Additional Information
Book Details
Abstract
This title is directed primarily towards health care professionals outside of the United States. It presents the important aspects of clinical chemistry in the "Made Easy" format for the senior clinical medical student or junior doctor on the ward. The book explains the rationale underlying the most common clinical chemistry tests to request and gives guidance as to what action is required on receipt of abnormal results. The text includes brief background to the underlying physiological processes involved, important differential diagnoses and further steps required in the clinical setting. The ultimate aim is to make the reader think carefully as to what clinical chemistry tests are required in different contexts and to ensure that they are equipped to deal responsibly with the result. This will result in improved clinical practice.
- Made Easy format.
- Aimed at the clinician using clinical chemistry tests on the ward (and not the laboratory-based scientist).
- Will allow rationale choice of correct test.
- Gives guidance on how to react to abnormal results
Table of Contents
| Section Title | Page | Action | Price |
|---|---|---|---|
| Front Cover | i | ||
| Clinical Chemistry | iii | ||
| Copyright Page | iv | ||
| Contents | v | ||
| Foreword | vii | ||
| Preface | ix | ||
| Chapter 1: Sodium and water balance | 1 | ||
| Introduction | 1 | ||
| Distribution | 1 | ||
| Control of sodium balance | 2 | ||
| Volume depletion (decreased total body sodium) | 2 | ||
| Volume overload (increased total body sodium) | 3 | ||
| Control of water balance | 3 | ||
| Water excess (hyponatraemia) | 4 | ||
| Water depletion (hypernatraemia) | 5 | ||
| When should I check sodium level? | 5 | ||
| What do I do with the result? | 6 | ||
| Hyponatraemia (serum Na <135mmol/L) | 6 | ||
| Two factors are required to develop hyponatraemia | 6 | ||
| Assessment of the patient | 7 | ||
| Laboratory tests | 8 | ||
| Symptoms and signs | 8 | ||
| Differential diagnosis of hyponatraemia | 8 | ||
| Hyperglycaemia | 8 | ||
| Pseudohyponatraemia | 10 | ||
| Artefactual hyponatraemia | 10 | ||
| Iatrogenic | 10 | ||
| Polydipsia | 10 | ||
| Diuretics and other drugs | 10 | ||
| Syndrome of inappropriate ADH (SIADH) | 11 | ||
| Management | 12 | ||
| Acute symptomatic hyponatraemia (<48 h) | 12 | ||
| Volume depletion | 13 | ||
| Chronic hyponatraemia (>48 h) | 13 | ||
| Recommended therapeutic strategies include: | 13 | ||
| Hypernatraemia (serum Na >145mmol/L) | 14 | ||
| Symptoms and signs | 14 | ||
| Clinical assessment | 14 | ||
| Laboratory results | 15 | ||
| Differential diagnosis | 15 | ||
| Non-renal water loss | 15 | ||
| Osmotic diuresis | 15 | ||
| Diabetes insipidus | 16 | ||
| Diabetes insipidus is divided into | 17 | ||
| Management | 17 | ||
| Non-renal EFW loss | 18 | ||
| Osmotic diuresis | 18 | ||
| Central diabetes insipidus | 18 | ||
| Nephrogenic diabetes insipidus | 18 | ||
| Assessment of polyuria | 19 | ||
| Water diuresis | 19 | ||
| Solute diuresis | 19 | ||
| Chapter 2: Disorders of potassium balance | 21 | ||
| Distribution | 21 | ||
| Potassium excretion | 23 | ||
| Renal potassium excretion | 23 | ||
| Gastrointestinal potassium excretion | 23 | ||
| When should I check potassium level? | 23 | ||
| Patients with cardiac disease | 23 | ||
| Patients receiving drugs that may affect serum potassium level | 24 | ||
| Patients with diabetes mellitus | 25 | ||
| Patients with major fluid and electrolyte fluxes | 25 | ||
| Patients with renal impairment | 25 | ||
| Patients with weakness of unknown aetiology | 25 | ||
| What do I do with the result? | 26 | ||
| Hypokalaemia (<3.5mmol/L) | 26 | ||
| Symptoms and signs | 26 | ||
| Differential diagnosis | 27 | ||
| Artefactual | 27 | ||
| Low potassium intake | 27 | ||
| Shift of potassium into the intracellular compartment | 27 | ||
| Gastrointestinal losses | 27 | ||
| Renal losses | 29 | ||
| Special situations | 29 | ||
| Heart disease | 29 | ||
| Liver failure | 30 | ||
| Management | 30 | ||
| Assessment | 30 | ||
| Emergency treatment | 30 | ||
| Non-urgent treatment | 31 | ||
| Hyperkalaemia | 31 | ||
| Symptoms and signs | 31 | ||
| Differential diagnosis | 33 | ||
| Artefactual and pseudohyperkalaemia | 34 | ||
| High potassium intake | 34 | ||
| Shift of potassium from the intracellular compartment | 34 | ||
| Reduced renal potassium excretion | 34 | ||
| Management | 35 | ||
| Assessment | 35 | ||
| Emergency treatment | 35 | ||
| Non-urgent treatment | 37 | ||
| Chapter 3: Assessment of renal function and urinary protein excretion | 39 | ||
| Introduction | 39 | ||
| Assessment of renal function | 40 | ||
| Serum creatinine | 40 | ||
| Serum creatinine levels may be increased in | 41 | ||
| The serum creatinine may be low in | 41 | ||
| Serum urea | 43 | ||
| The serum urea concentration may be raised in | 43 | ||
| The serum urea concentration may be decreased in | 43 | ||
| Glomerular filtration rate and creatinine clearance | 43 | ||
| Stages of chronic kidney disease | 45 | ||
| Equations to estimate glomerular filtration rate | 45 | ||
| Regulation of renal blood flow and the glomerular filtration rate | 47 | ||
| Assessment of proteinuria | 49 | ||
| Classification of proteinuria | 49 | ||
| Microalbuminuria | 49 | ||
| Benign proteinuria | 51 | ||
| Glomerular proteinuria | 51 | ||
| Tubular proteinuria | 51 | ||
| Overflow proteinuria | 51 | ||
| When should I consider performing dipstick urinalysis? | 51 | ||
| What do I do with the result? | 52 | ||
| Quantify the amount of proteinuria | 52 | ||
| Isolated proteinuria | 53 | ||
| Microscopic haematuria in the absence of proteinuria | 54 | ||
| When should I check renal function? | 54 | ||
| What do I do with the result? | 55 | ||
| Differential diagnosis of renal failure | 56 | ||
| Pre-renal causes | 56 | ||
| Renal causes | 57 | ||
| Glomerular disease | 57 | ||
| Tubulointerstitial disease | 57 | ||
| Post-renal causes | 57 | ||
| Management | 57 | ||
| Fluid balance | 58 | ||
| Renal biopsy | 58 | ||
| Renal replacement therapy | 59 | ||
| Chapter 4: Metabolic acid-base disorders | 61 | ||
| Introduction | 61 | ||
| Acid-base homeostasis | 61 | ||
| pH | 61 | ||
| The Henderson-Hasselbalch equation | 62 | ||
| Where does the acid load come from? | 62 | ||
| How does the body deal with the daily acid load? | 63 | ||
| Buffers | 63 | ||
| ECF buffers | 63 | ||
| ICF buffers | 64 | ||
| Respiratory control of pH | 64 | ||
| Renal regulation of pH | 65 | ||
| When should I check acid-base balance? | 65 | ||
| Seven steps to the clinical assessment of acid-base status | 68 | ||
| Step 1: What is the pH (normal 7.35-7.45) | 68 | ||
| Step 2: Check the serum bicarbonate (HCO3) (normal 22-30-mmol/L) | 69 | ||
| Step 3: Check the arterial PCO2 (normal 35-45mmHg [4.5-6.0kPa]) | 69 | ||
| Step 4: Assess the compensatory responses | 69 | ||
| Step 5: Assess the anion gap | 70 | ||
| Step 6: Assess the (change in serum anion gap/change in HCO3) (the \"delta/delta\") | 72 | ||
| Step 7: Identify underlying cause of acid-base disturbance | 73 | ||
| Metabolic acidosis | 73 | ||
| Causes of metabolic acidosis | 73 | ||
| How serious is the metabolic acidosis? | 74 | ||
| Lactic acidosis | 75 | ||
| Type A lactic acidosis | 76 | ||
| Type B lactic acidosis | 77 | ||
| d-Lactic acidosis | 77 | ||
| Treatment of lactic acidosis | 77 | ||
| Ketoacidosis | 77 | ||
| Diabetic ketoacidosis | 77 | ||
| Treatment of diabetic ketoacidosis | 78 | ||
| Alcoholic ketoacidosis | 79 | ||
| Renal failure | 79 | ||
| Poisoning | 79 | ||
| Methanol and ethylene glycol | 79 | ||
| Osmolal gap | 80 | ||
| Aspirin | 80 | ||
| Hyperchloraemic metabolic acidosis | 80 | ||
| Clinical assessment of a hyperchloraemic metabolic acidosis | 80 | ||
| The urine anion gap (UAG) | 80 | ||
| Gastrointestinal HCO3- Loss | 82 | ||
| Renal tubular acidosis | 82 | ||
| Proximal RTA | 82 | ||
| Distal RTA | 83 | ||
| Type IV renal tubular acidosis | 84 | ||
| Metabolic alkalosis | 86 | ||
| Causes of metabolic alkalosis | 86 | ||
| Urine electrolytes in metabolic alkalosis | 87 | ||
| Specific causes of metabolic alkalosis | 88 | ||
| Vomiting | 88 | ||
| Diuretics | 88 | ||
| Primary hyperaldosteronism | 89 | ||
| Chapter 5: Arterial blood gas analysis | 91 | ||
| Normal values | 91 | ||
| Respiratory physiology | 92 | ||
| Oxygen | 92 | ||
| Oxygen transport | 92 | ||
| Carbon dioxide | 92 | ||
| CO2 production | 92 | ||
| Respiratory function | 93 | ||
| Control of ventilation | 93 | ||
| Lung perfusion | 94 | ||
| Diffusion | 94 | ||
| Assessment of oxygenation | 94 | ||
| Clinical assessment | 94 | ||
| Arterial partial pressure of oxygen (PaO2) | 95 | ||
| Arterial oxygen saturation (SaO2) | 95 | ||
| There are two main pitfalls: | 95 | ||
| Alveolar-arterial oxygen gradient (AA gradient) | 95 | ||
| Assessment of tissue hypoxia | 96 | ||
| Assessment of ventilation | 97 | ||
| Respiratory failure | 97 | ||
| Treatment of hypoxaemia | 98 | ||
| Oxygen therapy | 98 | ||
| Use of oxygen in patients with chronic respiratory acidosis | 98 | ||
| Respiratory acid-base disorders | 99 | ||
| Assessment of respiratory acid-base status | 99 | ||
| Is a respiratory acid-base disorder present? | 100 | ||
| Is this merely respiratory compensation for a metabolic disorder? | 100 | ||
| Renal compensation for a respiratory disorder | 102 | ||
| Respiratory acidosis | 102 | ||
| Clinical features | 103 | ||
| Causes of respiratory acidosis | 103 | ||
| Acute versus chronic respiratory acidosis | 104 | ||
| Treatment of respiratory acidosis | 104 | ||
| Respiratory alkalosis | 105 | ||
| Clinical features | 105 | ||
| Causes of respiratory alkalosis | 105 | ||
| Treatment of respiratory alkalosis | 105 | ||
| Chapter 6: Calcium, phosphate and magnesium metabolism | 107 | ||
| Calcium homeostasis | 107 | ||
| Regulation of calcium homeostasis | 108 | ||
| Parathyroid hormone | 108 | ||
| Vitamin D | 108 | ||
| Calcitonin | 109 | ||
| Assessment of serum calcium levels | 110 | ||
| Protein binding | 111 | ||
| Acid-base status | 111 | ||
| When should I consider checking a patient's calcium level? | 111 | ||
| Hypercalcaemia | 112 | ||
| Hyperparathyroidism | 112 | ||
| Primary hyperparathyroidism | 112 | ||
| Secondary and tertiary hyperparathyroidism | 113 | ||
| Hypercalcaemia and malignancy | 114 | ||
| Granulomatous disorders | 114 | ||
| What to do if the plasma calcium level is raised | 114 | ||
| Treatment of hypercalcaemia | 114 | ||
| Hypocalcaemia | 115 | ||
| Rickets and osteomalacia | 117 | ||
| Hypoparathyroidism | 117 | ||
| Miscellaneous conditions | 118 | ||
| Treatment of hypocalcaemia | 118 | ||
| Phosphate homeostasis | 118 | ||
| When should I consider checking a patient's phosphate level? | 119 | ||
| Hyperphosphataemia | 119 | ||
| Renal bone disease | 119 | ||
| Hypophosphataemia | 120 | ||
| Hypophosphataemia in the alcoholic patient | 120 | ||
| Treatment of hypophosphataemia | 120 | ||
| Magnesium homeostasis | 121 | ||
| When should I consider checking a patient's magnesium level? | 121 | ||
| Hypomagnesaemia | 122 | ||
| Treatment of hypomagnesaemia | 122 | ||
| Hypermagnesaemia | 122 | ||
| Treatment | 123 | ||
| Chapter 7: Liver function tests | 125 | ||
| Introduction | 125 | ||
| Anatomy and physiology | 126 | ||
| Bilirubin metabolism | 127 | ||
| Direct and indirect bilirubin | 129 | ||
| Bile salts | 129 | ||
| Alkaline phosphatase (ALP) | 129 | ||
| gamma-Glutamyltransferase (GGT) | 129 | ||
| Aminotransferases | 130 | ||
| When should I consider checking a patient's liver function? | 130 | ||
| What do I do with the result? | 131 | ||
| Jaundice (with increased levels of bilirubin alone) | 131 | ||
| Haemolysis | 131 | ||
| Gilbert's syndrome | 132 | ||
| Obstructive pattern of LFTs with raised ALP and GGT levels | 133 | ||
| Alcohol and GGT | 135 | ||
| Patterns of enzyme rises | 135 | ||
| Hepatocellular pattern with increased ALT and AST levels | 136 | ||
| Patterns of raised aminotransferase levels | 136 | ||
| The AST : ALT ratio | 137 | ||
| Postoperative jaundice | 138 | ||
| Assessment of hepatic synthetic function | 138 | ||
| Albumin | 139 | ||
| Coagulation factors | 140 | ||
| Urea and ammonia | 140 | ||
| Glucose | 142 | ||
| Clinical assessment | 142 | ||
| Clinical history | 142 | ||
| Examination | 144 | ||
| Special tests | 144 | ||
| Hepatitis serology in liver disease | 144 | ||
| Hepatitis A (HAV) | 144 | ||
| Hepatitis B infection | 146 | ||
| Hepatitis C infection | 146 | ||
| Autoantibody screen in liver disease | 147 | ||
| Autoimmune hepatitis | 147 | ||
| Primary biliary cirrhosis (PBC) | 147 | ||
| alpha1-Antitrypsin (alpha1-AT) | 148 | ||
| Serum caeruloplasmin | 148 | ||
| Serum iron studies | 148 | ||
| alpha-Fetoprotein (AFP) | 149 | ||
| Other tumour markers | 149 | ||
| Chapter 8: Lipid disorders | 151 | ||
| Introduction | 151 | ||
| Classification of lipoproteins | 151 | ||
| Exogenous (dietary) pathway | 151 | ||
| Endogenous pathway | 152 | ||
| De novo cholesterol synthesis | 153 | ||
| Reverse cholesterol transport | 153 | ||
| Hyperlipidaemia and atherosclerosis | 154 | ||
| Measurement of the lipid panel | 155 | ||
| Who should be checked? | 155 | ||
| How should a lipid panel be measured? | 155 | ||
| Non-HDL cholesterol | 156 | ||
| Hypercholesterolaemia | 156 | ||
| Familial hypercholesterolaemia | 156 | ||
| LDL receptor mutations | 157 | ||
| LCAT deficiency | 157 | ||
| Combined hypercholesterolaemia and hypertriglyceridaemia | 157 | ||
| Familial combined hyperlipidaemia | 157 | ||
| Dysbetalipoproteinaemia | 157 | ||
| Hypercholesterolaemia in certain conditions | 158 | ||
| Diabetes mellitus | 158 | ||
| Renal disease | 158 | ||
| Liver disease | 158 | ||
| Cardiovascular risk assessment | 158 | ||
| Clinical management of hypercholesterolaemia | 159 | ||
| Diet | 160 | ||
| Lipid-lowering (statin) treatment? | 161 | ||
| Target of lipid-lowering therapy in high risk patients | 161 | ||
| Hypertriglyceridaemia | 161 | ||
| Causes of hypertriglyceridaemia | 161 | ||
| Lipoprotein lipase deficiency | 162 | ||
| Metabolic syndrome | 162 | ||
| Clinical management of hypertriglyceridaemia | 162 | ||
| Lipid-lowering drugs | 163 | ||
| HMG-CoA reductase inhibitors (statins) | 163 | ||
| Fibrate derivatives | 164 | ||
| Bile acid binding resins | 164 | ||
| Ezetimibe | 164 | ||
| Nicotinic acid | 164 | ||
| Omega-3 fatty acids | 165 | ||
| Hypocholesterolaemia | 165 | ||
| Chapter 9: Markers of cardiac and muscle injury and disease | 167 | ||
| Introduction | 167 | ||
| Creatine kinase | 167 | ||
| Creatine kinase levels | 168 | ||
| Clinical use of creatine kinase in cardiac disease | 169 | ||
| Cardiac troponins | 170 | ||
| Cardiac troponin levels | 171 | ||
| Clinical use of cardiac troponin levels | 171 | ||
| When should I check cardiac enzymes and troponin levels? | 172 | ||
| Assessment of acute MI | 172 | ||
| Definition of acute MI | 172 | ||
| Other markers of myocardial injury | 173 | ||
| Lactate dehydrogenase (LDH) | 173 | ||
| Aspartate aminotransferase (AST) and myoglobin | 173 | ||
| Additional tests in acute myocardial infarction | 173 | ||
| Haematological tests | 173 | ||
| Lipid panel | 174 | ||
| Disorders of skeletal muscle | 174 | ||
| Creatine kinase | 174 | ||
| Creatine kinase levels in muscle disorders | 174 | ||
| Rhabdomyolysis | 174 | ||
| Other muscle enzymes | 176 | ||
| Lactate dehydrogenase | 176 | ||
| Aminotransferases | 176 | ||
| Aldolase | 176 | ||
| Special tests associated with muscle disease | 176 | ||
| Autoimmune screen | 176 | ||
| Anti-acetylcholine receptor antibody | 176 | ||
| Thyroid function tests | 177 | ||
| Serum electrolytes (calcium, potassium and phosphate) | 177 | ||
| Genetic testing | 177 | ||
| Chapter 10: Immunological investigations | 179 | ||
| Introduction | 179 | ||
| Autoantibodies | 184 | ||
| Erythrocyte sedimentation rate (ESR) | 185 | ||
| C-reactive protein (CRP) | 185 | ||
| Immunoglobulins and light chains | 185 | ||
| Complement | 187 | ||
| When should I consider performing immunological tests? | 187 | ||
| What do I do with the result? | 188 | ||
| Index | 191 |