. Pregnant women with diabetes

BLOOD GLUCOSE


REFFERENCE VALUE OR NORMAL RANGE

Sample Fasting Glucose (mg/dL)

Plasma/Serum Adults : 74-106 mg/dL Children : 60-100 mg/dL Premature Neonates : 20-60 mg/dL Term Neonates : 30-60 mg/dL Whole Blood : 65-95 mg/dL CFS : 40-70 mg/dL

BLOOD GLUCOSE


NORMAL DM

1. FASTING 70-110mg/dl > 126 mg./dl

2. POST PRAN- < 150 mg/dl > 200 mg/dl DIAL 3. NON FASTING 100-150 mg/dl > 200 mg/dl

BLOOD SUGAR CONCENTRATION

METHODS



BLOOD GLUCOSE


Diabetes Mellitus Any one of following is diagnostic: 1. Classic symptoms of diabetes and casual plasma glucose concentration ≥200 mg/dL 2. Fasting plasma glucose ≥126 mg/dL 3. A 2-hours postload plasma glucose concentration ≥200 mg/dL during the OGTT

Impaired Fasting Glucose Fasting plasma glucose between 110 and 125 mg/dL Impaired Glucose Tolerance The following 2 criteria must be met: 1. Fasting plasma glucose <126 mg/dL 2. A 2-hour OGTT plasma glucose concentration between 140 and 199 mg/dL

CRITERIA for DIAGNOSIS of DIABETES MELLITUS

BS mg/dl BS

FASTING POSTPR

NORMAL < 110 < 150

GLUCOSE < 126 < 200 INTOLERANCE

DIABETES > 126 >200 MELLITUS

DIAGNOSIS

= HYPERGLYCEMIA

INCREASED LEVELS

• Diabetes Mellitus

• Acute Stress Response

• Cushing’s Syndrome

• Pheochromacytoma

• Chronic Renal Failure

• Glucagonoma

• Acute Pancreatitis

• Diuretic Therapy

• Acromegaly

= HYPOGLYCEMIA

DECREASED LEVELS

• Insulinoma

• Hypothyroidism

• Hypopituitarism

• Addison’s Disease

• Extensive Liver Disease

• Insulin Overdose

• Starvation

INTERPRETATION BLOOD GLUCOSE


METHODS

• Manual:

• Analyzer:

Specrophotometer


CARDIAC MARKER

CARDIAC MARKER

Christenson RH, Azzazy HME. Biomarkers of Myocardial Necrosis, Past, Present and Future. In: Cardivascular Markers Pathophysiology and Disease Management. Humana Press Inc. New Jersey. 2006.

Properties of Biomarkers of Myocardial Necrosis


FORM PERMINTAAN PEMERIKSAAN

LABORATORIUM DI

RSUDZA BANDA ACEH

MANUAL

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Bahan Kuliah Pakar Blok 9 Dewasa & Masa Tua

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