Assessment Part-7) Laboratory Medicine Series Part-1 Blood Chemistries

(Assessment Part-7) Laboratory Medicine Series Part-1 Blood Chemistries

Dr. Paul S. Anderson Date: 05-18-2021 © PS Anderson and www.ConsultDrA.com 2021

Laboratory medicine is a cornerstone of proper diagnosis and patient safety. This series is designed to break down the commonly used laboratory investigations in naturopathic and functional medicine. It will describe the tests in each category, discuss their meaning and define next steps to follow when abnormalities are found.

I. CHEMISTRIES II. HEMATOLOGY a. Components & Major indications for monitoring (Chemistry a. Components and Meanings of the CBC, Differential and Platelet Panels) Studies b. Common follow-up tests if abnormal values are found i. Reticulocyte and marrow function c. Liver and Renal assessment ii. RDW d. Bilirubin formation, metabolism and measurement iii. Neutrophil to Lymphocyte Ratio e. Inflammatory Markers iv. Common pathologies reflected in the differential i. CRP, ESR etc. b. Ferritin, Iron Binding, Hemosiderin, Transferrin etc. c. The Anemias Part-1 to this point: d. Hematological Malignancy f. Blood sugar assessment e. Clotting Function i. Insulinoma etc. f. B12, Folates, B6, Methylation and Hematopoiesis ii. Hypoglycemia g. Special roles and interactions of Cu – Fe - Zn iii. DM Syndromes & Insulin biology III. ALLERGY AND IMMUNOLOGY g. Malignancy and Red Flags a. Histamine and MCAS h. Measurement of Cu, Zn, Mg and other ions b. Inflammatory Cytokines i. Metabolic markers c. C-3&4a, CD57, NK Cell Function i. Porphyrins d. B and T cell function assessment ii. Pyrroles e. Anti-phospholipid and other syndromes iii. Uric Acid IV. TOXICOLOGY a. Metals b. Chemicals c. Mycotoxins

I. CHEMISTRIES a.Components & Major indications for monitoring (Chemistry Panels) b.Common follow-up tests if abnormal values are found c.Liver and Renal assessment d.Bilirubin formation, metabolism and measurement e.Inflammatory & Surrogate Markers i. CRP ii.ESR iii.AlkPhos iv.LDH

• A LOT is not on the slides.

• Many questions I get are answered in the audio portion

• So, it’s fine to skim the slides but please do both the “A” and the “V” parts

• Thank you!

(c) PS Anderson - www.ConsultDrA.com 2021 7 https://www.royalcollege.ca/rcsite/documents/credential-exams/clinical-lab-tests- reference-values-e.pdf

(c) PS Anderson - www.ConsultDrA.com 2021 8 https://www.royalcollege.ca/rcsite/documents/credential-exams/clinical-lab-tests- reference-values-e.pdf

(c) PS Anderson - www.ConsultDrA.com 2021 9 https://www.royalcollege.ca/rcsite/documents/credential-exams/clinical-lab-tests- reference-values-e.pdf

(c) PS Anderson - www.ConsultDrA.com 2021 10 https://www.royalcollege.ca/rcsite/documents/credential-exams/clinical-lab-tests- reference-values-e.pdf

(c) PS Anderson - www.ConsultDrA.com 2021 11 https://www.royalcollege.ca/rcsite/documents/credential-exams/clinical-lab-tests- reference-values-e.pdf

(c) PS Anderson - www.ConsultDrA.com 2021 12 https://www.royalcollege.ca/rcsite/documents/credential-exams/clinical-lab-tests- reference-values-e.pdf

Chem-6 Stat panel 6 serum analytes commonly ordered as part of a routine 'stat' profile: (Serum) Sodium, Potassium, Chloride, CO2, glucose, urea nitrogen Chem-7 Basic Metabolic Panel (BMP) Blood urea nitrogen (BUN), Carbon dioxide, Creatinine, Glucose, Serum chloride, Serum potassium, Serum sodium Chem-14 Comprehensive Metabolic Panel (CMP) Alanine aminotransferase (ALT/SGPT); albumin:globulin (A:G) ratio; albumin, serum; alkaline phosphatase, serum; aspartate aminotransferase (AST/SGOT); bilirubin, total; BUN; BUN:creatinine ratio; calcium, serum; carbon dioxide, total; chloride, serum; creatinine, serum; eGFR calculation; globulin, total; glucose, serum; potassium, serum; protein, total, serum; sodium, serum Chem-25 “SMAC-25” CMP (includes eGFR ) plus - Amylase, Serum; Albumin, Albumin/Globulin Ratio (calculated), Alkaline Phosphatase, ALT, AST, BUN/Creatinine Ratio (calculated), Calcium, Carbon Dioxide, Chloride, Creatinine with GFR Estimated, Globulin (calculated), Glucose, Potassium, Sodium, Total Bilirubin, Total Protein, Urea Nitrogen, Creatine Kinase (CK), Total, Serum, Gamma Glutamyl Transpeptidase (GGT), Lactic Acid Dehydrogenase (LD) (LDH), Lactic Acid, Plasma, Lipid Panel: Cholesterol, total; high-density lipoprotein (HDL) cholesterol; low-density lipoprotein (LDL) cholesterol (calculated); triglycerides; Non-HDL Cholesterol (calculated), Magnesium, Serum, Phosphate (as Phosphorus), Uric Acid, Serum

• We will be looking at blood sugar regulation in a future module. • I include it here as it is part of the blood chemistry panel world.

• Sodium

• Potassium

• Chloride

• CO2 (as Bicarbonate)

• Calcium (not in Chem-6 or 7)

(c) PS Anderson - www.ConsultDrA.com 2021 19 The resting membrane potential is predicated on the ionic balance between the ICF and the ECF. Changes in those ion concentrations create AP generation and cellular activation.

ICF ECF

[Na] [K] [K] [Na] [Mg] [Ca] [Mg] [Ca] Cl- (Cl- influx hyperpolarizes the cell, inactivating it.)

Plasma ECF ICF Na + 142 145 10 K + 4 4 160 Mg+ 3 2 35 Ca + 5 3 5 Cl - 103 120 2

HCO3- 27 35 8 HPO- 2 2 140

Blood ECF ICF

Recall, most K and Mg are in the cell.

**The Equilibrium Potential(c) PS Anderson is what - www.ConsultDrA.com turns off the 2021 Diffusion Potential 25 Na+ HANDLING ALONG THE NEPHRON • Numbers = % Na • Arrows = Direction of flow • PROXIMAL TUBULE – Reabsorbs 67% (2/3) Na & H2O – Reabsorbs all Glucose, HCO3, & Amino Acids – Reabsorbs Na via Cotransport with Glucose, AA’s, PO4; And via Countertransport in the Na+ / H+ Exchange. – Site of Carbonic Anhydrase Inhibitor activity (Blocks HCO3 reabsorption) • THICK ASC. LOOP of HENLE – Reabsorbs 25% of Na – Na-K-Cl cotransporter – Site of Loop Diuretic action • DISTAL TUBULE / COLL. DUCT – Reabsorbs 8% Na via. Na-Cl cotransporter – Site of thiazide diuretic action (c) PS Anderson - www.ConsultDrA.com 2021 26 K+ HANDLING ALONG THE NEPHRON • PROXIMAL TUBULE – Reabsorbs 67% K+ along with Na+ & H2O

• THICK LIMB …HENLE – Reabsorbs 20% K+ via the Na+-K+-2Cl Cotransporter

• DISTAL TUBULE / COLLECTING DUCT – Either reabsorb or secrete K+ based on dietary intake

Chemoreceptor: Type Location Stimuli for increasing resp-rate: CENTRAL MEDULLA ACIDIC pH & Increased pCO2

PERIPHERAL Carotid Bodies (CN-9) ACIDIC pH, Increased pCO2 Aortic Bodies (CN-10) Decreased pO2

REMEMBER FOR ACID-BASE PROBLEMS: ** “Respiratory” = CO2 ** “Metabolic” = Bicarb

Incr. CO2 = ACID Decr. CO2 = BASE Incr. HCO3- = BASE Decr. HCO3- = ACID

• Produced in the parafollicular cells of the thyroid • Lowers blood Ca+, Preserves Bone Ca+ • Acts on BONE and KIDNEY – In Bone: • Inhibits resorption • Inhibits Ca+ resorption by osteoclasts – In Kidney: • Concentrated in cortex • Increases Ca+, Na+, K+ excretion • Decreases Mg+ excretion

7-OH-CHOLESTEROL  CHOLECALCIFEROL (D3) : Parathyroi [SKIN] d Gland + + due to [LIVER] Falling Serum Ca 25- HYDROXYCHOLECALCIFEROL Aka: 25(OH)D3

[KIDNEY]

NET EFFECTS: NET EFFECTS: •Ca INTO Bone •Ca OUT of Bone •Ca Absorption in •Ca Absorption in Gut Gut •Ca Renal (c) PS Anderson - www.ConsultDrA.com 2021 37 •LOWERS SERUM Ca Reabsorption

•RAISES SERUM Ca Blood Bone Kidney Ca++ Ca++ Excretion Decrease Increase Increase: Calcitonin Ca / Na / K Decrease Excretion: Mg

Ca++ Ca++ Acts on Increase Decrease Vit. D to P.T.H. Decrease Ca++ Excretion

Trabecular bone turn over is key

• Lysis (loss) – Thyroid (mitochondrial) function, Gravity and bone stress and HYPOCLACEMIA – (+) osteoclasts – Osteoclasts leave behind Alkaline Phosphatase (ALK-PHOS)

• Blastic (building) – ALK-PHOS triggers Osteoblast activity

Often when you correct the Ca++ it isn’t really low or high… • Serum Ca++ high or low – Order an Ionized Calcium – Ionized Ca++ high or low • Order 24-hour urinary Calcium • 24-hour urinary Ca++ high or low – Work up Parathyroid, Vitamin D Metabolites – CONSIDER LYTIC BONE LESIONS

Suspected electrolyte abnormalityConsult (e.g., patient with loss of consciousness, or patient receiving diuretic therapy) • Laboratory Testing • Evaluate whether elevation or decrease is real • Hyperkalemia – evaluate for hemolysis in sample • Hyponatremia – evaluate for presence of hyperglycemia or hyperlipidemia • Initial screen – panel should include Na, potassium chloride, bicarbonate, blood urea nitrogen (BUN), creatinine, glucose, and Ca • Mg • Order concurrently in high-risk situations (eg, diabetes mellitus, alcoholism, diuretic therapy) • Albumin • Order serum test concurrently if calcium abnormality suspected • If hypocalcemia suspected – also order Mg https://arupconsult.com/content/electrolyte-abnormalities-life-threatening

The causes of hypercalcemia can be divided into seven categories: hyperparathyroidism, vitamin D-related causes, malignancy, medications, other endocrine disorders, genetic disorders, and miscellaneous causes Primary hyperparathyroidism and malignancy account for more than 90 percent of hypercalcemia cases.

Excerpted from AAFP at: https://www.aafp.org/afp/2003/0501/p1959.html I recommend this resource for deeper ddx.

(c) PS Anderson - www.ConsultDrA.com 2021 42 DDX Hypercalcemia ARUP-Consult • Calcium • Calculate corrected calcium • Corrected calcium = serum calcium + [0.8 x (normal albumin - serum albumin)] • Normal albumin is usually 4-4.5 g/dL, depending on testing lab • Consider ionized calcium if albumin is low • Total serum calcium • In asymptomatic patient with concentration >10.3 but <11.0 mg/dL, repeat with albumin measurement or ionized calcium • In symptomatic patient and/or patient with concentration >11.0 mg/dL – order PTH • PTH (intact) • Elevated or normal – indicates primary hyperparathyroidism; order urine calcium, 24-hour collection • High urine calcium (≥100 pg/mL) – primary hyperparathyroidism • Low urine calcium (<100 pg/mL) – familial benign hypercalcemia • Low – order PTH-related peptide (PTHrP) • High PTHrP – consider cancer

• Low or normal PTHrP – order vitamin D, 1,25-dihydroxy [1,25-(OH)2-D]

• High 1,25-(OH)2-D – consider lymphoma or granulomatous disease

• Low or normal 1,25-(OH)2-D – consider vitamin D excess, cancer, milk-alkali syndrome, or hyperthyroidism (c) PS Anderson - www.ConsultDrA.com 2021 43 Hypocalcemia

https://ddxof.com/hypocalcemia/

• Initial testing • Serum calcium and albumin • Corrected calcium = measured total calcium + 0.8 (4.0 - serum albumin) • Phosphate • Magnesium • Creatinine • If calcium is low, consider repeat testing with ionized calcium • Ionized calcium needs no correction for hypoalbuminemia but should be corrected for pH • If hypocalcemia is confirmed, order intact PTH • Elevated PTH, normal or high phosphate, normal magnesium, high creatinine – consider renal failure/pseudohypoparathyroidism • Elevated PTH, normal or low phosphate, normal magnesium, normal creatinine – consider vitamin D testing • Low vitamin D 25(OH) – vitamin D deficiency confirmed • Low PTH, normal or high phosphate, normal creatinine, low or normal magnesium – consider hypoparathyroidism or hypomagnesemia • Normal PTH, normal or low phosphate, normal creatinine, normal magnesium, low albumin – consider hypoalbuminemia (pseudohypocalcemia)

• Normal range – 3.3-5.0 mmol/L • Rapid changes have life-threatening consequences – may affect serum pH (inverse relationship) • Three controlling mechanisms • Intake • Distribution • Intracellular and extracellular fluid • Cellular distribution affected by insulin beta-adrenergic receptors and renal excretion • Excretion

• K-related disorders • Hypokalemia • Definition • Mild – 3-3.2 mmol/L • Moderate – 2.5-2.9 mmol/L • Severe – <2.5 mmol/L • Symptoms – may vary from asymptomatic to fulminant respiratory failure • Most common – weakness, fatigue • Electrocardiogram (ECG) – prolonged PR interval, Torsade de Pointes • Etiologies • Drugs (eg, diuretics, beta agonists) • Gastrointestinal losses • Renal losses (eg, osmotic diuresis, mineralocorticoid excess) • Hypomagnesemia • Dialysis/plasmapheresis • Inadequate intake (eg, anorexia, dementia) • Transcellular shifts (eg, alkalosis, hypothermia)

– Hyperkalemia • Definition • Mild – >5.1-6.0 mmol/L • Moderate – 6.1-7 mmol/L • Severe – >7 mmol/L • Symptoms – usually occurs only >7 mmol/L • Muscle weakness, cardiac arrhythmias • ECG – peaked T waves, widening of QRS, ventricular tachycardia • Etiologies • Sample collection error – usually hemolysis of specimen • Drugs (eg, angiotensin-converting enzyme [ACE] inhibitors, potassium-sparing diuretics) • Rhabdomyolysis • Metabolic acidosis • Renal failure, renal tubular acidosis type IV • Hypoaldosteronism • Hypoglycemia • Tumor lysis syndrome • Addison disease

• Normal range – 136-144 mmol/L • Consistent serum osmolality maintained through a balance of Na and water intake and excretion • Serum osmolality reference interval – 280-303 mOsm/kg • Calculated serum osmolality = (2 x Na) + (glucose/18) + (BUN/2.8)

• Na-related disorders • Hyponatremia – defined as <135 mmol/L • Most often a chronic condition but may worsen in acutely ill patients • Symptoms – most often found in patients with abrupt changes in sodium level • Nausea/emesis • Headache • Lethargy • Severe hyponatremia – seizures, coma, death • Etiologies • Pseudohyponatremia • Hyperglycemia – for every 100 mg/dL increase of glucose, serum Na is lowered by 1.7 mmol/L • Hyperlipidemia • Hyperproteinemia (eg, multiple myeloma) • Hypovolemic – thiazide diuretics, osmotic diuresis, adrenal insufficiency, ketonuria, gastrointestinal (GI) losses • Euvolemic – syndrome of inappropriate antidiuretic hormone (SIADH), hypothyroidism, HIV, certain cancers, glucocorticoid deficiency • Hypervolemic – psychogenic polydipsia, congestive heart failure, cirrhosis, and renal failure

Na-related disorders • Hypernatremia – defined as >145 mmol/L • Symptoms – mimics symptoms of hyponatremia • Etiologies • Hypovolemic – body fluid losses, diuretic use, GI losses, heat injury, osmotic diuresis • Euvolemic – central diabetes insipidus, fever, mediating tumors • Hypervolemic – Cushing syndrome, hemodialysis, hyperaldosteronism, iatrogenic (eg, saline enemas)

• Metabolic panel (Na, K, Cl, HCO3-) and arterial blood gases • Expect decreased bicarbonate level on both tests, along with acidosis on arterial blood gases • Calculate anion and osmolar gaps to further aid in differential • Anion gap = [Na] - ([Cl] + [HCO3-]) • Normal = 7-16 mmol/L • Osmolar gap = calculated plasma osmolality - measured plasma osmolality (2[Na+] + [glucose]/18 + [blood urea nitrogen (BUN)]/2.8) • Normal = -10 to +10 mOsm/kg

• Shift O2 dissociation curve to left (increased affinity for Hb-O2) • Right shift with increase TEMP, 2-3 DPG, H+ • Hypokalaemia • Hypocalcaemia • Hypochloraemia • Symptoms related to HYPOcalcaemia and HYPOkalaemia • Dizzy, light-headed • Chest tightness • Anxiety, dysphasia…..laryngospasm

• GIT (GI) excess acid loss • Vomit (and pyloric stenosis) • NGT drainage • Diarrhea • Ileostomy • Dehydration • Renal excess acid loss • Bartter syndrome • Gitelman syndrome https://rarediseases.org/rare-diseases/gitelman-syndrome/ • Diuretics (Loss of H+, K+, Cl-) • Overdose of base • Antacid OD, Laxative, Milk-alkali syndrome • Massive Hartmann’s transfusion • Iatrogenic use of HCO3 • Endocrine • Cushing syndrome • Steroid excess • Hyperaldosteronism

• Most Ca, Na and Cl is found in the ______• Cl under most circumstances ______the cell when Na enters. • The measure of CO2 is serum ______due to the ______effect. • In the elderly electrolyte imbalance is most often seen as ______sx.

• Andrew Levey, et. al. developed an accurate method to predict GFR (Levey, AS et. al. Ann Intern Med 1999;130:461-470) – Validated in cohort of patients that differed from the cohort used to derive it – Predicts GFR over a wide range – Useful for changing the dose of medications excreted by glomerular filtration

– Identifies renal insufficiency – Can detect progression of renal disease

– Detects end-stage renal disease • Levey’s formula uses demographic data and commonly available serum variables

• Glomerular filtration rate (eGFR) is the best method for determining renal function • The most accurate method for measuring GFR is the renal clearance of 125I-iothalamate

• 24-hour measured creatinine clearance overestimates GFR by 19%

• Healthy Kidneys: 60 or higher • Stage 1 Chronic Kidney Disease (CKD): – 90 or higher with HTN, Proteinuria, AbN Ki anatomy • Stage 2 Chronic Kidney Disease (CKD): – 60-89 with the above • Stage 3 Chronic Kidney Disease (CKD): – 30-59 • Stage 4 Chronic Kidney Disease (CKD): – 15-29 • Stage 5 – 15 or less / Dialysis

(c) PS Anderson - www.ConsultDrA.com 2021 60 Levy Calculator https://www.mdcalc.com/mdrd-gfr-equation #next-steps Useful in all CKD - not acute renal failure.

Reference Interval: • • Normal: 0-30 mg/day • Microalbuminuria: 30-300 mg/day • Clinical albuminuria: >300 mg/day

Use: Measurement of albumin levels in urine below the detection level of urine dipsticks. This test is useful in the management of patients with relatively early diabetes mellitus to assist in avoiding or delaying the onset of diabetic renal disease.

• Plasma concentrations of cystatin C are reliable markers for detecting and monitoring the progression of kidney disease. Both creatinine and cystatin C are each affected by factors other than GFR, with creatinine affected by factors related to muscle mass (age, gender, and race), and cystatin C affected by age, inflammation, obesity, and diabetes [13]. Like serum creatinine, cystatin C concentrations were much more stable in individuals without renal disease than was GFR measured by creatinine clearance [5]. • A possible advantage of cystatin C with minor glomerular damage is that, being a large molecule, blood levels of cystatin C might rise sooner than creatinine. https://acutecaretesting.org/en/articles/clarifying-the-confusion-of-gfrs- creatinine-and-cystatin-c

**Increased BUN in blood Differentiate site through Creatinine excretion Typically, Kidney has to be sick to have Creatinine rise = to BUN • Prerenal – Impaired renal blood flow – BUN & Cre both rise but BUN rises faster • Healthy Kidney with low GFR • High BUN/Cre • Intrarenal – Injury to the glomeruli, tubules, small vessels – Both high but equally so • BUN/Cre ratio normal • Postrenal – Obstruction – Labs tricky (BUN/Cre Normal early, rises after long oliguria).

• Acute renal failure is sudden loss of the ability of the kidneys to excrete wastes, concentrate urine, and conserve electrolytes. • Essentials of Diagnosis: – sudden onset of oliguria; 20-200ml/d – proteinuria; hematuria; isosthenuria sp. gr. 1.010-1.016 – anorexia, nausea, vomiting, lethargy, HBP – Na, Ca, HCO3

• Pre-renal: inadequate renal perfusion from  extracellular volume.

• Post-renal: glomerular and tubular dysfunction; obstruction from calculi,  prostate, tumors. • Renal: prolonged ischemia, toxins, acute GN, tubular necrosis.

• decreased urine output • decreased urine volume (oliguria) or no urine output (anuria) • ankle, feet, and leg swelling • generalized swelling, fluid retention • changes in mental status or mood – agitation – drowsiness, lethargy – Delirium or confusion – coma

• Decreased blood flow – trauma, complicated surgery, septic shock, hemorrhage, or burns; associated dehydration; or other severe or complicated illnesses. • Acute arterial occlusion of the kidney and renal artery stenosis • Over-exposure to metals, solvents, radiographic contrast materials, certain antibiotics, and other medications or substances. • Infections such as acute pyelonephritis or septicemia • Urinary tract obstruction

Blood Kidney Urine______[H+] [H+] [CO2] Glycine Glycine [NH3] + [H+] Glutamine Glutamine 1 [NH3]

NH4 Glutamate Glutamate 2 Alanine Alanine 3 Excretion Aspartate Aspartate

1: Oxidative Deamination 2: ALT 3: AST

(c) PS Anderson - www.ConsultDrA.com 2021 69 For a deep dive into kidney and liver function issues: https:// www.consultdranderson.com/ courses/33-kidney-and-liver- functions-lab-and-clinical-effects/

• eGFR via Levy calculation is ______sensitive than 24-hour Creatinine clearance.

• Transaminases are found in the kidneys ( T F )

• The tubular system normally reclaims (to the blood) ______of the Na and K filtered in the urine.

• Two classes of proteins are found in the blood, albumin and globulin. Albumin makes up about 60% of the total protein. Produced by the liver, albumin serves a variety of functions including as a carrier protein for many small molecules and ions, as a source of amino acids for tissue metabolism, and as the principal component involved in maintaining osmotic pressure (preventing fluid from leaking out of blood vessels).

• The remaining 40% of proteins in the plasma are referred to as globulins. The globulin proteins are a varied group. They include enzymes, antibodies, hormones, carrier proteins, and numerous other types of proteins.

• The level of total protein in the blood is normally a relatively stable value, reflecting a balance in loss of old protein molecules and production of new protein molecules.

Total protein may decrease in conditions: • Where production of albumin or globulin proteins is impaired, such as malnutrition or severe liver disease • That accelerate the breakdown or loss of protein, such as kidney disease (nephrotic syndrome) • That increase/expand plasma volume (diluting the blood), such as congestive heart failure Total protein may increase with conditions that cause: • Abnormally high production of protein (e.g., inflammatory disorders, multiple myeloma) • Dehydration

Common Causes Decrease in albumin (without decrease in globulins) Decreased production Severe liver disease Compensatory (with hyperglobulinemia) Maldigestion (EPI) Inflammation (negative acute phase protein) Increased loss Protein-losing nephropathy (PLN) Addison’s disease Increased globulins (without increase in albumin) Infection Inflammation (especially chronic) Neoplasia Multiple myeloma/other plasma cell tumors Some lymphomas

Common Causes Increased albumin/globulin ratio is not a common finding Artifact: hemolysis resulting in increased albumin with some methodologies Uncommon Causes Increased albumin Hemoconcentration (rare without concurrent increase in globulins) Decreased globulin Neonates (failure of passive transfer of colostrum) Decreased production Severe combined immunodeficiency disease (SCID) Agammaglobulinemia, transient hypogammaglobulinemia

• Albumin mostly reflects ______production.

• Globulin reflects ______production.

• Autoimmunity may show high ______.

– If you have the above the next test is ______.

(c) PS Anderson - www.ConsultDrA.com 2021 78 Selected Metabolic Markers Both are discrete users (as cofactors) of B-6 and Magnesium • AST (SGOT) “A sick heart can beat f-AST” – Identify and monitor HEART!!! Increased in early MI (peak at 24-36 hrs.) – If no cardiovascular Sx consider Kidney, Hepatocellular damage, ETOH-Toxin • ALT (SGPT) “L is for Liver” – Identify and monitor hepatocellular damage. – ALT>AST Mainly = Liver Dz.

• If total bili is elevated check direct - indirect • Indirect / Unconjugated – “Pre-hepatic” elevated in hemolytic conditions, or Glbert’ syndrome. – Think poor glucuronidation or excessive RBC lysis. – The glucuronidation patheay is also slowed by: • Toxic mushrooms • Acute Hepatitis • Acetaminophen toxicity • Direct / Conjugated – Hepatocellular disease (normally with increased ALT) – Biliary obstruction (Often with increased Amylase)

(c) PS Anderson - www.ConsultDrA.com 2021 85 Lange: Case Studies in Emergency(c) PS Anderson - www.ConsultDrA.com 2021 86 Medicine (c) PS Anderson - www.ConsultDrA.com 2021 87 DDX of Jaundice: Overproduction due to hemolysis Decreased uptake due to Gilbert Dz. Changes in the UGT1A1 gene cause Gilbert syndrome. This gene provides instructions for making the bilirubin uridine diphosphate glucuronosyltransferase (bilirubin-UGT) enzyme, which is found primarily in liver cells and is necessary for bilirubin conjugation. (People with Gilbert syndrome have approximately 30 percent of normal bilirubin-UGT enzyme function.) The bilirubin-UGT enzyme performs glucuronidation. During this reaction, the enzyme transfers glucuronic acid to unconjugated bilirubin, converting it to conjugated bilirubin. Bilirubin is glucoronized by uridine diphosphate-glucuronosyl transferase 1A1 (UGT1A1) mainly in the liver, and excreted into bile. The conjugated form is metabolized into the unconjugated form, and then into urobilinogen by bacteria in the intestine. Unconjugated bilirubin and urobilinogen are absorbed into the blood stream. The kidney filtrates conjugated bilurubin and urobilinogen into urine. Decreased conjugation: Hepatocellular Dz. Familial HC Dz. Drug induced HC Dz. Obstructive Biliary Duct Dz.

(c) PS Anderson - www.ConsultDrA.com 2021 88 (c) PS Anderson - www.ConsultDrA.com 2021 89 (c) PS Anderson - www.ConsultDrA.com 2021 90 Quick RG Quiz:

• Transaminases use up a lot of ____ & _____.

• An elevated total bilirubin needs what next test?

• GGT is concentrated in the liver, but is used

body wide ( T F )

• If ALT-AST are elevated B6 & Mg are being used in excess. These folks will need more. • NEVER draw blood for liver or renal functions for 48 (better 72) hours after any IV infusion (a small push of one item may be OK like GSH) nutrient, chemo etc. will all throw off Li&Ki tests! • Draw Li&Ki labs at least 24 hours post ORAL drugs which have Li or Ki effects. • If the person got hydration (LR, NS etc.) via IV electrolytes will be off for 24 hours.

• AlkPhos • Ferritin • LDH • CRP…

• Most of these are best used in serial measurements. • In extreme cases where they are elevated, they require workup.

(c) PS Anderson - www.ConsultDrA.com 2021 95 Transiminases Both are discrete users (as cofactors) of B-6 and Magnesium • AST (SGOT) “A sick heart can beat f-AST” – Identify and monitor HEART!!! Increased in early MI (peak at 24-36 hrs.) – If no cardiovascular Sx consider Kidney, Hepatocellular damage, ETOH-Toxin – “Inflammation” • ALT (SGPT) “L is for Liver” – Identify and monitor hepatocellular damage. – ALT>AST Mainly = Liver Dz.

• GGT (GGTP) • [Most every cell uses this for glutathione activity. Not really a “liver” test – but the liver has a high concentration of GGT activity.] – Useful in detecting space-occupying lesions, biliary dysfunction – DDX of elevated Alkaline Phosphatase (Liver = Higher GGT / Bone = Normal GGT). – ETOH abuse – Chemical toxicity. – High GGT + Low RBC Magnesium = Very poor cellular glutathione function. – “Inflammation” like AST

• Normally associated with osteogenic reticuloendothelial and hepatic activity. • In bone: – Osteoclast  Alk.Phos.  Stimulates Osteoblast activity • Highest associations in bone and liver cancers. • Can be made de-novo in malignancy and inflammation. • Stimulated by T3 – Low AlkPhos can be hypothyroid.

Conclusions: Various disorders were associated with high serum ALP levels in hospitalized patients. The three major underlying etiologies in our series were a) obstructive biliary diseases b) infiltrative liver diseases c) sepsis. Our results were in accordance with previous studies in developed countries. However, two interesting findings unique to our setting were identified. One was the high prevalence of cholangiocarcinoma as cause of hyper alkaline phosphatasemia. The other was that several tropical diseases were essential etiologies of marked elevation of serum ALP among Thai adult hospitalized patients. Viroj Wiwanitkit. High serum alkaline phosphatase levels, a study in 181 Thai adult hospitalized patients. BMC Family Practice20012:2. DOI: 10.1186/1471-2296-2-2

(c) PS Anderson - www.ConsultDrA.com 2021 99 (c) PS Anderson - www.ConsultDrA.com 2021 100 Liver is the isoenzyme most frequently elevated when total ALP levels are elevated. Liver ALP increases in the blood early in liver disease before most other liver function tests show abnormalities. The wide group of conditions leading to increased liver ALP include acute hepatitis, cirrhosis, fatty liver, drug-induced liver disease, obstruction of biliary flow by carcinoma at the head of the pancreas, bile duct stricture, primary biliary cirrhosis, and metastatic carcinoma of the liver. Bone isoenzyme is elevated as a result of increased osteoblastic activity. This isoenzyme is normally elevated in growing children and adults over the age of 50. The highest total ALP values have been attributed to an increased bone isoenzyme level due to Paget disease or renal rickets. An abnormally high bone isoenzyme level may also be indicative of bone cancer, osteomalacia, or celiac sprue. A decreased bone ALP in children may be attributed to cretinism or to hypophosphatasia. Intestinal alkaline phosphatase is seen normally in the serum of subjects who have B or O blood types, especially after a fatty meal. Pathologically, the band may be present in perforation of the bowel, ulcerative disease of the intestine, and faintly in liver cirrhosis. Acute infarction of the intestine will cause a release of intestinal ALP from the mucosa. Large erosive or ulcerative lesions of the stomach, duodenum or other small intestinal areas, or colon may result in an elevation of the serum ALP level. The small intestinal lesions associated with malabsorption are associated with an elevation of the serum intestinal ALP level only if there is an erosive or ulcerative mucosal lesion.

(c) PS Anderson - www.ConsultDrA.com 2021 101 Vroon DH, Israili Z. Alkaline Phosphatase and Gamma Glutamyltransferase. In: Walker HK, Hall WD, Hurst JW, editors. Clinical Methods: The History, Physical, and Laboratory Examinations. 3rd edition. Boston: Butterworths; 1990. Chapter 100. Available from: https://www.ncbi.nlm.nih.gov/books/NBK203/ • Exclude physiologic causes. Is the patient pregnant or an actively growing child? • Observe for the presence of clinical or biochemical clues to the origin of increased enzyme activity. Increased serum bilirubin or aminotransferase (either aspartate or alanine) activity suggests hepatic rather than bone origin. Disproportionate elevation of lactic dehydrogenase (LDH) relative to transaminase usually suggests nonhepatobiliary or multiorgan system disease. The association of elevated LDH, hypercalcemia, and hyperuricemia suggests metastastic neoplastic disease. • Is the elevation transient such as observed in various tissue reparative processes, healing bone fractures, or passive congestion of the liver? • Measurement of other enzymes such as 5′-nucleotidase or gamma-glutamyltransferase may assist with identifying the hepatobiliary system as a source of elevated ALP since these enzymes are not significantly present in bone. 5′-Nucleotidase is a highly specific but less sensitive indicator of hepatobiliary disease. Gamma glutamyltransferase is more sensitive; however, with the exception of its absence in bone and placenta, it is a less specific indicator of hepatobiliary disease than ALP.

(c) PS Anderson - www.ConsultDrA.com 2021 102 LDH (Lactate Dehydrogenase) Principal measurement to diagnose conditions in which there is tissue damage. • Isoenzymes [run to determine tissue of injury]: –LDH-1 Normally Lower than LDH-2 –In MI: LDH-1>LDH-2! –Liver Dz: LDH< AST&ALT –Pernicious Anemia LDH may be 50X Normal –LDH-5 Increase in Muscle Dz’s

(c) PS Anderson - www.ConsultDrA.com 2021 103 (c) PS Anderson - www.ConsultDrA.com 2021 104 LDH (Lactate Dehydrogenase) Principal measurement to diagnose conditions in which there is tissue damage. • LDH ELEVATIONS – Acute MI – Myocarditis – Liver disease – Tissue necrosis – CHF – Shock – Pancreatitis – Acute renal infarction – Hemolysis – Skeletal muscle disease – Trauma – Multi-system disease – Collagen-vascular disease

(c) PS Anderson - www.ConsultDrA.com 2021 105 (c) PS Anderson - www.ConsultDrA.com 2021 106 Lactate dehydrogenase (LD) is an enzyme that is found in almost all of the body's cells, but only a small amount of it is usually detectable in the blood. LD is released from the cells into the bloodstream when cells are damaged or destroyed. Because of this, the LD test can be used as a general marker of injury to cells. Although there is some overlap, each of the five LD isoenzymes tends to be concentrated in specific body tissues. In general, the isoenzyme locations are as follows: • LD1: Heart, red blood cells, kidney • LD2: Heart, red blood cells, kidney (lesser amounts than LD1) • LD3: Lungs and other tissues • LD4: White blood cells, lymph nodes, muscle, liver (lesser amounts than LD5) • LD5: Liver, skeletal muscle Changes of LD isoenzymes periodically measured following onset of chest pain, studying the relationships of the anodic fractions, provide important information for the differential diagnosis of acute infarct of myocardium. The differential diagnosis of certain other diseases is enhanced as well with the use of LD isoenzymes. Useful in the differential diagnosis of acute myocardial infarction, megaloblastic anemia (folate deficiency, pernicious anemia), hemolytic anemia, and very occasionally renal infarct. These entities are characterized by LD1 increases, often with LD1:LD2 inversion. The isomorphic pattern (total LD significantly high with no increase in percentage, of any fraction) is seen with neoplasia, cardiorespiratory diseases, hypothyroidism, infectious mononucleosis, and other inflammatory states, uremia, and necrosis. LD5 increases are seen with striated muscle lesions (eg, trauma) and with liver diseases (eg, hepatic congestion, congestive heart failure, hepatitis, cirrhosis, alcoholism). LD5 increase is probably more significant when the LD5:LD4 ratio is increased.

Normally, RBCs have negative charges on the outside of the cells, which cause them to repel each other. Many plasma proteins have positive charges and can effectively neutralize the negative surface charges of the RBCs, which allows for the formation of the rouleaux. Therefore, an increase in plasma proteins (present in inflammatory conditions) will propagate an increase in rouleaux formations, which settle more readily than single red blood cells. The settling of the rouleaux aggregates in the Westergren tube occurs at a constant rate. The formation of rouleaux allows the RBCs to settle at a faster rate, thus increasing the ESR. Therefore, the ESR is not the measure of a single marker but a physical process.

(c) PS Anderson - www.ConsultDrA.com 2021 108 The ESR is neither sensitive nor specific as a general screening test. Because an elevated ESR may occur in multiple clinical settings, it is meaningless as a stand-alone laboratory value. Furthermore, some patients who have malignant lesions, serious infections, or significant inflammatory disorders may have normal ESR values. An ESR level that is elevated should heighten the practitioner's index of suspicion of the potential for underlying illness. This may include: • Anemia • Arteritis • Infections (including bone and joint) • Kidney disease • Low serum albumen • Lupus • Lymphoma • Multiple myeloma • Polymyalgia rheumatica • Red blood cell abnormalities • Rheumatoid arthritis • Systemic vasculitis • Thyroid disease • Waldenstrom macroglobulinemia *Any process that elevates fibrinogen (e.g., pregnancy, infection, diabetes mellitus, end-stage renal failure, heart disease, malignancy) may also elevate the ESR.

(c) PS Anderson - www.ConsultDrA.com 2021 109 • CRP was discovered nearly 80 years ago by scientists exploring the human inflammatory response. CRP is produced by every single human being and plays a crucial role in the immune system as a sensitive and dynamic marker of inflammation.7 CRP can be increased 10,000- to 50,000-fold during acute responses to serious infection or major tissue damage, and usually peaks within 48 hours. Acute rises in CRP may be attributed to exercise, burns, trauma, or acute bacterial or viral infections. Situations known to cause chronic elevations in CRP levels include elevated blood pressure, elevated body mass index, cigarette smoking, cancer, metabolic syndrome, diabetes mellitus, decreased high-density lipoprotein (HDL), elevated triglycerides, estrogen and progesterone hormone use, chronic bacterial or viral infections, autoimmune conditions, and chronic inflammatory conditions. • To illustrate the difference between CRP and hs-CRP, traditional testing measures CRP within the range of 10 to 1,000 mg/L, whereas hs-CRP values range from 0.5 to 10 mg/L. In simpler terms, hs-CRP measures trace amounts of CRP in the blood. Hs-CRP is the analyte of choice for cardiovascular risk assessment, due to superior assay precision, accuracy, availability, and the existence of standards for proper calibration when compared to other acute-phase reactants.

(c) PS Anderson - www.ConsultDrA.com 2021 110 Pearson TA, Mensah GA, Alexander RW, et al. Markers of inflammation and cardiovascular disease: application to clinical and public health practice: a statement for healthcare professionals from the Centers for Disease Control and Prevention and the American Heart Association. Circulation. 2003;107(3): 499-511. Stone NJ, Robinson JG, Lichtenstein AH, et al. 2013 ACC/AHA guideline on the treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk in adults: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2014;63:2889-2934. Jacobson TA, Ito MK, Maki KC, et al. National Lipid Association recommendations for patient-centered management of dyslipidemia: part 1—executive summary. J Clin Lipidol. 2014;8(5):473-488. Ridker PM. Cardiology Patient Page. C-reactive protein: a simple test to help predict risk of heart attack and stroke. Circulation. 2003;108(12):e81-e85. Kaptoge S, Di Angelantonio E, Lowe G, et al. C-reactive protein concentration and risk of coronary heart disease, stroke, and mortality: an individual participant meta-analysis. Lancet. 2010;375:132- 140. Mcpherson M. C-reactive protein usage in medical treatment. Ezine Articles. June 3, 2010. http://ezinearticles.com/?C-Reactive-Protein-Usage-in-Medical-Treatment&id=4411095 Accessed June 12, 2014.

Serum gamma-glutamyl transferase (GGT) has been widely used as an index of liver dysfunction and marker of alcohol intake. The last few years have seen improvements in these areas and advances in understanding of its physiological role in counteracting oxidative stress by breaking down extracellular glutathione and making its component amino acids available to the cells. Conditions that increase serum GGT, such as obstructive liver disease, high alcohol consumption, and use of enzyme-inducing drugs, lead to increased free radical production and the threat of glutathione depletion. However, the products of the GGT reaction may themselves lead to increased free radical production, particularly in the presence of iron.

• Elevated GGT levels may be an indicator of cardiovascular disease and/or hypertension. Some studies have shown that people with increased GGT levels have an elevated risk of dying from heart disease, but the reason for this association is not yet known.

• Low levels of GGT are observed in certain genetic diseases where the flow of bile from liver is interrupted or suppressed.

• Drugs that may cause an elevated GGT level include phenytoin, carbamazepine, and barbiturates such as phenobarbital. Use of many other prescription and non-prescription drugs, including nonsteroidal anti-inflammatory drugs (NSAIDs), lipid-lowering drugs, antibiotics, histamine receptor blockers (used to treat excess stomach acid production), antifungal agents, antidepressants, oral contraceptives and hormones such as testosterone, can increase GGT levels. Certain anticoagulants (e.g., heparin) and immunosuppressive medications (e.g., methotrexate) also increase GGT levels in serum.

(c) PS Anderson - www.ConsultDrA.com 2021 113 Figure 1 [Antioxidants 2021, 10(4), 549; https://doi.org/10.3390/antiox10040549] GGT and other enzymes in the γ-glutamyl cycle. Extracellular GSH (γ-glutamyl–cysteinyl–glycine) is broken down on the cell membrane by membrane-bound GGT, making component peptides available to cells with successive reactions with other enzymes. Intracellular GSH is then resynthesized, increasing resistance to oxidative stress. AA, amino acid; ADP, adenosine diphosphate; ATP, adenosine triphosphate; GCL, glutamate-cysteine ligase; GGCT, γ-glutamylcyclotransferase; GGT, γ- glutamyltransferase; GSH, glutathione; GSS, glutathione synthetase; Pi, inorganic phosphate

Versus 

(c) PS Anderson - www.ConsultDrA.com 2021 115 The prevalence of several other clinical symptoms are correlated with GGT, including hypertension, insulin resistance, artery calcification, and albuminuria, as well as biological markers including lipids, creatine, triglycerides, uric acid, HbA1c, and hs-CRP. In many cases, GGT is a stronger predictor of disease risk than these other symptoms and markers.

Low antioxidant defenses are also correlated with elevated GGT, particularly reduced levels of glutathione. GGT is needed to metabolize glutathionylated xenobiotics in the liver and multiple other tissue sites including the lungs, and this is a simple explanation for its elevation in association with increased exposure to xenobiotics. GGT induces oxidative stress in the artery wall in the presence of free iron, and GGT also likely is an indicator of depleted supply of glutathione, especially in the liver, which leads to a cascade of problems related to increased oxidative stress.

(c) PS Anderson - www.ConsultDrA.com 2021 116 Koenig G, Seneff S. Gamma-Glutamyltransferase: A Predictive Biomarker of Cellular Antioxidant Inadequacy and Disease Risk. Dis Markers. 2015;2015:818570. doi:10.1155/2015/818570 GGT

• High GGT = inflammatory biology and a need for ReDox support and GSH+Cofactors. • Always best as a serial measurement. • REMEMBER: – GGT gets GSH into most cells – Magnesium in the cells increases GSH activity and levels • Low GGT has unclear significance in the literature. – Of note in chronically ill people low GGT may be depletion, so it is advisable to do a trial of 8 weeks GSH support with cofactors and re-test the GGT. – Low GGT in a healthy person is likely physiologic.

• LDH is a marker of ______metabolism.

• AlkPhos is associated often with bone because of ______activity.

• ESR and CRP are specific markers. ( T F )

• hsCRP differs from CRP in ______

• AST, LDH, GGT, CRP, ESR are triggered by inflammatory processes. • Some of their biology is global and some can be isolated via isoenzymes etc. • ALL are best NOT as lone markers but in serial measurement.

• https://www.consultdranderson.com/courses/33-kidney-an d-liver-functions-lab-and-clinical-effects/

• https://www.consultdranderson.com/courses/09-redox-an d-inflammation-cell-damage-and-therapies/

• Any search on ConsultDrA for “Renal” / “Kidney” / “Liver” /

“Hepatic” (c) PS Anderson - www.ConsultDrA.com 2021 121 QUESTIONS ABOUT (CE Cert, etc.) -----? Go here: https://www.consultdranderson.com/contact/

• THIS WEEK - May 21, 22 & 23 – CHRONIC INFECTION CASES – https://aampconferences.com/aamp-spring-conference- 2021/

• Fall – September 24, 25 & 26 – ONCOLOGY – https://aampconferences.com/aamp-fall-conference-20 21/ (c) PS Anderson - www.ConsultDrA.com 2021 123 Thank You – Questions?